Culture, disease, and stress among Latino immigrants

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Culture, Disease, and
Stress among
Latino Immigrants

Culture, Disease, and
Stress among
Latino Immigrants

Lucy M. Cohen
The Catholic University of America
Washington, D.C.

k
i RIlES Special Study
Research Institute on Immigration and Ethnic Studies
Smithsonian Institution, Washington, D.C., 1979

1979 by Lucy M. Cohen. All rights reserved
Printed in the United States of America

Library of Congress Catalog Card Number: 79-67153

The Research Institute on Immigration and Ethnic Studies,
founded in 1973, is a part of the Smithsonian's Center for the
Study of Man. The Research Institute focuses on immigration
flows which have been affected by legislation since 1965. It also
explicitly includes American extraterritorial jurisdictions among
its scholarly concerns.

Staff
Roy S. Bryce-Laporte, Director
Stephen R. Couch, Research Coordinator
Delores M. Mortimer, Program Coordinator
Betty Dyson, Administrative Assistant
MaryJane E. Kubler, Research Assistant
Constance M. 'Iombley, Secretary

To Isabel Sirias Garrovillas
lifelong model, friend, and immigrant

I think it can be said that there has never yet been a definition
of what is maximum medical care, and this is now in the papers
daily. Medical care is a right and not a privilege, but how much
medical care?
It is stated that since it is going to be a right there will be a
bottom level, a minimum; the maximum cannot be decided. The
president of the United States has a personal physician available
twenty-four hours a day. On the other end of the scale, a man or a
woman may be going around half dead on his feet, and won't have a
doctor at all.

(Dorothy Gill, M.D., comments from transcript, Greater
Washington Health Conference for the Spanish Speaking People,
December 11, 1971.)

Contents
List of Tables viii
Foreword xi
Acknowledgments xv
Introduction xix

1. How It Happened: Perspectives of the
Anthropologist 1
2. Latin American Popular Medicine and the Study of
Stress 27
3. Entry and Settlement of the Immigrants 57
4. Patterns of Work 101
5. Symptoms of Illness and Cross-Cultural
Communication 133
6. Syndromes of Illness and Popular Medicine 161
7. The Health Opinion Survey and Measurement of
Stress 195

8. Controlarse and the Problems of Life 227
9. Latin American Immigrants Transform Society 247
Notes 277
Appendix A. Letter of Introduction to Parents 295
Appendix B. The Research Process: Permissions and
Initial Rapport 297
Appendix C. Health Opinion Survey 299
Bibliography 303

List of Tables

1-1. Immigrants' Characteristics: by Groups, Sex,
Age, and English-Speaking Ability 15
3-1. Western Hemisphere Immigrants Admitted to the
United States, by Selected Countries of Birth,
Sex, and Selected Age, Year Ended
June 30, 1974 67
3-2. Marital Status of Immigrants 74
3.3 Location of Children, by Age Group and
Population 76
3-4. X2 Test of Independence: Location of Children
Seventeen and Under by Population 78
3-5. Location of Children, by Age of Child and Living
Situation of Immigrant Parent 79
3-6. Community and School Samples: Number of
Children in Home Country, by Age Group and
Caretaker 81
3-7. Single Persons: Household Composition 89
3-8. Married Immigrants: Household Composition 91
3-9. Single Parents: Household Composition 92
4-1. Males and Females: Education, Occupation, and
Income 111
4-2. Males and Females, by Work Status 119
5-1. Community and School Groups, by Presence or
of Absence of Health Problems 137
5-2. Consultants and Practitioners Used for Various
Types of Health Problems 139

6-1. Problems of the Blood: Types of Treatment 164
6-2. Heart Problems: Types of ITeatment 170
6-3. Digestive Problems: Types of Treatment 176
6-4. Kidney and Liver Problems: Types of Treatment 177
6-5. Hot/Cold Diseases: Respiratory Ailments and
Discomforts of the Eyesight Types of Treatment 182
6-6. Hot/Cold Diseases: Joint Pains/Muscular Aches
Types of Treatment 185
7-1. Distribution of Mean HOS Scores by Groups,
Sex, and Presence or Absence of Health Problems 204
7-2. Distribution of Stress Levels by Groups 204
7-3. All Immigrants: Distribution of Mean HOS
Scores by Age, Marital Status, and Education 212
7-4. All Immigrants: Distribution of Mean HOS
Scores by Occupation and Work Characteristics 217

FOREWORD

The Research Institute on Immigration and Ethnic

Studies was established in 1973 as part of the Smithsonian

Institution. Its objectives are to stimulate, facilitate,

and disseminate research on immigration into the United

States and its overseas jurisdictions. The Institute

has special interest in new immigrants who have entered

the country since the Immigration Act of 1965 because

this legislation has contributed to the emergence of a

dramatic new chapter in the history of immigration in the

United States.

The Research Institute views international immigra-

tion as a multifaceted process with implications for

research and policy. A sizeable proportion of new immi-

grants come from areas which in the past have not been

major sources of U.S. immigration. Many emigrate from

newly-independent or developing nations. Those who have

entered from neighboring areas such as Latin America

present new demographic and sociocultural characteristics

which have been largely overlooked. These newcomers pose

challenges for students of immigration and ethnicity, and

for policymakers. We believe that the new immigration

is not only a social and historical phenomenon; it is a

public issue as well. Consequently, in many of its own

past programs and publications, RIIES has drawn attention

to both the national and international implications of

the new immigration. The present book focuses on a

complementary aspect of the lives of immigrants -- on

their settlement in a specific urban metropolitan area

which is the typical site of residence of immigrants in

this country. The volume deals with patterns of adapta-

tion of people of Latin American heritage after entry

(legal or illegal) and with institutions of service to

the immigrants themselves, on the local and neighborhood

levels. These are some levels of concerns and experiences

that tend to be overlooked by public institutions and

the active anti-immigration and anti-immigrant establish-

ment as they operate, not only in Washington, D.C. but

throughout the nation.

The Research Institute on Immigration and Ethnic

Studies is proud to present Culture, Disease, and Stress Among

Latinos as the first publication in our monograph series.

It is the result of independent study carried out by one

of our first post-doctoral fellows during her year of

sabbatical leave from The Catholic University of America.

Culture, Disease, and Stress Among Latinos is an ethnographic study

about the lifeways of new Latin American immigrants in

Washington, D.C. The nation's capital is the scene of

scandalous raids in search of "illegal aliens" among

Latin American populations, by officers of the Immigration

and Naturalization Service. It is a metropolis known

xiii

most for its pervasive low political and high diplomatic

culture but it has received limited recognition for its

growing cosmopolitan orientation on the local and folk

levels which has resulted from the influx and activities

of immigrant and native minorities.

Washington, D.C. is a city of a most sophisticated

but still politically disenfranchised population in the

country where national and international policies take

precedence over local or urban policy. Culture, Disease, and

Stress Among Latinos addresses itself to problems of adapta-

tion, stress and illness, as well as the problems of

cross cultural communication, poverty and work in an

urban metropolitan context. It is also a study of a city

which should be viewed as a reflection on urban North

America, insofar as it reveals institutional and cultural

adversities which face new Latin residents in this country.

Dr. Lucy M. Cohen is to be congratulated for her

pioneer work, one which in another sense is part of an

established tradition of ethnographic studies on the

urban ethnic poor of which Washington, D.C. has had well-

known examples. The work reveals a serious effort on her

part to be scientific and humane. It represents a high

degree of convergence of anthropological and social work

training, university teaching and mental health research

and practice, and the sensibilities and advocacy of a

woman of Latin American identity. As such,Culture, Disease,

and Stress Among Latinos is an impressive challenge to the

negative stereotypes which the North American public has

learned to use in characterizations of the work and time

ethics, family organization, and particularly, the tradi-

tional role domains of women in Hispanic cultures. Dr.

Cohen leaves us with the need to rethink not only the

original validity of these stereotypes but also the impli-

cations of the charges represented in her findings for

the Latin American immigrants and the larger society.

We believe that the transformation of American urban

cultures will be increasingly shaped by new immigrants.

Policy makers in government and in the private sectors,

representatives of the professions and specialists in

Latin American studies, the public-at-large and the

immigrants themselves, all need to give serious attention

to the new populations who have challenged deeply-held

beliefs and values about the lives and impact of those

newly-arrived in our midst.

Therefore, we at RIIES hope our readers find Cu-ture,

Disease, and Stress Among Latinos not only informative but

useful. We thank all those who contributed to the suc-

cessful completion of this our first monograph.

Roy SimSn Bryce-Laporte

General Editor and Director

Research Institute on Immi-
gration and Ethnic Studies

ACKNOWLEDGMENTS

The research on which Culture, Disease, and Stress Among

Latinos is based was funded by grant number 21725 from

the National Institute of Mental Health, Center for the

Study of Minority Mental Health Programs. A Biomedical

Sciences Grant from the Catholic University Faculty

Research Fund supported part of the preliminary pilot

project and the final stages of data analysis.

The immigrants who participated in this study must

remain anonymous. I am deeply grateful for their collab-

oration and for their hospitality.

A number of representatives of programs in community

health and school services offered collaboration, without

which this investigation could not have been undertaken.

I. Blanche Bourne, M.D., Deputy Director of Public

Health, and Janet W. Neslen, M.D., formerly Chief, School

Health Division, District of Columbia, Department of

Human Resources and members of their agencies offered

helpful consultation. Mrs. Floretta D. McKenzie, former

Executive Assistant to the Superintendent, D.C. Public

Schools, Mr. Marcelo R. Fernandez, and Father Jose I.

Somoza, Division of Bilingual Education, D.C. Public

Schools, contributed their support during the ongoing

phases of the investigation.

His Excellency Bishop Thomas W. Lyons, former Direc-

tor of Education, Archdiocese of Washington, and school

officials in the Archiocese of Washington have offered

helpful collaboration and assistance.

I would like to acknowledge the interest and contri-

butions of Dorothea C. Leighton, M.D. In my search for

direction with the study of the sociocultural influence

on psychiatric disorder she not only provided consultation

but valuable criticism. I learned from discussions with

her, and she was an inspiring stimulus through all phases

of the research.

Regina Flannery Herzfeld, Paul Hanley Furfey and

Leila Calhoun Deasy kindly read the manuscript and

offered many perceptive comments. Roy S. Bryce-Laporte,

Director, Research Institute on Immigration and Ethnic

Studies, Smithsonian Institution, sponsored my affiliation

as Fellow of the Institute for the years 1975-1976.

During the preparation of this manuscript, the conferences

on new immigration held under the auspices of the Smith-

sonian offered broadened perspectives on the subject.

Jane Nakayama Cole was responsible for invaluable

xvii

research assistance, particularly with data coding,

special bibliographic searches, and general administrative

concerns. Carmen Fernandez undertook research with one

group of families and their children. Rita L. Ailinger

participated as an interviewer in the school parent

research phase. Mrs. Cole, Mrs. Fernandez, and Dr.

Ailinger have continued to offer strong encouragement

for the pursuit of this work to its completion.

Mary Louisa Luna was responsible for data processing

and computer analyses. Dr. Antanas Suziedelis provided

special statistical consultation for the Health Opinion

Survey Material. Cecilia Perez Bainum and Josd Luis

Restrepo Velez contributed to the refinement and testing

of the translated materials.

Mrs. Beverly McNamara efficiently typed several

versions of the manuscript. Linnea Back conducted

detailed data studies and manuscript proofreading, while

Karen Kerkering assisted with special analyses.

The painstaking cooperation of Ms. Delores Mortimer

and the staff of the Smithsonian Institution, Research

Institute on Immigration and Ethnic Studies, publishers,

has been distinctly inspiring and helpful.

INTRODUCTION

This is a book about culture and illness among

immigrants of Latin American origin who live in Washing-

ton, D.C. It describes concepts of disease and evidences

of stress in men and women who sought treatment for their

own health problems or those of members of their families.

It also discusses people who at the time of the study

stated that they did not have health problems, for much

can be learned about the physical and emotional health

of members of cultural groups by studying not only those

who report illnesses but also those who consider them-

selves to be "well." The work focuses mainly on the

lives of women because they constitute an increasingly

active force in the immigration from Latin America to

the United States.

The study of the lifeways of immigrants to the urban

centers of the United States has been a theme of central

interest to social and behavioral scientists. For immi-

grants are American history, as Oscar Handlin noted in

his classic work, The Uprooted. To discover how Latin

American immigrants think and feel, and how they act

upon problems of disease and the stresses of life, is

thus to dwell upon a familiar theme of the American
experience.
experience.

But there is growing recognition that the period

since World War II has brought new immigrants to this

country who do not fit the "ideal type" of peasant and

immigrant depicted in major works about the settlement

and adjustment of earlier newcomers. Passage of the

landmark Immigration and Nationality Act of 1965 (PL

89-236, 79 Stat. 920.) reminds us that Americans have

now chosen a policy which gives priority to what immigrants

do rather than to who they are. Skill and occupation,

rather than race and ethnic origin, are now the major

criteria for admission to the country. However, for

some regions of the world, such as Latin America, this

policy obscures the realities of what it means to enter

the United States, as shown by findings in the present

research.

Whereas the typical pioneers of immigration in the

past have been men, among Central and South Americans

today it is women who occupy a central place as leaders,

initiating a process which subsequently draws other

family members and friends to Washington. Moreover,

these women are not widows or young single persons who

venture on long voyages to the promised land. Rather,

they are mostly women who had established households in

their places of origin and then left children behind

under the care of maternal grandmothers or other kin.

The availability of relatives for child care has made

it possible for these women to engage in pioneering roles

as migrants.

Most of the men and women entered the United States

to improve their living conditions and their economic

status. Some were also motivated by a desire to join

relatives and friends or they had a commitment to work

with a preselected employer. For all newcomers, jobs

established the first line of contact with the host

society. Both the women and the men worked full time

(some "moonlighted" as well) in a broad range of semi-

skilled and unskilled positions. Partly because Latin

American women tend to have a meager formal education

they have fewer options for occupational mobility than

do their male compatriots, who are commonly better

educated.

When the immigrants in this study first entered the

United States the airports of Miami and Washington or

the U.S.-Mexican border were their first glimpses of the

new land. Airplanes link every Latin American nation

with the Miami airport; buses and cars facilitate arrival

at border points for those who have chosen to enter the

country as illegal aliens. Regardless of how they come,

however, the airplane remains a symbol of rapid communi-

cation for it enables good and bad news, as well as people,

to travel back and forth. These immigrants are therefore

not so isolated from their places of origin as were those

who came in the days of sail and steam.

xxii

Anthropologists who have conducted pioneering

investigations in Central and South America have devoted

limited attention to the transnational migrations of

these peoples or to an understanding of their lives in

such U.S. cities as San Francisco, Washington, New York,

Miami, and New Orleans. Yet these immigrants of the

1960s and 1970s are active creators of the present-day

development of the Americas. Contemporary Latino immi-

grants come from complex Third World societies which are

in the midst of change and revolution to settle in Ameri-

can cities such as Washington where the unplanned crises

of urban living threaten the stability of even long-

established residents. Latinos and Latinas bring the

optimism of newly arrived settlers who are highly moti-

vated by the wish to improve the status of the family

group. Yet they also carry a sense of realism about the

active struggles in which they have to become involved

in order to achieve a sense of mastery over difficult

life situations and social conditions in this country.

Theoretical issues and practical concerns have led

students of immigration to consider processes of settle-

ment and adjustment of newcomers. Anthropologists have

focused much of their research in this area on the study

of continuity or discontinuity of cultural traditions

and the impact of new experiences. But the cultural

beliefs and practices of these newcomers can no longer

xxiii

be single-typed as "indigenous," mestizo, "rural," or

"urban," as they have been described frequently in

literature on Latin America. Their cultural world con-

tains interwoven segments of knowledge and meaning drawn

from the many ideologies and traditions which are

impinging upon Latin America.

This mosaic of tradition is manifest in the multi-

cultural character of present-day Latino beliefs and

practices about health and disease which are a principal

subject of this study. The Indian heritage, the Spanish

tradition, patent remedies, homeopathic therapy, and

scientific biomedical tradition are all part of the

cultural background which influences the Latin American

immigrants as they strive to understand the etiology of

a specific illness and to cope with its problems. As

they face episodes of illness in Washington, Latinos

absorb new beliefs and restyle the old. This is not

always a simple or satisfactory process.

This research presents findings which highlight

cultural influences on common Latino concepts of health

and illness. The book emphasizes, in particular, links

between the management of health problems in the house-

hold and processes of consultation with caregivers from

the scientific biomedical community. It identifies the

major sociocultural factors associated with differences

in levels of stress.

xxiv

The concepts of health and disease held by newcomers

of Latin American origin have important mental health

implications. As these immigrants deal with the specifics

of each encounter with illness, they emphasize the central

role of "physical" health for the attainment of their

goals. Concepts of etiology used to interpret symptoms

of behavioral impairment are frequently linked to organic

disturbance. For example, Latinos view symptoms of stress

such as depression and anger as results of bodily dys-

function. Latino parents who receive reports of a child's

misbehavior in school frequently search for ways of

strengthening the child's blood and bodily systems, since

such measures are believed to prevent behavioral disturb-

ances. To the Latino, the concept of mental health

embodies the balance of body, mind, and spirit.

The annals of U.S. immigrant history and culture

contain relatively few known records about the experiences

of newcomers as they have dealt with the American systems

of medical care. Examination of how new immigrants

manage and cope with illness in our present-day society

can offer valuable perspectives on our own care-giving

institutions as well as on their ways of life. This

emphasis is important. In his recent work, Who Shall Live?

Victor Fuchs has rather dramatically drawn our attention

to the problem of critical individual and societal

choices which must be resolved to assist our nation in

XXV

meeting the urgent crises of medical care.2 The present

work illustrates the efforts of an anthropologist to

record the voices of Latino immigrants who, in dealing

with the health problems of their daily lives, also offer

penetrating insights into culture, disease and stress in

our own society.

This volume is directed to the attention of a varied

and wide-ranging readership. One obvious group, of course,

consists of those who want to obtain information about

the life styles and mental health problems of relatively

unknown but rapidly growing groups of Spanish-speaking

newcomers. By and large, mental health research on U.S.-

Hispanic populations has focused on Mexican Americans with

more limited attention directed towards Puerto Ricans and

Cubans. The least is known about the Spanish-speaking

people from Central and South America who constitute about

20 percent of the people of Hispanic heritage in the

United States.

This volume reports on a group of newcomers and a

group of established residents from selected Central and

South American countries. There are increasing numbers

of immigrants from these nations in the United States.

Some have become U.S. citizens; others are permanent

residents who aspire to citizenship; still others are

undocumented persons known to us as "illegal aliens."

The latter are of special concern just now. The

Domestic Council Committee on Illegal Aliens has pointed

xxvi

to economic and social issues that intensify the pressure

to emigrate from some of these countries. Hence there

are backlogs of applications for immigrant visas into

the U.S. that contribute to the stream of illegal immi-

gration. Those pressures and backlogs are not likely to

decrease in the immediate future.

Readers concerned with understanding the impact of

immigration on Latinos, and on ourselves as well, should

also find this volume of interest. In recent years

various official inquiries into the entry of immigrants

and undocumented workers have centered on the effect on

the U. S. labor market "with special concern," as the

Domestic Council Committee puts it, "that the employment

of the alien will not adversely affect wages and working

conditions of similarly employed U.S. workers." But,

"the great majority of post-1965 immigrants have entered

the U.S. on the basis of family ties to U.S. residents."3

It would seem logical, therefore, for policy-makers to

give attention to the impact of immigration on these

families. The findings in this book offer data which

contribute to understanding why Latinos enter, how they

organize their families and households, and what their

working aspirations are. It offers social and cultural

perspectives about stress-conducive situations and the

ways in which Latinos cope with these challenges.

xxvii

Finally, the book should give readers insight into

the changing values of people of Hispanic heritage. The

immigrants in this study do not fit the stereotype of the

"mafana-directed" or "present-oriented" types described

in popular works on Latin American life both in this

country and in their places of origin. The participants

in this study are careful planners, vigorously involved

in future-oriented activity for themselves and their

families. It is to be hoped, therefore, that the research

findings should contribute to more dynamic perspectives

about culture, mental health, and social change in the

lives of Latinos who are transforming themselves as they

carve new lives in our society.

CHAPTER 1

HOW IT HAPPENED: PERSPECTIVES OF
THE ANTHROPOLOGIST

Anthropological inquiry still carries the connota-

tion of research in far-off places and in someone else's

culture. The present investigation was, however, under-

taken in the city where I have lived for the past twenty

years and among a population whose cultural heritage I

share. My general research concerns in the present study

grew out of longstanding theoretical interests which I

have pursued in related investigations. As an anthropo-

logist, I have studied and observed at first hand the

ways in which similarities and differences in cultural

beliefs, values, and practices influence the prevention

and management of disease. As a social worker, I have

practiced in Washington and in Latin America, with spe-

cial interest in the development of effective social

policy and patterns of practice, particularly in the

field of health and in social action. In the present re-

search, as in past investigations, I have endeavored to

gain insight into the questions which face client popu-

lations as well as those with which agents of change must

deal as they attempt to prevent problems and cope with

needs. In my opinion some of the critical issues, which

should be the subject of research by the applied anthro-

pologist, arise out of both social and medical problems

met by action-oriented personnel vis-a-vis consumers of

services.

Since the 1960s I have held positions as a researcher

in the city-wide system of mental health services in

Washington and as a faculty member in an academic in-

stitution. At the same time, I have participated in pro-

grams and activities in the life of the Latino community,

attempting to respond to rapid changes in the city and

the concerns of members of the Latino group.

This particular study grew out of selected aspects

of my work in the Latino community of Washington. That

work focuses on two areas: (1) educational and con-

sultative activities among practitioners and decision-

makers interested in the relation between a knowledge of

Latin American cultures and successful program develop-

ment; and (2) advocacy in a walk-in free medical clinic

located in the Spanish-speaking community of the city and

related work with various types of caregivers in the

city.

The upsurge of governmental and public interest in

the life styles and problems confronting the growing

number of immigrants in the Washington metropolitan area

has been demonstrated by an increase in local and na-

tional meetings convened to focus upon the characteristics

of the Latin American population and to develop

strategies for action. On countless occasions I have

worked with city officials, agency administrators,

health care practitioners, and members of special

interest groups in their quest for information which

would help in the design of plans and programs to serve

the Hispanic population. As a result, I have been able

to focus some attention on the relationship between the

cultural information they request and their action-

oriented concerns.

Participation in the resurgence of ethnic con-

sciousness among Latinos in Washington has meant that,

in addition to my regular responsibilities as a univer-

sity professor, I work part of the time in a world which

extends beyond the boundaries of traditional university

life. A clear effect of these activities has been that

this research about Latin American immigrants is an out-

growth of questions derived from direct observation and

practice. In selecting research areas for the present

study I have drawn upon my own work, particularly as it

relates to the extension of health and mental health

services to Latinos.

Early in 1968 I helped a physician to organize a

once-a-week free walk-in medical service for Latino im-

migrants. This clinic is unique among such facilities in

the city because it does not have eligibility require-

ments; it serves as a first-stop facility for persons

with varied types of health complaints. The patients

are typically residents of the Latin community, includ-

ing those with limited resources, transient visitors,

and others, such as illegal aliens. The clinic is located

in a well-known multiservice agency under private auspices

which offers orientation to newcomers as well as other

programs such as counseling, advocacy, and special edu-

cation.

Several interrelated dimensions of my work in this

clinic spurred my interest in the present research. Out-

side the physician's office, I frequently took initial

histories of the prospective patient's view of his or

her problem. Within the examining room, I listened to

the physician's elicitation of medical histories and

served as an interpreter for patients with limited flu-

ency in English. I assisted the physician during exam-

inations and, afterwards, patients frequently told me

their perceptions of the prescriptive medical orders.

Referrals to specialists or to clinics for follow-

up led to work with various types of community resources

to insure their availability for the particular pro-

blems of the Latinos. Part of my follow-up activity

also included offering counseling services to persons

who faced crises which were difficult to resolve with

the limited resources of established community caregivers.

Descriptions of the history and nature of specific

problems and of paths towards their cure offered a

stimulus to study systematically the Latino concepts

of disease as these are expressed in modern scientific

biomedical contexts. There was evidence of the tenacity

of beliefs and attitudes derived from the body of tra-

ditional medicine of Latin America. There were, thus,

many classic expressions of the "hot" and "cold" syn-

dromes, as well as association of psychological mal-

functioning with causes such as aire (air) or c6Zeras

(anger). Nevertheless, observation indicated that

these and other folk concepts were also meshed with

beliefs and practices of the scientific medical tra-

ditions found in both Latin America and the United

States. It seemed that a focus of central importance

for research should be a careful description of ways

in which the multicultural body of Latino medical

tradition manifested itself in concrete form during

episodes of illness.

An area of related interest was the relation of

physical symptoms and psychological distress. In de-

tailed preliminary descriptions of their problems,

Latinos frequently presented such concerns as family

problems, anxiety about bad news from absent relatives,

or crises related to job tenure. Some linked troubling

interpersonal relations such as marital problems with

the recurrence of physical symptoms. Others searched for

upsetting emotional states within themselves as ex-

planations for the onset of disease. For example, feel-

ings of anger over unfortunate events were sometimes

viewed as explanations for disease of the joints or for

certain digestive disorders.

Linkages between various emotional states and symp-

toms of disease appeared to have high recurrence. Not

infrequently, however, Latinos who associated behavioral

dimensions with physical conditions did not discuss these

relationships with the physician. Moreover, my observa-

tions in examining rooms suggested that during the course

of a medical interview physicians did not, as a rule,

elicit behavioral problems. This apparent problem was

one of possible investigative interest and I paid in-

creasing attention to the process of communication between

physicians and Latino patients in several types of health

care settings. Common language was clearly a factor in-

volved in effective communication. Yet another dimension

was the caregiver's concept of his or her role as a diag-

nostician. Physicians, who carry primary responsibility

for the establishment of diagnosis, follow lines of

questioning which encourage a patient to describe symp-

toms of discomfort or pain. However, they do not usually

elicit the patient's conceptions of etiology; that is,

the patient's version of the reasons for the existence

of disease.

Typically, physicians ask patients to present the

problem or complaint -- for example, "pain in the stomach,"

"loss of breath," or "persistent burning sensation at

urination" -- and they ask subsequent questions to elicit

the details of symptomatology which are necessary to

establish a working diagnosis. Routine physical histories

do not tend to include the patient's conception of the

problems which are believed to have precipitated an in-

cident of illness. Physicians assume that it is their

role, rather than the patient's, to interpret the nature

of the problem. Thus, for me, a resulting issue of in-

terest was to determine just how patients syncretize

their understanding of explanations offered by profession-

al caregivers with their own concepts of the problems.

Upon examination of literature related to these

topics several gaps became evident. Anthropological re-

search investigating Latino concepts of disease offers

rich material about traditional concepts of disease, di-
1
agnosis, and curing. However, there is only a limited

body of literature which explores the linkages which

Latinos make between various indigenous traditions dur-

ing the processes of consultation with scientifically
2
trained practitioners. This gap in our knowledge con-

trasts with the body of available materials on the use

of traditional healers.

With regard to the influence of social and cultural

dimensions on psychiatric disorders, few epidemiological

studies of psychiatric disorders are known to have been
3
conducted among Latin Americans or among Latinos in the
4
United States. Studies of the concept of culture and

stress among working populations of Latinos and Latinas

in urban environments are few. This is the case despite

the fact that the general literature on the sociocultural

factors associated with stress has increased considerably

over the past few decades.

The combination of perspectives derived from my

varied activities led to a preliminary research project

whose purpose was to identify culturally defined concepts

of disease prevalent among Latin American immigrants.

This resulted in the development of a health history in-

ventory, which is the instrument used in the present in-

vestigation for the elicitation of problems concerning

disease, the use of practitioners, and patterns of curing.

AIMS OF THE RESEARCH

While a specific aim of the research was to examine

Latino perceptions and interpretations of the problems

of disease, a complementary one also existed: Identifi-

cation of social and cultural factors and of personality

reactions. A number of cases appeared to suggest that

Latinos frequently use general health agencies rather

than mental health facilities during times of behavioral

distress, although the distress was not usually dis-

cussed during the health interviews with practitioners.

An outgrowth of my awareness of the need for assess-

ment of relationships between sociocultural factors and

levels of stress, was the development of a second specific

research aim. During the past three decades the field

of mental health has been subject to burgeoning interest

in epidemiological analysis to determine correlations be-

tween overall symptom scores and selected characteristics

of population groups. These data have broadened our

knowledge about the etiology and distribution of mental

health problems. To my knowledge, however, there have

been few efforts either to undertake such studies among

people of Latin American heritage in the United States or

to identify instruments which might be feasible for such

study.

Therefore it became a specific aim of this research

to measure levels of stress and to correlate stress scores

with such sociocultural characteristics as age, occupa-

tional levels, marital status, and sex. In approaching

this aspect of the study, the writer was influenced by

the work of A.H. and D.C. Leighton and their colleagues
5
in the Stirling County study which suggests that the

development of symptoms of psychiatric disorder is a

result of interference with a person's strivings for the

satisfaction of certain basic needs; this interference

may originate within the individual or from external en-

vironmental forces. The development of symptoms during

attempts to cope with distress is common. Psychoneurotic

and psychophysiologic symptoms such as anxiety, depres-

sion, pounding heart and "stomach troubles" have been

found to be frequently exhibited by people who suffer
6
mild emotional upsets. Thus, identification of high-

risk and low-risk groups has theoretical implications

and may provide important knowledge for the extension of

mental health services to Latinos.

The third aim grew out of a concern with strategies

and mechanisms which Latinos use to cope with their pro-

blems. A necessary complement to the investigation of

differences in stress levels among Latino groups was the

identification of characteristic ways through which in-

dividuals reduced conflicts between their strivings and

the demands of their environment.

Carmen Fernandez and I have identified conflict-

reducing mechanisms of Latino-born children who have

faced the socializing demands of both the Anglo-based

educational system and the Latino-based home environ-
7
ment. Children who incorporate the learning of two

languages and two cultural systems with almost equal

proficiency often rely on the mechanisms of compart-

mentalization. They segment their perceptions and

and feelings, separating those associated with members of

the host society from linkages with their family or Latino

friends. They live in two worlds, cushioned from areas

of conflict in values.

Not all children, however, can use this defense

effectively. Some young immigrants tend to reject their

cultural heritage and to rapidly seek out Anglo role

models. They do not appear to respond to the efforts of

parents, educators, or ethnic-consciousness groups who

try to help them to retain their Latino heritage. These

children actively rely on the mechanism of identification

with representatives of the host society.

Examples drawn from the experiences of Latino child-

ren served to underscore the need to understand how Latino

adults deal with conflict. Research to identify the

mediating mechanisms which adults use in conflict re-

solution could contribute to an understanding of their

expectations in the socialization of their children. I,

therefore, focused on the identification of prevalent

patterns of conflict resolution followed by Latinos as

they met and dealt with tensions and obstacles in the

family or with "significant others." Values and norms

used as criteria for the resolution of conflict were

abstracted from specific "trouble cases."

To recapitulate, the research objectives represented

three levels of specific inquiry:

1. Study of beliefs and perceptions about disease

and the practices followed in the management

of illness. This focused on the world of inner

meaning of the immigrants as they incorporated

and interpreted concepts from the multicultural

systems of which they were a part.

2. Identification of levels of stress by socio-

cultural characteristics. This dealt with the

influence of environmental forces on the responses

of Latinos to crises.

3. Examination of patterns of conflict resolution.

This concentrated on linkages between values and

norms and the strategies used to handle problems.

THE STUDY POPULATION

The total of ninety-seven respondents included

seventy-one women and twenty-six men. The population

was drawn from two sources. The first was a group of

known seekers of health service from a multipurpose

community center. The second was composed of the par-

ents of children from the two schools in the city with

the highest proportion of Spanish-speaking children.

Over half (53.1 percent) of the school parents

had been in the United States six years or more, while

only 16.7 percent of the community sample had been in the

United States for that length of time. Whereas most

school parents were permanent residents or U.S. citizens,

41.7 percent of the community respondents were illegal

aliens.* The two individuals with the longest period of

residence in the country were a woman migrant worker who

had first entered in 1953 and a retired woman who entered

that same year.

For purposes of comparison, the health status of the

second group was unknown prior to research. The school

parents were selected for comparison because they were

assumed to be a more stable population than the community

respondents.**

*Immigrants are persons admitted to the United States as
lawful permanent residents. A nonimmigrant is a person who enters
the country for a temporary period. According to the Immigration
and Naturalization Service this group includes "diplomats and their
families, attendants, servants, and personal employees; visitors
for business or pleasure; persons transiting the United States;
treaty traders and investors; students; representatives to inter-
national organizations and their families, attendants, servants,
and personal employees, and others." (U.S. Immigration and
Naturalization Service, Annual Report, 1974, pp. 2-6).

The illegal alien is a category which includes: those who
enter through border points without proper papers; visitors or
students who overstay the terms of their nonimmigrant status; or
seamen who desert ship. (Ibid., p. 15). The usual Spanish word
for this category is indocumentado (without documents).

Persons who apply for U.S. citizenship tend to be those who
have had the required five years continuous permanent residence
in the United States and the spouses of United States citizens.
(Ibid., p. 19).

**One of the schools was a public school, and the other was
parochial. Forty percent of the children in the parochial school
were from households with parents of Latin American origin; 53.4
percent of the children in the public school were of similar origin.

The group of known seekers of service, hereinafter

called the community group, was composed of forty eight

individuals (fourteen males and thirty-four females).

Almost all had sought health care from the community

center in the fall of 1973. They represented the entire

group of patients from El Salvador and Colombia who had

sought health care in this period, plus a randomly

selected number from adjacent countries. A group of ten

domestics was included in this community sample because

of my special interest in the condition of women with

children who work as live-in domestics.

The forty-nine school parent respondents were chosen

by random stratified sampling, to match the country or

area of origin of the community group. The school group

included twelve males and thirty seven females (Table

1-1).

The age range of both groups together was from 18

to 65, with over two-thirds (74.2 percent) in the age

group of 30-49. Slightly over 10 percent were in the 15-

29 age group, while 14.4 percent were 50 and over.*

Over half of the immigrants were from Central

America (57.7 percent, from El Salvador, Guatemala and

*It is the author's impression that the recent migration of
Central and South Americans to this country has been initiated by
a high proportion of women and men who have entered the phase of
parenthood. However, these observations should receive more de-
finitive corroboration in the forthcoming census enumerations.

TABLE 1-1

IMMIGRANTS' CHARACTERISTICS: BY GROUPS, SEX
AGE, ENGLISH-SPEAKING ABILITY
(IN PERCENTAGES)

Attribute

Percentages

Males (n=26)
Females (n=71)

Respondent Group

Community Group (n=48)
School Group (n=49)

15-24
25-29
30-34
35-39
40-49
50-59
60 and over

English-Speaking Ability**

Speaks none
Speaks fairly
Speaks well
Unknown

26.8
73.2

49.5
50.5

3.1
8.3
24.7
22.7
26.8
10.3
4.1

17.5
54.6
26.8
1.0

*Analysis of the age groups between
vals was based on the original assumption
fall in these categories. I had expected
the 40-and-over groups; so I used 10-year

25-40 by five-year inter-
that most respondents would
to find few respondents in
intervals.

**Immigrants were asked to rate their own English-speaking
ability in relation to their perceived ability to make themselves
understood at work or in other commonplace activities. This did
not include reading or writing ability.

Nicaragua), and approximately one-third came largely from

the Andean area of South America (34.0 percent from

Colombia, Venezuela, Ecuador, Peru, and Chile). The rest

(8.2 percent) were from Mexico, Puerto Rico, and the

Dominican Republic. The choice of persons from the se-

lected countries was based on the proportions from Central

and South America estimated for the Washington Metro-

politan area, as well as on trends in immigration from

those areas for the country as a whole.*

Slightly over half of the group (54.6 percent) re-

ported a "fair" English-speaking ability, and one-fourth

(26.8 percent) stated that they spoke the language well.

*Data on permanent residents and other than permanent resi-
dents from the U.S. Immigration and Naturalization Service, Address
Report Cards (Form 1-53) for the years 1971 and 1973 show the com-
position of the Latin American population for the Washington Metro-
politan area, by country of origin. Cubans were twice as numerous
as those from any other Latin American country, particularly in the
suburban parts of the area. Colombia, Peru, and Ecuador were the
South American countries with the largest proportion of immigrants,
while Guatemala and El Salvador were the Central American countries
with the largest representation. The concentration of Central and
South Americans from these countries in Washington is similar to
national data on residents from these areas. In 1974, El Salvador
and Guatemala, and Colombia, Argentina, and Ecuador were the
countries from this part of the Western Hemisphere with the highest
numbers of residents in the United States (U.S. Immigration and
Naturalization Service, Annual Report, 1974).

It should be noted, however, that entry to the United States
from Mexico and from the Spanish-speaking nations of the Caribbean
(e.g., Cuba and the Dominican Republic) is proportionately larger
than the movement from any individual Central and South American
nation. In addition, none of the above-cited proportions includes
figures on the entry of undocumented aliens.

The remainder (17.5 percent) did not speak English at all

(Table 1-1). Of the total group, one-third had received

some specialized English language training in the United

States, most of which had been in private language aca-

demies or in courses organized by private community

agencies or in government-sponsored programs.

METHODOLOGY

The specific aims of the research called for three

types of data and the methods utilized reflect these foci.

Background information, material about entry and settle-

ment, and data on the problems of disease, required

quantitative and qualitative approaches. These data were

gathered through the structured and open-ended questions

included in the schedule. The body of information on

mental health status was elicited through the twenty

question Health Opinion Survey. Materials for the study

of conflict were chosen from the follow-up study of forty

immigrants and their significant others. Ways of life

of the immigrants and their problems were studied through

participant observation in a number of selected situa-

tions and through semi-structured interviews. Details

of methodology are presented in the following sections.

The Three-Part Schedule

In a pilot study conducted just prior to this re-

search, as well as during a period of more intensive

field work, I had explored ways to study sociocultural

aspects of stress and disease at a single point in time.

A three-part schedule, including items on sociocultural

components, biomedical information, and behavioral as-

pects, was developed and field-tested. This schedule be-

came a major data-gathering instrument for the present

study.

The first part of the schedule contained forty

questions regarding demographic and cultural character-

istics particularly in the area of family structure,

socioeconomic status, and work experience. Additional

data were gathered among parents with children left be-

hind in their country of origin.

The second section was the health history inventory,

which sought data about health problems among respondents

and members of their households at the time of the study.

The participants were also asked about their experiences

with twenty-four illnesses which I had found to be areas

of special concern among respondents who had participated

in the pilot study. In descriptions of disease, immi-

grants were asked to identify or describe the problem,

its course of development, types of caregivers, and cur-

ing approaches.

The third part of the schedule focused on the

identification of stress. Since I have special interest

in the measurement of levels of stress, and in types of

low-risk and high-risk life situations, I consulted ex-

perts in the field of social psychiatry to make inquiries

about instruments which could be adapted for use among

people of Latino origin. The most feasible instrument

appeared to be the Health Opinion Survey (hereafter cal-

led the HOS), which had been constructed for use in the

Stirling County study of psychiatric disorder and socio-

cultural environment.

There are relatively few studies of either treated

or untreated psychiatric disorder among Latin American

populations. I hoped that the present investigation would

offer a basis for assessment of some of the issues in-

volved in the adaptation of this instrument to the study

of stress levels among members of such a population. For

purposes of the present study, in consultation with other

collaborators, I translated the twenty-item HOS. The

translated versions were field-tested among persons with

national backgrounds similar to those of the respondents

in the study and among a small group of health caregivers

from these same countries.

With one exception, all interviews were conducted
8
in Spanish by me and the two collaborating interviewers.

Contacts with respondents took place in a variety of

locales in Washington, D.C. or its suburbs.

The Case Studies

A group of forty immigrants from the total sample

was studied over the period of one year, with the aim of

developing a more detailed understanding of their way of

life. Of particular interest were their perspectives

about ongoing problems of disease and its management, and

about the resolution of conflict. During the course of

the year, additional information came from contacts with

immigrants as I participated in joint activities with

them. These included such endeavors as sharing meals,

visits to the home of relatives and friends, participa-

tion in festivities, and joint shopping trips. I was

asked for assistance in such areas as translation of

documents, real estate and legal transactions, the inter-

pretation of current events in politics, and visits to

medical care specialists. Cases of medical emergencies

and family conflicts were further discussed with me.

These activities offered a basis for detailed study of

health beliefs and the cure of illness which I had origi-

nally discussed with them in the health inventory and the

HOS.

Observation in places of work and in health settings

also permitted me to study cycles of activity and their

general social environment. Interviews with health pro-

fessionals and work "bosses" offered special insights for

understanding their viewpoints of Latin American immi-

grants.

By personal contact and through telephone conversa-

tion, I asked selected caregivers, who carried the immedi-

ate responsibility for the provision of services to re-

spondents, for their impressions of respondents and their

problems. Conflicts and the patterns followed in their

resolution were studied within the particular situation.

During the summer of follow-up, I visited selected

communities of origin and the families of fourteen re-

spondents from Colombia and El Salvador.* Visits were

arranged by the respondents prior to my arrival. I

talked to returned immigrants in their home communities

and visited with the families and friends of Washington

residents, to gain insight into the ways of life in their

areas of origin. Observation and interviews with health

professionals in small towns as well as in metropolitan

centers offered perspectives on the changing nature of

health care delivery in Latin America. Field work in

these settings provided material for comparison with the

viewpoints about health care in the United States held

by the immigrants studied in Washington.

*It should be noted that I have longstanding interest in
Colombia, demonstrated through work experiences in the country and
research in areas of culture change, medical care, and ethnohistory.
I was born in Costa Rica and I have kinship ties in El Salvador.
This field trip constituted my third visit to El Salvador.

Consentfor the Conduct of Research

A study which relies on a combination of research

approaches requires consideration of ways to elicit the

interest, collaboration, and consent of respondents and

of their networks of significant others.

I sought and obtained written permission from school

authorities and appropriate agency administrators to con-

duct research within their organizations. Moreover, at

the time of initial contact with school parents, the

interviewers carried letters of introduction from the

schools and copies of the letters which the principals or

their designated representatives had sent to parents (See

Appendix A). These letters, written in Spanish and with

an English translation, explained the general purpose of

the investigation and assured respondents that they were

free to accept or refuse the invitation to contribute to

the research. (A more detailed description of the pro-

cess of seeking permission to conduct research is found

in Appendix B.)

Community respondents, who were drawn from a health

center population, were asked directly for their volun-

tary participation in the study. Since the research

might have been easily associated with the regular acti-

vity of the center, as well as with my own work in the

community, I was careful to note any "polite" indications

of assent which could have represented hesitation or

refusal. Throughout the research I kept confidential

certain information as requested by respondents such as

illegal aliens or their friends.

The field work with selected respondents and their

families in Colombia and El Salvador was undertaken

through introductions and contacts in Washington.

Visits to formal health organizations in these countries

were made with the assistance of national, regional, and

local health officers.

Data Recording and Analysis

Interview data were recorded on the schedule and on

Unisort Y9 cards. All interview and field materials were

kept in locked files in my office. Data were accessible

only to me and the research staff.

Data from the schedules were coded and punched on

data analysis cards. There were seven cards per person.

Computer analysis of frequency distributions and the

means calculated for the HOS were done on a PDP DECsystem-

10 computer.

The field data and related documentary material were

content-analyzed to permit the identification of themes

of central relevance for the major subject areas. De-

tailed case-by-case analysis offered a rich source for

the study of the processes through which the immigrants

adapted and faced their problems of health maintenance

and illness.

The scoring of the HOS was done according to pro-

cedures recommended by those who had done the Stirling
9
County studies. The method is described in Chapter 7

of this book.

Preliminary analysis of the HOS by demographic

characteristics was followed by comparisons of scores

between samples. Analysis of high, medium, and low-

stress categories offered a basis for more specific

identification of differences according to levels of

stress.

ORGANIZATION OF THE MATERIAL

The book is organized as follows. Chapter 2 will

offer a review of selected literature on Latin American

popular medicine. The second part of the chapter pre-

sents conceptual approaches for the study of socio-

cultural influences on behavior, with special emphasis

on psychiatric epidemiology and conflict-solving mechanisms.

In Chapter 3, I shall describe the processes of entry and

settlement of the Latinos in the study, focusing on the

organization of household and family, since domestic

units are major contexts within which health is defined

and problems of illness are managed.

Chapter 4 will have findings on work as a central

linking experience of the immigrant with the host society,

exerting differential influence on the careers of Latino

women and men. Data about patterns and types of work and

cultural values will offer a basis for my discussion of

the disjunctions between aspirations about work and the

Latino patterns of coping with job-related stresses.

Findings about the most frequently identified health

problems will be found in Chapter 5. Types of reported

symptoms influence the patterns of management and treat-

ment within the household and in consultation with inter-

mediaries from popular and professional medicine. In

these contexts, I shall discuss special issues in com-

munication between medical practitioners and patients,

with focus on cross-cultural aspects and the nature of

the physician patient relationship.

In Chapter 6 four commonly found syndromes of ill-

ness will be described: disorders of the blood, dis-

orders of the heart, digestive and genitourinary problems,

and diseases attributed to the hot/cold theory. These

syndromes reflect the multicultural character of Latin

American popular medicine. Sociocultural and demographic

conditions which influence levels of stress will be high-

lighted in quantitative findings about psychiatric symp-

toms, as found in Chapter 7, which also presents high or

low levels of stress for such categories as age groups,

socioeconomic levels, sex, and household organization.

Qualitative aspects of the management of stress will be

26

described in Chapter 8 through focus on the mechanism of

controlarse (control of the self). The behavioral pro-

blems of boys and girls and conflicts between men and women

in conjugal relations offer a basis to examine prevalent

conflict-reducing mechanisms and some of the problems in

using them as Latinos deal with the changing conditions

of their lives.

CHAPTER 2

LATIN AMERICAN POPULAR MEDICINE
AND THE STUDY OF STRESS

Anthropological study of concepts of health and

disease has grown out of a research tradition which covers

a broad spectrum of human life. Pearsall states that med-

ical anthropology encompasses the total range of human

experience -- biological, psychological, social, cultural,

and ecological -- as this bears on adaptation to disease
1
and the maintenance of health. The concept of health

reflects man's continuous attempts to change and to con-

trol the environment. According to Hughes, among most

people health is seldom narrowly defined as a concept

of perfect well-being of the individual body.

In many groups man is conceived to be continuous with
both the social and non-social aspects of his environ-
ment, and what happens in his surroundings affects his
bodily well-being. Not only a person's own actions,
therefore, but also those of kinsmen or neighbors can
cause sickness.2

Hughes also points out that, when we speak of health and

well-being, we confront persistent problems of adaptation

and equilibrium. For life reflects "continuing constel-

lations of adaptive processes, and disease represents

an exaggerated or abnormal use of defense reactions

or mechanisms on the part of the organism in its attempts

at adaptation to threatening circumstances either internal
3
or external."

LATINO CONCEPTS OF DISEASE

Anthropological research among the peoples of Latin

American heritage shows that concerns about states of

health and disease constitute major controlling forces

in their lives. Surveys and field studies in Indian

communities, in mestizo settlements, and in low-income

urban areas indicate that ill health is a source of con-

stant concern in households, since members frequently

suffer from illness. Accidents, muscular aches, nutri-

tional deficiencies, or endemic problems associated with

inadequate community hygiene contribute to this reality.

Tensions associated with the threats of the loss of

parents or unexpected strong emotional experiences also
4
lead to threatening psychological conditions.

That Latino concepts of health and disease have

central sociocultural significance has been noted by

students of the culture, as illustrated in the following

passage by Samora.

Health, as a state of being, in its two aspects, being
ill and being well, is one of the most important value
orientations in the life-ways of the people. It appears
with regularity in all institutional contexts. In
particular, those beliefs and attitudes related to or
expressed in religious, familial, and economic behavior

patterns express in a variety of ways the importance of
health. There is strong affect associated with the
polar states of being well or being ill. The cultural
forms associated with health are greatly elaborated.
The idea of health, then, pervades the culture. The
conventional greeting, "how are you?" (Como estd?)
has real health meaning; the response is likely to be
an account of the respondent's state of being, as well
as the state of being of those close to him.5

Beliefs about health and illness hold a central place

in social relationships within the Latino household and

in relations with other significant groups. These con-

cepts are part of the system of social control. Concern

about states of disease are learned from early childhood

onwards and exercise a continuing influence among adults

and in the events which give direction to their lives.

G. and A. Reichel-Dolmatoff note this from their detailed

study of Aritama, Colombia.

Since infancy the individual has been taught that
illness forms an essential part of life. To a large
degree the daily "dos" and don'tt" of child train-
ing refer to the avoidance of illness, and every
child is used to seeing ill people, hearing their
ailments discussed by others, and listening to their
own descriptions of symptoms and treatments. The
education by fear and to fear makes constant use of
the specter of disease as a controlling force which
may strike at any moment. In reality, the control-
ling power of society is illness and all moral law
enforcement is accomplished through the menace of
disease. But the child is not only given to under-
stand that such exterior influences as a rain
shower, a drought, or a certain food might cause
ill health; he is also taught, explicitly or implic-
itly, that rage, joy, sudden fear, or prolonged
sorrow might lead to organic dysfunction.6

In studying the principal features of popular medi-

cine* in Latin American communities and among Latinos

in the United States, most researchers indicate that

there is no single integrated Latino theory of disease.

Latin American popular medicine is eclectic in nature.

An important characteristic of this belief system is its

capacity to assimilate practices from various popular

and biomedical traditions. The indigenous beliefs,

Spanish medicine based on ancient and medieval concepts,

spiritualism, patent medicine, homeopathic therapy, and

the professional biomedical traditions are combined to

form a dynamic system. Commonly held etiological con-

cepts and the use of diagnostic resources and curing
7
approaches tend to reflect this multicultural character.

For example, a rural midwife, whose practice is

based on magical medicine plus her own experience, may

give an expectant mother a dose of quinine to accelerate

labor, or she may inject special doses of pituitrina
8
(pituitrin ampules) for the same purpose. Drugstore

*The terms "folk medicine" and "popular medicine" have been
used interchangeably by researchers to refer to medical systems of
indigenous rural and urban lower socioeconomic groups. Richardson
and Bode state that popular medicine is the medicine of the populace,
particularly the part that belongs to the lower economic'section.
Its scope includes available medical facilities, patterns of healer-
patient relationships, and the concepts of illness and health. These
authors consider popular medicine as "an adaptive response to a
social environment produced by the intersection of urban and social
features." (M. Richardson and B. Bode, Popular Medicine in Puntar-
enas. Costa Rica: Urban and Social Features), p. 253.

preparations and patent medicines are popular in some

areas, while sulfa drugs and penicillin, available over

the counter, are self-prescribed for a number of con-
9
editions.

Magic and Disease

Magical ideas, empirical categories, and strong

emotional states are the most commonly cited Latino be-

liefs about causation of illness. Diseases of magical

origin are those in which causative factors lie outside

the realm of empirical knowledge and cannot be easily

verified, while empirical or natural causes are those in

which known external factors operate directly on the

organism to produce illness. Diseases of psychological

origin are frequently those in which strong emotional

states lead to susceptibility to illness or to actual
10
organic dysfunction.

One of the most common diseases of magical origin

described in Latin American popular medicine is the evil

eye (mal de ojo). Symptoms of this illness generally

become evident in small children, although it is some-

times seen among adults who are in a weak or vulnerable

condition. The power to cast the evil eye may be volun-

tary or involuntary. It is transmitted usually through

an admiring glance at the object. For example, people

who admire an infant with a strong glance may be the agents

of illness.*

The most commonly found effects of the evil eye are

listlessness, weakness, diarrhea, and fever. Preventives

used to counter the effects of the evil eye include amulets

and special protective coverings. Cures include herbs, drug-

store remedies, and magical treatments, as with eggs,** to
11
diagnose and draw out evil.

Diseases of Natural Origin

Frequently mentioned diseases of empirical or natural

origin are those of hot and cold imbalance, of gastrointes-

tinal obstruction and dislocation of the internal organs,

and of the scientific biomedical categories of disease.

The Hippocratic doctrine of four humors, brought to

the Americas by the Spaniards, is the source of the belief

that the qualities of hot and cold found in nature lead

*Students of Latin American concepts of disease state that belief
in the evil eye in the New World is part of the heritage from the Spanish
and Portuguese. The belief appears to have diffused to the Iberian Penin-
sula through Arab contact, or it may represent earlier influences. It
should be noted, nevertheless, that the idea is widespread and prevalent.
According to Ellworthy, Plutarch said that certain men's eyes are destruc-
tive to infants and young animals. The Finns, Lapps, and Scandinavians
are reported to have been firm believers in the evil eye. Natives of India
had practices to protect themselves from the possibility of casting, as
well as being victims of, the evil eye. (F.T. Ellworthy, "Evil Eye,"
pp. 608-611.) See also C. Maloney, (ed.), The Evil Eye.

**In Central America and Mexico, diagnosis and cure of the evil
eye may be done by stroking or "cleansing" a patient with an egg. (Isabel
Kelly, Folk Practices in North Mexico, p. 120.)

to a variety of illnesses.* These qualities may have

nothing to do with actual physical temperature. Certain

foods, herbs, and beverages are classified as "hot" or

"cold." Illness is often attributed to an imbalance

between heat and cold in the body, and curing is accom-
12
polished by the restoration of proper balance. Distinc-

tions are made between these hot/cold qualities and the

actual contrasting hot and cold temperature which may

also lead to illness. Sudden changes in environmental

temperatures, in particular, -lay make a person vulnerable

to currents of air, commonly called bad airs. These enter

the openings of the body and lodge there, resulting in
13
aches, pains, and malfunctioning in the area affected.

Gastrointestinal obstructions are suspected in con-

cerns about a "dirty" or bloated stomach which needs
14
cleansing so that food may pass to the intestines.

Diseases of the dislocation of internal organs or loss of

muscular control can be associated with various causes,

including exposure to certain phases of the moon or

*Greek humoral pathology was brought to Spain by the Moslems.
This doctrine assumes that the human body in a state of health con-
tains balanced qualities of the four humorss": blood, phlegm, black
bile (melancholy), and yellow bile (choler). Each is characterized
by a combination of heat or cold with wetness or dryness. Foster
and Rowe point out that in the New World this Hippocratic classifi-
cation has undergone some changes. For example, substances were
classified as hot or cold, or wet or dry, and each attribute was
graded in intensity on a scale from one to four. In contemporary
times, the wet-dry concepts and the scale of degrees have not been
reported for any Latin American area. (G. M. Foster and J. H. Rowe,
"Suggestions for Field Recording of Information on the Hippocratic
Classification of Diseases and Remedies," p. 1.)

emotional trauma. With the diffusion of knowledge from

the scientific biomedical tradition, Latinos may seek

assistance to learn whether pathological agents such as

microbes, amoebas, or parasites cause symptoms of gastro-

intestinal dysfunction, signs of weakness, or the presence

of unusual masses.

Strong Emotion as a Cause of Disease

The idea that strong or sudden emotional experi-

ences produce physiological results is a concept wide-

spread among Latin Americans. Anyone can undergo ex-

periences such as anger, fright, shame, or disillusion-

ment and, as a result, become more susceptible to illness

or to serious incapacity. Jealousy and anger may lead

to the onset or recurrence of bilis (biliary disorder),

while certain types of fright (susto*) may be associated
15
with incapacitating physical and psychological symptoms.

*The Spanish word susto means a sudden frightening experience.
Some years ago John Gillin described the syndrome of "magical
fright" which was known in Spanish as susto or espanto. He em-
phasized the need for clarity in translation of the terms and in
understanding their connotations. The group of ailments in this
category are not just any ordinary fright, as noted in the follow-
ing excerpts from the work of this author. The words espanto or
susto mean fright, "but they are used in two different types of
context. On the one hand, they are used to describe 'ordinary' in-
cidents which involve fear but which do not affect the 'soul' --
that is, they are not believed to have serious psychological con-
sequences. For example, one may be 'frightened' by the prospect
of rain before the harvest is completed . In the second type
of context, however, espanto and susto always refer to an illness
or abnormal condition of the body and personality. For this rea-
son it seems best to render the latter concept in English by the
qualifying expression 'magical fright.'" (John Gillin, "Magical
Fright," p. 402.)

Bilis, one of the more widespread of these conditions,

has been cited by researchers in a number of Latin Ameri-
16
can countries and among Latinos in the United States.

Richardson and Bode noted that a sudden unexpected flow

of emotion inside the individual, such as the unexpected

appearance of a friend or an enemy or witnessing the death

of a close relative, may affect the digestive work of
17
the liver and result in serious illness. Kelly was

told that this overflow of bile manifests itself in stom-

ach aches. After experiencing a rage, the subject may
18
also have revulsion to food.

Susto is associated with such symptoms as sleepless-

ness, diarrhea, fever, withdrawal from normal social
19
activity and responsibility, nervousness, or depression.

Susto may or may not involve soul loss,* and this aspect

does not appear to result in important differences in the

syndromes of illness. A recent epidemiological study of

susto in three Mexican villages shows that social role

stress which derives from inadequate performance of role

tasks is strongly associated with a process by which one

defines oneself as asustado. Some of these findings sug-

gest also that those who have experienced the syndromes

*According to Adams and Rubel, soul loss in susto refers to
the belief that the soul wanders away from the body of its own
accord, usually while the individual is asleep but not necessarily
while dreaming. The danger is that the individual may wake up
while it is gone. Sickness and death will result if it is not
brought back. Among non-Indian populations, susto without soul
loss appears to be prevalent. (R.N. Adams and A.J. Rubel, "Sick-
ness and Social Relations," pp. 346-347.)

of susto appear to have more severe organic symptoms than
20
a group of matched controls.

Many other strong emotional experiences may occur

in association with the onset of symptoms of illness.

Life experiences which cause loss of face, such as a

husband's or a wife's desertion, may result in serious
21
organic illness for the spouse left behind. The un-

expected discovery of a daughter's sexual liaison may

contribute to the recurrence of longstanding digestive

problems. Sensory experiences such as unpleasant sights

may trigger off disturbing symptoms. It should be noted,

however, that men and women who are subject to these

illnesses may not consciously link emotional experience

with their illness. Diagnosticians and curers are ex-

pected to assist with the identification of possible

cause and to provide treatment. They search for ways in

which disturbing sociocultural forces, emotional ex-

periences, and organic factors contribute to the emer-

gence of symptoms of illness.

Curing Patterns

With regard to patterns of curing, the urban areas

of Latin America have a variety of healers. As noted

earlier, curing frequently draws on a wide range of

treatment sources, which may include herbs, over-the-

counter medicines, patent remedies, and the prescriptions

of physicians. Available literature indicates that the

use of one type of healer and cure does not preclude an-
22
other. Researchers believe that patients do not

categorize illness into those which home remedies cure

and those which only a physician can treat. Although

Simmons points out that certain diseases such as those

in etiological categories of severe emotional upset and

bad air are cured with popular means rather than with

doctors' remedies, he suggests that this is related to

the fact that these illnesses are usually ignored by

scientific medicine. He states, in addition, that

dichotomies between popular and modern medicine are not

so simple to determine, in view of the fact that popular

medicine offers cures for all the illnesses believed to
23
be amenable to physicians' treatment as well. This

pattern is what Richardson and Bode describe as a curing

strategy which makes for a wide-open maximization of

available resources, as noted in the following illus-

tration:

Having decided, for the moment at least, to utilize
human curers, (the sick person) can seek out ortho-
dox physicians who operate as resident doctors in a
charity hospital, as clinicians in a governmental
clinic, or as private physicians in their own offices.
He can request aid from members of the minor orthodoxy,
the pharmacist, the licensed midwife, or her un-
licensed colleague. He may go outside the orthodox
and seek the heretic curers, the homeopath, or the
naturist. Finally, he may shift from the human realm
and call upon supernatural healers. Available to
him are spirits, saints, and God. 24

Given the presence of this complex system, a ques-

tion of theoretical and practical relevance is: Just

how does the definition and selection of healers and

practices of medical care take place? For Latinos who

become immigrants to an urban center such as Washington,

,what assumptions about the nature of disease guide their

behavior as patients?

With increased recognition of the range of cultural

alternatives available to members of ethnic groups in

contemporary society, anthropologists need to study the

fine-grain detail of ways through which the reconceptuali-

zation and reformulation of medical beliefs takes place

as migrants face the specifics of illness in a new set-

ting, and particularly the linkages between popular

medical beliefs and practices and the scientific bio-

medical tradition. The theoretical and practical im-

plications of such a focus have been highlighted by

Fabrega and Firth. Fabrega has called for the genera-

tion of concrete information regarding clearly defined

illness-treatment episodes, together with a presentation

of the meanings and interpretations of these events to

individuals or families. Detailed depiction of medical

events is required in order to have a realistic aware-

ness of the reciprocal influences that cultural factors
25
have on illness and disease. Firth states that know-

ledge of existing beliefs and practices in medicine is

invaluable. But, he adds, one of the difficult ques-

tions to solve is this:

Just what are the existing beliefs and practices
which it is necessary to take account of (and by con-
trast, those which can be ignored or should be com-
batted)? It is often said nowadays that a medical man
should learn "something" about the customs and beliefs
of the people among whom he is going to work. But
what precisely does he need to learn? An unsystematic
collection of scraps of information may lead to an
exaggerated respect for taboos and an underestimation
of the importance of features of the society which may
throw a medical program out of gear. 26

Study of sociocultural conditions and illness events

should thus permit a more systematic discovery of the

knowledge which can be applied to action by health

practitioners.

SOCIOCULTURAL INFLUENCES ON
PSYCHIATRIC DISORDERS

A basic concern in the study of sociocultural in-

fluences on behavior has been the identification of

factors in the environment which produce, encourage, or

perpetuate psychiatric disorders. Conceptual approaches

derived from the work of A.H. and D.C. Leighton et al.,

have provided the background for my interest in this
27
area.

A.H. Leighton states that human beings exist in a

constant state of striving to satisfy their basic needs.

These needs include the following aspects:

(A) Physical security, including food, shelter,
and health; (B) Sexual satisfaction; (C) Opportunity
to give and to receive love; to express hostility
without reprisal; to gain recognition; and to express

creativity; (D) Orientation as to one's place in
society and the place of others; (E) Membership
in a definite human group; and (F) Belonging to a
moral order or system of values. 28

Interference with these strivings may come from

within a person or from his outside environment with

various consequences: The person may try harder to

overcome barriers; he may give up and withdraw; or he

may develop symptoms as body, mind, or emotions reflect
29
the lack of satisfaction. The types of reactions which

individuals show to interference with need satisfactions

depend upon various factors of life experience and

specific stress-conducive conditions. The presence of

noxious environmental conditions, the demands of critical

events in the life cycle, or the discontinuities of

changing cultural systems are factors in the environment

which provoke reactions of stress.

The development of symptoms at some stage of the

process of interference with these strivings is a common

human reaction. The concept of symptom patterns refers

to a classification of configurations or sets of dis-

turbances reported by an individual who experiences

them. They usually reflect some conflict and the in-

dividual's unsuccessful efforts to resolve these problems.

A growing body of research on sociocultural factors and

stress indicates that symptom patterns grouped under

psychophysiologic, psychoneurotic, and personality dis-

order classifications are present among a large number

30
of people. There may be symptoms related to gastro-

intestinal, cardiovascular, and other organic systems

or concerns, with or without chronic feelings of anxiety,

depression, or self-depreciation. Included also are

pervasive attitudes such as apathy, hostility, and

suspiciousness.

The degree of impairment caused by combinations of

symptoms in these areas may vary during a person's life-

time. But since, once present, these symptom patterns

tend not to disappear completely (or to be more and more

easily aroused), they are important "sources of danger."

An understanding of etiological factors which contribute

to the manifestation of symptom patterns is crucial, but

it calls for careful descriptions and analysis because

identical symptom patterns may occur as reactions to
31
widely different conditions. Meyer has emphasized

that the most valuable determining factor of symptoms

is "the form of evolution of the complex, the time and

duration and circumstances of its development, and the
32
character of possible transformations of the picture."

Two interrelated areas are the subject of interest

in the present research. The first deals with character-

istics of populations which are associated with higher

or lower levels of symptoms. The second involves the

identification of patterns of conflict resolution which

individual members of cultures are expected to use as

they face tension-producing conditions in their environment.

Psychiatric Epidemiology

Epidemiological investigation is a basic approach

used to study the influence of sociocultural environment

on symptoms of psychiatric disorders. It focuses on the

frequency of symptoms, their patterns, and their distri-

bution. Through the study of incidence (new cases which

occur within a specified period of time) or prevalence

(the number of both new and old cases of a disorder

present in a population group as of a specified point in

time), it is possible to identify negative influences

in the environment and susceptible points in the life

cycle, as well as apparently supportive and protective

circumstances, which bear on mental health status.

Hospital admission figures and other official

records have been major sources of epidemiological study.

These data necessarily reflect only "treated cases"

rather than "true prevalence" (treated plus untreated

cases). In contrast, community surveys enable investi-

gators to determine how many members of a whole popula-

tion (with some definite limits) have symptoms of the

sort that indicate the presence of a psychiatric re-

action, whether or not impairing to a "serious" degree,
33
and whether or not receiving any professional treatment.

Three investigations which use a community base are of

special relevance in the present research: The studies

34 35
of Leighton et al., Meyers et al., and Karno, Edger-
36
ton, and other authors. The writer has selected

material from these studies regarding the linkages be-

tween levels of reported symptoms and various socio-

cultural factors.

Disintegration as Shown in the Stirling County Study

In the Stirling County study, A.H. Leighton and his
37
colleagues had a central interest in understanding

relationships between sociocultural environments, in-

dividual basic needs, and reactions to interference with

these needs. Indices of social disintegration* were

used as guides to select maximally integrated communi-

ties within a rural county for comparison with maximally

disintegrated areas. It was assumed originally that

"severe social disintegration of a community produces

both psychological stress and lack of resources for

dealing with that stress; out of the resultant psycho-
38
logical strain, psychiatric disorder emerges."

In analysis of selected findings, D. C. Leighton
39
et al., show that the disintegrated areas studies had

indeed many more people with impairing psychiatric

*The indices of sociocultural disintegration included such
factors as: extensive poverty, cultural confusion, high fre-
quency of broken homes, few and weak associations, few and weak
leaders, few patterns of recreation, high frequency of hostility,
and weak and fragmented networks of communication. (A.H. Leighton,
My Name is Legion, pp. 318-326.)

symptoms than the integrated communities. The symptom

patterns indicative of psychoneurosis and psycho-

physiological disorder were much more prevalent in the

disintegrated groups. So too were mental deficiency,

sociopathic behavior, and personality disorder. The

rarer forms of symptom patterns such as the psychoses,

however, were found only in extremely small numbers in

any of the selected communities; the difference in pre-

valence of psychosis by community type appeared to be no

greater than chance would make it.

In a summary of the work on the integration-dis-

integration hypothesis, D. C. Leighton states that the

most clearly noxious aspects of sociocultural disinte-

gration appear to be those that affect the achievement

of love, recognition and spontaneity, and the sense of

belonging to a moral order and being right in what one
40
does. Such factors as the absence of warm interpersonal

feelings and social supports which may accompany broken

homes, a lack of belonging, and inadequate communication

contribute to a higher prevalence of psychiatric dis-

order. For individuals in disintegrated communities,

these noxious influences begin early in childhood and

may continue throughout life.

In disintegrated situations, it appears as if

choices are limited and there is little guidance for

making them. Substitutions for unattainable objects and

goals are difficult to attain. Persons who experience

disturbing psychological symptoms in disintegrated areas

appear to be likely to seek relief by following paths

conducive to increased distress, since sources for pre-

vention are weak or absent. Individuals may seek relief

by withdrawal into daydreams, or they may experience in-

creased anxiety or feelings of depression and apathy.

Some may derive satisfaction from paranoid thoughts,

while others may mask disturbed feelings through the in-
41
creased use of alcohol.

The Stirling County research illustrates how link-

ages between individual basic needs, role-specific life

situations, and mediating support systems influence

levels of symptoms in various population groups. In

the disintegrated areas of the county, for example, the

basic needs of the high-risk men and women were not

adequately met by family groups or other supportive re-

sources, and this contributed to the high prevalence of

psychiatric symptoms for both sexes.

A finding of special interest was that the dif-

ferential cultural situation of men and women in the

two integrated communities appears to have influenced

differences in their levels of symptoms. In the English

community of Fairhaven, men's needs were apparently well

met in consistency with the sociocultural system.

Women in the same community, however, were experiencing

role conflicts because they were aware of changes tak-

ing place in the role of women in the wider society, and

they were not able to fulfill new interests and needs

with satisfaction. They had the lowest self-esteem of

all groups studied, expressing self-doubts and lack of
42
self-confidence in their roles as mothers. While new

opportunities for work had become available for these

women, they were ambivalent about entry to these jobs.

The sight of a married woman at work caused some discom-
43
fort in the community. These factors contributed to

the higher prevalence of psychiatric disorder among

women, as compared to men.

In the French community of Lavalle the reverse was

true. Women continued to function comfortably accord-

ing to previously established patterns, and the prevalence

of psychiatric disorder among them was lower than both

the country average and the average of the men in their

own community. Women's needs here were evidently

satisfactorily supplied. This community, much more than

Fairhaven, had socioculturally based barriers against
44
the incursion of change from the larger society.

Lavalle men, however, seemed to be slightly more impair-

ed than Fairhaven men. These differences were based in

large part on the differences in ratings of the over-60

men in both areas. Although the number of cases in

these groups did not permit further analyses, it appears

as if Lavalle men did not derive a strong sense of self-

worth from their work as fishermen. At retirement these
45
feelings may have increased.

Support Systems and Symptoms ofDisorder

The perception of support systems among the low-

symptom groups, as contrasted with the high-symptom groups,

has been discussed also in the work of Myers, Lindenthal,
46
and Pepper. Their research on social class, life

change events, and psychiatric symptoms supports find-

ings which have shown a significant relationship between

social class and symptoms of disorder. In longitudinal

research conducted in the catchment area of a community

mental health center in New Haven, these authors found

that lower-class persons are subject to more high-impact
47
events of an undesirable nature than middle-and upper-

class persons. In addition, lower-class individuals ex-

perience more undesirable events which have a high re-
48
adjustment or change impact than do persons higher in

the upper ranks of the status system. These conditions

contribute to the higher prevalence of psychiatric symp-

toms in the lower class.

In interpreting these findings the authors state

that, for persons of the lower class, economic want and

associated indices of poverty contribute to increased

strain. Fragile interpersonal relations among members

of this group provide minimal social support as individuals

face undesirable events which require coping. Symptoms

might be viewed as cries for help which is not forth-
49
coming.

Lindenthal et al. studied perceptions of the systems

of social support available to these New Haven respon-
50
dents. Their inquiry was based on the belief that one

way to understand the interdependence of individuals

within the social structure is through the identification

of constellations of significant others to whom an in-

dividual turns when confronted with a crisis and in need

of support. They classified two major sources of help:

Primary supports (family and friends), and secondary

sources (help for which one usually leaves home and pays

a fee).

The authors learned that there was little difference

between those with and without symptoms in their percep-

tion of the usefulness of primary supports, but 72

percent of the symptomatic subjects perceived secondary

sources as useful, compared to only 44 percent of the
51
asymptomatic. The symptomatic were more likely to

perceive formal resources in the community as helpful
52
for a greater number of crises than did the asymptomatic.

Stress in Latin American Communities

There are few known epidemiological studies concern-

ing the incidence and prevalence of psychiatric symptoms

among peoples of Latin American heritage in the United

States or in Latin America. Among Mexican Americans in
53
the United States a subject of research interest has

been the investigation of differences in the use of

psychiatric facilities and the contrasts in incidence
54
and prevalence rates between Latinos, Anglos, or others.

With the exception of the work by Madsen and Karno and
55
Edgerton most data have been based on patient popu-

lations.
56
Karno and Edgerton elicited attitudes towards

mental illness from a sample of over seven hundred Mexi-

can American and Anglo American residents of East Los

Angeles. Their original interest was to determine

whether the reported underrepresentation of Mexican

Americans in both private and public psychiatric treat-

ment agencies could be related to their perceptions of,

or attitudes towards, mental illness. At the time of

their research, studies in Texas and in California had

shown that Mexican Americans appeared to have a lower
57
prevalence of major mental disorders. Several inter-

pretations had been offered for these findings.

On the basis of research in South Texas, Madsen had

indicated that data about underrepresentation in that

state could be interpreted through an understanding of

the anxiety-sharing and anxiety-reducing mechanisms pro-

vided by the Mexican American family in stressful situa-

tions. According to Madsen, stressful situations among

members of this ethnic group are less likely to produce

mental illness because they are shared by the family

group. Curanderos (folk curers) are resources available

to the family, and they have therapeutic success. In

addition, Mexican Americans do not worry about the pos-
58
sibility of mental illness as much as Anglos do.

The Karno and Edgerton research showed that, al-

though Mexican Americans in East Los Angeles were indeed

strikingly underrepresented as patients in psychiatric

facilities in California, they did not perceive and de-

fine mental illness in markedly different ways from
59
Anglos. A finding of importance was that at the time

of the investigation, there was a paucity of formal

psychiatric facilities in the area. Private family

physicians were by far the most actively sustaining
60
service in the community. There was little evidence

to suggest that the reported underrepresentation of

Mexican Americans in psychiatric treatment agencies was

due to the practice of folk psychiatry, because curanderismo
61
had diminished in importance.

With regard to the influence of the family on the

patterns of management of emotional disorder, there was

some evidence to suggest differences by acculturative

status. Respondents who were born in Mexico and con-

tinued to use Spanish as their primary language believed

that the recovery of mentally ill people within the

family was desirable. Those who were born in the United

States and who took the interviews in English felt, on

the other hand, that the mentally ill would not best re-
62
cover from their illness by staying with their family.

Although Karno, Edgerton, and their colleagues were

not concerned directly with the study of levels of im-

pairing symptoms among their respondents, their research

points to the value of identifying systems of support

used by ethnic groups, in order to help to interpret data

gathered from general patient population surveys. This

work has contributed to an understanding of changing

patterns of help-seeking as noted particularly in their

data about decreased reliance on folk curers. Such know-

ledge is important because concern with the influence of

cultural factors on members of ethnic groups should focus

attention on the traditional qualities of their cultures

as well as on the dynamic and changing aspects.

The findings highlighted in this section show that

research which identifies linkages between the sociocul-

tural environment and psychiatric disorder increases our

understanding of etiology by drawing attention to the

characteristics of communities which interfere with or

provide for the satisfaction and fulfillment of basic

needs of individuals in designated population groups.

This does not mean that persons in integrated communi-

ties or those in the middle or upper classes who have

lower overall rates of psychiatric disorder are free

from stress. Overall levels of symptoms should be

identified along with possible variations in subsamples,

as in the case of the differences between men and women

in the Stirling County integrated communities.

Findings regarding the functioning of systems of

support within a community are important for efforts to

understand the etiology of symptoms and the patterns for

coping with them. For certain groups, the absence of

sustaining "significant others" may increase the likeli-

hood that at times of heightened stress, symptoms will

develop or recur. Epidemiological study makes it pos-

sible to raise questions about the characteristics of

both the high-risk and the low-risk groups. As in-

creased attention is paid to the effects of desirable

and undesirable life change events among the low-risk and

high-risk groups in similar socioeconomic circumstances,

we should be able to understand why it is that some do

not succumb to noxious conditions while others develop

symptoms of disturbance.

An issue of special importance in epidemiological

research is the need to use, wherever possible, combina-

tions of data-gathering approaches which can strengthen

the interpretation of findings. For example, data about

the decreased use of folk curers, the absence of psychiatric

agencies in the community, and the use of family physi-

cians by Mexican Americans in Los Angeles pointed to

alternative explanations for findings about the under-

representation of this ethnic group in official records.

Leacock notes that community-based research is a most

fruitful way to study the relation between social environ-

ment and psychiatric disorder. This requires that in-

vestigators use broad epidemiological techniques as well

as complementary data-gathering approaches such as key

informant interviews, household surveys, or in-depth case
63
analyses. The data gathered through these combined

approaches provided the community context against

which to evaluate epidemiological findings.

CULTURE AND PATTERNS OF
CONFLICT RESOLUTION

As findings regarding indicators of stress have

begun to emerge, a critical complementary dimension re-

quiring attention is the process through which conflicts

which result from interference with basic strivings are

resolved. Conflict-solving mechanisms are guiding

forces in the behavior patterns followed by individuals

as they face the inconsistencies and contradictions of

their lives. With the help of these mechanisms, in-

dividuals respond to the perception of a threatening con-

dition, and they decide on potential avenues for its
64
solution or mastery. Culturally influenced conflict-

solving mechanisms help to determine what strategies a

given group of humans will use as they strive to antici-

pate and to master problems that arise in the various

circumstances of their lives.

White points out that all behavior can be considered

an attempt at adaptation, requiring strategies which

range "from the simplest ways of dealing with minor

problems and frustrations to the most complex fabric of

adaptive and defensive devices that has ever been ob-
65
served." Adaptation does not mean either a total triumph

over the environment or total surrender to it, but rather
66
a striving toward acceptable compromise.

The culture of any human group offers its members

guides about what to do in the face of the problems and

difficulties they encounter in daily life. Defenses,

mastery, and coping are mediating mechanisms which help

individuals to deal with major and minor problems of

adaptation.* Each culture provides a framework to guide

*Following White's definition, a defense is an "adaptive
response in which present danger and anxiety are of central im-
portance." Mastery is an adaptive response to problems having a
certain cognitive or manipulative complex but which at the same
time are not heavily weighted with. anxiety. Coping refers to
adaptation under relatively difficult conditions (R. White,
"Strategies of Adaptation: An Attempt at Systematic Description,"
pp. 48-49.)

individuals as to strategies that should be used when men

and women face problems. As Goldschmidt points out, man

as an adaptive being has learned to cope with an environ-

ment not only in terms of technology and knowledge but

also by means of institutions, values, attitudes, and
67
manifestations of personality. Differing demands and

experiences in cultural systems may result in variation

in the mediating mechanisms relied upon to resolve pro-

blems. As a result, for example, contrasts may be found

in the ways in which different peoples express affect

or emotionality, or in the extent to which direct or in-

direct action is used to resolve conflict.

Thus it would seem that, in this study of socio-

cultural factors and stress, knowledge of the character-

istic ways in which Latinos cope with stress would permit

a broadened understanding of the processes which con-

tribute to vulnerability and symptom development among

some Latinos and resilience and mastery over stress

among others.

The magnitude and pace of change which Latinos face

is not unique to them, for populations throughout the

world today are participating in equally rapid adapta-

tions within their own societies or in transnational

migration movements. Yet these realities underscore the

critical need, under such conditions, for understanding

the psychocultural strategies which permit men and women

56

to respond to symbolic and real transformations in their

lives. The Latinos who succeed in their efforts to im-

migrate and settle in the United States attribute this

to a number of factors such as the help of family mem-

bers, careful planning, or good luck with immigration
68
officials. But as Lifton and the Spindlers emphasize

the burden falls on the individual to establish guides

for behavior and to master the difficulties of changing

environments. An understanding of Latino strategies for

resolving conflict permits a broadened view of the forces

which contribute to their desired self-realization, as

well as to impairment and symptoms of disturbance.

CHAPTER 3

ENTRY AND SETTLEMENT
OF THE IMMIGRANTS

Entry into the United States is but one stage in a

continuing cycle of adaptation and change for Latin

American immigrants. Thus it is necessary to discuss

the dynamic aspects of crossnat-ional immigration and

settlement among Latinos who participated in this study.

Immigrants move across international boundaries and also

within the city to which they come. Major changes take

place in domestic units as families separate in order

to facilitate migration. To follow this complex pro-

cess, I have chosen to focus on the changes and realign-

ments in households and families as evidence of the

shifts involved in migration and settlement. Moreover,

since the domestic unit is the major context within which

health is defined and problems of illness are managed,

at this point it is useful to consider the complex ef-

fects of immigration on the household.

As the immigrants settle in Washington, they establish

nuclear or extended households. Even though some of these

households do not resemble the forms they had in the

country of origin, a strong pattern of interdependence

among members of households is clearly in evidence. For

some Latinos, the requirements of social life and the

guiding norms and values of the host city of Washington

call for fairly rapid assumption of new patterns in the

organization of domestic units. Others take years be-

fore they reestablish the household type which had been

familiar in Latin America.

Furthermore, the composition of a family naturally

changes with developments in the life cycle as children

grow up and parents grow older. Slightly over two-

thirds of the individuals in this study were women, and

most of them had migrated after they had begun to es-

tablish their households and to rear their children. If

a woman is to act as leader in a chain of migration, she

and many others must engage in careful planning, parti-

cularly as to the caretaking of children left behind and

of those brought to Washington.

Settlement in Washington means that the immigrants

become heavily committed to work for the advancement of

their children and for help to parents and siblings.

They hope that their children can join them in Washington,

but even if they do not, financial help and counsel must

be given during periods of crisis. As an example of the

dynamics of entering and settling in Washington, I will

sketch briefly the experiences of one family which cover

a span of approximately seven years. I shall then pre-

sent a detailed analysis of the population of my study as

to patterns of entry, characteristics of the families,

and compositions of households.

EULALIA MORA SETTLES
IN THE UNITED STATES

Eulalia Mora,* a fifty-four year old immigrant

from Central America, had first come to the United

States in 1969 to visit two daughters and two sons who

had preceded her and were living in Washington. In 1968

the elder daughter, twenty-eight year old Maria, had ac-

cepted an invitation to join friends who had come to

work in Washington. Leaving her only child in the care

of her mother, she entered the United States as a live-

in domestic with an American family who helped her to

secure a resident visa. She eventually married a man

from another Latin American country; each spouse brought

one school-age child by a previous marriage to their

newly established household. Both Maria and her husband

worked full time.

Helena, Eulalia's twenty-two year old daughter, ar-
/
rived in Washington in 1968, a few months after Maria's

entry. In order to come to the United States, she left

her son (age 3) in Eulalia's care. Helena hoped to do

well in Washington, so that she could eventually bring

both her child and her mother to live with her. This

*All names used in this book are pseudonyms. If the names
duplicate those of real persons, living or dead, this is entirely
coincidental.

meant that she would have to search for a job which would

qualify her for entry as a permanent resident. In

Central America, she had worked in various capacities,

such as clerical and sales work. She had entered the

United States with an A-3 visa, to work with a diplomatic

family.* After her arrival she found that she strongly

disliked the long hours involved in domestic live-in

work. But although she wanted to leave this job, she

stayed with it, because her visa limited her to jobs with

families in the diplomatic category.

Approximately a year after her arrival, Helena

sought the services of a lawyer to facilitate her plans

to apply for permanent residence in the United States.

He gave her advice regarding the jobs in high priority,

as listed by the U.S. Department of Labor, and helped

to fill out various application forms which were required

by this Department and by the Immigration and Naturali-

zation Service.** For these services, the lawyer charged

*An A-3 visa is a category extended through the Department of
State to persons such as domestics who work for families who are in
the United States as diplomats.

**The worker certification program was established and de-
veloped by the Department of Labor. A labor certification is a
"determination that sufficient qualified workers are not available
in the area of the United States to which the alien is destined to
perform the work in which he will engage, and that his employment
will not adversely affect the wages and working conditions of
residents of this country similarly employed." (U.S. Immigration
and Naturalization Service, Annual Report, 1974, p. 7.)

her $700. A few years passed before her application was

finally processed. Much to her joy, in 1973, she was

advised that her papers were ready. She went back to

her country of origin to wait for the "call" by the U.S.

consular officers who advise immigrants when they can

reenter the country as residents. She was particularly

happy because this would mean that she could bring her son

to the States with her.

In the meantime, two of Eulalia's sons, Rogelio and

Eugenio, aged twenty-six and twenty-two respectively,

had followed their sisters with the hope of improving

their economic status. In their country, Rogelio had

worked as a printer and Eugenio as a plumber. Upon ar-

rival in Washington they learned that unskilled food

service and cleaning jobs were more readily available to

them than specialized trades. As a consequence, they

have continued to work in unskilled jobs up to the pre-

sent. Eugenio married a woman from his own country, and

they have an infant son. A child of his by a previous

marriage remains in his country of origin under the care

of his former spouse, from whom he separated because of

reports of her unfaithfulness.

Eulalia and Mauricio, her sixteen year old son,

were the last members of the family to come to the United

States. After her first visit "to see what life was

like in Washington," she had returned to her country but

had decided that she would accept the invitation of her

children to immigrate.

When Eulalia first came to visit she stayed with

Helena. About this time, Eugenio married. Soon after

Eulalia returned home to prepare for her permanent re-

turn to Washington, Maria, her husband, and their child-

ren moved to a suburban townhouse complex whose tenants

were working-class families and students. Helena stayed

in Washington until she was joined by Eulalia and Mauricio.

She then rented an apartment in the same complex where

Maria lived and was joined by Eugenio, the married bro-

ther and his pregnant wife, who stayed with them until

a few months after the birth of the baby. He and his

family then moved to another apartment in the same area.

After Helena returned on a resident visa, with her mother

and son, they came to the same apartment complex. The

three now live there with Mauricio.
l
All of the adults in Maria's and Helena's households

work at some distance from their homes. Eulalia worked

for a short time. When she found her job too strenuous,

she decided to assume responsibility for the supervision

of her grandchildren when they came home from school.

Thus the process of entry of the Mora family --

Eulalia, her five children, and two grandchildren -- took

place over a period of seven years. The living condi-

tions of the Mora family seven years after entry

contrasted in several noticeable ways with the rooms in

live-in domestic jobs in which Maria and Helena had

started. The expansion and fission of the households

were shaped by life cycle events and their experiences

in Washington. The selection of places to live in the

city and the suburbs was made so as to facilitate and

support the bonds of reciprocity. While it was not pos-

sible to house the whole Mora family within a single

apartment, they lived so close together that kinship

ties were actively supported.

This glimpse of a seven year period underscores the

contributions of family members to the process of settle-

ment. The series of steps which permitted the members of

a household to enter, depart, and reestablish themselves

in the United States had to be planned and orchestrated

carefully. For example, Helena's dislike of her domestic

job with a diplomatic family had to be measured against

the cost and time required to secure resident status that

would give her greater freedom in the selection of jobs.

Retrospective descriptions of entering and settling

in Washington often brought to Eulalia memories of her

lifelong struggle to raise her family. Her own mother

had died when she was an infant, and her father did

"best as he could" with his limited means. Under these

circumstances, Eulalia went to school only a "couple of

years." After her marriage she worked at home at various

small businesses. When her husband left her, she start-

ed two home-based enterprises which gave her the income

needed to raise her children. For twenty-two years

prior to her decision to enter the United States, she ran

a comedor (dining room) where she served meals three

times a day. She also ran a small home-based store which

sold "a little bit of everything." Her cooking earned

her fame, and she herself believes that these experiences

taught her a great deal about life. She noted, for ex-

ample, that persons in business have to know about many

things, "especially figures and numbers," so that "peo-

ple don't cheat you." She had learned that in life "we

all have problems of one kind or another." What matters,

however, is that "we learn to face these problems" (lo que

hay que ver es como lo vamos afrontando). Eulalia be-

lieves that whether a person had good or bad luck in

life, he must be willing to face each problem and to over-

come it if he is to succeed.

PATTERNS OF ENTRY
INTO THE UNITED STATES

Most of the immigrants in this study came to the

United States to improve their general living conditions

and their economic situation. Some immigrants were moti-

vated by a desire to join relatives and friends; some had

a commitment to work with a specific preselected employer.

A few came for miscellaneous reasons such as a lifelong

ambition to come to this country, to undertake a course

of study, or because a previous marriage or business had

failed. In a number of cases, Latinos offered a combina-

tion of motives for entry.*

Washington was chosen as a first place of entry to

the United States by most respondents (78.6 percent).

Immigrants chose this particular city because they had

relatives or friends in the area or because they had pre-

arranged work agreements with employers. A few entered

for miscellaneous other reasons. Mothers who were single

or formerly married and had children twelve and under**

were motivated to enter largely by a desire to improve

their economic situation and to carve new opportunities

for themselves and for their children.. Their contact at

entry was usually a sibling, a friend, or an employer.

The families of immigrants did not move as a group.

The paths towards Washington were started by individual

*Sixty-six percent of the group came to the city because they
had relatives or friends in the area; 23.7 percent came with work
agreements; the remaining 10.0 percent came under miscellaneous con-
ditions.

**At the time of this study, there were twenty-four mothers
who were single or formerly married, with some children in the
birth-12 age group. Sixteen entered after one or more children had
been born in their country of origin. Six have had all their
children born here, and two separated after settlement here.

family members who would eventually bring relatives and

close friends to the area. There was nothing particularly

unusual about this "chain" migration of individual family

members since the history of immigration to the United

States is filled with such cases from all parts of the

world. It is important to remember, however, as noted

in Chapter 1 that the movement and settlement of the

Latinos in this study were led largely by women. More-

over, most of these women had begun to establish their

own households in Latin America prior to immigration, and

thus they were separated from children, husbands, or

other relatives for whom they had assumed some responsi-

bility. They represent a growing proportion of Latinos

who have received surprisingly limited attention in the

literature about new immigrants or in recent major works

about the people of Latin American heritage in the United

States.

Table 3-1 shows that women who came to this country

in the year ended June 30, 1974 constituted well over

half of the immigrants in the 20-39 age groups from the

Central American countries, Panama, and Colombia. In

these same age groups from Mexico, Peru, Ecuador, and

the Dominican Republic, men formed a slightly higher

proportion than women. It should be noted that these

statistics include immigrants who led the migration of

families and also those who entered as dependents. These

TABLE 3-1

WESTERN HEMISPHERE IMMIGRANTS ADMITTED TO THE UNITED STATES
BY SELECTED COUNTRIES OF BIRTH, SEX, AND SELECTED AGE,
YEAR ENDED JUNE 30, 1974

20-29 30-39 40-49 50-59
years years years years

Country of Birth Males Females Males Females Males Females Males Females Totals

Costa Rica
El Salvador
Guatemala
Honduras
Nicaragua
Panama
Colombia
Ecuador
Peru

Subtotals

Mexico
Dominican
Republic

2980 3976

10695 9144
1708 1807

Subtotals 12403 10951

Totals 15383 14927

1610 1954

4676 4479
1148 1012

5824 5491

7434 7445

508 915 238 623

1206
534

2252
694

1740 2946

2248 3861

769 1289
306 518

1075 1807

1313 2430

and Naturalization Service, Annual Report, 1974, pp. 45-46.

431
1305
1061
748
549
909
3660
2607
1534

12804

34510
7727

42237

55041

Source: U. S. Immigration

figures represent persons who established immigration

status for the year and do not include other groups of

aliens such as students, temporary visitors (e.g., tour-

ists), or undocumented workers.

Detailed examination of the history and sequence of

migration followed by Latinos and their "significant

others" in this study showed that in 68.9 percent of the

cases a female had been the first of the family group to

come to the United States. A good number of these women

had initiated the move after they had already established

conjugal relationships or had had children.* Such was

the case also for the men. In other words, this was not

a migration movement of single individuals who had not

yet assumed parental roles. It was led by individuals

-- both men and women -- many of whom had already entered

the phase of parenthood.

The initiative exercised by women as they became

the organizers and counsellors for other relatives

*Although women tended to lead the migration movement, there
are some differences in the proportions by male and female re-
spondents. Among the men, 46.2 percent had a woman such as a wife,
mother, or sister lead the migration of the group to the United
States, and in 34.6 percent of the cases the man himself, a male
relative, or friend had led it. Among women, in 74.7 percent of
the cases, another woman or the respondent herself had led the entry
to Washington.

In an analysis of trends in immigration and population growth
in the United States, Conrad Taeuber notes that more than two-thirds
of all immigrants to the country in the first decade of the Twentieth
century were male; in the decade of the 1960's, the percentage
dropped to 45. (Conrad Taeuber, "American Immigration and Popula-
tion Growth," p. 8)

who followed them to this country can be noted in the

case of Magdalena Torres, one of the school parents in the

study. At the time of the research, her household con-

sisted of her husband and herself, two children, and a

nephew. She worked as a beautician, although she had

entered as a domestic with an American family for whom

she had worked in her home country. Six months after

her arrival, she brought one of her sisters to Washington,

and a second sister followed a year later. Three adult

nephews -- sons of her sisters -- entered next. She then

succeeded in convincing her mother to come to visit them.

She and the two sisters and their families settled in

apartments located in the same block.

Magdalena and her husband were married in the United

States, but they had known each other in the home country.

Both had children by previous marriages. Her husband

left his children by the first marriage with their maternal

relatives, while Magdalena had brought her child to the

United States after she had settled here. At the time of

this research, she was involved in helping three other

nephews come to Washington.

This tendency to join kin or friends who were already

in Washington (noted also in the Mora family) points to

the strong influence of these types of networks in

Latino migration. This trend is reflected in statistics

about the immigration of family members to the United

States for the year during which this research was con-

ducted. In 1973, 63.3 percent of all Central Americans

admitted to the United States listed their occupation

as dependents, while 59.9 percent of all South Americans
1
fell in this same category.

Many of the immigrants who entered Washington under

prearranged agreements (such as domestics) came in with

the families directly from their country of origin.

Magdalena, for instance, had met and worked for her em-

ployers in her Central American home city, and this fam-

ily subsequently brought her with them to Washington.

In other cases, persons with friends in Washington,

such as Maria Mora, had originally solicited their help

to locate work. Usually careful prearrangements were

made in order to ensure a successful move. Margarita

Hernandez, a school parent, had consciously chosen to

remain at her job as a highly skilled seamstress in her

country for a period of five years because she knew that

this type of labor would qualify her for entry to the

United States. During this period, she was in active

correspondence with a girlfriend who located employers

willing to give her a work contract. Thus she came in

with an approved resident visa, and after she was settled

in her own apartment she brought her children to live

with her. Her husband remained at home. Margarita used

the move to Washington to separate from him because of

longstanding incompatibility.

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