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1 Tracy J. Andrews Department of Anthropology Central Washington University Vickie Ybarra Robert Woods Johnson Foundation Fellow, Political Science University of New Mexico L. LaVern Matthews Department of Anthropology Portland State University For the Sake of our Children: Hispanic Immigrant and Migrant Families Use of Folk Healing and Biomedicine _____________________________________________________________________________________ This article documents beliefs among Hispanic immigrant and migrant families in central Washington State about the etiology, symptomology, and appropriate treatments for illnesses experienced by their young children. Similar information was gathered fr om health care staff at several area biomedical facilities. We integrate data from the childhood health project and the authors' previous research to refine the ethnomedical knowledge base and assumptions about the impact of migration histories and accultu rative forces on Hispanic health belief systems and therapeutic decision making. The analysis is situated in the region's political economic context, dominated by agribusiness, which reveals the enmeshed structural forces that influence the children's heal th care. We conclude that only when cultural and structural factors are considered in concert, can these approaches most effectively contribute to understanding family responses to childhood illness at local community levels as well as at broader analytic scales, and to the development of culturally relevant and effective health care. [ ethnomedicine, m igration histories c hild health Hispanic healing t herapeutic decision making ] _____________________________________________________________________________________ S ome [illnesses] are not of the clinic. [ Josefina ] ***** Y ou take them to t he doctor and they say that ... [the children] ... are fine. The [doctors] don't give them anything There aren't doctors that believe [in] this haven't ever told [doctors that I massage my children] because I know when they have empacho and I massa ge them that takes care of it. [ Victoria ] ***** A ll the time children are affected, I am not going to go to curandero s or anything like that. All the time I think it is a better idea to seek help from the doctor [ Sara ]
2 Recently anthropological st udies have re intensified their gaze on ch ildren including parents' impact on their sociocultural and moral construction ( see Barlow and Chapin 2010; Bluebond Langer and Korbin 2007; L ancy 2008 ). A lthough currently an area of limited research, our focus is on adult decision makers' illness treatment choices for children too y oung to take action themselves. Hispanic 1 children are the fastest growing U S ethnic subgroup and our research area in central Washington State is characterized by a longstanding and growing Hispanic population The introductory quotes reflect family participants' choices in seeking effective therapies for sick children, with a focus here on gastrointestinal illnesses. They reveal both shared cultural knowledge of Hispanic folk healin g and variation in whether it is used T his study assesses sources of variability in local Hispanic family responses to childhood illness in a pluralistic health care setting where both biomedical and folk healing are available. Several approaches within m edical anthropology offer potentially relevant explanatory tools ; most specifically we draw from ethnomedical and immigrant health research as well as critical theory. The first quotes indicate there are conditions that biomedical healers cannot treat ef fectively, with a specific reference to one folk illness, empacho (indigestion or a gastrointestinal obstruction). Victoria notes that she has learned and administered a required massage treatment for empacho ; in other cases the skills of a sobador (massa ge specialist) or a more general and powerful folk healer, a curandero may be required. Sara clarifies that Hispanic families may prefer biomedical healers and we asked participants why they selected specific pathways in caring for their sick children. Me dical pluralism has been widely documented and generally one medical system (biomedicine in this study) is dominant (Leslie 1980; and see Capps 1994; Kamat 2008 ; Lehmann 2008 [ orig. 1985 ] ; Poss and Jezewski 2002). Explaining the complexity of reasons why and how patients make choices among different available systems worldwide, and discerning patterns, is a continuing challenge (Baer 2011). Erickson (2008:107), among others, concludes that variation in both knowledge of and belief in traditional healing systems within cultural groups, is largely based on education and acculturation level." Thus, Sara's preference for biomedicine in treating her children's illnesses might reflect a longer residence in the U nited S tates and greater familiarity with, and b elief in, the efficacy of biomedicine. The longstanding and varied immigration histories of Hispanic families in our study area provided an opportunity to assess the relevance of this assumption. Our research also highlights the significance of social netw orks, and clearly as more than economic safety nets (Vasquez Leon 2009). In designing this project, we followed closely two general goals of ethnomedical research: ( 1) understanding the learned cultural meanings and treatments associated with illness exp eriences ; and ( 2) medical translation or how emic perspectives of one group (micro level) can contribute to a broader (macro level) understanding of how to improve health care delivery (Erickson 2008 ; Good 1994; Green 1999; Kleinman et al. 1978; Low and M erry 2010 ; Nichter and Lock 2002:1; Quinlan 2011: 383 38 4; Sobo 2011:10 12 ). Building on our previous research and professional health care work in the community, we knew that folk healing is a part of local Hispanic family health seekin g behavior (Andrews 2001; Andrews et al. 2002 ). However, Garro (2000) identifies intracultural variation in understandings about illness, particularly in postmodern contexts of increasing globalization, as a key challenge to the continuing relevance of disease causation theor ies that are often based on information several decades old. Ethnomedical research to date has focused on adults managing
3 their own health care and we argue that readjusting the lens to examine adult therapeutic decision making for children can both help refine the knowledge base and address childhood health iss ues from new perspectives ( Granich et al. 1999; Miller 2011 ; Ryan and Martinez 1996 ). Critical medical anthropology emphasizes an additional component of our participants' lived experience global, national, and regional political economic forces that may impinge on family therapeutic decision making and options for their children's health care (Baer et al.1997; see Farmer 1999; Singer 2007). In biomedically dominant contexts, lack of access has oft en been identified as creating structural barriers to use of both traditional and biomedical treatments. Locally, Hispanic families have access to folk healers and ethnopharmacology as well as to biomedical services, including a network of migrant health c linics that serve low income families in the region However hegemonic power and structural constraints are often exerted more subtly (Baer et al. 1997:14; Kamat 2008). Here, we examine how local power dynamics in biomedical care settings and the agribusi ness dominated economy permeated Hispanic families' treatment decisions for their young children. We assess when and how both cultural and structural factors impinge on the lived experiences of families and biomedical staff as they seek to receive and pr ovide the most effective health care for the children. I ndividually however, neither ethnomedical nor critical theory adequate ly capture s the complexity in the families' lived experiences or the context in which they make decisions about their children's health care. Background Th is project developed in collaboration with the regiona l migrant health org anization and its satellite cl inics (referred to here as the Migrant Health Clinic [MHC] ) and other programs serving local Hispanic populations E thnomedicine and Immigration Histories Hispanic or Latino ethnomedical beliefs regarding a range of illness conditions have been documented in various cultural and geographical settings However Hispanic com munities in c entral Washington S tate wh ich have histories of transnational immigration for over a century have received little attention Also, juxtaposing biomedical and immigrant beliefs about the same illness is uncommon in the many recent studies of ethnomedical systems worldwide ( Baer 2011:419 ; C havez 2003:208). We use this approach to uncover overlaps and discordance between Hispanic immigrant families and biomedical practitioners in beliefs about illness transmission and prevention The discordance can create a barrier to biomedical health care use beyond simpl e access; the overlaps may provide options for developing treatment options that families find most effective. The varied nationalities and cultural belief systems included in broad categories such as Hispanic ethnomedicine render gener alizations about the beliefs of individual s questionable (Glazer et al. 2004; and see Garro 2000 ; Weller and Baer 2001; Weller et al. 1993 ). T here is an ongoing need for ethnomedical research to both update information to assure its relevance for contempor ary settings and to clarify distinct ions between symptoms and Hispanic folk illnesses linked to different beliefs about causation and transmission (Weller et al. 2002). This holds true for childhood gastrointestinal illnesses, wherein diarrhea may be ident ified as a distinct
4 condition, or as a symptom associated with several Hispanic folk illnesses (Kendall et al. 1990; Ryan and Martinez 1996; Weiss 1988 ). For example based on their multi site study of intracultural variation, Weller et al. (2002:452 45 3) report that susto is seen as a fright induced sickness with regional variat ions in symptoms and treatments ; however, diarrhea may or may not be a related symptom. In fact, susto is not one of the four most common types of folk illnesses that are associat ed with gastrointestinal disorders in the academic literature: empacho mal de ojo (evil eye), caida de la mollera (fallen fontanel), and lombrices (worms) (Baer and Bustillo 1993 1998 ; Kendall et al. 1990; Trotter and Chavira 1997 ; Weller et al. 1993 ). 2 F amilies in our study reported s ome types of childhood gastrointestinal symptoms that would require biomedical treatment, while others associated with illnesses lik e susto and empacho ar e "not of the clinic require folk remedies or healers and are not considered transmissible We assess how these responses fit with extant ethnomedical information on Hispanic folk beliefs and local biomedical public health approaches to managing childhood diarrhea. The acculturation process in immigrant studies focuse s on change tow ard the dominant/host culture; in the midst of debates about its usefulness i t continues to be used widely in health research in the U nited S tates to understand intracultural variation among Hispanic populations ( Brettell 2000; Fitzgerald 2 010 ; Hunt et al. 2004 ; Lopez Class et al. 2011 ) Our research foregrounds new aspects of social networks in understanding immigrant health and demonstrates the need for a longer baseline for assessing change To address these issues, we also incorporate da ta from our previous undocumented Mexican Immigrant Women (MIW) study whose initial analytic focus was on how having children influenced the women's immigration histories ( Andrews 200 0 ; Andrews et al. 2002 ). Here we include MIW information regarding t he us e of folk healers in the participants' Mexican home communities and their health care choices in the United States The Political Economic Context W e dra w on critical theory to assess impacts of participation in the regional agribusiness economy on Hi spanic family options for their children's health care However, we remained attentive to caretaker agency when making decisions to avoid depicting individuals simply as passive recipients of imposed change ( Brettell 2007:125 ; Hirsch 2003:251). A focus on immigrant agency also avoids a reification of Hispanic culture as a static, closed system, whose influence on health seeking behavior creates a fixed response determined by traditional healing beliefs In t he study area Yakima County in central Wa shington State Hispanics constitute 45% of the total population ( OFM 2008a ; U.S. Census Bureau 2010). Th ey are mainly Mexican immigrants o r migrant s 3 who have provided a critical regional labor force s ince the early 1900s, when large scale irrigation proj ects turned this rural, semi arid, shrub steppe environment into a center for agribusiness (Gamboa 1990 ). Yakima Valley is now "one of the most intensely irrigated and diverse agricultural areas in the United States ( Sell and Knutson 2002 : 7 ) and it ranks 12th in total value of all U.S. agricultural products sold ( USDA 2009 ). It also is home to the greatest concentration (28%) of immigrant and migrant farm workers and families in Washington State T he pattern of Hispanic immigration in this area has receive d litt le scholarly attention; however it fits Massey et al.'s (1994 ) characterization of behaviors and values that encouraged certain household members to emigrate as part of a long history of managing family
5 economic survival ( Andrews et al 2002 ; Gamboa 1981; Martin and Midgley 1999 ). More recently, segments of the local community have settled out and are characterized by longer term residence usually maintaining ties with their home communities Currently, Hispanic children up to age 19 make up 63 % of the overall child population in Yakima County ( Larsen 2009; OFM 2008 b ). This demograp hic trend is expected to continue nationally and has influenced t he growing emphasis on childhood health issues at the local MHC The main impetus for our focus on ch ildhood gastrointestinal illnesses was the developing concern about nitrate concentration levels above EPA safety standards found in area wells and likely connected to regional agribusiness enterprises Elevated levels of nitrates are associated with condi tions potentially linked to recurring gastrointestinal problems and specifically diarrhea in infants and young children a key target demogr aphic in this research project (Knobeloch et al. 2000 ; see Gleick 2002 ) Recurring childhood diarrhea can contribut e to both immediate and lo ng term health vulnerabilities and c ounties in central Wash ington have some of the highest incidences of diarrheal disease in the state. The MHC and regional public health programs had been communicating information about this he alth concern for about a year prior to our project. Initially, w e sought to document if and how Hispanic family participants' beliefs regarding childhood diarrheal illnesses incorporated this new causal agent and whether such information influenced treatme nt choices ( Andrews 2005). Apparently, t he issue of nitrate drinking water contamination was too nascent at the time of our study to emerge as a key component of either family or biomedical practitioners' therapeutic decision making Although this element was not available for analysis the project gen erally provided a rich database for refining ethnomedical theory and addressing community based childhood health care issues. Methods E thnographic methods were used to allow all study participants to id entify and define intersections of culture, health and socio political ci rcumstances significant to them and from their own perspectives. Qualitative open ended interview questions are particularly important to avoid oversimplifying ethnomedical models or health seeking behavior in the context of transnational migration and medical pluralism ( Brettell 200 7 ; Chavez 2003; see Foner [ 2003:25 31 ] for elaboration of relevance to immigration studies). I nitially we interviewed Hispanic immigrant adults who wer e decision makers for the health care of the family's children and they are the focus of this article. A second set of interviews was conducted with biomedical staff at the MHC; we include their information where it converges with salient topics We did n ot include interviews with expert folk healers because our focus is on how families interpret and act in situations of illness (Garro 2000:309). The Familie s Ideally, when interviewed the families had children younger than 2 years old t he age grou p most vulnerable to the immediate impacts of extended diarrheal illnesses. B y the required end of the project's fieldwork stage we had met our goal for family part icipant sample size ( N = 36). All interviews were conducted in person, and most occurred in the family's home. The family p articipants were an opportunity sample recruited through community organizations serving
6 Hispanic immigrant and migrant populations Project staff offered to conduct the interviews in either Spanish or English, and all parti cipants gave permission for audio taping to ensure accuracy in data collection. The semi structured family interview schedule included mainly open ended questions, focused on documenting the family participants' ethnomedical explanatory framework, inclu ding the causes of childhood gastrointestinal illnesses specifically when diarrhea becomes a problem beliefs about disease transmission and prevention and factors that influenced treatment decisions ( Kleinman 1980 ; Kleinman et al. 1978 ) W e did not intr oduce the names of a ny specific folk illnesses w hen we first asked about use of folk healing and many p articipants initially were reluctant to discuss the topic. We used t he concepts of stomach problems and diarrhea because they were familiar to both fami lies an d biomedical staff and because we wanted t o avoid directing the discussion from the onset to particular folk ill n e ss es Later in the interviews about their children's health, as project staff's knowledge of and interest in folk healing became appare nt most participants offered their perspectives in some detail. The Biomedical Health c are Staff S imilar information about childhood illnesses was gathered in a set of in person semi structured interviews with biomedical health care st aff (BHS) at se veral MHC fa cilities. F or these Andrews was the sole interviewer and sessions were tape recorded T he interviews occur red during a difficult transition period to a new management model for MHC patient care, and BHS participants indicat ed this likely contr ibuted to a lower than expected response from the target population of physicians. 4 A fter modifying the BHS eligibility criteria to include other providers besides MDs we exceeded the goal sample size (see sample characteristics below) The BHS i nterview schedule was composed mainly of qualitative, open ended questions about providing health care for their Hispanic patients including causes of childhood diarrhea encountered locally experiences in treating children's diarrheal illnesses, and knowledge of Hispanic folk healing and its use by patients 5 Analysis Our analysis relied heavily on qualitative interview data because of its potential for contributing deep insights into health and well being as embedded in everyday life contexts despite incon si stencies with actual behavior ( Garro 2010:473) This approach reveal ed unexpected and subtle, yet crucial, cultural and structural factors influencing change and continuity in medical belief systems and therapeutic decision making When family part icipant s chose to be interviewed in Spanish, the discussion was conducted in Spanish and then transcribed by bilingual Spanish/English speaker s Digital recording s were transfer r ed into electronic text documents used for rechecks of information with all participa nts. This also provided searchable text used in software programs specifically designed for qualitative text data content analysis, including information coding, themes analysis and pattern finding. W e selected Atlas.ti because it included a syntax genera ting interface with SPSS as well as providing an efficient and flexible categorization process for our data. We present responses with numeric data from the interviews where appropriate to analyze potentially important variability in local communities, whi le parsing out shared experiences that are impact ing treatment choices 6
7 Sample Characteristics F amily particip ants were mostly mothers with their young children (92%) The se mothers and other adult family members were the primary careta kers a common term that belies the depth of meaning associated with making decisions for their children 's health Most of the participants were the first generation of their families to live in the United States (83%), and almost all chose to be interviewed in Spanish ( Table 1) Those who chose to be interviewed in English (8%) were born in the United States and have established seco nd generation families. Table 1. Family Participants Age, Relationship to Child, and Education ( N = 36) A. Age No. B. Length of Residence i n Yakima Area No. C. Years of Education No. 20 yrs 3 <6 Mos. 3 3 or less 6 21 25 14 6 Mos. 1 Yr 8 4 6 years 12 26 30 5 1 2 Yrs 2 7 10 years 12 31 35 8 2 3 Yrs 3 11+ years 6 36 40 2 3 5 Yrs 6 > 40 yrs 4 5+ Yrs 14 Avg. yrs Education 9 Seventy two percent of the family partici pants had children ages 2 years or younger, and 95% had children 5 years or younger. In documenting employment history, "farm work" is defined here as consisting of field crop s and associated warehouse processing work. Nearly 70% of all households included at least one parent with current farm work employm ent or with farm work employment as their primary employment prior to the interview. Over 80% of this group were fir st generation families, and most of them (70%) worked as field crop laborers Caretakers in the remaining families worked in a variety of oc cupations including construction industrial labor, secretarial work, service industry, and day care work, or they worked in the home. Based on generalized data from local Hispanic service programs a representative range of Hispanic immigrant and migrant family backgrounds are included in this study (Table 1). The BHS interviewees ( n =12) represent an opportunity sample drawn from participants identified and contacted through the MHC Andrews interviewed eight care providers ( three pediatricians, two gen eral practitioners, three physician assistants ) and four support staff ( one registered nurse, two certified nurse assistants, one medical assistant ) T his modification turned out to be very useful in elucidating additional perspectives on biomedical healt h care contexts All BHS participants were bilingual except two ; however one of these had a working knowledge of Sp anish The sample included eight women and four men, and five identified as Hispanic T he average length of time participants had worked for the organization was 8 years, includ ing one with about 30 year s tenure We integrate data from this project and the authors' previous research to refine the ethnomedical knowledge base and assumptions about the impact of migration histories and
8 accultu rative forces on Hispanic ethnomedical belief systems and family therapeutic decision making a nd to reveal the enmeshed structural forces that influence health care for their children. We conclude that only when cultural and structural factors are consider ed in concert can these approaches most effectively contribute to understanding family responses to childhood illness at local community levels as well as at broader analytic scales and to the development of culturally relevant and effective health care Family Health Beliefs a nd Treatment Decisions When Is a Child Sick ? M ost basic to ethnomedical explanatory models is documenting when a health "problem" exists. In or der of increasing concern, family partic ipants identified initial problematic gas trointestinal sym ptoms as consecutive watery stools, which begin to occur with increasing frequency (diarrhea) and are associated with a child complain ing of stomach pains and losing interest in eating or drinking If the child has a fever some form of t reatment will be started immediately Family p articipants described clear indicators that the severity of the illness has increased to the point of being very problematic including: symptoms that continue into a second day, the child taking no food or li quid, and chiefly, the child vomiting or passing bloody stool. The most frequent concerns noted by the families were dehydration (66%) and a child's lack of appetite and thinness. One fourth of the participants feared that the general symptoms might deter iorat e so severely within two days that their child could die although as noted below this was not a concern shared by biomedical providers in our study Causes of Childhood Diarrhea Other factors in therapeutic decision making, and part of ethnome dical explanatory frameworks, are beliefs regarding the cause and transmissibility of an illness In the few cases wh ere participants had not mentioned them by the end of the interview, we specifically asked about the most common types of folk illnesses as sociated with gastrointestinal disorders : empacho mal de ojo caida de la mollera and lombrice s Food was the most frequently reported cause of gastrointestinal illnesses among all family p artic ipants (60%) and the main issue noted was switching a baby 's formula and using different types of milk. F ood that had "gone bad" or was not stored properly and "rich" foods or large quantities of fruit were also often described as causal factor s N ext uncleanliness and dirty hands were reported by 52% of the sam ple as linked to child hood diarrhea. Just over 40% of the families said folk illnesses were associated with their children's diarrhea; e mpacho was most frequently cited (just over 50%), followed closely by caida de la mollera and susto Although caida de l a mollera was an expected response, susto was n ot one of the prompts provided and occurred more often than expected based on the extant literature Prevention Transmission and Treatment Goals F amilie s identified specific measures to help their chil dren avoid getting diarrhea and expressed intense concern for prevent ing their children's suffering W ashing hands before eating was
9 mentioned specifically by over half of the participants ; others noted it was important to keep the children's hands out of their mouths in case they had touched dirt or other unclean objects. They also described avoiding or limiting the child's intake of certain foods and ensuring the food was well cooked and washed When asked whether children can pass diarrhea to others or get it from others, 33% said yes yet nearly half of these q ualified their response by stating diarrhea was contagious only if it was caused by a virus. Over half the participants said that diarrhea was not transmittable or they didn't think it was, with a few noting specifically that teething related diarrhea could not be passed from one child to another. Also, diarrhea associated wi t h empacho and susto w as regularly noted as not being transmi ss i ble among children ; in such cases biomedical treatments are i nadequate. Conversely, f amilies generally categorized diarrhea caused by viruses or bacteria on dirty food or children's toys as contagious in the biomedical sense; here biomedical treatments are appropriate and often sought after. For 75% of the f amilies, w hatever treatment they were using should end diarrhea by the end of the second day or it is considered ineffective. Stomach pains subsiding and resumption of eating are the associated immediate treatment goals. Family p articipants also described a commonly documented expectation that treatments should ultimately clean or clear out the child's gastrointestinal tract. In particular, for empacho the b enefits of massaging the stomach included clearing it out and this is a skill associated with folk healing. Folk Healing: S om e I llnesses A re N ot of the C linic Nearly 60% of th e family part icipants described using folk healing methods and/or healers for treatment of childhood diarrhea (Table 2) This figure is conservative since it represents use just for one childhood illness ; it does not include participants who only use herbal remedies or teas but not other types of folk healing practices. These practices cut across first and seco nd generation families as well as all age groups with family mem bers and skilled friends being consulted most frequently. Table 2. Family Participants Treatment for Childhood Diarrhea ( N = 36) A. Use Traditional Healing ( N = 36) B. Type of Traditional Healer (total responses) Do not use 15 Relative 23 Do 14 Friend 4 Use both traditional & biomedicine 7 Sobador 11 Curandero 3 Folk Herbal Remedies/Teas Yerbero 0 Use of Herbal Remedies 25 Espiritualista 0 Along with use of herbal remedies, families primarily sought out the skills of sobadores or folk healing specialists with massage and bone manipulation skills Sobadores were consulted
10 for stomach problems associated with empacho susto caida de la mollera, and mal de ojo A few families described consulting a curandero or folk healer with a broader skill set, in treating their children. However, there are circumstances where traditional healing was not appropriate (e.g. several families described their infants as being "too little for t he sobador o r "too young for mint tea" ). F amily p articipants tend ed to similarly conceptualize and respond to certain folk illnesses For e xample, t he following narrative reveals experiences shared by many families who use folk healing including: learning within the family physical manipulation of the child's back association of empacho with food getting "stuck" in the stomach and empacho being assoc iated with specific treatment decisions. M other : W hat we say is that when you have diarrhea, you have empacho When a food doesn't settle well and it ge ts stuck in the stomach, like my grandmother would say. .. I don't know if it's true. With my (son) he's the one that was cured of this. I cured him of empacho My grandmother told me how to massage his back First, here, the stomach going d ownwards and afterwards the back, and pulling the skin on his back. Interviewer : And where did you l earn? Mother: When an aunt from Texas lived here, she showed me. She was very old .. She was good at helping during births and with susto It was a gift that she had. Also s ignificant in the passage is the unprompted inclusion of susto as an illnes s r equiring traditiona l healing; s uch details within the participants' narratives provide a view of folk illnesses that are local ly importan t Herbal Remedies Participants described using a range of traditional teas or beverages for their children with manzanilla (chamomile) tea and rice water both being the most frequently used ( by about half the families ) ( see Kay 19 96 ; Waldstein 2006) The next most frequent remedy (20%) was y erbabuena ( mint tea ), and individual preferences included a lime leaf and wa ter tea, and atole (corn or rice based drink) without milk. Examples of explanations for why these work included : r ice water solidifies excrement "mint helped lessen stomach pain and "rice water provides nutrients." One participant described using a rice water tea mixed with Pedialyte, which reflects a recommendation noted below that one local physician often makes We did not focus on, or hear reports of, barrie rs to acquiring folk medicines with few exceptions they are commonly available in Hispanic communities of even modest size and duration (Chavez 2003:221). Biomedic al Health Care : When Is It Appropriate? Almost all participants described using biomedical services for a health problem although j ust over 40 % of the famil ies noted that they had taken their children to a biomedical facility for diarrhea The majority of these families first tried herbal remedies or other folk healing practices and sought biomedical treatment when they perceived that s ymptom severity was increasing and the chi ld had a fever Similar to research with other Hispanic immigrants, sever al family
11 par ticipants in this study move between both biomedical and folk healing systems (Table 2 ; and see Poss and Jezewski 2002; Reif f et al. 2003 ; Ross et al. 2011 ) I f key famil y members or friends cannot help th en specialists such as sobadores or curander o s outside the family are consulted. Such folk medical healers are often believed to have special God given skills or gifts If the traditional healing methods are not effectiv e, it is likely considered "God's will" that treatment be sought elsewhere usually from biomedical services (Perrone et al. 1989). This does not regularly undermine b elief in the potential relevance of folk healing : A s one family parti cipant explained, "i f one person doesn't work, then try another." The following interview excerpt reflects the type of treatment decision process characteristic of families who consider ed both folk healing and biomedical treatment approaches. This mother has learned massage skills that allow her to treat her own child: Interviewer : Are [ signs that diarrhea is a problem] the same for children of all a ges? Mother : Y es, I think so. It depends on what the problem i s because if it' s because of milk, it s okay, we know; but when it's because of a virus, it's different. Interviewer : Thinking about the last time (child) had diarrhea, did you notice anything in the days before that might have caused it? Mother: No, I only saw the problem with the milk. First I massaged him. After th at, I cu red him from ojo, because in Mexico you cure ojo when you see a child that has one eye smaller than the other one. Also, I cured him of this and mollera and when I saw that this didn't take care of it, I took him to the [biomedical] doctor [empha sis added ] Interviewer : What do you think would happen if y ou didn't massage children ? Mother: I think that it would [be worse for him] because y ou take them to the doctor and they say that ... [the children] ... are fine. The [doctors] don't give them anything, and the [doctors] only give the [children] suero for empacho There aren't doctors that believe [in] this. Interviewer : What do the doctors think about you doing massage? Mother : I don't know I haven't ever told them because I know when they h ave empacho and I massage them and that takes care of it because when they are empachados they don't eat. Family p articipants who used biomedical services described s uero ( serum; Pedialyte) as the most frequent treatment provided, and nearly 50% of th em said it w as the most successful treatment. When asked why suero worked, several participants described a link to preventing dehydration a view shared with biomedical health providers. Although this could be considered a socially desirable response, or official account" (Garro 2010), the interview data include folk practices such as herbal teas that are congruent with the use of Pedialyte. For the families, suero was considered effective in "clean[ing] the digestive system," an important outcome from a f olk healing perspective. However, the perceived effectiveness of suero may be influenced by the cause of diarrhea ; i n the example above, the mother indicates that suero itself will not be an effective treatment for empacho I n cont rast to reports of self administration of antibiotics being common among Hispanics groups in the U nited S tates (Larson et al. 2003; Pylypa 2001), j ust two participants listed antibiotics as the type of treatment children under 2 years old should receive when their diarrhea is a problem One of them identified her child as having been diagnosed specifically
12 with a bacterial infection at the clinic ; she said th at the antibiotic worked because it "kills the infection." N o family participa nts described requesting or expecting antibio tics themselves as an indicator that something is "really being done" for their sick child, although the o ver the counter availability of antibiotics in Mexico has been suggested as contributing to this perspective (Corbett et al. 2005 ; Gartin et al. 2010 ) Biomedical Health C are Staff : Beliefs and Practices The BHS generally emphasized wanting to provide appropriate and high quality care for their Hispanic patients, and several described coming to work with the MHC specifically because of its historica l emphasis on immigrant and migrant health care T hey reported that about half of the patients they see are young children, and about 25% of these have been brought to the clinics because of the caretakers' concerns about c hildhood diarrheal illnesses. Onl y about 5% of the cases were estimated as severe Causes of Childhood Diarrhea For Hispanic children, the BHS identified v iruses and bacteria as the most frequent causal agents (in equal numbers, n = 9), followed by parasites ( n = 6) S ingle reference s were made to other causal factors including food allerg ies teething, change in formula, and unsanitary living conditions presumably associated with poor socioeconomic status Most BHS noted that Hispanic caretakers do not offer their own explanations ab out the cause or the staff do not ask families any questions about the etiology of the children's illness. Those who learned about the caretaker s beliefs said that food was the explanation given most often which matches the most freque nt cause offered by the family parti cipants as noted above. If th e BHS did not mention caretakers folk medicine beliefs about d iarrhea, specific prom pts regarding empacho, caida de la mollera, lombrices and mal de ojo wer e offered. T he BHS identified empacho followed by susto as the most common folk illness es associated with diarr hea as did the family par ticipants. However, family part icipants described caida de la mollera as frequently as susto, while BHS did not report caida de la mollera at all. F olk Healing : Q uestions and Opportunities M ost BHS (80%) reported that they believe their Hispanic clients use some form of folk healing in treating childhood diarrhea, either alone or in combina tion with biomedical treatments. They noted that a few folk remedies potenti ally assist with their advised biomedical treatments, and specified that manzanilla tea and rice water are clear liquids that can help children stay hydrated. Several BHS also identified others that were found to be potentially dangerous and problematic be cause the y are not regulated by the FDA The MHC providers do receive training about folk remedies that emphasize s awareness of potentially lethal treatments such as greta and azarcon that contain lead and these are particularly known as remedies for empa cho (Trotter 1985). None of the doctors in this study had encountered such lethal effects of folk remedies Massaging a child's stomach, including skills of sobadores was identified by several BHS as offering some p otential benefits as long as "it s not too vigorous." One physician noted that sobadores :
13 can do a lot with relaxation and people have a really, really high belief that it's not just the touching or the moving of your hands, it's something else that's going on. And rubbing a child's belly in certain ways for colic, rubbing their bowels [can be effective because it is] calming. And [ I ] think a lot of childhood massage that we see in really high priced white neighborhoods are sobadores Th is same p rovider offered a cautionary note about d ehydration as an issue that is understood poorly by the general population as well a s a method to remedy the problem with families who use Hispanic folk healing: They [parents] do understand the whole concept of dehydration but just like white people, they don't understand the concept very well that dehydration doesn't mean lack of water but lack of salt water. So they give kids a lot of boiled rice water or other chamomile teas, things like that, which do help, but they can make kids' salt level go down s o far that it makes them have more vomiting. I teach people how to make chamomile Pedialyte. It doesn't matter to me if the [base liquid] is water or chamomile tea, but the grandmothers think it's the hottest thing because it respects what they believ e but it helps fix it, so it's a better practice. And so it just takes a lot longer to teach patients [emphasis added ] Yet, the BHS consistently emphasized that the limits imposed on their time with patients means such discussion s are rarely possible Challenges in Biomedical C are : R evealing D iscordance The biomedical staff were asked what they considered to be major issues for their Hispanic patients in using or seeking out biomedical therapies for childhood illnesses O ne commonly noted bar rier in health care settings occurs when providers and patients do not speak the same language. However, n o member of the staff reported hearing about p roblems with language barriers impacting patient use of such services locally, which matches family particip ant responses. This alone represents progress toward effective communication and its importance should not be underestimated Yet, f luency in Spanish may not translate to basic knowledge of folk illnesses or treatments. For example, staff members may speak Sp anish and have hear d the word empacho but they also say they don't know much about the meaning of the word or the attendant folk etiology and remedies On the other hand, h alf of the BHS report hearing that clients hav e transportation and access concerns ; they also said that occasionally money issues were raised. T he general category of e ducating parents about hand washing was described as by far the greatest challenge BHS see to effective treatment of childhood diarrhea among Hispanic families. However family participants r eport ed hand washing as the most frequently used method to help their children avoid becoming sick and preventing illness transmission This inconsistenc y between provider beliefs a nd family partici pant knowledge will be considered f urther below. S everal BHS also emphasized that some education issues related to the general population as well (e.g. how bacterial and viral infections differ and the associated limitations on treatment by antibiotics ) D iscussion
14 Adult therapeutic d ecision making for their children offers an important opportunity to r efin e the ethnomedical knowle dge base and theory and demonstrates its relevance in contemporary health care settings. An interactionist, relational analytic approach incorporating struc tural and cultural phenomenon is essential for understanding both local Hispanic immigrant treatment choices for their children and for immigrant health issues on broader scale s ( Fisher 2007: 1, 39; Hahn 1995:74; Sargent and Larchanch 2011 ) Therapeu tic Decision m aking: Rethinking Acculturative Forces and "Trust" T he complexity of factors impinging on Hispanic immigrant health in U.S. contexts of medical pluralism has resulted in a number of paradoxes in the medical literature" (Chavez 2003:206). On e example is debates about research indicat ing second generation immigrants and especially children, may be less healthy than those of the first generation ( Fitzgerald 2010). An other paradox is reflected in conflicting reports about use of traditional hea ling among Hispanic immigrant populations and whether it is remaining stable or declining. H owever, research on use of biomedicine and/or folk healing in count ry of origin is rarely linked with current medical system s use patterns W e incorporate data from our previous undocumented Mexican Immigrant Women (MIW) study to clarify why this is essential baseline information for assess ing change in ethnomedical beliefs and therapeutic processes. Although o ur current C hildhood H ealth S tudy (CHS) included famili es with much longer U.S. residence, t he proportion of families who use traditional healing ( near 70% total ; 5 8 % for childhood diarrhea ) was very similar to that found in our previous MIW study (71%) Further, a bout 20% of the CHS family p articipants spoke strongly against folk healing beliefs and practices, although these responses did not cluster within a particular age group or among the more recent immigrants as compared to longer term residents N early the same proportion of MIW participants described a longstanding and strong distrust of or disdain for traditional healers beginning when they lived in Mexico This was because healer lacked "education" and technology or because of their negative experience with a folk healer in Mexico. Le ngth of residen ce in the United States is often cited as a key variable that is positively associated with loosening ties to traditional Mexican cultural beliefs and traditions, including folk healing practices ( Holliday 2008 ; Hunt et al. 2004; Lopez 2005; Martinez 2009 ; Molina et al. 1994 ) I n our current study the use of folk healing remains fairly consistent across families with the shortest through the longest histories of U.S. or local residency I n fact, the lowest proportion of families using folk healing was amon g a group with local residence for six months or less. This challenges the assumption that use of traditional healing steadily declines over time and the MIW participants' e xperiences highlight several important complicating factors when considering a fam ily's health care choices For example, although only a few MIW participants had actually used Hispanic folk healers in the United States over half said they would if they or their children experienced symptoms that indicated folk healing treatment s were needed. Thus, t he shorter the local residence time, the greater the chance an illness will not have occurred that require s such treatment s A nother equally important issue was the mothers' lack of familiarity with local healers who they know can be trus ted. As one MIW participant explained : W e don t know curanderos locally except for what is heard on the radio about such people but we do not have confidence in them because we don t know them." This was the case even though the undocumented status
15 of the MIW study participants might have been assumed to encourage the use of less visible folk healers, rather than biomedical clinics. 7 Thus, in both of our studies a shorter length of residence in the United States did not link with use of folk healing in wa ys that reflected cultural beliefs alone In fact, families with longer residence in central Washingto n have greater opportunit ies for access through family and friends to a network of affordable and trusted folk healers Here the significance of social n etworks is highlighted and clearly as more than economic safety nets (Vasquez Leon 2009) Our research focus es on Hispanic communities in a region considered rural, which could be assumed to impact the participants' acculturation status. In contrast, Lopez (2005) reports on use of folk healers and tradit ional medicines among a group of 70 urban based Latina women (ages 20 47 years) in southern California This sample is characterized by "a high level of assimilation and some level of acculturation contributed to by their enrollment "in a rigorous profes sional [social work training] program" (Lopez 2005 : 27 ). Even among this highly assimilated sample, with long term residence in the U nited S tates Lopez concludes, "that these [folk] ... healthcare systems exist as a viable resource in Mexican American communities (2005:30 ; and see Chavez et al. 2001 ) Use of biomedicine was considered a credible option by participants in both of our studies. All of the MIW participants had some familiarity with biomedical health care during their lives in Mexico and n oted impacts of structural issues there on their treatment choices F or some participants biomedical care was free where it was available in rural Mexican settings although folk healers charged for their services ; others had the opposite experience In ce n t ral Washington, several women were connec ted to services through the MHC ; how ever for certain types of symptoms and illnesses treatment was sought through folk/indigenous healers and remedies rather than from the biomedical system. As one MIW study par ticipant noted, some conditions are not of the clinic "; other specific sets of symptoms (e.g. high, prolonged fever prolonged vomiting, blood from the nose) indicated that the use of biomedical care was most appropriate. Folk Healing and Biomedicin e: Intertwined Cultural Beliefs and Structural Constraints Family and biomedical staff narratives highlight the complex in tersections of cultural factors related to Hispanic folk illness and biomedical belief systems and the structural constraints inheren t in agribusiness and the dominant U.S. bi omedical health care system In both of our studies, family members noted symptoms that would prompt them to seek biomedical care. These contrasted with other specific symptoms that they knew would not be taken ser iously, or be treatable, by biomedical healers T hey expected to hear criticism for use of traditional folk practices in biomedical settings and several BHS noted their biomedical training and enculturation process had supported ignoring, at best, such to pics during patient appointments Generally, families described the clinic as a separate realm of health care so it would not be a relevant topic to bring up themselves Further, what the families consider a problem is often part of the normal progres s of diarrhea in the biomedical model. The BHS emphasized keeping a child hydrated, but letting the diarrhea "run its course" if no specific bacterial or parasitic causal agents are identified a process that may naturally take several days. However, Weller et al. (1993:118) documented general agreement among their participants at Latin
16 American and U.S. study sites that, left untreated empacho can lead to death. This echoes concerns of o ur family participant who worried that after tw o days, unm anaged diarr hea could be lethal, wh ereas the BHS estimate only 5% of the cases they see in children could be considered severe. Such disconnects between short term goals for treating childhood diarrheal illnesses were recognized by a number of the BHS, who cited lack of education and/or folk illness beliefs as problems associated with families bringing in children too often and too soon. Ethnomedical beliefs are not always a major issue, and for about a qua rter of the family participants they were not rel evant D espi te biomedical services being spread across the study region and in the form of several migrant health clinics a bout 25% of the family parti cipants said access problems influenced d ecisions not to use biomedical services T he BHS reported an even higher fi gure; about half of the Hispanic families the y treat voice d similar concerns Th e agribusiness labor market imposes constraints that penetrate into the fabric of therapeutic caretaker decision making for their children ; it is the primary income source for 70% of the family parti cipants For example, p articularly during harvest seasons getting a ride at a specified ap pointment time is often difficult or impossible. Family and neighbors with access to transportation may work in the fields until sunset, and if a child's diarrhea and disinterest in eating or drinking has persisted and increased during the day, only emergency rooms are likely to be open by the time transportation is available. Although there are some community based transportation programs, these often require advance notice of at least 24 hours and so are not consistent options. The MHC also has several walk in clinics that are open into the early evenings and on Saturday, but funding constraints limit their availability across its service area ( see Horton and Barker 2010 ) Further, such options belie the fact that structural violence with in migrant labor camps and work settings themselves may impede farm workers from even considering seeking biomedical health care (Benson 200 8 ). U se of biomed ical treatments for childhood diarrhea also is encouraged by institutional settings that recognize and reinforce its legitimacy. Several f amilies reported the need to meet licensed day care provider expectations as the motivation for their treatment decisi on ; state or federally supported programs often require signed documentation that a child with runny stools has been seen by a biomedical care provider. This supports current widespread public health efforts to limit the spread of infectious disease s, yet it also amplifies access challenges and may force increased use of emergency rooms Currently t he impacts of such requirements in institutional contexts, especially day care centers, is being scrutinized to ascertain whether this actually coincides with b iomedical recommendations for mild symptoms especially given its economic im pact on families (Hashikawa et al. 2010 ). T oo often the implications of institutionalized biomedical dominance are not examined and the focus shift s back to patients ; providers p erceptions of their cultural traits are often viewed as the major source of problems. The Muddled Reality of Contemporary Settings : E thnomedi cal and C ritical Approaches A re Piv o t a l Over half of family part icipants said that diarrhea was not contagio us or they didn't think it was Weller et al. (2002:467) ha ve docu mented that susto is generally not considered contagious Although not similarly described in the extant literature o ur study indicates that childhood diarrhea associated with empacho als o is neither contagious nor responsive to biomedicine. T his underscores an ongoing challenge in Hispanic ethnomedical research and theory distinguishing
17 symptoms as distinct from general folk ill ness categories (Weller et al. 2002) Weller et al. (2002) also n ote d iarrhea was not consistently linked with susto b y participants in their multi site study although it was in our project. Further, our family particip ants report that cause s of childhood diarrhea include unclean or inappropriate foods, viruses or bact er ium, and the like that are not linked to folk illnesses. D iarrhea as a distinct condition reflects a biomedical construction that may or may not correspond to folk illness categor ies S tudies of folk medical models must consider the implications of confl ating symptoms with distinct illness categor ies in ways that can obscure understanding s of therapeutic decision making (Ross et al. 2011). Hand washing was the key topic that BHS emphasized was needed in education about diarrhea contagion F amily narrat ives however, were saturated with statements that emphasized the importance of cleanliness generally, and the washing of hands food, and children's toys as important in preventing chil dhood diarrhea. The disjunction exist s between each group's ethnomedic al concepts of illness transmissibility and ha s clear implications for the spread of diarrhea among young children 8 Further, beliefs about folk illnesses do not necessarily create barriers; families demonstrated a n openness to and comprehension of the pre dominant biomedically based educational materials. The design of such materials require s specific information about what Hispanic families already know and about local ethnomedical beliefs and therapeutic decision making in contexts of medical pluralism F ew BHS said they had a good understanding of Hispanic folk healing beliefs and remedies although one described a method for combining traditional remedies with biomedical treatments The use of Pedialyte combined with a folk remedy is an example of what Buchard (2005) calls the "cultural reinterpretation" of a pharmaceutical product. This process can take place outside of biomedical control and thus raise concerns about safety ( Bledsoe and Goubau d 1985 ; Buchard 2005 ). Here the hybrid suero represent s a cooperative exchange between the doctor and caretaker that effectively contextualizes Pedialyte into an existing ethnomedical mode l and may, in fact, positively influence the "perception of its effect" ( v an der Geest 1988:343) In the short term, giving hy brid suero to children with diarrhea also addresses a common knowledge gap concerning the need for salts, not simply liquids Clearly, effective interconnections between biomedical treatments and traditional healing approaches can be designed without waiti ng for or requiring, major changes in medical belief systems (Harwood 1971 ). Beyond having appropriate ethnomedical information, effective health care for Hispanic immigrants depend s on direct communication with patients. However, t he MHC physicians rep orted that they rarely if ever have the time ava ilable for such discussions with parents of s ick children. T hus even if MHC practitioners are so inclined, structural constraints i n the U.S. biomedical health care system mean such opportunities may be lo st. Time limitations aside, however, physicians generally thought this topic was discussed by support staff, several of whom were Hispanic and so should know the appropriate questions to ask families Yet support staff also emphasized that time constraints made this impossible. Generally most BHS including support staff, indicated they did not have a more than rudimentary familiarity with folk medical systems themselves and that their biomedical training already had encouraged them to, at best, disregard folk healing practices as having little value (Holmes 2012) Younger support staff, in particular, indicated they would feel especially uncomfortable talking with older Hispanic patients about their use of folk healing.
18 Contributing to the development of culturall y relevant and effective health care has a rather long history within medical anthropology ( Clark 1959), but only more recently has a broader range of disciplines and the biomedical profession itself begun to consider the potential benefits of such efforts C hallenges exist at key junctures; family par ticipants said that they don't often discuss their use of home treatments and folk healers, and BHS providers said the y rarely have time to ask I ronically, similar to family par ticipant s statemen ts this often was not considered a relevant topic for the clinic settings The recent burgeoning of cultural competence training programs for staff in hospital and clinical care settings indicates a broader biomedical recognition of other ethnomedical bel ief systems (Chrisman 2007), although funding for such training is often vulnerable in the face of competing patient care expenses Such training often must be completed in a matter of hours or a few days, and critiques include that that the training is to o generalized and superficial. This can create a false sense of confidence in understanding other cultural perspectives and their significance for individual patient care (Bustillos 2005; Kleinman and Benson 2006). A nd if limited training /funding means ed ucation is focused mainly on worst case scenarios, such as lethal effects of a few folk remedies, then both the level of competence and the scope of cultural knowledge are deeply flawed. Although BHS training in cultural competence may be a component of th e solution, i t is insufficient without structural institutional changes that will sustain changes in practice For t he Sake o f Our Children The Future In 2003, Foner note d that hu ge recent immigration presented a challenge for anthropology as well a s other social sciences to unravel its effects in the U nited S tates and elsewhere (Foner 2003:6); a decade later transnational migration continues apace Our research r efin es theoretical assumptions about immigrant health and intracultural variation in th e context of medical pluralism and contributes to understanding change and continuity in ethnomedical belief systems Importantly, Hispanic i mmigrant families in our studies make health care choices that are not determined solely by cultural beliefs or str uctural constraints. Concentrating on one or the other, rather than taking an interactionist approach m ight provide a more parsimonious analytic focus but it would not capture the muddled reality of contemporary settings ( see Schneider 1965 ) Investig ating ad ult health care decision making for their children is a rarely used avenue for understanding learned cultural meanings and therapeutic decision making associated with illness experiences the key components of ethnomedical belief systems. T he import ance of this approach is amplified by the rapid regional and national increase in the numbers of Hispanic children. Nearly 60% o f the family parti cipants described using traditional folk healing methods and/or healers for treatment of childhood diarrhea a nd the majority of families who took children to biomedical clinic s for diarrhea problems first tried herbal remedies or other folk healing practices. Expressed through their commitment to improving their children's health, a focus on Hispanic parents' bel iefs about childhood illnesses can contribute to expanding ethnomedical knowle d ge while potentially providing additional information for address ing the health of adults. Our research also emphasizes the need for reassessing the assumed impact of migration histories on immigrant health In the context of medical pluralism, information about use patterns
19 in home setting s is an essential baseline for more accurate ly assessing ch ange and persistence in treatment patterns The use of folk healing among our stud y participants cut across fir st and seco nd generation families, all age groups, and recent immigrants as well as long term residents. In the extant literature, it is generally assumed that longer residence in the U nited S tates characterized by biomedical dominance, correlates with declining use of folk healing. Our study of participants lived experiences contradicted this expectation; in fact, those with the shortest length of residence used folk healing less than those with the longest residence histori es. Such community based research not only contributes to understanding intracultural variation in Hispanic ethnomedical models and therapeutic decision making, it also reveal s factors relevant to understanding immigrant health on broader, global scales Finally, a ssessing both the details of contagion in ethnomedical models, as well as embedded structural issues related to biomedical dominance a nd agricultural labor histories, was essential for clarifying h ow and why Hispanic immigrant families ma k e tre atment choices for their children Through j uxtaposing biomedical and immigran t beliefs, we identified important areas of discordance i n Hispanic family and biomedical practitioner beliefs about illness transmissi bility and appropriate prevention measures O ur research support s Holmes's (2012) conclusion that the culture of biomedicine and the structural limitations it imposes on th e provision of effective health care are essential components in biomedical competency training. Yet we find that ethnomedical knowledge also remains very r elevant in contemporary health care settings, and medical anthropologists are particularly well trained to design and carry out pertinent research. In some cases the ethnomedical information is already documented, but the pote ntial linkages with clinical care and medical anthropology's opportunities to contribute to more effective health care are unrealized I n many oth er cases additional information is needed ; a lthough not the primary cause o f inadequate cultural competence t raining if current information doesn t exist, it can't be used. S everal BHS suggested that further research on what the parents mean when they describe the ir child or themselves as "havi ng empacho would be useful b ecause they hear it mentioned so often in relation to diarrhea and stomach problems T his topic especially could provide an important two way educational opportunity between p atients and biomedical healers while addressing the general impression among families that discussing folk healing in t he clinic will only bring criticism However, the growing economic costs of maintaining biomedical health care were often perceived as severely limiting direct communication options even in contexts like the migrant health clinics Relying on published li terature from Hispanic immigrant studies in other locations can be helpful, but such literature does not necessarily provide information relevant in local settings Further, when limitations on cultural competence tra ining leave it focused on worst case sc enarios, its influence on providers' perspectives on folk healing and Hispanic patients may undermine effective health care An initial research goal was to assess how nitrate contamination of drinking water, as a potential new causal agent linked to dia rrhea in young children, had entered the family and/or biomedical practitioners models of illness causation and appropriate treatments. Given that nitrate water contamination was a regional issue emphasized by the MHC and other organizations, one surprisin g result was that it was not a concern for any of our study participants However, n itrate water contamination now is a major environmental health issue
20 regionally, nationally, and globally ( EPA 2011; Harter et al. 2012; Sutton et al. 2011) This is of par ticular concern for children and is potentially related to a range of health issues to which medical anthropology has a great potential t o contribute Assessing interwoven ethnomedical and structural factors af fecting both community members' and biomedical providers' illness beliefs systems and treatment decisions can play a part in not only anthropological theory but can also address this and other emerging and extant community health concerns Notes Acknowledgments We greatly appreciate the participation o f the families and biomedical health staff whose histories and experiences we recorded for this project. Staff members of the Migrant Health Clinic and several other regional social service agencies provided essential assistance with the field study segmen t of this project. We hope this article has contributed to all of their major concern s : improving health care for children. Funding for this research was provided by t he Wenner Gren Foundation (Gr.7229); the Washington State Department of Health, Environme ntal Health; and Central Washington Univers ity : Graduate Studies Program Faculty Seed Grant, and Summer Faculty Research Appointment. Anonymous reviewers and Dr. Mark Luborsky e ditor for Medical Anthropology Quarterly offered valuable suggestions and su pport 1. The common term used locally and comparable to "Latino which is in this community is considered to carry the sense of a more urban context 2. For a succinct, general introductory historical and illness specific overview see Chavez an d Torres 1995. More detailed overviews are available on empacho (Weller et a l 1993) and susto ( Rubel et al. 1984; Weller et al. 2002 ). 3. The term "Mexican immigrant" follows common usage to describe a person born in Mexico who has immigrated from Mexico and now resides in the U nited S tates It is not specific to citizenship status (someone who naturalizes would still be an immigrant) or to legal state. "Migran t refers to Mexican American or Mexican family participants who do not live p ermanently in the Yakima region but travel to work there on a seasonal basis from another home location in the United S ates ( e.g. Texas migrant laborers who come for the hop or fruit harvest seasons in the Yakima Val ley). 4. A dministratively the goal was to prioritize sta ff time to be available for patient care and to assure the sustainability of the clinic. Several clinicians emphasized that they felt pressured by this managed care approach, which provided a fairly comparable base salary with bonus incentive pay for highe r productivity. 5. H alf the interviews took place in an on site clinic room ; the others were off site for interviewee convenien ce. I nterviews lasted about 30 minutes; when possible, some continue d longer. 6. T he following guide to descriptors applies: few means 1 14%; several means 15 29%; less than half means 30 49%; more than half means 51 74%; and most means 75 99%. 7. In our MIW study, participants' lived experi ences of risk complicated the assumed distinctions betw een their initial undocumen ted/ illegal st atus, and subsequent stages of legal documentation ( Andrews et al. 2002 ). Their vulnerability is continually reinforced by reminders from adminis trative personnel that advancing through one documentation status adjustment hurdle towards citiz enship is no guarantee against revocation or denial of future applications and
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