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Folk Medicine in Contemporary America
David J. Hufford
It is my purpose in this essay to situate the regional folk medicine studies in this book within the medical and the national contexts.
Folk medicine is defined by contrast to modern, scientific medicine, the "official" medicine of the modern world. We say that a belief or practice is folk medicine because we recognize that it is not official. This enormous and diverse body of unofficial health culture is the foundation from which many patients derive their attitudes and decisions about medical care. However, this fact is not obvious from the medical perspective, and even when it has been recognized, the development of a reasonable way of taking folk medicine into account in the clinic is a complex job. I have been a member of the Behavioral Science Department of the Pennsylvania State University College of Medicine since 1974, and my suggestions here come from that experience of medical teaching, research, and consultation.
The national context is equally important. The stereotype of folk medicine associates it with populations isolated from the modern cultural mainstream. This is partly because of the erroneous assumption that modern medicine inevitably replaces all other cultural health resources as soon as it is available. Therefore, the documentation of folk medical traditions within any particular region, especially one that is rural, is often perceived as setting that region apart from the national culture. This notion of folk medicine as marginal is as unfortunate as it is incorrect (Hufford 242–53). The traditions documented in this book are cultural elements that North Carolina and Virginia patients have in common with patients elsewhere. As I shall discuss below, folk medicine is not restricted to any single region or demographically defined group. Instead, it represents a universal set of efforts to cope with illness in ways that go beyond—but do not necessarily conflict with—what modern medicine has to offer.
This is a central part of my argument for the medical importance of folk medicine. We are not dealing here with a few surviving vestiges of pre-modern medical thought. We are dealing with vigorous community resources for coping with illness that show no sign of being in decline. Both folklorists and health professionals need to recognize and strive to understand this fact if their analyses are to be sound and if their practice is to be effective.
THE EXTENT AND RELATIONSHIP OF AMERICAN HEALING SYSTEMS
The following five points are essential to a discussion of healing systems. Although they may seem obvious at first glance, they are nonetheless frequently overlooked when feelings begin to run high on matters of health.
American Healing Systems are Numerous and Varied
In the United States today there exist a great variety of traditions of healing. Some of these have the relief of physical disease as their primary goal; examples of such systems are modern conventional medicine and homeopathy. Others focus primarily on the prevention of disease, for example, conservative chiropractic; and others on the enhancement of health, for example, health foods and organic farming. Still others have a completely different primary goal: most religious healing practices exist within traditions in which salvation is the primary goal, while the healing of physical and mental disease is prominent but clearly of secondary importance.
Some of these systems occupy firmly established "official" positions in our society, such as conventional medicine and osteopathy. Others are definitely unofficial or "folk" in their status, as is the case with Pennsylvania German powwowing or the North Carolina burn-healing tradition discussed by Kirkland and Sammons in chapters three and four. Some are necessarily in conflict because they are based on diametrically opposed sets of assumptions, as Christian Science and medical science. Others, such as the tradition of prayer for healing in most Christian denominations and most forms of physical treatment of disease, are so accustomed to one another that neither clergy nor health care personnel normally think of themselves as in competition.
Some of these systems appear relatively new, but most of them are historically related to older traditions, as chiropractic is related to traditions of "bonesetting," much of the modern health food movement is related to ancient folk herbalism, and conventional medicine is the culmination of many strands of official and folk healing traditions spanning centuries. The current tension among these systems, especially between modern, conventional medicine and most other healing traditions, is sometimes characterized as a distinctly modern situation, but it too is a continuation of past struggles and requires an historical perspective to be properly understood.
This book discusses several important, representative systems found in North Carolina and Virginia, but these do not exhaust the possible examples. The fact is that we live in a pluralistic health culture, although one particular form of healing tradition has become the primary official one over the past eighty years or so. The variety of healing traditions shows no sign of decreasing, and a major purpose of this book is to seek an understanding of the regional sources and nature of this diversity and to look for ways in which such an understanding can work to the advantage of both practitioners of healing and their clients.
"Rational" and "Logical" Do Not Equal "Correct" or "True"
When discussing health systems with any group, I always begin by noting that most of them (from conventional medicine to psychic healing to herbalism to faith healing) are rational systems of thought. Immediately, I encounter an argument to the effect that this cannot be because such and such a system is not correct. Perhaps this judgment of correctness is right and perhaps not. But that judgment is not relevant to this point. "Rational" simply means based on the coherent use of human reason. Reasoning, including formal deductive logic, cannot guarantee truth. If assumptions, criteria for the admission of evidence and observations, differ, then the same kind of reasoning may lead to very different conclusions.
The importance of recognizing the rationality of a system of ideas is that it gives people with different viewpoints a common ground for discussion. A surgeon and a faith healer can rather easily be brought to understand the logic of each other's thought if each will listen to a straightforward description of the assumptions and observations involved. This understanding can lead to a reasonable discussion that can work to the advantage of each and, even more important, to the advantage of a patient who may be seeking help from both simultaneously. Because emotions tend to be so strong in such discussions, it may be necessary for a third party to help communicate the straightforward description—for example, a medical folklorist or anthropologist (or the patient in the middle)—but it is still not that complicated a task to accomplish.
"Understanding" Does not Equal "Agreement"
When contemplating a request to understand someone else's very different point of view, there is a certain amount of uneasiness, arising from the possibility that this understanding might mean agreement. Certainly when agreement between opposing points of view is possible, it is most likely to be gained by understanding. However, it is perfectly possible (and rational) that two parties may come to a fairly complete understanding of each other's viewpoints and still neither be able to agree nor to disprove the other's point. If that is so, what good is this understanding? Together with the grasping of the other's logic, this understanding makes possible reasonable discussion and negotiation. As I shall argue below, the removal of conflict between very different healing systems is possible to a certain extent in some cases. However, just as important is the ability to recognize those differences that are irreconcilable and find the basis for a rational negotiation that will reduce the negative effects of the conflict on individual patients and the public in general.
Honesty. Sometimes in discussions of the need to understand and respect the beliefs of patients, and at times to accommodate them in treatment, health professionals develop the impression that they are being asked to pretend. This is not the case. It would be neither ethical nor practical to pretend agreement with beliefs that one does not share. But agreement is not the primary thing most patients seek on this subject. They wish to have those beliefs that they see as relevant to their health and treatment listened to, responded to honestly, and taken into account in planning treatment. Such attitudes are prevalent among the individuals whose case histories on North Carolina rootworking traditions Mathews and Lichstein discuss in chapters five and six. And another excellent example can be seen when a Jehovah's Witness tells his surgeon he will not accept blood transfusions. He doesn't expect to convince the surgeon that transfusions are bad. He expects the surgeon to understand his religious basis for rejecting transfusions, to explain how this will affect his case, and then to honestly abide by his clearly stated wishes. These wishes may be taken directly from the entire teaching of the Witnesses, or they may be some personal variation of those teachings. Whatever they are, though, the Witness has a right to have his belief and wishes heard (the surgeon can never assume that he or she knows in advance exactly what an individual Witness's specific position will be), to be understood, and to be acted on.
It may seem at first glance that such an example, rooted as it is in the patient's formal religious commitment, is a special kind of exception. However, beliefs not officially derived from a religious institution—but part of the patient's lived world view—are often as firmly held, as personally important, and as ethically salient as those that are.
Alternative Health Systems Are Extremely Vigorous and Persistent
From the point of view of conventional medicine, the need for understanding and negotiation with alternative views of health has not seemed very urgent in this century. It has been assumed that alternatives were in the process of dying out in the face of modern medical technology. By the beginning of the 1980s, however, it is clear that this prediction is off the mark. Interest in and use of alternatives to modern medicine (often in addition to medical care rather than as pure alternatives) have, if anything, increased.
In 1988 I had the opportunity to document this startling fact with regard to cancer, while participating in a project of the U.S. Congress, Office of Technology Assessment, intended to lead to the objective evaluation of unorthodox cancer treatments. My research involved both literature review and fieldwork, but here I shall only comment on what the literature showed concerning hard evidence on the prevalence of folk medicine. The best quantitative study published to date was carried out by Barrie Cassileth and her colleagues at the University of Pennsylvania. This study involved 304 patients at the University of Pennsylvania Cancer Center in Philadelphia and 356 patients of unorthodox practitioners in the Philadelphia area. Among the Cancer Center patients, 13 percent were currently using or had used some form of folk medical treatment. Among the entire group of 660 patients, contrary to conventional expectations, "Patients on unorthodox treatment ... tended to be white (p<0.00001) and better educated (p<0.00001) than patients on conventional treatment only" (Cassileth et al. 107). The treatments used ranged from herbs to dietary changes to healing prayer and unorthodox medicine such as "immune therapies." The design of this study, like most other quantitative work, used a conservative definition that did not elicit many reports of self-treatment. Since self-treatment is very common in folk medicine, we must assume that these quantitative assessments yield very conservative figures. A colleague, Peter Houts, and I recently carried out a survey of folk medicine used by 628 cancer patients in central Pennsylvania, using a design intended to include self-treatments, so long as they were undertaken to actually combat the patient's cancer. We found that this approach yielded a utilization rate of more than 70 percent. The most frequently used methods were spiritual and religious, a kind of tactic that is almost universal in folk medical traditions. For example, 73 percent used some form of prayer and 7 percent attended some kind of formal healing service. Other kinds of methods used included visual imagery techniques (17 percent) and dietary strategies (11.3 percent), both of which are prominent elements in a variety of folk medical traditions (unpublished data).
Several other quantitative studies have been carried out on this topic within the past twelve years. All have found significant utilization of folk medical treatments among cancer patients ranging from a low of 6 percent reported among pediatric patients (Copeland) to substantially higher incidence than that reported by Cassileth et al. For example, the 23 percent reported by Newell et al. in 1986. Of those that have reported characteristics associated with utilization, all have supported the findings of Cassileth et al. For example, Newell et al. found that "the user of unorthodox cancer treatments was likely to be younger, better educated, more knowledgeable concerning cancer treatments," and Mooney found that "Users were more action-oriented, consulted more information sources, and were more familiar with treatment options." Studies outside the United States suggest that utilization of unorthodox treatments is even more common in other countries (Arkko et al.; Dady et al.; Pruyn). Such studies find a variety of practices ranging from the older, often ethnically linked traditions such as curanderismo in the Southwest to modern, "New Age," holistic approaches. These different traditions tend, as one would expect, to be utilized by different patient groups. However, the modern-looking approaches have strong, often explicit, connections with the older forms (as holistic health advocates seek to incorporate shamanism, herbalism, and other ancient techniques within a modern context), so this distinction should not be exaggerated.
Some might assume that these findings of high prevalence, especially among mainstream patients, is peculiar to cancer treatment. However, all indications, both quantitative and ethnographic, are that reliance on folk medicine is similar for all health matters. For example, in the spring of 1986 a study carried out under contract with the Department of Health and Human Services conducted a national survey of the attitudes that the "non-institutionalized, adult population" of the United States held toward the utilization of "questionable" treatments for disease in general and for arthritis and cancer in particular (Lou Harris and Associates). The general questions were asked of a national cross-sectional sample of 1,514, and the final cancer patient sample included 297 persons. The authors note that the questions focused on a "restricted domain of fifteen treatment areas, in which products have been systematically classified as scientifically acceptable or questionable" and therefore "these estimates should be treated as conservative" (ii). Certainly folk medical practices were counted as questionable in this study, but no doubt a great many were not asked about. The authors report that the general population is much more likely than cancer patients to use questionable treatments (26.6 percent), 21 percent having used them within the past year as compared to about 15 percent of cancer patients who are using such treatments. "College graduates seem more likely than those without a degree to use treatments that are questionable" (v), but the authors note that in other ways those who use questionable treatments are demographically indistinguishable from the general population.
Although research on folk medicine has been ethnographic much more often than quantitative, it is clear that what quantitative work has been done strongly supports the conclusion of folklorists and anthropologists that folk medicine is vigorous, persistent, and prevalent in the United States. This survey research also supports the observation that folk medicine is not linked to a particular segment of the population or that it survives only among the "ignorant."
In some specific cases, medicine may need to continue efforts to reduce the influence of these alternatives, or to alter the nature of their practice. That is, there are some for which a good case may be made that they are actually harmful. Nonetheless, it must be granted that in almost one century of intense efforts, bolstered by substantial legal and financial assistance, conventional medicine has not even begun to wipe out nonofficial healing practices and beliefs. This observation will be granted both by those who support and those who oppose these efforts at eradication. Therefore, the need to understand and to be able to negotiate concerning the issues involved seems very pressing. As early as the mid-1970s, articles in medical journals had begun to grant this point with regard to one of the systems with which it has been most at odds, chiropractic. An article in the New England Journal of Medicine by Gregory J. Firman, M.D., J.D., and Michael S. Goldstein, Ph.D., "The Future of Chiropractic" (639–42), concluded that "the role of chiropractic within the health-care system will remain stable in the future" (639). Or, as an article in Medical Economics by A. J. Vogel put it, "It's Time to Take Chiropractors Seriously" (76–85). This is true not only of the most highly visible instances, such as chiropractic. It is, in fact, time to take folk medicine in general seriously.
Excerpted from Herbal and Magical Medicine by James Kirkland, Holly F. Mathews, C. W. Sullivan III, Karen Baldwin. Copyright © 1992 Duke University Press. Excerpted by permission of Duke University Press.
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|Introduction: A Regional Approach and Multidisciplinary Perspective||1|
|1||Folk Medicine in Contemporary America||14|
|2||Traditional Healing Today: Moving Beyond Stereotypes||32|
|3||Talking Fire out of Burns: A Magico-Religious Healing Tradition||41|
|4||Parallels Between Magico-Religious Healing and Clinical Hypnosis Therapy||53|
|5||Doctors and Root Doctors: Patients Who Use Both||68|
|6||Rootwork from the Clinician's Perspective||99|
|7||The Cultural Epidemiology of Spiritual Heart Trouble||118|
|8||Herbal Medicine Among the Lumbee Indians||137|
|9||Childbirth Education and Traditional Beliefs About Pregnancy and Childbirth||170|
|10||Aesthetic Agency in the Folk Medical Practices and Remembrances of North Carolinians||180|