Use of Curanderismo in a Public Health Care System FREE

ALTERNATIVE MEDICINE and its therapies have become increasingly popular during the past decade. Information concerning these therapeutic forms of healing in the United States can be found in medical textbooks, brochures for healing groups, and a burgeoning variety of different medical information sources.¹ In 1990, a national survey conducted by Eisenberg et al² found that 33.8% of 1539 adults, which would extrapolate to approximately 60 million Americans, had tried at least 1 of 16 alternative procedures or therapies, including such practices as acupuncture, chiropractic, spiritual healing, herbal medicine, or folk remedies, within the past year. An additional one third of this subset of Americans were thought to have visited a nonphysician provider who practices alternative techniques on 1 or more occasions.² A national follow-up survey of 2055 adults, conducted again by Eisenberg et al,³ in 1997 revealed that 42.1% of the subjects, which would extrapolate to 83 million Americans, had used at least 1 of the same 16 forms of alternative therapy in the previous year.

A form of alternative therapy that tends to be used by Hispanic subjects is the ancient practice of curanderismo. Curanderismo is a diverse folk healing system of Latin America. It began with the Aztecan, Mayan, and Incan tribes and their religious beliefs of harmony with nature, spirit, and self. The Mexican Indians had many gods; they believed that their gods punished sins with illness. Therefore, disease or illness was supernatural in nature. As a balance, some mortals, who were spiritually chosen, were given the power to heal the wounded spirit and cure the supernatural illness. This is the role of the curanderos and curanderas.

A study⁴ based on interviews with 16 curanderos in California revealed that a typical curandero is in his mid-50s, is married, and has had 5.5 years of schooling, including some special training. Their fees are usually in the form of donations, and they have an income derived from sources other than curing.⁴Curanderos typically live in the neighborhood where they practice. The setting for their practice is often their home. They generally use prayer, massage, herbs, and reassurance to treat their patients. In addition, curanderos frequently share their patients' social class, background, language, and religion.⁵

Curanderos and their patients concurrently use the services of the old and traditional medical systems. Curanderos are not expected to treat the major medical problems of their clients. As a result, if asked to treat a case that is clearly beyond their abilities, a reliable curandero will refer the patient for traditional medical care.

Hispanics constitute about 11.4% of the US population, or roughly 31.1 million people, and are the single fastest-growing minority group in the United States.⁶ Hispanics in Denver, Colo, make up 23.3% of the population. Previous studies^7- 12 have estimated that 2% to 70% (mean, 24%) of Hispanics have visited a curandero. It is estimated that there are 150 to 200 curanderos in the Denver metropolitan area. There are no available figures on the number of curanderos in the entire United States. Since there is a large Hispanic population along with numerous curanderos in Denver, we assessed the use of curanderismo in Hispanic subjects attending outpatient medical clinics for routine and urgent health care.

An administered survey was conducted by a single research assistant (V.G.) from October 5 through December 18, 1998, at 13 different outpatient satellite clinics affiliated with Denver Health Medical Center, the public safety net hospital for Denver. Approximately 39% of the total patient population served by Denver Health Medical Center and its affiliated clinics are Hispanic.

Candidate subjects were identified based on their Hispanic surname during registration for their clinic appointments. They were then approached about their desire to participate in the survey while in the clinic's waiting room. The survey was available in English and Spanish. The only exclusion criteria were non-Hispanic subjects and subjects younger than 18 years. Subjects were paid $5 for a completed survey, and they were limited to 1 survey per person.

The survey consisted of a 2-page, 22-question document that gathered the following information: age, sex, ethnicity, level of education, primary language, whether bilingual, number of years in the United States, country of origin, marital status, employment status, history of use of a curandero, type of problem treated by a curandero, treatment outcome, frequency of use of curanderos, and overall satisfaction with curanderos. No interventions were performed. Subjects were considered to be bilingual if they spoke English and Spanish at home or with their physician.

Descriptive data analysis was performed using standard techniques, means ± SDs, and percentages. The percentage and corresponding 95% confidence interval (CI) was calculated for the use of curanderismo. Univariate analyses were performed for subjects who had been to a curandero and for those who had not. For univariate comparisons, a 2-sample t test was used when the variable was continuous. If the variable was categorical, a χ² analysis was performed. Multiple logistic regression was performed to evaluate the effects of independent variables (age, sex, level of education, amount of time spent living in the United States, primary language, bilinguality, country of origin, marital status, and household income) on use rates. Odds ratios and the corresponding CIs were calculated from the logistic regression variable estimates.

A total of 405 subjects were included in the survey. The demographic features of this group are defined in Table 1. Of 399 subjects, 352 (88.2%) were Denver Health Medical Center patients or associated with patients and 47 (11.8%) were clinic employees. Three hundred sixty-nine (91.1%) of the subjects claimed to know what a curandero was.

Of the 405 subjects, 118 (29.1%) (95% CI, 20.9-37.3) had been to a curandero at some time in their lives. Of those who had been to a curandero, 48 (40.7%) had been to one within the past year and 75 (63.6%) had been to one within the past 5 years. The overall 1- and 5-year use rates of curanderos in our study were 11.8% and 18.5%, respectively. When those who had been to a curandero were asked if their physician knew that they visited curanderos, 96 (81.4%) responded no, yet 86 (72.9%) believed that they benefited from seeing a curandero. Univariate analysis demonstrated an association between those who had been to a curandero and level of income, level of education, and whether the subject was bilingual (Table 2).

Results of fitting a multiple logistic regression model for use of curanderismo are presented in Table 3. Variables that are independently associated with use of curanderismo are level of education, level of household income, current age, and being bilingual.

Performance of a stepwise logistic regression model revealed an independent association between subjects who had been to a curandero and level of education (post–high school vs elementary school: odds ratio, 3.16; 95% CI, 1.45-6.86) and level of income (>$20 000 vs <$10 000: odds ratio, 2.19; 95% CI, 1.20-4.01).

Table 4 lists frequencies of problems evaluated by curanderos for our study group. Headache was most common, followed by empacho (pseudointestinal obstruction), nervios (nerves), and susto (fright). The following problems were listed 1 time by study subjects as being treated by curanderos: impotence, assistance with allergies, drug problems, arthritis, constipation, and palpitations.

The results of this study serve to reinforce that many Hispanics use the services of curanderos. This is important to know because Hispanics are the second largest and the fastest-growing minority group in the United States.⁶ Most of the previous studies^7- 12 are limited by a small sample size and wide variations in the degree of use of curanderos. The Hispanic Health and Nutrition Examination Survey is the largest study on this subject to date and included a survey from 1982 to 1984 of 3623 Hispanic subjects from the southwestern United States.¹³ In that study, the use rate of curanderos within the 12 months before the study period was 4.2%. The second largest of these past studies¹⁴ included 434 foreign-born subjects who were presenting for medical care at rural east Washington State migrant health clinics. Skaer et al,¹⁴ in 1996, found in this study that 21.4% of their subjects had been to a curandero within the past 5 years. Our study was conducted in an urban area with a similar number of subjects, although our study population was different from the foreign-born study population in the Skaer et al study in that 39% of our subjects were born in the United States, yet our overall 5-year use rate was similar, at 18.5%. This is consistent with the finding in our study that the amount of time spent living in the United States, which could be used as a surrogate marker for the degree of acculturation of the foreign-born subjects, did not have a significant impact on decreasing use in our study. The population in our study is similar to the population used in the Hispanic Health and Nutrition Examination Survey study, yet it is unclear why there is such a disparity in the degree of use of curanderos at 1 year in both studies.

Since Denver has a large Hispanic population and numerous practicing curanderos, it is apparent that these services are frequently being used. This has important implications for the Hispanic population because, despite the progress that has been made to improve access to health care, differences remain between Hispanic and non-Hispanic whites in health outcomes.^15- 17 For example, type 2 diabetes mellitus is more prevalent in this population,¹⁸ and Hispanics have an increased prevalence of diabetic retinopathy¹⁹ and diabetic end-stage renal disease.²⁰ Significant cultural and attitudinal issues associated with the use of curandero services could hinder efforts to improve care to Hispanic patient groups who are often beset with many long-term health problems.

Data from the Hispanic Health and Nutrition Examination Survey suggested that interviews conducted only in Spanish, along with dissatisfaction with modern medical care, predicted curandero use.¹³ Skaer et al¹⁴ also found that Spanish as the language of preference, having resided in the United States from 1 to 5 years, and having received medical care in Mexico within the prior 5 years also predicted use of curanderos. Nall and Spielberg⁹ found that not being married, not knowing most of the people in one's neighborhood, and being 39 years old or younger all predicted the use of curanderos. Our study revealed that being bilingual in English and Spanish was associated with a higher use rate of curanderos. We also found that at least some post–high school training and a somewhat higher household income predicted use of curanderos. Interestingly, as previously noted, level of assimilation, as defined by the amount of time spent living in the United States, was not a significant predictor of use in our study or in the Hispanic Health and Nutrition Examination Survey study. Reasons for this are not exactly clear, although it may be that certain cultural beliefs are not readily relinquished.

It is evident from this study that curanderos attempt to give therapy for a diverse range of problems. Many of these problems have a strong emotional component to them. As stated earlier, one of the basic tenets of curanderismo is that illness is the result of the punishment for a sin. There is no dichotomy between emotional and somatic illness. It is natural to process emotional problems through their somatic aspects.²¹ It is with these types of problems that curanderos can be of the greatest utility for patients. Their use of ritual prayer, massage, and reassurance does not place subjects at significant risk of medical complications and can provide substantial relief for what often turn out to be long-term complaints with a lot of psychosocial overlay. The use of herbal preparations could, however, occasionally be problematic if not used appropriately and with caution. Furthermore, some of the problems treated by curanderos may have significant medical causes. The fact that headache was the most common problem treated by curanderos in our study group is concerning as there may potentially be some serious pathological features that may go unchecked for a long period if not evaluated by a trained medical professional. The same applies for the evaluation of abdominal pain, back pain, kidney problems, and diabetes, all of which were identified as problems that our study subjects had treated by curanderos. Therefore, it is of utmost importance that a curandero knows when to refer a patient for more traditional medical care. This also reinforces the importance of physicians knowing when their patients might be using the services of curanderos. Keeping the lines of communication open with patients about their use of the services of alternative therapy practitioners is essential.

Our finding that most subjects who had been to a curandero had not informed their physician that they use these services has also been found in previous studies. Eisenberg et al^2- 3 found this to be true in 60.2% and 61.5% of the subjects who used alternative therapies in 1990 and 1997, respectively. This is a concerning statistic that is due, in large part, to physicians and allied health professionals not being trained or accustomed to inquiring about the use of alternative therapies when taking histories from patients. In response to this problem, Carrillo et al²² have developed a cross-cultural, patient-based curriculum that teaches a framework for analysis of an individual patient's social context and cultural health beliefs and behaviors.

In summary, although dealing directly with a patient's cultural view of his or her illness may complicate therapy by introducing new variables, one obvious benefit of doing this is establishing a better therapeutic alliance with the patient. A better therapeutic alliance leads to more optimal patient compliance, which improves the effectiveness of medical treatment. Our study demonstrates that many Hispanic patients are using curanderos, and many of these patients are not telling their physician about these visits.

The successful delivery of health services to Hispanics must involve an open discussion of health perceptions and practices. It is clear that race and ethnicity are powerful determinants of health outcomes, especially when cross-cultural interventions are involved. There is a need for a greater understanding of these cultural health beliefs to help reduce variations in care that may be contributing to inequities in the health care of the US population. There is also a need to determine whether curanderismo can assist with the successful implementation of culturally sensitive health interventions in chronic disease management and with the receipt of preventive services.

Accepted for publication October 2, 2000.

This study was supported by the small grants program at the Division of General Internal Medicine, Department of Medicine, University of Colorado Health Sciences Center, Denver.

Corresponding author and reprints: Ricardo Padilla, MD, Westside Family Health Center, Denver Health Medical Center, 1100 Federal Blvd, Mail Code 3000, Denver, CO 80204 (e-mail: rpadill@dhha.org).