Langdon Maclennan 1979

8/11/2019 Langdon Maclennan 1979

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Soc Sd. d

Vol. I3Il. pp.

211

10220

Pergamon Press Ltd 1979. Prinled

in

Grcal 8rituin

0160-7987,79;0901-1l21IS02.00,0

WESTERN BIOMEDICAL AND SIBUNDOY

DIAGNOSIS: AN INTERDISCIPLINARY

COMPARISON

E. JEAN LANGDON and

ROBERT

MACLENNAN1

Department of Anthropology, Cedar Crest College Allentown,

PA 18104, U.S.A.

and

t

IARC, 150 Cours Albert-Thomas, 69372 LYON, France

Abstract-In a household survey of

25

of the Sibundoy population, all persons reporting illness

were interviewed and examined by a biomedical team and a diagnosis was made. Intestinal disorders

were

most prevalent

in

young children, chronic respiratory disorders

in

adult men, and non-articular

rheumatism and chronic headaches

in

adult women. The same persons were independently interviewed

by an anthropologist soon afterwards. The Sibundoy classify illness by manifestations and/or aetiology_

Aetiological

beliefs

include biological, environmental, emotional, social, and mystical 4imensions, which

are explicitly recognized in their diagnostic categories. An illness may have multiple causes, and refer

ence

to mystical causation generally signifies a high level of concern with the illness as well as social

disruption. The results of the comparison between biomedical and Sibundoy diagnosis show that the

dimensions of illness recognized by the Sibundoy in their classificatory system are more comprehensive

in scope than those recognized in

the

Western classificatory system

which

is limited to disease as

such.

INTRODUCTION

Recent reviews

of

the literature in medical anthropo

logy reveal

that

the number of studies in medical

anthropology is increasing rapidly

[1.2].

These

studies most often represent one of two different per

spectives, those

that

focus on disease from the bio

medical perspective

and

those that focus upOn illness

from a cultural viewpoint [1]. Disease is viewed as a

distinct entity with the same symptoms in all indivi

duals.

The

basic ordering premise is biological. Illness

incorporates the beliefs, diagnosis, and treatment of

events of ll health as perceived by those under study.

Several dimensions may serve as ordering principles,

including the social, psychological, supernatural,

and

physical.

Only

a

few

studies have attempted to relate

native conceptions of illness to those of Western bio

medical science, while others have claimed

that

it

is

not possible to compare indigenous notions

about

causes, symptoms, and treatments to the conceptual

grid of scientific medicine [3]. Harley, a medical doc

tor, attempted such a comparison several years ago

[4].

Lewis, a mec;lical doctor and anthropologist, and

Jansen, an anthropologist cooperat ing with a phys

ician. have more recently made significant contribu

tions to this

area

[5,6]. Perhaps the largest.

numbers

of such studies are found in the literature

of

epidemio

logy

of mental health. For example, Foulks, an M.D.

and anthropologist, has studied arctic hysteria from

biological, ecological, and social perspectives

[7].

Such comparisons of native systems with Western

biomedicine are difficult, for they require the knowl

edge

of two highly specialized fields, anthropology

and medical science, utilizing theories, methods, and

goals that are often divergent.

The

research cited

above have been conducted by either individuals

t

The

history of exploitation of the Sibundoy Indians

on the part of the white settlers in the

valley

is documented

by Bonilla [11].

specialized in both fields or by anthropologists and

physicians cooperating closely.

This

paper reports an

interdisciplinary study conducted by an anthropolo

gist

and

physician

among

the Sibundoy Indians of

Colombia. t is concerned with all prevalent illness

during the period of research (as perceived by house

hold members) and compares Western biomedical

diagnoses with those of the Sibundoy. The focus is

upon

the possible dimensions of comparison of the

two systems of medicine. The cultural perspective of

Sibundoy medicine is described in depth by Seijas

[8-10].

The study here is not a duplication of her

material

but

an extension of aspects related to our

purposes. Those who wish more information from the

cultural perspective should consult her publications.

CULTURE AND ENVIRONMENT

The Sibundoy Indians (some 2000 persons) occupy

part of a small highland valley 2200 meters above

sea level in southern Colombia.

The

valley is also

occupied by a large white population (approximately

persons) and another Indian group, the Inganos

(3500-4000 persons) [9]. Although each group tends

to remain apart from the others, there is significant

interact ion between them, particularly in economic

matters.

The

non-Indian

population

dominates the

local economy and

has the best farmland.t The

Sibundoy have become acculturated in many ways

as a result of schooling, financial transactions and

other activities with the whites.

All

but a few elders

are fluent in Spanish, yet they bave continued to

maintain separate identity through traditional lan

guage in the home (Kamsa), traditional c1qthing and

separate residence.

The climate of the valley is cool (mean 16.2C and

exceptionally humid, particularly during the heavy

rainy season from June to August when the Sibundoy

feel especially vulnerable to damp coolness of


2/10

2 2 E JEAN LANGDON n ROBERT MACLENNAN

tbeir environment. They live in the marshlands

of

the

valley where the gardens are frequently flooded and

the paths deep in mud.

As

will be seen, the dampness

and

cold are perceived by the Sibundoy as causes

of

a significant number

of

disorders. .

The

Sibundoy are a horticultural group whose

staple crops are maize an d beans, although taro is

also important. Most raise chickens, ducks

and

the

native guinea pig; and some

own

cattle.

The

econo

mic

an d

medicinal use

of

plants are described by Bris

tol [12-16].

The Sibundoy have several medical

and

paramedi

cal services to choose from in the event

of

illness. The

Ministry

of

Public Health supports four bealth

centers in the valJey

an d

jointly supports a small hos

pitaJ with the Catholic Church. Each health center is

staffed by a practical nurse

an d

attended by one

of

the

two physicians in tbe valley. Consultations were

approximately SO.l5 (U.S.) in 1970, a minimal fee for

the Sibundoy. Several pharmacies provide a major

source

of

medical services, for the pharmacists give

free

medical diagnoses

and

are able to dispense

most drugs without a prescription. Another important

source for the Indians is

a white curer

curandero

who is regarded more highly than the physicians by

most of the Sibundoy. Prior to him, a Catholic priest

with substantial medical knowledge was a major

source for consultations until his death in the

19605.

.

i\mong

the Indians, there are two sources for the

dIagnosis

and

treatment

of

illness: heads

of

house

holds and the shamans. Most Sibundoy have knowl

edge

of

herbal remedies

an d

their gardens include

several herbs

an d

plants for the treatment

of

common

and

minor illnesses.

Th e

head

of

the household plays

a key role in administering treatment to family

members drawing

upon

these herbs

an d

also consult

ing the local pharmacist when necessary.

The

shamans have received formal training in the

use

of

herbal remedies

an d

the ingestion

of

the hallu

cinogen biaxii (Genus Banisteriopsis

t

is

of

major

importance in diagnostic

an d

therapeutic procedures

for illnesses believed to have supernatural causes.

Seijas' investigations revealed

that

the conceptual

scheme

of

Sibundoy aetiology is dichotomous: dis

ease can be attributed to mystical

or

non-mystical

causes [8]. This duality is similar to

that

pointed

ou t

for other groups throughout the world [17-19].

In most cases the Sibundoy are concerned with only

the immediate explanations

of

illness, which is attri

buted to some natural force, such as exposure to the

cold, lack

of

resistance, and such. As long as the con

cern with the illness remains' at this level, various

remedies

and

any of the medical practit ioners may

be utilized by the Sibundoy. However, when

an

illness

does

not

respond to treatment

or

exhibits unusual

symptoms, it is suspected of,having a mystical cause,

such as sorcery

or

evil wind .

so, the native sha

man must be called

upon

to perform the necessary

ritual in order to determine

and

counter the mystical

cause. During the ritual, he drinks the hallucinogen

Banisteriopsis

From

its visions, he interprets the exact

cause an d attempts to remove it.

The

dichotomy of mystical

and

non-mystical as de

scribed by Seijas does

not

imply that the Sibundoy

themselves recognize such a distinction.

t

signifies,

however, two levels

of

concern with regard

to

illness.

The first involves mild concern

and

a sense

that

the

iUness can be cured without the aid

of

a haman.

The

second involves more serious concern with the

outcome

of

the illness and a seeking

of

the ultimate

cause of the illness, the why

of

the event.

The

answer is most often found in the social

and

super

natural world in which the patient has caused

or

ex

perienced some disruption with his

or

her fellow

humans

or

with the spirit world.

METHODS

Biomedical

Two representative areas in the centre of the Sibun

doy hamlets were selected

and

all households were

visited by the medical team. There were

101

house

holds comprising 507 persons (25

of

the Sibundoy

population). Prevalent illness was first ascertained by

interview

of

adults

an d

older children. Two senior

male medical students then did a medical examin

ation (in the ill only) limited

to

a detailed history;

physical examination; blood haematocrit; urine sugar

and protein and

microscopy

of

faeces in selected

cases. Most

of the

ill were subsequently examined by

the physician

R M ~

especially where the diagnosis

was uncertain. Free treatment was given

bu t

the diag

nosis was

not d i s c u s ~ d at

this stage with the patients.

Anthropological

Within a few days the households

of

the ill were

visited by

an

anthropologist (EJL) who did

no t

know

the biomedical diagnosis. Directed interviews were

conducted with

an

adult member

of

the household

and or the person reported to be ill by the biomedical

team. Each informant was asked the name

of

the ill

ness, causes, history with emphasis on onset, symp

toms,

and

any treatment, including remedies. Inter

views were conducted in Spanish,

bu t

diagnoses were

recorded in

Kamsa

wherever possible.

RESULTS AND COMMENT

Biomedical diagnoses

Medical diagnoses are given by sex an d age in

Table

1.

Diarrhoea is the most prevalent illness in

both sexes, especially in young children (30.6

of

children under 5

yr).

Chronic respiratory disorders

rank second, are more frequent in adults an d a little

higher in men 15

yr an d

above)

than

in women

(12.6

an d

8.9 respectively).

One of

these was

almost certainly tuberculous

bu t

a definite diagnosis

could

not

be made due to the failure

of our

X-ray

equipment

an d

the refusal by the pat ient

of

an offer

of

free travel to the nearest X-ray facility. Non-articu

lar rheumatism (11.5 )

an d

chronic headaches

8 . ~ 1 o

were prevalent in adult women.

Th e

latter disorders

were rarely seen by

on e

of us (RML) in a large general

hospital involved in primary medical care in the Wes

tern highlands of New

Guinea

in 1957, although the

physical environment was similar.

Th e diagnoses in Table 1 are based

on

a history

of

symptoms

and

a careful physical examination. This

has inevitably limited

the

specificity

of

diagnosis. For

example, biliary colic was diagnosed in three males

on

the basis

of

a characteristic description of the pain.

Presumably this was

due to

gallstones which are not


3/10


4/10

4

E. JEAN LANGDON

and

ROBEIlT MACLENNAN

universe. It is not unusual for an illness, particularly

an acute or chronic one, to be attributed to several

causes. For example, a body

in

a state of weakness

through loss of

blood

is

predisposed to contracting

another illness. In this case, weakness

is

used as both

an illness and a cause, depending on the circum

stances. The psychological states of fright or sor

row work

in

similar

ways.

Both are illnesses

in

their

own right and also may be predisposing conditions

for other illnesses.

ur

findings support Seijas in that

etiology is dichotomous [8]. In the Sibundoy

view,

the dichotomy in the causes of disease is between

those causes which can be cured by any method of

healing and those which require the special ritual of

the shaman. The latter class are termed as ultimate

causes, for they relate the patient s illness to the social

and cosmological world giving an explanation of the

why of the

illness.

Foster has termed medical sys

tems with this kind of aetiological beliefs as persona

listic in which illness is believed to be caused by the

active, purposefu l intervention of a

sensate

agent who

may be

a supeniatural being ( a deity or a god), a

nonhuman being (such as a ghost, ancestor, or evil

spirit), or a human being a witch or sorcer) [21].

The patient

is

a victim of aggression or punishment.

As

mentioned earlier, this kind of cause represents a

level of serious concern over an illness and the specu

lation about it is begun only after several attempts at

healing the illness through other

ways.

The persona

listic system is complex, for two or more levels of

causality can be distinguished, and these levels must

be taken into account when curing.

Illnesses recognized by the informants

fail

into two

types: single-symptom illnesses and symptom

complex illnesses . the

first

type, the term describes

the major and usually only symptom, such as pie hin-

chado (swollen foot . The Sibundoy use these ad hoc

terms to name or identify any bodily ache or pain

that occurs. Simultaneously occurring symptoms in

different parts of the body are often diagnosed as

dif-

ferent single symptom illnesses rather than as mani

festations of one disease, although patients may

believe the ailments to be related (one may cause the

other). In the second type, the term implies to a set

of culturally recognized symptoms. The illness is

recognized as having several manifestations. Many of

the illnesses of this kind divide into sub-classes, and

the diagnosis in these cases depends on the symptoms

present and the presumed cause.

The listing of folk illnesses below reflects the order

ing principles utilized by the Sibundoy. The most pro

minant one is anatomy, and the list reflects those ill-

nesses that are perceived by the Sibundoy as having

common locations. Some have a cover term used

by

the Sibundoy, such as

pu/nwnes

or

lungs. Others do

not, and we have substituted English terms. The link

ing of the disorders, regardless of the cover term, re

flects the Sibundoy classification. The exception to

this are those under miscellaneous , which includes

the illnesses only reported one or two times in the

sample. The order of the categories, on the other hand

is a reflection of the order of prevalence in which

these illnesses

were

reported. The second ordering

principle refers to illnesses classified by aetiology. An

illness category may reflect both. So/tura (diarrhoea)

is

classified as a kind of stomach ailment. The sub-

classes of so/tura are classified by cause, such as from

worms or

fever.

A few diseases are not classified

by

body location, but primarily

by

cause. These include

those generally attributed to emotional states and

mystical causes.

ILLNESSES CLASSIFIED

BY

ANATOMY

AND AETIOLOGY

Est6mago;Stomach

Almost all abdominal disorders are considered

d r

de

eSlomago (stomach ache), the illness most

often reported. It is a symptom-complex illness which

divides into various sub-classes, which may be either

single-symptom or symptom-complex.

D r

de esto-

mago sub-divides into several single-symptom-iIlness

and one symptom-complex, sollura (diarrhoea), which

is

further classified

by

aetiology into: lombrices

(worms), solitaria (tapeworm), de fiebre (of fever , del

frio (of cold), de golpe (of a blow), and de mal viento

(of evil air).

Main type of soltura diarrhoea . Lombrices (intes

tinal worms) is the most common sub-class of so/tura

(Table 2 . For the Sibundoy, intestinal worms are a

natural fact of life. They believe that everyone suffers

from them from time to time and must be purged of

them. In cases of children, they often attribute the

cause to eating too many sweets. Although they know

of herbal remedies for lombrices, they rely more

heavily on patent remedies alone or in combination

with herbs. The set of symptoms for diarrhoea due to

worms includes yellow or brown diarrhoea, lack of

appetite, and a growling stomach. Most decisive

for

the Sibundoy, however,

is

the passage

of

worms after

a purge. In their absence the illness

is

reclassified as

another typ of so/tura.

Other types of soltura. These are less prevalent

(Table 2 than lombrices. Soltura de fiebre (of fever

is generally yellow, white, or brown. It is caused by

fever

one type of which corresponds to high body

temperature and causes diarrhoea. In the other type,

fever

is

believed to be localized

in

some body part;

thus, the fever of a diseased liver may cause diarrhoea.

It has also been said that the

fever

from

/ombrices

causes diarrhoea. Soltura del frio comes from the cold.

Cold generally refers to the climate. Many informants

said that during the winter, almost all diarrhoea is

from the cold. Its colour is generally green, possibly

with blood. However, the Sibundoy also recognize

that the presence of blood may be a result of a hard

blow de olpe causing bleeding. Diarrhoea with

blood is also classified by some as disenteria, a sub

class of dolor de estomago, but not of so/tura. So/tura

de mal viento is mystically caused from an

evil force

in the air. Its symptoms are discussed below with

other mystically caused illnesses.

Symptoms of soltura. Symptoms cited by the Sibun

doy that accompany all classes of soltura are vomit

ing, stomach-ache and fever. So/tura can cause other

complaints, such as estomago empachado (swollen

stomach), dolor de cabeza (headache), mareo (dizzi

ness ,

debilidad (weakness), or co/ico (colic). Diarrhoea

with blood is often considered a major cause of debili-

d d

and mareo, for they believe that an individual s

quantity of blood is limited and that loss of it will

cause weakness or debilidad.


5/10

Table 2. Sibundoy diagnoses by

e

and age

Male

Female

11 18

21 8 58

16

14

29

11

70

G-4 5 14

1>-44

45

Total

G-4

5-14 1>-44

45

Total

5

7

2

3

17

5

4

2 11

3 3 I

7

3 2

2

6

I

1

2

4

4

1 1

1

3

5

1 7

9

3 13

3

1 4

3

4

2

1

4 2 6

1 2

1 1

1

2

1

1

1 1

1 1

2 2

No. persons interviewed by anthropologist

Lombrices soltura

Soltura all others)

Dolor de estomago

Es/omago empachado

Solitaria

Vomi/o

Salida de /rasero

Colico

. Disenteria

Reumatismo

Mal

de

pulmanes

Mal

de

riiiones

Mal

de higado

Bllis

OIanda en

la boca

Granos

Sarna

De la

ma/riz

Nervios mareo

Dolor

de

cabeza

A/aques

De

cerebro

de mente

Fiebre

Gripa peste

Debl/idad

Dolor de eintura

Piquetes de corazan

Ardor en la espalda

Paperas

Venas amorliguadas

Orina

par

la

noehe

Tifo

Pique/es en el

pecho

Lovanillo

Tumor

Pie hinchado

Pie aeM/ado

Qlher minor conditions

Mal aire

Espanto suslo

Total

2

88

3

2

2

10

4

3

6

3

2

3

5

2

1

4

5

16

6

1

1

3

4

5

3

2

1

1

4

1

95

Reumatismo/

Rheumatism

Reumatismo rheumatism) is common in adult

women Tables I and

2 .

The Kamsa word for rheu

matism

is

sesna sokan sick from the cold ).

Any

ache

in a bone is usually diagnosed as rheumatism; the

most decisive symptom is the feeling of the bones

being chilled: e.g. one woman had pain and pricking

sensations

in

the chest, but since her bones ached

when they were

coli

she diagnosed her illness as reu-

matismo.

The major causes

for

rheumatism are cold

and humidity if a child

is

not kept dry,

he

will get

rheumatism ) and a weakened state

e.g.

the post-par

tum period of

forCy

days). One woman injured her

leg

and from the cooked blood she contracted reu-

malismo when she had to wade in cold water during

the winter. Two cases of reumalismo were attributed

to mystical causes: suslo fright) and sorcery.

Pulmones/Lungs

Mal de pulmones bad

in

the u n s ~ referring to

chest ailments, is most frequent among adult

men.

Several sub-classes are recognized: los seea dry

c o u g h ~ lOs

ferina coughing with blood, whooping

c o u g h ~ tos asma s t h m ~ tos vieja a deep old cough),

and pulmones

permanente

permanently damaged

lungs). The symptoms reported for lung disorders are:

cough dry or with blood); fever; pricks, pain, or

burning

of

lungs, back, arms and shoulder; and

breathing difficulties. In relation to the last symptom,

many first reported that they suffered from debilidad

and then specified pulmones.

Chest disorders are most commly attributed to the

cold or to work, particularly in men who cited carry

ing heavy loads

or

working too long

in

the drainage

canals, a communal task which each man must per

form. Also, if a man is working in the sun and it

begins to rain,

he

is susceptible to pulmones and one

informant said that the sweat mixes with the blood

and causes pulmanes if his clothes are not washed

after such circumstances. Other causes cited are a


6/10

6

E JEAN LANGDON and R08EItT

M CLENN N

blow in the chest

and

weakness due

to

lack

of

blood.

One patient claimed that mal de rinones will cause

pulmones.

Rii lones/Kidneys

Riiiones (kidneys), limited exclusively to adult males

in this sample, is characterized by pain in the back

or waist. Its causes are similar to those of

pulmones:

work, cold or a blow.

Higado/Liver

l

del higado (liver) is also believed to be caused

by work. although the major cause cited

is

too much

liquor

to

rink especially during communal work

projects mingas) on the canals. A man may pass out

and the heat from the sun is believed to damage the

liver. One case was attributed

to

espanto

or

fright.

The symptoms are: fever, a bloated s tomach or

an

ache in the liver (the centre

of

the chest), olanda

(thrush) in the mouth, yellow complexion, headaches,

and the irritability from heavy foods such as oil, meat,

corn beer or

corn

spirits. Higado can cause bilis (bile).

Skin lesions

Granos

and

sarna are lesions

that

appear on the

skin. Although believed to be caused by the rainbow,

the exact causal relationship between skin disorders

and the ra inbow was not ascertained, al though

we

suspect that it is related to spirits. One case was attri

buted to mol aire (evil air).

Matriz/Gynaecological

Gynaecological disorders, de la matriz (of the

uterus)

or

de vientre (of the womb) have two sub

classes: desarreglo (irregular period)

and

hemorragia

(hemmorrhage). In both, the menstrual period is said

to occur every two or three weeks;

but

in the laUer

heavy bleeding and severe pains occur. According to

a local hospital nurse there is a high incidence

of

menstrual problems

among

the women,

but

they

refuse to be examined by a male doctor and prefer

the woman curer in the valley town of San Francisco

to

treat such problems. Thus, it is probable

that

the

prevalence

is

higher

than

reported in

our

sample,

since the medical team was all male.

Gynaecological disorders

can

produce debilitkul

due to lack

of

blood and consequently mareo (dizzi

ness) and headaches.

The

main cause is desmando de

dieta,

i e not obeying the post-partum dietary restric

tions.

Cabeza/

H

ead

Marco. Mareo (dizziness), a complaint most com

mon

among adult women, is also called nervios

(nerves).

The

symptoms

are

headache, dizziness,

weakness, and being in a state of

susto

(fright). In

such a state, the person is easily startled by any

sudden noise or movement

and

often feels cold chills.

The major cause of nervios or mareo is believed to

be debilitJad. lack of blood or food. Fright was cited

as the cause of one case of

nervios.

Ataques. Ataques refers to attacks of unconscious

ness, accompanied by pains

and

palpitations in the

heart. There are two classes: de nervios (of nerves) and

de pena (of sorrow). Ataques de nervios occur in per

sons also suffering the symptoms of nervios. Ataques

de pena, caused by sorrow from the death of a loved

one worries, or fear, occur without the symptoms of

nervios. One patient claimed that he had suffered from

ataques ever since sorcery caused him

to

fall from a

bridge.

Two mental disorders

are

recognized: de cerebro

(described as forgetfulness)

and

enferma de

la

mente

(illness of the mind). The patient in the latter case

had

been in a mental clinic in Pasto. His relatives

reported

debilit u

due to lack of food

as

the cause.

ild disorders

Fiebre (fever), gripa, peste (common cold, flu) and

debilitkul (weakness) are terms used for mild states

of illness which are believed to make a person vulner

able to other

diseases.

The

onset

of many

chronic

or severe illnesses are attributed

to

the time when

the patient was weak

or

worked while

half

sick

medio mal) with jiebre, gripa, or peste. Cold weather

is cited as the cause of the last three.

Miscellaneous disorders

Most of the less

common

illnesses

are

single-symp

tom and

the causes

are

work. weather,

or

some

physical blow or accident. Those attributed

to

work

or weather are dolor de cintura (pain in the waist),

piquetes de corazon (pricks in the heart), ardor en

la

espalda (burning in the shoulder), paperas (lumps

forming in the veins

of

the neck), venas amortiguadas

(deadening of veins), and orina por la noche (bedwet

ting).

The

last is caused by the cold when a child

begins wetting the bed

around

5

or

6

years with no

previcus history

of

it.

Tifo (also known

as

pelador), although occurring

only once in our sample, is a symptom-complex ill

ness with an extremely high fever, severe headache,

and

a loss of hair

due

to the fever. The patients in

the sample complained principally

of

a chronic head

ache. Although they attribute its cause as the cold,

it is evidently a contagious disease (possibly typhus)

which has caused local epidemics.

Piquettes en el pecho (pricking. sensation in the

chest), lovanillo (lump), tumor (tumour), pie hinchado

(swollen foot),

and

pie achatado

(flat feet) are attri

buted

to

a blow or

an

accident. In the last two cases

the pregnant mother

had

received a blow in her

stomach in the vicinity of the child s foot. Other

minor conditions included general pains, burning of

the arms and shoulder, infected laceration, deafness

and

poor

vision.

ILLNESSES CLASSIFIED BY AETIOLOGY

Malaire

(evil air) and

espanto

or

susto

(fright) are ill

nesses classified by aetiology indicating the syndrome

falls primarily within the level of personalistic causa

tion

and

requires shamanistic treatment. l aire

comes from some unidentified supernatural agent in

the air, while espanto involves a frightening experience

that

mayor may not C?me from a supernatural agent.

Like mal aire, however, it requires the indigenous

ritual treatment

performed by a specialist in super

natural curing, preferably a Sibundoy shaman.

Although these terms specifically indicate a super

natural cause. illnesses classified by manifestation

may also be suspected to have a mystical cause. Thus,


7/10

Western biomedical and Sibundoy diagnosis 7

certain cases diagnosed as

reumatismo granos and

others previously described were attributed to sor

cery 1M aire and espanto.

The

prevalence

of

illnesses attributed to mystical

causation is low, representing 5.4

of

the total

number

of

illnesses reported

and

7.8

of

the total

number

of

patients. This small sample supports the

observations made by Seijas regarding the relative

distribution of mystically caused illnesses by sex

and

age [10]. Mal aire is limited

to

children, and three

of the five cases stemming from

espanto are

children.

In the other two cases, both patients were in a state

of

debilidad

when they suffered the fright.

On

the

other hand, in our study witchcraft only affected

adults.

Although the prevalence diseases requiring ritual

healing in our sample

is s m ~

this does not indicate

that the Sibundoy

are

not concerned with mystical

causes. Since they

are

generally associated with the

more serious

and

chronic cases, it is probable

that

the Sibundoy are

more

concerned about these dis

eases thl n with the

common

illnesses. Also, the preva

lence of these diseasees is probably underestimated

in this sample due to the reluctance of the Sibundoy

to discuss such beliefs with non-Indians.

Much of

this

stems from a mistrust

of

whites and the desire to

maintain a cul tura l barrier. Only informants with

whom good

rappon

had been established

prior

to

this sur.vey reported mystical causation. Furthermore,

since Multiple causation is common, it is probable

that many diseases

reponed

as having natural causes

might also have mystical ones which were not dis

closed.

Certain symptoms are

associated with mystical cau

sation, in particular

mal aire.

In children, chronic

and/or green diarrhoea ,

or

excessive crying, es

pecially at night, may indicate mal aire or espanto.

Among adults, headache, fever and swelling

of

the

body or limbs are symptoms of mal aire. However,

these symptoms are neither necessary nor sufficient

criteria for diagnosis of supernatural causation. t is

generally the presence of unusual symptoms or severe

illness which leads

to

suspicions of mystical causation.

The unusual

symptom

may occur

in

addition to the

expected symptoms,

at

onset

or

following treatment.

One case demonstrates this sequence particularly well.

Awoman became seriously

ill

Her husband, having exten

sive Imowledge of herbal remedies, attempted the first

treatment. Then

he

resorted to the drugstore and a white

curer

who prescribed a combination of herbs, baths, and

patent medicines.

As

her situation beca,ne more serious,

she

was taken to the doctor

in

the valley

who

diagnosed

the

disease as cancer or tuberculosis.

She

was hospitalized

for several months

in

the valley's small hospital, and the

doctor attempted to convince the

family

that she should be

taken

to a larger hospital

for

more thorough examination

and

treatment. The woman returned home, remaining bed

ridden for a few months until the family was able to trans

port

her

to the regional hospital. However, the doctors

there

said that she

was

too

far

advanced and sent her

home. The

family

then called on a local shaman and gath

ered for the hallucinogenic ritual. His diagnosis was sor

cery of such strength that it was incurable. At this point,

the family gave up in despair, recognizing the gravity of the

illness. Shortly thereafter, her coffin and a cross

were

con

structed

in

anticipation of her death, which occurred

six

months later.

S.S.M. 13/3B 0

Any disease with a sudden onset, such as a cold chill

or

sudden fever,

is

usually believed to have a mystical

cause. A child may suddenly wake up screaming or

cry when sleeping. Frightening experiences accom

panying the illness

or just

prior to it may imply mysti

cal causation. However, if the illness

starts

with

fiebre

tranquila calm fever another cause is suspected.

The response of the patient

to

treatment is perhaps

the most decisive indicator

of

mystical causation.

When

illness occurs, a member

of

the household diag

noses the disease and applies a remedy, drawing from

his knowledge of herbs and patent medicines. In the

case of failure, he may rediagnose the disease

and

try again, or he may resort

to

any of

the

medical

or

paramedical services in the valley.

treatment

continues to be unsuccessful, concern with the illness

increases and the Sibundoy begin to ask

what

is the

ultimate cause that accounts for the persistence of

the disease. At such a time, a

shaman

is requested

to

perform the hallucinogenic cur ing ceremony

to

diagnose

and

counteract ultimate cause,

making

the

patient receptive to herbal

or

patent remedies.

For

adults, the cause often stems from some disruption

in social relations, thus introducing the social dimen

sion in Sibundoy illness classification.

Comparison biomedical n Sibundoy diagnoses

Out of 507

persons in the households visited,

176

reponed illness

to

either the medical team or the

anthropologist.

Of

these 106 persons had both a

medical examination

and

an

anthropological inter

view with

an

additional

49

medical only and 21 an

thropological only. The differences were because not

all medically examined persons could be interviewed

by the anthropologist and some illnesses were first

reported to the latter . The additional cases have a

similar

pattern of

illness and

are

therefore reported

together with other cases.

The Sibundoy diagnoses in the 106 persons who

also had a medical examination are given by biomedi

cal diagnosis in

Table 3. This is

a

comparison of

two

classifications of illness in the same individuals. Many

categories show a close correspondence, due

to

the

similar descriptive

nature

of both classifications. Both

are based

on

a number

of

different axes rather

than

only one. Bodily location and cause, as noted, are

the two most

important

factors in the Sibundoy clas

sification and they

are

also

important

organizing fea

tures in the biomedical.

One

important difference,

however, is that whereas most Sibundoy illnesses are

of

the single-symptom type, a biomedical diagnosis

may

group

several symptoms as a complex related

to specific underlying cause. This is illustrated by bili

ary

colic in

Table

3. However, the biomedical diag

nosis may be no

more

than descriptive in the absence

of a diagnosed cause, e.g. chronic enterocolit is

and

chronic headache, where the Sibundoy diagnosis may

be

more

specific , perhaps

due

to their greater will

ingness

to

diagnose specific causes.

The diagnosis made in Western biomedicine often

depends

on

the context. A surgeon confronted with

acute abdominal

pain

will classify patients into those

to

be

treated

by

urgent surgery and those no t

to

be

so treated. Despite this therapeutic axis,

an attempt

will

be

made to

localize the disease (anatomical axis)

and assign if possible, a cause (aetiological axis). The


8/10

8

E

J LANGDON

and ROl tT MAClENNAN

Table

3

Comparison of biomedical and Sibundoy diagnoses

Biomedical diagnosis

Oral monilia

Biliary colic

Acute entero-enteritis

Chronic entero-colitis

Abdominal pain

Head cold

Acute bronchitis

Chronic bronchitis

Cardiac murmur

Cardiomegaly

Vaginal discharge

Menorrhagia

Lipoma

Scabies

Scattered pustules

Non-articular rheumatism

Muscular atrophy foot

Edema foot

Chronic headaches

Disorder of mood or behavior

Eneuresis

No abnormaJity detected

Number of

persons Sibundoy diagnoses

I

Olanda

I

3 Dolor de estomago I; higado 2

6 Diarrea 2; lombrices 2; other soltura 2

8 Ataques I; lombrices 12; other soltura

13

3

Dolor de est6mago

1;

lombrices

I;

1 Gripa peste 1.

2 Gripa peste 1; pulmanes

I

14

Mareo I; fiebre 1; pulmones

I

Higado

I

1

Reumatismo

1

1

Matriz hemorragia

1

2 Matriz desarreglo 1; hemorragia 1

1

Lobanillo

1

3 Granos 3

I

Sarna

1

13 Reumatismo

12;

ardor de espalda

I

1 Pie achatado I

1

Pie hinchado

1

7

Ataques

2;

dolor de cabeza ; debi idad

1;

mareo ; nervios mareo

3;

tifo

1

2 Nervios mareo 2

1

Orina por la noche

I

3 Estomago empachado 1; lombrices 1; soltura 1

biomedical diagnosis may become more specific

fol-

lowing a physical examination, the use of ancillary

tests such as microscopy and radiology, surgical inter

vention and/or response to treatment. The final diag

nosis

is

the one considered most probably in the basis

of the evidence available.

Sibundoy diagnoses also use initial diagnostic cate

gories based on symptoms. The treatment reflects a

pragmatic and basically empirical process that has

been well documented for other cultures [21-25]. A

provisional diagnosis

is

first made by members of the

household based on the symptoms present and any

significant features in the onset of illness that might

give clues as to its cause. A treatment found to be

successful for a similar illness in the past

is

first

sougHt. Thus, like Western biomedicine, the primary

axis of diagnosis

is

therapeutic. Remedies may include

herbs, patent medicines and modern drugs. The

Sibundoy usually begin with herbs and if no response,

proceed to other remedies, and health services offered

in the valley. Unsuccessful treatment leads to a revi

sion of the diagnosis as well as treatment.

In addition to

the

various persons consulted,

sources of information about disease and medicines

include advertisements on the radio most households

have a transistor radio) and in printed pamphlets

which often list the symptoms of common ailments

and suggest an appropriate brand-name drug treat

ment. Such advertisements use folk medical termino

logy and encourage self diagnosis and treatment. The

Sibundoy have also incorporated ideas on causation

from these sources. Several men, including one sha

man, produced notebooks describing the effects of

specific patent drugs used previously for various

self-

diagnosed illnesses. Thus, it can be concluded that

at least within the initial level of concern and treat

ment, the Sibundoy alter both beliefs and behaviour

based upon an objective analysis of the reaction of

an illness to a particular treatment. Moreover, sources

of change in their belief system come from the non

Indian culture. A similar process of change has been

reported in Ecuador [26].

f

the different treatments

fail

in alleviating the

symptoms, the Sibundoy will seek to discover the rea

SOil

why the illness does not respond to treatment

aetiological axis). Unlike Western biomedicine, how

ever, the search for the cause at this point indicates

both increasing concern for the outcome of the illness

and the questioning of the ultimate why of illness. f

the illness is of a serious nature, has unusual

and

severe symptoms, or fails

to

respond

to

a series of

treatments, then mystical causation is suspected.

f

so, it

is

believed that

only

the native shaman can cure

this ultimate cause, but his participation in the case

does not exclude the use of other remedies or even

other medical specialists prior to or after the ritual

curing ceremony. Beliefs about causation and treat

ment on the mystical level are less subject to empiri

cal testing. The secret knowledge of the shaman

is

used to counteract the ultimate or underlying cause

of illness rather than treat the manifestation as a dis

ease. The shaman assists understanding of the mean

ing of the illness within a wider socio-cultural context.

In this respect, the etiological dimension becomes sig

nificantly different from that of Western medicine.

t

is

in dimensions of causation that the greatest

differences appear between the two systems. The

Sibundoy,recognize several dimensions of causation

not accounted for in the biomedicine.

For

common

and easily cured illnesses, causes come from forces

in the natural environment, a run-down physical

state, or an emotional state. The causes attributed

by the Sibundoy were further analysed for two com-

, mon diagnoses. In 28 cases of chronic enteritis, 12

were attributed to the physical environment includ

ing

10

to the cold),

six

to food or drinks, nine to

unknown and one to mystical causes.

Of 17

cases

of chronic headache, six were attributed to the physi-


9/10

Western biomedical and Sibundoy diagnosis

219

\ I

environment,

and

three each to food

or

drink.

work, lack of resistance. and mystical causes. More

than one cause was often assigned per individual. or

the more serious illnesses, emotional

and

social

dimensions of illness are recognized

by

the Sibundoy.

As found by Seijas and reaffirmed by this study.

chronic and serious illnesses in .adults tend to be attri

buted

to

sorcery as the ultimate cause [10). These

cases implicate others

as

wishing ill toward the

patient and place the ultimate cause of illness within

the rea lm of social relations. Moreover.

attribution

of mystical causation

is

symbolic

of

the social disrup

tiveness

and

seriousness of the illness. Illness is a

social event, affecting

others

as well as the patient,

and this

is

particularly clear in those illnesses to

which some ultimate explanation is sought. Thus,

Sibundoy illness terms

as

found in this s tudy

not

only

reflect etiological beliefs concerning the physical.

emotional, and social

components

of illness, but also

lay signal the seriousness

of

the illness

in

certain

cases.

The

diagnostic nomenclature

of

Western medicine,

on

the

other

hand, is largely a taxonomy by patho-

logical

anatomy

[27]. I ts basic premises of causation

rest in biology and physiology. The capacity

of

emo

tions to effect the body is recognized to a limited

.extent in psychosomatic disorders, while the illness

Usto

or fright directly recognizes the emot ional

dimension. Moreover, in Western medicine, the social

aspects and consequences of disease are not included

in biomedicine as significant dimensions in disease

classification and diagnosis. although it has been sug

gested by abrega

that

this should be the new direc

tion in the

study

of disease [2).

A striking feature of the Sibundoy medicine is the

close resemblance

of

symptoms

and

aetiological

beliefs to olombian folk medicine [28-34).

or

example. diarrhoea is classified by the colour of the

excrement

[l

31 32]. and is believed

to

be caused by

cold weather, fever,

or

from worms [28). As with the

Sibundoy. physical environment has been cited in

other

studies

as

a cause

of

gynecological disorders;

hard work as a cause of lung disorders; lack of

blood

and

lack

of

resistance as causing susceptibility to

other illnesses [29, 30-33). Thus the Sibundoy disease

classification and concepts of natural causation in

general resemble those

of olombian

folk medicine

rather

than

forming a distinct

and

isolated indigenous

system. This is

not

true, however. for the many of the

personalistic causes recognized nor for the

method

of

treatment for such causes which

is

specific to the

Sibundoy and nearby indigenous groups.

The

many

differences may result from the role of treatment in

Subundoy diagnostic procedures, in which they con

sult a great variety

of

non-Indian medical practioners

for relief of symptoms not attributed to personalistic

causes.

This

suggests

that

they

are

not only adapting

western and folk medicines

as

used by the general

populace, but tha t they are also changing their medi

cal beliefs as they utilize non-indigenous cures.

DISCUSSION AND CONCLUSIONS

Although

none

of

the illnesses was severe

or

life

threatening at the time. the diagnoses were made in

a context similar to that of much

of

primary medical

care in the tropics. The medical team of physicians

and students were thoroughly trained in clinical medi

cine. and hence may have achieved more accuracy

than

is

usual in such situations

in

rural areas. Never

theless. the diagnoses listed in Table I are not specific,

especially with regard

to

aetiology. Thus, the pleural

effusion

and

some

of

the chronic bronchitis cases

may

have been tuberculous, and the specific bacterial or

parasitic causes

of

the many cases

of

chronic entero-

colitis were not elucidated.

The

International Classifi

cation of Diseases is not especially suitable for the

diagnoses of this survey, but nor is

the

International

Classification

of

Health Problems in Primary Care

[35J recently developed in a number of Western de

veloped countries.

The

modern

pharmacopoeia

con

tains a large number of drugs which require specific

diagnosis. This is often impossible in rural primary

care. especially in

the

tropics, and the usual solut ion

has been to base treatment

on

knowledge of the local

disease pat tern in a series

of

patients who have been

more extensively investigated.

The comparison between Western biomedicine and

Sibundoy medicine has revealed that Sibundoy medi

cine

is

a more comprehensive explanatory system

than western biomedicine. and that this greater com-

prehensiveness is reflected in disease categories

and

diagnosis. Although diagnosis of most common and

mild illnesses is largely restricted to the symptoms

and therapeutic goal. diagnosis and aetiological

beliefs utillized in serious illnesses place the condition

within the total social and

supernatural

universe of

the Sibundoy. On the other hand, Western biomedi

cine diagnosis and treatment remains largely restric

ted to diseases as such. Studies in social epidemiology

have revealed

that

disease is a function of social.

economic, cultural,

and

ecological factors. Yet these

findings have not been incorpora ted into the axes of

diagnosis.

Acknowledgements-We

are most grateful to Drs Carlos

Leon and Haydee Seijas for their assistance

in

preparing

the research proposal and to the laller especially

for

advice

and comments on our results. Drs Jairo Ortiz and Fer

nando Villanueva when students at the Universidad del

Valle. Cali, were an invaluable part or the biomedical team.

Much help was generously given

by

doctors and others

in the Putumayo medical services, and by the Sibundoy.

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