All cultures have ethnomedical systems: institutionalized practices for addressing health maladies. Westerners often consider biomedicine the only reliable health resource, but people around the world—and many in the United States—use other healing systems as well. Modern societies typically have medical pluralism , where within a single society competing ethnomedical traditions coexist and form distinct health subcultures with unique beliefs, practices, and organizations.
Kleinman (1980) illustrated this medical pluralism in showing that complex societies have three overlapping sectors or health care systems:
The popular (lay) sector involving culturally based personal and familial beliefs and practices
The folk sector involving cultural ethnomedical traditions and specialists The professional sector involving legally sanctioned professionals
The use of these sectors varies by immediate circumstances and as a hierarchy of resort or priorities. Generally, health concerns are initially addressed in the popular sector with self-assessment and self-help procedures in consultation with signifi cant others.
This may be followed by consultation with folk specialists or, if necessary and available, with biomedical or other professional services. Biomedical resources may be the fi rst choice but are generally accessed through decision making at the family (popular) level.
These sectors have implications for biomedicine because they are often used in conjunction with or as an alternative to biomedicine.
Popular (Lay ) Sector. The popular sector, also referred to as family care in nursing, is the basis for most personal health care decisions. These cultural understandings derived from family socialization provide principal interpretations of health and generally pre- empt biomedical care, constituting a fi rst line of resources. Family members and other interpersonal relations and social networks generally assist in assessing maladies and making decisions regarding treatment, including seeking biomedical care. The popular sector primarily involves what people, without recourse to specialists, believe and do about health care, including ignoring symptoms, and decide whether biomedical care is necessary or whether recourse may be made to the folk sector. Popular-sector health practices involve minor fi rst-aid preventive measures such as lifestyle activities, hygiene, and vitamins and over-the-counter medicines. Informed sources on TV, the Internet, and numerous publications also advise popular health behavior. Knowledge of popular health beliefs and behavioral patterns gives health care providers the basis for appropriate inter- pretations of help-seeking behavior, symptom presentation and complaints, communica- tion about the body, and sick-role behavior and coping strategies. If health care providers are not aware of the cultural frameworks used by patients to conceptualize and communi- cate about their ailments, then noncompliance , patients’ failure to comply with medical recommendations, is more likely. Case studies of African American health beliefs and Mexican American cultural factors affecting pregnancy and prenatal care illustrate the importance of the popular sector.
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Folk Sector. The folk sector involves a variety of traditional cultural healing prac- tices that are generally not part of an offi cial or professional medical system. These include religious and spiritual healers, natural and physical healers (such as herbalists, midwives, and masseuses), and psychological healers (diviners, fortune-tellers). These ethnomedical systems have been called superstitions, charlatanry, quackery, and worse, and biomedicine has generally discounted their effi cacy. But there is evidence that eth- nomedical systems provide amelioration of suffering through curative social, psycho- logical, and physiological processes. The appeal of this sector as both a complement and alternative to biomedicine is examined with specifi c examples from the U.S. subcultures such as Mexican curanderismo, African American religious healing, and Native American healing practices.
Other ethnomedical systems in the United States, often referred to as alternative medicine, are also of considerable economic importance, refl ected in expenditures that exceed the out-of-pocket expenses for biomedical care (Eisenberg et al., 1993; Eisenberg, Davis, Ettner, Appel, Wilkey, Van Rompay, and Kessler, 1998). The extent of this alterna- tive care indicates that health care providers need to understand this medical pluralism and how its utilization affects patient care. Other ethnomedical systems have implica- tions for biomedicine because they may be employed as a complementary rather than an alternative approach. This simultaneous use of several health care sectors is illustrated in treatments for HIV/AIDS.
Professional Sector. The professional sector of medical care is generally dominated by biomedicine, although other professional healers are found both in the United States and cross-culturally, such as naturopathic physicians. The professional sector provides the offi cial and legally sanctioned medical care services. In the United States, it includes bio- medical practitioners, osteopathic physicians, pharmacists, chiropractors, auxiliary prac- titioners such as nurses and physical therapists, and competing and often marginalized professionals such as naturopaths, homeopaths, and acupuncturists. What constitutes the professional sector differs cross-culturally, refl ecting the effects of culture and politics on health systems and practitioners.
The cultures of biomedicine are illustrated in cross-cultural variations in practice preferences and in differences between physicians and nurses. These cultural aspects of biomedicine affect clinical relations and can undermine patient compliance, requiring cross-cultural adaptation to be effective and competent in patient care.
The popular, folk, and professional sectors ideally represent the major differences in the principal health practices found in modern societies. There are differences cross- culturally in the practitioners found in each sector. The professional sector of one culture may function as a folk sector in another, such as Chinese medicine or acupuncture in China versus the United States. The distinction between sectors is not absolute: popular practices may overlap folk practices (such as herbal medicine use), and folk healers may adopt biomedical practices (such as stethoscopes). The relationships among practition- ers and sectors may change as folk healers professionalize and collaborate with the bio- medical sector or when professional healers adopt folk practices, such as acupuncture in biomedicine.
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CASE STUDY
Alternative or Complementary Medicine?
The case of Lia Lee shows the pattern of the simultaneous utilization of multiple sectors of care:
biomedical, popular, and folk practices. Lia Lee’s parents did seek biomedical help for her powerful seizures, taking her to the emergency department during her more serious episodes. Physicians’
services when their other children were ill in the refugee camps had proved useful. But they were not willing to give Lia all of the medications prescribed because of the numerous side effects.
Instead, a variety of traditional remedies were also employed.
Hmong in the United States still use rituals, herbal medicines, soul recovery, coining and cupping, and various other ritual practices. Lia’s mother had dozens of cans and buckets in which she grew medicinal plants used for treating a wide range of conditions: colds, stomach problems, postpartum conditions. Her mother gave her herbs from her garden and engaged in healing rituals designed to absorb the sickness into an egg. The Hmong also employed a practice known as cupping in which a small heated cup is applied to the skin, creating a suction that causes the skin to rise in a welt and “negative infl uences” to be extracted. Her family changed Lia’s name so that the evil spirits could no longer fi nd her, but the doctors undermined this by continuing to use Lia’s name. A man’s responsibilities as head of household include ritual offerings to ancestral spirits to maintain the health of the family. But many of the traditional ceremonies involve animal sacrifi ces that are prohibited in this country.
The failure of the biomedical approach to cure Lia and the limited effects from the traditional rituals led her parents to have several ceremonies carried out by shamans. The shamans also treated
The relationships among health care systems need to be analyzed according to structural superiority and functional strength. Structural superiority is concerned with the medical sys- tem’s role in the national society and factors such as the power and wealth of its practitioners and their social prestige. The dimension of functional strength is concerned with the extent to which services are used and their distribution in a region. Biomedicine has achieved struc- tural superiority in virtually all countries of the world, but the functional strength is highly varied across countries. Local medical systems often have greater functional strength, with many factors, including cultural relevance, contributing to their greater use. In most societies of the world, biomedicine dominates the political power structure, but this structural superi- ority is challenged by the functional strength of traditional healing systems.
This chapter examines some of the implications of these different sectors of care. Pri- mary importance of the popular care sector involves the implications for the recognition of symptoms, care seeking, the signifi cance of and response to pain, and the conceptual- izations of the body and bodily processes that infl uence communication with providers.
The considerations of folk healers illustrate why such practices are such an important fea- ture of the American health care scene and why it is that alternative and complementary ethnomedical practices have such a strong appeal in the United States. This cultural per- spective also helps reveal factors affecting the practice of biomedicine.
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