SARAGURO:MEDICAL CHOICES,MEDICAL CHANGES

Ruthbeth Finerman

Portraits TOC

HEALTH, ILLNESS, AND CULTURE

Health is a mirror to culture. Since it is so basic to survival,the ways that societies conceptualize health and respondto sickness tell us a great deal about the challenges they

face in adapting to a setting, and the diverse strategies theyemploy to cope with these challenges. They also reveal a society’smost deeply held values, beliefs, and practices, and lend insightinto the process of culture change.

My research into illness and healing in the Andes spansnearly two decades. The long-term focus of my research is theindigenous community of Saraguro, comprising Quichuandescendants of the Inca who today populate the southern high-lands of Ecuador. Over the years I have witnessed how Saragurosadopt and modify medical innovations obtained through contactwith neighboring groups and with Spanish and mestizo (mixed-blooded) colonists. What emerges from this exchange is a rich,contemporary mixture of old and new health customs.Ethnographers often decry contact and change as threats to cul-tural image. For Saraguros, though, the very ability to incorporateinnovation into tradition is a hallmark of the persistence andvitality of their culture and their healing traditions. At the sametime, while Saraguros are receptive to many medical innovations,some features of care have resisted pressures for change. Forexample, families continue to rely on mothers to treat nearly allcases of illness in the household.

Sickness threatens individuals, families, and society as awhole. Consequently, groups make massive efforts to maintain orrecover health and constantly search for new ways to resolvehealth problems. As groups adopt innovative healing conceptsand procedures they also spur change in other spheres of culture,introducing new technologies, products, social roles, beliefs, val-ues, and expectations.

THE STUDY OF HEALTH

People are concerned about their health and readily discussissues of sickness and curing. The health issues individuals raiseilluminate their ideals and expectations; however, they may notbe aware of their most common and serious health threats. Forinstance, individuals might voice concerns about risk of violence

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yet they might actually be at much greater risk for accidentalinjury. Personal concerns reveal cultural perceptions about thenature of violence, while measured risks for injury illustrate howpopulations might ignore or minimize other health priorities.This makes the topic a popular if challenging one for researchers.Health studies need to strike a balance between popular assump-tions and statistical risks.

Health studies also have to distinguish between hypotheticalsituations and actual behavior. For instance, individuals usuallyclaim that they follow their doctor’s orders when, in reality, theyregularly disregard diet regimens, medication schedules, andinstructions about exercise, smoking, and alcohol consumption.

The best way to distinguish hypothetical cases from realbehavior is to combine research strategies, collecting data from avariety of sources. General interviews produce preliminary dataon health and treatment ideals. Follow-up interviews help detectsubtle variations or changes in attitudes that emerge with timeand fresh experiences. Over the years I have repeatedly inter-viewed more than 350 Saraguro women and numerous tradi-tional and nontraditional health providers on a range of issues,using structured surveys, informal questioning, and group dis-cussions that produced extensive information on health con-cepts, curing practices, and changes in medical traditions overtime.

Participant-observation is an especially valuable strategy forlearning how people actually manage health and healing. Thisprocess provides first-hand exposure to illnesses and to the out-come of different treatments. Communities are usually quitereceptive to the participatory technique because it frees individu-als to demonstrate, rather than merely describe, healing proce-dures. Personal experience with the participant-observationprocess is illustrative, if rather humbling. Saraguros tired of sim-ply recounting their healing traditions in interviews showedobvious delight whenever I fell ill, since my suffering offered rareopportunities to demonstrate their skills. On some days Saragurowomen lined up outside my door, patiently awaiting their turn toply me with a battery of remedies for my headcolds, tarantulaspider bites, and mortifying if brief episodes of diarrhea. Whilesickness was certainly unpleasant and subjecting myself to theministrations of numerous healers felt decidedly awkward, theseexperiences yielded better research results than did an entire yearof surveys and interviews.

Many women also took pains to teach me family curing pro-

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cedures. A few eventually confided that they considered mytraining essential after reasoning that my pale skin, my laboredbreathing at high elevations, and my comparatively light buildand childless condition demonstrated obvious incompetence inmanaging my own health. They feared, perhaps quite reasonably,that I would never survive fieldwork without intervention andintensive training. Thus, for my own good I was accorded oppor-tunities to assist with cures in order to learn how to recognizeand respond to illness.

THE CONTEXT OF HEALTH

IN SARAGURO

Health and sickness are intimately linked to the physical and his-toric context of a population. Saraguro’s environment poses man-ifest health risks, but at the same time offers a rich body of thera-peutic resources. Historical events, particularly contact with otherpeoples, exposed Saraguros to innovations that shape currenthealth-related attitudes and behaviors, and provided access toalternative treatment options.

Saraguro is nestled in an intermontane basin in the Andes.This chain of volcanic mountains runs the length of Ecuador, sep-arating the country’s hot, humid coastal strip by the Pacific Oceanfrom the tropical rainforests of the Amazon interior lying to theeast. The residential community of Saraguro and its surroundingpasture lands are located at elevations of eight thousand totwelve thousand feet above sea level. The area supports a some-what moist, cool-to-temperate climate that graduates to a colder,windier, and drier climate at the highest elevations. Theseextremely high-altitude plateaus, called the altiplano or paramos,are largely unpopulated and are primarily used to graze cattle.

Saraguros divide their labor between crop cultivation andlivestock husbandry. Crops consist largely of corn, beans, pota-toes, barley, wheat, and squash. Families often till several fieldsat different elevations, allowing them to grow a range of cropssuited to distinct soils and climates. All family members over theage of five participate in cultivation. Children help to plant,weed, and harvest crops, while adult women also handle heavierdigging with mattocks. Plowing, a highly strenuous activity that

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is regarded as an art, is most often undertaken by adult males,although some Saraguro women have also mastered this skill.Corn is a prized crop and the name Saraguro in the Quichua lan-guage means “land of corn.” Not surprisingly, the corn harvesteach May is the focus for a major celebration in the community.

Many families raise a small number of chickens, pigs, guineapigs, and goats to supplement their diet or their income, but mostpastoral labor is devoted to herding cattle and sheep. Cattle hus-bandry is usually managed by men, who tend herds that are keptat high elevation pastures and transport the cattle to markets inlarger cities. Saraguro women also use milk from these herds tomanufacture cheeses that are sold throughout the province.Sheep are raised for their wool, which Saraguros use to fabricateclothing for the household.

Locals maintain a unique dress pattern little changed sincethe seventeenth century, making Saraguros, like many indige-nous communities in the Andes, distinctive and easily identifi-able. Both men and women wear their long hair in a single braidthat they plait in a complex style from numerous small hairstrands. Saraguro males wear short pants, a tunic called a cushma,and a blanket-like cloak called a poncho, all made from wool.Women wear hand-embroidered blouses, sets of embroideredand pleated wool skirts called anacos and pulleras, and woolenshawls or sarapos held by antique silver shawl pins called topos.When they attend church, market, and holiday celebrations,Saraguro women adorn themselves with very large antique silverearrings that hang down to their shoulders, and beaded necklaceswoven into fans that drape around their shoulders. Saraguros arenever without their hats. Most wear a simple fedora in either adark wool or a woven straw that is then painted white, but onspecial occasions many wear a traditional white wool hat with awide, flat brim. Because Saraguro clothing is made from hand-spun and handwoven wool, women spend much of their timespinning on hand-held spindles and men pass their eveningsweaving on traditional backstrap looms. All Saraguro woolensare dyed a deep blue-black color, which legend claims is inmournful tribute to Atahualpa, the last Inca ruler, who died at thehands of Spanish conquerors.

Social organization preserves a number of traditions. MostSaraguros are bilingual, speaking both Quichua and Spanish.During the 1960s the Quichua language approached extinctionbut has since been revived through a series of educational pro-grams. Saraguros describe themselves as devout Catholics,

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although they retain many pre-Christian concepts such as a beliefin nature spirits like the sun, the rainbow and winds, and theprevalence of supernatural forces like evil eye, soul loss, andmagical fright. The community is organized into a system ofwork groups known as mingas, which cooperate in the manage-ment of any community-held lands, maintain roads and irrigationditches, and supervise the construction of communal buildings.Families also foster powerful alliances through kinship and mar-riage. Saraguro women retain their family surname and their ownlands and property after marriage, which gives these women adegree of financial independence that is rare in the Andes.Children receive both their maternal and paternal surname andinherit through both family lines. Many marry within their ownbarrio or local neighborhood. This permits offspring to remainclose to their parents and allows families to combine their forcesfor labor and production. In recent decades, though, Saraguro hasexperienced a population surge that has reduced the availabilityof land for homes, crop cultivation, and grazing. As a result, thetraditional pattern of extended households has begun to erode asyoung Saraguros migrate to the tropical lowlands in search ofgrazing lands, or to cities in a quest for wage labor opportunities.

Saraguro’s ecology and production systems present a rangeof health risks. A few common threats include parasitic infectionfrom livestock, unpurified water, and the absence of sewage andwaste systems; rabies from dog bites; hypothermia from exposureto the cold climate; respiratory infections aggravated by openhearths with wood fires; and influenza, whooping cough,measles, and tuberculosis promoted by confined sleepingarrangements.

Saraguro’s ecosystem and network of social relationshipsoffers health opportunities as well. The environment supports arich and relatively diverse food supply, making malnutrition rel-atively uncommon in this population. The diverse ecology of theregion also supports a tremendous variety of medicinal plantspecies that residents exploit for nearly all health conditions. Inaddition, extended religious, kinship, and community ties offeraccess to a safety net of labor and financial resources for individ-uals requiring emotional support and material assistance in timesof sickness.

Saraguro’s history, like its environment and social organiza-tion, has also shaped health. During the Incan Empire (A.D.1476–1534) Saraguros were conscripted to operate a way stationthat serviced the Incan highway that ran through the Andean

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highlands. The Inca also compelled them to supply tribute in theform of labor, crops, and gold excavated from regional mines.After Spanish conquest in the sixteenth century, Saraguroretained the obligation to offer labor, taxes, and supplies to colo-nial authorities. During this period colonists of Spanish descentappropriated most of the land in Saraguro’s administrative cen-ter. These colonists, locally known as Whites, or Blancos, continueto dominate the town. Still, indigenous Saraguros preserved theirownership of farming and grazing property surrounding thetown; most other indigenous peoples in the Andes lost their landsduring the colonial period. Historically, Saraguros did not materi-ally benefit from contact with other populations. Instead, thecommunity’s energies and resources were exploited, first byIncan and later by European colonial powers. This experiencereinforced values of self-reliance and autonomy, and fostered adegree of resentment and suspicion of outsiders that has beenextended to all forms of external intervention, including the intro-duction of innovative health services. As it will become clear,Saraguros resist many new medical programs because they areseen as a threat to their culture and independence.

THE MEANING OF HEALTH

The more cosmopolitan, biomedical viewpoint on health differsfrom that of Saraguros in two principal ways. First, the biomed-ical model draws a distinction between conditions affecting themind and those affecting the body, while Saraguros see mind andbody as integral and mutually interactive in health. Second, bio-medicine tends to create the impression that health and diseasecomprise entirely separate states, so that someone is either prob-lem-free or suffers from some pathological condition, whileSaraguros, like many other non-Westernized populations, regardhealth as a more complex and inconstant ideal.

Mind-body dualism, or separating diseases into physical andmental disorders, is a hallmark of contemporary biomedicine.Physical complaints such as pain or dysfunction are nearlyalways attributed to organic causes like trauma or infection.Potential psychological triggers like stress or depression tend tobe discounted or minimized, as is the impact of physical diseaseon emotional well-being. Similarly, mental illnesses are infre-

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quently linked to biology, and those cases ascribed to organic ori-gins are usually reclassified and treated as physical dysfunctions.

Saraguros do not distinguish between physical and mentalillness. Rather, all conditions are seen as inseparable and interac-tive. Here, experience and emotion have an equal footing withinfection and contagion as risk factors. Sorrow, anger, and frightappear as threatening as bacteria, accidents, and viruses.Moreover, Saraguros contend that harmful emotional states giverise to physical disorders, as when anger produces colic.Similarly, organic dysfunction impairs mental and emotionalfunctioning, as when pain fosters depression. Thus, diagnosisdemands evaluation of an individual’s emotional life as well ashis or her manifest physical condition, and treatment depends onthe holistic recovery of both mental and physical faculties.

Physicians and other biomedical practitioners also tend tothink of health and disease as contrasting states. Reality, how-ever, is rarely that simple. Individuals can be presumed healthydespite the presence of undetected disease, or ill although lackingany clear signs of disease. Moreover, a healthy or unhealthy sta-tus can rapidly change. Anthropologists like to point out thathealth and illness are filtered through cultural beliefs and expec-tations, so that the two states can actually coexist. Individualswho appear to be free of diagnosed disease can still feel decid-edly ill, as in cases of chronic fatigue syndrome. Others may havea disease but feel perfectly healthy; a frequent occurrence inundetected or asymptomatic disorders like hypertension (highblood pressure), the early stages of cancer, or latent (inactive)phases of some sexually transmitted diseases. Still others learn tomanage chronic problems like arthritis, clinical depression, orheart murmurs and consider themselves otherwise healthy.Finally, some disorders such as parasitic infection are so perva-sive in some settings that such populations accept the conditionas perfectly normal.

Saraguros share this vision of health as a complex and fluidcondition. They regard health as an ideal, one that is difficult toachieve and virtually impossible to sustain for very long. Theynote that people always seem to suffer at least some minor ail-ment and that everyone eventually experiences serious illness.Several characteristics combine to form the Saraguro definition ofhealth. Some features are fairly predictable, particularly theabsence of physical pain and emotional distress. However,Saraguros also describe other less typical qualities as essentialcomponents of good health, including an ability to work, har-

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mony within family and community, and freedom from bothsupernatural and natural illness agents.

Andean populations often equate work and physical activitywith health. Most of these groups produce their own food anddepend on physical labor for survival. Individuals here cannotturn to social services for assistance if incapacitated. Saragurosoften use the refrain that one works or one goes begging and hun-gry. So it is not surprising that they prize energy and endurance,and view physical activity as a broad health indicator.

Saraguros describe social harmony as another elemental fea-ture of health. Since Saraguros presume that emotional and phys-ical processes interact to shape illness, they reason that anger,sorrow, or suffering brought on by discord could yield both psy-chological distress and physiological disorders. They report thatinterpersonal conflicts produce ailments ranging from head andstomach aches to insomnia, fatigue, and susceptibility to infec-tion; symptoms not uncommon to anyone who has experienced atension headache, upset stomach, or lowered disease resistancefollowing trauma. This link between conflict and illness providessecondary benefits in terms of social control because Saragurofamily members and acquaintances feel compelled to conform tosocial expectations and conventions to avoid the adverse healthconsequences of disobedience and hostility.

While work and social cohesion are important, Saragurosregard the suppression of harmful forces within the realms ofnature and the supernatural as essential to health. Concepts ofnatural and supernatural blend historic and contemporary influ-ences on beliefs about illness.

Natural illness agents include infection, injury, aging, anddietary deficiency, as well as the belief in humoural forces, awidespread concept in Central and South America. Saragurosassert that two humours, comprising heat and cold, persist inmutual opposition. The qualities pervade the physical environ-ment and the human metabolism. They are not exclusively associ-ated with temperature; rather, they exist in all things, includingcolors, climates, seasons, plant and animal life, and emotionalstates. Balancing hot and cold components in personal diet, dress,emotions, and physical activity protects health, while any excessor sudden change in humoural status produces illness.

Heat can be caused by strenuous activity, overexposure tosunlight, excessive consumption of hot foods like red meat, pep-pers, and oranges, or by hot emotions like anger and passion.Heat imbalances induce disorders such as fever, infection, andcolic. Cold may be produced by extreme inactivity or sleep, expo-

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sure to cold winds or water, overconsumption of cold foods likesugar, fish, and rice, or by cold emotions such as sorrow and apa-thy. Cold causes ailments such as chills, bronchitis, sterility, andmost cases of diarrhea. Cases of hot or cold humoural imbalancereceive allopathic treatment; that is, an excess of a humour likeheat is gradually countered by the opposing quality of cold torestore equilibrium. This process is actually quite delicate; sud-den exposure of hot ailments to extreme cold can worsen mattersand induce a dangerous chilling known as resfrio. Rapid warmingof a cold disorder produces a risk of excessive heat, called gan-grena.

Saraguros attribute some illnesses like evil eye (mal ojo), soulloss (espanto), magical fright (susto), and envy sickness (envidia) tothe deliberate action of supernatural agents, particularly witchesand spirits. Cases are actually relatively rare, but children are themost common victims. Infants and children are consideredweaker and more vulnerable to supernatural powers, and theirvery youth is said to make them the targets of envy. Supernaturaldisorders often produce varied and unpredictable symptoms, andthe cause may go unrecognized at first. Cases are usually attrib-uted to supernatural causes only after more conventional diag-noses and treatments fail. This is especially common when aseemingly healthy individual falls ill, when onset is sudden andthe condition deteriorates rapidly, when a collection of symptomslacks conformity with more mundane syndromes, when previ-ously effective treatments are exhausted without success, orwhen unusual events like a mystical or frightening experienceprecede or coincide with the onset of a mysterious illness. Suchcases are treated by freeing the patient from spirit influences. Thisis achieved by cleansing, luring or frightening a spirit away fromthe victim through various treatment combinations, includingteas, lotions, baths, steam vapor, purges and emetics, sprays,scents, or powerful prayers and incantations.

Saraguros say one can detect health and sickness from a num-ber of observable signs, including skin tone, energy level, and,most critically, fatness. Ruddy, red skin and active behavior sug-gest vitality. Weight is a crucial index of health and prosperity.Saraguros complement each other by noting how fat, or gordo,they have grown, and mothers consider it the ultimate compli-ment to hear their children described as fat. Indeed, Saraguros arepuzzled by North America’s emphasis on slimness, which mostsocieties equate with emaciation, wasting, and disease. Saragurosdo differentiate between a solid build and morbid obesity, whichthey regard as excessive but not necessarily unhealthy. Still, the

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relationship of fatness with health among Saraguros is often atodds with the nutritional counseling of biomedical practitioners.

HEALTH PROVIDERS

AND OPTIONS IN SARAGURO

Over the years many traditional and nontraditional medical assis-tance options have emerged to help Saraguros manage threats ofnatural and supernatural disorders and their varied physical,emotional, and humoural facets. The notion of a health specialistis a new one for most Saraguros, although an emphasis on med-ical specialization has accelerated in recent years, accompaniedby a marked deterioration of some curing traditions. What hasnot changed, however, is an almost fierce reliance on mothers toprovide most of the health care for family members.

The most traditional practitioners in Saraguro includeshamans or curanderos, herbalists, and midwives. These healingroles predate the introduction of Westernized biomedicine andhospital care. Traditional curing roles in Saraguro are actuallyquite informal. The healers rely on their own skills, personalexperience, and reputation rather than on formal training, licens-ing, and titles to attract clients. Nevertheless, changes such as theadvent of biomedical care create an uncertain future for some ofSaraguro’s indigenous healers.

Curanderos usually treat supernatural illnesses, especiallycases of soul loss and evil eye. They are occasionally asked toremedy other conditions, such as alcoholism, infertility, and unre-quited love. Most Saraguros are unable to specify exactly whattreatments curanderos provide, since few have consulted suchhealers. Most remedies reportedly involve cleansings, sprays, andincantations to drive out evil forces tormenting a patient.

Saraguros agree that magical healers have been known tosucceed where other practitioners fail, but most also fear and dis-trust these curers. This is because curanderos can use powers foreither good or evil and seem equally disposed to cure or cause ill-ness. Some clients seek relief from complaints, while others paycuranderos to use their magical skills to inflict illness on enemies.Curanderos do not distinguish between good and bad in theirpractices; they merely act as their clients bid. Saraguros contend

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that such healers cannot be trusted and that some curanderosconsort with dangerous spirits to achieve their powers. In actual-ity, virtually all Saraguros refer to the practitioners of magicalhealing as brujos, meaning witches. Few employ the term curan-dero, or curer. Public ambivalence and outright antagonism havediminished the status of magical healing in Saraguro and reducedthe pool of clients willing to seek such assistance. The emergenceof other innovative medical options has further decreasedreliance on curanderos. As a result, magical healing seems to be adying profession in the community. Aged curanderos are dis-abled and most have died without training apprentices, so thatfew remain in practice today.

Herbalists treat both natural and supernatural disorders.Treatment, as one could expect, emphasizes the use of medicinalplant preparations such as teas, baths, plasters, and sprays, aswell as advice on diet and healing foods. Saraguros rarely consultthese specialists because most residents already possess extensiveinformation about medicinal plants. Most consultations occuronly after individuals exhaust their own knowledge or whenunusual or chronic conditions arise.

Midwives, known as parteras in most of Ecuador, assist inreproductive health issues. In Saraguro, the formal title of parterais virtually unrecognized. Instead, residents simply describe theseproviders as local women who have raised many healthy off-spring, or as women with a great deal of experience and skill inmatters of childbearing. Such women may be consulted foradvice on pregnancy, birth, and child care. Some are called toassist with difficult deliveries or to treat infertility. Most Saragurowomen prefer to manage reproductive care themselves, so mid-wives or women with such knowledge are usually sought byinexperienced first-time mothers, or if complications arise.

Access to biomedical curing options in Saraguros acceleratedin the last three decades. Pharmacists, nurse practitioners, andphysicians share qualities like formal titles, training, and licens-ing, which set them apart from the informal roles of curanderos,herbalists, and midwives. They also share a Westernized view ofhealth and illness that differs substantially from the beliefs ofmost Saraguros. This allows them to offer innovative, if some-times incompatible, diagnostic and treatment options.

In Saraguro and all of South America, licensed pharmacistsand smaller, independent druggists dispense medications with-out prescription. Pharmacies in Saraguro also stock a range ofherbal preparations and exotic imported curatives. By offering

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this combination of remedies they bridge the worlds of tradi-tional and biomedical healing. Some pharmacists also offer occa-sional advice on diet and therapy. Pharmacist recommendationsand the ability to purchase medication without prescriptionallows patients to circumvent the intermediate step of seeing adoctor.

Free advice and the availability of both herbal remedies andprescription medications make pharmacists a very popularresource for Saraguros. However, pharmacies have limitations.Druggists are poor at diagnosing conditions, especially if symp-toms are unusual or complex. Consequently, most Saraguros visitpharmacies after making their own preliminary diagnosis. ManySaraguros, perhaps justifiably, suspect that druggists might alsorecommend unnecessary drugs or more expensive brands sincethey are, after all, motivated by profit. Fewer recognize the addi-tional risk that pharmacists unfamiliar with a patient’s historymight overprescribe or sell dangerous drug combinations,although several such cases have occurred. Finally, pharmacistsdo not offer hands-on care; instead, they sell remedies that areusually self-administered. Consequently, Saraguros considerpharmacists to be suppliers rather than health providers.

Nurse practitioners in Saraguro include registered nursessent to the community to work in the government-run hospital,as well as indigenous Saraguro women trained as nurse practi-tioners who operate out of smaller neighborhood health posts.Nurses based at the government hospital mainly assist physicianswith patient care and administration. Indigenous nurse practi-tioners at health posts provide assistance with minor health com-plaints, immunize children against disease, and offer communityhealth and preventive care courses on issues like nutrition, childcare, and family planning. In many respects Saraguro nurses areculture brokers. Their shared cultural background helps themcommunicate biomedical concepts to residents in a culturally-appropriate and understandable format. However, neighborhoodhealth posts are poorly stocked and understaffed, so that nursesmust refer most cases to the hospital. Limited resources and sup-port reduce their potential impact on public health.

A few physicians in Saraguro operate private practices, butmost are medical residents employed in the government-ownedhospital. Medical students are required to provide a year of resi-dence service in a rural clinic before pursuing private practice,usually in larger cosmopolitan settings. Saraguros often complainthat this residency process continually subjects patients to unfa-

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miliar and inexperienced providers who rotate out of the commu-nity every year. A majority also emphasize the fact that mostphysicians are males, making them appear less nurturant andexperienced in healing than are mothers, who spend years tend-ing to the health needs of family members. Historically, doctorshave been outsiders to the community. A few were volunteersfrom the United States who operated a mission clinic, now closed.Currently, most are members of the Spanish-descended middleand upper classes who come from larger, more urbanized cities inEcuador. None are considered familiar with or sympathetic toSaraguro’s culture and people. Recently, one indigenousSaraguro was trained as a physician and operates a private prac-tice. While he is regarded as far more understanding of Saragurohealth needs, he remains a secondary option for many residentsbecause females are still widely regarded as more compassionateand experienced healers.

Saraguro’s hospital opened in 1978 and provides facilitiesincluding laboratory tests and some surgical procedures.However, as already noted, Saraguros can purchase medicationswithout prescription, so most circumvent physician examinationsand instructions and obtain the bulk of biomedical advice andpharmaceuticals directly from druggists.

MEDICAL CHOICE IN SARAGURO

Saraguros might easily appear overwhelmed by the sheer rangeand abundance of options for medical assistance. Nevertheless,they are remarkably consistent in their pattern of health-seekingbehavior. They select from medical alternatives by weighingtreatments likely to help against the sacrifices or costs each alter-native might exact.

Most people think of medical costs as financial, such as con-sultation fees, medication purchases, wages or productivity lostwhen work is abandoned to obtain treatment, and the cost oftransportation to consult a practitioner. However, patients faceother less perceptible costs, such as a loss of social status, expo-sure to frustrating, inappropriate, or unnecessary treatments, orthe experience of emotional trauma.

Lost social status is considered a real risk for Saraguros, par-ticularly for women, who attract gossip if they disrobe for private

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examinations by male physicians. Women also risk lost prestige ifthey employ midwives or other attendants for births, sincewomen are expected to manage delivery alone or, at most, withthe help of spouses. Women lose further status when they makethe decision to surrender control over health care.

The emotional consequences of care can also prove costly,and for many Saraguros such costs take precedence over financialconcerns. Patients everywhere are frustrated by long waits forattention and by conflicts with provider views about treatment.Unfamiliar treatment procedures, particularly those provided byoutsiders, are also disorienting and stressful for most patients.Few are versed in the technical jargon of physicians or feel com-fortable submitting to complex and often mechanized proceduressuch as physical examination, CAT-scans, and blood tests. Thestress, fear, and emotional costs of such care are compounded forindigenous Saraguros, who share neither the health values northe culture of biomedical providers. However, most Saragurosassert that many traditional practices, particularly magical heal-ing by curanderos, seem equally exotic and produce similarstress, fear, and a reluctance to seek their help.

In an overwhelming majority of cases, Saraguro family mem-bers turn to the female head of the household for medical assis-tance. Reliance on mothers as family health providers is notunique to Saraguro. In fact, it is the most common pattern world-wide. Children in any society are most likely to seek out theirmothers when they feel sick. Certainly children are unlikely toschedule medical appointments and consult directly with physi-cians or other practitioners. Husbands are similarly prone torequesting support from wives when they become ill or incapaci-tated. A wife or mother is the most reasonable health choice forSaraguros. She is immediately accessible, experienced, compas-sionate, and intimately familiar with family needs and problems.Moreover, and in contrast to nonfamily practitioners, a wife andmother is more likely to be personally concerned about kin andmore willing to do all she can to restore family health.

FAMILY-BASED HEALING

Mothers, like other traditional practitioners, gain their curingskills through informal training and experience. Women learnabout healing by assisting their own mothers with family care

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and gain extensive curing experience as they manage a broadrange of family health complaints on a daily, even continual,basis. In this process they learn to anticipate the unique signs andsymptoms of illness in offspring. Saraguro women often claimthey can detect illness even before a family member realizes he orshe is sick. Women expand their curing knowledge by sharinginformation with friends and kinswomen and by participating incommunity health courses. Consequently, many Saraguro womenexpress the opinion that they possess broader knowledge abouthealth than do more specialized practitioners in the community.

Maternal curing beliefs and practices are, in fact, among themost complex healing systems in Saraguro, combining elementsof most traditional and biomedical systems. Women possess abroader repertoire of healing knowledge since they interact withmany different practitioners, adopting techniques through thiscontact and through trial and error and experience in treatingfamily members. Women gain initial information on health andhealing as young girls, as they assist their own mothers with fam-ily care duties. They expand this knowledge base as they marryand tend their own offspring, learning to spot the signs of sick-ness and discovering effective treatments through testing andeliminating those that fail. Women further enhance their knowl-edge through information exchanges with neighbors and friendswho trade advice and recipes for effective remedies. Women alsoobtain fresh curing ideas from traditional and biomedical practi-tioners when they accompany sick family members to consulta-tions. Most women accompany children and spouses to see thera-pists, and providers usually direct their instructions on treatmentto the wife or mother, rather than to a spouse or child who needscare. As a result, women are exposed to new health views, diag-nostic procedures, illness categories, and therapies. Such informa-tion exchanges rarely occur between other practitioners, who mayjealously guard their expertise and scorn other treatmentapproaches. Thus, curanderos do not tend to consult physiciansto learn about biomedicine, nor do they meet with midwives tosecure advice on fertility care. Physicians are similarly unlikely torequest instruction from magical healers, herbalists, and mid-wives.

Family-based healing includes traditional and nontraditionalapproaches to prevention and treatment. It combines natural,supernatural, physical, and emotional elements that womenadopt from diverse medical systems and incorporate to producetheir own unique healing system.

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Saraguro mothers constantly strive to prevent illness amongfamily members. They dress children in layers of clothing to pro-tect them, as doctors and nurses advise, from the chilly climateand, as traditional healers warn, from attack by evil winds andairs. Women also contend that layered clothing preventshumoural imbalance from sudden exposure to the cold. Spouseand offspring are also reminded to wear their hats while out-doors. Saraguro women suggest that this practice protects thehead from evil winds and also shows respect for the sun. The sunwas an object of worship by the Inca. Its influence continuesamong contemporary Saraguros, who claim that the sun strikesdown the sacrilegious who demonstrate contempt by going outwith their heads bared. Infants often go naked at home, but whenmothers carry infants outside they are heavily protected fromsickness. First, the head is covered with a scarf. The baby is thenwrapped with blankets and carried beneath shawls so that he orshe remains hidden in public. Saraguro women cover weak, vul-nerable infants to protect them from cold and contagious diseasesdescribed by doctors, and to shield them from traditional threatsposed by the envious gaze of others, which might precipitate evileye or envy sickness. Finally, mothers tie red cord to the wrist orankle of each child in the belief that red color wards off witch-craft. They also caution children to burn any hair lost in combingand to bury their waste when they defecate outdoors, since hairand excrement are also used to cast spells.

Women’s main contribution to preventive care concerns diet.They supervise all meals and prepare combinations of foods thatbalance a biomedical emphasis on nutrition with more traditionalconcerns about humoural equilibrium. They mix individual foodsor add herbs and spices to balance the hot and cold qualities ofdishes. Women also protect family members from health risksposed by food taboos. For instance, women feed children withhot colics cooling foods to gradually stabilize their condition.Mothers forbid daughters to eat avocado while menstruating,believing the food’s cold nature makes it toxic during the particu-larly cold state of menstruation. I witnessed one mother whosnatched her daughter’s dish of avocado and flung it down inalarm when the girl remarked that she was menstruating.

Saraguro mothers gain lifelong experience in managing fam-ily illness and learn to spot its early signs, such as reducedappetite, changes in sleep patterns, fatigue, or fidgeting. Familymembers may also approach mothers with symptoms like nau-sea, injury, or pain. When illness is detected, mothers examine

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kin for symptoms to establish a diagnosis. They usually check forfever or subnormal temperature and further signs of pain, bleed-ing, or dysfunction. Most check the eyes, tongue, urine, and spit-tle for discoloration, and the skin for changes in tone, rashes, orswelling. Mothers question the sick about their behavior preced-ing illness, inquiring about dress, hygiene, diet, emotional experi-ences, and (for husbands) drinking and personal comportment, aswell as unusual incidents that might suggest supernatural causes.In most cases, mothers can make a diagnosis based on prior expe-rience. In those rare instances when mothers cannot identify adisorder, they may ask a practitioner to determine the problem.Even so, mothers still treat the family member themselves withhome-based remedies.

Most home-based healing combines herbal remedies withdiet, rest, and limited physical therapy. Saraguro women oftenpride themselves on their knowledge of medicinal plants. Whenasked, most can name dozens of varieties at will. Older womenwith more experience can often recall two to three hundredspecies. When asked about specific species, women are able toidentify still more plants, and describe features like growinghabits, seasonal availability, uses for specific parts such as flow-ers or leaves, preparation methods, and proper applications.Nearly all Saraguro women tend house gardens, or huertas, filledwith medicinal plants. The gardens are comparable to first aidkits, placing remedies close at hand for emergencies.

Herbal treatments are often quite simple, particularly whenfamily members suffer few symptoms. In such events remediesmight contain only one or two ingredients, like a poultice madefrom potato slices for fever, a steam bath of menthol and eucalyp-tus to treat coughs, or a tea of lemon grass, chamomile, or pep-permint for hot or cold colics. However, syndromes with complexsymptoms require greater effort. For instance, treatments for soulloss, nerves, infections, and measles can combine dozens of ingre-dients and take days to prepare, making family healing an ardu-ous, time-consuming process.

A typical case illustrates the energy and resources Saragurowomen expend on home-based curing. “Rosa’s” four-year-oldson fell ill with a fever, diarrhea, rash, and facial swelling. Atfirst, Rosa treated each complaint individually, making a poulticeto reduce the boy’s fever, feeding him herbal teas for his diarrhea,and mixing an ointment for the skin rash and swelling. Despitethese efforts, the boy’s condition did not improve and Rosa grewconvinced that her son was suffering from a supernatural ail-

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ment. She questioned the boy further and determined that he suf-fered from bao de agua, or soul loss sickness, caused by a snakethat had frightened her son and stolen his spirit. Rosa and hertwo daughters spent days collecting ingredients for her son’scure, including wild and domesticated plants and remedies fromneighbors and the local pharmacy. Treatment involved twostages. First, the boy was given a sahumar vapor bath, inhaling thesteam from a heated basin holding more than twenty aromaticingredients like menthol, eucalyptus, Spanish broom, tobacco,garlic, roses, and urine. Then the boy was given a sopla, or“blow,” using an extract boiled from nearly thirty plants such aslinseed, elder, garlic, roses, tobacco, feverfew, and mallow. Rosathen made the sign of the cross on her son’s chest, took the liquidin her mouth, and sprayed it over the boy’s skin. Rosa empha-sized that the sopla must be performed at high noon and berepeated for four days. After Rosa expended more than thirtyhours of care and attention and a month’s income to treat this oneepisode of sickness, her son recovered his soul and his health.

In most cases, Saraguro mothers administer herbal remediesin conjunction with pharmaceuticals. They believe that medica-tions also have hot or cold qualities that can alleviate individualsymptoms and correct humoural imbalances. Various brands ofanalgesic, bicarbonate, and antibiotics are the most popular andheavily used medications, but combinations can be dangerous.Some cases of drug overdose or interaction have been reported asa result of overprescription or the mixing of incompatible med-ications. It is not uncommon for mothers to administer four ormore different brands of aspirin or bicarbonate to a family mem-ber at one time. Overmedication is encouraged by the fact thatbrand names imply that they relieve specific symptoms, notbroader ailments. For instance, different aspirin brands implythat they either reduce fever, treat cold, ease pain, relax muscles,or stop infection. Not surprisingly, then, mothers administer acombination of pills to treat each of these distinct symptoms.

Saraguro mothers also feed the sick special foods selected tocorrect humoural disorders. Less often, they massage and bathesick kin, and attach red cords or amulets to deflect supernaturalagents. Perfumes and plant remedies are sometimes sprayed inthe patient’s face or on the skin to frighten off spirits.

If herbal remedies and pharmaceuticals fail, Saraguro womenmay seek assistance from traditional and nontraditional healthproviders. Rare cases of supernatural illness might be presentedto curanderos or herbalists. Midwives may manage cases of infer-

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tility, pregnancy, or birth complications. Physicians and nursesattend to most disorders that prove unresponsive to home-basedcare. However, mothers often combine the advice provided bypractitioners with additional home-based remedies, and usuallyattribute successful recovery to their own efforts, discounting anycontributions made by other practitioners.

Saraguro women are often frustrated by specialized care, par-ticularly physician consultations. Much of this frustration stemsfrom a basic conflict between the cultures and medical systems ofSaraguro women and that of providers. Mothers often disagreewith physicians on diagnostic and treatment approaches. Forinstance, mothers fear that disrobing for medical examinationsexposes sick kin to dangerous cold airs. Doctors may also advisepregnant women to eat citrus fruits and drink milk, foods thatSaraguros consider dangerous during pregnancy. Many mothersare also antagonized by doctors, who very often criticize patientsfor their reliance on home remedies, saying it causes a delay inseeking “proper” biomedical attention. Mothers who take chil-dren with diarrhea to a doctor commonly receive stern rebukesand lectures on hygiene and diet instead of the purgatives andwarm humoural remedies they expected.

It is important to note that Saraguro’s doctors often feelequally frustrated by such exchanges, which most attribute to amix of stubbornness and superstition on the part of their indige-nous patients. Unfortunately, biomedical providers in Saragurolargely resist recommendations that they modify patient treat-ment to show greater cultural sensitivity, even though culturallyappropriate care has been proven effective in encouragingpatients to seek medical advice and to obey a doctor’s orders.

INNOVATION

IN FAMILY-BASED HEALING

While Saraguro mothers are unwilling to abandon their role asfamily healers and to place family health care in the hands of tra-ditional or nontraditional providers, they eagerly adopt innova-tive ideas and resources. Medical innovations are not considereda threat to home-based curing. Rather, fresh concepts and proce-dures help to expand and revitalize more traditional approachesto family care.

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It warrants emphasis that all medical “traditions” receiveconstant revision, and Saraguro’s home-based curing system is noexception. Humoural concepts found throughout Latin Americaare considered a byproduct of conquest by the Spanish, whothemselves adopted the humoural theories of China and Greece.The notion of evil airs could derive, in part, from pre-Inca con-cepts of winds and from nineteenth-century European medicine,which attributed disease to poisonous “miasmas” or putrid airs.

Saraguro women have also cultivated home-based versions oftreatments offered by other traditional practitioners. They incor-porated shamanic practices like sprays and cleansings in homecare along with medicinal plant knowledge acquired in part fromherbalists. In other words, Saraguro’s traditional health systemdoes not reflect a medical process trapped at one point in history;instead, it comprises a successful, complex blend of therapies pre-dating the introduction of more recent, cosmopolitan biomedi-cine.

Saraguro women adopted biomedical resources as readily asthey did other more traditional therapies. They have incorporatedpharmaceuticals into their repertoire of home remedies, combin-ing medications with medicinal plants in teas, baths, lotions, andsprays. They allot pharmaceuticals a hot or cold designation onthe basis of curative properties and observable features. Womenassume that remedies that alleviate hot conditions like fever,colic, and infection are cold, while drugs that relieve colds,coughs, and diarrhea are hot. White, blue, or green coloring sug-gests a cool medication while red, orange, or yellow indicates thedrugs are humourally hot. Humoural classification determineshow medicines are used in home remedies. For instance, sodiumbicarbonate produces a “cold boil,” making medicinal plants bub-ble and churn in a pot without any heating.

In the last decade Saraguro mothers increased their use ofother resources like laboratory testing, vitamin supplements forpregnancy, infant immunizations, and powdered milk and milksubstitutes. At the same time, novel medical concepts gained cre-dence as many employed new diagnoses and illness terms. Forinstance, Saraguro women now identify diseases like parasites,cancer, whooping cough, and tuberculosis and describe theadverse effects of germs and bacteria, concepts discounted adecade ago since microscopic life forms too small to see couldhardly be considered real or particularly dangerous. ManySaraguro women also possess newly-enhanced, accurate knowl-edge of human anatomy and organ function as a result of consul-

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tations with midwives, lectures by nurses in community healthcourses, and discussions with children enrolled in biologycourses. Women welcome fresh information and new products asopportunities to expand and improve the effectiveness of home-based healing.

CULTURE CHANGE

AND REVITALIZATION

Expanded use of biomedical knowledge has not displaced tradi-tional medicine or a tenacious confidence in the value of homeremedies. Illnesses like evil air, nerves, and magical fright persist,and Saraguros consider these to be as serious as are biomedicaldisease categories. Home remedies remain the most commonform of treatment, and recovery is invariably attributed to thepotency of medicinal plant preparations. Biomedical conceptsand practices have not supplanted traditional care; instead, inno-vations have enhanced and even rejuvenated such care, expand-ing preventive care, diagnosis, and treatment options. Saraguroscan actually increase their reliance on home-based healingbecause it accommodates new concepts and procedures thatimprove the quality of care.

Biomedical care has also failed to eliminate the maternal cur-ing role in Saraguro. This might seem surprising, since such ser-vices are commonly expected to dominate all other forms of careonce they become accessible. After all, biomedicine seems to offermany advantages. Treatment is generally assumed to be moreeffective, while traditional healing is frequently dismissed assuperstition and its practitioners as charlatans. Moreover, the useof hospitals and biomedical services can potentially enhancesocial status, making clients who abandon tradition in favor ofcosmopolitan care seem progressive, modern, and enterprising.In the case of Saraguro, reliance on physicians, nurses, hospitaltreatment, and similar resources would also relieve mothers ofthe constant burden of protecting and restoring family health.

Despite these apparent advantages, indigenous Saragurosremain unwilling to abandon home-based healing. Historicevents reinforce cultural values stressing autonomy and indepen-dence. Families strive to manage health problems within the con-

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text of the household and resist external aid, including thatoffered by traditional curers like curanderos, herbalists, and mid-wives. Families particularly prefer maternal care because, as dis-cussed earlier, such providers are accessible, familiar with familyhealth needs, and far more nurturant, compassionate, and con-cerned about their patients than are other practitioners.

Saraguro mothers are equally loathe to surrender their role asfamily curer since it offers valuable advantages in terms of pres-tige. Women enjoy enhanced status in the household by virtue oftheir healing role. Their knowledge accords them power andauthority to regulate all health-related behaviors in the family,including diet, dress, work habits, and personal comportment,and they can enforce compliance by cautioning household mem-bers about the health risks of disobedience. Mothers derive fur-ther kin support, gratitude, and influence with each successfulcure. Women also achieve public status and recognition by super-vising family well-being. Female friends and neighbors compli-ment Saraguro mothers who have healthy, vigorous offspringand often seek their advice on curing and child care. By contrast,women with sick children may be targeted for gossip and ridiculefor their perceived inadequacies as family health providers. Thus,any mother who willingly cedes her healing role to traditional ornontraditional providers faces reduced family and social statusand scorn for abandoning her duties. Since the self-image ofmothers is inherently linked to their role as family healer, grow-ing pressures to shift care to biomedical providers threatensSaraguro women’s very identity.

THE FUTURE OF HEALTH CARE

Quality care does not require that populations abandon theirhealth values and popular healing traditions. For instance, tradi-tional and nontraditional medical systems successfully coexist inparts of China, India, Southeast Asia, and the Middle East. Bothsystems may benefit from this exchange. Traditional options savephysicians and hospitals from being overwhelmed by demands totreat minor or chronic complaints that can be managed effectivelywith home care. More cosmopolitan biomedical services offer analternative resource for acute and severe conditions.

Cosmopolitan care is also an unrealistic option for the manycommunities that lack physicians and hospital care. It is unrea-

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sonable to expect such populations to depend on biomedical ser-vices. Instead, basic care can be funneled through mothers andother traditional providers. Several recent international healthprograms train women and other local practitioners to superviseprevention and treatment, tracking weight in children to detectand address malnutrition, preparing and administering oral rehy-dration therapy for infants with diarrhea, distributing vitaminsupplements to pregnant women, and directing community sani-tation programs.

Mothers can be particularly powerful allies in the quest topromote long-term health improvement, since they train theirown daughters in family care and home-based curing. Motherswho are instructed in biomedical therapy can transmit these inno-vative concepts and procedures to subsequent generations,thereby perpetuating programs for years to come. To succeed,however, projects must be designed to recognize mothers andother traditional curers as opportunities rather than as threats tohealth promotion.

SUGGESTED READINGS

Belote, Linda, and James Belote. “Development in Spite of Itself: TheSaraguro Case.” In Norman Whitten, ed. Cultural Transformationsand Ethnicity in Modern Ecuador. Urbana: University of Illinois,1981, pp. 450–476. Surveys culture change and socioeconomicdevelopment in the Saraguro community since the 1960s.

Finerman, Ruthbeth. “‘Parental Incompetence’ and ‘SelectiveNeglect’: Blaming the Victim in Child Survival.” Social Scienceand Medicine 40 (1995): 5–13. Describes how medical choices forchild health are influenced by economics, physical access, andcultural beliefs and values about appropriate care.

Finerman, Ruthbeth. “The Forgotten Healers: Women as FamilyHealers in an Andean Indian Community.” In Carol McClain,ed. Women as Healers: Cross-Cultural Perspectives. New Brunswick:Rutgers, 1989, pp. 24–41. Examines the training of women asfamily health providers, curing beliefs and practices, and theimpact of the health provider role on women’s status in the fam-ily and community.

Finerman, Ruthbeth. “Tracing Home-Based Health Care Change inan Andean Indian Community.” Medical Anthropology Quarterly 3(1989): 162–174. Details the process of blending traditional curingpractices with innovative medical practices and materials to cre-

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ate a new system of health care that bridges cultures and valuesystems.

Finerman, Ruthbeth, and Ross Sackett. “Saraguros.” In JohannesWilbert, ed. Encyclopedia of World Cultures, vol. 7: South America.New York: G.K. Hall/Macmillan, 1994, pp. 293–295. Offers ageneral ethnographic description of the population.

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Portraits TOC