limited kinship networks typical of Euro-American middle-class families, many cultures have extended kinship structures that play an important role in everyday life. This extended kinship structure often constitutes the network within which health care and the associated social and economic support are provided during illness. Because of their fun- damental role in organizing human social systems, kinship expectations have important health functions. Functions of kinship that affect health care include responsibilities for the care of related children and the provision of material assistance and resources to kin.
The obligation of kin to support the ill may create institutional problems such as dozens of relatives visiting a patient in a hospital. Different concepts of family member can also cause problems in hospitals where visiting policies are largely structured on the assump- tions of the traditional middle-class American family: nuclear structure with few children.
The concept of fi ctive kin refers to unrelated individuals who assume kinship roles and terms: for example, a close female friend being called “sister” by another person, whose children refer to her as “auntie.” In today’s society where there are many families disrupted by divorce, fi ctive kin often play central roles in family systems. Culturally sensitive providers recognize these relations and extend to them the prerogatives allowed under narrower conceptions of the nuclear family.
I have called “shamanistic healers” (Winkelman, 1992a, 2000a). These practices, which take diverse forms cross-culturally, manifest human cultural universals of healing that include
The use of altered states of consciousness
An engagement with what is considered to be the spirit world Healing provided in the context of a community ritual Diagnosis through information provided by the spirit world Illness caused by the evil intentions of other humans or spirits
These aspects of our “primitive” past were supposed to disappear as science and bio- medicine discovered diseases and their cures. Yet, religious healing remains a dynamic and widely used resource even in postmodern societies, as illustrated in the many exam- ples in Barnes and Sered’s (2005) Religion and Healing in America. This use of religious healing persists among major religious denominations, across cultural groups, and even among patients of biomedicine. Some might even suggest that religious healing is partic- ularly important among patients of biomedicine because it helps them deal with some of the negative and toxic effects of the interpersonal dimension of biomedical treatment. In any case, health providers need to understand how people’s religious beliefs affect their clinical relations and patients’ compliance with prescribed care.
Providers need to recognize that most of their patients today think that religious issues have an infl uence on the outcome of their malady. Religion affects perceptions of causes because maladies may be seen as punishment by god or spirits, a consequence of immorality, or punishment for sins. The acceptability of treatment opportunities may be affected by religious beliefs, for example, in terms of
Acceptability of birth control, artifi cial insemination, and abortion Preparation of a body for burial
Use of blood products and animal-derived medicines Acceptability of euthanasia or advanced directives
Dietary products considered acceptable (e.g., food combinations, pork, beef) Acceptability of organ donations and autopsy
The scientifi c training of physicians generally emphasizes atheistic perspectives. The doubt expressed about the power of religion to heal may seem scientifi c, but even this will be questioned in Chapter Nine. Rather than doubting and challenging a patient’s belief that God can help resolve a health problem, a more appropriate approach would be to recog- nize the important role of such beliefs in managing the broader impacts of maladies.
Curing, Healing, and Care
Assessing a person’s health concerns is complicated by the intersecting dimensions of disease, illness, and sickness. Addressing the totality of health, these different but inter- secting dimensions of well-being can be enhanced by understanding the different ways
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in which health maladies are addressed in personal experience and biological reality. It requires a conceptual framework in which the processes of removing the effects of dis- ease from an individual are distinguished from the processes involved in the remission of the problems derived from illness and sickness.
The concept of cure has been applied to the removal of disease: one can be cured of pneumonia, diarrhea, syphilis, and the common cold. When bacteria are eliminated by the actions of antibiotics and one’s own immune response, we can say that the person is cured. If, however, someone is seriously injured in a brutal physical attack and rape, the person may soon recover from the physical wounds. But is that person all better? Or are there still some psychological wounds, scars of trauma that need to be addressed? Patients may be physically cured of their wounds but still need healing from trauma.
The concept of healing contrasts with cure in embodying a recognition of the need to recover one’s well-being in areas other than just the health of the physical body. Healing involves processes of “whole-ing,” putting one’s psychological and emotional life back into balance. One’s physical wounds may have closed, but the emotional trauma and fears may still be present and in need of healing. Religion has played a central role in this process of healing and of maintaining a faith in one’s ability to recover in the face of stark medical reality that suggests a poor prognosis for recovery.
Pilgrimage as Social Healing The social healing processes derived from group participa- tion and the telling of stories of illness are described in Pilgrimages and Healing (Dubisch and Winkelman, 2005). Pilgrimage is a form of personal and popular empowerment pro- duced by a journey to a site with religious, historic, and mythological signifi cance. The pilgrimage may begin as an individual quest, but it is typically part of a collective physical movement of up to a million people to a site. These bring the social dimension of the pil- grimage to the experience, where one recounts one’s story of illness and search for cure with fellow travelers. These connections provide signifi cant personal meaning and emo- tional release from guilt, shame, and promises. These experiences induce healing through a realignment of self-concept, status, and identity with the other, both cultural and divine.
Symbolic healing involves a process by which meaningful explanations provide a sense of relief that is as much physiological as psychological (see Chapter Nine on the stress response and metaphoric healing). The rituals of pilgrimage provide processes through which participants tap into unconscious innate structures and processes underlying the self and sense of identity. These experiences produce a powerful sense of emotional integra- tion with the community. These symbolic healing processes provide meaningful mytho- logical explanations that counteract the stress reaction, allowing the effects of beliefs and the powerful transformative potentials of ritual to heal the self.
Culture Care
Leininger, the “grandmother of transcultural nursing,” has championed an understanding of health care needs in terms of cultural preferences and perceptions. Human needs for care are universal, a part of our human nature, but the ways in which care is provided and expected is particular to culture. Care , which is the essence of nursing services, is the assistance necessary for recovery from illness and maintaining well-being and health in
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Religion and Healing in Contemporary America
The effi cacy of religion in dealing with many aspects of health maladies is not something confi ned to the poor or people without access to biomedicine; there is a broad range of religious healing in contemporary America, as illustrated in the dozens of articles in Barnes and Sered’s (2005) book, Religion and Healing in America. Across the spectrum of ethnic and religious groups, religious healing activities have remained an important part of contempo- rary America. Central aspects of contemporary religious healing in the United States are exemplifi ed in a study of the United Church of Christ (McKay and Musil, 2005). The con- cerns of spiritual healing were not predominantly in the physical area, in response to disease.
However, when disease was involved, its resolution was often a spontaneous event, a miraculous deliverance from disease in response to intense prayer and spiritual experi- ences . Even when disease was not resolved by prayer and faith, there was often a positive outcome, a paradoxical sense of being healed and at peace without being cured. This was explained by the most frequently reported characteristic of spiritual healing, the experience of peace, a transformation of one’s habitual state of being. For patients, spiritual healing involved feeling the presence of God, the unexpected discovery of a presence of God in their ordinary lives. The perception of the role of disease in patients’ life included a sense of it bringing them into an awareness of God’s presence, making the illness a blessing that brought the person to God.
Religious healing through inner transformation is part of a long metaphysical tradition in America that is also manifested in the more secular New Age movement (Fuller, 2005).
New Age spiritual healing practices coexist within the framework of Judeo-Christian beliefs in the sacralizing of the self: the transformation of the sense of self into a sacred being through production of a personal experiential encounter with a sacred reality. The American metaphysical traditions involve the personal and experienced dimensions of the spirit world, engaging with subtle energies of the spiritual world and direct encounters with the divine.
This has led to an understanding of the intertwined nature of the physical and spiritual that goes beyond contemporary science and religion. For instance, the physical experience of alternate realities and their real-world power is manifested in healing energies that can be sensed and transferred to others. The experiential engagement with subtle energies and realities produces an expansion of consciousness, propelling a spectrum of physical, emo- tional, social, and cognitive transformations. These assist in the abandonment of dysfunctional identities and the development of a new sense of self derived from the effects of the experi- ences and insights. The healing power of spirituality, like religion in general, leads to an emotional transformation and new self-identity involving the social relationships and ideology of the group.
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culturally meaningful ways. Health is culturally defi ned and, consequently, so, too, is the care necessary for maintaining and restoring it.
To provide appropriate care, providers must interact with and respond to patients in ways that are consistent with their care expectations. For instance, should a nurse be chatty and friendly, playful and joking, while performing your rectal examination? Or should nurses be serious, quiet, and reserved? The ways in which care is expected to be provided always come with a cultural style: a refl ection of cultural norms, values, beliefs, and expectations.
An accommodation to the life ways of patients and their accustomed style of social relation- ships is necessary for the appropriate provision of care. For example, care expectations in the Mexican American community include the notion that a well-mannered person will also ask about the well-being of other family members besides the patient. In most countries of the Middle East, however, in general it would be inappropriate to ask a man about his wife’s health unless he was there to answer questions for her in the consultation room.
Leininger (1995) proposed a cultural systems model that she later renamed the “Sun- rise Enabler,” a cognitive map for discovering multiple embedded cultural factors affecting health and care. This focuses on the environmental context as the totality of the situation affecting life circumstances and health, including environmental factors and cultural mean- ings, symbols, values, and views. It also includes consideration of generic cultural concepts of care and care expression, cultural values and beliefs regarding care, care patterns for maintenance and re-patterning of health behaviors, and indigenous care practices. Aspects of the culture relevant to such care include technology, economics, family and kinship organization, politics, education, and religion.
Care includes sensitive actions that provide necessary assistance with daily activities and health care, being supportive and enabling in helping to improve a patient’s condi- tion. The way in which care is provided is symbolic, conveying a sense of protection and respect by being culturally congruent care: providing a meaningful fi t with the cultural values and care expectations of the client. Care also involves how we help a patient’s family deal with illness, disability, and death in other family members. So a signifi cant feature of care includes how impending death and poor prognoses are to be communi- cated to the patient: directly, through the family, or perhaps not at all.
The provision of care in culturally congruent nursing care includes actions that Reinforce cultural patterns of care and health preservation or maintenance, reinforc- ing the retention of benefi cial cultural self-care beliefs (strengths perspectives) Accommodate to patient needs in providing care that is culturally congruent and effective (cultural responsiveness)
Engage patients in modifying their self-care patterns to change behavior in ways that attain better health
Witch-Doctor’s Legacy
Traditional ethnomedical practices have had a multifaceted effectiveness that is increasingly lacking in interactions between physicians and their clients. Press (1982) illustrates that biomedical care can be enhanced by using the traditional symbolic
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resources of ethnomedical traditions—what he calls the “witch-doctor’s legacy”—
involving psychosocial and interpersonal dynamics of healing. Central elements of these approaches are
Accepting clients’ presentation of symptoms, worldview, and explanatory model Addressing clients’ concerns and the personal and social consequences of illness
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Cult of the Saints in the Care and Management of Medically Induced Sickness
The role of religion in health care can involve the management of negative experiences induced by disease, illness, and sickness, including the adverse effects of a gloomy medical prognosis or physicians’ indifference to religious dimensions of health care. Religious faith and focus can be an important ally in managing the depression and fears that disease brings, providing a counter to defeatist attitudes and an effective tool in combating stress.
Osis’s (2005) examination of the “cult of the saints” in American Catholicism illustrates the reasons for the persistent use of saints in healing. Saints provide care through symbolizing expectations of healing and curing and linking the patient with the loving feelings of absent family members. The healing power of saints includes their role in the expression of care, sup- port, and assistance. Saints’ representations in pictures and objects are a means of expressing care as a gift, with the saints’ presence providing the patient assistance with experiences of sickness. The images of saints are particularly important when a patient is isolated in a hospital and dominated by the images of the medical settings. Saints help patients resist the domination of biomedical beliefs and instead respond to the inspiration of faith in their ability to be healed—even cured—by divine intervention. The potential power of the saints and their mira- cles allow patients and their families and friends to imagine, to construct an alternate scenario of health, and to have hope. The beliefs in the saints’ healing powers also may elicit patients’
innate healing processes through the hope and positive expectations derived from those beliefs.
Saints’ potential interventions allow patients to maintain an emotional state of positive expecta- tion rather than succumbing to depression and acceptance of the inevitability of death.
The saints help produce this positive expectation by their immediate presence. The dis- play of saints’ images provides a focus of attention, a sense of a protecting companion, and a focus for prayer. The saints come to be experienced as consolers, providing a sense of the presence of others who are there to help. The gifts of saints’ images and relics from different friends and family members provide a tangible connection with them that links the isolated patient back into a network of social support, reinforcing the connection with the social net- works and their supportive relationships. These memories elicit feelings of love, generosity, and support from family, linking the patient to them emotionally despite the isolation. Osis characterizes the power of the saints as providing patients and their families with solace and the strength to care for their health and resist a feeling of marginalization.
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Using cultural approaches to enhance client confi dence and disclosure
Developing a personal style that enhances clients’ sense of acceptance and positive relations
Cultivating a charismatic approach that enhances client confi dence Creating a positive community image
Incorporating folk healers into medical settings is normally impractical, as is having medical practitioners learn all forms of cultural healing relevant to their multicultural patient populations (Press, 1982). Press suggests that biomedical practitioners can, however, adopt folk healers’ general practical principles and stylistic characteristics as guidelines for enhancing clinical care and reducing stress. Cultural knowledge and anthropological perspectives can help providers utilize interpersonal and symbolic resources to enhance healing. These are essential for providing culturally responsive care. Physicians’ addressing patients’ broader concerns counters the alienation that inhibits cultural healing processes.
Engel (1977, 1980), himself a physician, suggested that failure to address the psychosocial concerns undermines the dynamics of the patient-healer relationship that elicits and sup- ports healing. Press suggests that the “biomedical health practitioner should be expert in theology, anthropology, psychology, and urban studies” (1982, p. 196) and self-consciously utilize symbolic resources.
An anthropological medicine (Helman, 2001; Hahn, 1995) can help providers con- nect with the interpersonal dynamics of healing through
Giving primacy to understanding clients’ concepts and experiences
Examining the sociocultural roots of clients’ and providers’ conceptual frameworks Understanding cultural-behavioral relations and intercultural dynamics
Possessing personal skills for managing intercultural relations and communication Possessing knowledge of specifi c sociocultural norms and health behaviors Adapting to the social and cultural aspects of illness and clients’ coping resources Managing differences in explanatory models to treat both illness and disease Eliciting the symbolic, psychocultural, and emotional dynamics of healing
In addition to issues already addressed here and in Chapters Two and Three, these issues of anthropological medicine are addressed throughout this book, particularly
Cultural presentation of symptoms and clients’ conceptual frameworks (Chapter Five)
General models of cultural-behavioral relations and psychocultural dynamics (Chapter Six)
Consumer empowerment by understanding the politics of medicine (Chapter Eight) The psychosocial dynamics of the placebo healing response (Chapter Nine)
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Part of the engagement with patients’ cultural infl uences means an acceptance of their worldview as it pertains to their health concerns. For instance, what if a patient believes that his or her STD is a result of being sinful and that it will only fi nally be cured if he or she prays for forgiveness? Providers need not agree with or dispute patients’ explanatory models and beliefs if they do not directly impede the treatment. Contradicting them will not reduce anxiety nor necessarily lead to compliance or healing. An attitude that does not reject patients’ beliefs helps make patients more amenable to biomedical treatments.
Unless personal healing practices are known to be harmful, most cultures should be respected and accommodated. This is therapeutic because culture provides important com- plementary components to biomedicine in addressing illness and sickness.
Acceptance of patients’ worldview facilitates accommodating personal concerns in treatment. Traditional healers generally accept symptoms presented by patients and fam- ily at face value, permitting some degree of control over formulating diagnoses. This is in contrast to physicians’ often selective utilization of symptoms for diagnosis and the ten- dency to ignore patient complaints not amenable to biomedical diagnostic categories (Press, 1982). Disease is treated, but illness and sickness remain unaddressed, compel- ling many patients to seek complementary care practices.
Enhancing biomedical healing requires addressing the social and symbolic dimen- sions of illness and healing. To be more effective in care, health care providers need to recognize that symbolic and social interactions are key aspects of healing processes in all cultures. In many cultures, the processes of healing are integrated throughout social life—economic, familial, religious, mythological, ceremonial, and so forth—and may require the participation of the entire community. The social linkages of therapy are often extended to the deceased and their concerns, represented as ancestor spirits that refl ect the values of the society. Ritual healing is often directed at reinforcing this moral order and strengthening social relationships through the resolution of confl icts.
This suggests that biomedicine could benefi t by responding more directly to the social dimensions of healing processes, including familial and community healing rituals to help resolve the sick role as well as social tensions and confl icts. The use of social sup- port in preventing and ameliorating maladies is part of the community dynamics of heal- ing and has implications for biomedicine because epidemiological study results have established the relationship of social support and networks to health (see Chapter Nine).
Premodern healers were part of the local community and aware of the social dynamics and personal and family histories that affected individuals. Healers could then assess the long-standing anxieties and concerns of a patient and incorporate the family system into healing processes (Press, 1982). Physicians’ disconnection with the communities they serve and health providers’ lack of awareness of patients’ perspectives and the effects of culture on health leave them unable to address these signifi cant determinants of health behaviors. This can be remedied through knowledge about sociocultural factors that affect health and the development of cultural responsiveness to these broader concerns.
Cultural responsiveness is embodied in the concepts of quality patient care and the recognition that treatment outcomes can be enhanced by addressing patients’ values and communication styles, providing integration of care and emotional support, and involv- ing family and community (Delbanco, 1992). Engagement with these dimensions of care
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