EN BUSCA DE OTROS CAMINOS: TRANSCENDING MEDICAL

BOUNDARES IN CIENFUIEIGOS, CUBA

A Thesis

Presented to

The Faculty of Graduate Studies

OP

The University of Guelph

by

STACEY R. BUSSE

In partial fulfilment of requirements

For the degree of

Master of Arts

December, 2000

O Stacey R. Busse, 2000

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ABSTRACT

EN BUSCA DE OTROS CAMINOS: TRANSCENDING MEDICAL BOUNDARIES IN CIENFUEGOS, CUBA

Stacey R. Busse The University of Guelph, 2000

Advisor: Dr. E.A. Cebotarev

This thesis is an exploratory study of perceptions of health and illness, etiological

agents and factors infi uencing medical choice of individuals living in two barrios, La Iuanita

and San Lazaro, within the Cuban City of Cienfuegos. Research focuses on the three main

arenas of health care: customary, traditional and conventional medicine. Using work from

Laguerre, emphasis is placed on the media through which medical knowledge is reproduced

withiti the study population. Next 1 examine the social interaction between these systems

with the help of Arthur Kleinman's mode1 on medical pluralism. Data obtained from a

survey, semi-structured interviews and participant observation indicate that whiIe individuak

defined health and ilhess in terrns of physical ailments, etiological agents varied between the

stnctly natural, to supernatural (eg. the evil eye, witchcraft, envious individuals, etc.). Social

factors and the characteristics of heath services and illnesses were arnong the major influences

on medical behavior and decision-making. Al1 individuals reported a combined use of the

aforernentioned medical systems and expressed faith in the effectiveness of conventional

medicine. Al1 exhibited basic knowIedge of customary medicine. however belief in

traditional forms of medicine varied. The household was listed as the main focal point

through which medical knowledge is reproduced. Next in importance was the media, family

doctors and religious orientations. Finatly, interviews with doctors, cztrnrzcferos and

informants from both barrios indicate a cornplementary health care system with casas

particulares (private homes) and pharmacies providing increased access to al1 rrznterin

ACKNOWLEDGENIENTS

1 am deeply grateRiI to the many individuals who have contributed not only to the

success of this study but also to my intellectual growth and developrnent. Conducting

research ir. Cuba has been an amazin_g experience and there are many people that 1 must

thank, for the opportunity itself. and for making the process of îïeldwork excitin;.

interesting, and inspiring.

First and foremost. 1 wo~ild like to extend my gratitude to the University of

Cienfuegos and in particular. Director Rene Padron and Profesora Ratïela Soto. To

Padron, for providing me with an institution to work and learn in, and Ratïela for her

rnany houn of input and giidance, thank you.

1 am grateful for Dr. Nora Cebotarev's unwavering encouragement and support

and Dr. Frans Schryer's insight and interest in my research. I would also like to thank

Dr. Christiane Paponnet-Cantat, for her intliience on my ncademic career that have

extended above and beyonrl this masters degree.

This work is a result of combined efforts frorn a number of important individuals.

in addition to my acadernic advisors, I am indebted to Francisco. Giselri ancl Rebecca.

who provided me with a wc;ilth of information on Afro-Cuban religious traditions. To

Elisa and Barbara, who tüuglit me a11 about plants and their many uses. I'm glad y011 are

my friends.

1 wish to thank niy beaiitiful Cuban family for taking me in and inaking my

second experience in Cuba one of the most wonderful times of my life. My love for

Cuba is largely due to my love for you. Last, but certainly not least, I'm gratefiil to my

parents for always having fitith in my abilities. supporting my endeavors and for giving

me the first and the most important form of education. which stressed honesty. integrity.

and hard work. Without al1 of these qualities imparted early in me. 1 would never have

accomplished this educationril height. I'm so proud to be m y motlier's dau~htrr.

TABLE OF CONTENTS

ABSTRACT

ACKNOWLEDGEMENTS .................................................................................................... i ... TABLE OF CONTENTS ...................................................................................................... I I I

LIST O F TAl3LES ................................................................................................................ vi .. ............................................................................................................. LIST O F FIGURES vii . . LIST OF IMAPS VI 1 ...................................................................................................................

............................................................................................................... INTRODUCTION- 1

Objectives ............................................................................................................................... 3 Met hodology .......................................................................................................................... 4 Limitations of the S tudy ......................................................................................................... 5

..................................................................................................... Organization of the Thesis 5

CHAPTER 1: ............................................ DEFTNING CONCEPTS & THEORETICAL FWVEWORK 7

1.1 MEDICAL ANTHROPOLOGY .................................................................................... S 1.1.1 HeaIth .......................................................................................................................... 9 1 . 1 2 lllness ......................................................................................................................... 10 1.1 -3 Sufferer's Experience ................................................................................................. 1 1

..................................................................................................... 1.2 ETHNOMEDICINE 12 ...................................................................................................... 1.2.1 Disease Etiologies 13

........................................................................................... 1-22 TerminologicaI Problenis 15

1.3 DEFINING CONCEPTS ............................................................................................... 16 1.3.1 Health Care Systems .................................................................................................. 16 1 -3 -2 Medicd S ystems ........................................................................................................ 17 1.3.3 Traditional Medicine .................................................................................................. 18

.................................................................................................. 1.3.4 Customary Medicine 19 1 .3.5 Conventional Medicine .............................................................................................. 20

1.4 MEDECAL SYSTEMS AS CULTURAL SYSTEMS .................................................. 20 ...................................................................................................... 1.4.1 Medical PIuralism 23

1.5 REPRODUCATION OF MEDICAL KNOWLEDGE .............................................. 34

CHAPTER II: LITERATURE REVIEW PART 1: POLITICAL. SOCIOCULTURAL AND

......................................................................................... HISTORICAL PERSPECTIVES 26

... I I I

2- 1 A SYNOPSIS OF CUBA'S POLITICAL. SOCIAL AND ECONOMIC HISTORY .. 27 3.1.1 Colonization ............................................................................................................... 27 2.1.2 Ten Years War ........................................................................................................... 29 2.1.3 RevoIution .................................................................................................................. 31 2.1.4 Life Under Socialism ................................................................................................. 32 2.1 -5 Special Period in Times of Peace ............................................................................... 33

2.2 INFLUENCE OF AFRICAN CULTURE ON CUBAN SOCIETY ............................ 34 2.2.1 Slave Society .............................................................................................................. 34

.............................................................................................................. 2-32 Slave CuIture 37 2.2.3 Cuba's Free Black Population .................................................................................... 38 2.2.4 Folk Catholicism ........................................................................................................ 39 2.2.5 Cabildos ...................................................................................................................... 41

.............................................................................................................. 2.3 SYNCRETISM 43

CHAPTER III: LITERATURE REVIEW PART II: TRADITIONAL AND CONVENTIONAL MEDICAL S YSTEMS ......................................................................................................... 46

...................................................................... 3.1 TRADITIONAL MEDICAL SYSTEMS 47 ................................................................................................................. 3.1.1 Curanderos 47

....................................................................................................................... 3.1.2 Santeria 48 ............................................................................................................ 3.1.3 Regla de Palos 57

................................................................................................................. 3.1.4 Espiritismo 61

3.3 DEVELOPMENT OF CONVENTIONAL ,hl EDICiNE IN CUBA ............................. 67 3.2.1 Conventionai Medicine Before ~ h e Revolution ...................................................... 67 3 - 2 2 Conventional Medicine After the Revoliition ............................................................ 68

...................................................................................... 3.2.3 The Family Doctor Program 70 ........................................................................................ 3.2.4 Medicine and the Embargo 71

CHAPTER IV: METHODOLOGY ............................................................................................................... 75

......................................................................................... 4.1 PERSONAL EXPERENCE 76

4 2 MEANS OF DATA COLLECTION ............................................................................. 7 S The Sample ............................................................................................................... 73

................................................................................................. 4-21 Quantitative Methocls 82 ................................................................................................... 4.3.2 Qualitative Methods S3

4.3 DATA ANALYSIS ....................................................................................................... S7

4.4 LIMITATIONS OF THE RESEARCH ........................................................................ SS

.............................................................................................................. 4.5 FIELD WORK 89

CHAPTER V: AGENTS OF ILLNESS AND FACTORS thrFLUENCWG HEALTH CARE DECISIONS ......................................................................................................................... 94

5.1 DEFINING HEALTH AND ILLNESS ........................................................................ 95

5.2 ILLNESS ETIOLOGES ............................................................................................... 96 5.2.1 Spiritual Entities and the Espiritisrc~ .......................................................................... 96

........................................................................................ 5-22 LOS Nervios (Bad Nerves) 102 .................................................................... .............................. 5.3.3 Envich (Envy) ,. 104

.............................................................................................. 5.2.4 Md rie Ojo (Evil Eyt., 105 5 - 2 5 Btqjericr ( Witchcrat't ................................................................................................ [ OS

................................................................................... 5.3 HEALTH CARE DECiS IONS 112 ............................................................................. Socio Econornic Factors ........... ,., 112

..................................................................................................................... Gender 112 Age .......................................................................................................................... 115

................................................................................................................. Education I I 7 Religoi~is Affiliation ................................................ ,...,. 1 19 The Big Picture .................................................... ... 12 1

. . ............................................................................ Characteristics of Hcal t h Services 124 Cost of Treatrnent ..................................................................................................... 124 Avaiiability of Resoiirces ......................................................................................... 126 Characteristics of Ill nesses ....................................................................................... 12s Seriousness of Illness ............................................................................................... 12s Etiology .................................................................................................................... 12s

CHAPTER VI: REPRODUCTION OF MED ICAL KNO WLEDGE ....................................................... 132

6.1 MEDICAL KNOWLEDGE AhrD THE INDIVIDUAL: INSTITUTIONS OF 99 ..................................................................................................................... EDUCATIOhr 1 J-J

6.1.1 The Household ......................................................................................................... 133 6.1.2 The Media ................................................................................................................ 130 6 - 1.3 The FarniIy Doctor ................................................................................................... 139 6.1 -4 Religioris/SpirituaI Orientations ............................................................................... 143

6.2 TECHNIQUES AND PROCESSES FOR TRANSMISSION OF KNOWLEDGE ... 145

6.3 CRCUMSTANCES THAT FAVOR THE TRAIVSMISSION OF KNOWELDGE . 147

6-4 PROBLEMS AFFECTiNG TRANSMISSION OF MEDICAL KNOWLEDGE ...... 148

CHAPTER VU: INTERACTION BETWEEN CUSTOMARY. TRADITIONAL AND CONVENTTONAL MED IC LNE ........................................................................................ 152

.............................. 7.1 BUSCA UN OTRO CAMINO "LOOK FOR ANOTHER PATH" 153

7.3 REMEDIOS CASEROS DE LA ABUELA "GRANDMOTHERS REMEDES" ....... 164

7.4 CASAS PARTICULARES Y FARMAC~AS "PRIVATE HOMES Ai?iD PHARMACIES1' ................................................................................................................ 166

SUMMARY AND CONCLUS IONS ................................................................................. 173

Summary ............................................................................................................................ 173 Conclusions and Recomrnendations ................................................................................... 180

REFERENCES .................................................................................................................. 1SS .................................................................................... ................... APPENDICES .... 197

LIST OF TABLES

....................... 4. la Summary of Participant Characteristics for Inforrnants of La Juanita SO

4.1 b Sumrnary of participant Characteristics for Informants of San Lrizaro. .................... S 1 4.2 Section three of stnict~ired interview with informants frorn San L5z;u-O and La

Juanita ........................................................................................................................ S2

4.3 Summary of Key Resexch Participants not included in the Structured Interview .... S5

5.1 Common Somatic and Psycho-Somatic cornplaints Iisted by Espiritistas interviewed ............................................................................................................... 102

5.2 Table indicating knowledge of customary medicine. general belief in the credibility of traditional medicine rind education by male informants from San

............................................................................................... Likaro and La J~iani ta I 13

5.3 Table indicating knowledge of medicinrrl plants employed in customriry medicine by women i n formants from La Juani ta, and San Lrizaro ........................... 1 14

5.4 Table indicating belief in the credibiiity of traditional medicine by women frorn La Juanita and Siin L,uaro. ........................................................................... 1 15

Table indicating age of interview-survey informants for San LAzaro rind La Juanita .................................................................................................................... 1 15

Table indicating averaze ntimber of medicinril plants recognized and employed according to age in La Juanita and San Lrizaro ........................................................ 1 16

Table indicating by Lige group, the number of individuals who have h i t h in traditional medicine .................................................................................................. 1 17

Table indicating the Ievsl of education of the thiry informants and their comparative knowleclse regarding medicinal plants ............................................... 1 18

Relationship between eciucrition and nurnber of individuals that hve h i t h in traditional medicine .................................................................................................. 1 19

Table indicating belief in tradicionril rnedicine by informants frorn San Lrizriro ............................................................................................................ and La Juanita 120

vii

LIST OF FIGURES

Model i llustrating how etionlogical agents are classi t?ed .. ........................... -.-. .-...-... 95

Model illustrating factors that influence l-iealth care decisions. ................................... 95

Multivariate analysis ot' sociai factors. knowledge of custornary medicine and belief in the effectiveness of traditional rnedicine ........................................... - .-.---. 22

Variables affecting h d t h care decisions as listed by inforrnants tiom San Lkaro and La Juanita .................................................................................... 130

Mediums through which information regarding rnedicinal plants is reprodticed ............ 140

7.1 Model illustrating the interactions between customary. traditind and conventional medical systerns .......................................................... . -----.. ---- - - - - -------.- 153

LIST OF MAPS

INTRODUCTION

Medical anthropology has been defined as a hotistic means of studying the effects

that culture has on disease and health care (Logan and Hunt: 1978:xiii). How people

approach illnesses, and employ existing medical systems differ according to histoncal

background, econornic realities, and political orientations. UltirnateIy, it would be

impossibIe to understand the very nature of these medical systems and the illnesses they

treat without first attempting to comprehend the cultural context of which they are a part.

In Cuba, distinctive systems of medical knowledge, beliefs, and practices stem

from a cultural syncretism that has taken piace as a result of colonization by the Spanish

and the arriva1 of thousands of African slaves to the New World. Generations have both

adopted and passed down varying beliefs regarding iIlness, illness causation, and

naturalistic healing techniques which include the use of medicinal plants. These belief

systems continue to interact with and influence today's health care practices.

Knowledge in the realm of conventional medicine can also be seen through the

eyes of syncretism and colonization. More specifically, it can be seen through

colonialism and neo-colonialism. With the mival of the Spaniards to the New WorId,

physicians were sent to Cuba to see to the needs of those who decided to stay and work

for the greater good of the mother country. Medical physicians, dentists, bloodletters, and

other individuaIs claiming to be qualified health care experts, came across to develop

their careers, but training in these areas could Vary dramatically. After the War of

Independence (1898), Cuba expenenced stability and rising prosperity. Govemmental

investment in public health increased, and international medical advances came to Cuba.

Yet, these advances did not benefit the entire population and those who could not afford

conventional medicine continued to rely on traditional or customary medical systems

(Finlay, 1979: 69-75).

Today, Cuba is on par with most first world nations in terms of its developments

within the field of conventionaI medicine. Cuba has a free public health care system and

its population has a lower doctodpatient ratio than the United States (Schwab, 1998: 61-

62)- Despite Cuba's medical advances, the recent economic crisis (1989-2000) has had a

detrimental impact on the health of population. Two external factors were responsible.

First, the fa11 of the Soviet Union led to extensive financial losses for the Cubans; second,

the strengthening of the US embargo restricted access to food, medicines, medical

supplies and equipment. Al1 of these have had an enormous impact on health care and the

options that were available to the Cuban people. How has Cuba coped with this

situation? Broadly stated, i t has looked towards naturalistic healing techniques to

compensate for losses in the conventional realm.

This thesis is exploratory in nature. It proposes to focus on health and illness

perceptions along with factors influencing medical choice. Two popular barrios, la

Juanita, and San Liizaro, located within the city of Cienfuegos, were selected as case

studies to illustrate how medical knowledge is reproduced at the local level. The analysis

is based on data collected during interviews, participant observation, and discussions with

a wide variety of informants. The population under study can be viewed as a medically

pluralistic society in which traditional and customary medicine have persis ted along with

the development of a modern conventional medical systern. This thesis hopes to explore

how Cubans use diverse medical systems to best address their health care needs.

Objectives:

The thesis addresses three major objectives. First, it examines definitions of

illness causation and diagnosis by looking at how people manipulate and use traditional,

conventional, and customary medical systems. It investigates how individuals learn about

naturalîstic heding techniques and medicina1 plants by addressing the following

questions: 1) What is the level of knowledge held by most individuals regarding

customary medicine and self-treatment and is this form of knowledge active or passive?

2) How do individuals attain and reproduce medical knowledge? 3) How do these

traditional, customary and conventionai areas of health care interact on a social IeveI?

Second, the thesis examines current health care in Cuba by reflecting on the

country's political and historical and cultural background. This approach helps us gain a

more thorough understanding of local definitions, knowledge management and decision-

making processes regarding health, illness, and medicine. The hypothesis proposed here

is that customary and traditionai medicine have remained part of the local cultural

practices because of Cuba's economic situation (deprivation), govemmental incentives to

promote green medicine, and Cuban religious syncretic traditions.

Third, the thesis focuses on the level of social interaction that exists between the

three medical systems based on factors such as: the severity of the illness, the acceptance

of the validity of conventional medicine by the seagrnent of the religious/spiritual

population, the be1ief in the possibility of rniracles and spiritual healing by medical

doctors (varying, of course, with the individual) and the extent to which plants are used.

The participants of this study were usua1Iy familiar with naturalistic healing techniques

through some biological and medicinal knowledge of Iocal plants. Al1 could articulate

how these pIants would best treat an illness, or couId choose mediurns which would best

rectify the problem. Also, it becarne apparent that medical physicians, nrranderos and

other religious healers would help their patients look into these alternative medicai

systems for best resuIts.

Methodology:

The data collected for this study were both quantitative and qualitative.

Quantitative data were gathered through the use of survey-interviews adrninistered at

random in San Liizaro, and La Juanita. The survey rnethod (based on questionnaires)

included characteristics of the population, dong with their approaches to various illnesses

and knowledge of naturalistic healing techniques (medical plants), whether this be

through self-treatment or through other practices. It investigated the forums through

which individuals Iearn about self-healing and their opinions on traditional and

conventional medicines, and the interaction that exists between the two. Quantitative data

analysis used descriptive and non-inferential exploratory statistical techniques.

Qualitative data pathering relied on participant observation, dong with

unstructured, in-depth, and semi-structured interviews in order to add depth to the

quantitative data and provide a more personal approach to the information collected.

Interviews conducted with the genera1 public and family doctors were done randomly.

Informants who were spiritual and religious heaiers, pharmacy empIoyees, and

individuals who sel1 pIants privately from their home were selected through snowball

sampling. These methods were complemented by secondary sources.

Limitations of the Study:

One limitation is the small size of the sample, which makes generalization about

the entire Cuban population a bit riçky. Another limitation is the fact that I am not a

native Spanish speaker. To cornpensate for this potential problem, 1 went into the field

early so that 1 could obtain language skills before beginning interviews with various

infonnants. 1 was also accompanied by a faculty member from the University of

Cienfuegos Agronomy Department while conducting the interviews with the general

public.

Organization of the Thesis:

This study is divided into seven chapters. Chapter One Iooks into the field of

rnedical anthropology and defrnes terms Iike 'health,' 'illness,' and 'suffer experience.'

Customary medicine, traditional medicine, and conventional medicine are also outlined to

illustrate how they are used specifically for the purposes of this thesis. Chapter One

highlights the conceptual framework used to interpret research findings. This framework

combines ethnomedicine with Kleinman's interpretive mode1 of plurdistic health care

systems and Laguerre's notions on the reproduction of medical knowledge.

Chapter Two provides backgound information on Cuba and the socio-economic

and historical events thai have influenced present-day health care. African slave history

and culture is also discussed here since it has strongly influenced the traditional rnedical

sector. In Chapter Three, the development of conventional medicine is analyzed dong

with the difficulties it encountered during the "Special Period" which led to the birth of

the Family Doctor Program. This chapter further examines ccrranderismo within the

context of the Santedz and Pa10 Monre Religions, and Espiritismo (Spiritism).

Information regarding the use of pIants and heôling techniques within Afro-Cuban

religious traditions are discussed in terms of their curative contexts.

Chapter Four discusses data collection for this thesis. It highlights the use of

qualitative and quantitative approaches to obtain data, dong with an account of my

'personal experiences' in the field and interaction with informants. It describes my

interest in this field of inquiry and the limitations 1 encountered while conducting my

fieldwork.

Chapter Five explores the subjective expenence of health and illness of the

popuIation studied. Health and iIIness are defined along with illness terminology like

padescimientos, enfermedades. nervios, empacho, the evil eye, spiritual entities, and

witchcraft. Decision-making processes regarding illness treatments are also exarnined.

Chapter Six examines the mediums through which individuais l e m about

medicinal plants and naturaIistic healing techniques. It investigates in greater depth why

individuals have been able to maintain knowledge of traditional f o m s of medicine and

intertwine them with conventional medical approaches. It is here that Cuba's politicaI,

economic, reIigious/spiritual background is discussed in relation to the levels of

knowledge held by the population regarding naturalistic healing techniques and medicinal

plants.

Chapter Seven briefly discusses the interaction between different realms of

traditional and conventional medicine as they relate to patient treatment in terms of the

interplay that exists between religious/spiritual healers, pharmacies, family doctors, and

herbalists.

CHAPTER 1

DEFIMTION OF CONCEPTS AND THEORETICAL FRAMEWORK

Preamble

This chapter defines basic concepts such as health, illness. and sufferer-

experience within medical anthropology and then narrows its perimeters to those

concepts that are most relevant to this thesis. Ethnomedicine, with its emphasis on

disease etiologies and indigenous terminology, is also examined in detail since the

research conducted partially falls within this discipline.

Health care systems and medical systems are important concepts in medical

anthropology. The word 'concept' is important here since, as Kleinman (1980: 25-26)

emphasizes, health care models are denved from the researcher's understanding of how

the actors in a social setting think about health care, define sickness, and make decisions

regarding treatment. This is reflected in Chapter Four's exploratory analysis of etiological

agents and factors affecting health care decisions. Particular attention is paid to defining

traditional medicine, customary medicine and conventional medicine, since these are

explored in this thesis. Field research canied out on the interaction between medical

systems falls directly within works by Arthur Kleinman.

1.1 MEDICAL ANTWROPOLOGY

WhiIe there is g-rowing unity arnong those who define themselves as medical

anthropologists, there does not exist a widely shared definition or an agreement regarding

where its boundanes lie (Colson, and Selby 1974: 245). A simplistic definition of

medicai anthropology is that it is a discipline concerned with "the bio-cultural

understanding of man and his works in relation to health and medicine" (Hochstrasser

and Tapp, 1970245). This bio-cultural understanding of hurnans includes: rnedico-

histoncal, medico-legal, and medico-socio-cultural aspects, dong with public health

issues that are of concern to various populations (Hasan and Prasad 1959: 21-22). Lieban

highlights the reciprocal relationship between society, culture and medicine, stating that

rnedical anthropology "encompasses the study of medical phenomena as they are

inffuenced by social and cultural features, and sociaI and cultural phenomena as they are

illurninated by their medical aspects" (1973: 1034). This newly developed field has

already made significant theoretical stndes and empincal contributions to the

understanding of the cultural embeddedness of medical knowledge and practice.

Joralman (1999: xiii) asserts that medical anthropology is a connecting point for

biologicaI, cultural and evolutionary works related to medicine. It brings to the fore the

healer's role in medicine, dong with the effects of general economic and political forces

on the health of the individual and their comrnunities and the interplay between existing

social structures, ecoIogica1 settings and disease-causing agents.

Building upon these premises, Good (1994) defines rnedical anthropology as an

oxyrnoron. The term "medical," situated in the natural sciences insinuates or denotes a

domain of rationality. Within this realm, culture is seen as being intrusive upon scientific

understanding and rational therapeutics. Anthropology, on the other hand, advocates a

tenet that d l knowledge is situated culturally within a particular perspective and relative

to a historical era. Culture and reality are reflected or embedded in Our practices as

individuals in a society. Our activities interact with the social and ernpirical world,

further providing a picture of Our own (medical) reality. Interpretive practices produce

distinctive modes of experience, and these experiences can in turn become associated

with culturalIy specific forms of illness, or definitions of illness and health. ULtimately,

as Good (1994: 174-179) States, "reality does not precede interpretation, but resides

amidst the interactions or relationships between the physical body. the lived body, the

interpretations of the sufferer, healer and others in the social world." This perspective of

medical anthropology directs attention to an examination of some of the more basic

concepts.

1.1.1 Health

HeaIth is defined by the WorId Health Organization (1978) as "not merely the

absence of disease and infinnity but complete physical, mental, and social well being." It

is considered to be more than an emotional state or a physiological state; it is instead a

concept that has developed in many societies as a means of describing their overall sense

of wellbeing. Health, within the realm of medical anthropology, is regarded as a cultural

construction that differs from one society to the next or according to distinctive periods of

time. HeaIth, within the realm of critical medical anthropology, is defined as access and

control over basic resources. These resources include primary material or nonmaterial

products that in general sustain and promote Iife (Baer et al., 1997: 4-5). Health, in this

thesis, conforms to al1 of the above mentioned definitions.

1.1.2 Illness

Foster and Anderson (1978: 40) define illness as the social recognition that a

person is unable to adequately fuIfi11 hisher normal roles in society. To best descnbe

illness, however, one must discuss the notion of disease. For these authors, where disease

is generdly considered to be a pathological concept, illness is most definitely a cultural

experience. Human diseases become socialIy significant only when they are identified as

illnesses, or as a physiological malfunctioning that is seen to threaten the individual and

society. Societies define illness according to different frameworks and symptoms and

what is considered evidence of an illness in one community rnay be ignored in the next.

Even within that same community, illness definitions may differ with time. An illness

episode can ultirnately be interpreted as words, situations, s y m p m s and feelings which

are associated with an illness. The sufferer then @es this illness meaning like for

exarnple, the release from normal roles or duties (Good, 1977:39).

Explanatory models of ilIness recognize the importance of context. These models

specify, for an illness episode, the beliefs and understanding related to the episode's

cause, the time and mode of onset of symptoms, patho-physioIogy, the course of the

sickness, and its related treatment. Expianatory models are formed and ernployed to cope

with a specific health problem and consequently they need to be analyzed in that concrete

setting (Rubel and Hass, 1990: 123; Kieinman, 1980: 106).

1.1.3 Sufferer Experience

Both M q a r e t Lock and Nancy Scheper-Hughes (1987,1990, L994) have written

some very influential works on sufferer experiences, or the manner in which an

individual expresses hisher distress. Since this thesis explores illness etiology, medicai

choice, and medical pluralism, it would be erroneous to continue on without

acknowledging works relating to sufferer experience.

Lock and Scheper-Hughes define themselves as critical-interpretive medical

anthropoIogists. They reject the longstanding notion of the mind and body existing as two

separate entities. Lnstead, contrary to biomedical theory, they discuss the sufferer's

expenence through the notion of the "mindful body" (Scheper-Hughes and Lock 1987).

More specificaily they discuss the "mindful body" as it exists in three different

perspectives:

I ) The individ~rûl body, which they define as "the Iived experiences of the body-self." The body on this Ievel exists apart from other independent bodies. It is an embodied self-existing, a constant experience of self.

2) The social body is referred to as the representational uses of the body. It is seen as a syrnbol with which to think about nature, society and culture. It is here that one determines the relationship that exists between the naturd and the social world- A person, or body, experiencing an illness for example offers a mode1 of social disharmony, perhaps conflict or disintegration.

3) The body poliric is defined in terms of the regulation, surveiIlance and control of bodies in terms of sexuality and reproduction. Whether individual or collective this control of bodies also is extended on to include work, leisure, and sickness (Lock and Scheper-Hughes, 1990: 48-51; Scheper-Hughes, 1994: 232).

Within these contexts, it becorne apparent that illness and death can be attributed to social

tensions, contradictions and hostitities. Social relations are understood as key contributors

to individual health and illness. Health is dependent on, and vulnerable to, the feelings,

wishes and actions of others, whether these others are human or non-human entities. "The

body is not understood as a complex machine but rather as a microcosm of the universe."

This is, of course, in opposition to conventional biomedicine where the body and self,

according to Scheper Hughes (1990), are understood as distinct and separate entities and

according to whom illness is thus either residing in the body or the mind. Social relations

as such are seen as partitioned, segrnented and situational. These relations are not

conceived as being continuous with health or sickness.

Sufferer experience cm therefore be seen to constitute a social product. It

inchdes categories of meaning that are socially constituted and inclusive of the political

and economic forces that shape daily life. The image that people hold of their bodies is

mediaîed by their own socio-cultural interpretation of what is meant to simply be hurnan.

This holds true whether applied to a person who is healthy or one who is in a state of

disease. As is eloquently stated by Lock and Scheper-Hughes (1990: 63), the body can be

thought of as a cognitive map of natural, supernatural. and socio-cultural spatial relations.

Consequently, it is generally unorthodox therapies that provide a unifying interpretation

or perspective on the individuaI' s sentiment of sadness, affliction, and illness, thereb y

lending a more satisfying treatment program to the patient. The key to this lies on the

ability of these medical systems to explicitly locate disorders within their wider sociaI

context (Scheper-Hughes, 1990: 194).

1.2 ETHNOMEDLCINE

Ethnomedicine can be defined as the study of beliefs and practices relating to

disease which are products of indigenous cultures. EthnomedicaI data and descriptions

appear in the earliest ethnographie records (works by early travelers, rnissionaries and

colonizers) since medicine would be, and still is considered, an integral part of any

complete study on society (Foster and Anderson, 1977: 5-6). Fabrega (1975: 969)

interprets ethnomedicine as "the study of how members of different cultures think about

disease and organize themselves toward medical treatrnent and the social organization of

treatment itself." Lieban (1977:23), reiterating the doctrines of the larger discipline,

asserts that ethnomedicine should not be considered to be independent, with its own

motivations and movements, rather, it is dependent both in character and significance

upon larger cultural patterns.

1.2.1 Disease Etiologies

Central to the study of traditional rnedical systems is the investigation of disease

classification or etiologies. Foster and Anderson (1978) discuss two categones of disease

etiologes: personalistic and naturalistic. These terrns are used specifically to refer to

causality concepts, although they can also be employed to distinguish entire medicd

systems. Within personalistic medical etiologies, illnesses are believed to be the result of

the active, purposeful intervention of an agent that may be supernatural, non-human, or

human. Deities or godly figures cm be induded within the realrn of supernatural beings

and, in the context of my own research, this wouId refer to the on'slzas within the Sarzten'a

religion, XZrnpungtilu within Pa10 Monte, and sailzts within the Catholic religion. Non-

human entities are comprised of figures such as ghosts, ancestors, or evil spirits. Human

agents inclusive of more powerful living individuals would consist of witches/sorcerers,

saïzteros, paleros (religious practitioners of Santen'a and Pa10 Monte respectively), and

those who are known to have mal vista (give the evil eye).

h the case of personalistic disease etiologies, the afflicted person is being

victirnized or plagued with health problems due to reasons that are specific to hirnher

aione. These illnesses are not obtained at random but are instead the products resulting

from an individual's actions, abilities, or other persona1 characteristics. TraditionaI forms

of medicine and curaizderismo (abilities to cure) as medical approaches generally address

these types of etiological agents.

When illnesses are explained in impersonal or systematic terms they generally faII

within the realm of naturaiistic disease etiologies. This is seen more explicitly in the case

of customary (family) and conventional medicine. Within both of these medical systems

illnesses exist when the individual is in a state of physical disequiIibrium. Most illness

agents are thought to be elernents of the natural environment (heat, cold, age, strong

emotions, menstruation, prepancy, vimses, foods, fatigue, and other factors that hinder

or interfere with ones normal physical balance).

Tt would be a mistake to think that personalistic and naturalistic etiological

systems are mutually exclusive. There are numerous occasions where individuals appeal

to personalistic causes to explain illness and sirnultaneously recognize the existence of a

naturai or chance cause. Likewise, those individuals for whom naturalistic causes

predorninate almost invariably explain certain illnesses as due in part to the workings of

witchcraft or the evil eye. Personalistic medical etiologies are generally part of a more

comprehensive explanatory system; sorcery and the evil eye, for exarnple, are responsible

for general misfortune and bad luck above and beyond illness. Naturalistic etiologies,

alternative1 y, are rnainl y restricted to illnesses (Foster and Anderson, 1978: 53-54,67).

With personalistic etiological systems, the patient will usually go to see a

curandero, whether they are a religious heaIer or non-religious healer. Such individuals

have generdly learned his/her practice through apprenticeship, tradition and divine

blessing. In naturaIistic systems, practitioners tend to be individuals who have learned

their skiIIs through observation and practice and have not acquired this information

through divine commission, Doctors, herbalists, and elders within the family are

individuals who qualify as having this type of training (Foster and Anderson, 1978: 68-

70).

1.2.2 Terminological Problems

When studying rnedical systems outside of one's own cultural background, the

researcher can often find him/herself at a loss for using accurate terminology. The terms

comrnonly used to discuss medical systems often impIy a qualitative gap between

"modern," "Western" or "conventional" medicine and "indigenous," "non-Western" or

"traditional" medicine. This is emphasized by past classifications and tenninology Iike

"scientific" versus "primitive." Although the term "primitive" has Iong been eliminated

from anthropological works due to its pejorative implications, there still exist qualitative

gaps in the usage of terms that suggest evaluation. Following Foster and Anderson (1978:

52-53), this thesis will focus on a frarnework that places emphasis on etiological agents,

causality concepts, and practitioner typology rather than societal types. Terms like

"conventional" and "traditionaI" will be used to define both etiological agents, and

treatment approaches so that they do not add to this qualitative gap.

1.3 DEFINING CONCEPTS:

1.3.1 Health Care Systems

As mentioned previously, a health care system, according to Kleinman (1980),

should be considered a concept and not an entity for, in his estimation, it is a conceptual

mode1 that is held by the researcher. Such models are created only after a number of

conditions of research have been met. These include an in-depth study examining a

society's beliefs about sickness, decision making criteria on how to respond to specific

sets of illnesses are examined, and an investigation into the people's expectations and

evaluations of specific types of care. Only after these three levels of investigation have

been carried out is the investigator in a position where he/she can begin to construct a

mode1 of a society's health care system. The health care system is inclusive of people's

beliefs and patterns of behavior, and these beliefs and behaviors in tum are govemed by

cultural rules (Kleinman, 1980: 26-27). The health care system, like other cultural

systems, thus integrates the health-related components of society. These components

include patterns of belief about the causes of illness; norms governing choice and

evaluation of treatment; socially-legitimated statuses, roles, power relationships,

interaction settings, and institutions (Ibid.: 24).

An approach to health care systems can range from Baer's (1997:g) more

simplistic definition, "the social relationships that revolve around the healer and his or

her patient"; to Pedersen's and Baruffati's (1989:487) which States that health systems

are considered to be systerns that "comprise of the whoIe array of elements or

components of the broader social system which are related to the health and physical,

mental and social weI1-being of the population." Ultimately, health care can be seen as

the ways in which societies organize themselves and use the knowledge they have with

regard to disease to care for the sick. One of the more obvious functions of a health care

system is its ability to mobilize the resources of the patient, his family and society to

bring them to bear, in the most effective manner, on the illness episode (Foster and

Anderson, 1978: 37)-

This study will look at three differing medicai systems that are part of the larger

health care system in Cuba. As the literature review indicates, Cuba's unique econornic

situation, political history, and its cultural background, have shaped and influenced the

existing health care system so that the system itself reflects people's beliefs and patterns

of behavior.

1.3.2 Medical Systems

Al1 human societies create medical systems of one form or another. They consist

of beliefs and practices that are consciously directed at promoting health and alleviating

diseases. As with health care systems, medical systems are not cIearly differentiated from

social institutions such as religion and politics (Baer et al., 1997: 9). This is evidenced by

the practitioners like the sarttero or palero whose roles are both curative and magico-

religious.

Medical systems can also be seen as an organized array of human resources,

technologies and services specificall y designed for the developrnent and practice of

medicine. These systems are constructed from a relatively uniform set of schools,

hospitals, clinics, professional associations, and agencies which train personnel. Every

medical system has its own distinct or organized set of technologies (materia medica,

dmgs, herbs and various procedures such as divination). Included within this structure are

practitioners (doctors, nurses, sharnans, healers, bonesetters, herbalists, etc.) who work

within a distinctive ideological substratum (system of concepts, notions and ideas

regarding health and illness) and these substrats in turn form an indissoluble part of the

cultural repertoire of society (Pedersen and Baruffati, 1989: 487). What is undoubtedly

the most important and repeated theme throughout this review of concepts is the fact that

medicai systems cannot be understood solely in t ems of themselves. It is only when they

are seen as part of total cultural patterns that these systerns are fully appreciated (Foster

and Anderson, 1978: 39).

1.3.3 Traditional medicine

Traditional medicine is often defined in contrast to modem, scientific, or

conventional medicine. A belief or practice is sornetimes categorized as traditional or

folk when it is not recognized as an official medicine. Thus it is from a diverse body of

knowledge that is "unofficial" that many derive their attitudes and decisions regarding

medicd care (Hufford, 1992: 14-15).

In this work, traditional rnedicine is defined as those medicines that involve a

c~wandero, or person who has the divine ability to cure various illnesses. These

individuals generally stand out in t ems of their capacity to successfully cure particular

illnesses. A curandera may include a well-known herbalist who has extensive knowledge

to cure with plants, and they rnay or may not work within a religious or spiritual

framework. Non-religious clcranderos will also be included within this traditional realm

since they have a special ability to cure health problems that stand out from the rest of the

population and the beliefs and practices they follow and cary out depend greatly on

tradition. 1 confom to the definition established by Kleinman that traditionai healers

typically undergo non-formal education, often by apprenticeship, to learn their curing art

(Joralemon, 1999: 62; Kleinman, 1980: 59).

Traditional medicine here includes the complex hybridization of rnedical

knowledge as discussed in works by Kleinman (L978) and Pedersen and Baruffati (1985

and 1985). Medicai knowledge is inclusive of, but not Iimited to, the religious syncretism

of pre-Hispanic gods, Christian saints, and the complex spiritual and religious cosmology

of various African religions brought across with slavery, along with popular Folk

Catholicism and Spiritism.

1.3.4 Customary Medicine

Customary Medicine refers to a family/household based medical system in which

individuals have attained knowledge regarding self-treatment through the application of

various techniques, the most predorninant of which is the utilization of medicinal plants.

The term ccCustomary" rneans that the practice has been passed down through farnily

generations. Stated in another manner it is a custonzary family response to treating

illnesses. Typical family responses in attempts to rectify illness episodes in this case give

way to a system of medicine both in diagnosis and treatment. Customary medicine is

specialized due to three main factors:

(1) the availability of certain resources particularly within the ecology of the area; (2) skiils acquired by practice and passed dong through oral tradition from relatives in

one generation to those in the next; (3) exchange of rhis knowledge between househoIds.

Family or customary medicine is generally restricted to the use of plants in herbd or

homemade remedies. Attempts to treat physical illnesses in these instances are most

always in response to naturai etiologicai agents. Customary medicine, like conventional

medicine, generally does not treat probIerns that are spintuai or supernatural in nature.

1.3.5 Conventional Medicine

There have been a variety of descriptive labels used to discuss the conventional

medical system that has become globally dominant during this last century. 'Regular

medicine,' 'allopathic medicine,' 'scientific medicine,' 'modem medicine,' and

'cosmopolitan medicine' are but a few examptes used to describe conventionai or

biomedicine. The focus of conventional medicine is on human physioIogy and human

patho-physiology. This form of medicine assumes a mech'anistic ideology, with chemical-

based cures, and technology that functions efficiently within an urban-industrial

frarnework. It has a relatively extensive support system with laboratones, clinics, and

hospitals for highly skilied doctors, nurses, hospital staff, etc. who have been trained in

medical schools. This form of medicine is more capital intensive than labor intensive

although in Cuba it is accessible to al1 of its citizens (Bastien, 1982: 795). Within this

study, focus is placed on the family doctor or the local clinic since it is here that the first

approach to an illness episode is generally taken (at Ieast within the conventional realm).

1.4 MEDICAL SYSTEMS AS CULTURAL SYSTEMS

Out of al1 of the frameworks that take into account rnedicaily pluralistic societies,

perhaps the one that best suits the data that 1 collected is Kleinman's approach to

exarnining "rnedical systems as cultural systems"(1980:24). Like Pedersen and Baniffati

(1989), Kleinman States that there are ranges of rnedical beliefs about disease and illness

which exist among specialists (doctors, healers, etc). The author recognizes three

overlapping sectors in health care systems: the popular sector, the folk sector and the

professional sector, but before these sectors can be examined or explained, it is first

necessary to reflect on his notion of 'exploratory models' and their context within health

care systems.

Kleinman defines exploratory models of medicine in terms of etiology,

symptorns, patho-physiology, and the evolution of sickness and treatment. According to

him, these models should be viewed as individual manifestations, thus providing leeway

for variance according to persona1 perspectives. With differing medical expenence over

time come different explanatory models. Medical systems must be placed within their

cultural contexts and take into account the different realities that exist, particularly the

s yrnbolic realities under whic h illness and healing occur (Pedersen and Baruffati. 1989:

490). Effort is made within this forrn of ethnomedical work to understand how

individuals perceive, label, and react to illness.

Kleinman's mode1 (1980: 51-52) works with three different medical systerns, the

first of which is labeled the popular sector, and is thought to be the largest of the systems.

This sector consists of the sick person, the family unit or household, and various social

networks and communities. The popular sector includes a variety of therapies like speciat

diets, herbs, exercise, baths, massages, over the counter drugs, etc. It is within this sector

that we perceive and experience the first syrnptoms of a disease. Here, an illness is

labeled, validated, sanctioned with a particular kind of sick rde and a decision is made on

appropriate treatrnent(s).

The folk sector is comprised of healers of various sorts who function informally

and often on a quasi-legal and depending on Iocd laws, an illegal basis. Examples

include herbalists, bonesetters, midwives, rnediums and magicians. The sartrero, palero

and espiritista would fit into the folk sector.

The professional sector consists of any organized heating professions.

Biomedicine is perhaps the largest professionai sector and encompasses doctors, and

nurses working in hospitals, clinics and private practices. This form of medicine does;

however, include such practices as Chinese acupuncture where certain indigenous

medical systems have been professionalized (Baer et al., 1997: 8; Meinman, 1980: 54-

55).

According to Pedersen and Baruffati (1989), who focus their works on Latin

America, the folk and professional explanatory models share a lot of common ground

despite there being different traditional and historical backgrounds. The popular sector

thus brings together a range of different beliefs regarding health and illness, and materia

medica from both sectors. The rnixing of knowledge results from people passing between

the two sectors and leading to what KIeinrnan (1980: 56) coins as the popularization of

the professional mode1 and the medicalization of the popular and folk models. More

specifically, it has led to such occurrences as the joint use of prescription medicines with

that of herbal remedies or magical medicine (Pedersen and Baruffati, 1989: 49 1).

Altematively, i t may also include the incorporation of conventional medical facilities

within folk medical systems for the diagnosis or treatment of an illness.

In accordance with Kleinman's model, I discuss traditional, family (customary),

and conventionai medicines as medical systems within the context of culture. 1 also

examine their interactions as part of a medically pluralistic health care system. While

traditional and conventional medicine fit comfortably within Kleinman's traditiond and

professional definitions of medical systems, placing customary medicine within his

model would cause complications. Part of this complication arises from the fact that most

of my discussion on household medicine is mainly limited to herbai remedies. Popular

medicine is characterized as a sort of middle ground where the beliefs found within the

traditional r e a h and the conventional realm become somewhat more integrated. It

would, however, be misleading to state that customary medicine takes on this role.

Whether or not individuals incorporate beliefs from both of these systerns in their

household treatment of illnesses, to state that customary medicine is equivalent to that of

popular medicine would be an encompassing statement that 1 do not feel cornfortable

supporting from the data that will be presented. Although Kleinman's mode1 does allow

for leeway with regard to variation in medical beliefs, 1 prefer to elaborate on these three

medical systems and then discuss their interaction separately. This draws attention to the

fact that rnedical beliefs within a Society can Vary to an extreme, be excrusive to one

system or become combined in differing ways to serve the health needs of the patient.

1.4.1 Medical Pluralism

Defined as the pattern of a coexistence of an array of medical systems, medical

pluralism offers special advantages for biological survival and for the solving of

psychosocial conflicts or tensions. It represents a gamut of cuItural adaptive strategies

necessary for survival and management of disease and illness. The heaIth care system of

a society consists of the totaIity of medicd subsystems that coexist in a cooperative or

cornpetitive relationship with one another (Pedersen and Baruffati, 1989: 494). In the

context of Cuba, there are a variety of subsystems, there exist conventional medical

systems, alternatives like chiropractics, massage therapy, and acupuncture, Afro-Cuban

religious healing systems like Santeri'a and Pa10 Monte, Spiritism, curai~derismo, and

customary medicine, to name but just a few. As will be examined in detaiI in Chapter Six,

1 argue that the medical systems in Cuba are complementary to one another. Al1 have

their role to play in the larger health care system, providing services, illness theones and

treatments to fil1 in the gaps where other systems may be lacking, or may have faiIed to

suit the needs of the individual.

1.5 REPRODUCTION OF MEDICAL KNOWLEDGE

After defining medical systems and pluralistic practices within health care, it is

appropriate to consider how these medical systems are reproduced. Specifically, there is a

need to account for how medical knowledge within these three systems becomes

reproduced and transmitted. Laguerre, in his book Afro-Caribbean Folk Medicine,

investigates the transmission of foik medicaI knowledge and provides a framework that

can be broadened to accommodate the Larger scope of this thesis. Laguerre (1987, 35-36)

lists the institutions or 'niches' of transmission as: the household, the multi-household,

the clinic, the ethnic church and voluntary associations. This thesis looks at the

househoId, the farnily doctor, religious/spiritual orientations, and the media as being the

mediums through which individuals learn about medicinal plants.

Laguerre (1987,38-39) examines the circumstances that favor and the problems

that hinder reproduction of medical knowledge. He recognizes the fact that there are

many circumstances influencing how people learn about medicine and these issues are

very relevant to my research regarding medicine and rnedical decisions in Cienfuegos.

The transmission of medical knowledge is not Iirnited to any one process or event but is

more of an aggregation of many different circumstances, practices, institutions and

experiences. Informal socialization, family traditions, educational prograrns, rnass media,

government health care campaigs, and religious orientations would al1 contribute to the

level of medical knowledge held by an individual.

Conclusion

Taken from an interpretive, ethnomedical perspective, this chapter examined the

theoretical contexts under which the themes of this research can be best understood. It is

only after such an exmination that one can build more cornplex systems of study,

particularly with regards to heaith care systems and their pluralistic nature.

As reiterated throughout the discussion on ethnomedical and interpretive rnedical

studies, medicinal and socio-cultural features of a given society have a reciprocai

relationship. Thus one can understand the importance of investigating the role of

prominent social factors characteristic of health services and ideological belief systems in

health care decisions. The folIowing chapter examines the political, historical, and social

contexts into which the three medical systems have developed and now exist in Cuba.

LITERATURE REVIEW PART 1: POLITICAL, SOCIOCULTURAL AND HISTORICAL PERSPECTIVES

Preamble:

In order to understand the development of Cuba's medical systems, this chapter

will examine the political, social and historical background of the island. Cuba with its

unique past, has seen the evolution of a variety of different medical systems but, before

these systems can be studied, it is necessary to provide a brief overview of the island7s

history from colonization to present.

The colonization of Cuba, the episode of the Ten Years War, and the years

Ieading up to and after the revolution, will be outlined along with a section briefly

describing life under socialism. Particular emphasis will be given to 'the Special Period',

as it has had more imrnediate impacts on health care and medical decisions by the general

public. Special attention will also be paid to Cuban culture and more specifically on

African influence and history on the island as it is this interaction between colonizers and

Africans that has shaped traditional, customary and even conventiona1 medical systems.

The background on African slave history and culture provides useful information

regarding spiritual and religious orientations that are tied to the African diaspora. An

examination of the role played by the Spanish Catholic Church in the evolution of these

different religious orientations is also important. Palo Monte, Sarztek and Espiririsrno

refiect religious syncretism and so do their traditional medicai practices.

2.1 A SYNOPSIS OF CUBA'S POLITICAL SOCIAL AND ECONOMIC HISTORY

2.11 Colonization

Knowledge about the early inhabitants of Cuba is sketchy at best. Indigenous

people that Columbus described as 'Indian' had already been living on the island long

before the Spaniards anived. Through the writings of early explorers, archeologicai data,

and village and burial sites, researchers claim that there were at Ieast three native groups,

the Guanahatabe yes, the Cibone yes, and the Tainos.

Columbus landed in Cuba in 1492, and by1508 the Spanish Crown began a

campaign to colonize Cuba in earnest (Le Riverend, 1967: 40). As was done in the

former Espafiola (Haiti and Dominican Republic) the coriqriistadors appropriated Indian

lands and created a system called encorniendas. This system granted colonists the right to

collect tribute, in the fonn of labor, from a specified group of Indians in retum for their

protection by the Spanish and their Christianization (Suchlicki 1974: 19-20).

From 1511 to 1541, Cuba became an important outpost of the Spanish Empire

being strategically located so cioseiy to Central and South America (MacGaffey, 1967: 3-

4). The economy did well at this time and continued to do well for the initial twenty-five

years after colonization (Ridesdale, 1999: 26) but an outpost was al1 that it remained.

From about 1540 untii the late eighteenth century, Cuba was under-populated (McGaffey,

1962: 4). During this time sugarcane was introduced to Cuba from the Spanish owned

Canary Islands but it was not until later that it became a major export crop (Ruffin, 1990:

38,41).

The Seven Years War between England and France brought important changes to

Cuba. In 1762, the British occupied Havana for ten months and opened up former trade

restrictions to free the market to encourage rapid economic expansion. (Pérez, 1988: 57-

58). European consumption patterns of sugar between 1750-1850 grew exponentially

and, this was reflected in the development of the plantation economies, and by extension,

the slave markets of the Caribbean (Mintz, 1985:148-149; Ridsdale 1998: 29). The

economic rewards for selling sugar made the trading of African slaves extremely

profitable, especially since most of the indigenous population had died off.

According to Castellanos and Castellanos, African slaves mived on the island

long before sugarcane becarne the heart of Cuba's economy. There is evidence

suggesting that Portuguese slavers by 1510 began trading slaves to the Caribbean

countries with Cuba and Brazil being the major importers (1988: 19-20). Alejo

Carpentier's book, La Mrisica en Cuba music in Cuba], suggests that Afrïcans were

being transported to Cuba by at Ieast 1513, and by 1531 there were already a thousand

African slaves on the island (1946: 37). No one is sure about the number of slaves that

were brought across to Cuba, but it is estimated that in total, the numbers range anywhere

from 527,828 to 702,000 (Murphy, 1994: 23). Slave trade carne mostly from Britain.

Thomas, in his book Cuba: T7ze Prcrsrlit of Freedurn, suggests that no Spanish ship had

ever set foot on the West Afncan Coast, nor did they have trading establishments there as

most other European nations did. They relied above al1 on the English who dorninated the

slave trade. The South Sea Company of London, from 1713 to 1739, had an exclusive

license to sel1 slaves to Cuba and to the Spanish Empire. Later Cuba bought slaves from

the Spanish National Company, which in tum obtained their suppiy from the South Sea

Company and other English merchants in Jamaica (197 1: 3 1-33).

2.1.2 Ten Years War (1868-78)

The first independence movement in Cuba was initiated in 1868 and resulted in a

major civil war. The rebel Creole force was made up of landowners and planters of the

Orient together with a group of lawyers and professionals headed by Carlos Manuel de

Céspedes. In the beginning, the war was quite successfuI and, with General Miiximo

G6rnez Ieading the rebel army, Criollos were able to obtain military control of the eastem

half the island. A new constitution was adopted and provisional govemment created.

Spain, however, responded by sending reinforcements to Cuba and the result was

complete physical destruction to the eastern side of the island and eventually both sides

called for a conclusion to the war. Although Spain promised a number of concessions and

widespread political reform, most problems remained unresolved. This war did however

have a dramatic and lasting effect on Cuban society. It created a sense of nationalism in

the country which led to the War of Independence. It set the stage for the abolition of

slavery in Cuba and opened up new avenues of resistance for slaves. It also undermined

the control of the white eIite in the eastem haIf of the country (Ridsdale, 1998: 75-76).

With the sinking of the battle ship Maine in Havana harbor, Amenca went to war with

Spain and this effectively saw to Cuba's independence in 1898.

A Bill of Rights was created for the newly Iiberated Cuba with an emphasis on the

separation of the church from the State. The American govemment imposed the Platt

Amendment that was accepted by the Constituent Assembly as an attachment to the

Cuban constitution (See Appendix 1). This amendment allowed the American

govemment to intervene in the event of future politicai instability or in situations where

American investmentshnterests were threatened (Ruiz, 1968: 22-25).

Economically, the early years of the 20" Century showed a rise in the price of

sugar resulting from destruction of beet sugar in Europe during World War One. The

Reciprocity Treaty of 1903 provided for a 20 percent reduction in U.S. tariffs on al1

Cuban exports to the United States. Tariffs were also decreased on American exports

entering Cuba American investment led to the construction of Iavish casinos, hotels and

resorts, which boosted tounsm in Cuba. Coinciding with the world depression, the sugar

market collapsed in 1930. With this collapse and the increase in sugar tariffs enacted by

the United States, cornmerciai activity remained low. Cuba had become completely

dependent on the sugar industry and it was especially obvious during this penod (Simons,

1996: 225-226; McGaffey, 1962: 19). U.S. influence accelerated land consolidation and

this in tum decreased land for subsistence agriculture. Consequently, Cuba becarne

dependent on the sugar exports to purchase its own food supplies and increases in

unernployment rates led to a growing disparity between the rich and the poor (Thomas,

1971: 694-695; Suchlicki, 1974: 151; MacGaffey, 1962: 23-24).

Capitalism and increased levels of govemment corruption became characteristics

of the newly 'independent' Cuba. Presidents from Estrada Palma (1902-1906) to Alfredo

Zayas (1921-1924) and Gerardo Machado (1925-1933) al1 ruled without much support

from the Cuban people, using repression and terrorism to rnaintain their power and access

to govemment resources. Carlos Manuel de Céspedes, son of the hero of the Ten Years'

War, eventually superseded Machado. Then the focus began to shift towards anti-

American and non-interventionist orientations. These sentiments still did not deter the

Amencan influence on Cuban politics, which was particularly evident from the actions of

Fulgencio Batista Zaldivar. Having gained the support of American Ambassador

Benjamin Sumner Wells, and power through his previous position as head of the military,

Batista ruled for two terms, embezzling governrnent funds (Betheii 1993: 68-71;

McGaffey, 1962: 20-22 Pérez, 1988: 394-395; Simons, 1996: 214-219). It was during his

presidency that the U.S. governrnent and corporate investors gained their foothold on

Cuba's economy (Simons, 1996: 262-263; Schwab 1999: W. Half of the country's

national income was derived from sugx exports, and the dependence of its economy on

the fluctuations of an industry in trouble throughout the world posed problems that no

government could soive (McGaffey, 1968: 22-24).

2.1.3 The Revolution

On July 26, N53, the first attempt to overthrow the Batista government was made

against the Moncada army post in Santiago de Cuba. Most of the revolutionaries were

killed or imprisoned. Their leader, Fidel Castro, was jailed. Whiie incarcerated, Castro

redrafted his farnous address before the tribunal sentencing him, his brother and other

conspirators to prison. History WiI1 Absolve Me, an outline of his political program, was

then distnbuted throughout Cuba.

Upon his release from pnson in 1955, Castro fled to Mexico where he prepared to

return to Cuba and pick up where he had ieft off. In 1956, he and his fellow

revolutionaries retumed on a boat named the Grarîrna in an attempt to infiltrate the island

and launch a second attack against the Batista regime. For the second time they failed and

they were forced to flee to the mountains of the Sierra Maestra where they began Guedla

tactics that in time gained ovenvhelrning support by the Cuban population. On January 1,

1959 Batista, and his Cabinet had fled the country and by the 8" of January, Fidel was in

charge (McGaffey, 1962: 24-26 ; Suchlicki, 1974: 167-172).

2.1.4 Life Under Socialism

In the 1960s a Central Planning Board was created to direct the country's

economic development. The government expropriated al1 lands and foreign

in vestments/companies, especiall y in rnining and petroleum. Banks, dong with private

telephone and transportation companies, were ais0 nationalized. The Castro governrnent

began to establish strong relations with the Soviet Union and Eastern Europe, and ir was

dunng this time that the United States announced its first embargo on exports to Cuba.

In 1961, diplomatic relations between the United States and Cuba ended and, in

Apd of that year, a CIA-spomsored invasion force of 1,200 exiles landed at Cuba's Bay

of Pigs in an attempt to overthrow the govemrnent. The Cuban army defeated them

within 72 hours. Relations be tween the U.S. and Cuba became more hostile and by 1962

there was a strengthening of tfie embargo on Cuba to include food goods and medicines

(Jatar-Hausmann, 1999: 13-16).

From 1959 to 1963, economic diversification and industrialization were the

govemment's developmental prïorities to decrease dependence on foreign trade. The

strategy mode1 was one of 'irnport substitution' and the agricuitural sector was being

geared toward this. Sugar exparts were seen as essential in attempts to industrialize Cuba

(Cole, 1998: 24-35).

By the 1970s, debts continued to increase at a rate faster than export revenues.

Sugar prices decreased and dependency on the socialist bloc remained strong (Ibid: 3 1-

42). Production of items such as milk, bread, vegetables, and clothing was low, and

ultimately industrial production was lagging behind established goals.

2.1.5 Special Period in Times of Peace

The fa11 of the Soviet Union in 1989 had severe repercussions for Cuba. The

entire economy went into a tailspin. The Soviet Union had been buying Cuba's sugar for

approximately five times the world market price. It had aIso provided Cuba with much

needed petroleum and supplies, which consequently fell from 13.3 billion tons in 1989 to

4 billion tons in 1993. Cuba lost about 70% of its import capacity, declining from over $8

billion to under and 3.5 billion annually (Schwab, 1999: 39). Food shortages were severe

and conditions in Cuba were bleak, power outages were cornmon in attempts to conserve

energy, as were shortages of fueI for cooking. Fidel Castro named this era the Special

Period in Times of Peace.

The U.S. anticipated the crumble of the Castro government and decided to tighten

its grip on the country by increasing the embargo. The Cuban Democracy Act (CDA) was

signed in 1992. It put an end to U.S. corporate subsidiary trade with Cuba and it applied

pressure on other Western countries to enforce the embargo. It also gave provisions for

sanctions on Latin Arnerican countries that traded with Cuba and allowed the government

to designate funds and supplies to anti-Castro groups inside and outside of Cuba. Most

importantly, it closed U.S. ports to al1 foreign vessels carrying goods to or from Cuba for

180 days after docking at a Cuban port (Simons, 1996: 14-16).

The Helms-Burton Bi11 in 1996 further imposed the embargo on third-country

trade by penalizing any country that conducted trade with Cuba, including again

medicines and foods (Schwab, 1999: 53-54). Despite these efforts by the U.S. to Iimit

Cuba's access to imports, the government has slowly managed to pull the economy up

through various economic reforms and a great deal of ingenuity. The ability of the Cuban

government to organize and mobilize its population has been its strongest defense against

numerous threats both internally and externally.

A general overview of Afro-Cuban culture will reorient Our attention to the

development of traditional medical systems. Background information on slave culture

helps to contextualize Afro-Cuban reiigious healers and cztrartderos.

2.2 INFLUENCE OF AFRICAN CULTURE ON CUBAN SOCIETY

2.2.1 Slave Society

O rig irzs

Tt is the area between Senegal and Angola that yielded

World. Africans brought over to Cuba represent more than

the most slaves to the New

twenty tribal groups and a11

of them have had a tremendous impact on Cuban culture, which is evident in the island's

music, dance, art and religion. There has been some disagreement surrounding the

categorization of certain African groups, and as such, it must be kept in mind that many

sIaves were named for their port of departure rather than their geographic origin.

Matibag lists six major ethnic groups and lists their places of origin.

These six principal ethnic groups include:

1. The Luccumi, who originated from the Yoruba of southwest Nigeria. the so-called Slave Coast and from Dahomey, Togo, and Benin.

3. The Carabali, peoples of the Calibar who came from what is today known as southeast Nigeria and southwes t Carneroon.

3. The Arara, who trace their origins to Dahomey and the western part of Nigeria, including the Ashanti and the Fanti.

4. The Congos (or Bantus). Africans drawn from the Congo Basin, which extends through present- day Congo-Brazzaville, Angola, Cabinda, Baszaïre, and Gabon.

5. The Mandinga. who were taken to Cuba from their homelands of the upper Niger and the Senegai and Gambia valleys.

6. The Gang&. that once lived on the coastal and interior regions of Sierra Leone and northern Liberia.

(Matibag, 1996: 19)

Because of inaccuracies with transportation records of the early sixteenth century it is

dificult to tell when exactly the first black slaves entered Cuba or from where they

originated. Slaves were purchased from Africa with money, or goods such as sugar,

tobacco, mm, guns, gunpowder, beads, cloth, machetes, or iron bars. Once in the

Carïbbean they were traded for sugar and mm, which were transported back to Europe to

begin what came to be called the "triangular trade" route (Castellanos and Castellanos,

1988: 22). The European slave trade with West Africa increased drarnatically with the

beginnings of the sugar plantations in America. Life for these individuals would never be

the sarne, especially for those on the plantations.

Plantation Lzye

Most of the individuals who survived the joumey over were sent to sugar

plantations. These big mills or ingenios were horrific places to work. Conditions were

unbearable and many of the absentee owners found it more profitable to work the slaves

to death and buy new recruits than to provide livable conditions for the existing slave

cornrnunity. Life was cheap and the frantic cycle of cultivation and harvest often led to

20-hour workdays (Murphy, 1993: 34). Those who worked nights in the boiling house

were also expected to work the following day i n the field. The sole objective of the

administrator was to get the most hours of work pss ib le out of their slaves (Pérez, 1988:

98). Slaves were subject to relentless floggings a n d beatings that were carried out to

control their actions through terror. Malnutrition and preventable diseases were common.

Slaves were not expected to live for more than seven years. Annual death rates were as

high as 10-12 per cent. Suicide was a common occurrence and often plantation owners

would be forced to take precautionary measures to ensure that this did not happen.

Further intimidation included shackles and constant surveillance (Simon, 1996: 115,

117).

For those living on the ingerrios, the Catholic Church did not exert a great deal of

power. Since the slave population was working 20 hours a day, there was Iittle tirne for

them to l e m the langage of the priests, let alone Latin so that they might understand the

prayers. Most individuals preferred to spend their free time sleeping. Individuals working

on other types of plantations, particularly the tobacco plantations, had more time to

become acquainted with Spanish culture and the Catholic religion (Ridesdale, 1999: 52-

53).

City L$e

There were fewer slaves found in the cities than in the countryside, yet these

individuals had the largest impact on Cuban culture. I n the cities, slaves had the ability to

make a life for themselves, since many had the opportunity to l e m trades. Some worked

for wages and lived the lifestyles of freed men. CathoIic and civil laws in Cuba

guaranteed the slave population (in the city and countryside) rights to private property,

inviolable mariage, and personal security. These rights were often ignored but it was

much more difficult to do this in the city where civil and diocesan authorities worked to

enforce these laws. In the country and on the plantations, there was little protection in the

way of civil nghts.

The opportunity of a relatively independent lifestyle gave Africans in urban

centers independence and the ability to form a vibrant cultural Iife. They could meet

regularly with their relatives and countrymen to celebrate the old ways and pass their

traditions on to their children. In the mid-nineteenth century, free people of color formed

nearly one-sixth of the total population (Murphy, 1993: 24-35).

2.2.2 Slave Culture

Slavery in Cuba survived up until 1880 at which point there were about 150,000

still working on the island. Although the Amencan South could rely on a re-producing

slave population, most of the Canbbean nations depended on a continuai irnport of sIave

Iabor. The constant influx of these new Africans allowed for infusions of West African

language, customs, folklore and liturgies to strengthen and reaffirm the religion and

culture of the slave population (Lewis, 1993: 189).

Out of the many African languages that were introduced with the slave trade, only

three exist today, Yoruba, Fon and Efik. Phrases of other African languages are found in

liturgies of more numerous reIi@ous cults. Ijaw, Ibo and even Arabic are examples. The

three more cornmon languages are from the Niger-Congo language family of West and

Central Africa and depend prirnarily on religious use for their survival in Cuba.

Religion became an important part of preserving African culture. In remaining

faithful to their ancestra

descendants preserved

discrimination and other

traditions through religîous practices, African slaves and their

a source of resistance against forced labor, prejudice,

foms of oppression. According to Matibag, "it was through the

process of the cultural mixing that this resistance occurred, precisely by taking objects,

terrns, practices and narratives identified with European and African ethnic groups and

making them over into the ingredients of a 'national culture' (1996: 17-18).

2.2.3 Cuba's Free Black Population

From 1500 to 1800, slavery was relatively 'mild' or small-scale. Slaves working

as artisans or on srnaIl farrns had the right of conrtacihz, which meant that they had the

right to buy their freedom. Their price would be pubticly announced in a court of law and

then he/she would go about paying it through a number of installments (Wolf L969: 253).

Many were able to save enough to pay % of the purchase price (about $50) and se11 their

trades to earn the rest. Coartacihz was purchased rnainly by native born slaves or criollo

slaves. Bozales or slaves bom in Africa had to be on the island for at least seven years

before their prices could be set.

Interestingly. it was the free black population that played an integral part in

Cuba's military forces. From the onset of colonialism, this group constituted a large

portion of the Cuban military. From the sixteenth century until the eighteenth century,

they contributed more to the country's national defense than the white population.

Incentives for them to remain involved in the military continued through the height of the

slave vade as army service became a means of buying one's freedom (Klien 1967: 196-

197, 199).

It was dunng the 1800s that Cuba began to see another category of free blacks,

fhe cinzarrones. These bands of escaped slaves hid in the mountains and forest areas.

They created small communities and etched out a living by cultivating small plots of land

called palenques (Ridesdaie, 1999: 40). These groups also occasionally raïded plantations

for food, sometimes killing slave owners and freeing slaves (Murphy, 1988: 118). These

cimarrones were considered a threat to the government and plantation owners since they

provided a haven for runaway slaves and a basis for slave insurrection. These

communities reproduced as best they could the structure of their native societies and as

they were not Iimited or controlled by the Spanish sovereign and the Catholic Church,

returned to their African culture and roots (Kiien, 1967, 69-70; Murphy, 1988: 118).

2.2.4 Folk Catholicism

Al1 religions evolve over time and the Catholic religion is no exception. Before

Catholicism anïved to Cuba it had undergone a number of changes in Spain. During the

sixteenth and seventeenth centuries there was a rnovement to create a doctrine that

aIlowed for a compromise between new official ecclesiastical Catholicism and the basic

Catholic cult manifestation or folk interpretations which placed more emphasis on the

saints. These folk interpretations had specialized cults of personags. The cult of Jesus

Christ and the cult of Virgin Mary are examples. The Catholic Church wanted to unify its

masses and reaffirm its influence by uniting al1 of these folk cults under a more integrated

doctrine. The Spanish missionary movement was Iargely a reaction to the growth of

Protestantisrn in Europe (Brandon 1993 : 45-48, 167; Ridesdale, 1999: 3 1-33).

Tt was this form of Folk Catholicism that was initially brought across to Cuba and

most colonists remained faithful to it even after the new doctrines were promoted in

Spain. Although the Catholic Church would have preferred that the Spanish colonies

adopt new 'purer' doctrines, the Catholic administrators and clergymen were unable to

control the practice of FoIk Catholicism. Ultimately, the Church realized that it was of

greater importance that individuals stay within the reaIm of the Catholic religion than

aggravate followers into rnoving towards Protestantism. Most settlers in Cuba, black and

white, had a past which related directIy to, or gravitated towards Folk Catholicism.

Eventually, the majority of religious practices, from Afro-Cuban to FoIk Catholics,

considered themselves to be Catholic even though the term 'Catholic' would be defined

in varying manners (Ridesdale, 1999: 32).

Dechrations and ordinances put forth during the seventeenth century stipulated

that ail African slaves were to be converted into the Roman Catholic faith, and the

purpose of the Church, with regards to slavery, can be seen as being purely evangelical.

Slavery was believed to be the best method by which Africans could be shown the way of

God. They were considered to be 'tools with souls.' The black population was required to

serve their masters while being encouraged to Save their imrnortal souls (Thomas 197 1:

39; Simons, 1996: 99)

2.2.5 Cabildos

Although cabildos are known throughout Latin America as municipal councils

made up of local property owners, the term cabildo had an additional significance in

Cuba (Pérez, 1988, 41). Cabildos were organizations or clubs that were made up of both

urban slaves and genre de color (or freed slaves). These societies generally consisted of

individuals from the same African nation or ethnic groups. Cabildos were particularly

important since they allowed for the preservation of African mythologies and customs.

These clubs provided a forum for the performance of traditional dances, songs and

religious practices and a haven in which they could remember their African roots and a

way of life that was now lost.

The organization of the African-Cuban cabildos was largely a result of the

conditions of urban slavery and the skilled slaves who were rented out as musicians,

cooks, etc. and thus had access to free time (Klein, 1967:lOO-102). Each cabildo

represented what the Catholic Church of Cuba felt to be a distinct African 'nation' or

ethnic group. Their members formed a self-supporting, mutual-aid society providing care

for the infirm, elderly, and arranging funerals for the dead. In some cases cabildos

collected funds to buy the freedorn for its sIave members (Murphy, 1988: 28-29). The

cabildo thus brought certain benefits of secunty, association and entertainment into its

marginalized space within Cuban society, while preserving African languages (Matibag,

1996: 22-23).

Surprisingly, these clubs received support from the Catholic Church. Religious

officiais felt that, by alIowing the clubs to exist, they could take advantage of these

forums to carry out their evangelical work to a broader population. Priests would often go

to visit these cabildos to adrninister confirmations, teach the Christian doctrine and pray

before the images of the saints (Simons, 1996: 101). Clergymen were often appointed to a

specific cabildo where they would preach on Sundays to preach a sermon. The Church

also assigned to each club a saint which was to be its patron saint - a practice is reflected

in the organization of today's Afro-Cuban religious orientations (Ridesdale, 1999: 48).

UItirnately, the hegemonic project of the Catholic Church never redly succeeded

because the African popuIation never fully converted. Cabildos eventually were forced to

becarne underground secret organizations as restrictions and Iaws designed to contain

cabildo dances in the nineteenth century becarne increasingly intrusive and restrictive

(Brandon, 1993: 85).

It is important to mention a number of the ethnically distinct Afro-Cuban religions

that arose from interactions of these 'brotherhoods' or clubs. As Murphy States, "various

Congo groups established Ngalzga, Mayombe or Polo Maizte traditions, while the Efik of

the Niger delta created the Abakua society (often referred to as iiafiigos)" (1988: 32).

Sanreria arose out of these cabildos designated to Yoruba peoples. It is worth noting that

even today these religions are largely secret - a result of the past persecution of the

cabi Idos.

2.3 SYNCRETISM

According to Melville Herskovits (1937 quoted in Ridesdale, 1999: log), the term

'syncretism' is defined as the merging of African and Roman Catholic religions in

different locations of the worId. He views this assimilation as being without much

forethought on the part of their practitioners. Herskovits' mode1 of syncretism, coupled

with notions of traditional anthropological research which have in the past presented

studies on what was deemed to be bounded, 'simple, 'primitive' isolates, have led to the

misinterpretation of syncretism. Syncretism under this guise was thought to be the

adoption of new belief systems by a confused group of individuals who have had no

active role in this process (Brandon, 1993: 158; Ridesdale, 1999: 109-1 10).

Another definition of syncretism, put forth by Roger Bastide, presents the idea of

syncretism and syrnbiosis in a context, which displays a very specific view of structural

differentiation and harmony between African and Christian religions. In his book The

African Religions in Brazil, Bastide explains syncretism on an ecological level Iooking at

the CO-existence of the two religions in space and tinie, clairning that they exist within the

same structural framework. He goes on to state that it was the ecological conditions of the

time that created temporal and spatiai religious associations and relationships that were

forced on the slave population. The Afncan slave population had to shift their religious

festivals and holidays to that of the saints, and this meant accepting the Gregorian

calendar. They had to adapt their representations of sacred time and space to fit the

CatholidSpanish ideology (Murphy, 1993: 122; Bastide, 1960: 272).

The life of oppression that was forced upon slave society was not without its

means of resistance, and one form was the maintenance and continued practice of African

religions. As Murphy puts it, " The very act of keeping alive an alternative religion such

as Santel-ia is an act of resistance, a refusal to capitulate to the ideology of slavery and the

selective Christianity that supported it" (Murphy, 1993:119). To the public world, slaves

would be practicing Catholics, but they would use this religion to help maintain their own

religious traditions and empower themselves against the white world.

Following Ridesdale (1999) and Brandon (1993), 1 think that it was only through

the hiding of their own religious orientations that the Catholic religion became cornbined

with that of various African traditions. The syncretism that came to exist between the

Catholic Church and various Afncan traditions was in my view a correspondence

between religions. African religions influenced each other, and each adopted and adjusted

their practices accordingly. Those who practice Regla de Palo, for example, also have

adopted figures similar to the Yoruba orishas that are called kimprmgrdu. Their names are

different, but the basic representations are the same. Included within this religious

syncretism is also the practice of Spiritism or Espiritismo, which initially was considered

a 'scientific' phenomenon of cornmunicating with the dead. This spintual orientation was

promoted in books written by Alex Kardec and, once in Cuba was readily accepted into

both Santen'a and Regla de Pa20 (Ridsdale, 1998: 41-42; CasteIIanos, 1996: 48).

2.4 TUNSCULTURATION

To sum up, it seems fitting to end this section with a bnef note on an important

concept put forth by famous Cuban anthropologist Fernandez Ortiz. According to him, a11

elements of Cuban culture can be defined within the realm of 'Transculturation" and,

since both religion and society are reflections of this process, it is a term that can offer

clarification in attempts to understand Cuba and its sociaI history.

AI1 ethnic groups brought to the island undenvent a process that Ortiz defines as

"the extremely complex transmutations of culture." This process of transculturation saw

"each cultural group being tom from its native moorings and faced with the problem of

disadjustment and readjustment, of 'deculturation' and Lacculturation."' Africans coming

from the Senegal, Guinea, the Congo, Angola and even Mozambique were taken from

their own social spheres and their cultures were crushed under the weight of the dominant

European rule. Ortiz further States that, arnong al1 peoples throughout historical

evolution, there has always existed a process of change from one culture to another and

that this occurs at differing intervals. What is interesting about Cuba is the fact that, since

the 16" Century, al1 of its classes, races and culture, imrnigrating by will or force, have

been exogenous and have been tom from their pIaces of origin, al1 having to cut their

links with their old society and adjust themselves into another. The term transcuIturation

seems more fitting to the case of Cuba because, in the transitory process of adopting

another culture, Afro-Cubans had to undergo a process of loss or an uprooting of a

previous one, a deculturation (Ortiz, 1947: 98-103). What is important about Ortiz's

notion of transculturation is that it offers explanations into the new religious orientations

that came to appear later. It defines the process through which these new religions came

into existence and the adaptations that the old religions came to undertake. One could

even suggest that the concept of transculturation expIains how Cubans came to define

their own identities both in colonial and post-colonial times.

In discussing cultural identity and the development of Afro-Cuban culture, one

can now narrow the scope down to religious and spiritual orientations, for it is here that

the realm of traditional medicine developed. The following chapter examines several of

the more common Afro-Cuban religious orientations, and Spiritism, to provide

explanations regarding religious/spiritual healing practices. From here, the developrnent

of Cuba's conventional medical system is discussed dong with its more recent struggles

and accornplishments.

LITERATURE REVlEW PART II: TRADITIONAL AND CONVENTIONAL lVEDICAL SYSTEMS.

Prearnble:

Most practitioners of traditional medicine in Cuba perform their healing practices

through a specific religious perspective. Al1 of the concepts exarnined here are

interconnected within a system of syncretism that has corne to characterize Cuban

culture. The description of healing and herbalistic properties within traditional rnedicine

wilI provide insights into why such religions would influence health care decisions.

Medical traditions wilI be examined in detail, to illustrate with geater clarity the works

of spiritual and religious crrranderos.

The second section of this chapter provides background information of the

developrnent of Cuba's conventional medical system, it describes the Farnily Doctor

Program and examines how the political and economic situations stemming from the

United States' long standing embargo have affected today's health care practices. It

discusses how Cuba has managed to work around these obstacles in its drive to maintain

its high standards in orthodox rnedicine which have, since the revolution, been freely

accessed by the island's entire population.

3.1 TRADITIONAL MEDICAL SYSTEMS

3.1.1 Czwanderos

The definition of curanderismo is diverse and the techniques it comprises Vary

from region to region and country to country. Tt may also have different labels attached

to it, including rural folk medicine, Mexican American healing practices, Indian or Afro-

Cuban traditional practices, etc. According to Perrone et al (1989), cz~randerisino is

defined as a set of folk medical beliefs, rituals, and practices that address the needs of

traditional people. These needs may be psycholo@cal, spiritual and social. This form of

healing is holistic in nature since there is no mindhody separation. The authors of

Medicine Women. Curanderas. and Women Doctors consider it to be the art of Hispanic

healing. The curaridero/a treats his or her patients with remedies that have helped for

generations and believe that they are successful only when their patients recover. If the

patient does not recover, then the curanderoh feels that it is God's wiIl (or the wills of the

gods) will that they look elsewhere for treatment.

Different theories exist about illness. Some patients feel that they are sick as a

result of the devil gaining a foothold on their lives, because of evil magic, or witchcraft.

Sickness is frequently thought of as an imbatance between good and evil within the body

and the czrraitderu represents the healing graces of God who brings equilibrium back into

their lives (Penone et al., 1989: 86-87). One of the equilibrium mechanisms of

curuizden'srno culture is the notion that God fights against the devil. Religion is the

positive influence on the patient, in the procedure, techniques and treatments (Ibid: 90-

93). This can be seen in religious orientations like Regla de Palo, Spiritualisrn and

Santeria.

The term crwandero is somewhat generic and can encompass herbs, midwifery,

massage, and spintual techniques. A herbaiist or yerbera may also be considered a

cztrandero or vice versa. in Cuba, there are canzpasinos (peasants) who have a geat deal

of knowledge regarding plants and the rnedicinal properties of plants and because of this

ability they are labeled crtranderos. In general, anyone can be considered a crtrandero as

long as he/she has the capacity to cure that exceeds that of the average person, even if it

is for only one illness. A czcrandero can be religious or non-religious, this is not deemed

to be important; again it is only the capacity to heal that matters.

3.1.2 SanferiQ

Cuban SailterLa is denved from the orislia-based religion practiced by the Yoruba

of West Africa. The Yoruba were not a unified or cohesive group, but a configuration of

more than fifty politically diverse subgroups. These subgroups did, however, share a

cornrnon history, language, dress, rnythology and ritual symbolism (Matibag, 1996: 5 1).

According to Murphy, the Yoruba were and still are great urban people. They are people

who had lived in an urban atmosphere for at Ieast one thousand years before amving to

the New World under the bondage of slavery (1988: 7). This is reflected in the ease with

which they could accept various elements of the Catholic religion and adopted them into

their own practices. The Yoruba had long been exposed to foreign cultures and religious

orientations.

The Yoruba religion itself is monotheistic where one God, Olod~irnare, is

worshipped. It is from him that al1 living things are created and his force is incarnated in

the world as ashé. Ashé is his power. It is Iife. strength and riphteousness. It is the

divine power from which the universe was created. Humans are able to obtain some of

this power through rituals, divinations, spells, possession, and invocations by providing

animai sacrifices and food offerings colIectively known as ebbo to the orishas (Gonzales-

Wippler, 1998: 5, 12; Ridsdale, 1998: 18).

The Yoruba worship figures that can be compared to guardian angels who are

caIIed orishas. Orislzas are the chiidren or servants of Olodrimare. Every individual's life

is overseen by one of these orishas. Yoruba priests invoke these oridzas so that they may

undertake cures, cast spells, carry out rnagic and successfuIIy perfom rituais. Each

orislza has particular charactet-istics and represents or controls a specific aspect of life

(Flores Peiia and Evanchuk, 1994: 8; Gonzales-Wippler, 1998: 14-15). The main o~s f zas

worshiped in Cuba can be found in Appendix 2 with their accorded properties.

In addition to the orislras, the Yoruba also practice ancestor worship. They cal1

their ancestors' ara onin, or "people of heaven," and every generation appreciates and

recognizes the one before it. These ancestors are often petitioned by the living to grant

favors and wishes. The Yoruba believe that each individual has an OB' or 'spiritual force'

that is more than just a soul. Et is the very source of the individual and as such is shared

by members of the individual's family, living or dead. It provides a continuum, a line

connecting humans from their past to their present. Similarities in 'physical appearances

amongst families are thought to be a reflection of this sharing of souIs (Murphy 1993: 9-

10; Santiago, 1993: 15).

Priests and priestesses or santeros and santeras of the Santeni religion must

participate in a Iengthy and detailed training process to truly understand and l e m the

attributes of the orishas. These attributes include spells, dances, prayers, songs, and

herbal healing. The herbs are a way of classifying al1 of Yoruba expenence, a form of

grammm for the religion that is paralleled by the characteristics or attributes of the

orishas (Murphy, 1993: 13-15).

Higher up in this religious hierarchy is the babalow. A babaloiv cm only be a

man and he is the high priest of Santerfn. He is initiated under Oninlal and has a system

of divination that is much more complicated than that of the sulztero. Babalows spend

their entire life learning the verses and lessons of Ifa (Lefever, 1996: 321). They use three

systems of divination, the opelé, the Table oflfa and the ikirt. The opelé consists of a

chain holding eight oval medallions made of coconut rinds and is used in everyday

consultations. In more complicated situations. the Table of Zfii is employed which consists

of a round wooden tray that has vanous African figures carved into it. The most

important of the divination systems is the sacred paIm nuts or ikitz. These are used for the

crowning of kings and in various initiation ceremonies. Santeros will sometimes seek out

a babalow when they are faced by very difficult situations or are in disagreement about

various issues (Gonzales-Wippler, 1998: 99-100; Barnet, 199535).

Santeros speak to their gods through a systern of divination that uses coconuts and

cowrie shells. Through divination, the sarztero can determine the events occumng in a

person's life, what hisher probIems are and how they can be addressed. This information

cornes directly from the orisha. This system can also be used to find out which orisha

' Orunla is the patron of babalawos, he is known as the holy diviner (Gonzalez-Wippler, 1998: 362).

rules a person's life and to ask questions about rituals and ceremonies (Ramos, 1996: 70;

Lefever, 1996: 321).

Communication with the orishas is not only limited to the divination systerns

mentioned above, but also through the advent of possession. Dances, songs and

drumbeats are well rehearsed and choreographed to represent each of the orishas who are

easily recognizable. These movements, music and the adrenaline experienced by the

folIower trigger the possession of the priests/priestesses by a given orishn. Once in this

trance the orisha can speak directly to his audience and give them advice to deal with

their problems, prophesy about their future and answer any questions that they may have

(Ridsdale, 1998: 2 1-23).

Plants or herbs are an integral part of the religious ceremonies and have an

important role in casting spells, healing, as ebbo, and essentially every facet of religious

practice. The herbs, plants, roots and trees used in Sameria are collectively called erve.

According to Gonzales-Wippler, al1 sanreros are botanical experts, and one of the first

Iessons that an initiate or yaw6 must learn is how to identify various plants and herbs,

dong with their characteristics (1998: 133).

Herbal baths, with plants that have the ashé of various orishas are often

prescnbed. They are thought to wash away the evil influences that may be dorninating a

person or causing them physical illness, There are times when the spiritual world of

magic inflicts physical pain on an individua1. Herbs are often used in remedies to address

these evil spells or influences (Ibid: 138-139). Santenh is discussed as a traditional

medical system by William Harvey in his article "Voodoo and Santerfa: Traditional

Healing Techniques in Haiti and Cuba," but unfortunately the author barely touches on

most of the important issues related to the curative elements of the religion, particularly

the use of plants.

Dancing with the Saints, a book by Miguel Santiago, on the other hand, provides a

cornprehensive explanation of the role of plants within Santeria. He claims that,

.- .medicina1 herbs and roots, as weI1 a s poisonous ones, obtain their properties from the supematural world. These embody souis, thus becoming a sort o f nonhuman spirit, The reasoning cornes from the idea that plants and anirnals, as human beings, live and die; therefore, they also belong to the spiritua1 world.

Plants and roots then, as weI1 as nonliving elements such as Stones and water, are perceived as sacred vehicles of the gods' power that can be used for, in, o r against people. AI1 ekments of nature, fiowers, water, etc., represent a sort of neuual vehicle for active forces that can be intercepted and used when necessary. This neutrality towards man represents the mysterious gift they incarnate through the orishs. A Ieaf o r seed that could be used in tea to heal, can also be used in other ways to kill. In other words, the power that lies behind these natural forces is neutral to man until, by way of knowledge. experience, and intention. these forces are intercepted and asked to serve (1993: 15-16).

Plants are often collected and used in the creation of a sacred liquid called onziero.

Known also for its curative property omiero is a mixture of herbs, water, the sacrificial

blood of animals , and other secret ingredients (Gonzales-Wippler, 1998: 138-142). In

accordance with works published by Gonzalez-Wippler, Murphy States that, "herbs

sacred to the orishas are like holy infusions, to focus and channel ashé, and this ashé in

turn has amazing powers to cure the body and soul." Omiero is always present during

cerernonies, and rituals in Sameria. It is used to consecrate and purify items. In this

sense its properties are similar to holy water. Orniero can be used to purify the body if

touched with it or ingested.

Depending on the ceremony and orisha celebrated, the oiniero consists of plants

attributed to this particular figure. Elecarnpane (a plant of Obatala) that has been blessed

in a ceremony can be used to cure bronchitis; sarsaparilla, a plant of Chango, will also

alleviate nervous disorders if it is consecrated (See Appendix # 4). Herbs are used to

energize spiritual rnedicines. Bits and pieces of small symbolic articles can be pieced

together with appropriate herbs to protect the owner from evil. They are called niche

Osain, or medicines sacred to Osain. Osain is the orisha that controls al1 ewe. According

to Murphy, he hides in the Forest and tells his secrets only to those who know where to

look (1994: 46-47).

These cowxie shek rnake up the sea-shetl divinationbm as caracoles. The systemuses sideen shefls &hough there are twenty-one iatotaL Five we set asi& by the teeder. Through the pattern6 m which these sheh fa& the orÏshas give th& messages and advice.

A smaû shrine fannd in the home of one of my inf'onmu&s. On dite tnp sheifis the figara ai Santa B d a r a (Chango).

3.1.3 Regla de Palos: Pa20 MontePaLo Mayombe

Regla de Palos, also known as Palo Monte and Palo Mayonzbe, is a monotheistic

religion that orïginated from the Kongo. The Kongo, which was the colonial Belgian

Congo, is present day Zaïre (Matibag, 1996: 155). Pulo is a Spanish word meaning

'bnnch' or 'wooden stick' which is an appropriate narne for this religion since its

practitioners work with various trees, woods and herbs to conduct their magic spells.

Knowledge and appreciation of flora are highly significant in this religion since it is

believed that each living plant has a sou1 or spirit and Paleros/Mayoïnberos (priests

within the Palo Monte religion) rnust pay homage to these spirits (Gonzalez-Wippler,

1998: 338).

Both females and males cari be initiated as pnests- Within Pa10 Mayornbe ihere

are two branches or divisions. There is the good branch calIed "Christian" Mayonibe and

the evil branch calied the "Jewish" or "unbaptized" Mayombe (Barnet, 1996: 98). One of

the main differentiations made is in how they feed their cauldrons. Good Mayomberos

sprinkle their ngarzga (or cauldron in which their secrets are kept) with holy water. The

"Jewish" Palero does not. Following the CathoIic tradition, in Sameria and Palo Monte,

it is believed that anything that is not baptized is evi1 and does not belong to God. It is

thought that holy water repels evil, and purifies, and that evil spirits are frightened away

by this water (Gonzales-Wippler, 1998: 238). A good Palero in Mayornbe, rnost

importantly, works with the forces of God, whom they cal1 Sambia or Nsarnbi. PaIeros

jztdios (Jewish) or the 'unbaptized ' work with the forces of evil and Kadienzpembe, a

name given to the devil by the Kongos.

Al1 paleros, however, work with the spirits of nature, such as trees, plants, rain,

river water, and animaIs (Matibag, 1996: 167-168; Bamet, 1996: 103-107; Gonzales-

Wippler, 1998: 239). They also work directly with the spirits of the dead. A 'Christian'

palero will work with positive spints while the 'Jewish' palero works with spirits of

suicides, criminals, and evil witches. The spirit that lives inside the cauldron is cailed

Mpruzgo Nkira or Fuiri. The chants used to invoke the spints are called mambos. The

source of a palero 's power is the cauldron also known as the prenda or rigaizga, a Kongo

word that means "dead," "spirit," or "supernatural force."

Found within this rzgarzga is a human skulI and bones. With the skull and the

brain, the spint can think; additionally, the fingers, toes, ribs and long leg bones allow it

to ' r u ' and carry out its duties. Also included are graveyard dust, branches, herbs,

insects, animal and bird carcasses and hot spices. This is its basic foundation (Gonzales-

Wippler, 1998: 239; Matibag1996: 163). According to Cuervo Hewitt (1988:57), pieces

of glass or mirror are also placed in the cauldron since it is considered a sign of power

among descendents of the Congo.

The izganga does what its owner tells it to do. When the spirit carries out the

orders of its master, then the master orpalero will feed it the blood of a sacrificial animal

as an expression of gratitude. Ashes are rubbed on the hands before and after a ritual for

purification (Cuervo Hewitt, 1988: 54: Matibag, 1996: 155). The Mayoinbero believes

that his nganga is like a small world that he dorninates. The spirit rules over the herbs and

the animais residing in the cauldron with it. The palero in tum rules the Fuin' who obeys

its orders. It is like a slave to the Mayoinbero (Matibag, 1996: 246).

Paleros also practice ancestor worship and pay homage to the spirits of the dead.

They too, like the Santerfa practitioners, worship figures that have been syncronized with

the Catholic saints and the orishas. These figures are called kimpungulu. The figure

known as Chang6 in Santeria, Santa Barbara in the Catholic religion and Siete Rayos

(seven lightening bolts) or Nsasi in Pa10 Monte is the most actively worshipped figure by

practitioners. Paleros communicate with their nganga and Kinzp~i~tgtrl~r through pieces of

coco, although some can speak directIy to their spirit and do not require a divination

system.

In terms of religious healing, "Christian" paleros often do positive works for the

cornmunity. Many believe that they possess the ability to treat cifficult and incurable

diseases (Gonzales Wippler, 1998: 241). According to Cuervo Hewitt (1988: 58), a witch

from the Kongo with his medicinal objects can cure whatever is harrning or hurting a

person. Whether or not a medicine is curative or poisonous depends on, and is always

controlled by, the priest or palero.

A ni3&Lmmrigrngaaiththcpslos mdtk kipnbainridc.

3.1.4 EspiritismolSpiritism

Stemrning from a European background, Espiririsrno or Spiritism is a religious

orientation that has been integrated into ail of the Afro-Cuban religions. This is due

partially to the element of ancestor wonhip that is practiced by these followers and

practitioners. Santeros and paleros consider themselves to be espir-zlistas but an

espiritista is not necessarily a sanrero or palero. Such individuals simply have the

capacity to communicate with the spirits of the dead.

Espirilismo in Latin America developed from a mixture of Spintualism and the

beliefs of a French philosopher called Hippolyte Leon Denizard Rivail, known under the

pseudonym of AlIan Kardec. Kardec believed that spintual progress could only be

achieved through a series of progressive reincarnations. He claimed that spirits must pass

through a number of tests to enhance their moral purity by overcoming episodes of

suffering and ethical dilemmas. Life itself is the test and it is up to individuals to make

the most of it so they may ascend the celestial hierarchy. Kardec, in this sense, adapted

Spiritism to Christianity and the notion that what is done in this life is either punished or

rewarded in the afterlife. He wrote two very influential books called 'The Gospel

According to Spintism" and "the Book of Spirits." Kardec emphasized how important it

was for people to communicate with the spirit world to address their own personal

problems. Latino Espin'tismo teaches of the importance of realizing one's spiritual

essence and giving up matenal desires to become closer to God (Kardec, 1963: 96-97;

Gonzalez-Wippler, 1998: 376).

According to AIan Harwood, an espiritista or Spintist is defined as any person

who exhibits at least one of the following characteristics: " i) identifies as a Spiritist, ii)

believes in mediumistic communication and the removal of h m f u l spiritual influences

through the intervention of mediums, iii) regularly, or in times of cnsis, visits a Spiritist

either privately or at public sessions, and iv) perforrns certain rituals in the home to

cleanse the prernises of harmful spiritual influences" (1977: 27). Although this definition

is specific to his own sample of inforrnants, it does highlight three general characteristics

worth noting, the basic beliefs in rnediurnship, the belief in spirits and, the beIief that

humans can cornmunicate and impose their wiII on these spirit entities. Al1 of the

characteristics mentioned above can be seen in Cuba's version of Espiritisrno.

Espin-tismo was originally viewed more as a science than as a religious

manifestation, and this allowed it to diffuse through Cuban society in the mid-late

nineteenth century from the urban Creole rniddle class down through to the rural areas. It

did not contradict the Catholic religion but instead became mixed with the prevalent Folk

Catholicism and was also adopted into the Afro-Cuban reIigions. It is interesting to note

that through this adoption of Espiririsrno, a larger number of white Cubans became

interested in the African religious orientations (Ridsdale, 1998: 62).

When its popularity increased arnong the lower middle class and lower classes of

both bIacks and whites, people bepan to focus on its potential healing aspects. They

looked for solutions to sickness and other problems of day to day living. Solutions to

these problems were sought during a séance (Ibid: 64).

A typical séance is conducted with several rnediums. There are several variants of

mediums: those that see spirits, those that see the future, those that hear the spirits,

rnediums that become possessed by spirits and rnediurns that can banish spirits.

Sometimes espiritistas will hold cetttros (centers) on specific days and meet to have

séances, Here consultations are @en to visitors and, dunng a session, the medium will

ascertain the problems facing the client (often cards are used to do this) and give him/her

a recela which is like a prescription with instructions on what to do to alleviate the

situation. This may range from an herbal bath to prayers to the dead, a cornplicated

deansing ntual, or magic spelk.

Problems in these sessions can be personal, ernotional, or physicd. Often people

who are experiencing health problems, or have farnily members expenencing hedth

problems, will visit an e ~ p i ~ t i s t a . On various occasions, herbal remedies are suggested,

other times perfumes are created. This generally depends on the medium and the problem

faced by the client. Certain espiritistas are better than others when it cornes to using

medicinal plants, sorne specialize in diagnosing health probIems and others do not

(Gonzales-Wippler, 1998: 279).

It should be rnentioned that, although this review of Iiterature addresses the four

foms of religious/spiritual orientations above and their curative properties, traditional

healing is neither limited to, nor dependent on, strong religious beIiefs. There existed

many curaizderos and yerberos (herbalists) who had extensive knowledge of the curative

properties of local plant-life but, as later discussed in chapter 6, there exists quite a bit of

movement between the boundaries of these medical systems and thus the practices of the

c~iraizdero. A curandero/a, for example, can be a Catholic only, a santero/a, or

espiritista, and yet the ability to heal may have nothing to do with hisher beliefs in these

areas.

It is important to reiterate at this point that the traditionai medical systems

discussed and studied in this thesis rest heavily upon the retigious traditions of the Cuban

population, particularly Afro-Cuban traditions. Thus, in an attempt to outline the

development and the practices of some of these traditional medicd systems, it has been

necessary to delve into some of the basic religious orientations and their specific views

on healing and the use of herbs.

In the following section, conventional medicine will be examined to complement

the medical systems previously discussed. Special emphasis will be gïven to the Farnily

Medicine P r o p m , which has been integral part of the country's approaches to provide

adequate care to its population, dong with the use of herbal medicines to combat drug

shortabes.

3.2 DEVELOPMENT OF CONVENTIONAL MEDICINE IN CUBA

3.1.1 Conventional Medicine and Cuba before the Revolution

With colonization, initial conventional health care provided in Cuba was a frGl

transplant of the Spanish system. The main 'orthodox' figures in the realm of medicine

were the barber, bIeeder, dentist, surgeon, pharmacist and physician. Physicians in those

days, and rnedicine in general, revolved around metaph ysical notions of vital fluids,

bleeding techniques, balsams and purgatives. Traditional forms of medicine via the

curandero, Afro-Cuban religious healers, and other herbal experts were also valuable

medical resources (DanieIson, 1979: 22-23).

Colonial hospitals were supported by the Spanish king and from charïty from the

nch. Needless to Say, funding for medicine was not a high priority. Public sanitation and

vaccination campaigns against small pox were initiated but, due to the lack of structural

organization, they were unsuccessful in carrying-out large scale inoculation of the

population. On the plantations, the owner was unlikely to employ a Spanish surgeon or

bleeder, etc. to protect the health of his slaves. African traditional healers were generally

given freedom and encouragement to practice their arts.

During the tum of the lgLh and early 2oth century (18984927). yellow fever and

malaria outbreaks were eradicated and sanitary conditions improved in various parts of

the island. Small advances were made in surgery and clinical medicine. There was also

an increase in the number of prepaid clinics and hospital plans that were offered to

Spanish immigrants.

According to Danielson, from 1930-1945, an increase could be found in

professional federations, employment secunties, govemment recognition of professional

autonomy, hegemony of physicians and private and cooperative prepaid clinics. New

legislation implemented several secunty progarns with health care benefits. Despite the

scientific revolution in medicine at this tirne, and industrial revolutions taking place

across the globe, organization and dispersion of adequate conventional health care

throughout Havana and the interior regions of Cuba still was not possible (1974: 20-22).

In the first part of the 2oth century, there existed huge inequalities in the

distribution of conventional medicine between rural Cuba and Havana. Only 26 percent

of the population lived in Havana, yet it contained 60 percent of physicians and 80

percent of the hospital beds. Four out of five rural workers did not have access to

conventional medical systems. Rural populations lived in poverty stricken conditions

where intestinal parasites, undemourishment, and sicknesses due to unsanitary conditions

were common. There was only one hospital located in rural Cuba at this time. During

Batista's time in power, Cuba's poor suffered neglect and oppression, especially when it

came to conventional medicine (Schwab, 1998: 55-56).

3.1.2 Conventional Medicine and Cuba after the Revolution

After 1959, the new povemment used money from newly nationalized companies,

industries and property and began rebuildinp Cuba and its conventional health system. In

the 1960s and 1970s, the new health care system had three major objectives: to increase

skilled health workers, since it had Iost so many in the exodus to America when the

revolutionaries gained power; to promote the revolution through literacy carnpaigns,

circzdos Nzfaiztiles (daycare), improved transportation, etc. for, without a literate

population and adequate infrastructure, problems in the area of conventional health care

could not be adequately addressed; to become an example to the world that low economic

status did not mean appalling health figures (MacDonald, 1999: 135). Improvements

were emphasized in the area of food supplies, hygiene, and housing. With these goals in

mind. the post revolutionary medical system had succeeded in reducing the frequency of

infectious diseases to levels comparable to that of the West (Guttmacher, 1989:169).

The pre-revoIutionary conventional medical system had failed to accommodate

the rural population and the poor. After 1959, installations were made into the rural

medical service network, dong with the development of polyclinics, hospitals and

preventive and speciaiized treatment centers. According to Schwab, "Cuba has become a

powerhouse of medical innovation. In this small country of only 1 I million people there

are 284 hospitals, 440 polyclinics, 11 national research institutes, 4 dental schools, and 28

medical colleges, with some 60,000 doctors and more than 5,000 researchers." Today,

urban and mral neighborhoods each have polyclinics that in total serve 30,000 to 40,000

people. These community-based centers emphasize preventative and primary care and

reach 95 percent of the population. Family planning resources and contraceptives are

provided by the polyclinics and 99 percent of births take place in hospitals (1998: 61-61).

For the first time in history, the country has an organized 'orthodox' medical system that

sees to al1 of its citizens. After the revolution, Cuba began to produce its own

pharmaceuticals. By 1974, national production of medicine had increased in volume by

80% and by type 300% (MacDonaId, 1999: 113).

3.1.3 The Family Doctor Program

Family doctors became an important innovation for the conventional system. In

198 1 it had been found that a nurnber of general practitioners were unable to cary out

new therapies or provide new medicines available from Cuba's other breakthroughs

(pharmaceutical research especially) because of lack of access to new information. By

1984, Poder Popuiar, a Local organization that deals with municipal issues, established a

proposal by which farnily mediciiie would be given a specialty status.

A program was initiated called ''Integral General Medicine-" Here doctors

received three years of training in farnily medicine before they chose between generalist

and specialist careers. Training to become a family doctor would indude rotations in

primary care specialties: interna1 medicine, pediatrics, and obstetncs and gynecology.

These three years of study would be cm-ied out in the context of work experience as a

general practitioner. The idea was that each general practitioner would spend three days

working in the c h i c and the rest of the week studying course matenal. The ultimate

objective of this program was to have at least 20 percent of Cuba's senerai practitioners

specializing in farnily medicine by 1989. Numbers exceeded origind expectations and, as

of 1989, 50 percent of the population was being served by a farnily rnedical specialist as

their regular doctor (MacDonald, 1999: 157-58; Waitzkin, et ai, 1997: 251-252).

Training consisted of the compIetion of twelve modules that G.P.s can take

through correspondence. Although teaching prograrns are located in larger centers, the

teaching staff will also travel around and hold three-hour residentiai tutond sessions on

the materials to al1 the polyclinics participating. The family medical specialist has a

number of primary responsibilities. This individual is involved in cornrnunity health

activities like Iocai food safety, hygiene cornmittees, workshops, etc. She/he is also

involved in addressing sources of community stress (Iike bad housing or social habits

within families) and is generally seen as an agent for health promotion (MacDonald,

1999: 158-159).

The family doctor is the cornerstone of Cuba's primary heaIth care system. The

creation of the Farnily Medical Specialist has changed the role of the polyclinic. It

facilitated inter-disciplinary consultations, and became a site conducive to research and

training centers for the family doctors (Ibid: 179). The polyclinic has also been

instrumental in helping the Cuban 'orthodox' medical system deal with the losses it has

encountered through the U.S. embargo and the dramatic decrease of financial support

from the Soviet Union.

3.1.4 Medicine and the Embargo

In more recent times, Cuba is no longer lacking in terms of specialists,

institutions, or facilities. The embargo has resulted in a loss of medical resources that

would enable Cuban doctors and specialists to deal effectively with their patients'

illnesses. Health workers are overburdened with increasing numbers of sick people and

the lack of medicines to effectively address many of their health problems (Schwab,

1998: 62-63). WhiIe the Ministry of Health has been working diligently to develop

innovative medicines and techniques to deliver services to the Cuban people, the public

health sector and hospitaIs must literally shop around the world and pay exorbitant rates

to obtain, often secretly, medical supplies that are avaiIabIe in the U.S. "Up to 1989, the

embargo pIaced conditions on 15 percent of Cuba's international trade which fell outside

the socialist market; after 1991, the embargo had a resuictive influence on more than 90

percent of that trade" (Schwab, 1964:71-72). Most antibiotics are produced under the

patent of the United States. As such, they are restructured under the terms of the embargo

and cannot be exported to Cuba.

Third-party countries can also be denied aid or penalized by the US. for trading

with Cuba. The U.S. has also effectively blocked any help from reaching Cuba via the

World Bank or the International Monetary Fund 0, largely cutting Cuba off from

foreign loans. In 1998, the United Nations Development Program allotted 1.15 million in

aid to Cuba, but monies allocated to Cuba by the UN are usually paltry. Extra shipping

costs incurred by having to purchase supplies from far away countnes and mark-ups

resulting from both legal and illegal trade added up to some $9 million between 1994-

1997 (Ibid: 72).

As mentioned earlier, the government covers Most costs associated with medicine.

The Cuban government oniy covers the costs of drugs prescribed to most outpatients and

for other items Iike orthopedic prostheses, wheeI chairs, crutches, and similar items Iike

eyeglasses. Prices of these items are relatively low and subsidized by the state. Despite

the embargo and the difficult economic situation that has existed over the last few years,

the Cuban government has continued to pour money into its health care sector. Ninety-

three percent of the municipal budget goes to health expenses. Between 1990 and 1994,

there was a reduction in hospital spending but, to compensate for this, the government

increased money designated to pnmary health care. In 1990, 32.4 percent of current

expenditures went to primary care and 52.7 percent to hospital care and, by 1994,36.1

percent went to primary care and 45.2 percent to hospitals.

"In 1989 total spending in the health care sector reached (considering allocation

and income from balance bodies) was $227.3 million. In 1994 these costs were only

$74.9 million." Suffering from this loss is the pharmaceutical industry's drug production,

shortages in diagnostic equiprnent and reductions in consumable medicines for health

care centers. Optical and dental services have also been undercut by the embargo (Rojas

Ochoa and Lope2 Pardo, 1997: 800-803).

Due to the embargo, the standard and quality of life for most of the Cuban

population has been adversely affected. Water potability indexes are down and the

systematic treatment of drinking water has decreased by 42 percent between 1990 and

1994. Sewage treatment and disposa1 have also been affected, and there is a definite lack

of resources for maintaining and repairing the existing systems. Shortages of equipment

and construction materials have aIso deteriorated with time @id: 805).

To address these health care shortages, the Cuban government will reorient the

heaIth system toward pnmary care, advocate the more rational use of resources and

facilities, promote the implementation of intersectional health planning and try to

incorporate economic analyses in the adoption of new programs, drugs, and technologies

(Opcit: 802).

The Minister of Public Health has encouraged alternative therapies based on

traditionally used herbs and other plant materials. Herbalism has been examined in

greater detail in pharmacological research in attempts to discover new agents to address

various ilInesses. On a more grassroots Ievel, the Ministry has also distnbuted to

practitioners throughout the country a national formulary and educational materiaIs on

green medicine which was compiled by 17 prominent scientists in medicines and biology

(Waitzkin, et al, 1997: 25 1-252).

Conclusion

Although there has been a 'conservative' elernent within Cuba's medical history,

especially due to its European and American influence, orthodox medicine alone is not

the only form of treatment sought out by the population. Traditional forms of medicine,

especially those whose roots lie within Afro-Cuban religions and Spiritism, ais0 play an

important role in the overall health care options availabIe to the population.

Cuba's health care system developed from the interaction between Afncans and

Spaniards, the rich and the poor, and socialism and capitalism. Taken as a whole, Cuba's

medical systems have emerged out of the crossroads of tradition, low-tech innovation and

high-tech development.

CHAPTER IV

METHODOLOGY

Objecriv* car2 be g~iaranreed in suclz cornrnirted reseurch by lhe distance ttzrozigtz self-reflectiorz wlziclz researclzers caïz rake from rlzenzselves and tlzeir oivn persona1 and ctiltriral biases and the political- econonzic corzrexr to rvhiclz rhey striictru-ally belong (fiiizer, 1979: 35).

Upon entering the field, 1 began to question the whole notion of objectivity and

representation. 1s objectivity even tenable within the social sciences? 1s it not the

ethnographer who ultimately selects the subject, creates the interview questions, and

upon writing up the results decides what information to include or exclude? 1s it not the

researcher again who has the abiIity to legitimize or delegitimize the informants' voices

in order to sustain the ideological view he/she as a researcher is trying to support?

Objectivity is most obviously a human problem, but one that 1 still felt I should try to

attain.

Clifford (1986a), Haraway (1991) and Fabian (1994) discuss this issue using self-

reflection and positionaIity. Clifford argues that ethnographie representations are always

"partial tmths" (1986a: 6). My own social reality in Cienfuegos as a Canadian woman

from a capitalist society would be different from that any Cuban carrying out the same

study. 1 do not feeI, however, that my study is Iess valid because 1 am not Cuban since, in

recognizing rny social identity as an exîranjera (foreigner), 1 make an effort to improve

the objectivity of my work by presenting my realities and my biases. Haraway States,

"...objectivity turns out to be about particular and specific embodiment, and definitely not

about the false vision promising transcendence of al1 Iimits and responsibility. The moral

is simple: Only partial perspective promises objective vision" (1991: 190). It is up to the

ethnographer to have an awareness of hisher position within the research for it is through

acknowledgement of one's personality, culture and language that this partial perspective

is defined. This autobiography allows the writing subject's actual history and

involvernent to be considered cntically (Fabian, 1994: 82). To address the issue of

positionality, I would like to provide an 'autobiography,' so to speak, of my field

experience. This personal background information wiIl inform the reader of how 1

developed my interest in this research project, what 1 felt were some of the limitations of

my work, my methodology and, finally, an overall discussion of my field experience.

4.1 Personal Experience

Persona1 experience shapes Our work and, as rnentioned above, 1 feel it is my

responsibility to make the reader aware of my own social reality. In doing so, 1 hope to

provide balance in my work, engaging the reader in the nuances of my study with its

background, discussion, dialogue and examples.

1 first went to Cuba in 1996 on a semester exchange set up between the University of

New Brunswick and the University of Cienfuegos. This anthropology exchange was

established to facilitate a rural extension and ethnographic component to our program. It

was through this arrangement that 1 made rny first connection with the University of

Cienfuegos' Agronomy department.

In 1996, Cuba was slowly recovering frorn the worst part of its economic crisis.

My Cuban friends developed my awareness of how bad things were, especialIy in terms

of access to medical supplies. But my interest in Cuba's health care system did not

develop in earnest until we began a case study on a UBPC (Basic United Cooperative

Production) farm in San Nicolas. One of my assignments was to study the demogaphy of

the cooperative. Data were obtained through accessing files at the local medical clinic or

co~zsultorio where records were kept on community members, living arrangements (how

many lived in each house), and health status. 1 began to wonder about how Cuba's

socialist bio-medical system operated and was impressed with how doctors were

responsible for compiling such deraïled information.

During my first stay, 1 became briefly exposed to the religious tradition of

Saizfenk. 1 had not encountered nor leamt about Pa10 Monte, or Spintisrn, but 1 had

visited the festival of Santa Barbara in Palmira (a small community on the outskirts of

Cienfuegos). Once 1 returned to Canada, 1 began reading up on Afro-Cuban religious

traditions, the importance of plants in these traditions and the role of religious and

spiritual practitioners in the treatment of illnesses. This remained a strong interest of mine

long after having left the island.

Once 1 completed the first semester of my Master's program at the University of

Guelph, 1 began to think about retuming to Cuba. 1 contacted my former adviser from

UNB, who had been responsible for the exchange program in 1996, for research

suggestions. She encouraged me to contact the agronomy department and it was from

here that my research began to take shape. As part of a qualitative methods course, 1 had

previously designed a generation study on health care choices and thought that it would

be interesting to study traditional medicines and the logistics of health decisions of

residents of Cienfuegos.

During rny first few months of language training in Cuba, 1 narrowed my research

down to two barrios, San Laziiro and La Juanita. By this tirne I had become acquainted

with both of these districts and thought that their differing levels of economic

development would add an interesting component to the study. La Iuanita is a wedthier

barrio and has a visibly better infrastructure. San Ljizaro has a lower socio-economic

status, and a visibly higher Afro-Cuban population. It is also has a reputation as beins a

barrio where Saitren'a and other Afro-Cuban religious practices have a strong presence.

Cuba boasts a universal health care system that is accessible to all and 1 was interested in

seeing if econornic variance would have a strong effect on health care decisions.

1 was also fascinated with how knowledgeable people would be about local plants

and their potential uses. Although Canada has experienced a revivai in green and

naturalistic rnedicines, these medicines are stiil produced and packaged for the consumer.

In Cuba, people seemed to know where to find herbs or plants, extract the part of the

plant necessary for self-treatment, and then prepare it for consumption or as a topical

ointment. These were the factors that led to the creation of this thesis.

4.2 Means of Data Collection

The Sainple:

Structured interviews were carried out with thirty individuals, fifteen from San

Liizaro, and fifteen from La luanita. Informants were selected through a random

sarnpling technique. The interviews covered twenty-four females and six maIes. Two

thirds had between a ptimary and secondary education, and the average age was between

30-59 (see figure 3.la and 3.lb).

Semi-stmctured interviews were carried out with ten farnily doctors. Four were

from San Liizaro and six from La Juanita. A slightly larger number of doctors were

interviewed in La Juanita since it has a Iarger population than San L&aro. Doctors in

these two barrios were also unevenly represented in terms of gender and the majority

interviewed were women. In terrns of age, four were between 20-29 and six between 30-

39. Most had graduated between 1985 and 1998.

Twelve traditional healers were interviewed. Al1 were selected through snowball

sampling. Shortly after my amving at the University, the director of the sociocuttural

department introduced me to a santero who was prominent in the comrnunity. The

healers who participated in the study were equally represented in terms of gender: six

men and six women. Seven out of the twelve crrranderos /traditional practitioners were in

their thirties and forties. Three individuais were in their fifties and two in their sixties.

Interviews were carried out at two local pharmacies: one in Calle ArgueIIes, the other

in La Calsada. These are two of the busier streets and pharmacies in Cienfuegos. One

interview was also conducted with an attendant at Farmacia Marilope, a pharmacy that

specializes in rnedicinal plant products. Al1 those interviewed at these pharmacies were

wornen in their forties and born in Cienfuegos.

Three individuals - or herbalists in this thesis-- sold medicinal plants from their home

or casas pa~iiczdares (named used in Cienfuegos for such private businesses). These

herbalists have no forma1 training, only extensive knowledge of different plants both in

ritual and for medicinal purposes. Two of the herbalists were women, the other a man. In

tems of age, one was in her forties, the other her sixties, and the third in his seventies.

One informant had attained her pre-university education, which is equivaient to grade

twelve. The other two inforrnants were literate, but 1 was unable to know the level of their

formal education. Unstructured, semi-stmctured and in-depth interviews were generally

camied out with doctors, traditional heaiers, herbalists, and various infomants from San

Lkaro and La Juanita.

Another set of interviews were conducted with individuals frorn two medicinal plant

farms: a man in his forties from 'La Granja Provincial de Plantas Medicinales' and

another in his late sixties or earIy seventies from 'La Granja de Plantas Medicinales' in a

cornmunity located forty-five minutes outside of Cienfuegos called "La Sierrita*" Many

of the plants cultivated on these two farms would find their way to 'El laboratorio

Provincial de Fitofarmicas y Pifir'. This laboratory/factory processes and packages plants

into bottles and containers to supply local pharmacies, 1 was abIe to interview the

supervisor, she was in her thirties and had a post-secondary education. Pharmacy

attendants, individuals who worked at medicinal plant farms, and an employee at the

medicinal plant factory were al1 interviewed using a serni-structured format (See figure

3 2)

Table 4.la Sumrnary of participant characteristics for infonnants of La Juanita

Informants Inf. 1 Inf. 3 Inf. 3 Inf. 4 Inf. 5

Inf. 8 Inf. 9 Inf. 10

Inf. 6 Pre-University ( 12) Married Inf. 7 35 Male Pre-Universitv ( 12) Married

Age 59 50 59 54 28

Inf. 11

71 60 65

Inf. 12 Inf. 13

Sex Male Fernale Female Fernale FemaIe

65

Inf. 14 Inf. 15

Male Male Female

74 76

Education Pre University (1 1) Secondary (9) Prirnary (6) University Pre-University (12)

Fernale

60 82

Marital stat& Single Married Married Mamed Single

Secondary (8) Primary (6) Pre-University (12)

Female Female

Married Single Married

Technical School Secondarv (9)

Fernale Fernale _

Married Primary (3) Primary (4)

Married Married

Prirnary (6) Primary (6)

- 1

Married Single

Table 4.lb Sumrnary of participant characteristics for informants of San Lataro

Informants Inf- 1 Inf. 2 Inf. 3 Inf. 4 Inf. 5 Inf. 6 Inf. 7 Inf. 8 Inf. 9 Inf. 10 Inf. 11 Inf. 12

Data Collection:

Age 30 55 50's 47 49

Inf. 13 Inf. 14 Inf. 15

My research relied on a number of different methods to obtain data. Quantitatively, 1

89 3 2 34 34 42 54 21

used questionnaires. This allowed me to find out about levels of knowledge regarding

Sex Female Female Fernale Female Female

59 59 25

customary medicine, attitudes towards medical practices, and other related factors that

FemaIe Male Fernale FemaIe Male Female Fernale

influence health care decisions. It provided me with statistics that couId later be fleshed

Education Pre-University ( 12) Secondary (9) Secondary (?) Primary (?) Secondarv (9)

Fcmale Fernale Fernale

out into descriptive information. Qualitatively, I employed semi-structured interviews,

Martial Status Sinsle Mam-ed Divorced Marrïed Mamed

P rimary (4) S e c o n d q (8) Primary (6) Pre-University (12) Secondary (8) Secondary (8) Pre-University (technical school)

unstmctured interviews, participant observation, and couple of small group discussions.

~ k i e d Mam'ed Mmïed Married Married Manïed Married

University Primary (6) Secondary (8)

These methods complemented the questionnaires since they defïned and explained the

Divorced Divorced Marrïed

meanings behind the quantitative data. They provided a context to better understand

beliefs and attitudes regarding illness, health care knowledge and decisions.

4.2.1 Quantitative:

Srrrvey-in fervie ws:

Before administering the questionnaires, I conducted a taxonomy study with four

individuals (three females and one maIe) to identify the more common illnesses. This

background information was used in the first portion of the questionnaire and the

informants were asked what they would do if they or a farnily member had this illness. In

other words, how would they approach the problem (see Figure 3.2)? The results

obtained were organized into a survey-questionnaire and @en a trial. Difficult or

arnbiguous questions were then re-written.

Table 4.2 Section three of stmctured interview with informants from San Lharo and La Juanita

- What illnesses are most common and most frequent in your family? - Which ones are present now? - Have these illnesses changed or are they different than they were before the 'Special

Period?' - What remedies do you seek for illnesses that are most cornmon? Have they been suggested

by your famiIy doctor or did you learn this from tradition? - Do you grow any medicinal plants in your house or garden? If so, what are they? - Where do you obtain information about the uses of medicinal plants? - What relationships to you think exist between customary medicine and conventional

medicine? - Under what circumstances would a person use 'custornary medicine' and not visit a family

doctor? - Under what circurnstances would a person visit a visit a Curmtdero, Smitero or person with

a gift for healing and not visit a doctor or specialist? - Under what circumstances would a person consult a famiIy doctor only?

Before conducting any survey, permission had to be granted from the president of

al1 of the local CDRs (Cornmittees for Defense of the Revulution) within the barrios of

La Juanita and San Lkaro to carry out the interviews.' With the assistance of a

representative from the University of Cienfuegos, 1 distnbuted thirty sunrey

questionnaires in total to the two barrios. The survey was carrïed out in person within the

participants home's between the hours of 8:30am to 4:OOpm. Any arnbiguity regarding

the questionnaire would be clarïfied on the spot. Participants were chosen through

random sarnpling from five barrios with three houses from each barrio being selected. To

determine the sample, a number was designated to each barrio. These numbers were

wntten on pieces of paper, folded and then five were randornly selected from the pile.

Within each barrio the houses were counted and numbered and the sarne technique used

again. The questionnaire took on average about twenty minutes to complete. The longest

interview lasted for about one hour. See Appendix for Section A of the survey-interview.

4.2.2 Qualitative:

Unstrttctzcred and Semi-Stncctured Iuterviews:

AI1 interviews generally took place within the homes of the informants.

Conversations were sometimes tape-recorded. Notes were jotted down as the interview

proceeded. Full notes were then wrïtten up as soon as possible to prevent information

loss. When interviews were unstmctured, as in the case of herbalists and traditional

healers or practitioners, 1 was abIe to revisit the informants to ask further questions as my

own knowledge of the field increased.

CDRs were originally created in 1960 to rnobilize political participation. As time passed, they came ta serve as instruments of neighborhood social control, providing a means to monitoring local events. They also have become an extremely successful agent through which the population can be organized. CDRs are often used in health and vaccination campaigns (Schwab, 1999: 112).

Interviews couId range anywhere from h d f an hour to two hours depending on issues that

arose from conversation.

Family doctors were frequendy very busy and not easily available. Interviews

were often short, most taking no longer than twenty minutes. For them, 1 followed a

semi-structured format. Interviews with pharmac y attendants, the adrninistrator at the firo

famica factory, and individuals from the medicinal plant f m s were arranged through

the university and ranged from a half an hour to three hours.

Before interviewing the informants, 1 always explained my research and how their

information would contribute to my thesis. 1 stressed that al1 narnes were to remain

anonymous. I also emphasized that, should anything come up in the interview that the

informant did not want the pnera l public to know, to inform me and it would be kept

confidential. This was most applicable to Afro-Cüban religious leaders since there are

aspects of the religion that are kept secret.

1 did not use signed consent forms, since 1 believe that no harm would come out

of this project. in addition, the use of a consent form may have made some of my

informants wary. By asking individuals to sign a form, 1 believe that I would have

aroused suspicion where none was due. Yet, 1 am sure that my interviewing did attract

attention by neighbors and perhaps other local organizations.

1 returned recently to Cienfuegos for a week. During that third and last trip, 1 was

able to contact two individuals who cure the evil -eye. 1 prepared a questionnaire which

was administered by my Cuban assistant. She knew both of these individuals on a

personal basis.

Table 4.3 Summary of Key Research Participants Interview,

Medicos de la familia (Family Doctors)

#s Gender

Age

Origin

Curanderos and TraditionaUReligious Heaiers

Education

Methodology

1 O 7 - Fernales 3 - Males 4 - Twenties 6 - Thirties

I - Santa Clara 2 - Palmira 1 -Rodas 1 - Guantanarno 2 - Cienfuegos 1 - Lajas 2 - Unkno wn 10 - Serni-structured

12 6 - Females 6 - Males 3- Thirties 4 - Forties 3 - Fifties

10 - University

1 - Anietes 2 - PaImira 5 - Cienfuegos 1 - Habana 3 - Unknown

2 - Sixties N/A

3 - Unstructured Participant Observation 1 - Focus Group

not included in the Stnictured

Pharmacy Attendants and Fi tofarrnica

Her balisl

Administrator 4 4 - Females

3 - Forties

3 2 - Fernales

1 - Thinies 1 - Sixties 1 - Seventies

1 - Mate I - Forties

4 - Semi-structured 3 - Semi-stmctured 5 - Unstructured Participant Observation

3 - Post Secondary 2 - Pre University

L 1 1 1 Focus Group * Some of the ages for these individuals are rough estimations. There are a number of 'unknowns' found throughout the chart that shouid be explained. If the informant was worried about their identity being revealed, or people 'guessing' who they rnight be then 1 generally skipped over the demographic section, onIy taking note of ripproximate age. There were also circumstances where I feIt I would have embmassed an informant if 1 had asked them about their leveI of education. Under such circumstances, I would generally omit the question.

1 - Pre University 2- Unknown

Participarzr Observatiorz

Participant observation for this research took place at different settings. For the

most part, 1 was able watch or participate in various religious/spiritist ceremonies that

dealt with preservinz health or addressing illness. 1 also spent quite a bit of time with two

herbalists in their home-based shop. 1 was abIe to observe the different concerns people

had regarding illnesses and what plants the herbalists would recommend to address these

health problems. Through such settings and interactions with key informants, 1 was able

to obtain expianations for important symbols and practices. 1 kept a small notebook and

pen handy at d l times to ensure that I would not miss anything while 1 was participating.

These notes were later typed into my laptop, coded and classified. Using Bernard's text

Research Methods in Anthropolo.gv, 1 coded my notes with numbers that described the

setting, context of the participant observation and the informants involved. Generally,

these entnes were included in my daily reports. These reports could range from a half a

page in length to three pages single spaced, depending on the events of the day.

Foctw Gro~ips

In total, 1 conducted two focus groups and this was of a haphazard nature. Durhg

my time spent with a key informant, specifically the herbaIist who was dso an espirirista,

there often congregated small crowds of people, many of whom would just drop in to

pass the time. It was during these IittIe group discussions that 1 would gain a great deal of

insight into this spiritual practice and the roIe thac it played in health care decisions. 1

would ask a couple of questions and thereafter the conversation would take on a life of its

own. These discussions were Iengthy and rarely veered off topic since this was an

interesting subject for al1 involved.

The second focus group discussion was also quite spontaneous and fell into place

as I and two of my satirero informants were discussing some of the basic principles of the

religion. Several other individuals involved in this religious faith dropped by. I was able

to obtain some very useful opinions and perspectives regarding the use of herbs within

the religion and how practitioners can use their magic (with permission of the orislias of

course!) to heal vanous illnesses. UnfortunateIy, due to the spontaneity of these focus

group sessions, 1 was not able to tape and transcribe the interviews, but 1 did take notes

during the conversation and Iater wrote out a more detailed version of the discussion.

4.3 DATA ANALYSIS

Qualitative analysis was conducted on the data collected. To begin this process,

audiocassettes recorded from interviews with doctors, pharmacists and traditional

practitioners were transcnbed. Questions asked during survey interviews with informants

from San Liizaro and La Juanita were also studied. The data were then sorted according

to the major questions and themes that were brought up in the interviews. While

exarnining the responses, notes were made in the margins, outiining topics and categories

that emerged from that particular set of data. The framework for my thesis was then

devised and the information inserted accordingly. Al1 field notes were coded with

numbers representing both my informants and topics of discussion. This helped speed up

the process of data analysis.

Frequencies and percentages for specific responses in the survey interviews and

serni-structured interviews were then computed and placed into tabIes. For the

quantitative element of my research analysis, 1 also used a duat scaling technique to

explore hidden structures of my categoncal data (sex, education, age, and

knowledge/belief in traditional and customary forms of medicine). Dual scaling provides

a means of constmcting an 'optimal' composite of these categoncal variables, to provide

a multidimensional analysis of the reIations manifested within. CIusters of points are

generated ont0 a scatterplot called a map. Through analysis of Iinear distances between

points of this map, we can detect patterns of similarities and differences in the attributes

of informants (Nishisato & Nishisato, 1994: 3, 11).

Quotations and descriptive data from interviews were incorporated into their

explication. In addition, descriptive information gathered from the analysis of newspapers

and taped videos was organized into the appropriate sections of the thesis.

4.4 LIMITATIONS OF FIELDWORK

Informants who were spiritual and reiigious healers, pharmacy employees, and

individuals who sotd plants pnvately from their home were selected through snowball

sampling. Religious crrranderos were especially difficult to find and 1 came to rely

heavily on an individual who had the title of 'Oba' or leader of ceremonies. Through him

1 was able to meet a number of individuals within his religious community, many of

whom were his godchildren, friends and acquaintances.

For interviews with family doctors and various curamierus, santeros, paleros, and

espiritisisus, when possible, 1 used a tape recorder and had the tapes transcribed.

However, on certain occasions. I was not allowed to tape record. 1 did not always have

my assistant with me. Thus, there were times when 1 felt missed certain aspects of

conversations that 1 am sure would have contnbuted greatly to my study.

Time ana budget constraints imposed upon my research reduced the depth of the

data collected. Three months of intensive fieldwork is too short a penod to attain an in-

depth understanding of the ethnognphic character of the group studied. Individuals that

participated in the structured interviews frorn the two barrios I was onIy able to visit

once. Repeat visits were simply impossible for the time allowed. It would have taken a

greater period of time to carry out the study in the comprehensive manner that I would

have pre ferred,

Time limitations were also a factor influencing my research of traditional

medicime. 1 was only able to participate in a srnall number of ceremonies and thus some

of the explanations given with regard to illnesses and possible methods of curing,

including plant use, have been explained through unstmctured and serni-stmctured

interviews and not through participant observation as 1 would have preferred.

1 plan to make a translated copy of this thesis during my next trip to Cuba and

give orne to the department of Agronomy, one to the library at the University of

Cienfuegos and one to the local library in Cienfuegos. 1 also hope to wnte a short report

for the local newspaper, so that those who participated in the study can see the results.

4.5 FIELDWORK

I t was during my first trip to Cuba in 1996 that 1 experienced my first true feelings

of culture shock. As mentioned earlier, 1 had spent three and a half months in Cienfuegos

during rny undergraduate degree program, and can in retrospect say that 1 had been truly

unprepared for what 1 encountered while I was there. 1: do admit that this was in part due

to my own imrnatunty, travel inexperience, and my more obvious inability to

commurnicate adequately in Spanish. Needless to Say, in such a situation, 1 did not fare

weII and misunderstood much about what was going on around me. Unfortunately, 1 did

not have the opportunity to get over my feelings of homesickness and open myseIf up to

the experience as 1 now feel 1 should have. So it is without reservation that 1 candidIy

admit th at the thought of returning to Cuba to carry out my Master's research was

daunting. 1 looked upon it with both dread and anticipation. 1 was passionate about the

topic and 1 had a solid interest in the different areas of rny research, but 1 was still unsure

about how 1 personalIy would fare in Cuba for a WHOLE SIX MONTHS!

It was to my surprise that 1 found my first experience in Cuba had helped me

more than 1 could have imagined. For one, 1 had decided not to unpack my bags until I

was living with a Cuban family. 1 let the university make the arrangements, but I was

deterrnined that 1 would develop my Spanish skills and create a network for myself so

that 1 would not feel as isolated as 1 had before. 1 accomplished both and can honestly Say

that I am sure that my research would not have gone as smoothly as it did if it had not

been for the ongoing support of my Cuban farnily. With their help, I was able to find

ways around various difficult situations, and their unending patience helped me

understand social nuances that othenvise would have been lost to me.

Having already been acquainted with the agronomy department was also an

advantage since 1 had made them aware of my return and they had in turn provided me

with many valuable resources, and even an advisor to assist me in my study. Rafiela put a

great deal of input into my work and al1 of the semi-structured interviews, minus those

with czwarzderos and traditional healers, were a joint effort. We both share copies of the

results of these interviews. As an agronomist, she was particularly interested in the type

of plants people used to address iIlness and the level of knowledge households had with

regard to medicinal plants.

I thoroughly enjoyed my fieldwork experience and would go back in a heartbeat.

It would, however, be misleading if I did not own up to some of the difficulties 1

experienced whiie conducting my fieldwork, first of which was the amount of

bureaucratic red tape that 1 had to wade through in order to carry out my study. 1 was

lucky in that the agronomy department knew how to maneuver through these formalities,

especially with the survey-interviews, but contacting individuals to rnake arrangements

was very difficult and it would take weeks just to move through the proper channels to

start my research in the two barrios. Had 1 been biessed with tne possibility of a longer

stay in Cuba, this would not have even been an issue, but, keeping in rnind the limited

time in which 1 had to carry out my research, every day counted. For this, there was really

nothing 1 could do except wait. In this, 1 feel that f was treated no differentiy than any

other Cuban, despite my being an exrrarzjera, and 1 in tum respected the wait.

Repayrnent was a second ethical issue that 1 struggled with. How would 1

compensate for the time and energy expended by those who agreed to take part in my

interviews? Had my research been fully funded, perhaps this wouId have been less of a

problem for me but, because 1 financed my own fieldwork in Cuba, 1 did not have much

money to spare. 1 am positive that, in many situations, had 1 offered to pay individuals for

their participation 1 would have given offence. For the individuals who agreed to take

part in my survey, 1 gave a small gift of soap and pens, the value of which was

approxirnately $2.50 Cn. Having asked a number of my Cuban fnends how much the

average worker makes, which is ten to fifteen dollars a month US, 1 felt that the gifts

were adequate. The high prices of necessities such as soap were often a topic of

conversation and most individuals seemed very content with my small gift. The only

individuals that 1 compensated with money were the cz~ramieros and religious healers.

For thern, time was money, and gifts of money were something they were accustomed to

receiving. 1 still struggIed with how much to give as 1 had no idea what cru-anderos or

saizteros usually received for their time, so 1 probably ended up overdoing it. But 1 also

do not doubt that in a couple of cases this was the on1 y reason that 1 kept their attention.

Most, however, were simply surprised and maybe even a little flattered that 1 showed

such a strong interest in their beliefs.

I also experienced several other common anthropologicd problems, such as trust

issues and the experience of working as foreigner. 1 did encounter a couple of situations,

especially within the reaIm of traditional medicine where people were suspicious of my

work and were hesitant to answer certain questions. This is, 1 believe, in part due to their

former experiences of foreigners coming in to study Afro-Cuban religions, especially

Santen'cr and rnisconstruing the information. Many of the practices within this religion are

very secretive and 1 recall instances where even the practitioner would be hesitant about

what they should or should not tell me. My only recourse to this situation was to state that

1 would in no way present their religious orientation in a negative light and that 1 was not

interesting in exposing the secretive elements of their religion. This did not, however,

guarantee their trust and in the end 1 simply had to hope they could pick up on my

si ncerity.

UltimateIy, one of the most important lessons 1 was able to draw from my

research experience was the importance of rapport. 1 built many friendships during my

six months in Cuba and, upon my week long return six months Iater, 1 was able to collect

quite a bit of data in a short amount of time. By returning to Cuba and making a point of

visiting most of my key inforrnants, 1 had demonstrated to them that our relationship was

not dependent on my six-month research period and that 1 had fulfilled an earlier promise

that 1 had made to retum. During this visit, a number of informants opened up and

provided me with a great deal of personal information related to my research. Although 1

would not divulge any of their stones without expressed permission, it gifted me with an

understanding of the rationality behind various patterns found in my research and

provided an extra context through which 1 could better visualize the data 1 had already

collected..

The following three chapters will present the data analysis of this thesis. Once

again, 1 wiIl reiterate that the quantitative element of this study was mostly a means of

opening up a more solid qualitative study. Heavy emphasis was placed on the semi-

structured interview.

AGENTS OF ILLNESS AND FACTORS INFLUENCING HEALTH CARE DECISIONS

Preamble

The first section of this chapter examines some of the more common etioIogical

agents listed by informants interviewed in Cienfuegos. These agents are linked to the

traditional ideological substratum which again stems from the belief systems exarnined in

chapter two. This is largely the ethno-medical component of the study. The agents

discussed here should not, however, be considered a complete account, they are simply

the ones that have been included in the research. These, often supematural agents, are

responsible for the onset of particular health problems and influence the type of health

care decisions made by the individual.

Etiological agents can be grouped according to defined characterïstics, the

mechanisms by which they cause human affliction, and the specific bioIogical health

problems for which they are held to be responsible. For each illness, there is a set of

beliefs outlining both the causes and cures (Balladelli, 1990: 20). In order to understand

the logic behind health care decisions, first 1 investigate how informants define illnesses

and health, keeping in mind that additional factors also influence health care decisions

outside of the agent itseIf and, second, 1 examine some of these factors in details.

Special attention is given to the social and economic attributes of inforrnants from

San Lkaro and La Juanita. This helps determine wherher or not there exist patterns

between gender, age, education and religious affiliation and medical knowledge and

heaith care behavior. Health services and the illness itself are also in tenns of their effects

on decision-making. Figure 5.2 illustrates various factors that influence health care

decisions.

Figure 5.1 Mode1 illustrating means of classifying etiological agents.

Etiological Agents are Classified According To:

Mechanisms by which human amiction is caused

Characteristics of various health problems

Figure 5.2 Mode1 illustrating factors that influence heal th care decisions.

Typology of IHness (Etiological Agents) Seriousness of Illness

Factors Influencing Health Care Decisions

SocioEconomic Factors Cost and access to health resources

5.1 DEFINING HZALTH AND ILLNlESS

In general, interviewees perceive illnesses as being a physical problem with the

body. People understand the scientific medical concept of illness and most rationalized

illness within the conventional realm. There are, of course, varying degrees of illness,

some being minor and others being more senous. Padecimierztos were defined as

ailments and perceived as physical problems that can exist on their own or as symptoms

of other itlnesses. Headaches, coughs, fevers, sore throats, etc. were al1 categorized as

Enfennedades are more senous illnesses that can affect a person for extended

penods of tirne, sometimes a Iifetime. They are considered to be illnesses Iike migraines,

hepatitis, high and low blood pressure, intestinal parasites, etc. Al1 agreed with the

general concept of illness being that 'the body was not performing at its maximum

potential.'

Diffenng views exist on the ~Iassification of illnesses. Classifications are made

according to assumptions on how these illnesses are caused. According to Rodriguez

(1992: 71), people tend to cling tightly to 'orthodox' medical diagnoses of illness or

disease causation, and do not stray from this perspective. My sample indicates that this is

not the only perception held by the popdation. Outside of the conventional realm,

Cubans believe that illnesses can be caused by spintual entities/problerns, envidia (envy),

emotional States, or rzervios (nerves), mul ojo (the eviI eye), and bntjeria (witchcraft).

An in-depth exploration of the beliefs associated with illness causation, and more

specifically the agents listed above, will be conducted to understand more traditional

notions of iIlness agents. A decision-making rnodel will illustrate how resources from the

differing rnedical views are selected-

5.2 ILLNESS ETIOLOGIES

5.2.1 Spiritual Entities and the Espiritista

My research with espiritistas regarding illness causation revealed information on

par with that of AIan Harwood and his work on "espiritisrno" and psychotherapy in

Puerto Rico. The human being is seen as composed of both physical and spiritual matter

and problerns attnbuted to one or the other are likely the cause of illness. For physical

problems, individuals are sent to a doctor, but for problems spiritual in nature, the best

person to address this issue is an espiritista (L977,74).

Insomnia, suicida1 urges, repeated nightmares (especially involving the dead),

unaccountable crying or silent brooding are al1 thought to be symptoms that imply

illnesses that are spiritual in causation @id: 75-78). lMany espiritistas will begin a

session by looking for the probIem for which their client has come, ". . .headaches,

stomach aches, aches in the kidney area, the legs, and mind gone, clouding or failing

vision, etc.." They are carrying out an exercise known as bcrscmzdo la causa or finding

the cause (Gamson, 1997: 87). According to Hanvood, al1 espriristas feel that good

physical health is an indication of good spiritual health. Most espiritistas will also

recommend that a person first see a doctor if they are a i h g and return if they are unable

to resolve their problems. They tend to believe that iIInesses are a sign of spiritual

disequilibrium. If the medical treatment tins not proven to be satisfactory, or if the illness

is Iife threatening the sufferer IikeIy approaches an espn'rista or continues on a dual

treatment Ievel (1977: 75-78).

On one occasion, 1 was invited to go to a spiritist center to see how things

operated. The foIlowing passage is taken from rny notes on the session.

At tlzis particulur session a womarz ccutze seekirzg advice about hotv to develop ?zer spir-ïtzral side. SCze also Aad a iz~inzber ofpersorzal problems that she wa~zted to dear crp. Wzile in trame or possessio?~ by her g~iidiltg spirit, one of the otlzer Espiritistas began to tnlk tu tlze woman abozrt Izer son. Slze asked the lady if*she had recerttly takerz /ter son to the hospital. TJze wornatz said tlzat lzer soit Rad beeiz sick lately, but that she lzad rzot had tlze dzance tu take him ro a doctor. Tlze spirit told her tlzat slze had to take Izer son to dze Izospital tu have lzis stomach dzecked out. TIze lady nodded in agreement. The Espiritista also told the lady to come back the follo wing week so that they cocsld ask the spirits and make szue that the problem with her son was being resolved properly (Researclz, Oct.31, 1999).

This particular case indicates that the problem faced by the woman's son was

perceived as physical and not spiritual in nature. The medium did not suggest that the

woman bnng her son to the Center and no spiritual problems accompanied the initial

diagnosis. Although it was suggested that she retum to confirm that things were taking

their proper course, it was still felt that his problems would be better addressed through

conventionai medicine.

During an interview with Maria, a santera, 1 encountered a second instance where

an illness was both diagnosed and treatment sugpested by an espiritista. The excerpt

below cornes from my field notes.

Dziriizg tlzis Nzterview witlz Maria, her snzall clzild begarz to feel ill. Atfirst she begarz to get Lipset and cry, luter she vonzited and afienvnrds fell asleep on the cozcclz. Sllortly a fer the commotion, a man, wlzo I lzad coizducted an interview with before, and is well knorviz in Cienficegus as a well repzrted Espiritista, ivaiked in wirlz a mutual acqziaiiztaizce. After brief irzrrodr~ctiorzs, and soirte iizterestirzg srnall talk about eaciz of rheir abilities as spirincally developed iizdividzrals, tlze nialz looks at Maria's little girl and says, "She Iras a very bad case of anenzia rlzar may be cazised in part from mal de ojo (evil eye). Slze aiso lzas n case of parasites thar must be seeiz to. You slzordd rake her to the lzospiral rvirlziiz the next day or so, and iiz acklitioiz to this, rnake aiz ebbo (sacriJice) to Yerneya' for the next seven days. " Fronz here he asked Maria to look for an egg and some perfkrne and he would curry ozct a cleaizsing ritual to help tzer dattglzter feel better. The woman rvertt in search of the items and retrrnzed witlz botlz. 73e man tlzen soaked the egg in perfurne and began to ïnake the sign of the cross on the girl's stomaciz witlz rtle egg. During this tinze Ize said a prayer under his breatlz. The egg was tlzeiz to be giveiz as an oflering to Elegpa (Researclz, IVov.5'". 1999).

The espiritisra (spiritist) in this case was also a newIy ordained santero. As a

result, there was evidence of overlap between methods of healing. The healer had some

thirty-two years experience as an espiritista and felt cornfortable using his Spiritist

abilities to diagnose and prescribe remedies. By espifista, 1 refer to his use of 'muertos'

or spiritual guides to direct him. During this episode, what became apparent was the

dualism in the approach to curing the child of her health problem. Not only was the girl to

be taken to the doctor, but also the mother had to make offerings to the orishas of the

S a n t e k religion. In addition, the espirirista carried out a heaIing ritual to further heIp

clear up her problems. The diagnosis was that the child was suffenng frorn mal de ojo,

anemia and intestinal parasites. The problem therefore needed to be addressed through

both a spiritual and physical approach.

It shouId be mentioned here that espiritistas believe that they have varying levels

of strength and ability. idaria, for example, did not know what was ailing her Iittle girl,

even though she is herself an espiritista. As mentioned before, al1 sarzteras and santeros

are also espirifistas. At one point during the conversation, José (the Espiritista) said to

her, "You have already asked Yemayii (the materna1 goddess) what is wrong with your

daughter, she has not responded. I know what is wrong."

During an espiritistas session, or a Cerztro, there are a number of etiological

agents that are identified. Harwood lists la envidia (envy), la bnljeria (sorcery), la rnala

NtJirrerzcia (evil influencej, las facultades (development of ones abilities), la pmeba (test

or trial), la caderza (chain) and el castigo (punishment). In my field work, two

phenomena, las facultades (spirits of various ranks who possess the body of a person

insufficiently trained at controlling such entities) and la caderza (familial influence from

the past which causes unhappiness in the present), did not present themselves. El Mal de

ojo, la erzvidia, and la bnveria will be discussed in later sections since they can a11 just as

effectiveiy be addressed outside of the domain of an espidista as within. Mala irzJIuerzcia

occurs when spirits from the lowest leveI of the spiritual hierarchy attach thernselves to a

particular household, giving problems and troubles to any of the individuals within. They

can be spirits that are bad or spirits that have lost their way because they simply cannot

see the light. These spirits cause human health probIems or afflictions such as persistent

headaches and chronic fatigue and fever. Mala influencia is particularly suspected if the

person was never sick before. This agent causes persona1 problems and overd bad luck.

The spirit or muerto aims to disrupt a person's general peace of mind.

It is thought that some spirits only want to communicate and will therefore haunt a

person until he/she finds a means for the spirit to express its desires. Sometimes it btings

illness because it wants a deed to be a completed deed so that it can move on. Other

entities such as 'muertas osczrros' (dark spirits) may want to have a table made (hace m a

mesa) with a white tablecloth, flowers and giasses of water. Once the spirit has been

appeased, the sick should regain spiritual and physical equilibrium (Research June 14".

2000).

La Pnreba (test or trial) is an important spiritual category through which health

issues and illnesses can be diagnosed. Life's hardships in general may be discerned as

being thepnreba. It too is an agent through which physical problems may arise. Here, the

affected person alone must Iearn to overcome the triaI. God, to test the individual,

imposes thepnreba(the test) and, should the sick person behave well, the next life will be

much easier. The pnleba is diagnosed after al1 other spiritual pathways have been

examined and refuted. It is thought that only God's intervention can give the sufferer

relief. The prrteba also can be applied to the situation where mediums are in training and

endure hardships given by them by their spirit guides and protectors (also known as their

cornmittee) to see if these novices are dedicated to seeing to their needs (Harwood, 1977:

9 1).

In addition to the pnrebu, there is the incidence of Casrigo or punishment. This

can be applied to anybody but under diffenng conditions and levels. When used to refer

to mediums, the meaning is similar to the psychoanalytic concept of regession. For

mediums, once they begin to practice as an espiritista, they must forever pay homage to

their patron saints and spiritual guides. If they fail to do this, they will likely re-

experience the sarne phenornenon that led them to discover their capacity in the first

place. For ordinary people, castigo (punishment) occurs when people make promises to

saints and then do not uphold their end of the bargain (Harwood, 1977: 92-93). Since

castigo appears as a physical illness that leads people to ask for something from the

spirits or the saints, or leads them to a centro to develop their spiritual side, refusing to

honour promises can lead back to problems once again.

1 encountered numerous stories about how promises to saints had to be kept. For

instance, once 1 had a conversation with a woman walking from door to door asking for

donations for the church on behalf of San Lharo. She had promised she would do it

every year for her saint if he healed her very il1 son. San Liizaro fulfilled his part of the

bargain, and now she had to do the same so as not too anger the saint. Otherwise, el

castigo, would have Iikely put her son's health at nsk once again (Research October 12,

1999).

Headaches, stomach aches, aches in the bones or body, Iack of concentration,

failing visions, family problems, depression, etc. frequently require a visit to the

espiristu. In a chart, Garrison lists the cornplaints she discovered while doing research in

a smdI Puerto Rican community in New York City. These symptoms may or may not be

spiritual in origin, yet individuats go and seek out an espiritista for treatment or advice.

Usually these symptoms are chronic or the person is a strong believer in Spiritism if they

go and seek out a center for help. The ones 1 encountered in Cuba correlate with those

listed by Garrison. Below, I use Garrison's mode1 to present the most common symptoms

found in the population 1 studied.

5.2.2 Lus Nervios

According to Finneman, "izervios (nerves) is a psychosomatic illness resembling

Table 5.1 Common Somatic and Psycho-Somatic complaints listed by Espiritistas interviewed.

depression, and is an illness rnainly affecting women." This agent is common arnong

Somatic Complaints (physical illnesses) Asthma Headaches Stornach Problems Allergies Impotence Fatigue Insomnia

most Latin American countnes. My data indicare that nervios includes depression,

Mood, Thought and Feeling Complaints 'Nervios,' restless, anxious, tense, worried, lrritability Depressed, sad Apathetic Bad dreams Many pro blems Feeling Iike they are going crazy. Vague feehgs of illness, "not feeIing weI1"

psoriasis, headaches, high blood pressure, tremors, fever, and complaints of being

Cienfuegos data based on Gamson' s model, 1977.

apathetic (for more information about 'nervios, ' see the study carried out by Finerman,

1988: 162). Garrison found forty percent of the clients had at one point reported that they

had been or were in the process of being treated for nervios. Some took medication and

some did not (1977: 129).

The definitions 1 gathered on nervios were as foilows,

Nervios is art illrzess that people have tlzat is carrsed by stress or depression. n e r e are varying levels of rzervios, and varying symptoms that accompaïzy nervios. Some have problems rvith high blood pressrire arzd others have depression. T'zey don 't want to leave tize house, get out of bed, eat or sleep. Some people get tremors, and headaches, and fever. Symptoms var- according to the persorz (Researclz, Jrine 18, 2000, In f #52).

Nervios is ivhen you feel rzervorrs and yori feel stress. TIzere are people who have serious problerns witfz izewios and tlzose rvlzo have less severe cases. It is ca~rsed by various problenzs. Stress at work, problerns ivirlz tize farnily, whatever causes a person stress, sometimes it c m be hereditary. m e n people Izave newios they caiz have severe cases of depression, some do rzothilzg, arzd sray home. Some refuse ta talk to others, many do izot sleep, and it cal2 briizg orz otfzer problerns like psoks i s arzd headacfzes (Researclz, Jrcne 14, 2000, Infl28).

TIzere are a lot of people who have problenzs ivith 'los newios' and it was r7zuch worse duriizg tize special period when people kad fewer resorirces and were rvorried abo~rt Izorv tizere were going tu get shoes for their cizildren or b~ iy the rzecessities for thenzselves like soap, aizd food (Research Jruze 18, 2000, in f #18).

On the question related to how does one decide where to go to address their

problems with los rzervios, 1 received the following comments:

Wh ?n it is not a severe case of rzewes, one can take tilo (linden jlower), and not look o~ftside for help. Wzen it is more severe, a person n z q need to go and see a doctor. Sonze go to the clinica de salrrd mental (mental healtft clinic). Otfzers enter the Izospital drtrïng the day and retiinz to their honzes at night. Many people take pills for izervousness. Nirrazepan, clorodiasepoxido, tr@uoperazina and meprobainatu are t12e most conzrnon. If others Izave more faith tlzeir religion or Spiritism, they ivill look tfzere to resolve their pro blenzs (Research, June 14, 2000, Inf#28).

Some informants disagreed with whether or not spiritual healers and religious

healers were capable of curing los nervios. A key informant of mine felt that religious

individuals generally took advantage of these patients, finding ways to squeeze more and

more money out of them, increasing their problems in the end by taking al1 their money

(Inf. 28). Others interviewed (Inf. 18 and 53) believed that it was not as impartant which

redm you approached, whether traditional or conventional, as long as you believed that it

could work Individuals suffering from stress and anxiety problems usually g o to see

espidistas. sarzteros, babaloww, and physicians. Sometimes they take medication to help

them cope, especialiy during cases of severe depression, if they feel they can find relief.

BeIievers in Spiritism will seek help there, others who have faïth in Sanrerrla or Palo

Moizte will look there, stilI others who do not have sever cases and a knowIedge of

rnedicinal plants will attempt to treat themselves. There are recourses in a11 axeas for this

etiologicd agent, and treatment depends on the seventy of the syrnptoms a n d one's

personal faith.

I fa persorz has faith, t/zey carz be cztred. T/zis is the case ïfyou Aave faitlz in wltarever religion yorc follow, or even withirz tlze field of medicine. r f yori Crave faith in the docrors, ir carz greatly NzJZrcence your a b i l i ~ to overconze yow problerns with nemes. (Infl18, Researclz Jzare 18, 2000)

5.2.3 Envidia (envy)

Religious or not, Cubans tend to believe that unexpressed envy of one's close

fnends, relatives or neighbors can bnnp misfortune to one's household. It is also believed

that the person who receives the misfortune of this erzvidia is not necessarïly the one who

is being envied. The penon in the house who has the lowest level of spiritual

development, or the least amount of spiritual protection, which is often a child or an

animal, often receives the injury. Erzvidia is also at times called rnalafé (untnrstfulness).

It is thought that it is the spirit of the envious person that causes the harm to others,

although not everyone believes this. Others Say, for example, that it is unexpressed envy

aione that is sufficient to cause h m to others (Research June 13,2000; Harwood, 1977:

84-85). This agent is believed to cause bad luck, family and health problems. Whatever

the object of envy, it c m be destroyed.

Envy is a poweq%l thing. Yotc 've lzeard tlzut emy is the worst sin? Yozc can know rkis man, and ifyo~c envy Fzim, your spirit can attack his spirit and make hirn sick. At ~zight wlzen you are asleep, your spirit roams around. Ifyou have envy for anyune, yorc have made a descnptiorz in your rnind. then your spirit will fiizd him and attack him3

As with mala iiiflzlencia, the person affected by eizvidia experiences many of the

same physical illnesses or padecimieiztos: headaches, anxiety, chronic fatigue, stomach

aches, any kind of ongoing or strange illnesses are among the more common. With

envidia, it is said chat a person rnust wage hisher own battle with the spirits and, to do so,

must build up or deveIop spiritua1 strength. It is also felt that espiritistas and other

spiritually or religiously deveIoped individuals like pnleros and s~uireros can eliminate

eizvidia with a despojo or cleansing with flowers. Again, it wouId depend on how an

individual would read these illnesses before they seek help. If they can not cure these

padecimientos themseIves, they may decide to go to a doctor; if they are religious or

accustomed to participating in spintuaiist sessions, they may decide to seek help there. Tt

would depend on the seriousness of the case and the beliefs of the individual.

5.2.4 Mal de Ojo (the evil eye),

Mal de ojo is an etiological agent that is provoked when a person who has mal

vista looks admiringly at a person, animal, or plant. The mechanism by which such an

This quotation derives from the fieldwork camed out by Harwood (1977:85). It is a quote that he used CO

explain how envidia can affect the person. It is a good example of how people believe such an agent can damage the physical well being of the victim.

agent can cause illness is said to be through the eIectrîcity or magnetism in the eyes.

Often people who have mal visra do not intentionally mean to harm another person.

Some individuals know that they have the ability to give mal de ojo, and therefore do not

give compliments for this reason. Children are thought to be particularly susceptibIe to

mal de ojo. The evil eye is less active on adults or any other living thing for that matter.

Parents are very conscious and wary of the evil eye.

Symptoms include fever, irritability, bad colds, stomach pain, vomiting, diarrhea

and headache mesearch, December lsl, 1999; Estrellia, 1977: 13 1). There are individuals

who can tell if a person is suffenng from mal de ojo. They are called upon to help

santiguar the victim. The term santiguar rneans to 'rnake the sign of the cross' as a

blessing over the victim so that he/she is released from the influence of the evi1 eye.

Curing usually involves a prayer to San Luis Beltriin (See Appendix 4). A number of

preventative things can be done to ward off the evil eye. A broach or azabaclze with the

eyes of Santa Lucia is placed on the child to reflect negative energy, dong with two

beads, one red to concentrate energy away from the chiId and the other black to dismiss

the evil eye. From my observation, a parent Iooks to cure the child's symptoms with

househo1d remedies first, find someone to sarztiguar the child second and, if the illness

persists, take the child to a doctor. If these illnesses continue, parents may decide to look

elsewhere for heIp.

One of my key inforrnants said that there were v q i n g degrees of darnage that the

evil eye could do, since it depends on the person who sends it and how stronp their mal

visla is. She said,

Wzen i kvas a yoring girl and my dariglzter was little, Z Izad a h e n d who lived just dowtz the block from me. She once told me a story that I never forgor. A woman slze had bzown frorn out of town had a beautz!jiil little girl wlzo was about four years of age. This little girl was playing quietly in dze house wheïz a stranger looked in and started talking tu the moîIzer. Slre said, 'you have a beautifil little girl tlzere, sIze is adorable, and so well behaved. ' Tlze next thing rhar happened, the little girl collapsed and had to be nished ro rire hospital. Slie was dead before they even arrived. This wontan had had a frernendous mal vista. Mal de ojo was always a big worry of mine. I never forgot this srory because as I said, nzy dazcghter was about the same age (Researclz Jurze 14, 3000, in$ 43).

This type of stones, real or mythical, reproduces wariness of the evil eye for that

particular informant. On a more typical and less dramatic note, 1 encountered a second

example of the effects of this agent.

In the fourth rnonth of my fieldwork, one of my informants gave birth to her first

child. During that month, the farnily received quite a few visitors who came to see the

baby. The parents had purchased an aznbacIze4 and it was always pinned it on the baby's

clorhes. On several occasions, when the baby was particularly fussy and upset, they

would cal1 the woman down from the apartment above. She has the ability to tell if

someone has faIlen victim to the evil eye. She would feel tension and pain in her head

similar to a headache. A couple of times she said that yes, the baby had been a victim of

mal vista, and would have three people recite the prayer of Saint Luis de Batron (See

Appendix for Prayer). This is the most common form of curing the evil eye and it is

believed to have the best results.

4 An azabaclze is a broach that has the eyes of Santa Lucia to reflect negative energy, d o n g with two beds, on read ato concentrate energy away Frorn the child, and the other balck to disrniss the evil eye.

5.2.5 Brujeria

Another more serious agent through which a person is thought to experience

physical harrn is bnijeria. Usually transLated into the word 'witchcraft,' in Spanish it is

used to signify the work of evil sorcerers. fndividuals can be sameros orpaferos, and in

an extreme case an espinlista, but this i s very rare. Those working with black magic are

called bngos and bnqas. They are believed to have the ability to cause harm to others

and can coerce spirits of the dead or the orishas to do their bidding for good and evil-

With sorcery, there is a social relationshtp that is characterized by antagonism and this is

shrouded in secrecy (Garrison, 1977: 95; Research 1999). A11 of the sarzreros and paleros

that 1 interviewed dissociated themseIves with bnqeria and were careful to define for me

a strict line between the two. 1 found that sometimes if 1, for one reason or another,

politely refused a beverage when offered, the person would almost always Say, ccizosorros

rzo sornos bnijos, rzo te tieizes que preoccnpar", which meant "we are not witches, you

don? have to worry."

Perhaps one of the best known Cuban authors regarding Sarztert'a and Palo Morzte

is Lydia Cabrera. In her book El Monte, which deals with the use of plants within these

religious orientations, there is a brief section about illness and brrqeria. She States that,

"Illness, one of the most temble enemies to the happiness of man, and for the poor in

general, this invariably confirms the experience of bnqeria, that has influenced the

body." She goes on to discuss how it is that this spell or malevolent energy sent from

one's enemy can do harm to the victim. S h e claims that folIowers of Palo Mayombe have

a tendency to lean towards bnijena. Palo Monte in some respects is thought to be more

powerful than Santeria because the actions of the individual are not mediated by the

approval of the oriskas. The paZero/a is in direct control of al1 spells and outcornes. Once

a spell is cast, and perhaps an illness is produced through malice, one can only be cured if

the divine intervenes. More specifically, a rzganga must fight a ngunga, good energy

against bad energy (1996: 15). My research indicates that there are palerus who do

benevolent good works and that not al1 involved in Pa10 Monte or Pa10 Mayontbe

practice black magic. CanzaIes, in WulkiPzg Wirlz rhe Niglzr, also mentions black magïc in

Palo Mayumbe and addresses the issue of illness as a result of evil witchcraft (1993: 1 I l -

113).

In Natialia Bolivar Ar6steguiYs book, Czrba: Dnhgenes y Relatos de rrn M~rndo

Mkgico, one finds an impressive account of rnagic spells cornrnon within the Sarztedz

and Pulo Monte religion. The author Iists spells that can harm and spells that can cure

against illness and brztjeria (See Appendix 5 for examples). During my fieldwork, 1 was

often told stories about near death experiences that were either accident related or

illnesses that were considered incurable in the realm of medicine, that tumed out to be the

result of black magic. Any kind of accident or physical illness that causes h m to the

individual can be interpreted as black magic. Again, it is usually the individual who is

religious or comfortable within these religious circles, who seeks out advice; others corne

in a more desperate state, looking for new approaches to help cure themselves or their

loved ones.

One woman told me about her next door neighbor who had been the victirn of an

evil spell. This individual had died as a result of black magic and, with the subsequent

admission of his mother into the hospital, the other only remaining daughter of the farnily

went to see ü snrztero. He told her that both her mother and brother were victims of

bnrjeria and, more specifically, they had been poisoned with the powder from the skin of

a male frog which is especially deadly. It was the widow of the brother who had aIlegedly

done this, as she wanted to gain sole ownership of the house and was not happy in her

mamage. Fighting energy against energy, the saiztero reversed the spell and the mother

survi ved.

Now that a number of etiological agents and their associated physical illnesses

have been outlined, it is important to take this one step further and look at how

individuals act according to them. The second half of this chapter will examine the

diffenng factors that affect health care decisions.

These white nylon bags hold the contents of rnagic spells. They are placed beneath the Ceiba tree, which is sacred in both the Santeria and Paio Monte religions.

5.3 HEALTH CARE DECISIONS

Health care choices and the variables that influence them shift arnong individuals

and groups across time (Finnerman, 1984: 329). IIIness treatment decisions were

discussed through the survey-interviews with informants from San Liizaro and La Juanita.

Included arnong these variables are socio-econornic factors (age, sex, religious affiliation,

education), characteristics of health care services (cost, access and opinions regarding

health care resources), and characteristics of the illness (etiological agents, and severity).

5.3.1 Socio-Economic Factors

gender It is difficult to generalize about the extent to which there exist discernible gender

differences with respect to health care decisions since my samples were gender biased. It

was only possible to collect information during the day, and at this time there was a much

Iarger percentage of women than men in the home. Out of the thirty individuals

interviewed, only six were male. AH six men had basic knowledpe of customary

medicine and Iisted between 9-10 medicina1 plants. They expressed confidence in

conventional medicine and listed a number of pharmaceutid dmgs that they commonly

used. Aspirin was by Far the most common pharmaceutical remedy employed for

illnesses. Three out of six men said that they would visit a traditional healer if there were

no other recourses, but it must also be noted here that two of them clarified that the

traditional healer they were referring to was the non-religious curundero.

Table 5.2 Table indicating knowledge of customary medicine, general belief in the credibility of traditional medicine and education by male informants from San Lazaro and La Juanita.

Inforrnants Medicines 1 Male

Informant 1 Informant 2 Informant 3 Informant 4 Informant 5 Informant 6

(# of Plants) L 1 9 6 15 1 O 6

Knowledge of Customary

1 Yes Yes (curandero)

l No Yes (curandero) No No

Traditional Medicine (Yes/No)

Level of Education

Pre-University Pre-Universi ty Secondary Primary Secondary Secondary

In general, when men were asked under what circumstances they would employ

custornary, conventional and traditional medicines, three out of the six replied that they

would go and see their doctor first before they would use customary medicine. Once it

was established that the problem is not serious, then they would use plants or household

remedies to address an illness. The other three informants felt that one should see a

doctor for more serious or chronic health issues, but that they would first look towards

customary medicines to see if their problem could be resolved in a simpler manner.

From the much Iarger sarnpIe of women interviewed, trends in medical choice

were much easier to discern. Table 5.3 indicates that there was slightly higher degree of

knowledge of customary medicine by females from San Lfizaro. This is particdarly

interesting since La Juanita has an older population. Out of the eleven women

interviewed in La Juanita, only five knew of 11 plants or more that could be used for

medicinal purposes. In San Lharo, eleven women out of the thirteen interviewed listed

anywhere from 1 1 plants or more.

Table 5.3 Table indicating knowledp of medicinal plants employed in customary medicine by women informants from La Juanita, and San Lkaro .

Number of Medicinal Plants Employed for Customary Medicine

5-10 Plants 11-20 Plants

Nineteen of the twenty-four women interviewed listed anywhere from five to

twenty plants they would employ in custornary medicine. When asked to discuss the

circurnstances under which they would employ customary, traditional, and conventional

medicine, thirteen of the women stated that they would use customary medicine as an

initial approach to an illness. Again, as with the males, most stipulated that with chronic

or serious health problems they would see their family doctor first. Ten out of the

twenty-four women said that they would go to their farnily doctor first and then see

which plants he/she would recommend.

Table 5.4 indicates that thirteen out of the twenty-four women interviewed said

that they wouId visit a religious heater o r c~irmzdero if alI other rernedios had failed. In al1

cases this was thought to be a last resort, once customary medicine and conventional

medicine had failed. San L k a r o wornen were more inclined to do this than women in La

Juanita. One must, however, keep in mind that there were a slightly larger number of

wornen interviewed in San Lkaro. Only one woman stipulated that she would only see a

non-religious curarzdero.

Women in La Juanita

21+ Plants Total

(6) 55% (5) 45%

Wornen in San Liizaro

(O) 0% 11

Women frorn Two Barrios and Knowledge of Medicinal Plants

(2) 15% (6) 46%

8 11

(5) 38% 13

5 24

Table 5.4 Table indicating belief in the credibility of traditional medicine by women from La Juanita and San Lkaro.

Belief in I Women in San Tobl Traditional Medicine Juanita L6zaro 1 ~ o r n e n from

( Total I l l 1 13 1 24 1

YES

Results from the interviews collected indicated several interesting age-related

patterns. As illustrated in Table 5.5b, middle aged and older informants knew of a greater

(4) 36%

number of medicinal plants than the younger ones. This is not overly surprising since

they have more years ofexperience using medicinal plants and would likely remember

(9 ) 6 9 8

customary practices employed by their parents before conventiona1 medicine became as

both barrios. 13

accessible as it is today.

Out of the eight youth interviewed, five had knowledge of eIeven medicinal pIants

or more. Thus, knowledge regarding customary medicine was not lost to younger

generations. This in part can be explained by the political and econornic crisis of the

Special Penod during which time the new generation rediscovered and employed

customary remedies when access to certain medicines declined (MacDonald, 1999: 23 1).

Table 5.5a. TabIe indicating age of interview-survey informants for San Lkaro and La Juanita

~ i d d f e (36-55) Old M.5) 1 14

1 Young (235)

( Total 1 15 1 15 1 30 1

La Juanita 2

San L5zaro 6

Total 8

TabIe 5.5b. TabIe indicating average number of medicinal plants recognized and employed according to age in La Juanita and San Lkaro

As wil1 be discussed in the next chapter, there are many mediums through which

younger generations and older generations l e m about medicine, inclusive of customary

medicine. It is worth mentioning here that two of the youth interviewed stated that they

had learned about medicinal plants in school.

With respect to traditional forms of medicine, it was found that the number of

individuals who have faith in curarzrlerismo is relatively evenly dispersed. Sixteen of the

thirty people from San L5zaro and La Juanita stated that they would look towards

traditional medicines if they could not find help in the conventional or customary realm.

Out of the eight individuals under the age of thirty-five, five stated that they would

employ traditional medicine if conventional and customary medicines had failed (this is

63% of youth interviewed). This differed slightly from elders in the cornmunity where

57% expressed faith in traditional medicine. Those who were in the middle age goup

were less likely to believe in traditional medicine, 75% stated that they would not visit a

tradi tional practi tioner.

Ofd (>55)

Number of Medicinal Plants used in Cus to mary iMedicine

5-10 Plants 11-20 Plants 2 1 t Plants Total

Young

(235)

(3) 37% (5) 63% (0) 0% (8) 100%

Middle (36-55)

(5) 63% (1) 12% (2 ) 25% (8) 100%

(4) 29% (7) 50% (3) 21% (14) 100%

Table 5.6 Table indicating by age group, the number of individuals who have faith in traditional medicine.

Belief in Traditional

Several factors influence belief in traditional medicine. Both older and younger

individuals have grown up in periods where there has been an acknowledgernent of other

avenues of medical treatrnent. Both of these generations have also lived during a period

where access to medicines has been limited. Those above the age of fifty-five remember

what it was like before the revolution brought conventional medicine to al1 sectors of the

population, and those under thirty-five, through the Speciai Period have been taught to

look for and appreciate alternatives outside of conventional medicine.

Middle-aged individuals were raised during the most economicaIIy successful

penod of the revolution. D ~ n n g the 1960s and 1970s, the govemment worked towards

industrializing and diversifying its economy, these initiatives were reflected in the

mindset of Cubans at this time. I-ndividuals becarne socialized into the notion that

development could only be equated with science and technology and this is inclusive of

medicine.

Medicine YES

Edzcariorz

Research indicates that education influences an individual's health care choices.

According to Cavender and Beck, misconceptions regarding the correlation between

Young (235)

(5) 63%

Old (> 55)

MiddIe (36-55)

To ta1

(3) 25% (9) 57% '04

education and knowledge of traditional medicines have tainted past anthropologïcal

studies. According to them, people "gather their information from older, Iess formally

educated, geogaphically isolated and irnpoverished populations and then present their

findings as representative of the population" (1995: 129). This trend did not hold true for

my research; instead, as is apparent in the table below, there appears to be no strong

correlation between level of education and knowledge of rnedicinal plants. Out of those

individuals who knew the most about medicinal plants (21t Plants), three out of five had

a primary education.

Table 5.7 Table indicating the level of education of the thirty informants and their comparative knowledge regarding medicinal plants.

1 Total 1 (10) 100%

Number of Medicinal Plants Employed for Customary Medicine 5-10 Plants 11-20 Plants 21+ Plants

Primary Education

(3) 30% (3) 40% (3) 30%

In terms of traditionaI medicine, individuals with a pre-university education or

greater were more receptive to approaching c~rraizderos (whether the y are reli gious

healers, herbaiists, or people who just have a gift to heal) than were individuals who had

completed secondary schooI. Eight out of ten individuals with a primary education also

expressed faith in traditional medicines. The chart below looks at the number of

individuals that expressed their belief and disbeiief in the validity of traditional medicine.

Secondary Education

(5) 50% (4) 40% (1) 10%

Pre-University Education or Grea ter (4) 40% (5) 50% (1) 10%

Table 5.8 Relationship Between Education and Number of Individuals that Have Faith in Traditional Medicine

Belief in Secondary Pre- To ta1 TraditionaI Education Education University Medicine IPrimary 1 1 Educatioo 1 E S NO

*Two individuak, one with a pnmary education and the other with a pre-university education stipdated that they wouId onIy see a non-religious Curandero, one female with a secondary education also made this stipulation.

1 1 I 1

It should be emphasized again that gender, age, education and, religious affiliation

(8) 80% (2) 20%

Total 1 10

should al1 be considered in conjunction when examining knowledge of customary forms

10 1 10 130

of medicine and faith in traditional medical systems. Individuals with a secondary level

(1) 10% (9) 90%

of education tended to lean more towards conventional medicine but, as indicated in

Table 5.7, most aIso have competent knowledge of customary medicine. This will be

or Greater (8) 80% (2) 20%

discussed further in a later section.

17 12

Religious Afiliation

For years in Cuba, under the socialist govemment, religions of any kind were not

openly practiced. The power of the Roman Catholic Church, any religious hierarchy for

that matter, would be in direct contradiction to the cornmunist egalitarian ideal. The

revolutionary madwoman did not practice religion, or at Ieast they did not do so openly.

Today, peopIe have the liberty to practice whatever religion they desire and, as many of

my informants stressed, more and more people are openly doing so. Yet, despite this,

many individuais are still hesitant to discuss their religious beliefs.

In terms of religious or spiritual affiliation, it was not part of the survey to ask

what an individual believed. With religion being a closeted phenomenon for such an

extended period of Ume, it would be difficult to know if a person was answering

honestly, if they responded at aI1. There were several occasions where an individual

wouId tell me that they believed in nothing, and then a month or so later 1 would meet up

with them in a religious setting. It was only after 1 had built up a level of trust with my

informants, that they would provide me with any detail about their religious beliefs.

San L k a r o is a barrio strongly rooted in Afro-Cuban reIigious tradition. This may

influence when or where an individual would decide to seek out reinedios within the

traditional realm. Although there were a higher number of individuals who believed in

the effectiveness of curanderisnzo in San Liizaro, the nombers were not as large as I had

originally anticipated. There was onIy a relatively small attitudinal difference between the

two barrios. Nine out of the fifteen (60%) individuals frorn San Lizaro said that they

would look towards traditional medicine shouId their problems remain unresolved. Seven

out of fifteen people from La Juanita (47%) said they would do the same. That is a

difference of about thirteen percent.

Table 5.9 Table indicating belief in traditional medicine by inforrnants from San L k a r o and La Juanita

r

Beiief in Informants in Informants in TotaI Traditional La Juanita San Liizaro Medicine YES (7) 47% (9 ) 60% 16

1 Total 1 l5 1 15 1 30 I

Several informants confirmed that when individuals are very il1 and perhaps knocking on

death's door, whether they have specific religious orientations or not, they will seek out a

traditional practitioner. As one lady said,

Its like rhis, ofrerz people have gone to a doctor and medicine does nothirzg for rhern; they will go ro a ccrrandero. We are somewhat fanatical about such things, and people will look there tu fiïzd relief from their illnesses (Research Augctst 1, 1999, In$ # 54).

Nothing is Ieft to chance, every possibility for treatment is examined. Many individuals 1

had interviewed claimed not to follow any of the Afro-Cuban religions or Spiritism, yet

al1 had a story to tell about when one of their farnily members or loved ones was il1 and

they went to see a traditional healer to try and resolve the problem.

TIte Big Pictcire: Conzbiïzing Socio-Ecorzonzic Data

Now that some of the social characteristics of informants form San Lkaro and La

Juanita have been individually discussed, it is important to combine thern to determine if

there are certain distinguishable patterns of behavior. This will in turn Iead to a more

comprehensive explanation as to why individuals choose the treatments that they do, or

have gained the knowledge regarding medicine that they have. It wiIl provide us with a

more concise understanding of the population itself.

Through the use of a program for dual-scaling, better known as correspondence

anaIysis, it was possible to examine which traits (variables) were shared by individuals

(and vice -versa, which individuals shared the sarne traits) in order to identify similarities

and differences in the population and how they relate to levels of knowledge of

A ~re-univershv Education - -

- - --\+ ---- Beiîeve in effeciiveness2 traditional medicine * -Pianiif=,, D

252181) + - 5'

,--f + -10 /

1.5

Hi Plant Use i - + medicine

- Medium to kkhuse of

- Low to m e b u s e of mediunatpbnts - Some beliefin traditiod -

- Mostly poung, rome O& individuais - Hkh kveL o f education - Fernales a d some males

C - - Me& to highuse of medicinal p h t s - Belief in traditionai medick - OIder individuah

customary and traditional medicine.' The map below represents the clusters of infamants

revealed through the first and second solutions of the dual-scaling progrm. While the

Nishishato's software program illustrates trends or patterns that extend beyond the

second solutions, the results, of fourth analysis did not show any relevant patterns or

trends within the data set colIected.

Older and middle-aged, less educated women, generally with a primary level of

schooling, and highly educated young women were both equally likely to use medicinal

* Dual Scaling refen to a form of non-inferential statistics. also known as a data reduction technique. that generates a cluster of points in a scatter plot called a map. It allows us to 'carve out' class grouping for visual representation. The linear distances between the points on the map represent individuals with the sarne attributes. or vice versa. and are interpreted in terms of a rnultidimensional 'social space.' In rny thesis, the Multiple Choice option of Nishishato's software package was used (Nishisato. 1994).

plants although older women tended to know the medicinal properties of a greater variety

of plants (See A, B, and C ) . There was however, one man within this cluster who was

highly educated and used a medium amount of medicinal plants. Those who had an

extensive level of knowledge with regards to customary medicine also tended to believe

in traditional medical practices.

Individuals who knew Iittle with respect to customary rnedicine also stated that

they did not believe in the effectiveness of traditional medicine. There were a few

exceptions where a smaI1 number of women did use medicina1 plants even though they

claimed that they did not believe in traditional medicine. Men and women with secondary

education who had low levels of knowledge of medicinal plants were also more Iikely to

say that they did not believe in traditional medicine (See D).

Thus, younger generations tend to have higher education, and from the economic

problems experienced with the Special Penod, are apt to look outside of the conventional

realm to address their problems. These individuals are also likely more influenced by

today's media and the promotion of different medical approaches (particularly with

plants) to health problems. Middle aged individuals with lower education levek (with a

few exceptions) tend to have medium to low use of plants and lower levels of belief in

traditional medicine. This again can be explained in part as a resulr of their socialization

into believing that science was the key to resolving health problems and that other

methods outside of that realrn were less advanced and therefore less effective. Finally,

elders in the comrnunity with low levels of education and high levels of knowledge with

respect to customary medicine are more likely to state that they believed in the validity of

traditional and customary medicine. They grew up before the revolution, or at least

before the changes brought about by the revolution had taken effect, when access to

conventional health facilities and educational institutions would have been lirnited. Due

to these limitations, their reliance on customary and traditional forms of medicine would

have been greater. Such individuak would be Iess Iikely to trade in their beliefs in

traditional ways for their children's newer convictions in developrnent through notions of

science and technology.

If we take gender as a variable, it would appear that women know slightly more

about medicinal plants then men, and are aiso more likely to seek out a traditional healer

if they feel it is warranted. It is difficult to make solid generalizations with regard to

gender, due to the low number of men. Aside from the above-mentioned patterns, there

were no large differences in either use of medicinal plants and levels of education

between the two barrios.

5.3.2 Characteristics of Heakh Services

Cost of Treatrnerzt

In terms of conventional medicine, the cost of services is funded by the state, but

the cost of drugs is only partially funded. Dmgs can range from being affordable to

expensive. If the illness being treated is chronic or if it requires the purchase of

prescription drugs in large quantities, it is expensive. In addition to Cuban pharmacies,

medicines are aIways available, at least in Cienfuegos, at the international ch ic . These

dmgs, however, are sold in American dollars and not in Cuban pesos. Since these clinics

cater to tourists and foreigners, their prices are rnuch higher than what the majority of the

Cuban population can afford,

Within the realm of traditional medicine, curanderos and religious healers are

normally paid in cash but, in sorne cases, services and products can be exchanged for

treatment. Depending on the severity of the illness, or the reputation of the crrrandero,

their fee can be expensive or cheap. Generally it is felt that an individual with a gift to

heal should not request high pices, and that the client should only pay what he/she can

afford to give. This is not always the case, and there are occasions when people take

advantage of an individual's misfortunes to charge exorbitant fees. Generally such

individuals gain a bad reputation as being 'interesados' or self-interested.

The rates of an espiriiista can Vary accordingly. Again, it is generaIly thought that

a legitimate espiritisra will not demand a set price but let patients decide what they can

afford. Costs tend to depend on how many visits were required to heal the person of their

illness and the efforts made by the espidista in this endeavor. Since these things Vary

from case to case it would be difficult to establish a set pattern regarding the costs of such

services.

With sarzreros or paleros, prices wodd also Vary according to whether or not a

ntual involving an animal sacrifice is required in the healing process. Often an animal,

normally a chicken, is sacrificed to the orishas or to the rzgarzga so that they will listen to

the sick person's request for healing. With cambio de vida, or life exchange, the animal is

sacnficed to take the place of the person whose life is at nsk. Such ceremonies,

depending on the goods required to conduct it, can become costly. One ceremony 1 went

to involved the sacrifice of three animaIs and the man told me aftenvard that by the time

he had paid for the cost of the two sarzrero's services and the animals, he had

accumulated quite a large debt.

In terms of non-religious healers, the one cnrandero 1 interviewed who cures

bums told me that he could not ask for any money at all. Should he try to charge money

for the miracles that he performs, then he would lose his grace to heal. In these

circumstances, people generally donate money or give gifts of food, animals, etc. Another

non-reIigious cctraïzdero that 1 heard about charged money but according to the woman

who had visited hirn, he did not ask for rnuch. However that which she found inexpensive

could be considered exorbitant for another person. Again, it is important to keep in rnind

how this can Vary.

Customary medicine, on the other hand, is absolutely free, considering that most

individuals can recognize and know where to look for the plants that they need. On

occasion, if there are plants required that do not grow in the city, individuals will go to a

yierbera or herbalist who sells plants. Often these individuals are supplied with plants

from the countryside that are difficult to find in the city.

Over the counter pharmaceutical goods are sold in pesos and are also relatively

cheap, when in stock. Tt is interesting to note that even for these sorts of products one

must go and obtain a prescription from the doctor and present it at the phmacy. Aspirin

and other over the counter antibiotics are inexpensive and commonly used by the

population.

Accessibility of resortrces

Conventional medicine is accessible to all, and this held true for the population

studied. AI1 thirty individuals lived within walking distance of a corzsrtltor?~ or clinic

where they had their own family doctor. As mentioned in the previous chapter, the farnily

doctor program was initiated and promoted by the Cuban govemment to improve pnrnary

health care and preventative medicine (MacDonald, 1999: 158-159).

Perhaps the largest factor influencing health care decisions for most of my

inforrnants is lack of medical resources within the realm of conventional medicine. This

is a direct result of the United States' embargo against Cuba. Quite often there are no

medicines available to seIl in the pharmacies or tests are not possible because supplies for

medical equipment are not available outside the US. One of my informants told me that

she has had her eyes checked free of cost and she has had a prescription for eye-glasses

for months, but there is no glass to make the lenses. She will likely have to wait for

several months before a limited amount of glass becomes available once again. At the

height of the Special Period, individuals were left to invent whatever solutions they could

to see to their health problems.

Although transportation in Cuba is often difficult and challenging, to say the least,

the government tries to provide services by way of buses that travei directly to the

hospitals. The further one is in the countryside, the more difficult this becomes but, for

the population studied, al1 lived in the city and transportation was not an issue. Most were

in walking distance to al1 medical centers.

With both traditional medicine and customary medicine, access is pretty much

available to all. Individuals generally know where they can find traditional practitioners

and then arrange to see these individuals. Access would only be hindered if the

crtrandero lived far away or if they charged prices that the population could not afford.

Plants grow wild in Cienfuegos and, as long as you can recognize them, finding them is

not a problem. Customary medicine is also a very social practice in that, if a person does

not remember a plant used for a particular illness, they will ask a neighbor or friend.

5.3.3 Characteristics of IIlnesses

Health Decisioizs depeizding on Seriottsness of Illness

The level of seriousness of an illness is also a large determinant of health choices.

Close to two thirds of the individuals interviewed stated that customary medicine was the

first action against illness that they would employ. The other one third go to the doctor as

soon as there is something wrong and only use medicinal plants or naturalistic healing

techniques if their doctor advises them to do so. One half of those interviewed claimed

that, if there were no results from customary medicine and their pain or iIlness continued

to bother them or if an injury was S ~ ~ O U S from the onset, then they would generally go

straight to their farnily doctor or go to the hospital. Finally, if individuals do not receive

satisfaction from the medical field, or if it looks as if there is no viable course of action to

help them within conventional rnedicine, they would explore other forms of healing

andior possibilities within traditional medicine. Many will also use different medical

systems in tandem to ensure recovery.

Etiology

As was found in the study camed out by Kroeger and Freedman (1992: 276).

illness etiological agents can influence the type of care that is sought. My study, like

theirs, found that there was a large preference for conventional health services for

accidents, injuries, infections and basic chronic illnesses. Traditional medicines were

often sought out for pain and in those cases where individuals felt that they needed more

than the conventionai medical system was providing.

Should an individual believe that the agent causing the illness is not within the

physical realm, as with the evil eye, or with mal irzflriencia, for example, they wiIl likely

seek out an Espidista, a person who cures the evil eye, or any other spiritual healer or

czlrandero. If the individual has a great deaI of faith in these curartderos, whether

religious or not, he/she may choose their approach to heaIth care accordingly. 1

conducted an interview with a c~trarzdero from a srnaIl cornmunity called Ametes, who

was known for his ability cure severe bums without leaving scars. Many people in

Cienfuegos knew and talked about this man and people came to visit him from al1 parts of

the island. Those who had seen the results of his work or held a strong faith in his ability

to heal would forgo visiting the hospital and go straight to see this c~warzdero.

From Figure 5.4, it becomes apparent that there are many different paths that

influence health decisions regarding medical systems. Socio-economic factors,

characteristics of health services, and characteristics of a particular illness al1 play their

role in an individual's approach to heakh issues.

Figure 5.4 Variables afFecting health care decisions as iisted by informants fiom San Lkaro and La Juanita

1 ~ocio-economic Factors 1 1. Age - 2. Gender 3. Education 4. Reiigiow Affitiation

Characteristics of anIhess: 1. Serious or ntinor 2. Etiology(naturai or

supernaturai)

Perceptions of the Chuacteristics of Health Scmces 1- Accessibility 2. Opinion of services

Perception of the bauïers (or convenience) of s e e h g treatment

i Traditional Me dicd S ystem (Curandero)

Conventional Medicd S ystem @amilyDoctor)

System (Family/Householâ)

Taken frcm Kroeger andFreedmann, fhis figure has been m o a e d to illustrate the p e t , throu* which dtcinons are made far infonn ardsinSanL&aro and La Juanita. (Kroeger and Freedmann, 1992: 266)

Conclusion

Eïzvidia, bngeria, ïnala iïzj7rteïzcia, la pnleba, el casrigo, eiwidia. and mal de ojo

are al1 agents of illness. Although spintual or supematural in nature, they have an impact

on the body and are known to cause physical ailments. Thus, before one can gain an

understanding of the process through which medical decisions are made, one must first

define the agents from which illness can be caused, whether they are considered to be

purely bioIogical/naturalistic, or personalistic agents. The first portion of this chapter

highlighted some of the main etiological agents responsible for illness causation as

expenenced by the population interviewed.

From here, a focus was placed on other influences affecting the decision making

process. More specifically, gender, age, education, and spiritual/religious affiliation play

a role in determining the social characteristics that can affect this decision-making

process. Al1 of these factors must be considered in the treatment of illness, since it is

experience, exposure that influence an individual in any of the health care choices that

he/she may make.

Cost of treatment and accessibility to resources are also major factors that affect

medical decisions. In the conventional realrn, there is no cost for medical services;

medical supplies are another story. Prescriptions are partially funded but, depending on

the economic situation of the family, accessibility can be limited. Since the embargo,

there have also been shortages of drugs so chat a medicine prescribed is not necessarily

easy to obtain. In terms of traditional rnedicine, treatments can range from being

expensive to extremeIy cheap. Depending on the crrrandero, this form of medicine can

either easy or difficult to access.

Thus farniliarity with the different agents inducing illness and the reproduction of

medical knowledge regarding their possible treatments al1 play a role in influencing the

decisions of an individual. The following chapter will further examine the reproduction

and transmission of medical knowledge as it applies to the general public. The focus will

be placed on the reproduction of information as it relates to customary, traditional, and

conventional medicine.

CHAPTER VI

REPRODUCTION OF MEDICAL KNOWLEDGE

Preamble:

While a large body of research examines the ways in which culture can shape

illness manifestations, the issue of how illness is modeled has been little explored. How is

a mode1 and its component parts reflected in the minds of representative members of a

culture? Research on medical knowledge indicates that non-practitioners who are

mernbers of the same cultural goup share an understanding about native illness

terminology and c m generally describe specific illnesses. Individual beliefs and practices

need not fa11 within the realrn of medicine practiced by the crtrandero or physician for

non-specialists to understand illness definitions and etiology. Such reasoning can also be

applied to medical treatments as well. Thus, knowledge about illnesses and treatments

seems to be shared within a aven culture (Fabrega, 1971: 25). During my fieldwork, 1

became aware that to gain an understanding of medical systems -- whether customary,

traditional or conventional - would require an examination of the process through which

medical knowledge is transferred or reproduced.

In his book on Afro-Caribbean folk medicine, Laguerre analyzes the transmission

of folk medical knowledge as it occurs through family tradition, and within the context of

religious/spiritual healing practices. He uses the term 'folk medical traditions' to refer to

the totality of health knowledge and medical practices of the Afro-Caribbean population

that falls outside of mainstream orthodox medicine (1987: 35). Laguerre's mode1

discusses the roIe of institutions such as the household, the muIti-household, the ethnic

church, the folk c h i c and voluntary associations that impact on knowledge to form a

more complete picture of existing medical systems. Using aspects of this model, my

research focuses on the niches of medical transmission as they occur through the

household, the media, religious/spiritual orientations, and the family doctor. Each of

these institutions plays an important role in how individuals define and approach illness

episodes. In other words, the rneans by which information is accessible to the population

has a direct influence on the knowledge base from which health decisions are made and

medical behavior is understood.

6.1 MEDICAL KNOWLEDGE AND THE INDIVIDUAL: INSTITUTIONS OF EDUCATION

6.1.1 The Household:

The survey interviews were conducted with thirty individuals to gain a basic

knowledge of customary medicine. Survey-interviews dealt wi th past and present medical

practices related to illness such as "what did your parents do when you were young?" or

"do your practices differ from those carried out by your parents?" In the majority of

cases, individuals responded that they had lemed these practices from their parents and

continue to apply the sarne techniques. Eighty percent said that their knowledge of

medicinal plants stemmed from 'family tradition.' A number of individuals also stated

that if they were not aware of what plants could be used to address an illness, they would

simply ask a family member, fnend, or neighbor. Most of the interviewees, and 1 would

say the population in general, have a strong knowledge base of local flon and its

potential uses. Thus, transmission of customary forms of medicine seems to take place

between and within households.

Cino Colina (Granma International. June 2gth, 1992, in McDonnald, L999:23 1)

writes: "Herbal rnedicine, as it is currently called, has gained new importance as has

grandrnother's remedies, in the face of a dmg shortage." Customary and traditional

rnedicines have played a significant role in helping many individuals cope with the

hardships experienced dunng the 'Special Period' which reflects how medical knowledge

has been reproduced to suit the needs of the younger generation.

The term "grandmother" highlights the institution of the family as the locus of

medical know Iedge reproduction. Children learn from their parents how an illness is

defined and the treatment that can be used in response to this definition. The

circumstances under which parents decide to treat an ithess with customary, traditional

or conventional rnedicine depend on a number of factors, in particular, the history or past

expenences of the family or household unit. The household, as the survey data indicated,

shouId never be underestimated since it is by far the most influential.

Front patio of an ~~ house fiom San h o , M;srry of these plants are used by the household fw medicinal purposes.

The mcticmal plant ï30, &O hown as Linden fiuwers, is beiug grown outside the home for f a d y consumption

6.1.2 Media:

The media play an important role in health care because of the high level of

Iiteracy in Cuba since 1959. This enables public-health carnpaigns to be successful. The

Castro administration has made extremely effective use of the print, radio and television

media to further mass vaccination efforts and distnbute important information regarding

sanitary practices (Diaz-Briquets, 1983: 109).

During the 'Special Period,' the media became, and still are, a forum through

which information regarding alternative medical practices is distrïbuted. The data from

the survey show that eight individuals claimed that they had leamed of medicinal plants

through books, two read about plants in a local newspaper, one watched a television

program and one listened to a radio show for information.

Dunng rny stay in Cuba. I obtained several taped versions of the television

program "De Sol a Sol" which is a weekly program on Sunday nights at 7p.m. that

focuses on local plants with or without medicinal coverage. Themes covered dut-ing the

program include: information on the processing of herbal remedies that make their way to

local pharmacies, the use of essential oils in plants, or the multiple uses of one or two

specific plants. To assist home gardeners, the show also caters to areas of interest outside

of medicine. Natural rnedicine shows follow a general fonnat. This includes: a visual

illustration of the plant is provided, along with a description of its charactenstics and

medicinal properties; the ideal conditions under which specific plants should be grown

(eg. Sun, shade, water, and soil); and finally, information on how these plants should be

cut, stored and prepared.

The media, in Cuba, can be used for preventative medicine. For instance, cartoon

commercials from the department of health are used to illustrate the importance of

hygiene. A frequently shown ad featured a little marshmallow -shaped child who did not

wash his hands after playing outside in the dirt, or after using the bathroom, and later

ends up sick in bed. Once the child is seen in bed with a thermometer in his mouth, the

voice explains how keeping hands clean helps to keep gocd health.

Another example is a daily 1 h m . brief segment on the radio that discusses issues

of concem to the general population. Occasionally, the show addresses health issues and

the use of medicinal plants. The format is again simifar to that of the television program.

General information is given regarding the plant and its rnedicinal properties. Preparation

techniques are explained as well as possible side effects of the medication.

In addition to regular radio and television programs, the governrnent or health

officials can have access to the media to cover relevant health issues. Should there exist

any health nsks with infectious diseases, or outbreaks, sanitation issues and problems

regarding medical centers or programs, they are usually announced on the radio or on the

television news-

Books on customary medicine -- the most common of which is called j&

Medicina Folkl6rico de Cuba - aIso provide reIiable sources of information. Six of the

interviewees read books for medical instruction. Two said that they looked to the

newspaper. Weekly, the national newspaper features one or two medicinal plants and

their possible uses. The article includes a description of the plant, along with the

scientific and common names. Its medicinal properties are highlighted, techniques used

to prepare the plant are outlined, along with any adverse side-effects associated with its

use.

Two clippiogs tacai Eam a local newspapu- Every week a d&mtnt me- plant ïs âaftrnd ïhe plants characttrishcs and uses are ouîiïned

6.1.3 Medicos de la FarniZià (Family Doctors):

There were only two occasions dunng my stay in Cienfuegos in which an

individual expressed to me an inherent distrust towards doctors and conventional

medicine. For the most part, there was a relatively even division between those

individuals who would first try to treat themselves via customary medicine, and those

who would go straight to their family doctor. Those who did practice customary medicine

as a first approach stated that for senous illnesses or if they saw no results from self-

treatment, they would visit their famiIy doctor. Family doctors constitute a reliable and

frequently used source of information on conventional forms of medicine.

It is the family doctor who prescribes medicines and pharmaceutical products

when needed and advises patients on various medical decisions. Eventually, patients

l e m to recognize symptoms and illnesses and to ascertain which ones Iikely require

drugs/pharmaceutical products, hospitalization, or regular visits to a c h i c . From

exposure, individuals also inevitably acquire a gea t deal of information on a variety

medical treatments, their associated characteristics and particular methods of

administration. Individuals generall y consult medical doctors for advice. In case dmgs

are not required or are not available, the doctor can facilitate an alternative treatrnent.

Interviews with doctors reveal that these treatments were most comrnonly green

medicine, chiropractic medicine, homeopathy, and physiotherapy, fangoterapia (mud

t herap y).

According to the doctors who were interviewed, clinics or consultorios display

public charts with the listing of commonly used plants, their medicinal properties and

preparation techniques. in reality 1 saw only two displays in the ten clinics that 1 visited,

but quite a number of doctors stated that each clinic is supposed to have a poster on

display. Family doctors are also expected to grow a small parden next to the conszilto~o

or have a number of medicinal plants on the premises so that they may better illustrate

and facilitate the use of plants for curative purposes. Accordirig to most of the physicians

interviewed, patients are generally familiar with al1 local plants and know how to prepare

them for medicinal purposes.

Using texts and the information provided to them by the government, and through

pre- or post-graduate courses, doctors often incorporate the use of medicinal plants in

their treatment. Eight out of the thirty informants interviewed listed their doctor as one of

the mediums through which they learned about medicinal plants.

In addition to working with basic plant material, family doctors often prescnbe

medicinal plant producîs which are sold at local pharmacies, although most products can

be bought without a prescription. Doctors receive lists of plant tinctures and remedies that

are available at local pharmacies on a regular basis.

The Family Medicine Program in Cuba has a very strong preventative cornponent.

Al1 doctors are supposed to spend a portion of each day making unsolicited visits to

patients. The doctor will check their sick patients in their home, and usually pass a

comment or two about smoking, diet and general health (Research, November 20-27,

1999; MacDonnald, 1999: 8-9; Danielson, 1979: 201). They also assess the living

conditions of the individuals within the barrio and make suggestions on how to prevent

the spread of certain transmitable illnesses Iike scabies, lice, colds, etc, and how to deaI

with chronic illnesses like asthma. Their role is educational. They inform patients on

illnesses and available treatments. They help educate their patients in family planning and

work to prevent premature pregnancies. Doctors are involved in such community health

activities as local food saiety, hygiene cornmittees, sheltered workshop provision, etc

(Danielson, 1979: 158- 159).

Conventional medical knowledge, which in the area of farnily medicine includes

this preventative eIement, is reproduced within the general community and particularly

with the population studied through the these aforernentioned methods. It is worth noting

that the family doctor program and the liberalization of conventional medicine in Cuba

since the 'Special Period' has facilitated a much greater understanding of what were

considered to be alternative foms of medicine and likewise customary treatments.

Family doctors today are much more involved in alternatives Li ke chiropractics,

acupuncture, message therap y and herbal remedies than ever before. With their greater

acceptance of such medical practices, there has also been an expansion in the levels of

knowledge held by the population regarding these alternatives.

DispIay found msi& the consultono. It Iists a d e r of m e d i c d plants dong w i h th& possible apphcations and preparafion techques.

6.1.4 Religious/Spiritual Orientation

Religion or spintual orientation was not listed in the survey-questionnaire as a

means through which people l e m e d about medicine. Interestingly, however, a number of

survey participants admitted that they would go see a crrrandero, or religious healer if

they had found no other forms of effective treatment through conventional or customary

medicine. It is thus important to discuss religious/spiritual orientations since their

practices are so intricately intertwined with knowledge of plants. The fact is that one-half

of those interviewed said that they did have faith in traditional medicine whether it be in

the non-religious crrrandero or in religious/spiritual practitioners, therefore it is important

to look at this medical system and its methods of educating individuals about health care

issues. As rnentioned earlier in the literature review, saizrerns, paleras and even

espiririsras in general develop their knowledge of medicine and plants as it is considered

by many to be part of spiritual development.

It is through religious and spiritual orientations that many people learn about

etiological agents that cause health problems. This in no way can be Iimited to

practitioners, for many individuals may not be following any particular religion, yet

accept or give credence to elements of a belief system and perhaps in the rniraculous

abilities of a crtrandero. Thus defining illnesses depends largely on the exposure of

individuals to various belief systerns. Examples of traditional treatments would include

bathing with certain plants to purify the body and get rid of evil influences that are

causing physical syrnptoms. This practice stems from religious and spiritual beliefs and is

only one of the healing techniques applied to these foms of illness. In such cases any of

the advice given and actions carried out in response to the illness, whether they employ

plants or not, are spintual in context.

Traditional heaIers have a great deal of knowledge regarding medicinal plants and

how they are used in terms of custornary medicine. In four of the interviews conducted

with religious individuals, books on medicinal plants were discussed as a rneans to

heighten their spiritual powers. These books are the same forrns of media mentioned

above and not lirnited to religion.

Like a family doctor, it is the practitioner who is the main distributor of medical

knowledge with respect to traditional medicine. Should a person visit a religious

practitioner for help with an illness, it is highly likely that the individual expenencing the

illness would learn how the problern is generally addressed within this particular medicai

system. Individuais may learn to employ religious practices while others would be

dependent on the presence and abilities of the practitioner. At any rate, people involved in

the process, whether at a higher or lower Ievel, wouId leam about the rituals, and the

basic tools used within the religion to address a given health problern.

Some healing techniques do not require plants for their success and in such cases

the person would at the very least learn the ceremony or actions taken in the

practitioner's attempts to cure the illness. Unless the individual is religious, it would be

unlikely that he/she would acquire the detailed information required for more intensive

healing rituals and ceremonies within the traditional realm. Data indicate that visits here

are a general 'last case scenario' and not necessarily a common practice.

6.2 TECHNIQUES AND PROCESSES FOR TRANSMISSION OF KNOWELDGE

The techniques or processes resulting in the reproduction of medical knowledge

are numerous. Such processes may include formal teaching from trained personnel that is

very structured and practical in nature, or it may be informal, developed through

superstitious beliefs and tales. Et can be overt, as is mainly the trend within the

conventional system, or covert, as seen through a santero 's use of a divination system

which involves an interpretation of Iearned proverbs.

Information regarding medicine is reproduced through writings, particularly in

newspapers and books. Such mediums once again can be formal or informai in nature.

Occasionally, people keep records of household remedies through a use of personal

diaries or, in the case of conventional medicine, use official publications to train future

family doctors. Many cru-anderos aIso keep written records of various herbai remedies, or

spells to counter illnesses, and promote overall health and wellbeing. In today's media

age, as discussed in earlier sections, one must aIso not overlook the role of television and

radio as of means teaching and learning medical information. Shows like De Soi a Sol

can be recorded for further reference and use.

Yet despite writing and media, there are also occasions in which knowledge

regarding medical treatments is participatory and liturgical in nature and can not be

transmitted adequately through verbal expression. There also exist forms of healing that

are quite secretive in nature and, as Brandit expresses, "This kind of knowledge is

unlikely to be transmitted verbally, but some information must be acquired by viewing

and participating in ntual and ritual preparation" (1980: 127). A practitioner, after all,

must at some point apply the knowledge that he has learned to the actual physical process

of curing or healing a patient.

FinaIly, the most important means through which medical knowledge is

reproduced is, once again, the home. The household is an ongoing environment of

practical work experience in the area of medical traditions. Through the basic patterns of

socialization one Iearns the medical traditions of the family. Thus Our daily habits

become related to this socialization of practices and behaviors both within and outside the

home. Much of what we believe and practice is passed on in this rnanner. It is here that

many of the approaches taken for an illness episode are taught to younger generations.

Should one's household lean more towards medical treatments in the conventional realm,

it is also quite likely that their children will aIso have greater knowledge and faith in this

form of treatment. The same holds true with customary medicine and traditional

medicine. Yet it must be kept in mind that there do exist different perspectives on

medicine between different generations and newer ideological ideas may contrast with

tradi tional household values.

If one's household is heavily involved in Afro-Cuban religious traditions, it rnay

also be quite Iikely that the individual will seek out medical aid in the traditional medical

system. Socialization and belief with respect to religion can therefore influence an

individual's medical behavior and decision-making processes. UItimately, what must be

considered is the extent to which an individual accepts or rejects the idea that there exists

legitimate medical knowledge outside of the "scientific world" to address i llness and

promote health. Should people recognize the validity of approaches outside of the

conventional redm, they are more likely to look towards a variety of different treatments

until one is found that best suits their needs.

6.3 CIRCUMSTANCES THAT FAVOR TRANSMISSION OF MEDICAL KNOWLEDGE

There are a number of circumstances that can initiate the discussion of both

conventional and non-conventional forrns of medicine. These circumstances either occur

outside or inside an illness episode which in turn provide a context within which

knowledge can be reproduced or passed on. Should someone become ill, there is often

expenmentation and sharing of medical information in attempts to help the afflicted

person recover. This discussion of medicine often takes place in the presence of other

family members or fnends and they in tum acquire practical or empirical knowledge

regarding medicine. Adults will acquire new Iiturgical knowledge in the case of religious

or faith healing when the healer is called upon to help the sick, or more conventional

knowledge of medicine should they cal1 upon the family doctor.

Outside of an illness episode, there are also circurnstances that favor the

transmission of medical knowledge. A person is sometimes born with a gift or 'doit' for

healing. This was particularly evident through one of my informants who was an

espidis ta who has been in contact with his spiritual guide since before he was ten. He

had a spiritual gift to heal and was often involved in discussions surrounding the topic of

traditional and customary rnedicines. This gift has become a focus of his life, leading to

numerous discussions on traditional and customary medicines and an appetite for

learning so as to maintain his reputation as an effective crirandero ( Laguerre, 1988: 38).

6.4 PROBLEMS AFFECTING TNE TRANSMISISON/REPRODUCTION OF MEDICAL KNOWLEDGE

Nurnerous problerns affect the transmission of medical knowledge. These

problems will be conceptualized here in terrns of alteration, addition, and elimination.

The content of medical knowledge can be altered because of one's previous experience or

sociaiization. The socialist ideology of the Fidel Castro's government, which did not

support religious practice, is an example of this socialization process. Cuba's forty-one

years under socialist rule wouId have inevitably resulted in the loss of a certain arnount of

traditional medical knowledge. Castro has always been quite lenient with small scale

religious practices, but the revolution has inevitably led to changes in the belief systems

of numerous Cubans. Many set aside their religious practices in exchange for the island's

new egalitarian socialist principles. Consequentl y, previous medical knowledge

associated with religion became lost since parents may not have passed these traditions

on to their children.

The process of socialization is further illustrated through the data collected

regarding customary medicine. A person is generaIIy socialized into Iearning home

remedies and medicinal plants, but only if emphasis is placed on these areas within the

farnily or household unit. Medical knowledge here cm either expand or decline as time

passes. Information from the media, from doctors, and other sources are thus areas where

beliefs and elements are added into a system or other notions of illness and treatment are

subtracted €rom a healthcare system. It is in this area that I would like to conduct further

research. Lirnited research time and a small sample of curanderos made it difficult to

determine the extent to which this occurred.

The inability of a person to remernber previous knowledge, or the unavailability

of certain mareria medica are often prerequisites for alteration. Medicines are often

substituted and solutions sought elsewhere. This is illustrated in the revival of 'green

medicine' and other alternative medicines that had for years remained on the periphery of

Cuba's conservative orthodox medical system. This was again a direct result of the

economic taiIspin experienced by Cuba in response to loss of financid support from the

Soviet Union, and the tightening of the U.S. embargo Lirniting access to available

medicines. Substitution is often based on the pnnciple of similarity. When Afrïcans were

brought over with the slave trade, the medical elements of their religion would have

changed dramaticaIly under the principle of substitution. Plants in Afnca would have

been substituted by Cuban plants.

Information can also be forgotten or lost in the youth generation because of Iack

of need to remember it. Sometimes medical knowledge from a traditional or customary

system has been forgotten or has become obsolete due to the emergence and access to

conventional medicine. From the population studied, it was apparent that the older

generations knew more about customary medicine than did the rniddle-aged generations.

During the 1970s and 1980s conventiona1 medicine was opened up to the entire Cuban

population and this generation would have grown up without recognizing a need to learn

about customary or traditional forms of medicine (Laguerre, 1988: 39).

Mediums Through Which Knowledge Regarding Medicinal Plants is Reproduced

25 20

# o f 15 Responses 10

5 O

Family Media Doctors Other

Mediurns of Learning (N=30)

Figure 6.1

Conclusion

To conclude this chapter on the transmission and reproduction of medical

knowledge, it is fitting to examine figure 6.1 which illustrates the mediums throuph

which knowledge regarding medicinal plants is reproduced. During survey-interviews

informants were asked to list the forums in which they had leamed about medicinal

plants. This in tum led to funher discussion on the transmission of knowledge regarding

medicine in general. From the surveys it became apparent that it is through customary

medicine, via the farnily, that most individuals claimed they had leamed about medicinal

plants and their uses. The media were second, which indicates the position taken by the

government with respect to medicine since the onset of the 'Special Penod.' The farnily

doctor was the third largest institution of transmission. These three institutions facilitate

the reproduction of medical knowledge and extend far beyond simply the use of

rnedicinal plants. What becornes important to remember is the fact that people simply do

not receive this information in a vacuum. Individuals l e m from a large variety of

sources, many of which are not discussed here. The mediums examined in this chapter

are the ones that arose frorn the survey-interviews and were often talked about by

informants. It must also be reiterated that there are situations that facilitate, with greater

ease, the reproduction of medical knowledge and those which hinder the transmission.

Ultimately, d l play their part to create a cycle of knowledge reproduction that extends

throughout al1 existing health care arenas.

As the graph indicates, despite differing mediums, al1 use medicinal plants as a

means of treatment. This is not the only area of commonafity and, as the next chapter

illustrates, there are numerous interconnections that exist between customary, traditional

and conventional medicine.

CHAPTER VI1

INTERACTION BETWEEN CUSTOMARY, TRADITIONAL AND CONVENTIONAL MEDICINE

Preamble:

From discussing how individuals define ilInesses, factors determining medical

choices, and the institutions through which medical knowledge is transferred or

reproduced, i t is fitting that the focus is placed on the interaction that exists between the

different medical systems.

As discussed previously, my data show that informants from San Lizaro and La

Juanita operate under a pluralistic health care system. Thus it is important to understand

the dynarnic of a pluralistic health care system and to examine the interaction that exists

between customary, traditional and conventional medicines. Their fluid boundaries make

it difficult to separate one from the other. Using primary data and Iibrary sources, this

chapter focuses on how interconnections present themselves and how they are viewed by

informants. Figure 7.1, below, provides a visual image to complement the ideas presented

in this chapter. The roles of government pharmacies and casas parriculares (private

homes that sel1 plants) are also examined as facilities that provide clients with nzateria

rnedica from each medical system so that people can in tep te and choose the approaches

they deem most suited to their health care needs.

Figure 7.1: Illustration of interactions between customary, traditional and conventional medicine.

F Casas Particulares -,, 1 Conventionil Mediciue

Exchange of Exchange of Knowledge Knowledge

\ Exchange of Knowledge

7.1 BUSCA C/N OTRO C A M M "LOOK FOR ANOTHER PATH"

"1 Izave received clienrs oiz rlze reconzineizdarioiz o fa doctor N t nzarzy cnsesyes. Dzey say, Tor here, tlzere is rzotIzing, look for otlzerparhzs'" (Irzf: 34).

" Wlzerz [Izere is no artstver wirh doctors, arzd inodenz nzedicine, the doctors will tell then1 to 'look for arzorher patlz'" (lrzj32).

These quotes were extracted from interviews carried out with one sarzrero and one

sarzrerdpalera, both of whom were aIso key inforrnants of mine. These were not the onIy

occasions that 1 had heard the phrase 'look for other paths' or 'brtsca otros camirzos'. It

had surfaced in quite a few conversations 1 had had regarding saizreria and its validity as

a traditional medical system and through questions 1 had asked on how religious healing

was viewed by those in the conventionaI field.

Frorn the doctors interviewed, eight referred to botanical non-religious curanderos

in their definition of traditional medicine. Two of them mentioned the santero. palero, or

espiritista in their discussion of traditional medicine, and one stated that he had even

accompanied a person to see a curanderci after his patient had sought treatment at the

hospital and attempts to heal her burns had failed. SeveraI doctors said that they knew of

other medical doctors within the conventional reaIm who had recommended that a patient

visit a curandero. Ethically, most doctors could not directly tell their patients to seek out

a ctirandero or santero/palero etc. If something were to go wrong, they could be held

responsible and their reputation would be put at risk. Instead, many simply said, "'Iook

for another path' because there is nothing that can be done for you here."

The interaction that exists between traditional and conventional medicine rests

mostly on the recommendations of clients to the 'traditional' system. A number of

doctors were religious and IikeIy familiar with the use of plants in the traditional arena.

Unfortunately, it was not possible to examine the extent to which this information was or

was not used in practice or how these doctors may have combined their knowIedge of

conventional and traditional medicine in their patients' treatments. Those who were

practitioners or followers of the religion tended to distance it from their role as a doctor

reinforcing their professionalism by emphasizing their conventional training and thus

separating themselves from religion and traditional medicine-

With this stated, Cuba has made unprecedented advancement in the realm of

conventional medicine. For more than three decades, the island has had a stable position

at the forefront of world medicine and biotechnology, excelling in the creative discovery

of new substances and new methods for treating illnesses. As Ralph AIan Dale States,

"although there is a world wide need to develop natural medicines in most countries the

interest in utilizing alternative dmgs and surgery is welcomed much more by patients

than by medicai and pharmaceutical establishment." Thus we can see the more

capitalistic side of rnedicine, as rnanifested in the conventional medical system (1997:

34).

Since 1990, the conventional medical sector has started to 'look for another path'

to compensate for lack of supplies and prescription medicines. More specifically, it

Iooked towards green and natural medicine. My data indicate that conventional medicine

has not only incorporated or integated concepts and therapies from other medical

systems, but has also expropriated some of their elements (eg. chiropracties, acupuncture

and the use of medicinal plants, dong with its taxonomy) as part of its own medical

repertoire. Cuba tends to regard itself as scientifically conservative. Until the 1960s, a11

forrns of rnedical treatment other than orthodox medicine were banned, although they

were still practiced in rural areas where there was little to no access to orthodox

treatment.

After the revolution. the Cuban Ministry of Health began to appropriate or adopt

the plants popular in customary medicine by investigating their various pharmacological

properties and promoting their use within the 'scientific' realm (MacDonald, 1998: 229-

232). Family doctors started to prescribe medicinal plants within the primary health care

sector, claiming them to be part of their own 'scientifically tested' orthodox medical

system. It should also be mentioned that other alternative medicines like mud-therapy,

massage therap y, chiropractie therapy have also undergone this same process. While still

being dubbed alternative medicines, these practices are now becoming increasingly

accepted within the realm of conventional rnedicine and are thus credited with scientific

validity.

An analysis of several key questions from my interviews with ten family doctors,

indicates that there were alternatives outside of conventional medicine that doctors

employed to help treat patient's illnesses. Homeopathy, acupuncture, and mud-therapy

were some of the alternatives rnentioned. AI1 ten stated that they had used rnedicinal

plants to treat a variety of illnesses; among the most common were asthma, respiratory,

digestive and dematological problems. The foIlowing quotes sum up their reasons:

"Beca~ise, Nzdepeizdeiztly of the recent boom, our artcestors rrsed tlzenz and the popularioiz bzows a lot. We have seerz that tlzey are izor darzgerorw"(1ilf: 47).

"Tlzey have good resrilts that have been scierztificaily demonstrated in practice " (In$ 50)

"Because they have fewer adverse reactioizs, arzd they are cheaper" (In$ 46).

According to the informants, the validity of medicinal plants resided in the fact

that plants' properties have been passed on through generations and "are not considered

to be danperous." Others emphasized the scientific qualities of the plants which prove

their effectiveness, reaffirming their validity. It is important to mention that many farnily

doctors have spent their entire lives being exposed to customary medicine and many

knew of plant remedies long before compIeting their degrees in medicine and any

training they rnay have taken with regard to green medicine. As one h i l y doctor put it,

"1 learnt about medicinal plants because 1 am Cuban and from childhood 1 knew of

it"(Inf.47). Yet the use of rnedicinal plants did not officially become integated and

promoted within the conventional realrn until just before the 'SpeciaI period.' In the

course of the interviews, doctors were asked how they had learned about medicinal

plants. Five out of ten doctors said that they had received undergraduate training. Three

said that they had learned about plants dunng their rotation between different wards

while they were canying out their practicum. Two individuals had taken a course that

dealt with herbal remedies and five out of the ten had attended serninars during their

postgraduate careers. Such data are supported by Dale (1997: 22-24) who discusses the

integration of natural medicines with conventional medicine in Cuba. According to him,

the adoption of green medicine into the sphere of conventional medicine has led to a

number of infrastructure adjustments to facilitate greater learning in this area. HoIistic

courses were introduced to medical colleges in 199 1, eIective courses in acupuncture and

green medicine were available to both undergraduates and postgraduate students. In

September 1994, there was an integration of acupuncture and herbal medicine at al1

medicai colleges, sponsored by the Ministry of Education. It was decided that these two

areas would become a mandatory part of the rnedical cumculum. During this sarne year a

Postgaduate and Masters degree was offered in natural medicine. It is a pilot program in

holistic medicine, one of the four integrated modules in Cuban herbal medicine.

Thus, the extent to which conventional medicine interacts with and adopts

elements from other medical systems can Vary according to the experiences of the

practitioners within this field, but i t also depends heavily on the infrastructure of the

system and what it promotes and discourages. For example, recommending that an

individual go and visit a traditiona1 healer is not something that would be encouraged by

the infrastructure surrounding the conventional system of medicine. It is highly unlikely

that medical students would be advised that, in case of failure of the medical system, to

send their patients to santero, palero or general cura~zdero. To recornmend discrefely that

a person 'look for another path' is to fa11 back on one's own individual knowledge and

awareness of traditional medicine. Green medicine, on the other hand, which has its roots

in the customary medicaI system, has been modified, adopted, and thoroughly prornoted

by the conventional medical infrastructure. Instances such as these emphasize how

discrete and obvious these interactions between medical systems can be, and this is

further illustrated in the following section.

"Wzen it uppears irt the caracoles, thut a person s/zoztld go to the doctor, we send t/zern. l i z Yontba it is called obaclzegun " (II$ 33).

This quote illustrates the relationship that exists between traditional medicine in Cuba

and its conventional counterpart. This relationship is not competitive in nature; rather

there tends to be a strong adoption of conventional medicine into this traditional reaIm as

a tool to further aid clients in their quest for health and weII being. More specifically,

these interconnections became obvious when individuak were asked in the interviews

how they had Iearned about plants and ritual healing techniques, how they detennine

whether someone is healthy or ill, and how they defined traditional and conventionai

forms of medicine.

According to the traditional practitioners interviewed, individuals generally l e m

about plants and ritual healing techniques from their padri~zos and madrinas (godparents).

In addition to this, many practitioners state that they have leamed and continue to learn

Likely derived from the Yoruba word Onisliegun. which rneans herbalist, or he/she who cornpounds medicine. This terrn may also be uanslated as healer. Obacliegurz can also mean that the person shouId work with the orislra Olokrm to solve his her probIem (Inf. 3 1 & Inf. 55, September 16,2000).

about plants and healing techniques from spintual guides. whether they are rnrrenos

(ancestor spirits), a ganga spirit, o r through communication with the orfslzas. Most

individuals stated that, when they try to figure out which plants to use for various

ceremonies, spells, etc., they would ask their spin tua1 guides direct1 y.

Various medical practitioners also stated that nobody taught them about plants and

that they either were simply blessed with this gift of knowledge, or again that their

rnuel-ro or spiritual guide has always communicated information about plants and healing

techniques.

A number of santeros did not beiieve that it was possible to l e m about plants if the

practitioner did not look for the answers, and did not c m y out the research hidherself.

Although they felt that one should consuIt their spintual guides when conducting

ceremonies involving plants, they did not feel one could rely solely on their spiritual

guide for answers. Knowledge regarding plants was seen as a skill, not just a gift. As one

of my major informants told me,

I do rzot have a lot of coizfiderzce in sameros tlzat Say thar they kzow aborrt plants, and have never asked about tlzese tlzirzgs. TIzey Say that they have a gzjl or a grace for th& You do rzot obtailt this i@onnation ar~tornatically wlzeiz yorr receive yoctr saint, you have to leant aborrt al1 of this - you yorlrself ( h f : 33).

Opinions about how individuak Iearn about plants are divided. Some people use

them in conjunction with other sources outside the spiritual/religious realm. The

multifaceted approach of gaining knowledge about plants and healing is best illustrated in

the following passage where a relatively young santero discusses the process through

which he learns about pIants and their use in various healing techniques.

" yes, niany (sarzteros/espiritistas) stzidy pianis, and others no. Many have a grace to heal. ï7zis is not always the case however. 1 leanzt about plants on rny own. Nobody showed me. nzis grace that I have. is my ache, I was blessed with tlzis abiliry, and independently I have good @ends in Escarnbrq (municipaliry), found in Cuba's interior. I ask them. tizese courztrymen, and older people. I ask my mzterto and he tells me, tizis serves for tizis. tkis and lhis. This serves for Izepatitis, for cancer, for the t/zroat, etc. " (In$ 40).

Several informants claimed that most of the instruction they received about plants

and their uses occurred outside of the traditional/religious realm. Others expressed their

leaming process as a joint effort to master customary and traditional medicine- One of the

older and more powerful santeras toId me that she had learned most of what she knew

about healing and plants from her widowed neighbor who had Iost his vision and had

needed her help to collect plants.

Knowledge regarding plants within the religious realm does not exist in a

vacuum, with only the practitioners or devout obtaining the information. Any curandera,

whether involved in the Afro-Cuban religion or not, likely prescnbes any remedy that has

been found to be successful in atternpts to help the patient. This in tum strengthens the

curandero's credibility as an individual with divine power to heal, and success increases

power. Medicinal plants would undoubtedly be adopted into the realm of traditional

medicine if found of be effective. This would be the adaptive element to the transmission

of medical knowledge.

In order to analyze the interconnections between traditional and other foms of

health care, each practitioner was asked in the interview to define sickness, health, a

healthy person and a sick person. One of the first sarzteros interviewed stated the

folIowing,

"For us. we define health and illness throziglz tlze caracoles. Sichess is what the saint says or def ies it tu be. For the numbers that preserzt thernselves, you can deme what a person has. For example. $the nzrrnberfive appears when consrilti~zg the caracoles, yort k-ow that the person izas a problem with contamination of the skirz. corltanzinatiorz tlzrorrgh semal contact or contamination of the blood. " (Inf: 34).

For him, health and illness were defined according to what the saints proclaimed.

Caracole shells are used to communicate with the saints and determine whether there is a

physical problem ailing their client or if they are healthy. Another santero also reiterated

the importance of the divination system in defining health and illness.

".. . With a healtlzy persorz the caracoles speak well, the saint s a y ~ that everything is fine. Sonzetinzes the saint will advise a persorz tu take care of their healtlz, because a man is always close to sichzess becarcse sickrzess is in tlze air. fi is a dangero~is absorptiorz. today you can be fine, and tornorrow sick. This depends on wlzat the coco suys."(bzf: 40, Researclz. Fa11 1999).

Interestingly enough, a couple of individuals defined a sick person as one who has

sought the medical attention of a doctor but has not recovered from the illness. One of the

practitioners went on to Say, "After 1 have consulted them, they return well.. .healthy."

His criterion for healthy was for the most part a function of his own ability to cure their

illness, under the prerequisite that conventional medicine, as a first remedio, did not

successfully address the illness (Inf.# 39, Research, Fa11 1999). Anotherpalera further

expressed this confidence in tradi tional medicine,

"Sonzetirnes yorr go to a palero and it uppears as lfyou are healttzy, you feel Izealthy, but the pulero tells ifyorc are sick and wlrerz yort go to rhe docror, you are sick. Wren a palero says that you 're sick, it is a sure rhing " (II$ 36).

This quote also illustrates the interaction that exists between the conventional and

traditional realm by seekinp out confirmation and possible treatments from a doctor.

Interaction between these realms would bounce between cunng those individuals that

conventional medicine could not cure, or sending clients to a doctor to confirm an illness

and find treatment there. In my research, 1 did not encounter distrust of the conventional

reaim by traditionai practitioners. Most considered it one of the tools needed to best

diagnose a patient, and an important means of approachin; an illness. It was viewed as

one of a number of possible approaches taken against illnesses.

Another means of discovenng interconnections between traditionai medicine and

other health care institutions involved looking at how individuals within the

spintual/religious reaIm define both traditional and conventional medicine. Through these

definitions, one can see how practitioners define their own health care category and how

they view it in relation to conventional medicine. The following are a list of quotes that in

general represent varyîng views of a11 of the traditional practitioners interviewed. The

first definition is from a santero.

I cvorild corzsider the fonn of crrrïrzg enzployed irz Sameria to be traditional. Better tlzarz conve~itiorzal, you cnrz find arzd use these cures ivith greater ease. Soinetinîes tlzere are no rnedicirzes for health problerns, and with rhis fomz of mediciize (traditional) yotc caiz fizd rernedies. Traditioual ntedicirze works more witlz herbs and brartches. Corzve~ztioizal medicirze is more about doctors a~zd hospitals. (In$ 34)

One of the prerequisites given by the sarttero in his categorization of traditional

medicine is its use of plants and nature. Conventional medicine was separated from this

realm by defining the use of plants against that of the employment of doctors and

hospitals. In the following quote, the sanrero defines his religion in terms of nature and

conventional rnedicine as complernentary to Satzteria and as an institution that works in

conjunction with natural medicine.

1 coizsider tize f o m of curing rtsed in Santeria to be natrtral. As Ive fzave encountered iiz the 'Special Period' this large in Cuban history, the people already go to l?ze doctors &J also they go to the Santero. Wt2eiz I make the first coizszrltatio~z 1 rcsually send iny godchild to a doctor, to see what he/size has. In Cuba orte goes to both places. The Yonrba religion is well advuizced. it cures and saves (In$ 39).

The quotes indicate interplay between the religious/spiritual realm and that of

conventional medicine which converge and interact on a non-cornpetitive manner. In fact,

the traditional realm uses the conventional realrn as a tool to address illnesses

experienced by their client. Although there are occasional references made to one realm

of medicine being superior to the other, traditional healers tend not to regard modern

medicine in a negative light as most use conventional medicine to complement the

traditional. In some cases, conventional medicine was thought to be the first step in

addressing the problem. As one palera put it,

"Coizveïztioizal nzedicirze.. .hz Cuba there are few recoruses alzd for this people corne to us. 17zere are izo mediciizes because of the blockade. Wrzere tizey (people) s/zorcld go flrst is to their doctor, aiid rytlzere is i2o cure Nz thar route one shi lc l go see a suntero or palero (hf# 36).

There is little doubt left as to the interconnection between conventional and

traditional medicine from the perspective of traditional practitioners. It is seen as a

necessary tool to aid in the recovery of a client. This is best stated in the words of one of

my key infamants, "El niédico es fiuzdameiztal entre rzosowos. Eiztre los dos podernos

uyztdar mucho. Clratro ojos veit nzds que dos ", ("The doctor is fundamental to us,

between the two of us we can help a lot. Four eyes see more than two") (Inf# 39,

Research, Nov. 1999). Nine out of the ten religious practitioners stated that they have in

the past sent clients to see a medical doctor.

Thus the connections between traditiond and conventional medicines our time

have become further intermeshed What also became apparent from the data is the extent

to which rernedios caseros or home remedies have found their way into other systems of

medicine, and how they too have also adopted pnctices from other realms. The following

section discusses this in greater detail.

7.3 REMEDIOS CASEROS DE LA ABOELA (HOUSE REMEDES OF OUR GRANDMOTHERS)

As discussed in the previous sections, custornary medicine has largely been

embraced and combined into the other medical systems. With the blockade against Cuba,

conventional medicine has adopted many of these remedies, often researching and re-

patenting them into a 'scientifically' sound product or prescription. Nevertheless, a large

percentage of these remedies were bom out of family traditions. Green medicine, herbal

medicine, etc. al1 have their roots within this customary realm and those remedies that

work with the rnost consistency are generally the ones that find their way into other

systems. According to MacDonald (1999: 233), the long-term farnily remedy of treating

skin burns by rubbing a mixture of sugar-cane juice and ash mixture on the burned area

has led to Cuban researchers isolating important nitrofuranic pharmaceuticaIs, and have

in tum found a place within the conventional medical system. Camomile and oregano, for

example, are plants that were Iisted by a number of the family doctors as effective

medicines for hypertension, the flu, and digestive problems respectively (60% used

camomile, 40% used oregano). These same plants were also arnong the most frequently

Iisted customary medicines as indicated in the survey-interviews with informants from

San Lazaro and La Juanita (63% for carnomile and 60% for oregano respectively).

Traditional medicine has likewise adopted many of these farnily remedies.

Followers of Palo Monre and Saiztei-ia stated that they treated the flu, diarrhea, or

parasites with many of the same medicinal plants and remedies found in interviews with

the general public on customary medicine. Linden flowers (Tilo), dong with carnomile,

were listed by them as effective means of treating these iIlnesses. Linden flowers was

mentioned in 80% of the survey interviews conducted with the general population.

Certainly not al1 of the traditional healers or cru-anderos responded with the sarne healing

remedies found in customary medicine, but a number of them did and this is a significant

illustration of the overlap that exists between these two rnedicai systems. Likewise, I am

sure that there are various techniques that are used in custornary medicine that have their

roots from traditional medicine. While carrying out interviews in San Liizar-O on

customary medicine, 1: asked one woman what she does when she has a headache, to

which she responded:

" WIzerz I have a Iteadache, i make the sigrz of tlze cross on tlze crowiz of my head wirh a piece of coco and suy Obatalüs nanze over and over again. Tlzerz Iput oiz a whire bandaita and rest. l also nlb alcolzol on iny temples for a headache, it is very soothing " (Zizfomant # 90. Researclz. November 8, 1999).

Obatala is one of the oriskas worshiped within the Sarzteria religion. Thus one

could see from the interview that this individual camed out traditiond practices in

conjunction with practices comrnonly found in customary medicine, Le. the use of

alcohol. Data from San Lkmro and La Juanita indicate that in the regular everyday

approaches to illness, customary medicines are more likely to be used in conjunction with

other medicinal forms as a support o r back-up system.

Should a family rnember or family members practice Spiritualisrn, Sarzreriu, Palo

Monte, or any forrn of cclranderisnzo (whether they visit the man known to cure burns,

parasites etc.), the information they obtain can be adopted into day-to-day practices for

treating iIlnesses. From here it is then spread through generations, and between

households so that over time these practices become incorporated into customary

medicine. The magazine article below is an illustration of this. This is an older magazine

which provides a picture of a local plant. It shows its medicinal properties are and

expIains how they are prepared.

Information regarding plants and curative therapies provided by doctors is also likely

to be incorporated into everyday customary medicine if they are shown to be effective

and accessible to the general public.

7.4 CASA PARTICULARES AND PHARMACIES

Pharmacies and casas parîiczdares (private homes) sel1 medicinal plants. These

two institutions pull the three medical systerns together by providing a service to al1 who

seek out medicines in whatever form they prefer. Pharmacies and casas particdares

increase the capacity through which individuals can utilize al1 of these medical systems,

whether they take a pluralistic approach or not, by providing a means through which the

rnedicines (drugs, plants, plant products, etc.) applied in each become accessible to the

greater popuIation.

Pharmacies sel1 both prescription medicine and processed green medicines. To

purchase medicinal plant products, a doctor's receipt is not required. In each of the

pharmacies 1 visited, small displays were posted that illustrated some of the more

comrnon medicinal plants and their uses. Like family doctors, pharmacists interviewed

for this study stated that they receive their information regarding medicinal plants from

the '%onnalario Naciorta[ de Medicines Verden which is a publication that was created

and distributed by the government. Most of the medicinal plant products are received

from a factory located close to the city center. This factory, in turn, obtains its resources

from government farms specializing in the production of medicinal plants and from here

processes the products. Government pharmacies thus facilitate the use of both types of

rnedicine to treat a singIe illness, depending, of course, on the approaches preferred by

the individual. My research indicates that the sale of medicinal plant products is a

relative1 y recent phenomenon as a consequence of the ' S pecial Period. '

Casas particulares that se11 medicinal plants also fulfill a service to their

community and demonstrate the pluralistic nature of medicine in Cienfuegos. Often

peopIe will corne here to look for specific plants and branches, many of which can only

be found in the countryside. Unlike the pharmacies, these casas particcllares seIl the

plants in tlieir natural forms (ive. leaves, and branches, flowers and roots). Thus they cater

to both traditional and customary medicine,

The two casas paniczdnres in which I conducted interviews had other products

belonging more specifically to the traditional reaIm. Aside from various ritual plants

used for religious purposes, cascarilla' was sold which is used fundarnentally within

Spiritism and also in the various Afro-Cuban religious orientations. This product is

thought to have cleansing and protective properties and to ward away negative spiritual

influences.

At one of these locations, books, pamphlets and sheets with prayers and

information specific to Santenk and Palu Mante were available. The individuals who

worked in these businesses were herbalists and had extensive knowledge about the uses

of plants, both within the customary and traditional sense. According to them, they

obtained their information and passed it on through word of mouth or else learned it

through books and experience. My key informants kept notes on a large variety of plants

and their medicinal and ritual uses. Likewise, many men and women during the day

would stop by to ask about an illness and what plants could be used to address this

illness. One herbalist stressed the importance of asking a client hedhis medical history

before making recommendations about which plants he/she should try. She said, "some

plants can be harmful to those who have high or low blood pressure, one must remember

that each plant has its properties, which are sometimes helpful and sometime harmful"

(Inf.#12, Research, October 1999).

I noticed that the plants at the two casas particr~lams are cut in a specific way.

Only individuals who have a strong knowledge of plants and are famiIiar with Afro-

Cuban religions are sent to collect them.

Cascarilla, consists of dried eggshelI that is crushed into a powder. It is often used as a means of cleansing the body of al1 impurities. UsualIy it is used in baths. It is often used in reIigious ceremonies, tike for example at the spiritists Table, and can be used as part of the divination process by the sczntero, palero and babaforve.

For a plant to be effective in the Afro-Cuban religions several conditions must first be

met. First, an individual rnust first ask permission to cut it from osain, who is known as

the orislza of herbs and plants, and a set amount of money paid as an offering to him.

Second, the individual must also ask the plant for permission to cut it, since ail plants

have a spirit or ashé. Since these plants possess a spirit and can be easily offended, one

rnust make sure that permission is granted. If it is not granted, these plants can render

themselves ineffective to those who would use them in magic or medicine. Al1 plants

have specific times of the day or night at which they can be cut at the height of their

potential. It is also taboo to cut plants when they are not alert, and thus one must know

the hours in which pIants can and cannot be harvested. The contexts in which products

available at these casas particulares are employed depend on the individual and how

he/she wishes to approach or address an illness.

In both the casas parriculares plants, are obtained according to the traditions

outlined above. This enables them to extend their services beyond the provision of plants

for customary medicine to be inctuded in traditional medicines and the use of plants for

ritual, and magical purposes. Thus one can see how the plants provided at these small

private businesses make existing medical systems more accessible to al1 of their clients.

Because medicinal plant products found within the local pharmacies are not cut

according to these sarne traditions, and because the plants themselves were grown in a

more artificial environment, they are not considered effective in the traditional realm.

Plants have to be asked for their permission to be cut, and the plants with the most aché

or spiritual power are the ones that grow in the wild. One would not bring a bottIed

tincture of carnomile to use in a ceremony, make onziero, or cast a speI1. Informants who

wish to use plants for rituai purposes to address health problems are Iirnited to obtaining

them at casas particulares, looking for the plants themselves, or paying a

sanrero/palero/espiririsra to go and collect them.

Through the combined services and goods offered by these casas partictrlares and

governrnent pharmacies, products from a11 three medical systems are made available.

Individuals have many choices since there is such open access to a wide variety of

medical products. Each medical system caters to differing needs depending on the

diagnosis of the illness that is defined according to the beliefs of the individual. Thus it

becomes apparent that medicines sought out by the public in no way Iimit access to other

health care approaches. Pharmacies and casas particulares thus provide links between

each system, and again highlight the pluralistic system of health care employed by

residents.

Herbalists at a casapartidsrthat s& medicinal and Btualplants.

A casa particul= that se& plants fm mediPnd and iaual pinposes. The hab- obtain the piants fmm the comtqside and are carelül to hmest them m the m-er appropriate fur use in Afio-Cuban religions.

17 1

Conclusion

When we view al1 of the medical systems in conjunction and look at how they

interact at the level of patient treatment, one can see how the lines defining each can

become blumed. Approaches taken can differ at extremes, or they can shift between

boundaries so that they provide similar treatments within different medical settings-

Without doubt, it can be stated that there exist large exchanges of information between

sys-tems and plenty of opportunity for the individual to decide where they can seek help

to best approach their illnesses. Casasparticzilares and pharmacies play a large role in

th is process by providing al1 of their clients with access to the different mnreria rnedica.

T h e health care system operating in Cienfuegos is without doubt pluralistic in nature and

there is Iittle in the way of limitations when it comes to accessing medical aid. It should,

however be stipulated that medical beliefs could Vary in the extreme, from profound faith

in traditional medicine to rejection of anything outside of the conventional realm. There

is n a one category that adequateIy describes the practices of the population studied. It can

only be said that there existed no limitations in their abiiity to choose between these

systems and integrate eIements according to their beliefs regarding illness.

SUMMARY AND CONCLUSION

7.1 SUMMARY

As stated in the introduction, this thesis constitutes a preliminary exploration of

health and illness, factors that influence individual medical decisions, mediums through

which rnedical knowledge is reproduced and the pluralistic nature of health care in

Cienfuegos, Cuba. As a result of this endeavor, it becomes possible to distinguish certain

patterns of rnedical behavior and how these medical systems interact to address the

overall needs of the population.

Upon initiating any study that deals with medical choice and medicine in general,

it is important to reiterate that any successful diagnosis or treatment of an illness must

take into account the sufferer's experience. The images that people hold of their bodies

are strongly influenced by broader social and cultural interpretations of reality. The mind

and the body must not be considered separate entities, but rather a union into a 'mindful

body.' Traditional and customary medical systems have the capacity to address these

broader social aspectslfeatures of illness and this in turn has led to their continued use by

residents of Cienfuegos, even with the development of a sophisticated conventional

medical sector.

This thesis is strongly influenced by Kleinman's notion of 'exploratory models'

within the context of a health care system. Any study of medical systems must take into

account, etiology, symptoms, patho-physiology, popular definitions of illness and various

treatment techniques. Not only does this Vary according to the individual but also

according to a given cultural context. Through his discussion of the popularization of the

professional model, and medicaiization of the popular model, he highlights the mixing of

knowledge between medical systems, and illustrates the fluidity of boundaries that exist

between these sectors. Customary, traditional and conventional medicine, al1 exists

within such a pluralistic system. Knowledge flows berween medical perimeters and

individuals choose approaches from each system according to their needs. In using

Kleinman's model as a framework, 1 attempt to outline an exploratory model for residents

of Cienfuegos. Tt is only after this has been accomplished that it becomes possible to

move fonvard into a discussion of medical knowIedge and medical pluralism.

One of the first steps in creating this model was to examine how people defined

the health and illness. WhiIe most individuals articulated notions of health and illness in

rems of physical ailments or problems with the body, the source of these problems could

Vary from being stnctly biological in nature to being the result of spiritua1 or supernaturaI

forces. A number of persona1 disease etiological agents were discussed in this thesis since

they in turn influence the types of treatments that are sought out. With brujeria, r?ml de

ojo, or mala inflzierzcia a person generally addresses an illness through traditional

medicine. It should be noted, however, that belief in such agents differs considerably

depending on the individual. If it is thought that an illness is caused by a natural

biological agent, people are more inclined to first treat their problem through customary

or conventional medicine.

In examining the use of health resources or patterns of medical behavior in Cuba

it became apparent that factors such as gender, age and cost and availability of treatments

al1 influenced approaches to illness. Health seekers in the two barrios of San Lkaro and

La Juanita reported the combined use of traditional, customary and conventional medical

systems to maximize health care outcornes. As a first approach to an illness, informants

responses were divided, with approximately one-half stating that they would look

towards customary medicine and the other half stating that they would seek out

professionals in the conventional realm, provided it was not life threatening or extremely

senous. This same pattern was observed when inforrnants were asked about secondary

approaches to illness episodes. Traditional medicine was generally used as a last resort if

neither of the above systems had provided the desired outcome.

After looking at the social charactenstics of the popuIation interviewed, a number

of trends became apparent. Women generally knew more about customary medicine than

men and would more readily go to see a crimndero. Due to the uneven representation of

men and women in the survey-interviews, it is difficult to determine the extent to which

sex influenced decisions regarding approaches to health care. From those individuals

interviewed older wornen displayed a higher degree of knowledge regarding varieties of

different medicinal plants with their associated uses and demonstrated a greater faith in

traditional medicine. InterestingIy, oIder, Iess educated women and younger, more highly

educated women both demonstrated a greater propensity to lean towards customary

medicine and the use of medicinal plants, than middle aged individuals with a secondary

education. This is largely due to the fact that both younger and older generations have

grown-up during penods of greater economic hardships. One generation having to cope

with pre-revolutionary economic dispanty between the nch and the poor, and lirnited

access to health care facilities, and the other being forced to bear-up against strengthened

U.S. sanctions in the heart of an economic cnsis. Both situations share one simiIar trend

as it relates to medicine.. . a growth in the acceptance of alternatives outside the

conventionai realm. Middle-aged men and women with secondary education, as

discussed in Chapter V, expenenced the full force of the revolution, with its goals to

industrialize, and modemize. The Castro government stressed the importance of

education and access to conventional medicine for ail citizens. Less 'scientific' fonns of

medicine and particularIy those associated with religion, did not fit the ideological

substratum associated with the revolution. As a resuIt, these individuals leaned more

towards conventional medicine and tended to say that they did not beIieve in the

effectiveness of traditionai medicine. They also did not place a great deaI of importance

on customary medicine.

It is appropriate to mention here that, the two popular barrios of La Juanita and

San Lizaro were chosen for this study in part due to their different socio-economic

situations. La Juanita is a wealthier banio with a stronger infrastructure than San Lizaro.

San Lbaro is also characterized by a larger Afro-Cuban population and has a stronger

foIIowing within the Saiz~erh and Palo Monte religions. Contrary to my expectations, the

data showed that there were few differences in terms of use of customary medicine,

knowIedge of medicinal plants and beIief in traditional forms of medicine between the

two barrios. There were aIso no divisions encountered with regard to rnedical decision

making Al1 informants expressed faith in conventional forms of medicine, and had some

knowledge of customary medicine. Individuals from both barrios accepted and rejected

traditional forms of medicine as valid approaches to illness.

Individuals were not asked to provide information on income during the thirty

survey-interviews because it is generally assumed that the government pays most of its

workers anywhere from 10-15 pesos a month. Many who have jobs on the side to earn

extra and would not 'officially' reported these activities to the govemment would not

discuss it with myself and n representative of the university. For this reason, the

economic situation of the respondents did not initially appear as a significant factor with

respect to medical choice. 1 did take note of the housing conditions in each interview, but

this too is not necessariIy a reflection of economic status. For this reason, it is difficult to

express conclusions with regard to income and the use of medical resources by

informants in San Lkaro and La Juanita.

It was only after more in-depth interviews that it became obvious that a person's

income would have a definite influence on the types of medicinehreatments that he/she

could obtain. WhiIe health care services in any of the three medical systems examined

provide relatively equal access to services and facilities, the availability and affordability

of medicines could Vary considerably. Customary medicine is the rnost inexpensive of the

three s ystems, but both conventional and tradi tional medicines can fluctuate from being

relativeiy cheap to extrernely expensive. Factors such as availability of medicine and

typology of iilness influence prices and medicines within the conventional realm, even

though they are partially subsidized by the government and can be beyond the price range

of particular families. Access to these medicines is influenced by numerous factors, the

US. embargo being one of thern.

Within the traditional medical system, there are crrranderos who charge exorbitant

pnces for their services and the others who do not. Costs often depend on the

effectiveness of the cru-arzdero and the methods used to cure specific health problems.

Rituals, sacrifices, and healing ceremonies in peneral may require the purchase of a

number of animals, foods, or objects, which can become quite expensive.

Interestingly, results also showed that there was an overwhelming trend by the

population to seek out services within the conventional realm (farnily doctor, clinic, or

hospital) if iIlnesses appeared to be serious. OnIy after treatment in this realm had failed

or did not provide enough pain relief for the sufferer did individuals tend to search for

dia,onosis and treatment within traditional medical systems.

Al1 informants discussed the family or household unit as the focal point through

which they had attained knowIedge regarding medicinal plants. The transfer of medicaI

knowledge at this level is informa1 and a product of socialization and oral tradition.

Family doctors and cIinics are also mediums through which individuals learn about

conventional medicine and medicinal plants. As for traditional medicine, information is

for the most part passed on orally from practitioner- to Iayperson within the context of

reIigious/spirituaI orientations. Since there are younger more educated people who have

high levels of customary medical knowledge and believe in the validity of traditional

forms of medicine, one can assume that there has been a definite increase in the exposure

of youth to information from these areas. This may be due to a number of reasons, the

more discernible of which would include: increased use of medicinal plants in the home

and renewed faith in curanden-smo due to lack of prescription rnedicines, and recent

liberties to practice religion which includes healing practices. The media are also quite

influential as a means of distributing information on health care issues. Through

television, radio and newspaper the Ministry of Health has been able to provide

information to the population on issues of hygiene, sanitation, and self-treatment through

green medicine. It has also helped with the promotion of information on alternatives

slightly outside of the conventional realm of medicine, like for example mud therapy and

acupuncture. As time has passed in this revoIutionary era, today's youth are being taught

to look beyond scientific medicine to a host of other viable medical systems.

As discussed in Laguerre (1987), and has become apparent through this study, the

transmission of medical knowledge is more likely to happen in situations where an

individual within the family or household is experiencing an illness episode. Suggestions

and the general exchange of information regardin; illness symptoms, causes and

treatrnents, are more intensive during such periods. Conversations regarding medicine are

aIso more frequent amongst practitioners whose work is specidized in healing

techniques. Likewise, there also exist numerous factors that affect this transmission.

Inability of a person to remember things previously leamed, lack of access to certain

materia media, or kick of emphasis or attention given to different foms of medicine can

affect the transmission and reproduction of knowledge related to medicine.

Customary, traditional, and conventional medicine for the most part complement

each other. This is particutarly obvious in situations where traditional practitioners send

their clients to see a doctor to confirm the diagnosis of illnesses. These individuals accept

conventional medicine and incorporate elements of the system as an additional tool to

help maintain the health of their clients. Traditional practice often overlaps with the

practice of customary medicine since it improves the practitioner's ability to cure an

illness. The more information he/she knows about plants and their uses, regardless of the

source of knowledge, the higher the success rate he/she will have. Many doctors also

recognize the validity of customary and traditional forms of medicine. Whether

recommending medicinal pIants that have long existed within customary medicine or

discreetly telLing a client to 'look for another path,' the physician aiso contributes to the

pluralistic nature of health care in Cienfuegos.

When discussing medical choices and pluralism within this heaith care system one

must also include institutions that help facilitate the combined use of medical resources.

Casas Particrciures and pharmacies are both institutions that are easily accessed by the

population in times of sickness. They increase the capacity through which individuals

can utilize al1 three of these medical systems. Whether a person is looking for plants for

customary or ritual purposes, or prescription dnigs, between these two institutions he/she

can obtain whatever marena m e h necessary to treat hisker problems.

7.2 CONCLUSION AND RECOMMENDATIONS

Theoretically, this research encompasses a number of different frarneworks, the

first of which is a descriptive ethnomedical account of disease etiology. Through an

examination of common disease etiologies, the ideoIogicaI substratum associated with

each system, and particularly traditional medicine, is clearly demonstrated. Laguerre's

work on traditional medicine in the Caribbean provides an additionai interpretation to

these data as they address issues related to the transmission of medical knowledge. His

discussion on the agents, techniques and circumstances that favor or hinder the

transmission of medical knowledge provides a more complete picture of the three

medical systems and their unique characteristics. By recognizing the process through

which medical knowledge is reproduced one can obtain further insight into the factors

that may affect medical decisions, either promoting or deterring various treatments

options.

The study also incorporates Arthur Kieinman's notion of pluralistic medicine.

Through the use of his model, 1 was able to provide a more complete account of local

health care realities. The structural components of health care systerns - whether they fit

into Kleinman's notion of popular, folk and professional medicine, or customary,

traditional and conventional medicine, - prirnarily interacts because patients are able to

pass between them. The lines of demarcation between sectors functions as points of

entrance and exit for patients who follow the trajectories of their illness through the maze

of the health care systern (Kleinmanl980: 60). The complementary nature of the

differïng medical sectors encourage this trajectory, by reinforcing the validity of

alternative treatments, and providing access and information to help patients look for the

more appropriate path to recovery.

Factors leading to choice in resource use via custornary, traditional, and

conventional heaIing have al1 been examined in my research in Iight of the process

described in Young's (1980) and Fabrega7s (1973, 1974) works. According to Young,

illness is a recurrent problem with which al1 groups and individuaIs at one time or another

rnust face. Because it is a recumng problem and the consequences of a "wrong" decision

may be severe, people usually develop and corne to rely on specific standards for making

choices involving the treatment of ilInesses (1980:107). They develop a set of procedures

for deciding how to deal with health related issues. Illness Iabeling, or the recognition and

evaluation of an illness, allows the patent to determine the problems he/she must

overcome and from this evaluation assess the benefits, costs and practicality of a

treatment. The underlying premise is that people will evaluate an instance of illness using

economic affordability as a consideration and the best optimal action that rnay eliminate

the illness (Fabrega 1974:174-175). To assess these treatments however, one must

understand the sufferer's experience, agents of illness, the associated cures, and other

social and economic factors that influence medical behavior, especiall y with regard to

such features as religious affiliation, gender, age, education, and income.

To sum up, it is important to note that culture and reality are reflected or

ernbedded in our practices as a society and this is inclusive of our medical practices.

There are culturally specific notions of health, fonns of ilIness and methods of treatment.

Institutions such as religion and politics exist within the same domain as medical systems

and cannot be viewed as separate entities @aer et. al: 1997: 9). Cuba's history in terms

of its political, economic and social development has without question shaped the health

care system as it exists today. From the religious and spiritual orientations brought

across with African slaves (Santen'a, Pa10 Monte), the belief systems introduced by

Spanish colonizers (Spiritisrn, Folk Catholicisrn), to the development of conventional

health care before and after the revolution, it becomes possible to visualize the

development of traditional and conventional medical systems as they exist today.

Customary medical practices that have risen out of household and family approaches to

address illness has always existed and were further reinforced in Cuba through unequal

access to conventional medical care and the embargo on medical supplies. Moreover, if

we were to trace Cuba's economic patterns over the years, both in its colonial years, its

neo-colonial years to its socialist positioning, we would see corresponding shifts in the

development of health care. As discussed by Kleinman, medicine is a cultural system, a

system of symbolic rneaning anchored in particular arrangements of social institutions

and patterns of interpersonal interactions. Customary, traditional and conventional

medicine must therefore be viewed as cuItura1 systems subject to change according to

politicaI and economic influences.

This particular study has some interesting implications since it is perhaps among

one of the first to look at Afro-Cuban and Spintual medical/healinp practices in Cuba in

the same framework as it does conventional medicine. There have been numerous books,

thesis', and articles published with regard to Santeria, Palu Monte, and Spiritism in Cuba

(see Bamet, 1995; Cuervo Hewitt, 1998; Gonzalez-Wippler, 1998; Matibag, 1996;

Murphy, 1994; and Ridesdale, 1998). These religious orientations are viewed as vital

elements of Cuban culture and many focus a portion of their text on healing and the use

of medicinal ptants. There has also been an extensive literature written about Cuba's

conventional hedth care system since it has often been cited as an exarnpIe of how

developing countries can achieve an effective and accessible health care delivery system

(Waitzkin, et al, 1997; Rojas and Pardo, 1997; MacDonald, 1999; Guttmacher, 1989 and

Danielson 1979; Diaz-Briquets, 1983 and Dale, 1997). What has not been exarnined in

any detail in the majority of these publications is the relationship that exists between

these two rnedical systems. Considering the fact that many sarzteros and paleros send

their clients to doctors, and the discreet acceptance of traditional practices by some of

these doctors, it is quite obvious that there are substantial overlaps when it comes to

treatment. It is hoped that the results from this research will be taken under consideration

by other social scientists and further works will be conducted in this area. Traditional

medicine must be examined as a portion of the health care system that is as equdly

relevant and valid as that of conventional and customary medicine since it does obviously

fulfil a particular need for those individuals who participated in my research.

Customary medicine, often described in the literature as 'grandmother's

remedies', 'green medicine' and 'home remedies,' has received attention within the Iast

few years, particularly with its revival in the home and adoption by younger and higher

educated generations. This is Iargely due to the economic challenges associated with the

'SpeciaI Period' and the resulting need to search for alternatives to inaccessible

medicines in the conventional realm. Home remedies have, according to many of my

informants, aIways been respected and in this study it becomes apparent that seldom do

conflicts exist between customary medicine and any of the other medical systems-

There is a need for more extensive research regarding health and healing within

the Afro-Cuban and Spiritist reIigious traditions and crrra~zderisrno in general. Many

individuals who find fauIt with conventional medicine Iook towards the traditional reaIm.

There is a definite necessity for in-depth studies on different healers, their demogaphic

characteristics (eg. from what sectors of society do these individuals belong), the nature

of their healing abilities and the similarïties and differences in these abilities and the

processes of training. Such studies would contribute to cross-cultural generalizations

about categones of healers and heaIing practices chat wiII in turn help guide further

fieldwork on the subject.

While this study did not focus on alternative medicines (like chiropractie

treatment, massage therapy, water therapy, and homeopathy) or traditional healing

practices within the Catholic Church, these institutions and practices can also be defined

in ternis of medical systems. 1 would recommend further research in these areas since

they tao play a role in health care practices for residents of Cienfuegos. More information

would provide a better picture of decisions and practices related to health, iIIness and

medical decisions. It would also be interesting to see how such systems interact with

customary, traditional and conventional medicines.

More extensive studies should be conducted on the social and economic

characteristics of those individuals who frequent traditional healers. Understanding the

nature of the clientele would permit for more effective treatment both interna1 and

external to traditional medical systems. Understanding the population that seek out

traditional healers is also beneficial since it again defines the need or demand that its

services fulfil within the larger society. It would also be beneficial for local conventional

medical institutions to have a clearer understanding of the traditional sector. Recognizing

other systems of knowledge regarding health and disease management can lead to new

ways of extending health services to more successfully satisfy the basic needs of the

popuIation.

AIthough this thesis examined definitions of health and illness, dong with illness

etiologies, detailed research into signs and symptoms of illnesses would also be an

interesting area of study. Through tabulation and description of the symptoms reported by

patients suffering from particular sicknesses, it is possible to discover a consistent

assemblage of indicators of an illness and further identify relationships between illnesses

(Fabrega 1977). This kind of study can inform us whether two individuals who cornplain

of envidia, for example, share more syrnptoms than a person who complains of envidia

and another who complains of mal de ojo.

An examination of the distribution of illness episodes arnong men and women

would provide a great deal of insight into medicine and medical practices of a population.

Through studies such as these, it would become possible to track which illnesses tend to

be widespread or confined to one or several segments of the population. One could

investigate whether women suffer more from certain illnesses than men, whether

individuals who suffer from los nervios (bad nerves) are more likely to be women or

men, etc. This type of research wouId enable the researcher to determine if certain

illnesses are confined to social and political status. For example. one could examine

whether people who have a better economic situation suffer more from envidia than those

at lower economic levels.

The effects of healing procedures should also be exarnined in greater detail to

discover the extent to which the goals of a healing procedure have been attained, whether

those goals are improved social relationships, improved social wellbeing or improvement

in an individual's biological or mental health status. Within this arena, the healing

implications of patient support groups demand greater research. Such group studies

would also consider the gender of either patient or healer and whether this influences the

performance and success of treatment procedures. Research in this area can provide

information regarding healing procedures as it relates to social status and the social

characteristics of the healer and participants.

There is also a need for more extensive or in-depth studies on the process of

heaIth care decision-making. Individual illness episodes should be tracked and recorded

to highiight the decisions and the factors that influenced them. Inforqation regarding the

interaction between different rnedical systems would result from exploring and recording

treatments sought during independent illness episodes. Such a study would also provide a

more qualitative component to empirical works existing in this area Inclusive in such a

study should be a element on the reproduction of medical knowledge since there has been

relatively little work carried out in this area.

Finally, further information with respect to casas particulares and pharmacies is

also essential since they play such a Iarge role in Cienfuegos' health care systern. These

institutions help facilitate pluralistic practices in medicine and research in this area would

contribute to a more holistic account of these factors

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APPENDIX # 1

PLATT AMENDMENT

The President of the U.S. is hereby authorized to 'leave the govemment and control of the island of Cuba to its people' so soon as a govemment shall have been estabhshed in said island under a constitution which, either as a part thereof or in an ordinance appended thereto, shall define the future relations of the United States with Cuba, substantially as follows:

1.

II.

m.

IV.

v.

VI.

m.

That the government of Cuba shall never enter into any treaty or other compact with any foreign power or powers which will impair or tend to impair independence of Cuba, nor in any manner authonze or permit any foreign power or powers to obtain by colonization or for military or naval purposes or otherwise, lodpen t in or control over any portion of said island. That said government shall not assume or contract any public debt, to pay the interest upon which, and to make reasonable sinking fund provision for the ultimate discharge of which the ordinary revenues of the island, after defraying the current expenses of the govemment, shall be inadequate. That the government of Cuba consents that the United States may exercise the right to intervene for the preservation of Cuban independence, the maintenance of a govemment adequate for the protection of life, property, and individual liberty, and for discharging the obligations with respect to Cuba imposed by the Treaty of Paris on the United States, now to be assumed and undertaken by the govemment of Cuba. That al1 acts of the United States in Cuba durinp its military occupancy thereof are ratified and validated, and al1 lawful rights acquired thereunder shall be maintained and protected. That the government of Cuba will execute, and, as far as necessary, extend, the plans already devised or other plans to be mutually agreed upon, for the sanitation of the cities of the island, to the end that a recurrence of epidernic and infectious diseases may be prevente4d, thereby assunng protection to the people and commerce of Cuba, as welI as to the commerce of the southern ports of the United States and the people residing therein. That the Isle of Pines shall be ornitted from the proposed constitutional boundaries of Cuba, the title thereto being left to future adjustment by treaty. That to enable the United States to maintain independence of Cuba, and to protect the people thereof, as well as for its defense, the government of Cuba will sel1 or lease to the United States lands necessary for coaling or naval stations as certain specified points, to be agreed upon with the President of the United States.

(Suchlicki, 1974: 96-97)

APPENDIX #2

ATTRIBUTES OF MAJOR ORISKAS

Principal 1 Function or

controL fate, the unexpected; justice personified

Colors Red and black

Green and vellow

power Messages;

/ Divination

White Peace, Purity

Red and white Power, passion, controt of enemies

Red and green Control of enemies Sackcloth Causes and cures

illness Blue and white Maternity,

~ o m a n h o o d With and Love, mariage. Yeilow goId Maroon and Protection against white I deilth

j Force in Nature

Corners, Cross Roads

Fatherhood, al1 white substances

Fire, thunder and lightning

Iron, steel

Al1 game animals Volcanos Smallpox, leg ailments The ocean

Wind, burial grounds, thunder

Weapon or Symbol Clay or cement head with eyes and mouth made of cowrie shells. Table of If5

Imke (horsetail with a beaded handIe) Double edged ax, rnortar castle Metal weapons and knives Crossbow

Crutches

Seas hells, ranoes, coraIs Fans, mirrors. 30ats Horsetail

Numbers

3

16

8

4.6

7

7

9 17

7

5

Gonzales-Wippler, 1998: 73

APPENDIX # 3

PLANTS USED FOR OMIERO

Plant

Hedionda Yerba mora

Rompe-zaragüey

English or Latin Name

Albahaca Zarzapami Ila

(in baths)

Cassia occideritalis Solanium nignirn

Eupaton'unz odato mm

Parais0

Owner(s)

Basil Sarsaparilla

Uses

Elegguii Oggfin, Yemay5

Chang6

Melia azede rach

Anil Verbena

1 Oshiin 1 Intestinal trouble, 1

Against colitis Throat infections, nerves, skin trouble Against evil (in baths)

Oggiin, Yemay6 Chang6

Chang6

kchuga Yerba buena

Stomach troubles Rheumatism, nerves,

Indigo plant Vervain

1 1 1 1 headaches. cancer 1

Lettuce Spearmint

Campana Higuereta

1 Algodon 1 Cotton (plant) 1 ObataI5

Yemayi, Oshfin Yemay5, Oshiin

Tumors, epilepsy Liver, care of the hair

Yemayii, OshGn Yemayii

Elecarnpane Ricinus cornrn ~uzis

Bronchitis, asthma, 1

Against evil S kin troubles, for luc k

Verdo I aga Malva té Berro Anis HeIecho Calabaza

tumors Good luck Purifying baths Stomach irritations Indigestion, h ysteri a Aoainst eviI

Obatalâ Obatalâ

Burns, skin diseases, 1

- - -

Bronchitis Diphtheria,

f urslane Corchonts siliqr~os~rs Watercress Aniseed River fem Pumpkin

Yemayii Oshiin Yemay5, Oshfin

Oshiin Yemaya, Oshfin Oshiin

Gonzales-Wippler, 1998: 143- L M )

Espartillo Sporobolus Eleggua, Ochosi whooping cough Against evil

APPENDIX #4

MAJOR ORISHA, CATHOLIC AND aMPUNGULU SYNCRETISMS

ORISHAS (Santeria) Eleggua

1 OagUn 1 Peter 1 Zarabanda 1

Oninmila

O batalii Chang6

SAINT (Cat holicism) Anthony

1 1 1 Furnbi 1

KIMPUNGULU (Palo Monte) Fata Elegua, Quicio-Puerta, Nkuvu Nfinda

Francis of Assisi

Our Lady of Mercy Barbara

Ochosi Babalu-Ayé

Tata Funde, Cuatro Vientos, Tond5 TiembIa Tierra Siete Rayos, Nsasi

Our Lady of La Candelaria

Norbert Lazams

1

Yemay5 Oshiin

Centella, Mama Wanga, Kariern~embe

Nkuyo, Watariarnba Tata Kafién, Tata

(Gonzales-Wippler, 1998: 74; Matibag, 1996: 168)

Our Lady of Regla Our Lady of

- - -

Baluandé Chola Wengue

APPENDIX #5

[Nombre y apellidos : ( Lugar de nacimiento : 1 First and Last Name: Edad :

Preguntas: que persona de la familia nos podna bnndar informacion sobre la forma en que han enfrentado los problemas de salud que han tenido?

Place of Birth:

Age: Sexo: Sex: Nive1 de escolaridad : Level of Schooling:

Who in your family could we obtain information with regards to methods that have been used in the past to treat different health problems?

Direction del dornicilio : House Address Estado civil : Marital Status:

que haria hoy si usted tuvier ( ver listado de enfermedades)?

What would you do today if you had (See list of illnesses)?

i que hacian sus padres cuando usted era mas joven ante esta situacion?

What would your parents do when you were young in this situation?

Lista de problemas de satud: (List of Health Problems)

1. Catarro (Cold)

- Fiebre (fever)

- DoIor de Cabeza (Headache)

- Dolor de Garganta (Sore Throat)

- Tos (Cough)

- Vomito (Vomiting)

2. Diarrea (bacterialina viral, O por parikitos) (Diarrhea: bacterial, viral or parasitic)

3. Parasi tos (Parasites)

- Intestinal (Intestinal)

- Riîiones (Kidneys)

- Estomacales (Stomach)

4. Asma (Asthrna)

5. Alergia (Alergies)

6. Presion baja O Presion alta (LOW or High Blood Pressure)

7. Acidez estornacd (Heartburn)

8. Ventazon (Gas)

9. Enfermedades de la Pie1 (Skin Problems)

10. DoIor de oido (Ear Ache)

I l . Nervios (BadNerves)

12. Migrafia (Migraines)

13. Pediculosis (piojo) (Lice)

Escabiosis (picazod Sarna) (Scabies)

Honjo en los pies (Foot Fungus)

Dolor de Muelas (Tooth Ache)

Ulcera (U lcers)

Problemas con los rifiones (Problems with the Kidneys)

Hemorroides (Hemorrhoids)

Hepatitis (Hepatitis)

Varicela (Chickenpox)

Enfermedades Cardiacas (Heart Prob lems)

Otitis (Cronic Ear Infections)

Dermatitis (Dermatitis)

Neumonia (Pneumonia)

Diabetes (Diabetes)

Trombosis (Th rombosis)

Cancer (Cancer)

S I D A (AIDS)

Tuberculosis (Tu bercuIosis)

APPENDIX #6

Oracion a San Luis Beltriin

Criatura de Dios, yo te juro, ensalmo y bendigo en nombre de la santisima Trinidad. Padre + Hijo + y Espintu Santo + tres personas y una esencia verdadera y de Ia Virgen Maria nuestra seiïora concebida sin manchas del pecado original, Virgen antes del parto + en el parto + después del parto + y por la gloriosa Santa Gertrudis, tu querida y respetado esposa, once mil Vfrgenes, Seiïor San José, San Roque y San Sebastian y por todos los Santos y santas de tu corte celestial, por tu gloriosisirna encmaci6n + gloriosismo nacimiento + santisima pasion + gioriosisima resurreccion + ascension- Por tan altos y Santisirnos mistenos; que creo y con verdad, suplico a tu divina majestad poniendo por intercesora a tu santisima madre apoyada, Nuestra Sefiora, libres, sanes a esta afiigida cnatura de esta enferrnedad, mal de ojos, accidentes y calenturas y otro cualquier dafio, herida o enfermedad, Arnén Jesus +

No mirando la indignidad de persona que prefiere tan sacrosantos misterios con tan buena fe te suplico. Sefior, para mâs honra tuya y devocion de los presentes, te sirvas por tu piedad y misericordia de sanar y librar de esta hendad, Ilaga dolor, humos, enfennedad quitandole de esta parte y Iugar. Y no permita tu divina majestad le sobrevenga a accidente, corrupcih ni daiïo, dandole salud para que con ella sirva y cumpla tu santisima voluntad. Arnén Jesus +

Yo te curo y ensalmo, Jesucristo nuestro sefior redentor, te sane, bendiga y haga, es toda tu divina voluntad. Amén Jesus + Consumatum Est. + consumatum Est. + Amen Jesus. Es contra maleficios y todo género de enfermedades, etc. +

APPENDIX #7

SPELES USED TO COUNTER ILLNESSES AND B R U J E ~ A

PARA LAS ENFERMEDADES DEL -ONES Y LA VEJIGA (FOR SICKiVESS OF THE KIDNEYS AND BLADDER} Cocirniento de chayote. Se recomienda para las enfermedades del rifion y la vejiga. Ayuda a expulsar los c5lcuIos.

Herbcrl teci of chayote. It is reconzrnendeci for illnesses of the kidney and ~ h e blndder. It helps expell kidney srones

PARA LA EXPULSION DE LA LOMBREA SOLITARIA (FOR EXP ULSiUN OF SOLlTAR Y PVORM?) Las semillas de la calabaza pulverizadas y rnezcladas con leche herida son tradicionalmente conocidas para el tratamiento e expulsion de la lombriz solitaria.

The serds of the prtmpkiit grozmd und nziked wirh boiled milk ara tr-nciitionolly known for- trecitnzent and exptrlsion of the solitcity worrn.

PARA CURAR EL VIENTRE DE DOLORES O DE MALAS DIGESTIONES (TO CURE PA IN IAJ THE WOMB OR STOMA CHE OR B.4 D DIGESTiO!V) Coger una calabaza y pasarla por el vientre, primer0 en Cruz y luego en redondo. Se toma la medida del vientre que se va a curar y se pone dentro de una calabaza con 5 bollos. 5 yemas de hirevo, miel de abejas y manteca de corojo. Se lleva al rio con el dinero de1 derecho, se le mete dentro una vela encendida y se abandona a la corriente. Este trabajo es en nombre de O c h h

Tcike one ptrriîpkin. cindpciss it over the stomache. fir-sr in the sigj7 of'ci cross and /citer in a circlc. Tcrke the nzecisurenzent of the stonzach that yozt are going to cure rrndprrt ii inside the pzimpkin with five bollos, five egg y o k , hoiîey and iI fi-orn ci corojo plemt (ilcl-ornici ciczrleatcr). Tcrke it to rhe river- ~ t i t h crn oflering of n~oney. pur insick it a lit ccrntile crnd cibandon it to the crir-rent. This. spdl is in rhe ncme of Ochrin.

PARA ALEJAR A LOS ENEMIGOS (TO GET RID OF YOUR EArE1bIiES) Se cuelga una rama de tuna silvestre detras de cina pcierta de la casa.

Hong the bmnch of wildpew- behand a door of the hozise.

PARA ESPANTAR A UN MUERTO (TO FEUGHTEN AWAY A DEAD SPIRIT) Tres Bailos de hoja de gandul hervida.

TItree b a t h wit/z the boilded leaves of t/ze plant gandrtl (Cajanris iizdicns)

PARA R E U ~ T I C O S Y TULLIDOS (FOX RHEUMATISM AND CRIPPLES) Se pone carquesa en alcohol (toda la planta). Se usa dislocaciones, dolores musculares y para friccionar diariamente a los reumiiticos.

Put the plant carquesa (Ambrosia kispida) in alcohol (all of t/ze plant). Use for dislocariorzs, in ~iscular pain and rizertrnatics ca~z Lise it for daily massages.

Map 1. Island of Cuba. Research was carried out in the province and city of Cienfuegos.

Map 2. Map of the city of Cienfuegos. San Lazaro and La Tuanita were the sites where stnrctured survey interviews were carried out.