Module 4
Health Domains
A. Health and Illness
HEALTH and the countless ways by which it is maintained, protected, and
restored is the foundation of this text. HEALTH connotes the balance of a person, both
within one’s being—physical, mental, and spiritual—and in the outside world—natural,
familial and communal, and metaphysical. The HEALTH Traditions Model is a method
for describing beliefs and practices used to maintain through daily HEALTH practices,
such as diet, activities, and clothing; to protect through special HEALTH practices, such
as food taboos, seasonal activities, and protective items worn, carried, or hung in the
home or workplace; and/or to restore through special HEALTH practices, such as diet
changes, rest, special clothing or objects, physical, mental, and/or spiritual HEALTH.
The accompanying image Figure II-1, salud, is a metaphor for HEALTH in countless
ways. Here, it is whole and emerging from the shadows of early morning. Just as the sand
sculpture is fragile, disappearing overnight, so, too, is HEALTH. It brings to mind the
reality that HEALTH is finite, and each of us has the internal responsibility to maintain,
protect, and restore our HEALTH; the reciprocal holds true for the+external familial,
environmental, and societal forces—they, too, must look after and safeguard our
HEALTH. This book, in part, is a mirror that reflects the countless ways by which people
are able to maintain, protect, and/ or restore their HEALTH. Just as there is an interplay
between a sand sculpture and the natural forces that can create and harm and destroy it,
so, too, it is with HEALTH and the forces of the outside world.
ILLNESS is the imbalance of the person, both within one’s being—physical,
mental, and spiritual—and in the outside world—natural, familial and communal, and
metaphysical. HEALING is the restoration of this balance. The relationships of the
person to the outside world are reciprocal. When these terms, HEALTH, ILLNESS, and
HEALING, are used in small capitals in this text, it is to connote that they are being used
holistically. When they are written in the general text font—health, illness, and healing—
they are to be understood in the common way.
The physical aspect of the person includes anatomical organs, such as the skin,
skeleton, and muscles. It is our genetic inheritance, body chemistry, gender, age, and
nutrition. The mind, mental, includes cognitive process, such as thoughts, memories, and
knowledge. This includes emotional processes as feelings, defenses, and self-esteem. The
spiritual facet includes both positive and negative learned spiritual practices and
teachings, dreams, symbols, and stories; gifts and intuition; grace and protecting forces;
and positive and negative metaphysical or innate forces. These facets are in constant flux
and change over time, yet each is completely related to the others and related to the
context of the person. The context includes the person’s family, culture, work,
community, history, and environment. There is also an overlap of the mental and spiritual
facets of the person.
The person must be in a state of balance with the family, the community, and the
forces of the natural world around him or her. This balance is what is perceived as
HEALTH in a traditional sense and the way in which it is determined within most
traditional cultures, as you will note in Chapters 9 through 13. ILLNESS, as stated, is the
imbalance of one or all parts of a person (body, mind, and spirit); a person may be in a
state of imbalance with the family, the community, or the forces of the natural world. The
ways in which this balance, or harmony, is achieved, maintained, protected, or restored
often differ from the prevailing scientific health philosophy of our modern societies.
However, many of the traditional HEALTH-, ILLNESS-, and HEALING-related beliefs
and practices exist today among people who know and live by the traditions of their own
ethnocultural and/or religious heritage.
B. Health Traditions Model
The traditional methods of HEALTH maintenance, protection, and restoration
require the knowledge and understanding of HEALTH-related resources from within a
person’s ethnocultural and religious heritage, and a reciprocal relationship exists between
the person’s needs and the available resources within the family and community to meet
these needs. The methods may be used instead of or along with modern methods of health
care. They are not alternative methods of health care because they are methods that are an
integral part of a person’s ethnocultural and religious heritage. Alternative, or
complementary, medicine is a system of health care that persons may elect to use that is
generic and not a part of his or her personal heritage. The burgeoning system of
alternative medicine must not be confused with traditional HEALTH and ILLNESS
beliefs and practices. In subsequent chapters of this book, traditional HEALTH and
ILLNESS beliefs and practices are discussed, following (in part) the models (Figures 5-5
and 5-6). This model is two-dimensional in that it examines HEALTH as the internal
perceptions of a person and addresses the ways by which a person can externally obtain
the+objects and/or substances necessary for his or her HEALTH. Tradition is the essential
element in this model, and the model recognizes the fact that the role of tradition is
fundamental. “When tradition is no longer adequate, human life faces the gravest crises”
(Smith, 1991, p. 163). Given that the United States has been a melting pot, it has
frequently weakened the traditions of immigrants during the processes of acculturation
and assimlation, especially where health beliefs and practices are concerned. Many
people relate that they “threw these practices away” when they came to the United States.
The traditional ways of maintaining HEALTH are the active, everyday ways
people go about living and attempting to stay well or HEALTHY—that is, ordinary
functioning within their family, community, and society. These include such actions as
wearing proper clothing—boots when it snows and sweaters when it is cold, long sleeves
in the sun, and scarves to protect from drafts and dust. Many traditional ethnic or
religious groups may also prescribe garments, such as special clothing or head coverings.
Many “special objects,” such as hats to protect the eyes and face, long skirts to keep the
body clean, down comforters to keep warm, special shoes for work and comfort, glasses
to improve vision, and canes to facilitate walking, are used to maintain HEALTH, and
they can be found in many traditional homes.
Mental HEALTH in the traditional sense is maintained by concentrating and
using the mind—reading and crafts are examples. There are countless games, books,
music, art, and other expressions of identity that help in the maintenance of mental well-
being. Hobbies also contribute to mental well-being. The keys to maintaining HEALTH
are, however, the family and social support systems. Spiritual HEALTH is maintained in
the home with family closeness—prayer and celebrations. Rights of passage and kindred
occasions are also family and community events. The strong identity with and
connections to the “home” community are a great part of traditional life and the life
cycle, as well as factors that contribute to HEALTH and well-being.
C. Health Protection
The protection of HEALTH rests in the ability to understand the cause of a+given
ILLNESS or set of symptoms. Most of the traditional HEALTH and ILLNESS beliefs
regarding the causation of ILLNESS differ from those of the modern epidemiological
model. In modern epidemiology, we speak of viruses, germs, and other pathogens as the
causative agents. In “traditional” epidemiology, factors such as the “evil eye,” envy, hate,
and jealousy may be the agents of ILLNESS.
ILLNESS is most often attributed to the evil eye. The evil eye is primarily a belief
that someone can project harm by gazing or staring at another’s property or+person
(Maloney, 1976, p. 14). The belief in the evil eye is probably the oldest and most
widespread of all superstitions, and it is found to exist in many parts of the world, such as
southern Europe, the Middle East, and North Africa. The evil eye is thought by some to
be merely a superstition, but what is seen by one person as superstition may well be seen
by another as religion. Various evil-eye beliefs were carried to this country by immigrant
populations. These beliefs have persisted and may be quite strong among newer
immigrants and heritage-consistent peoples.
Among Germans, the evil eye is known as aberglobin or aberglaubisch, and it
causes preventable problems, such as evil, harm, and illness/ILLNESS. Among the
Polish, the evil eye is known as szatan, literally, “Satan.” Some “evil spirits” are equated
with the devil and can be warded off by praying to a patron saint or guardian angel.
Szatan also is averted by prayer and repentance and the wearing of medals and scapulars.
These serve as reminders of the “Blessed Mother and the Patrons in Heaven” and protect
the wearer from harm. The evil eye is known in Yiddish as kayn aynhoreh. The
expression kineahora is recited by Jews after a compliment or when a statement of luck is
made to prevent the casting of an evil spell on another’s health/HEALTH. Often, the
speaker spits three times after uttering the word.
ILLNESS also can be attributed to people who have the ability to make others
ILL—for example, witches and practitioners of voodoo. The ailing person attempts to
avoid these people to prevent ILLNESS and to identify them as part of the treatment.
Other “agents” to be avoided are “envy,” “hate,” and “jealousy.” A person may practice
prevention by avoiding situations that could provoke the envy, hate, or jealousy of a
friend, an acquaintance, or a neighbor. The evil-eye belief contributes to this avoidance.
Another source of evil can be of human origin and occurs when a person is temporarily
controlled by a soul not his or her own. In the Jewish tradition, this controlling spirit is
known as dybbuk. The word comes from the Hebrew word meaning “cleaving” or
“holding fast.” A dybbuk is portrayed as a “wandering, disembodied soul which enters
another person’s body and holds fast”.
Amulets are sacred objects, such as charms, worn on a string or chain around the
neck, wrist, or waist to protect the wearer from the evil eye or the evil spirits that could
be transmitted from one person to another or have supernatural origins. For example, the
mano milagroso (miraculous hand) (Figure 5–7) is worn by many people of Mexican
origin for luck and the prevention of evil. A mano negro (black hand) (Figure 5–8) is
placed on babies of Puerto Rican descent to ward off the evil eye. The mano negro is
placed on the baby’s wrist on a chain or pinned to the diaper or shirt and is worn
throughout the early years of life. Amulets may also be written documents on parchment
scrolls, and these are hung in the home. Figure 5–9 is an example of a written amulet
acquired in+Jerusalem. It is hung in the home or workplace to protect the person, family,
or business from the evil eye, famine, storms, diseases, and countless other dangers.
Table 5–1 describes several practices found among selected ethnic groups to protect
themselves from or to ward off the evil eye.
The second practice uses diet to protect HEALTH and consists of many different
observances. People from many ethnic backgrounds eat raw garlic or onions in an effort
to prevent ILLNESS. Garlic or onions also may be worn on the body or hung in the
Italian, Greek, or Native American home. Chachayotel (Figure 5–13), a seed, may be tied
around the waist by a Mexican person to prevent arthritic pain. Among traditional
Chinese people, thousandyear-old eggs are eaten with rice to keep the body HEALTHY
and to prevent ILLNESS. The ginseng root is the most famous of Chinese medicines. It
has universal medicinal applications and is used preventively to “build the blood,”
especially after childbirth. Tradition states that, the more the root looks like a man, the
more effective it is. Ginseng is also native to the United States and is used in this country
as a restorative tonic.
A third traditional approach toward HEALTH protection centers, in part, on
religion. The words spirituality and religion are frequently used synonymously, but they
are not the same. Spirituality connotes the way we orient ourselves toward the Divine, the
way we make meaning out of our lives, the recognition of the presence of Spirit (breath)
within us, a cultivation of a lifestyle consistent with this presence, and a perspective to
foster purpose, meaning, and direction to life. It may find expression through religion, or
religion may be a tool for finding one’s spirit.
Religion is embedded in the life of many heritage-consistent traditional people in
countless ways. For example, the religion’s calendar gives order to people’s lives by
defining holidays in their season. A religion has sacred objects, spaces, and times;
stipulates practices, such as dietary and wardrobe; teaches the rituals surrounding
conception, pregnancy, birth, and the child’s early life; and instructs how to bring babies
into the world, and how to care for and remember the dead. It may also, in many cases,
instruct how to protect ourselves from the envy of others and/ or the evil eye (Leontis, A.
2009, p. 32). It strongly affects the way people choose to protect HEALTH, and it plays a
strong role in the rituals associated with HEALTH protection. It dictates social, moral,
and dietary practices that are designed to keep a person in balance. Many people believe
that ILLNESS and evil are prevented by strict adherence to religious codes, morals, and
practices. They view ILLNESS as a punishment for breaking a+religious code. For
example, I once interviewed a woman who believed she had+cancer because God was
punishing her for stealing money when she was a child. An example of a protective
religious figure is the Virgin of Guadalupe (Figure 5–15), the patron saint of Mexico,
who is pictured on medals that people wear or in pictures or icons hung in the home. She
is believed to protect the person and home from evil and harm, and she serves as a figure
of hope.
HEALTH restoration in the physical sense can be accomplished by the use of
countless traditional remedies, such as herbal teas, liniments, special foods and food
combinations, massage, and other activities. The restoration of HEALTH in the mental
domain may be accomplished by the use of various techniques, such as performing
exorcism, calling on traditional healers, using teas or massage, and seeking family and
community support. The restoration of HEALTH in the spiritual sense can be
accomplished by healing rituals; religious healing rituals; or the use of symbols and
prayer, meditation, special prayers, and exorcism.
D. Health Care Choices
There are countless ways to describe and label health/HEALTH care beliefs,
practices, and systems. “Health care” may be labeled as “modern,” “conventional,”
“traditional,” “alternative,” “complementary,” “allopathic,” “homeopathic,” “folk,” and
so forth. The use of the word traditional to describe “modern health care” is, by
definition, a misnomer. Traditional connotes a tradition—“The passing down of elements
of a culture from generation to generation, especially by oral communication: cultural
practices that are preserved by tradition,” or “A mode of thought or behavior followed by
a people continuously from generation to generation; a custom or usage”.
As stated earlier, in nearly every situation when a person becomes ill there is an
expectation for the restoration of health/HEALTH, and the person usually recovers. As
far back as historians and interested social scientists can trace in the extended history of
humankind, the phenomenon of recovery has occurred. It made little difference what
mode of treatment was used; health/HEALTH restoration was usual and expected.
Established cultural norms have been attributed to the recovery from illness, and over
time the successful methods for treating various maladies were preserved and passed
down to each new generation within a traditional ethnocultural community. It is the
occurrence of natural recovery that has given rise to all forms of therapeutic treatments,
and the attempts to explain a phenomenon that is natural. Over the generations, natural
recovery has been attributed to all sorts of rituals, including cupping, magic, leeching,
and bleeding. Today, the people who are members of many different native, immigrant,
and traditional cultural communities in the United States—American Indian, Black,
Asian, European, and Hispanic—may continue to utilize the practices found within their
tradition.
Folk medicine today is related to other types of medicine that are practiced in our
society. It has coexisted, with increasing tensions, alongside modern medicine and was
derived from academic medicine of earlier generations. There is ample evidence that the
folk practices of ancient times have been abandoned only in part by modern health care
belief systems, for many of these beliefs and practices continue to be observed today.
Natural folk medicine has been widely practiced in the United States and
throughout the world. In general, this form of prevention and treatment is found in old-
fashioned remedies and household medicines. These remedies have been passed down for
generations, and many are in common use today. Much folk medicine is herbal, and the
customs and rituals related to the use of the herbs vary among ethnic groups. Specific
knowledge and usages are addressed throughout this text. Commonly, across cultures, the
herbs are found in nature and are used by humans as a source of therapy, although how
these medicines are gathered and specific modes of use vary from group to group and
place to place. In general, folk medical traditions prescribed the time of year in which the
herb was to be picked; how it was to be dried; how it was to be prepared; the method,
amount, and frequency of taking; and so forth.
The use of natural products, such as wild herbs and berries, accessible to healers
developed into today’s science of pharmacology. Early humankind had a wealth of
knowledge about the medicinal properties of the plants, trees, and fungi in their
environment. They knew how to prepare concoctions from the bark and roots of trees and
from berries and wildflowers. Countless herbal preparations that were used many
generations ago are in popular use today. Examples include purple foxglove, which
contains the cardiotonic digitalis, that was used for centuries to slow the heart rate and
feverfew, used to treat headaches.
The magico-religious form of folk medicine has existed for as long as humans
have sought to maintain, protect, and/or restore their HEALTH. It has now, in this
modern age of science and technology, come to be labeled by some as “superstition,”
“old-fashioned nonsense,” or “foolishness,” yet for believers it may go so far on the
continuum as to take the form of religious practices related to HEALTH maintenance,
protection, restoration, and healing. Chapter 6 addresses these belief systems in more
detail.
E. Health Care Philosophies
Two distinctly different health/HEALTH care philosophies determine the scope
of health/HEALTH beliefs and practices: dualistic and holistic. Each of these
philosophies espouses effective methods of maintaining, protecting, and restoring
health/HEALTH, and the “battles for dominance” between the allopathic and
homeopathic philosophies have been hard fought in this country (Starr, 1982) over the
past century. One manifestation of these struggles is an emerging preference for
homeopathic or holistic, complementary or alternative medicine among people from all
walks of life.
The Allopathic (Dualistic) Philosophy, the dominant health care system in the
United States is predicated on the allopathic philosophy. The word allopathy has two
roots. One comes from the Greek meaning “other than disease” because drugs are
prescribed on a basis that has no consistent or logical relationship to the symptoms. The
second root of allopathy is derived from the German meaning “all therapies.” Allopathy
is a “system of medicine that embraces all methods of proven, that is, empirical science
and scientific methodology is used to prove the value in the treatment of diseases” (Weil,
1983, p. 17). After 1855, the American Medical Association (AMA) adopted the “all
therapies” definition of allopathy and has exclusively determined who can practice
medicine in the United States. For example, in the 1860s the AMA refused to admit
women doctors to medical societies, practiced segregation, and demanded the purging of
homeopaths. Today, allopaths may show little or limited tolerance or respect for other
providers of health care, such as homeopaths, osteopaths, and chiropractors, and for such
traditional healers as lay midwives, herbalists, and American Indian medicine men and
women.
Homeopathy, or homoeopathy, comes from the Greek words homoios (“similar”)
and pathos (“suffering”). In the practice of homeopathy, the person, not the disease, is
treated (Starr, 1982). This system has not been “tolerated” by the allopaths, yet it
continues to thrive and is used by countless people. It espouses a holistic philosophy—
that is, it sees health as a balance of the physical, mental, and spiritual whole.
Homeopathic care encompasses a wide range of health care practices and is often referred
to as “complementary medicine” or “alternative medicine.” Complementary, alternative,
unconventional, or unorthodox therapies are medical practices that do not conform to the
scientific standards set by the allopathic medical community; they are not taught widely
in the medical and nursing communities and are not generally available in the allopathic
health care system, including the hospital settings. These include such therapies as
acupuncture, massage therapy, and chiropractic medicine. Presently, this situation is
changing, and the use of services such as acupuncture is more widespread in modern
health care settings.
The period from 1870 through 1930 was when the allopathic health care model as
we know it today was established. During the time that the roots of this system of health
care were becoming firmly established, the ideas of the eclectic and other schools of
medical thought were also prevalent. Homeopathy was popular in 19th-century America
and Europe because it was successful in treating the raging epidemics of those times. In
1900, 20% to 25% of physicians were homeopaths. Due to allopathic efforts to wipe out
the homeopaths beginning in 1906, the movement has dissipated. A small group of
homeopaths still exists in the United States, however, and there are larger practices in
India, Great Britain, France, Greece, Germany, Brazil, Argentina, and Mexico
(Homeopathic Educational Services).
Osteopathy, developed in 1874 by Dr. A. T. Still in Kirksville, Missouri, is the art
of curing without the use of surgery or drugs. Osteopathy attempts to discover and correct
all mechanical disorders in the human machine and to direct the recuperative power of
nature that is within the body to cure the disease. Osteopathy is the knowledge of the
structure, relation, and function of each part of the human body applied to the adjustment
or correction of whatever interferes with the body’s harmonious operation. As far back as
1921, George V. Webster described osteopathy as “the knowledge of the structure,
relation and function of each part of the human body applied to the adjustment or
correction of whatever interferes with the harmonious operation of the same.”
Furthermore, it claims that, if there is an unobstructed blood and nerve supply to all parts
of the body, the effects of a disease will disappear (Dolgan, 2006). According to the
American Association of Colleges of Osteopathic Medicine there are currently 26
colleges of osteopathic medicine in the United States, offering instruction at 34 locations
in 25 states, that offer the doctor of osteopathic medicine (DO) degree.
Chiropractic is a health care profession that focuses on the relationship between
the body’s structure—mainly the spine—and its functioning. It is a controversial form of
healing that has been in existence for over a century. It, too, adheres to a disease theory
and a method of therapy that differ from allopathy. It was developed as a form of healing
in 1895 in Davenport, Iowa, by a storekeeper named Daniel David Palmer, also known as
a “magnetic healer.” Palmer’s theory underlying the practice of chiropractic was that an
interference with the normal transmission of “mental impulses” between the brain and the
body organs produced diseases. The interference is caused by misalignment, or
subluxation, of the vertebrae of the spine, which decreases the flow of “vital energy”
from the brain through the nerves and spinal cord to all parts of the body. The treatment
consists of manipulation to eradicate the subluxation.
The word eclectic means “choosing,” and it refers to choosing the means for
treating disease. Methods and remedies are selected from all other systems. This school
of medicine believes that nature has curative powers, and practitioners seek to remove the
causes of disease through the natural outlets of the body. They treat the cause of disease,
rather than the symptoms, and do not use bleeding, antimony, or poisons to treat diseases.
In the late 18th century, mesmerism was a popular form of healing by touch and was
named for its founder, Friedrich Anton Mesmer. Mesmer believed that illness was a
condition in which the body and mind of a person were influenced by a mysterious force
emanating from another person. He further believed that the stars exerted an influence on
people and that this force was the same as electricity and magnetism. Initially, he
believed that stroking the body with magnets would bring about a cure for illness. He
later modified this to the belief that touch alone could heal.
The National Center for Complementary and Alternative Medicine (NCCAM) at
the National Institutes of Health was founded in 1998 and is the federal government’s
lead agency for scientific research on complementary and alternative medicine, or CAM.
The agency describes the different approaches to health care that are outside the realm of
conventional medicine as either complementary or alternative. Conventional medicine is
health care that is practiced by M.D.s or D.O.s and allied health professionals, such as
registered nurses, physical therapists, and psychologists. The NCCAM differentiates
between complementary and alternative medicine in that complementary medicine is
used together with conventional medicine. An example of a complementary therapy is
using aromatherapy to help lessen a patient’s discomfort following surgery or while
undergoing cancer therapies. Alternative medicine is used in place of conventional
medicine. An example of an alternative therapy is using a special diet or medication to
treat cancer instead of undergoing the surgery, radiation, or chemotherapy that has been
recommended by a conventional doctor. The list of what is considered to be CAM
changes continually, as the therapies that are proven to be safe and effective become
adopted into conventional health care and as new approaches to health care emerge.
Since 1990, Eisenberg and colleagues have studied the trends in the use of
alternative medicine in the United States. They reported the results of a national survey of
1,539 subjects in 1993 and reported the findings of a 1997 survey in 1998. They found in
1991 that about a third of all American adults use some form of unconventional medical
treatment; this number rose to 42.1% in 1997. A more recent study, in May 2004, CAM
Use in America: Up Close, found that, in the United States, 40% of adults are using some
form of CAM. The most frequent users in both the early studies were educated, upper-
income White Americans in the 25–49 age group who were most likely to live on the
West Coast. CAM use presently spans people of all backgrounds. However, according to
the 2004 survey, some people are more likely than others to use CAM. Countless
research studies regarding the use, efficacy, and costs of CAM are ongoing.
It is difficult to sort out which aspects of complementary and traditional medicine
have merit and which are a hoax. From the viewpoint of the patient, if he or she has faith
in the efficacy of an herb, a diet, a pill, or a healer, it is not a hoax. From the viewpoint of
the medical establishment, jealous of its territorial claim, the same herb, diet, pill, or
healer is indeed a hoax if it is “scientifically” ineffective and prevents the person from
using the method of treatment the physician-healer or other health care provider believes
is effective. The tensions between allopathic and homeopathic philosophies have been
going on since the late 19th century. In this chapter, we have explored traditional ways of
maintaining, protecting, and restoring HEALTH; the choices available to patients; and
health/HEALTH care philosophies
F. Ancient Forms of Healing
The professional history of nursing was born with Florence Nightingale’s
knowledge (1860) that “nature heals.” In more recent times, Blattner (1981) has written a
text designed to help nurses assist patients in upgrading their lives in a holistic sense and
in healing the person—body, mind, and spirit. Krieger (1979), in The Therapeutic Touch,
has developed a method for teaching nurses how to use their hands to heal. Wallace
(1979) has described methods of helping nurses diagnose and deliver spiritual care. She
points out that the word spiritual is often used synonymously with religion but that the
terms are not the same. If they are used synonymously as a basis for the health care and
nursing assessment of needs, some of the patient’s deepest needs may be glossed over.
Spiritual care implies a much broader grasp of the search for meanings that goes on
within every human life. In addition to answers to these questions from nursing raised in
the introduction to this chapter, one is able to explore the concept from the classical and
historical viewpoints of anthropology, sociology, psychology, and religion.
From the fields of anthropology and sociology come texts that describe rituals,
customs, beliefs, and practices that surround healing. Shaw (1975, p.+121) contends that,
“for as long as man has practiced the art of magic, he has sought to find personal
immortality through healing practices.” Buxton (1973) describes traditional beliefs and
indigenous HEALING rituals in Mandari and relates the source of these rituals with how
humans view themselves in relation to God and Earth. In this culture, the healer
experiences a religious calling to become a healer. HEALING is linked to beliefs in evil
and the removal of evil from the sick person. Naegele (1970, p. 18) describes healing in
our society as a form of “professional practice.” He asserts, however, that “healing is not
wholly a professional monopoly and that there are several forms of nonprofessional
healing such as the ‘specialized alternatives.’ ” These include Christian Science and the
marginally professional activities of varying legitimacy, such as chiropractic, folk
medicine, and quackery. He states: “To understand modern society is to understand the
tension between traditional patterns and self- conscious rational calculations devoted to
the mastery of everyday life.”
ILLNESS was considered to be a crisis, and the people of ancient times developed
elaborate systems of HEALING. The cause of an ILLNESS was attributed to the forces
of evil, which originated either within or outside the body. Early forms of HEALING
dealt with the removal of evil. Once a method of treatment was found effective, it was
passed down through the generations in slightly altered forms. If the source of sickness-
causing evil was within the body, treatment involved drawing the evil out of the body.
This may have been accomplished through the use of purgatives, which caused either
vomiting or diarrhea, or by blood-letting: “bleeding” the patient or “sucking out” blood.
(The barbers of medieval Europe did not originate this practice; bleeding was done in
ancient times.) Leeching was another method used to remove corrupt humors from the
body.
Various rituals were involved in the treatment of ILL people. Often, the sick
person was isolated from the rest of the family and community. In addition, it was
customary to chant special prayers and incantations on the invalid’s behalf. Sacrifices and
dances often were performed in an effort to cure the ILLS. Often, the rituals of the healer
involved reciting incantations in a language foreign to the ears of the general population
(“speaking in tongues”) and using practices that were strange to the observers. Small
wonder, then, as superstition abounded, that at times the healers themselves were
ostracized by the population.
G. Religion and Healing
Religion plays a vital role in one’s perception of HEALTH and ILLNESS. Just as
culture and ethnicity are strong determinants in an individual’s interpretation of the
environment and the events within the environment, so, too, is religion. In fact, it is often
difficult to distinguish between those aspects of a person’s belief system arising from a
religious background and those that stem from an ethnic and cultural heritage. Some
people may share an ethnicity yet be of different religions; a group of people can share a
religion yet have a variety of ethnic and cultural backgrounds. It is never safe to assume
that all individuals of a given ethnic group practice or believe in the same religion. The
point was embarrassingly driven home when I once asked a Mexican-American woman if
she would like me to call the priest for her while her young son was awaiting a critical
operation. The woman became angry with me. I could not understand why until I learned
that she was a Methodist and not a Catholic. I had made an assumption, and I was wrong.
She later told me that not all Chicanos are Catholic. After many years of hearing people
make this assumption, she had learned to react with anger.
Religion strongly affects the way people interpret and respond to the signs and
symptoms of ILLNESS. So pervasive is religion that the diets of many people are
determined by their religious beliefs. Religion and the piety of a person determine not
only the role that faith plays in the process of recovery but also in many instances the
response to a given treatment and to the HEALING process. Each of these threads—
religion, ethnicity, and culture—is woven into the fabric of each person’s response to
treatment and HEALING. There are far too many religious beliefs and practices related to
HEALING to include in this chapter. An introductory discussion of religious HEALING
beliefs from the Judeo-Christian background, however, is possible.
There are countless places in the United States and in this world where people
make spiritual journeys, or pilgrimages, for the purpose of giving thanks or petitioning
for favors. The shrines are related to magico-religious folk medicine and the use of
charms, holy words, and holy actions. For example, at many shrines petitioners leave
amulets or written petitions or light candles. Shrines range from small memorials—such
as shrines that are created at the sites where accidents have occurred and people were
killed to large, famous shrines where people who are part of a given religious tradition or
a follower of a given healer may go to pray or petition at the site. In the United States,
and throughout the world, people make pilgrimages to a number of shrines in search of
special favors and HEALING. Shrines are not limited to any one-faith tradition, and they
can be secular as well as religious. Over the years, I have visited many sacred shrines and
have learned that they are indeed extraordinary places. The essentials that each of the
shrines has in common are a feeling of peacefulness and serenity to the visitor; a calm,
soothing atmosphere; and a place where petitions and/or objects are left when petitions
for HEALING are made; or prayers have been answered, and people leave objects in
gratitude. Most, but not all, have a source of water as part of the milieu, and it is a part of
the tradition to take home water from the shrine.
The Shrine of St. Peregrine for cancer sufferers (Figure 6–8) is located in the Old
Mission San Juan Capistrano in California. This statue is housed in a small grotto in the
shrine. St. Peregrine was born in Italy in 1265 and died in 1345. He was believed to have
miraculous powers against sickness and could cure cancer. This won for him the title
“official patron for cancer victims.” Once a woman was afflicted with cancer and a lady
gave her a prayer to St. Peregrine. The woman prayed for 6 months, and her cancer was
arrested. In gratitude for this, the woman had a statue of the saint placed in the mission.
Today, the belief in this saint has spread, and countless documents attesting to his healing
powers are on display in the mission.
Chimayo, New Mexico, is the home of the Shrine of our Lord of Esquipulas. The
shrine was built between 1814 and 1816 and is visited by thousands of people each year.
The shrine has been called the “Lourdes of America,” and countless healings have been
reported in this location (Figure 6–9). There is a hole in the shrine, and it is believed that
eating the mud from this hole will cure many illnesses. The mud may also be mixed with
water and rubbed on the+body+(Informational brochure, n.d.). The National Shrine of Our
Lady of the Snows (Figure 6–10) is located in Belleville, Illinois. It is a site that provides
an atmosphere where people of all faiths have the opportunity to pray for HEALING and
hope. There are numerous locations where petitions may be placed.
One example of a present day petition is the following: “Enagradecimiento por
devolver la vida a neustro sobrino, I. G. R. 14-9-01”; this translates to “Praise (or
exaltation) for returning the life of our nephew.” This brief note was found at the shrine.
The immediate image was that of a couple making the difficult pilgrimage to Montserrat
and placing this petition there. Note that the date is September 14, 2001—3 days after the
attacks on the United States. Could it be that this person, the nephew, survived the attack
on either the Pentagon or the+World Trade Center? Could it be that the family sought and
found a way to express their gratitude? The journey to Montserrat is difficult; the image
this note evoked was one of sacrifice and homage.
Believers combine elements of traditional Catholicism, Indian dances, herbology,
and laying on of hands in effecting cures. It is believed that certain individuals receive the
Niño’s power to heal. They are called Cajitas or Materias (women) and Cajones (men)
—“receptacles” of the Niño’s power—and they cure in the name of Niño Fidencio and
God. During the celebrations, they roam Espinazo curing all who wish a cure-blessing.
There are several holy places in Espinazo where curing is conducted: Fidencio’s tomb,
temple, and deathbed; 2 trees; a cemetery hill; the hill of the bell; and the “charco” or
mudpond, where Fidencio conducted baptisms to cure his patients. The pilgrimage to
Espinazo has increased in popularity over recent years and extensive studies have been
conducted in Espinazo.
H. Healing and Today’s Belief
It is not an accident or a coincidence that today, more so than in recent years, we
are not only curious but vitally concerned about the ways of HEALING that our ancestors
employed. Some critics of today’s health care system choose to condemn it, with more
vociferous critics, such as Illich (1975), citing its failure to create a utopia for humankind.
It is obvious to those who embrace a more moderate viewpoint that diseases continue to
occur and that they outflank our ability to cure or prevent them. Once again, many people
are seeking the services of people who are knowledgeable in the arts of HEALING and
folk medicine. Many patients may elect, at some point in their lives, more specifically
during an ILLNESS, to use modalities outside the medical establishment. It is important
to understand the HEALERS.
When a person is suffering from a disease or has been involved in an accident that
resulted in some form of bodily damage, physical HEALING is appropriate. Laying on of
hands and speaking in tongues usually accompany physical HEALING. The person is
prayed over by both the leader and members of a prayer group. When the body and mind
are victims of evil from the outside, exorcism is used. In order to effect treatment, the
person must be delivered, or exorcised, from the evil. The ongoing popularity of films
such as The Exorcist gives testimony to the return of these beliefs. Incidentally, the priest
who has lectured in my classes stated that he does not, as yet, lend credence to exorcisms;
however, he was guarded enough not to discount it, either.
The people who HEAL, both in the past and in the present, often have been those
who received the gift of HEALING from a “divine” source. Many receive this gift in a
vision and have been unable to explain to others how they know what to do. Other
HEALERS learned their skills from their parents. Most of the HEALERS with acquired
skills are women, who subsequently pass their knowledge on to their daughters. People
who use herbs and other preparations to remove the evil from the sick person’s body are
known as herbalists. Other HEALERS include bone setters and midwives, and although
early humankind did not separate ILLS of the body from those of the mind, some
HEALERS were more adept at solving problems by using early forms of
“psychotherapy.”
I. Ancient Rituals Related to The Life Cycle
Today, just as it did in antiquity, religion also plays a role in the rites surrounding
both birth and death. Many of the rituals that we observe at the time of birth and death
have their origins in the practices of ancient human beings. Close your eyes for a few
moments and picture yourself living thousands and thousands of years ago. There is no
electricity, no running water, no bathroom, and no plumbing. The nights are dark and
cold. The only signs of the passage of time are the changing seasons and the apparent
movement of the various planets and stars through the heavens. You are prey to all the
elements, as well as to animals and the unknown. How do you survive? What sort of
rituals and practices assist you in maintaining your equilibrium within this often hostile
environment? It is from this milieu that many of today’s practices sprang.
In the minds of early human beings, the number of evil spirits far exceeded the
number of good spirits, and a great deal of energy and time was devoted to thwarting
these spirits. They could be defeated by the use of gifts or rituals or, when the evil spirits
had to be removed from a person’s body, with redemptive sacrifices. Once these evil
spirits were expelled, they were prevented from returning by various magical ceremonies
and rites. When a ceremony and an incantation were found to be effective, they were
passed on through the generations. It has been suggested and supported by scholars that,
from this primitive beginning, organized religion came into being. Today, many of the
early rites have survived in altered forms, and we continue to practice them.
The power of the evil spirits was believed to endure for a certain length of time.
The 3rd, 7th, and 40th days were the crucial days in the early life of a child and the new
mother. Hence, it was on these days, or on the 8th day, that most of the rituals were
observed. It was believed that, during this period, the newborn and the mother were at the
greatest risk from the power of supernatural beings and thus in a taboo state. “The
concept underlying taboo is that all things created by or emanating from a supernatural
being are his, or are at least in his power” (Morgenstern, 1966, p. 31). The person was
freed from this taboo by certain rituals, depending on the practices of a given community.
When the various rites were completed and the 40 days were over, both the mother and
child were believed to be redeemed from evil. The ceremonies that freed the person had a
double character: They were partly magic and partly religious.
The birth of a male child was considered more significant than that of a female,
and many rites were practiced in observance of this event. One ritual sacrifice was cutting
off a lock of the child’s hair and then sprinkling his forehead with sheep’s blood. This
ritual was performed on the eighth day of life and may be practiced today among
Muslims. In other Semitic countries, when a child was named, a sheep was sacrificed and
asked to give protection to the infant. Depending on regional or tribal differences, the
mother might be given parts of the sheep. It was believed that, if this sacrificial ritual was
not performed on the seventh or eighth day of life, the child would die (Morgenstern,
1966, p. 87). The sheep’s skin was saved, dried, and placed in the child’s bed for 3 or 4
years as protection from evil spirits. The practice of cutting a lock of a child’s hair and
the sacrifice of an animal served as a ceremony of redemption. The child could also be
redeemed from the taboo state by giving silver—the weight of which equaled the weight
of the hair—to the poor. Although not universally practiced, these rites are still observed
in some form in some communities of the Muslim world.
The ceremony of baptism is also rooted in the past. It, too, symbolically expels
the evil spirits, removes the taboo, and is redemptive. It is practiced mainly among
members of the Christian faith, but the Yezidis and other nonChristian sects also perform
the rite. Water was thought to possess magical powers and was used to cleanse the body
from both physical and spiritual maladies, which included evil possession and other
impurities. Usually, the child was baptized on the 40th day of life. In some communities,
however, the child was baptized on the eighth day. The 40th (or eighth) day was chosen
because the ancients believed that, given performance of the particular ritual, this day
marked the end of the evil spirits’ influence.
Early human beings, in their quest for survival, strove to appease and prevent the
evil spirits from interfering with their lives. Their beliefs seem simple and naive, yet the
rituals that began in those years have evolved into those that exist today. Attacks of the
evil spirits were warded off with the use of amulets, charms, and the like. People recited
prayers and incantations. Because survival was predicated on people’s ability to appease
evil spirits, the prescribed rituals were performed with great care and respect.
Undoubtedly, this accounts in part for the longevity of many of these practices through
the ages. For example, circumcision and baptism still exist, even when the belief that they
are being performed to release the child from a state of being taboo may not continue to
be held. It is interesting also that adherence to a certain timetable is maintained. For
example, as stated, the Jewish religion mandates that the ritual of circumcision be
performed on the eighth day of life as commanded by Jewish law in the Bible.
It was believed that the work of evil spirits and the duration of their evil—
whether it was 7 or 40 days—surrounded the person, family, and community at the time
of and after death. Rites evolved to protect both dying and dead persons and the
remaining family from these evil spirits. The dying person was cared for in specific ways
(ritual washing), and the grave was prepared in set ways (storing food and water for the
journey after death). Further, rituals were performed to protect the deceased’s survivors
from the harm believed to be rendered by the deceased’s ghost. It was believed that this
ghost could return from the grave and, if not carefully appeased, harm surviving relatives.
There are several areas in which there is an intersection of HEALTH, HEALING,
and RELIGION. The following are examples of additional spiritual/religious factors that
link with the myriad of facets that have been described earlier in this chapter and in
Chapter 5. One’s religious affiliation may be seen as providing many links in a complex
chain of life events. Religious affiliation frequently provides a background for a person
regarding HEALTHY behavior and contributes to HEALTH. Participation in religious
practices provides social support and this in turn brings HEALTH. In addition, religious
worship may create positive emotions; this, too, contributes to HEALTH.
J. Family Health Traditions
There is an extremely rich tradition in the United States related to selfcare. This
includes the early use of patent medicines. Throughout most of their history, patent
medicines enjoyed a free existence and were very popular with the people of the times.
Some of the most popular medicines of the early 20th century contained alcohol; others
contained opium and cocaine. This increased their popularity, and the practice continued
until passage of the Food, Drug, and Cosmetic Act of 1938. Today, as our lives become
more complex and the health care system becomes more complicated, costly, and
difficult to access, we see a return to self-care and an increasing use of traditional and
homeopathic health care systems.
We are now ready for a transition, and it is time to resume climbing the steps to
CULTURALCOMPETENCY. The foundation—a discussion of heritage, an overview of
demographic issues, an exploration of terms such as health and illness, and a discussion
of HEALTH and ILLNESS as they relate to religion and spirituality—has been presented
and what remains is the ascent! It has been mentioned earlier in this text that the first step
for developing CULTURALCOMPETENCY is to know yourself, your heritage, and the
health/HEALTH and illness/ILLNESS beliefs and practices derived from your heritage—
ethnic, religious, or both. It was pointed out in Chapters 5 and 6 that many daily
HEALTH practices have their origins in one’s heritage, yet may not be thought of in this
context.
There are 2 reasons for exploring your familial heritage. First, it draws your
attention to your ethnocultural and religious heritage and HEALTH-related belief system.
Many of your daily habits relate to early socialization practices that are passed on by
parents or additional significant others. Many behaviors are both subconscious and
habitual, and much of what you believe and practice is passed on in this manner. By
digging into the past, remote and recent, you can recall some of the rituals you observed
either your parents or your grandparents perform. You are then better able to realize their
origin and significance. There are many beliefs and practices that are ethnically similar,
and socialization patterns may tend to be similar among ethnic groups as well. Religion
also plays a role in the perception of, interpretation of, and behavior in health/HEALTH
and illness/ILLNESS.
The maternal side is ideal for your interview because, in today’s society of
interethnic, interracial, and interreligious marriages and complex family structures, it is
assumed that the ethnic beliefs and practices related to health/HEALTH and
illness/ILLNESS of the family may be more in tune with the mother’s family than with
the father’s. By and large, family nurturance and health/HEALTH maintenance,
protection, and/or restoration have been the domain of women in most cultures and
societies. The mother tends to be the gate-keeper—the person within a family who cares
for family members when illness/ILLNESS occurs. She also tends to be the prime mover
in protecting health/HEALTH and seeking health/HEALTH care. It is the mother who
tells the child what and how much to eat and drink, when to go to bed, and how to dress
in inclement weather. She shares her knowledge and experience with her offspring, but
usually the daughter is singled out for such experiential sharing. However, this is not a
“universal” circumstance, and in many family heritages it is the father who is the family
caregiver. If that is true for your family, it is your paternal family whom you must
interview. Given the complex familial changes and social changes related to family life, it
behooves you to question both your maternal and your paternal relatives.
The second reason for this examination of familial health/HEALTH practices is to
sensitize you to the role your ethnocultural and religious heritage has played. You must
reanalyze the concepts of health/HEALTH and illness/ILLNESS and view your own
definitions from another perspective. If your familial background is presented in a class
or another group setting, the peer group is able to see the people in a different light. A
group observes similarities and differences among its members. You discover peer beliefs
and practices that you originally had no idea existed. You may then be able to identify the
“why” behind many daily health/HEALTH habits, practices, and beliefs in your family.
K. Consciousness Raising
In my experience, as discussion continues, people realize that many personal
beliefs and practices do, in fact, differ from what they are being taught in nursing or
medical education to accept as the right way of doing things. Participants begin to admit
that they do not seek medical care when the first symptoms of illness appear. On the
contrary, they usually delay seeking care and often elect to self-treat at home. They also
recognize that there are many preventive and health maintenance acts learned in school
with which they choose not to observe. Sometimes, they discover that they are following
self-imposed regimen for health-related problems and are not seeking any outside
intervention.
Another facet of a group discussion is the participants’ exposure to the similarities
that exist among them in terms of HEALTH maintenance and protection. To their
surprise and delight, they find that many of their daily acts— routines they take for
granted—directly relate to methods of maintaining and protecting HEALTH. As is
common in most large groups, students seem to be shy at the beginning of this
exploration. As more and more members of the group are willing to share their
experiences, however, other students feel more comfortable and share more readily. A
classroom tactic I have used to break the ice is to reveal an experience I had on the birth
of my first child. My mother-in-law, an immigrant from Eastern Europe, drew a circle
around the child’s crib with her fingers and spat on the baby 3 times to prevent the evil
spirits from harming him. Once such an anecdote is shared, other participants have less
difficulty in remembering similar events that took place in their own homes.
The effects of such a verbal catharsis are long remembered and often quoted or
referred to throughout the remainder of a course. The awareness we gain helps us
understand the behavior and beliefs of patients and, for that matter, other people better.
Given this understanding, we are comfortable enough to ask patients how they interpret a
symptom and how they think it ought to be treated. We begin to be more sensitive to
people who delay in seeking health care or fail to comply with preventive measures and
treatment regimens. We come to recognize that we do the same thing. The increased
familiarity with home health/HEALTH practices and remedies helps us project this
awareness and understanding to the patients who are served.
In this day of computers and sophisticated medicine, including transplants,
cloning, and intricate surgery, the most prevalent need expressed by people who practice
traditional medicine is to protect people and prevent “evil” from harming them or to
remove the “evil” that may be the cause of their HEALTH problem. As students, we
analyze and discuss a problem and its traditional treatments and we begin to see how evil
continues to be considered the cause of ILLNESS and how often the treatment is then
designed to remove it.
The goal of this kind of consciousness-raising session is to reawaken the
participant to the types of health/HEALTH practices within her or his own family. The
other purpose of the sharing is to make known the similarities and differences that exist
as part of a cross-ethnocultural and religious phenomenon. We are intrigued to discover
the wide range of beliefs that exists among our peers’ families. We had assumed that
people thought and believed as we did. For the first time, we individually and collectively
realize that we all practice a certain amount of traditional medicine, that we all have
ethnocultural-specific ways of treating ILLNESS, and that we, too, often delay in seeking
professional health care. We learn that most people prefer to treat themselves at home
and that they have their own ways of treating a particular set of symptoms—with or
without a prescribed medical regimen. The previously held notion that “everybody does it
this way” is shattered. The greatest challenge in this activity is to encourage students and
others to think of HEALTH, rather than simply health. This exercise brings you to the
window on the glass door pictured in the introduction.
L. The Health Care Provider’s Culture
The providers of health care—nurses; physicians; social workers; dietitians;
physical, occupational, respiratory, and speech therapists; and laboratory and
departmental professionals—are socialized into the culture of their profession.
Professional socialization teaches the student a set of beliefs, practices, habits, likes,
dislikes, norms, and rituals. Each of the professional disciplines has its own language and
objects, rituals, garments, and myths, which become an inherent part of the scope of
students’ education, socialization, and practice. The providers view time in their own
ways, and they believe that their view of a health and illness situation and subsequent
interventions are the only possible answers to the complex questions surrounding a
health-related event. This newly learned information regarding health and illness differs
in varying degrees from that of the individual’s heritage.
As students become more and more immersed and knowledgeable in the scientific
and technological domains, they usually move further and further from their past belief
systems and, indeed, further from the population at large in terms of its understanding
and beliefs regarding health/HEALTH and illness/ILLNESS. Just as it is not unusual to
hear providers say, “Etoh, bid, tid, im, iv,” and so forth, it is not uncommon to hear
patients say things such as “I have no idea what the nurses and doctors are saying!”
“They speak a foreign language!” “What they are doing is so strange to me.” In addition,
there exists an underlying cultural norm among health care providers that “all must be
done to save a patient, regardless of the patient’s and family’s wishes” and regardless of
the financial consequences to the patient and family, to the health care system, or to
society in general. A consequence of this philosophy has been the rise of iatrogenic
health problems and the escalation of out-of-control health care costs.
As a result, health care providers can be viewed as an alien or foreign culture or
ethnic group. They have a social and cultural system; they experience “ethnicity” in the
way they perceive themselves in relation to the health care consumer and often each
other. Even if they deny the reality of the situation, health care providers must understand
that they are ethnocentric. Not only are they ethnocentric, but also many of them are
xenophobic. To appreciate this critical issue, consider the following.
A principal reason for the difficulty experienced between the health care provider
and the consumer is that health care providers, in general, adhere rigidly to the modern
allopathic, or Western, system of health care delivery. (These terms may be used
interchangeably to describe health care.) With few exceptions, they do not publicly
sanction any methods of protection or healing other than scientifically proved ones. They
ordinarily fail to recognize or use any sources of medication other than those that have
been deemed effective by scientific means. The only types of healers that are sanctioned
are those that have been educated, licensed, and certified according to the requirements of
this culture.
M. Health Care Costs
The American health care system is both a source of national pride—if one has an
expensive and adequate health insurance package or the money, it certainly is possible to
get the finest medical/technological care in the world—and a source of deep
embarrassment—those who are poor or uninsured may be wanting for care as people with
a low family income, do not have consistent health insurance. According to Kinney, “the
elephant in the room when it comes to healthcare is its cost.”
The sources for paying for care in 1960 were primarily personal, out of pocket or
private insurance; Medicare and Medicaid did not yet exist until 1965. It is obvious that
they now make over 50% of health care expenditures possible— coverage shifted from
the private sector to the public sector and is presently shifting back to the private sector.
Technology has exploded, the costs of health care have soared, and many of the health
care-related programs are seen as “entitlements.” The costs of services are blindly
covered and quite often it is impossible for a patient to get an itemized bill, yet, when
people get them, they are astonished at the costs but state, “My insurance covers it and it
costs me nothing.” However, for more and more people the costs of heath care have
become so high that their health insurance companies either disallow desired procedures
or stop payments after a certain amount is reached. Families are left bankrupt in many
instances or finding it necessary to choose between care or financial insolvency.
It does not matter whether a person or family gets health benefits through work,
buys insurance themselves, has a small business and desire to provide health coverage to
their employees, are on Medicare, or don’t currently have insurance, the Affordable Care
Act gives a better control of decisions about health coverage.+It is designed to make
health care insurance affordable by providing small businesses with a tax credit to
provide coverage, and in 2014 it will provide tax credits to those who need help in buying
insurance. This facet represents the largest middle-class tax cut for health care in history.
The Affordable Care Act is projected to reduce premium costs for millions of families
and small business owners who are priced out of coverage today (2011). This could help
as many as 32 million Americans who have no health care receive coverage.+
During the days of the early colonists, our health care system was a system of
superstition and faith. It has evolved into a system predicated on a strong belief in
science; the epidemiological model of disease; highly developed technology; and strong
values of individuality, competition, and free enterprise. Two major forces—free
enterprise and sciences—have largely shaped the problems we now face. Health
problems have evolved from the epidemics of 1850 to the chronic diseases of today,
notwithstanding the resurgence of tuberculosis and the AIDS epidemic. In 1850, health
care technology was virtually nonexistent; today, it dominates the delivery of health care.
We now take for granted such dramatic procedures as kidney, heart, and liver transplants.
New technologies and biomedical milestones are materializing daily.
Social organizations and peer review bodies to control the use of technology did
not exist in 1850; today they proliferate, and the federal government is expected to play a
dominant role. The belief that health care is a right for all Americans is still a prominent
philosophy, yet the fulfillment of that right is still in question. The trends, begun in the
1980s and early 1990s, such as the cutbacks in federal funding for health services and the
attempt to turn the clock back on social programs have led to a diminished and denigrated
role for the government in people’s health. On the other hand, the events of September
11, 2001, have pointed out the consequences of these cuts and the enormous and
compelling need to boost public health and national security efforts.
Biologics are complex medicines that are manufactured with the use of living
organisms. The increasing use of biologics and new follow-on biologics are the cutting
edge of pharmaceutical therapies. The biogeneric market is about $2 billion. The
Biotechnology Industry Organization has stated that “the safety and effectiveness of a
chemical drug can be established by the specification of its active ingredient, but the
safety and effectiveness of a biotech product is determined by the manner in which it is
made” (Samalonis, 2004). In other words, the consequences of this pioneering medicine
will be expensive iatrogenic problems.
N. Common Problems in Health Care Delivery
Many problems exist within today’s health care delivery system. Some of these
problems affect all of us, and others are specific to the poor and to emerging majority
populations. It has been suggested that the health care delivery system fosters and
maintains a childlike dependence and depersonalized condition for the consumer. The
following sections describe problems experienced by most consumers of health care, as
categorized by Ehrenreich and Ehrenreich (1971, pp. 4–12). It is interesting to note that
this historical framework was developed in 1971, yet it holds as a framework today.
It may be difficult for even a knowledgeable consumer to receive adequate care.
One summer, I was on vacation with my 11-year-old daughter. She complained of a sore
throat for 2 days, and, when she did not improve on the third day, I decided to take her to
a pediatrician and have a throat culture taken. She was running a low-grade fever, and I
suspected a strep infection. I phoned the emergency room of a local teaching hospital for
the name of a pediatrician, but I was instructed to “bring her in.” I questioned the
practicality of using an emergency room, but the friendly voice on the other end of the
line assured me: “If you have health insurance and the child has a sore throat, this is the
best place to come.” After a rather long wait, we were seen by an intern who was
beginning his first day in pediatrics. To my dismay and chagrin, the young man appeared
to have no idea of how to proceed.
The resident entered and patiently demonstrated to the fledgling intern—using my
daughter—how to go about doing a physical examination on a child. Since I had brought
the child to the emergency room merely for a throat culture, I felt that what they were
doing was unnecessary and said so. After much delay, the throat culture was taken; we
were told we could leave and should call back in 48 hours for the report. As we left the
cubicle, we had to pass another cubicle with an open curtain—where a woman was
vomiting all over herself, the bed, and the equipment while another intern was attempting
to insert a gastric tube. Needless to say, my daughter was distressed by the sight, which
she could not help but witness. The reward for this trial was an inflated bill.
I related this personal experience to bring out two major points. First, it is not
easy to obtain what I, as a health care provider, consider to be a rather minor procedure.
Second—and perhaps more important—it was expensive! The average health care
consumer in such a circumstance may very well have no idea of what is really going on.
When health care is sought, one should have access to professionally performed
examinations and treatment. When one is seeking the results of a laboratory test, the
results should be available immediately at the agreed-on time and place instead of being
lost in a jungle of bureaucracy.
O. Pathways to Health Services
When a health problem occurs, there is an established system whereby health care
services are obtained. The classical theoretical work that was developed in the mid-1960s
and the 1970s continues to establish a viable framework for describing sources of patient
problems. Suchman (1965) contends that the family is usually the first resource. It is in
the domain of the family that the person seeks validation that what he or she is
experiencing is indeed an illness. Once the belief is validated, health care outside of the
home is sought. It is not unusual for a family to be receiving care from many different
providers, with limited or no communication among the attending caregivers. Problems
and complications erupt when a provider is not aware that other providers are caring for a
patient. Let us not forget that, in rural and remote areas, comprehensive health care is
difficult to obtain. For patients who are forced to use the clinics of a hospital, there is
certainly no continuity of care because intern and resident physicians come and go each
year. This is known as the level of first contact, or the entrance into the health care
system.
The second level of care, if needed, is found at the specialist’s level: in clinics,
private practice, or hospitals. Obstetricians, gynecologists, surgeons, neurologists, and
other specialists make up a large percentage of those who practice medicine. Recently,
hospitalists have been added. The third level of care is delivered within hospitals that
provide inpatient care and services. Care is determined by need, whether long term (as in
a psychiatric setting or rehabilitation institute) or short term (as in the acute care setting
and community hospitals).
To many students, the health care delivery problems of a given hospital unit are
far removed from the scope of practice they know from nursing school and from what
they ordinarily see in a work setting (unless they choose to work in a city or county
public hospital). Many students assume that the care they observe and deliver in a
suburban or community private hospital is the universal norm. This is a fundamental error
in experience and understanding, which can be corrected if students are assigned to visit
first the emergency room of a city hospital and then the emergency room of a suburban
hospital in order to compare the two milieus. Unless students visit each setting, they fail
to gain an appreciation of the major differences—how vastly such facilities differ in the
scope of patients’ treatment. Students typically report that, in the suburban emergency
room, the patients are called by name, their families wait with them, and every effort is
made to hasten their visit. The contrast with people in urban emergency rooms— who
have waited for extended periods of time, are sometimes not addressed by name, and are
not allowed to have family members come with them while they are examined—is
astounding. The noise and confusion are also factors that confront and dismay students
when they are exposed to big-city emergency rooms.
P. Barriers to Health Care
The people of today’s youth-oriented, cure-expecting, death-denying society have
unusually high expectations of the healers of our time. We expect a cure (or if not a cure,
then the prolongation of life) as the normal outcome of illness. The technology of modern
health care dominates our expectations of treatment, and our primary focus is on the
curative aspects of medicine, not on prevention. As control over the behavior of a person
has shifted from the family and church to a physician, “be good” has shifted to “take your
medicine.” The role that physicians play within society in terms of social control is ever-
growing, so that conflict frequently arises between medicine and the law over definitions
of accepted codes of behavior and the relative status of the 2 professions in governing
American life. Zola (1966, 1972) uses the following examples to illustrate the
“medicalization” of society.
This step is, in essence, the right to perform surgery and the right to prescribe
drugs. In the life span of human beings, modern medicine can often determine life or
death from the time of conception to old age through genetic counseling; abortion;
surgery; and technological devices, such as computers, respirators, and lifesupport
systems. Medicine has at its command drugs that can cure or kill—from antibiotics to the
chemotherapeutic agents used to combat cancer. There are drugs to cause sleep or
wakefulness, to increase or decrease the appetite, and to increase or decrease levels of
energy. There are drugs to relieve depression and stimulate interest. (In the United States,
those mood-altering drugs are consumed at a rate higher than the medications prescribed
and used to treat specific diseases.) In addition, medicine can control what medications
are available for legal consumption.
This expansion is illustrated by the use of medical jargon to describe a state of
being—such as the health of the nation or the health of the economy. Any political or
economic proposal or objective that enhances the “health” of those concerned wins
approval. There are numerous areas in which medicine, religion, and law overlap. For
example, public health practice, law, and medicine overlap in the creation of laws that
establish quarantine and the need for immunization. As another example, a child is
unable to enter school without proof of having received certain inoculations. Medicine
and law also merge in areas of sanitation and rodent and insect control. A legal-medical
dispute can arise over the guilt or innocence of a criminal as determined by his or her
“mental state” at the time of a crime.
Abortion represents an area replete with conflict that involves politics, law,
religion, and medicine. Those in favor of abortion rights believe that it is a woman’s right
to have an abortion and that the matter is confidential between the patient and her
physician. Opponents argue on religious and moral grounds that abortion is murder. At
present, the law sanctions abortion. In many states, however, Medicaid will no longer pay
for an abortion unless the mother’s life is in danger, a policy that makes it increasingly
difficult for the poor to obtain these services.
