African American Alternative Medicine : Using Alternative Medicine to Prevent and Control Chronic Diseases 9780313012853, 9780897897471

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African American Alternative Medicine Using Alternative Medicine to Prevent and Control Chronic Diseases

Eric J. Bailey

BERGIN & GARVEY Westport, Connecticut • London

Library of Congress Cataloging-in-Publication Data Bailey, Eric J., 1958– African American alternative medicine : using alternative medicine to prevent and control chronic diseases / Eric J. Bailey. p. cm. Includes bibliographical references and index. ISBN 0–89789–747–1 (alk. paper) 1. African Americans—Health and hygiene. 2. Alternative medicine. 3. African Americans—Diseases—Alternative treatment. I. Title. RA448.5.N4B248 2002 615.5′089′96073—dc21 2002025203 British Library Cataloguing in Publication Data is available. Copyright © 2002 by Eric J. Bailey All rights reserved. No portion of this book may be reproduced, by any process or technique, without the express written consent of the publisher. Library of Congress Catalog Card Number: 2002025203 ISBN: 0–89789–747–1 First published in 2002 Bergin & Garvey, 88 Post Road West, Westport, CT 06881 An imprint of Greenwood Publishing Group, Inc. www.greenwood.com Printed in the United States of America

The paper used in this book complies with the Permanent Paper Standard issued by the National Information Standards Organization (Z39.48–1984). 10 9 8 7 6 5 4 3 2 1 Copyright Acknowledgment The author and publisher gratefully acknowledge permission for use of the following material: Excerpts from Eric J. Bailey, Medical Anthropology and African American Health (Westport, CT: Bergin & Garvey, 2000).

Contents Preface Acknowledgments

vii ix

Part I. The Current Status of Alternative Medicine

1

1 Alternative Medicine in the United States

3

2 Mainstream American Alternative Medicine

15

Part II. Alternative Medicine and African Americans

31

3

African American Alternative Medicine

33

4

Cultural Historical Review of African American Alternative Medicine

51

Part III. How to Do Applied Medical Anthropological Fieldwork 5

Strategies for Collecting Qualitative Alternative Medicine Data

61 63

Part IV. Disease-Focused Alternative Treatment Practices: Research Including African Americans

85

6

Hypertension and Alternative Treatment Therapies

87

7

Cancer and Alternative Treatment Therapies

99

8

Diabetes Mellitus and Alternative Treatment Therapies

111

vi

9 10

Contents

Cerebrovascular Disease (Stroke) and Alternative Treatment Therapies

121

Mental Health and Alternative Treatment Therapies

133

11 Conclusion: Culture and Alternative Medicine

145

Index

153

Preface African American Alternative Medicine: Using Alternative Medicine to Prevent and Control Chronic Diseases is another teaching text and resource guide for students, health care professionals, health care researchers, health care policy makers, and the general public that examines alternative medical belief systems and practices from an African American perspective. As I completed my first book with Greenwood Publishing (Bergin & Garvey imprint, 2000), Medical Anthropology and African American Health, I realized a unique opportunity to examine another compelling research issue associated with African Americans—alternative medicine. Although I had become aware of this issue years earlier when I was collecting my qualitative and quantitative health data among Detroit African Americans from 1984 to 1987 in a hypertension/health belief study, I was not aware of its significant role in health care seeking, health disparity, and, in particular, preventive health care maintenance among African Americans. In addition, after I gave presentations, talks, and discussed the major themes of that book with individuals, groups, reporters, and other experts, I saw the “desperate need” to research alternative medicine in the United States, especially from an African American perspective. Thus, this book is actually an outgrowth of research issues related to my last book, as well as of comments, questions and inquiries from the public, and the general lack of serious public dialogue, public policy, and research agenda for African American alternative medicine and its potential in reducing and preventing major chronic diseases in the United States. Therefore, the major goal of this book is to examine African American alternative and complementary therapies from a clinical and cultural relativistic perspective.

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Specifically, Chapter 1 discusses Americans’ current use of alternative treatment therapies, the major research agency in charge of investigating alternative medicine in the United States, and one of my early studies highlighting the use of alternative medicine among African Americans. Chapter 2 reviews the major mainstream American alternative medical systems, their origins, and how they are currently organized. Chapter 3 highlights two recent studies on alternative medicine involving African Americans and discusses the reasons for using alternative medicine within the health belief system of African Americans. Chapter 4 examines early African American medical practices from documents describing the health care practices of enslaved and free African Americans in the United States. Additionally, recent studies showing the use of African American alternative medical practices are highlighted for the purpose of showing a connection between current African American alternative medical practices and early African American medical practices. Chapter 5 discusses the basic strategies for conducting applied medical anthropology studies and how they can be used to collect qualitative alternative medicine data. Qualitative ethnographic strategies used in clinical, public health, and community settings are highlighted. In addition, I discuss ethical issues in the context of being an African American health care researcher who studies African Americans. Chapters 6 through 10 examine five major chronic diseases/disorders such as hypertension, cancer, diabetes mellitus, stroke, and mental health and the current alternative medical practices that have been documented to be effective in preventing or reducing their development among African Americans. Chapter 11 discusses the connection between culture and African American alternative medicine and how various alternative medical practices can help to improve overall health status and reduce health disparity in the United States. Each chapter begins with Critical Thinking Questions and ends with Post-Evaluation Questions.

Acknowledgments First and foremost, I want to thank all of the students, researchers, policy makers, family members and friends who responded to my first book with Greenwood Publishing, Medical Anthropology and African American Health. Your comments and thoughts helped me not only to re-examine that book but also to develop the foundation and approach to this book on alternative medicine. I want to thank also Greenwood Publishing, Jane Garry, and Shana Grob for their continual support of my various book projects. While I am still conducting fieldwork in the U.S. Public Health System, I want to thank the entire academic community for continuing to stimulate my research endeavors with opportunities to present my medical anthropological studies and approach to all types of academic audiences. As always, I give my respect and guidance to my family members past and present: my outstanding mother, Jean Bailey, father, Roger Bailey, and very supportive brothers, Dwight Bailey, Ronnie Bailey, Billie Bailey, and Michael Bailey. Finally, I want to thank my incredible family for following me around from state to state and supporting my applied research endeavors over the many years—my wife, Gloria, daughter, Ebony, son, Darrien, and new son, Marcus Marcelus.

Part I

The Current Status of Alternative Medicine The first section of the book introduces you to the field of alternative medicine and the major factors influencing its rising use in the United States. My approach challenges the current structure, organization, and research orientation of this field primarily because they purposefully omit the significant role of culture and ethnicity in alternative medicine’s early beginnings and its growth in mainstream America. An overview of the major mainstream American alternative medical practices is provided.

Chapter 1

Alternative Medicine in the United States CRITICAL THINKING QUESTIONS 1. Why do you think there has been an increased interest in alternative medicine within the recent decade? 2. What are the major factors for alternative medicine’s increased use in the United States? 3. Which agency or institutions are responsible for investigating alternative medicine in the United States? 4. Why has African American alternative medicine not received much attention when Americans think of alternative medicine?

INTRODUCTION Americans’ Use of Alternative Treatment Therapies Recently, there has been a virtual explosion of interest in alternative and complementary medical treatment therapies in the United States. Everywhere you turn now, alternative medical practices and therapies are promoted and used by many more people than ever before. During the past 10 years, the number of published research articles on alternative medicine in medical journals has increased ten-fold. In the same period, the number of trade books published on this topic has increased fifty-fold. In addition, Americans’ hunger and interest in alternative medicine have influenced the U.S. health and medical systems to drastically change their approach to basic health and medical care for all Americans. For instance, a 1990 national survey of alternative medicine revealed that alternative medicine has had a substantial presence in the U.S. health

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care system (Eisenberg et al. 1993). Eisenberg et al. (1993) conducted a national sample of 1,539 adults 18 years of age or older and found that one in three respondents (34%) reported using at least one unconventional therapy in the past year, and a third of these saw providers for unconventional therapy. The frequency of use of unconventional therapy varied somewhat among sociodemographic groups, with the highest use reported by nonblack persons from 25 to 49 years of age who had relatively more education and higher incomes. The majority used unconventional therapy for chronic, as opposed to life-threatening, medical conditions. Among those who used unconventional therapy for serious medical conditions, the vast majority (83%) also sought treatment for the same condition from a medical doctor. However, 72% of the respondents who used unconventional therapy did not inform their medical doctor that they had done so (Eisenberg et al. 1993: 249). Eisenberg et al. (1993) found that roughly 1 in 4 Americans who see their medical doctors for a serious health problem may be using unconventional therapy in addition to conventional medicine for that problem, and 7 of 10 such encounters take place without patients telling their medical doctors that they use unconventional therapy. Furthermore, use is distributed widely across sociodemographic groups (Eisenberg et al. 1993: 251). Interestingly, Eisenberg et al. (1998) conducted a follow-up study and interviewed 2,055 in 1997. The interviews were presented as a survey conducted about the health care practices of Americans by investigators from Harvard Medical School. The 1997 survey also asked about use for a representative sample of other medical conditions and expanded the list of therapies beyond the original 16 assessed in 1990 (Eisenberg et al. 1998: 1570). Eisenberg et al. (1998) found that their survey confirmed that alternative use and expenditures increased dramatically from 1990 to 1997. Specifically, the use of alternative therapies in 1997 was not confined to any narrow segment of society. Rates of use ranged from 32% to 54% in the wide range of sociodemographic groups examined. Use was more common among women (48.9%) than men (37.8%) and less common among African Americans (33.1%) than members of other racial groups. The 1990 survey estimated that 33.8% of the U.S. adult population (60 million people) used at least 1 of the 16 alternative therapies, while the 1997 survey estimated that this proportion increased significantly to 42.1% (83 million people). The largest increases were in the use of herbal medicine, massage, megavitamins, self-help groups, folk remedies, energy healing, and homeopathy (Eisenberg et al. 1998: 1571). In addition to examining the increased use of alternative therapies by the U.S. adult population, Eisenberg et al. (2001) recently examined the perceptions of complementary therapies relative to conventional therapies

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among adults who use both. From their 1997 national survey of 831 adults who saw a medical doctor and used complementary and alternative therapies, they found some startling results: • Roughly 4 of 5 (79%) respondents agreed that using both conventional and alternative therapies is better than using either one alone; • For respondents who saw a Complementary Alternative Medicine (CAM) therapy provider and a medical doctor, 41% agree that their CAM provider was a better listener, and 52% disagreed; • 42% agreed that their CAM provider did a better job explaining their medical conditions, and 56% disagreed; • Seven out of ten respondents reported typically seeking the services of a CAM provider after or concurrent with their visits to a medical doctor; and • 63% did not disclose use of at least one of their CAM therapies, and 28% disclosed all of their three or fewer CAM therapies.

It is interesting that respondents agreed with the following statements as to their reasons for not disclosing the use of CAM therapies to their medical doctors: “It was not important for the doctor to know.” “The doctor would not understand.” “None of the doctor’s business.”

These statements and data results are strong evidence that American adults are opting out of the “traditional belief pattern” that the medical doctor is the one and only source for health care treatment and understanding. They reveal a changing pattern of seeking care from alternative and complementary therapists. In fact, Eisenberg et al. (2001) suggest the following: Collectively, these data suggest that many patients, in their capacity as consumers of care, view medical doctors as members of a larger, patient-selected health care team. Increasingly, medical doctors are being viewed as one of several professionals whom the average adult seeks for advice or treatment of health-related matters. This is consistent with societal trends toward increased autonomy and personal responsibility for one’s health. A deeper understanding of the extent to which these perceptions are affecting CAM use and disclosure will require additional qualitative and quantitative investigation. (350)

Since more Americans are using alternative and complementary therapies, the question arises: What are the sociocultural factors (level of income and/or ethnic group health beliefs, attitudes, motivations) underlying a person’s decision to use alternative therapies?

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African Americans’ Use of Alternative Treatment Therapies Although the previously mentioned studies included African Americans, the findings are still somewhat incomplete as they relate to the African American community. In order to uncover a more detailed and in-depth analysis of African Americans’ use of alternative medicine, Boyd, Taylor, Shimp, and Semler (2000) conducted the first national analysis of family and individual use of home remedies by African Americans. The major purpose of this study was to assess the relationship between sociodemographic characteristics and home remedy usage for African American families and individuals. The African American data originated from the National Survey of Black Americans (NSBA), a nationally representative cross-sectional sample of 2,107 adult (18 years old and older) African Americans living in the continental United States in 1979 and 1980. In this analysis, “users” of home remedies were those respondents who indicated they used home remedies all the time or sometimes, whereas “nonusers” were those respondents who indicated that they never used home remedies. The data were analyzed from two perspectives: use of home remedies by the respondent’s families and use of home remedies by the respondent (Boyd et al. 2000: 343). The demographic data for the 2,107 respondents revealed that 29.6% were less than 30 years of age while 16.1% were 65 years of age or over; only 37.8% were men; almost one half of the respondents (46.3%) had less than a high school education, whereas 8.7% graduated from college; approximately 40% reported an income of less than $5,000 and only 6.1% reported an individual income exceeding $20,000; the most prevalent marital status was married; over one half (53.4%) were residents of the South while 5.9% resided in the West; approximately 8 out of 10 (79.0%) respondents resided in urban areas. Boyd et al.’s (2000) major findings were as follows: • 69.6% of respondents reported that their families used home remedies; • 35.4% of respondents reported that they used home remedies; • Of the preparations used, 68.2% were home remedies or herbal preparations; • Among preparations, 15.1% were nonprescription drugs; and • 16.7% of preparations could not be placed into one of the aforementioned categories and were classified as “others.”

The major sociocultural factors that were found to have a significant association with families’ use of home remedies included: family size, mother’s education, father’s education, importance of religion to the family, living with grandparent, and living in a rural area and southern geographic region of the country. For example, in the case of family size,

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families with 1 to 3 children were 35.4% less likely to use home remedies than were families with 7 to 20 children. Additionally, bivariate analysis found the following significant associations: • Males were 47.4% less likely to use home remedies than females; • Individuals not living with a grandparent as a child were 26.3% less likely to use home remedies than individuals living with a grandparent as a child; • Individuals living in the northeast region of the United States were 33.1% less likely to report that their families used home remedies than were people living in the South; • Families in which the father had 11 years or less of education were 77% more likely to use home remedies than were families in which the father had some college or a college degree; • Individuals who reported religion as being only fairly important or not too important to their families were 38.3% and 53.3% less likely to report that their families used home remedies than were individuals who reported that religion was very important to them; • Individuals not living with a grandparent while growing up were 37.9% less likely to report that their families used home remedies than were individuals who lived with their grandparent while growing up; and • Individuals who reported living in a non-rural area were 28.5% less likely to report that their families used home remedies than were individuals living in a rural area.

Although Boyd et al. (2000) stated that their study’s findings among African Americans showed some consistency with other studies, one major advantage was the richness of the data in addressing the study objectives. First, their study provided the first national examination of home remedy use by African Americans. Second, the many variables included in the data set allowed for closely examining the family and individual sociodemographic characteristics of African Americans. Finally, the analysis raises interesting points about self-medication among a diverse group of African Americans and is relevant to the increased interest in self-care, ethnopharmacology, and alternative medicine. GOVERNMENT’S INTEREST IN ALTERNATIVE MEDICINE Since alternative and complementary treatment therapies have established such a solid position with the general public, the U.S. Congress felt compelled to find out why so many Americans are seeking alternative and complementary therapies not just for minor illnesses but for specific diseases. Thus, in 1992, the U.S. Congress funded a permanent research Center in the National Institutes of Health (NIH) to investigate scientifically alternative and complementary treatment therapies.

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Initially called the Office of Alternative Medicine (OAM) and now the National Center for Complementary and Alternative Medicine (NCCAM), the Center’s sole purpose is to facilitate the evaluation of alternative medical treatment modalities to determine their effectiveness. Congress also mandated that this Center provide a public information clearinghouse and a research training program. Thus, the mission of the NIH NCCAM is to conduct and support basic and applied research and training and disseminate information on complementary and alternative medicine to practitioners and the public. The NCCAM focuses on the following efforts: • Evaluating the safety and efficacy of widely used natural products such as herbal remedies and nutritional and food supplements (e.g., megadoses of vitamins); • Supporting pharmacological studies to determine the potential interactive effects of CAM products with standard treatment medications; and • Evaluating CAM practices such as acupuncture and chiropractic.

At the National Institutes of Health, NCCAM works toward the following goals grouped under three main headings: Research, Research Training, and Communication. The goals for each of three main objectives of the NCCAM are as follows: Research • Collaborate with other NIH Institutes and other Federal agencies to advance CAM scientific study; • Identify and investigate promising, understudied areas; • Establish a global network for CAM research.

Research Training • Implement a comprehensive research-training plan; • Provide research training and clinical fellowships; • Educate CAM scientists about biomedical research methods; • Educate conventional researchers about the nature and principles of CAM.

Communications • Establish effective partnerships with CAM researchers, health professionals, and the public; • Collaborate on CAM information dissemination with other NIH institutes and other federal agencies;

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• Distribute scientifically based information about CAM research, practices and findings to health care providers and consumers.

The first-year goals for each center included the development of an organization structure and operating plan. The second and third years focused on the execution and evaluation of programmatic objectives. These centers also allowed alternative medical practitioners and research scientists to conduct specific joint research projects. However, at the Senate Appropriations/Department of Health and Human Services Subcommittee hearing on alternative medicine on March 28, 2000, Senator Tom Harkin noted that NIH’s National Center for Complementary and Alternative Medicine receives about $67 million annually, which is less than one-half of 1% of the total funding for the entire NIH budget. Furthermore, Harkin asserted that he was skeptical about NIH institutes supporting as many CAM projects as they claim (“NIH Should Increase” 2000). The primary reason for highlighting NIH’s National Center for Complementary and Alternative Medicine is to show that despite the public’s increased interest in, use of, and demand for alternative and complementary medicine, federal funding for alternative and complementary medicine remains a low budget priority. To what degree does Congress actually perceive the need to seriously fund research on alternative and complementary medicine and what sociopolitical priority does it have within the general discussion of truly eliminating the health disparity among so many specific populations, particularly African Americans in the United States? This is obviously a national public health and medical issue that must be addressed, better understood, and seriously re-examined in light of its relationship to how people normally seek care in our country. Do they opt immediately to seek care from a conventional physician and/or nurse practitioner, or do they opt for an alternative and/or complementary treatment therapist such as chiropractor, nutritionist, herbalist, massage therapist, fitness expert, or self-therapist? This is the basic question that the NCCAM should be able to answer—both clinically and culturally! MY RESEARCH INTEREST IN ALTERNATIVE MEDICINE As a medical anthropologist who was unaware of the relatively high use of alternative medicine among the general public and particularly the African American community, I was confronted with this issue during a 1985–1986 fieldwork project in Detroit, Michigan. For this fieldwork project, I interviewed 285 African Americans at seven sites in the Detroit metropolitan area for the purpose of examining their health care treatment patterns.

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Of the 285 interviews, four case studies related directly to the increased use of alternative and complementary treatment therapies among African Americans. Their cases are as follows: Informant 54: A middle-aged African American man with a history of essential hypertension who uses sassafras and leaf teas in treating his slightly elevated blood pressure. Although under doctor’s care, he continues his folk treatment regimen in conjunction with his physician’s prescribed medication because, “If I tell him that I am using herbs, he would think that I was silly.” (Bailey 1988:1110) Informant 4: A 59-year-old African American woman who practices a folk care regimen (vinegar and herbal teas) to treat her high blood pressure and believes that one’s health is the responsibility of the individual, not the physician. Moreover, her lack of information about the seriousness of high blood pressure and the hereditary component of hypertension had delayed her from seeking health care from medically trained professionals. (Bailey 1991: 293) Informant 31: A 44-year-old, middle-income African American health care professional, she adhered to a folk ethnomedical treatment pattern as well as the mainstream treatment pattern. A native Detroiter, this woman received her medical training from a local university and thereafter served as a nurse clinician for 10 years at a major urban hospital. She eventually became disenchanted with the clinical aspect of the medical field and switched to the health insurance field because she felt that it would better serve the African American community. (Bailey 1991: 293)

As a divorced parent, informant 31 was assisted by her extended family network in raising her two children; her parents, brothers, sisters, and great aunt all assisted in the care of her children. Although she received training and worked in mainstream health care facilities for 20 years, she often sought advice for treating minor and serious illnesses from extended family members. For instance, symptoms associated with high blood pressure (headaches, blurred vision, and throbbing pain) were treated with white potatoes around the back of the neck and eyes in an effort to absorb the pain. If the pain persisted, aspirin and leaf tea were taken in varying amounts. This informant learned and adhered to these treatment remedies not from her training in the medical field but from her great aunt and the local folk practitioner (Bailey 1991: 293). The case of another woman typifies a majority informant’s relationship with alternative medical therapies with hypertension. Diagnosed with borderline hypertension in her thirties, this elderly woman attempted to adhere stringently to the antihypertensive regimen prescribed by her physician. During the past 33 years, however, her blood pressure had increased steadily (to 160/90 mmHg), thereby causing her to question the physician’s antihypertensive therapy. Although her physician suggested

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a number of behavioral modifications, the informant’s non-awareness of the risk factors associated with hypertension (family history, cholesterol, and obesity) and the financial, logistic, and ethnically influenced inability to make the adjustments to mainstream health care patterns allowed her to discredit the efficacy of the treatment therapy and search for other means (home remedies) to control her blood pressure. This informant emphasized frequently that as a senior citizen she simply did not have the time or energy to make the type of behavioral modifications that her doctor requested. As she stated, “I’m in charge of 40–50 senior citizens who can barely take care of themselves. How can I afford the time and money to look for the things that my doctor said? I have too many people depending on me just to survive. Besides, my herbs and teas have been doin’ me just fine” (Bailey 1991: 293). The individual personal accounts of informants heightened my interest in learning more about African Americans’ use of alternative and complementary treatment therapies. Key questions that come to mind with regards to their use in the African American community are: • What are the various types of alternative and complementary therapies actually used on a regular basis in the African American community? • Who are the individuals most likely to use alternative and complementary treatment therapies in the community? • Which alternative and complementary treatment therapies are truly effective in the African American community? • Which alternative and complementary treatment therapies originated in the African American community? • Do African Americans share similar belief systems with mainstream Americans as to the use of alternative and complementary therapies?

All are important questions that need to be answered if we as a country and we as researchers are truly concerned about alternative and complementary treatment therapies for all people, particularly African Americans. Alternative and complementary therapies may play a vital role in reducing the continuing disparity with which major diseases affect the African American community today. CONCLUSION The increased interest in and use of alternative and complementary medicine in the United States have garnered the attention of the White House, the National Institutes of Health, research scholars, and the general public. Despite this increased attention and general acceptance of alternative and complementary medicine, there is still a lack of insightful,

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detailed, and comprehensive analyses of African American alternative and complementary medicine. Using a medical anthropology approach, we can answer not only a number of sociocultural questions associated with African American alternative and complementary treatment therapies but we can also give African American alternative and complementary medicine its proper attention, understanding, analysis, and inclusiveness in comparison to the other major ethnic and mainstream alternative medical systems in the United States. POST-EVALUATION QUESTIONS 1. Americans have increased their usage of alternative medical therapies within the past decade. What does this pattern tell you? 2. Are there any other specific programs that the government should develop regarding Americans’ use of alternative medicine? 3. To what degree, if any, are you or other family members using alternative medicine to treat your minor or major illnesses?

BIBLIOGRAPHY Bailey, Eric. 1988. “An Ethnomedical Analysis of Hypertension among Detroit Afro-Americans.” Journal of the National Medical Association 80: 1105–1112. ———. 1991. “Hypertension: An Analysis of Detroit African American Health Care Treatment Patterns.” Human Organization 50: 287–296. Boyd, Eddie, S. Taylor, L. Shimp, and C. Semler. 2000. “An Assessment of Home Remedy Use by African Americans.” Journal of the National Medical Association 92: 341–353. Eisenberg, David, R. Davis, S. Ettner, S. Appel, S. Wilkey, M. Rompay, and R. Kessler. 1998. “Trends in Alternative Medicine Use in the United States, 1990–1997: Results of a Follow-up National Survey.” Journal of the American Medical Association 280: 1569–1575. Eisenberg, David, R. Kessler, C. Foster, F. Norlock, D. Calkins, and T. Delbanco. 1993. “Unconventional Medicine in the United States: Prevalence, Costs, and Patterns of Use.” The New England Journal of Medicine 328: 246–252. Eisenberg, David, R. Kessler, M. Van Rompay, T. Kaptchuk, S. Wilkey, S. Appel, and R. Davis. 2001. “Perceptions about Complementary Therapies Relative to Conventional Therapies among Adults Who Use Both: Results from a National Survey.” Annals of Internal Medicine 135: 344–351. Marwick, Charles. 1998. “Alterations Are Ahead at the OAM.” Journal of the American Medical Association 280: 1553–1554. National Center for Complementary and Alternative Medicine (NCCAM). 2000. General Information About CAM and the NCCAM. Publication M32. Washington, DC: U.S. Government Printing Office. “NIH Should Increase Support for CAM Research.” 2000. The Blue Sheet 43(13): 4.

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WEB SITES OF SIGNIFICANCE Journal of the American Medical Association: www.jama.ama-assn.org Journal of the National Medical Association: www.nmanet.org National Center for Complementary and Alternative Medicine: www.nccam.nih.gov National Center for Complementary and Alternative Medicine’s Strategic Plan to Address Racial and Ethnic Health Disparities: www.nccam.nih.gov/ strategic/health_disparities.htm White House Commission on Complementary and Alternative Medicine Policy: www.whccamp.hhs.gov

Chapter 2

Mainstream American Alternative Medicine CRITICAL THINKING QUESTIONS 1. What do you consider as mainstream alternative medical therapies? 2. How should mainstream alternative medicine be subdivided into specific categories? 3. Is there a difference between the mainstream American alternative medical therapies versus the ethnic alternative medical therapies in the United States?

INTRODUCTION Alternative and complementary medicine involves the use and practice of therapies or diagnostic techniques that may not be part of any mainstream Western health care system (Spencer and Jacob 1999). Alternative and complementary medicine, sometimes referred to as CAM (Complementary and Alternative Medicine), covers a broad range of healing philosophies, approaches, and therapies that conventional Western medicine does not commonly use, accept, or make available (NCCAM 2001). The emphasis is on prevention or treatment or both by means of either natural substances or other procedures or techniques. In some cases both “mind and body” are used as a total entity in healing rather than focusing on illness or disease. The terms “alternative” and “complementary” are often used together to describe treatment therapies that are outside the traditional, mainstream Western way of treatment. Specifically, “alternative” includes therapies that generally replace or substitute for mainstream Western treatment, whereas “complementary” means treatment in addition to traditional medical care.

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People use alternative and complementary treatment in a variety of ways. Therapies may be used alone, as an alternative to conventional therapies, or in addition to conventional, mainstream therapies, in what is referred to as a complementary or an integrative approach (NCCAM 2001). For example, if a hypertensive patient is prescribed antihypertensive medication by the physician and the patient decides to supplement treatment therapy with the use of garlic or sassafras tea along with relaxation techniques, we would consider these latter two techniques as alternative and complementary to mainstream Western medicine. Although there are distinct differences between alternative and complementary treatment therapies, some common beliefs are woven through these therapies: • The body has the ability to heal itself; • Healing is related to a harmony of mind, body, and spirit; • Basic good health practices build the foundation for healing; • Healing practices are individualized; and • Clients are responsible for their own healing.

If individuals are not successful in healing themselves with the use of alternative and complementary treatment therapies, they often seek advice and/or treatment from practitioners of alternative and complementary therapies. Practitioners of alternative and complementary therapies come from a wide range of backgrounds with vastly different educational preparation and experiences based on their specific alternative/complementary area. Some alternative practitioners, such as chiropractors and doctors of naturopathy, have completed college degrees in their fields and received clinical supervision. Others, such as acupuncturists and some massage therapists, have been trained, clinically supervised, and certified in the therapy. Still others may have gained expertise through experience, selfstudy, mail-order programs, or courses (Eliopoulos 1999). Regardless of the type or experience level of the alternative/ complementary practitioner, there are a number of common characteristics in their approaches toward healing and their relationships with clients as mentioned by Eliopoulos (1999): • View the client as a whole composed of body, mind, and spirit, and consequently, address all aspects of the individual when treating an illness rather than one symptom or body part; be interested in the total person. • Favor interventions that address physical, mental, and spiritual concerns. • Build up the client’s general health status and promote healthy practices. • Tailor treatment to the needs of the individual.

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• View the client as being an active participant in the treatment plan and in control of self. • Promote self-care by client. • View healing as an ongoing process. • Encourage inner development and a balanced life. • Use touch, empathy, good communication skills. • Spend more time with clients than conventional practitioners. • Demonstrate openness and creativity in healing approaches. • Respect nature and a higher power.

As evidenced by the growing number of individuals in the United States who are seeking advice and treatment therapies from alternative and complementary practitioners, these common characteristics regarding healing and relationship with clients are proving to be effective in allowing practitioners to reach their targeted audiences. ALTERNATIVE AND COMPLEMENTARY MEDICINE CLASSIFICATION SYSTEM In the United States, the research agency that established the classification of alternative and complementary medicine is the National Institutes of Health’s National Center for Complementary and Alternative Medicine (NCCAM). It is divided into seven major categories and includes examples of practices or preparations in each of the following categories: • Mind-body medicine • Alternative medical systems • Lifestyle and disease prevention • Biologically based therapies • Manipulative and body-based systems • Biofield • Bioelectromagnetics

Within each category, medical practices that are not commonly used, accepted, or available in conventional medicine are designated as complementary and alternative medicine. Those practices that fall mainly within the domain of conventional medicine are designated as behavioral medicine. Practices that can be either CAM or behavioral medicine, depending on their application, are designated as “overlapping.” According to the National Center for Complementary and Alternative Medicine, the seven major types of complementary and alternative

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categories, although not absolute, do, however, influence how a majority of researchers, clinicians, and public health administrators view alternative and complementary medical practices and therapies in the United States. I. Mind-Body Medicine: Mind-body medicine involves behavioral, psychological, social, and spiritual approaches to health. It is divided into four subcategories: mind-body systems; mind-body methods; religion and spirituality; social and contextual areas. Mind-body systems: This subcategory involves whole systems of mind-body practice that are used largely as primary interventions for disease. They are rarely delivered alone; instead, they are used in combination with lifestyle interventions or are part of a traditional medical system. Mind-body methods: This subcategory contains individual modalities used in mind-body approaches to health. These approaches are often considered conventional practice and overlap with complementary and alternative medicine only when applied to medical conditions for which they are not usually used (e.g., yoga, hypnosis, art therapy). Religion and spirituality: This subcategory deals with those nonbehavioral aspects of spirituality and religion that examine their relationship to biological function or clinical conditions (e.g., confession, special healers). Social and contextual areas: This subcategory refers to social, cultural, symbolic, and contextual interventions that are not covered in other areas (e.g., holistic nursing, Alcoholics Anonymous) II. Alternative Medical System: This category involves complete systems of theory and practice that have been developed outside of the Western biomedical approach. It is divided into four subcategories: acupuncture and oriental medicine; traditional indigenous systems; unconventional Western systems; naturopathy. Acupuncture and oriental medicine: This subcategory consists of acupuncture, herbal formulas, diet, external and internal Qi Gong, Tai Chi, massage and manipulation (Tui Na), and acupotomy. Traditional indigenous systems: This subcategory includes major indigenous systems of medicine other than acupuncture and traditional oriental medicine (e.g., Native American medicine, ayurvedic medicine, traditional African medicine, curanderismo). Unconventional Western systems: This subcategory includes alternative medical systems developed in the West that are not classified elsewhere (e.g., homeopathy, environmental medicine). Naturopathy: This subcategory is an eclectic collection of natural systems and therapies that have gained prominence in the United States. III. Lifestyle and Disease Prevention: This category involves theories and practices designed to prevent the development of illness, identify and treat risk factors, or support the healing and recovery process. Lifestyle and disease prevention is concerned with integrated approaches for the prevention and

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management of chronic disease in general or the common determinants of chronic disease. It is divided into three subcategories: clinical preventative practices; lifestyle therapies; health promotion. Clinical preventative practices: This subcategory refers to unconventional approaches used to screen for and prevent health-related imbalances, dysfunction, and disease (e.g., medical intuition). Lifestyle therapies: This subcategory deals with complete systems of lifestyle management that include behavioral changes, dietary changes, exercise, stress management, and addiction control. To be classified as conventional and alternative medicine, the changes in lifestyle must be based on an unorthodox system of medicine, be applied in unconventional ways, or be applied across non-Western diagnostic approaches. Health promotion: This subcategory involves laboratory and epidemiological research on healing, the healing process, health promoting factors, and autoregulatory mechanisms. IV. Biologically Based Therapies: This category includes natural and biologically based practices, interventions, and products. Many overlap with conventional medicine’s use of dietary supplements. This category is divided into four subcategories: herbalism; special diet therapies; orthomolecular medicine; pharmacological, biological and instrumental interventions. Herbalism: This subcategory addresses plant-derived preparations that are used for therapeutic and preventive purposes (e.g., ginkgo biloba, garlic, ginseng, echinacea). Special diet therapies: This subcategory includes dietary approaches and special diets that are applied as alternative therapies for risk factors or chronic disease in general (e.g., pritikin, high fiber, vegetarian). Orthomolecular medicine: This subcategory refers to products used as nutritional and food supplements for preventive or therapeutic purposes. They are usually used in combinations and at high doses. Pharmacological, biological and instrumental interventions: This subcategory includes products and procedures applied in an unconventional manner that are not covered in other categories (e.g., cartilage, bee pollen, therapy). V. Manipulative and Body-Based Systems: This category refers to systems that are based on manipulation and/or movement of the body and is divided into three subcategories: chiropractic medicine; massage and body work; unconventional physical therapies. VI. Biofield: This category involves systems that use subtle energy fields in and around the body for medical purposes (e.g., therapeutic touch, healing touch). VII. Bioelectromagnetics: This category refers to the unconventional use of electromagnetic fields for medical purposes.

RECENT STUDIES ON MAINSTREAM ALTERNATIVE AND COMPLEMENTARY MEDICINE As stated in Chapter 1, Eisenberg et al. (1998) found that the number of Americans using an alternative therapy rose from about 33% in 1990

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to more than 42% in 1997. People in this study reported using the following therapies most often: herbal medicine, massage, megavitamins, selfhelp groups, folk remedies, energy healing, and homeopathy. In addition, the National Center for Complementary and Alternative Medicine reported that Americans spent more than $27 billion on these therapies in 1997, exceeding out-of-pocket spending for all U.S. hospitalizations (NCCAM 2000). Illustrating the prevalence of the trend toward alternative and complementary medicine in the United States are two additional studies—a study in Florida and another in Portland, Oregon. First, Burg et al. (1998) conducted a telephone survey to assess the use of alternative medical practices among Florida residents in four regions of Florida: southeastern Florida, the Tampa Bay region, the Orlando region, and the remaining primarily rural counties of the state. Among the 1,012 who completed interviews, 62% of the survey respondents had used one or more alternative therapies at some time in their lives. Approximately 44% had used one or two types of therapy, and 19% had used three or more types (Burg et al. 1998: 1128). Not surprisingly, home remedies were the most frequent type of therapy used (31% of the respondents had used them at some time). The data indicate that most persons who use alternative therapies use them for relief of symptoms—including cold symptoms, stress, muscle pain, and arthritic pain—and for general health maintenance purposes. The reasons most frequently given for use of home remedies were cold symptoms and general health maintenance purposes. The types of home remedies most frequently used were various teas, preparations made with honey, cough syrup, and salt water (Burg et al. 1998: 1128). The analysis suggests that alternative therapies are not typically used as a last resort when conventional medicine fails. Most users of alternative therapy have regular physicians, and the primary reasons for use of alternative therapy within the general population fall into the category of minor symptom relief and general health maintenance. Burg et al. (1998) state that alternative therapies are used primarily for ongoing self-care rather than as a replacement for conventional medicine. The second study presented in this section found similar results. Elder et al. (1997) conducted a research study at four family practices in Portland, Oregon. The major goals of their study were: (1) to better define which family practice patients use alternative medicine and which factors are associated with its use; and (2) to better understand the reasons for family practice patients to use or not use alternative medicine. This study was conducted at four different family practice clinics: • Site 1: a university-based family practice center staffed by residents and faculty that sees predominantly Medicaid and indigent patients.

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• Site 2: a university-affiliated community clinic also staffed by residents and faculty, but with a larger percentage of insured patients. • Site 3: a community practice of three female physicians, with predominantly insured patients. • Site 4: an older community practice of two male physicians nearing retirement and their new partner. They see predominantly insured and Medicare patients.

Questionnaires were completed by 113 family practice patients, and data from focus groups were analyzed to find pertinent themes. Elder et al. (1997) found the following results as they relate to use of alternative health care: • 50% (57/113) of patients had or were using some form of alternative medicine, but only 53% (30/57) had told their family physician about their use. • No differences were attributed to age, race, gender, or education. • Chiropractic was used by most, followed by massage, herbal medicines, megavitamins, and meditation. • Homeopathy, naturopathy, and acupuncture were each used by 10% of the respondents. • Although most respondents used only one or two forms of alternative medicine, some participants used as many as six different types.

It is interesting that the main reason given for using alternative medicine, alone or in combination with care from a family physician, was a belief that it would work and achieve faster resolution of symptoms. Many of those who worked in combination with a family physician spoke of acceptance and control, but those who did not work with their physician mentioned traditional medicine’s limitations and narrow-mindedness (Elder et al. 1997:181). In fact, patients may be seeking more control over their health by choosing alternative practitioners, as well as expressing their frustration with conventional medicine, or they may just be seeking another treatment modality. Elder et al. (1997) suggest that it is important for physicians to know about their patients’ use of alternative medicine. Herbs, vitamins, and other treatments from alternative providers are not without adverse effects. They may contain ingredients that can worsen some medical problems or interact with medications patients are receiving from their family physicians. Thus it is imperative that family physicians ask their patients about their use of alternative health care, in an accepting and nonjudgmental manner (Elder et al. 1997: 184). Overall, these two studies reflect the continual growth of alternative medicine in mainstream America—from Oregon to Florida. Americans are using alternative health care practices whether their physicians

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understand this or not. This leads to the key question: What are the major mainstream American alternative and complementary treatment therapies? MAINSTREAM AMERICAN ALTERNATIVE MEDICAL SYSTEMS Although the number and variety of alternative and complementary therapies continue to increase each year in the United States, there are a select few that have been identified as the most frequently used alternative and complementary therapies in the United States. This section will highlight the major mainstream alternative and complementary medical systems. Acupuncture Acupuncture is a treatment modality that originated in ancient China over 3,000 years ago and is currently used throughout the world. Acupuncture is an umbrella term that includes many techniques such as acupressure, laser acupuncture, scalp acupuncture, Korean hand acupuncture, moxibustion, electro-acupuncture and more (Ulett, Han and Han 1998: 115). Most acupuncture techniques involve the use of needles with mystic rituals explained by metaphysical concepts derived from ancient practices of traditional Chinese medicine. Acupuncture along with the use of medicinal herbs, massage, and dietary therapy make up the major therapies used in traditional Chinese medicine. The therapeutic techniques of Chinese medicine, including acupuncture, are unified in the principles of yin and yang. Yin refers to the passive, female cosmic element or principle that is opposite but always complementary to yang. Conversely, yang refers to the active, masculine cosmic principle. In conjunction with yin and yang, another significant Chinese concept in traditional medicine is qi. Qi is the life force within an individual that encompasses all vital physical, spiritual, emotional, and mental activities. Invisible pathways or channels called meridians circulate qi on the body surface. Qi ensures a balance of yin and yang that helps to keep the body functioning and protects it from external forces that could be harmful. A deficiency or blockage of qi can cause discomfort and illness (Eliopoulos 1999). The essence of diagnosis is to attempt to understand how an individual’s yin and yang balance has been disrupted and where the flow of qi has become disturbed. Once known, the essential goal of treatment is to balance the yin and yang of the patient and establish a harmonious flow of qi. The various techniques of Chinese medicine always work to manipulate, augment, and balance qi. For example, acupuncture therapy is directed to balance the qi of the body, which flows along specific pathways or meridians. In herbal and

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nutrition medicine, it is the qi of the herbs and foods that is considered when therapeutic effect is sought. Additionally, therapeutic exercises are designed to affect the qi of the bodily organs and emotions and to harmonize the general qi of the patient. Acupuncture has only recently gained popular attention and use in America. In fact, a National Institutes of Health (NIH) Consensus Development Panel on Acupuncture (1998) stated that promising results have emerged for the use of acupuncture in treating the nausea and vomiting related to chemotherapy, adult postoperative surgery pain, and postoperative dental pain. There are other situations—such as addiction, stroke rehabilitation, headache, menstrual cramps, tennis elbow, osteoarthritis, low back pain, asthma—for which acupuncture may be useful as an additional treatment or an acceptable alternative in a comprehensive management program (NIH Consensus Panel 1998: 1522). The phenomenal growth of acupuncture shows how a once-perceived very alternative ethnic treatment therapy can become a mainstream American alternative treatment therapy. Homeopathy Homeopathy (from the Greek words homeo, meaning “like,” and pathos, meaning “suffering”) is based on the principle of similars. For example, a substance that causes certain symptoms in a healthy person will cure those symptoms in a sick person (Marti 1998). Homeopathic treatments are dilute forms of a biological material (plant, animal, or mineral) that produce symptoms similar to that caused by the client’s disease. An extract of the substance is made by soaking it in alcohol to form a “mother tincture.” The mother tincture is then diluted many times to achieve different levels of potency. In homeopathic remedies, the more dilute a substance is, the higher the potency. The final solution can be added to sugar tablets or a powder for consumption. Some homeopathic remedies are prescribed in lotions and ointments for external use. The homeopathic remedy stimulates the body to fight the disease. The more closely the effects of the remedy match the client’s symptoms, the more effective the remedy will be. Thus, homeopaths, practitioners of homeopathic medicine, observe the client’s symptoms and reactions and prescribe accordingly (Eliopoulos 1999). Historically, homeopathy was developed during the late 1700s by a German physician, Samuel Hahnemann. Dr. Hahnemann found that administering the similar medicine—a medicine that was capable of producing symptoms similar to those his sick patient was experiencing—could greatly relieve the patient’s suffering (Marti 1998; Cassileth 1998). After much experimenting, he found that diluting and shaking the medicines could enhance their healing effects while reducing their harmful effects.

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The more he diluted and shook the medicines, the more potent they became. In 1825, homepathy was introduced to the United States. Although it was not initially accepted by the American Medical Association and the general populous, homeopathy continued to grow steadily and currently is practiced by several hundred medical doctors and other health care professionals (Marti 1998). Ayurvedic Medicine Ayurveda is a form of medicine that has been practiced in India for thousands of years. Ayurvedic medicine places equal emphasis on the body, mind, and spirit and uses herbs, yoga, diet, meditation, massage, exposure to the sun, and breathing exercises to restore balance to the body (Eliopoulos 1999). In ayurvedic medicine, individuals are viewed as having metabolic types of doshas: these doshas are vatta, pitta, and kapha. The primary goal of ayurveda is to keep all three doshas in balance. An individual’s dominant dosha, along with the impact of the other doshas, determines the ayurvedic health plan prescribed to an individual. Following the individual health plan—which includes physical, psychological and spiritual components—is said to promote wellness, prevent disease, and enhance life in general. When the delicate balance of the doshas is disturbed, the body is vulnerable to external stressors and shows signs of illness. According to ayurvedic medicine, the body’s balance can be disrupted by any of seven factors: genetic, congenital, internal, external trauma, seasonal, natural habits, or magnetic and electrical influences. To restore the body’s balance, the ayurvedic physician relies primarily on observation of the patient to diagnose and then develop the appropriate individualized health plan (Eliopoulos 1999; Cassileth 1998). A typical plan may consist of the following: • Physical exercises, including yoga postures and yoga breathing exercises; • Lifestyle changes, including meditation; and • Dietary practices, including use of herbs and fasting.

For example, a typical day for someone who subscribes to the ayurvedic approach to health might include rising early, meditating once or twice, eating a vegetarian diet, taking walks, practicing yoga, and going to bed early. This type of health plan is designed to prevent diseases and to keep the three doshas in balance. In general, ayurvedic medicine is one of the few ancient healing systems that remain popular today, although in greatly modified and mod-

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ernized form (Cassileth 1998: 22). It is based on the idea that illness is the absence of physical, emotional, and spiritual harmony. Thus, it stresses proper physical and mental self-care to ensure good health and enhance longevity (Cassileth 1998: 22). Ayurvedic medicine encompasses prevention and health maintenance, which works well within the prevention and health maintenance paradigm of the American mainstream alternative medicine system. Naturopathy Naturopathic medicine is based on the healing systems of many cultures, including India’s ayurvedic medicine, traditional Chinese medicine, the medicine of Native American cultures, and Greek medicine. According to Cassileth (1998), it is organized around six fundamental principles: • The body has natural abilities to resist disease and to heal itself. Naturopaths work to promote these abilities. • Disease is caused by the intersection of multiple factors, so the naturopath should strive to treat the whole person. This means taking into account physical, mental, emotional, environmental, and other factors. • The less disruptive the treatment, the better able the body is to heal itself. Thus, naturopathy de-emphasizes treatments such as surgery. • The root cause of illness, rather than just the symptoms, should be addressed. Symptoms should not be suppressed because this may interfere with healing. • The patient and naturopath should work together to assess potential risk factors such as genetics, diet, and environmental conditions. • Naturopaths see themselves as teachers. Teaching people healthy practices, especially those that prevent illness, is very important for the naturopath. Naturopaths also encourage patients to take an active role in their health care and be responsible for their overall wellness.

In general, naturopathy’s overarching goal is to enlist the natural healing power of the body to fight disease. It uses a collection of natural treatment modalities such as botanical medicine, nutritional therapies, homeopathy, acupuncture, traditional Asian medicine, hydrotherapy (use of water for therapy), counseling, and physical medicine (manipulation of muscles and bones) (Cassileth 1998). For example, naturopaths use food as medicine, ensuring that each patient follows the optimum diet for his or her health and lifestyle. Healthful, nutritionally balanced diets are prescribed. There are a number of researchers who point to increasing evidence about the role of nutrition in disease, and the extensive training in nutrition received by naturopathic doctors compares with conventional physicians. Thus, through detailed examination of the patient’s lifestyle and medical history, naturopathic

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physicians emphasize treating the whole person and understanding his/ her overall lifestyle, environment, and the interactions that will influence well-being (Cassileth 1998). Chiropractic Therapy Chiropractic therapy, a specialty developed in the United States in the latter part of the nineteenth century, is the use of manipulation or adjustment of the spine and joints to restore proper alignment (Eliopoulous 1999). According to chiropractic therapists, misalignments of the spine, known as subluxations, can cause pressure on nerves, which can lead to interference with bodily functions and pain. Thus, proper realignment of joints is said to alleviate the pain and pressure of certain health problems. It is interesting that therapeutic manipulation of the skeleton, particularly of the spine, has ancient roots several centuries old, including Hippocrates (fifth century B.C.), Aesklepiades (100 B.C.), and Galen (second century A.D.) (Marti 1998: 8). In actuality, the word “chiropractic” is taken from the Greek word that means “done by hand.” In America, chiropractic was invented by Daniel David Palmer, who performed his first spinal adjustment in 1895 and claimed that he had cured an African American janitor of deafness. From this miraculous event, Palmer deduced that the nervous system was the ultimate control mechanism of the body and that even minor misalignment of the spine, which he termed “subluxations,” could significantly impact a person’s health (Marti 1998: 8). Thus, the term chiropractic, a method of restoring wellness through adjustments of the spine, was coined. Today, there are an estimated 39,000 chiropractors practicing in the United States. They constitute the third largest medical profession after physicians and dentists and are licensed to practice in every state without supervision or referral from medical doctors. They cannot, however, prescribe drugs or perform surgery (Marti 1998: 10). Chiropractors usually make their diagnosis from a physical examination, history, and palpation of the spine. If adjustments of the spine are needed, they may include (Eliopoulous 1999): • Active motion, in which the client independently moves or stretches; • Passive motion, in which the chiropractor assists the client in moving or stretching; and • Palpitation, in which the chiropractor touches the spine.

Additionally, chiropractic techniques can be forceful or non-forceful. A forceful technique is an adjustment in which the joint is gently stretched beyond its normal range of motion; sometimes an audible click is heard during this maneuver. A non-forceful technique involves the application

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of gentle pressure or touching along the spine, skull, and pelvis. In all cases, these adjustments are said to vary depending on the characteristics of the client and the problem. Herbal Medicine Herbal medicine is one of the oldest practiced therapies in the world. Herbs are used to initiate healing responses in the body through synergistic responses, unlike the usual specific curative properties associated with pharmaceuticals. Modern pharmaceuticals are direct descendants of herbal therapies (Cohen, Rousseau, and Robinson 2000). Herbs are plants or plant parts—such as flowers, leaves, stems, bark, and roots—that are used to season foods (culinary herbs) or applied to alleviate health problems (medicinal herbs). Every culture throughout history has used plants to treat medicinal problems. For example, medicinal plants were important to the transplanted Africans who used them for preventing and curing diseases. Oral histories of former slave women from all over the South contain frequent and sometimes elaborate descriptions of the wide variety of plants which constituted the material base from which the slave medical practice operated (Goodson 1987: 200). Dispensing medical care was a natural occupation among enslaved Africans. Many enslaved Africans of southeastern Louisiana recounted dispensing experiences handed down from their mothers, fathers, grandmothers, and grandfathers. The pharmacopoeia of enslaved Africans included herbs, roots, leaves, bark, compounds, and, to a limited extent, vegetables—which were prepared in the form of soups, teas, tonics, poultices, etc. Thus, herbal medicine is one of the oldest practice therapies in the world (Cohen, Rosseau and Robinson 2000). Herbal medicine may utilize a whole plant or just the bark, fruit, stem, root, or seed. Herbs can be purchased fresh or dried and in pills, capsules, and tinctures (preserved in alcohol, glycerine, or some other liquid). Herbs or botanical therapies, classified as official drug plants, constituted a significant part of the U.S. Pharmacopoeia and National Formulary until the 1930s. Modern pharmaceuticals are direct descendants of whole plant formulas (Cohen, Rousseau and Robinson 2000: 59). Herbal remedies differ from prescribed pharmaceuticals in several ways. Typically, they include the entire herb or an entire part of the herb, such as the leaf, flower, or bulb. In contrast, pharmaceuticals, including those made from herbs, contain only the isolated and purified chemicals found to be the active ingredients, plus an inert liquid for tinctures or a binding substance for pills (Cassileth 1998). Herbs can be used either internally or externally. Internally, herbs can be consumed through teas, capsules and tablets, tinctures, or syrup. Externally, herbs can be applied through baths, compresses, poultices,

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ointments, or oils. The following are examples of internally and externally prepared herbs (Marti 1998): • Encapsulated: Many botanical medicines are finely ground into powder and enclosed in capsules. These capsules can be easier to use and are probably the best form for people who need to know the precise dosage. • Fomentation: Are usually prepared by soaking a towel or cloth in the desired botanical tea and then applying the towel (as hot as possible) over the affected area. • Fresh Plants: The potency and toxicity of each plant species vary according to what part of the plant is used—the leaves, roots, or flowers—and what combination of chemical compounds it contains. • Infusion: Once the most common way of preparing herbs, a teaspoon of leaves, blossoms, or flowers is boiled in water and steeped for three to five minutes. • Poultice: Usually used to reduce swelling; a warm paste of powdered herbs applied directly to the skin. • Plaster: Similar to a poultice, except that the herbal materials are placed between two pieces of cloth and applied to the affected surface. This is a desirable alternative when the skin is irritated. Subce plasters help prevent the herb from coming in direct contact with the skin. • Tincture: Extract of a plant in a solution of water and alcohol that is easy to use and can retain its potency for several years or more. The disadvantage is its alcohol content which, taken in high doses, can present a risk for alcoholics or anyone with a liver or digestive disease. • Solid Extracts: Obtained by first preparing a tea or tincture and then evaporating it until a gummy residue remains. The residue is mixed with other substances and sold as capsules. This is the most expensive of all herbal medicine forms, as well as the most reliable and potent. • Teas: Many herbal medicines are now available as teas—either as single plants or a combination of several plants. Teas lose some of the properties of whole plants because any constituents that are not soluble in water are lost. Heating also evaporates some of the plant’s medicinal components.

CONCLUSION This chapter highlights the major mainstream alternative medical therapies that are currently recognized and used by a substantial number of Americans in the United States. Ironically, these so-called new alternative and complementary therapies and belief systems have been established and adhered to by various ethnic and cultural groups for decades, and in most cases for centuries. Now that the popular press, the medical establishment, the public health policy makers, the pharmaceutical companies, clinical researchers, and the general mainstream public have recognized alternative and complementary medicine’s positive impact on health care

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maintenance and prevention, it will be quite interesting to see if our society will truly embrace and respect the cultural health traditions and practices among all cultural and ethnic groups in the United States. POST-EVALUATION QUESTIONS 1. Should mainstream American alternative medicine therapies be included in the traditional conventional medical therapies in the United States? 2. Are there additional mainstream alternative therapies that need to be added to this list? 3. Since more Americans are using alternative medicines, what can your doctor do to become more aware of this significant health trend?

BIBLIOGRAPHY Aakster, C.W. 1986. “Concepts in Alternative Medicine.” Social Science & Medicine 22: 265–273. Astin, John. 1998. “Why Patients Use Alternative Medicine: Results of a National Study.” Journal of the American Medical Association 279: 1548–1553. Autotte, Phyllis. 1995. “Folk Medicine.” Archives of Pediatric Adolescence Medicine 149: 949–950. Burg, Mary, R. Hatch, and A. Neims. 1998. “Lifetime Use of Alternative Therapy: A Study of Florida Residents.” Southern Medical Journal 91: 1126–1131. Cassileth, Barrie. 1998. The Alternative Medicine Handbook: The Complete Reference Guide to Alternative and Complementary Therapies. New York: W.W. Norton & Company. Ceniceros, Salvador, and George Brown. 1998. “Acupuncture: A Review of Its History, Theories, and Indications.” Southern Medical Journal 91: 1121–1125. Cohen, Susan, M. Rousseau, and E. Robinson. 2000. “Therapeutic Use of Selected Herbs.” Holistic Nurse Practitioner 14: 59–68. Eisenberg, David, R. Davis, S. Ettner, S. Appel, S. Wilkey, M. Rompay, and R. Kessler. 1998. “Trends in Alternative Medicine Use in the United States, 1990–1997: Results of a Follow-up National Survey.” Journal of the American Medical Association 280: 1569–1575. Elder, Nancy, and Amy Gillcrist. 1997. “Use of Alternative Health Care by Family Practice Patients.” Archives of Family Medicine 6: 181–184. Eliopoulos, Charlotte. 1999. Integrating Conventional & Alternative Therapies: Holistic Care for Chronic Conditions. St. Louis: Mosby. Engebretson, Joan, and Diane Wardell. 1993. “A Contemporary View of Alternative Healing Modalities.” Nurse Practitioner 18: 51–55. Goodson, Martia. 1987. “Medical-Botanical Contributions of African Slave Women to American Medicine.” The Western Journal of Black Studies 2: 198–203. Lazar, Joel, and Bonnie O’Conner. 1997. “Talking with Patients about Their Use of Alternative Therapies.” Primary Care 24: 699–712. Marti, James. 1998. The Alternative Health & Medicine Encyclopedia, 2nd ed. Detroit: Gale Research.

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National Center for Complementary and Alternative Medicine (NCCAM). 2001. Major Domains of Complementary and Alternative Medicine. NCCAM Clearinghouse Pub. No. X-42 (December): 1–4. NIH Consensus Development Panel on Acupuncture. 1998. “Acupuncture.” Journal of the American Medical Association 280: 1518–1524. Spencer, John, and Joseph Jacobs. (1999). Complementary Alternative Medicine: An Evidence-Based Approach. St. Louis: Mosby. Ulett, G., J. Han, and S. Han. 1998. “Traditional and Evidence-Based Acupuncture: History, Mechanisms, and Present Status.” Southern Medical Journal 91: 1115–1120. Wardwell, Walter. 1994. “Alternative Medicine in the United States.” Social Science & Medicine 38: 1061–1068. Youngkin, Ellis, and Debra Israel. 1996. “A Review and Critique of Common Herbal Alternative Therapies.” Nurse Practitioner 21: 39–45.

WEB SITES OF SIGNIFICANCE Aspet Interest Group: Herbal Medicine and Medicinal Plants Interest Group: www.faseb.org/aspet/H&MIG3.htm#top Herbal Information Center: www.kcweb.com/herb/herbmain.htm Herb Research Foundation: www.herbs.org National Center for Complementary and Alternative Medicine: www.nccam.nih.gov University of Washington Medicinal Herb Garden: www.nnlm.gov/pnr/uwmhg

Part II

Alternative Medicine and African Americans In order to examine the importance of alternative medicine to the African American population, this section focuses on the African American health belief system and the treatment strategies often used and documented. In addition, Chapter 4 provides a cultural historical view of alternative medicine’s use within the African American community and shows how it was an integral part of African American culture. The major purpose of this section is to show how African American alternative medical belief systems and practices have always been a significant part of the African American experience.

Chapter 3

African American Alternative Medicine CRITICAL THINKING QUESTIONS 1. Why has there been such little attention to and research on African American alternative medicine and therapies? 2. Are there reliable peer-reviewed studies that document the use of African American alternative medicine? 3. Have you used an African American alternative medicine and, if so, why?

INTRODUCTION Currently, most of the attention concerning alternative medicine in the United States derives from mainstream America. In chapters 1 and 2, I documented Americans’ use of and/or interest in alternative and complementary medicine. However, very little attention has been given to African American alternative and complementary medicine. Research conducted on African American traditional medicine as a medical system has been limited (Fontenot 1994). Additionally, it is rare that African American medical traditions have been documented or thought worthy of scientific investigation as a “medical system,” having rational, logical order and meaning (Hill 1976). Often these studies fail to analyze the medical tradition as a means to better understand cultural beliefs, behaviors, and attitudes associated with the causes and cures for illnesses among African Americans (Fontenot 1994). In fact, only a few studies to date have acknowledged African Americans’ contemporary use of alternative medicine.

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RECENT STUDIES OF ALTERNATIVE MEDICINE AND AFRICAN AMERICANS Two different studies—one in New York City and the other in San Francisco—are indications that African Americans use alternative and complementary medicine similarly and differently than Caucasians. For example, Cushman et al. (1999) wanted to explore the use of complementary and alternative medicine among African American and Hispanic women residing in New York City. Focus groups were conducted with two groups of African American and two groups of Hispanic women (aged 18–40 and 41–80; total sample: 39) as preparation for the development of a quantitative instrument to assess the prevalence and determinants of alternative and complementary medicine use among women of various ethnic backgrounds. Cushman et al. (1999) found that herbs, usually taken in the form of infused teas, were used by all groups and were the most common alternative and complementary treatment therapy mentioned across age and race/ethnic categories. Chamomile, cranberry, black cohosh, ginger, and mint, among others, were taken for a variety of conditions, including stomach discomfort, menstrual cramps, PMS, fibroid pain, and menstrual and menopausal symptoms. Other remedies mentioned in all groups, particularly for dealing with stress and preventing disease, were vitamins and nutritional supplements, prayer and spiritual healing, meditation and relaxation techniques (Cushman et al. 1999: 194). Few race/ethnic differences emerged in the discussions of Complementary and Alternative Medicine (CAM) remedies and treatment. Colonic cleansing and spiritual practices were mentioned more by African Americans than Hispanics. African American women also defined several terms for CAM such as: pot likker (juice of green vegetables), tar and sugar (for colds), and red clay and turpentine or vinegar (to reduce swelling). Finally, all women in both race/ethnic groups mentioned learning about alternative remedies from older female relatives, particularly mothers and grandmothers. In general, Cushman et al. (1999) study’s results suggested that African American and Hispanic women used a variety of treatments and practitioners, both to alleviate specific symptoms and for prevention. Generally, their knowledge of and interest in alternative and complementary medicine was high. Beyond health concerns that commonly vary by age (pregnancy, menopause), the women had similar health concerns and used similar modalities across age and race/ethnic categories (Cushman et al. 1999: 195). In another alternative and complementary medicine study, Lee et al. (2000) researched the types and prevalence of conventional and alternative therapies used by women in four ethnic groups (Latino, Caucasian, Chinese, and African American) diagnosed with breast cancer from 1990 through 1992 in San Francisco and explored factors influencing the choices

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of their therapies. A total of 100 African Americans, 100 Latino, 82 Chinese and 97 Caucasian women participated in the 30-minute telephone interview. Lee et al. (2000) found that the most commonly reported alternative therapies were dietary therapies (26.6%), megavitamins (8.2%), other specialized diets (19.8%), spiritual healing (23.7%), herbal remedies (12.9%), physical methods (14.2%), and psychological methods (9.2%). Prevalence of use of these therapies varied by ethnicity. African Americans most often used spiritual healing (36%), Chinese most often used herbal remedies (22%), and Latino women most often used dietary therapies (30%) and spiritual healing (26%). Among whites, 35% used dietary methods and 23% used physical methods, such as massage and acupuncture (Lee et al. 2000: 43). In general, African American women were less likely than women of the other three ethnicities to use dietary and physical therapies, while Latino women were more likely to use mental, physical, and herbal therapies. Chinese women were less likely to use dietary and mental therapies, but they were two times more likely to use herbal therapies (Lee et al. 2000: 43). In addition to ethnicity, other demographic factors, including younger age and high school or higher education, were consistently associated with using alternative therapies. In conclusion, Lee et al. (2000) suggested that because women with latestage breast cancer were more likely than those with early-stage cancer to report using any alternative therapy and because most of their participants had early-stage cancer diagnosis, the prevalence estimates of use of alternative therapy reported in this study probably are conservative. Moreover, not only did their data show that the use of alternative therapy varies among ethnic groups but also that factors influencing choices of treatments vary by type of therapy and ethnicity. Their data provides no clear reasons for these ethnic differences but it does suggest that research is needed to understand cultural origins of different therapy choices and options, both for conventional and alternative therapies. REASONS FOR THE USE OF ALTERNATIVE MEDICINE In order to understand the reasons for the use of alternative medicine among African Americans, we must view this pattern in the context of their illness/disease perception and treatment actions. Illness is defined as sickness of body or mind; disease is defined as a harmful departure from the normal state of a person or other organism (Green and Ottoson 1994: 697). Often, the public views these two terms similarly. Yet, medical anthropologists and other health care researchers distinguish these two terms as completely different: illness is a subjective abnormality of health, and disease is an objective physiological abnormality.

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Illness/Disease Perception Illnesses are classified as either naturalistic or personalistic (Snow 1974). Naturalistic agents identify what caused an illness, whereas personalistic agents recognize who caused the illness (Chino and Volleweiller 1986). Such impersonal agents as inadequate rest, poor nutrition, and germs cause illnesses. The etiology of illnesses falls into three general categories: environmental hazards, divine punishment, and impaired sociocultural relationships. In some cases, serious and life-threatening illnesses are perceived to be sent by God or some other personalistic agent as punishment for sin (Snow 1974; Hill 1976). Many African Americans, for example, who suspect a terminal illness may delay medical diagnosis. During this delay and/or denial period, many African Americans turn to powers considered greater than themselves to fathom the reason for the disease, thereby accepting terminal illness as “God’s will” and believing that nothing more can be done. Examples of naturalistic and personalistic causative agents are described in two studies. First, a study investigating the treatment patterns of hypertension among 285 African Americans in the Detroit metropolitan area contended that African Americans’ beliefs about the etiology of hypertension were based on naturalistic agents (Bailey 1991b). Bailey reported that informants considered inadequate rest, poor nutrition, weather disturbances, and imbalances in hot and cold properties as naturalistic agents affecting their blood pressure. Informants described such “rich” foods as heavily salted greens, pork, and sweets as naturalistic agents. Moreover, cold weather was described as a naturalistic agent that can affect the viscosity of one’s blood and affect blood pressure (Bailey 1991b: 294). These findings were directly comparable to those of other studies on folk symptomatology (Blumhagen 1982; Dressler 1982; Garro 1986; Snow 1974). Second, a study investigating the narratives of 26 African American women with advanced breast cancer found that these women attempted to relate the meaning of their cancer to an indigenous model of health and disease (Mathews, Lannin, and Mitchell 1994; Lannin et al. 1998). The women interviewed ranged in age from 39 to 83 years, with the majority being over the age of 50. Cancer was seen by patients to be the worst of all diseases because they believe it is always fatal and is essentially incurable. Consequently, for many of the women interviewed, cancer resembled illnesses that did not respond to conventional categories or cures in the indigenous medical system (Mathews, Lannin, and Mitchell 1994: 795). Thus, the only likelihood of finding a cure for cancer was “to turn it over to God.” One of the informants said, “Cancer is a horrible disease. It just eats you up. The only one powerful enough to overcome it is the Lord. You just have to trust in

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Jesus to do battle for you and save you from this horrible affliction” (Mathews, Lannin, and Mitchell 1994: 795). Mathews, Lannin and Mitchell contend that here the battle metaphor is used to portray a struggle between God, as the all-powerful force for good, and cancer as consummate evil. Mathews, Lannin, and Mitchell state that another informant had rejected the medical system and its interpretation of the disease primarily because of a bad personal experience with the medical staff and her belief in the causation of the cancer. Fortunately, at the urging of a close friend at the medical center, this informant returned for care under her own terms and guided by her belief in God. Interestingly, Mathews, Lannin, and Mitchell suggest that too often in the past health care professionals have assumed that patients who delay seeking treatment for cancer or who fail to utilize the screening services available either lack knowledge, are too poor to access services, deny reality, or are excessively fatalistic. In actuality, these patients have wellworked-out ideas about their own health and about their disease (Mathews, Lannin, and Mitchell 1994: 799). Patients, in this case African Americans, also have well-worked-out ideas about treatment strategy depending on whether the illness is perceived as naturalistic or personalistic. Alternative Treatment Actions: Naturalistic Causation The types and sources of treatment actions among African Americans are likely to vary according to gender, class, region of the United States, and degree of assimilation in mainstream society. In the United States, most ethnic groups have the option of selecting from a variety of sources: (1) formal health professionals; (2) licensed health professionals; (3) alternative or native health practitioners; (4) caregiving network; and (5) self. If the illness is perceived as naturalistic (i.e., due to inadequate rest, poor nutrition, or germs), African Americans tend to use initially one or a combination of the following treatments: self-care, caregiving network, alternative indigenous health practitioner, and formal health professionals (Jackson 1981; Spector 1985; Jacques 1976; Leininger 1985; Bailey 1991b). Self-Care Self-care includes positive steps taken by individuals to either prevent disease or improve general health status through health promotion or lifestyle modification; medical self-care for the identification or treatment of minor symptoms of ill health or self-management of chronic health conditions; and steps taken by laypersons to compensate or adjust for functional limitations affecting routine activities of daily living. National research studies have indicated that African Americans use a variety of self-care strategies depending on the illness and/or disease (Fahie 1998;

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Becker et al. 1998; Resnicow et al. 1997; Arcury et al. 1996; Skelly et al. 1995; Bailey 1991b). The use of home remedies or herbs is an example of a self-care strategy. The basic assumption behind the use of herbs/home remedies links the natural organic properties of herbs with the natural healing capabilities of human beings. Herbalists use these organic substances in an effort to neutralize or eliminate one’s body of harmful substances that impair its power to heal itself (Lust 1974: 8). According to herbalists, any herb, if mixed and used properly, can treat effectively any natural illness. Spector (1985) has identified some African American home remedies as successful in the treatment of disease. The following are a few selected examples: 1. A method for treating colds is hot lemon water and honey. 2. When congestion is present in the chest and the person is coughing, the person can be wrapped with warm flannel after his/her chest is rubbed with hot camphorated oil. 3. Hot toddies are used to treat colds and congestion. These drinks consist of hot tea with honey, lemon, peppermint, and a dash of brandy or whatever alcoholic beverage the person likes and has available. Vicks VapoRub is swallowed. 4. Herbs from the woods are used in many ways. Herb teas are prepared to treat pain and reduce fevers. Sassafras tea frequently is used to treat colds. 5. Placing raw onions on the feet and wrapping them in warm blankets can break a fever. (Spector 1985: 196–197)

In addition, chicken soup is used for a whole host of illnesses. Davis (1997) states that these include upper respiratory illness, lack of energy, the flu, upset stomach, listlessness, fevers, nausea, and vomiting. In general, self-care strategies such as home remedies and herbs are convenient and effective sources of therapy (Davis 1997). The three major reasons for their continual usage in the African American community are as follows: 1. Folk remedies may be the only alternatives to costly treatment of acute illness by the health care system. 2. Folk remedies have been given the stamp of approval by generations of African American caregivers. 3. The loving care, attention, and overall nurturance that accompanies the use of folk remedies cannot be overlooked. (Davis 1997: 433)

Furthermore, Davis (1997) states that employing folk remedies in treatment follows closely the culture of a particular group of people and is

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replete with memories, comfort, and familiarity. In fact, folk remedies may be so enmeshed in tradition that not to perform them is tantamount to sacrilege. Yet this important understanding and cultural symbolism are lacking among a majority of health care providers (Davis 1997: 434). Caregiving Network For the purpose of our discussion in this section, I refer to the caregiving network as the lay, nonprofessional, nonspecialist domain of society, where ill health is first recognized and defined and health care activities are initiated (Helman 1985: 43). It includes all the therapeutic options that people utilize, without consulting either folk healers or medical practitioners. Helman (1985) states that among these options are self-treatment or self-medication; advice or treatment given by a relative, friend, neighbor, or workmate; healing and mutual care activities in a church or self-help group; and consultation with another layperson who has special experience with a particular disorder or treatment of a physical state. In reference to African Americans, the caregiving network and the meaning of caregiving are culturally based in long-standing traditions. Health care researchers have also referred to this caregiving network within the African American community as the “informal and/or extended familial network.” Whether referred to as an informal network, extended familial network, or caregiving network, this network consists of those individuals who are family members, friends, neighbors, or other nonfamily associates who would help the individual African American if he or she were sick or disabled (Chatters et al. 1985; Neighbors and Jackson 1984; Chatters et al. 1986; Taylor and Chatters 1986). Interestingly, this “caregiving network” plays an important social, cultural, and health function in the lives of African Americans (Hays and Mindel 1973; Stack 1974; Neighbors and Jackson 1984; Haley et al. 1996; Cox and Monk 1996). Neighbors and Jackson (1984) state that social networks are utilized by African Americans as an alternative to formal help seeking as well as a supplement to professional help utilization. For example, in a national survey of black Americans, Neighbors and Jackson (1984) found that informal help is used more frequently than professional help as a means of coping with problems. Statistics indicated that a vast majority (87%) of the 1,292 African Americans sampled talked to at least one informal helper; most people used informal help (43%) or both informal and formal help (44%). Thus, the majority of respondents were categorized as users of informal help taken into account (Neighbors and Jackson 1984: 643). Neighbors and Jackson suggest that research on how the social network functions, both as an alternative treatment source and as a referral system, should prove to be a fruitful area of investigation for social scientists interested in the help-seeking behavior of African Americans.

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The reasons given for caregiving and the high use of the caregiving network among African Americans as it relates to treating illness again reflect the importance of cultural values and traditions. In an in-depth study of seventeen African American caregivers for older ill relatives, Nkongho and Archbold (1995) classified the reasons given for caregiving as familial, relational, and personal. The familial category consisted of maintaining family integrity and role modeling. Past and present actions affected the relational category, which included reciprocity, affection, and respect. The personal category addressed the caregiver’s beliefs, values, and attitudes (Nkongho and Archbold 1995: 118). In particular, caregiving among this sample provided a way of demonstrating their beliefs. Beliefs and values identified by caregivers included caring for one’s own family and harmony. All (100%) caregivers expressed the importance of looking after, or providing for, their own families. One caregiver stated, “You care for your own. You take your sisters and your mama and your daddy and everybody else and you take care of them yourself. You don’t need anybody out there taking care of them. It is a thing that you do” (Nkongho and Archbold 1995: 118). These findings suggest that caregivers and the caregiving network will consistently be options for seeking care for minor and major illnesses within the African American community. Alternative Indigenous Health Practitioners In addition to the caregiving network and the variety of home remedies or patent medicines used among African Americans, there are primarily two types of alternative indigenous health practitioners serving the African American community: (1) the independent practitioner and (2) the cultic practitioner (Baer 1985: 327). These two types of alternative indigenous health practitioners operate as individuals or are affiliated with some sort of occult supply store, either as the owner, employee, or someone who rents office space. The cultic practitioner is affiliated with a religious group and practices in both public and private settings. The multiplicity of African American alternative indigenous health practitioners today stems from the role adaptability of traditional African American healers of the past (Bailey 1991a). For instance, one type of African American alternative indigenous health practitioner, the neighborhood prophet/Old Lady, does not dispense medicine but merely advises clients about concocting herbal medicines. Rather than selling or giving an herbal remedy, the Old Lady tells the client to use it in varying proportions to treat the perceived illness. In addition, she gives advice for various emotional, personal, and domestic problems. She does not receive monetary gifts for her service, only gifts of food or expression of gratitude (Jordan 1979: 38). The neighborhood

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prophet/Old Lady treats the individual’s mind, body, and spirit in an attempt to return the individual to harmony with nature. This alternative indigenous health practitioner, as well as many others, has successfully matched a holistic approach in treating illness/disease with the model or perception of treating illness/disease among many African Americans. Although there are no specific utilization data to document the total numbers of African Americans seeking care from these alternative indigenous health practitioners, their presence and growth within the alternative health delivery network can no longer be denied and overlooked. For example, in southwest Louisiana African American alternative health practitioners today are described as “secret doctors, treaters, mind readers, and grannies” (Fontenot 1994). There is broad knowledge about herbal lore among them. Healers learn their skill from someone in the family who is a secret doctor and who passes on the knowledge. Learning takes place at home, in some instances by observation. For the most part, however, beginning secret doctors rely on themselves and call on a mature secret doctor for advice. Fontenot (1994) states that experience, age, and sex play very important parts in determining the kinds of diseases and type of persons one can cure. Older male secret doctors seem to be able to cure severe illnesses in anyone of any age and sex. Female secret doctors for the most part treat children and minor illnesses in adults. Furthermore, this belief coincides with the community’s loyalty and respect for male and female elders whose role in the community is the sharing of wisdom through experience. Overall, one of the major functions of these secret doctors is their role as a special servant of God and hence their ability to cure minor and major illnesses (Fontenot 1994: 43). Formal Health Practitioners In this section, formal health practitioners are referred to as licensed medical doctors (M.D.s) and doctors of osteopathic medicine (D.O.s) in licensed allopathic (M.D.-staffed) and osteopathic hospitals. The U.S. Department of Health and Human Services (1986) regularly documents the number of physician contacts by the general public. Interestingly, the national health care utilization data have always shown a distinct difference between African Americans’ and European Americans’ use of formal health practitioners. For example, blacks sought care from the doctor’s office (47%) less than did whites (57.7%). Blacks were also less likely to contact a doctor by phone (9.2%) than were whites (13.4%). Yet, blacks were reported to have experienced more physician contact in hospital outpatient departments (21.4%) than whites (13.7%) and to have more

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physician contact at home (5.8%) than whites (2.5%) (U.S. Department of Health and Human Services 1986). Most health care researchers would contend that an obvious explanation for the difference of physician utilization between blacks and whites is economics. There is no doubt that the costs of seeking care and the lack of health insurance cause many African Americans to delay or fail to seek care from formal health practitioners. However, some researchers contend that there are other social and cultural factors that are the true causes of the disparity in seeking care from formal health practitioners. In particular, Blendon et al.’s (1989) study of 10,130 persons living in the continental United States found that even blacks above the poverty line have less access to medical care than their white counterparts. The researchers contend that ethnic-related differences in health care arrangements and lifestyle were the most significant factors in disparity between black and white health care utilization. For example, blacks are more likely than whites to report that during their last visit their physician did not inquire sufficiently about pain, did not tell them how long it would take for prescribed medicine to work, did not explain the seriousness of the illness or injury, and did not discuss tests or examination findings. In addition, fewer than three-fifths of blacks were completely satisfied with the care provided during their last hospitalization, compared with more than three-fourths of whites (Blendon et al. 1989). It is apparent that there are differences not only in access but also in the perception of the care provided for blacks and whites. Blacks seem to adhere to alternative health beliefs, and they use alternative health care therapies more extensively than do whites (Blendon et al. 1989). Alternative Treatment Actions: Unnatural Causation Unnatural illnesses are perceived to be caused by a supernatural spirit, magic, sorcery, voodoo, or some other personalistic agent (Snow 1974; Hill 1976; Bailey 1991a). The literature on African American illness causation suggests that the African American healing tradition considers the universe a place where the forces of good and evil, God and Satan, struggle for control (Gregg and Curry 1994: 522). Therefore, unnatural illnesses are perceived to be a struggle between the forces of good and evil. Within this belief system, religion or spirituality is of utmost importance to illness perceived to be caused by unnatural means. Even though religion and spirituality are most commonly reported as important sources of social support for African Americans, they can also be used for dealing with unnatural illnesses in a more positive way (Stolley and Koening 1997; Gregg and Curry 1994; Ford et al. 1998; Jackson, Jackson, and Nixon 1970; Taylor and Chatters 1986). Taylor and Chatters (1986) and Stolley

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and Koening (1997), among others, have shown that African Americans’ use of religion and spirituality for natural as well as unnatural illnesses is their particular method of treating an illness/disease within their health belief system. In fact, one of the cultural institutions that symbolizes and represents the diverse religious and spiritual beliefs among African Americans is the black church. Black churches provide an array of emotional and learning experiences and embody therapeutic factors that enhance group cohesion and promote empowerment and social changes. Black churches have also served as mutual aid groups, providing for African Americans a sense of belonging, role models, interpersonal learning, and safe environments in which to share and express ideas and feelings. In sum, the black church is a form of group activity that provides healing and other health and learning benefits to its membership within the African American community (McRae, Carey and Anderson-Scott 1998). Another means of treating an unnatural illness, and sometimes natural illness, is with voodoo “rooting.” As a form of religion, voodoo is a complex of African belief and ritual governing, in large measure, of the religious life of African natives (Jordan 1975). Harvey (1988) states that “as a belief system which combined historical conceptions with practices that were acceptable in a holistic social environment, voodoo is a striking example of a cultural adaptive mechanism used by members of an oppressed group as a survival technique.” The African American form of voodoo medicine consists of three components. The first is the mystic component, which deals with the supernatural such as spells and spirits. The second component is that part of voodoo that deals with psychological support of the individual, and the third part is herbal and folk medicine. African American voodoo prospers particularly in the South, primarily because it fills a void left by inaccessibility and denial of medical care by formal American health practitioners (Jordan 1979: 38). An example of its usage was indicated in a study by Morgan (1996). Examining the prenatal care patterns of African American women in selected U.S. urban and rural cities, she found that one of her key informants first denied believing in voodoo but on a subsequent visit gave an account of her experience of having a spell on her. Additionally, this key informant, as well as others, believed that unnatural illnesses demand alternative indigenous healers and practices for relief. Morgan states that in both settings alternative indigenous health care providers were often found to ameliorate or cure natural and unnatural illnesses and other misfortunes that befell African Americans. African Americans tend to consult alternative indigenous health practitioners primarily because of:

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1. Their attempt to cope with health problems within the context of one’s resources and social and cultural environment; 2. Their belief that alternative indigenous health practitioners have some control over the forces that cause illness/disease in a person’s life, whereas Westernized medical physicians cannot heal certain cases of illness and misfortune; and 3. Lower monetary expense associated with such treatments. (Cockerham 1968: 88; Hill 1976: 14)

CONCLUSION This review of the alternative medical practices among African Americans highlights the “cultural basis” for their continued use and status within the African American community. The persistence of traditional African American health beliefs and practices in today’s African American alternative medical practices shows not only the role they play in maintaining a sense of ethnic identity but also provides a practical pattern of adaptation to social and economic conditions both within the African American community and within the larger society. Only when these critical issues are truly addressed and understood can African American alternative medicine become more a part of mainstream American alternative medicine. POST-EVALUATION QUESTIONS 1. What information would you add to this discussion on African American alternative medicine? 2. Are the research study findings truly reflective of alternative medicine use in the African American community? 3. How is African American culture interrelated with the current and past use of African American alternative medicine?

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Mathews, H., D. Lannin, and J. Mitchell. 1994. “Coming to Terms with Advanced Breast Cancer: Black Women’s Narratives from Eastern North Carolina.” Social Science and Medicine 38: 789–800. Mbiti, John. 1975. Introduction to African Religion. Ibadan: Institute for Urban Studies. McRae, P. Carey, and R. Anderson-Scott. 1998. “Black Churches as Therapeutic Systems: A Group Process Perspective” Health Education & Behavior 25: 778– 789. Morgan, Marjorie. 1996. “Prenatal Care of African American Women in Selected USA Urban and Rural Cultural Contexts.” Journal of Transcultural Nursing 7: 3–9. Neighbors, Harold, and James Jackson. 1984. “The Use of Informal and Formal Help: Four Patterns of Illness Behavior in the Black Community.” American Journal of Community Psychology 12: 629–644. Nkongho, Ngozi, and Patricia Archbold. 1995. “Reasons for Caregiving in African American Families.” Journal of Cultural Diversity 2: 116–123. Orgue, Modesta, B. Bloch, and L. Monroy. 1983. Ethnic Nursing Care: A Multicultural Approach. St. Louis: C.V. Mosby. Postell, William. 1951. The Health of Slaves on Southern Plantations. Baton Rouge, LA: Louisiana State University Press. Resnicow, K., R. Vaughan, R. Futterman, R. Weston, J. Royce, C. Parms, M. Hearn, M. Smith, H. Freeman, and M. Orlandi. 1997. “A Self-Help Smoking Cessation Program for Inner-City African Americans: Results from the Harlem Health Connection Project.” Health Education and Behavior 24: 201–217. Risser, A., and L. Mazur. 1995. “Use of Folk Remedies in a Hispanic Population.” Archives Pediatric Adolescence Medicine 149: 978–981. Satcher, David. 1992. “Afterwords.” In Health Issues in the Black Community, edited by Ronald Braithwaite and Susan Taylor. San Francisco: Jossey-Bass. Saunders, Elijah. 1991. Cardiovascular Diseases in Blacks. Philadelphia: F.A. Davis Company. Skelly, A., J. Marshall, B. Haughey, P. Davis, and R. Dunford. 1995. “Self-Efficacy and Confidence in Outcomes as Determinants of Self-Care Practices in Inner-City, African American Women with Non-insulin Dependent Diabetes.” Diabetes Educator 21: 38–46. Snow, Loudell. 1974. “Folk Medical Beliefs and Their Implications for Care of Patients.” Annals of Internal Medicine 81: 82–96. ———. 1977. ”Popular Medicine in a Black Neighborhood.” In Ethnic Medicine in the Southwest. Edward Spicer, ed. Tucson, AZ: University of Arizona Press. Spector, Rachel. 1985. Cultural Diversity in Health and Illness. New York: AppletonCentury Crofts. Stack, Carol. 1974. All Our Kin: Strategies for Survival in a Black Community. New York: Harper & Row. Staples, Robert. 1971. “Towards a Sociology of the Black Family: A Theoretical and Methodological Assessment.” Journal of Marriage and Family 33: 19–138. Stolley, Jacqueline, and Harold Koenig. 1997. “Religion/Spirituality and Health among Elderly African Americans and Hispanics.” Journal of Psychosocial Nursing 35: 32–38.

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Sussman, L. 1988. “Treatment Seeking for Depression by Black and White Americans.” Social Science and Medicine 24: 187–197. Tallant, Robert. 1990. Voodoo in New Orleans. Gretna, LA: Pelican. Taylor, Robert. 1985. “The Extended Family as a Source of Support to Elderly Blacks.” The Gerontologist 25: 488–495. Taylor, Robert, and Linda Chatters. 1986a. “Patterns of Informal Support to Elderly Black Adults: Family, Friends, and Church Members.” Social Work 31: 432–438. ———. 1986b. “Church-Based Informal Support among Elderly Blacks.” The Gerontologist 26: 637–643. Tinling, David. 1967. “Voodoo, Root Work, and Medicine.” Psychosomatic Medicine 29: 483–490. U.S. Department of Health and Human Services. 1986. Black and Minority Health: Report of the Secretary’s Task Force: IV. Washington DC: U.S. Government Printing Office. Wardwell, Walter. 1994. “Alternative Medicine in the United States.” Social Science and Medicine 38: 1061–1068. Warren, Rueben. 1992. “Health Education and Black Health Status.” In Health Issues in the Black Community, edited by Ronald Braithwaite and Susan Taylor, 241–254. San Francisco: Jossey-Bass. Williams, Christopher. 1990. The African Experience in Community Development: A Programmed Workbook. New York: Kendall/Hunt Publishing Company. Williams, Richard Allen. 1975. Textbook of Black-Related Disease. New York: McGraw-Hill. Youngkin, Ellis, and Debra Israel. 1996. “A Review and Critique of Common Herbal Alternative Therapies.” Nurse Practitioner 21: 39–45.

WEB SITES OF SIGNIFICANCE Black Health Net: http://www.blackhealthnet.com Healthweb African American Health: http://www.lib.mus.edu/health/hw/minority/ african.html National Center for Complementary and Alternative Medicine: http://altmed.od.nih.gov/ nccam Office of Minority Health Resource Center: http://www.omhrc.gov

Chapter 4

Cultural Historical Review of African American Alternative Medicine CRITICAL THINKING QUESTIONS 1. Why is it important to examine the cultural history of alternative medicine within the African American community? 2. Is there an identifiable connection between African health care practices and African American health care practices? 3. Why would African Americans have had to use various alternative medical therapies in early time periods?

INTRODUCTION African Americans are primarily descendants of West African people who share a common history, place of origin, language, food preferences, values, and health beliefs that engender a sense of exclusiveness and selfawareness of being a member of this ethnic group (Staples 1971; Franklin and Moss 1988). This chapter will not only highlight the cultural–historical health belief connection that current African Americans have with their West African descendants but also show how a majority of African Americans, regardless of region of the United States (Charleston, South Carolina, and Detroit, Michigan) share a number of alternative health practices from one time period to another. As early as the 1500s, West Africans were forcibly transported to South America, the Caribbean, and North America. Over half of the West Africans came from the coastal areas of what are now Angola and Nigeria. Others came from the regions that are today Senegal, Gambia, Sierra Leone, Liberia, Togo, Ghana, Benin, Gabon, and Zaire. In addition, they belonged to different kinship groups—the Mandingo, Hausa, Efiks,

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Fanting, Ashanti, Bambara, Fulani, Ibo, Malinke or Yoruba—and spoke different, though related, languages (Dixon and Wilson 1994: 17). In the process of adapting to the new settings, West Africans merged their African cultural traditions with European and Native American traditions. With regard to health beliefs and health care practices, African Americans are believed to have retained many of the preventive and treatment practices associated with indigenous West African cultures, primarily because these methods were perceived to be most useful and because they shared similar belief systems of living, health, illness, and spirituality. For example, in the African Living Belief System, living refers to the African emphasis on life as a dynamic, perpetually evolving condition that includes the way in which the ancestors “live” on long after their death. Belief is the thought/rationale behind the African’s worldview, customs, and behaviors. Finally, system is the totality of a complex, highly organized structure of ideas and behaviors that is passed on (actively and passively) from generation to generation. Thus, the African Living Belief System encapsulates a holistic quality whose emphasis equally relates community, man/woman, deity, and natural elements for living out the system of belief (Bankole 1998: 135). EARLY AFRICAN AMERICAN ALTERNATIVE MEDICINE Enslaved African folk doctors were often sought after for their medical knowledge, which in most cases was based on traditional forms of healing and preventing sickness. Early trust and faith between African folk doctors and African slaves were strengthened because of shared medicoreligious beliefs related to the cause of illness (Fontenot 1994: 32). One African American alternative practitioner who relied heavily upon the similar psychological and cultural orientation to health, illness and disease among the new African Americans was the “black conjure doctor.” The black conjure doctors were African healers who used “magic” plants, spells, and suggestions to heal. These doctors were far ahead of Europeans in their appreciation of the power of the mind over the body. They used the beliefs and superstitions of their patients, and their powers of persuasion often healed illnesses that white doctors could not cure. They could also work their powers of suggestion in reverse, casting spells to bring sicknesses to a well person. Thus, white slave owners often detested the conjure doctors, probably because these healers, who had a long tradition in Africa and the West Indies, could readily influence other blacks (Dixon and Wilson 1994: 16 and 246). In order to get a true sense of how slaves viewed the black conjurer, this section presents two testimonials from former slaves as described in the book Lay My Burden Down: A Folk History of Slavery (Botkin 1989).

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Us children hang round close to the big house, and us have a old man That went round with us and look after us, white children and black children, And that old man was my great grand-daddy. Us sure have to mind him, cause Iffen we didn’t, us sure have bad luck. He always have the pocket full of things to conjure with. That rabbit foot, he took it out, and he work that on you till you take the creeps and git shaking all over. Then there’s a pocket full of fish scales, and he kind of squeak and rattle them in the hand, and right then you wish you was dead and promise to do anything. Another thing he always have in the pocket was a little old dry-up turtle, just a mud turtle ‘bout the size of a man’s thumb, the whole thing just dry up and dead. With that thing he say he do most anything, but he never use it iffen he ain’t have to. (Botkin 1989: 38)

The following is a testimony of a conjure that didn’t work: They was pretty good to us, but old Mr. Buck Brasefield, what had a plantation jining us’n, was so mean to his’n that ‘twa’n’t nothing for ‘Em to run away. One man, Rich Parker, runned off one time, and whilst He gone he seed a hoodoo man, so when got back Mr. Brasefield took Sick and stayed sick two or three weeks. Some of the people told him, “Rich been to the hoodoo doctor.” So Mr. Brasefield got up out en that Bed and come a yelling in the field, ”You thought you had old Buck, But by GOD he rose again.” Them people was so scared they squatted In the field just like partridges, and some of ‘em whispered “I wish to GOD he had had died.” (Botkin 1989: 43)

The primary purpose of presenting these two testimonials of former slaves is to show how much perceived power they had within the slave community. In fact, in the slave’s world, the conjuror was the medium for redressing wrongs committed by his master or fellows, as well as serving as druggist, physician, faith healer, psychologist, and fortune-teller (Berry and Blassingame 1982). He was the source of love potions, poisons, and “trick bags.” In removing spells and curing illnesses, he used what was tantamount to autosuggestion or hypnotism and his knowledge of herbs. Mixing teas made from boiling sassafras, nutmeg, asafoetida, or wild cherry, coak, dogwood, and popular bark with vinegar, cider, whiskey, turpentine, quinine, calomel, molasses, and honey, it was said that the conjuror was remarkably successful in curing the slaves of colds, fevers, chills, and other illnesses. Whether he was successful or not, the conjuror or hoodoo became a fixture as an alternative health practitioner in the slave and free African American communities. In general, the great strength of early African American alternative medicine was that it was holistic. It was not enough to treat physical symptoms of an illness; sociological and psychological manifestations had to be considered as well. This protocol followed from a general African conviction that illness was due to a natural or unnatural element (Piersen 1996: 99).

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Early African American alternative medicine was greatly influenced by the type of medical system practiced by a majority of the slave owners, the overseers, and the physicians. It’s easy to understand how home remedies, self-care, and alternative practices became important among slaves as they turned to one another for help (Dixon 1994: 246). Because enslaved Africans received medical care from white planters, overseers, and physicians who prescribed blood-letting, induced vomiting, performed experimentation procedures, and used other standard treatments of the day, it is obvious why enslaved Africans developed their own healing arts based on African practices, a combination of spiritualism and herbal medicines. Interestingly, the most gifted healers were usually women who had been given permission by the planters to learn “white medicine” and minister to ailing slaves (Dixon 1994: 246). Dixon states that recipes for cures by these enslaved African women circulated secretly through the slave quarters, were whispered from ear to ear, and passed down from parent to child. For example, female African American slave doctors used drugs derived from plants to prevent and cure worms, croup, pneumonia, colds, teething, and measles. Sometimes, they used the root, and at other times, they selected the leaf, bark, fruit, or gum resin to boil into tea, make into a poultice, or wear in a bag around the neck (Goodson 1987: 20). Not only did African American slave doctors have this medical knowledge of plants, but many other slaves knew how to diagnose and treat illnesses. In fact, a number of medicine chests have been discovered filled with the popular preparations of the day: calomel, blue mass pills, castor oil, ipecac, tartar emetic, teas, tonics, and various tinctures (Ewell 1813; Bankole 1998). Thus, much of the early African American alternative medical treatment practices developed in the slave era and operated within the very shadow cast by the white medical world. During the 1700s and 1800s in the United States, African American alternative medical beliefs and practices continued to show similarities with the West African and Haitian religion of “Voodoo” or “Vodoun” (Tallant 1990). Voodoo to a large extent governs the religious life of the African natives. According to Harvey (1988), voodoo is an example of a survival tactic used by members of an oppressed group. African American voodoo was particularly popular in the south where African Americans were for the most part denied medical care by traditional American physicians (Jordan 1979: 38). Thus, African American alternative medical beliefs and practices merged with elements from the voodoo religion of Haiti and Africa in an effort to treat the individual biologically and spiritually. African Americans in Charleston, South Carolina With the abolition of slavery, African Americans continued their reliance on natural remedies for ailments. Another well-known and recog-

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nized alternative practitioner during this time period and thereafter was the “granny.” When a person became ill, the granny, who served as midwife and general health practitioner, was called upon by the family to offer her expert advice. The granny was often the first choice of African Americans who lived in areas where medical attention from doctors was unavailable because of distance or financial cost. When help from a trained doctor was available, parents would consult the doctor and try the remedy offered. However, if they were not satisfied with the results, the parents would return to the more traditional cures offered by the area granny or midwife. Doctors were aware of this and often grew to respect the natural remedies, and, in some cases, incorporated them into their practice. The tradition of being a midwife or granny was passed on from mother to daughter. From a young age, girls learned from their mothers which herbs worked best for curing particular ailments. Each individual family had its own traditions concerning what herbs or roots they used for particular problems, but whenever an illness arose that they were unsure how to handle, families often turned to the eldest woman in the area. African Americans in Detroit, Michigan To better understand the use of alternative medicine among African Americans during the early 1900s, I examined the use of alternative medical practices among Detroit African Americans. In particular, I discovered that Detroit African Americans used alternative health practitioners during the early 1900s for a variety of reasons. Although African American patients preferred to be treated by African American physicians, Detroit residents still opted for outpatient services or used traditional folk remedies and healers. Ironically, the most prevalent diseases in the African American community required hospitalization for effective treatment. Because of the inaccessibility of local health facilities and the inability to receive adequate treatment, many died needlessly from pneumonia and tuberculosis. Fear of hospitals, a common occurrence in all groups, caused many African Americans to avoid using mainstream health care facilities. This fear was based on a long-standing traditional belief that hospital physicians practiced experimental laboratory tests on patients. Therefore, it was not difficult to understand why the use of alternative health practitioners and remedies became an integral part of Detroit African American health care. A large of proportion of ill African Americans depended entirely on alternative health practitioners for treatment. These practitioners operated in several African American communities and specialized in a variety of health care problems.

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The two major types of alternative health practitioners serving the African American community were independent specialists and spiritualists. Independent specialists consisted primarily of herbalists, neighborhood prophets, and magic store vendors. Each specialist treated a wide variety of physical and mental problems. Like traditional African folk healers, the alternative practitioners used treatments such as religious rituals, herbs and roots, and the observance of certain prohibitions or directives to cure individuals. Spiritualists, referred to as “Divine Healers,” were also prospering in the community with their alternative therapy of laying on of hands. For example, Washington (1920) stated: One of these healers started in business only a month ago charging 50 cents a treatment. He has built up such a following that he is now charging from $2.00 to $25.00, according to the amount he thinks a patient will be able to pay. His office is always full of sick blacks who get up early in the morning to be first in line when his place of business opens.

African Americans consulted various alternative health practitioners because of: • A need to cope with health problems within the scope of their own resources and social environment; • A belief that alternative health practitioners had some control over the forces that cause anomalies in a person’s life, whereas Westernized physicians could not heal certain cases of illness and misfortune; • The lower treatment cost; and, most important, • A need to be involved in the family’s caring, nurturing, and healing process.

Interestingly, these African American alternative health practitioners were not only accepted and used by the African American community but also were used by whites (Washington 1920). In general, as more African Americans migrated to northern cities during the mid-1800s and early 1900s, they brought a repertoire of health care beliefs and practices. African American alternative medical beliefs and practices thus became a composite of elements from a variety of sources: European folklore, Greek classical medicine, modern scientific medicine, Vodoun religion, Christianity, and particularly African folklore (Hill 1976). With such a mixture of health belief systems, it is no wonder why African American medical beliefs and practices are currently shared by all segments of the American population.

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CONTEMPORARY AFRICAN AMERICAN ALTERNATIVE MEDICINE During the latter part of the 1900s, very few studies documented African American alternative medical practices and practitioners. In fact, researchers tended to purposely avoid investigating African American alternative medicine and practitioners primarily because there was not much credible evidence of its existence. The following two anthropological studies show how the African American alternative health belief system and practitioners are still striving today. Morgan’s (1996) study of prenatal care beliefs and practices among African American women in selected U.S. urban and rural settings found that folk health beliefs, practices, and indigenous health care providers were widely used by women in the African American community. Her qualitative study among 13 key informants and 33 general informants revealed that folk health beliefs and practices influenced the health and well-being of African American women in both the urban and rural settings. Morgan (1996) found that in both the Midwest and South, there are many health beliefs and practices related to unnatural causes. There were many descriptors in stories told by informants about voodoo and hexing people, thereby causing illness and misfortune. In particular, two general informants in the South talked about frizzled chickens and their importance in voodoo. Another general informant recounted the story about her friend who was wasting away while the physicians could not find anything wrong. The informants also shared several theories as to how to keep dead people from returning to haunt people (Morgan 1996: 7). Morgan’s (1996) study also found that there was a need for indigenous healers to cure unnatural illnesses. All of the informants agreed that health care professionals are often able to cure or help the natural illnesses and are sought out for this purpose. However, unnatural illnesses demand indigenous healers and practices for relief. In both settings, alternative indigenous, alternative health care providers were often found to improve or cure natural and unnatural illnesses and other misfortunes that befell the people. Nonprofessional healers were consulted often by the key and general informants. Morgan emphasized, however, that while this was found in each of the settings, the practice was more prevalent in the rural South (Morgan 1996: 7). Bailey, Erwin and Belin’s (2000) study of African American women’s perception of cancer is another example of the similarity in health belief systems between present-day African Americans and the enslaved and free African Americans of the past. The study was based upon qualitative data gathered from focus group sessions conducted between 1989 and 1991 and in 1996. The primary purpose of these data was to provide a

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framework to understand and apply cultural data to the development of an intervention to increase breast cancer screening behaviors. The cultural data were also used to assess how this intervention could further address direct utilization of services. Sixty women (median age of 50 years) participated in the five focus groups. Sixty-six percent of the women had a high school degree or less, and 62% had annual incomes below $15,000. The groups met in urban and rural community-based and clinical settings in Little Rock, North Little Rock, and Wynne, Arkansas. From the qualitative results, Bailey, Erwin and Belin (2000) found that some women felt that cancer is a stigmatized disease—so don’t talk about it—and that cancer is a punishment from God. For example, in their experiences, people diagnosed with cancer often keep it a secret. One participant revealed for the first time that she had had breast cancer 10 years before. Her neighbor and best friend, sitting beside her in the focus group, did not know it until that moment. Mothers often don’t tell their daughters that they have a lump or that they were diagnosed with cancer. In addition, the cause of one’s cancer may be perceived as some kind of punishment from God: “It’s just like Job in the Bible, some folks think that you’re bein’ punished for somethin’ you’ve done if you get cancer” (Bailey, Erwin, and Belin 2000: 139). Therefore, even when African Americans have a positive experience with an early stage cancer, they are less likely to talk about it because they may interpret it as some kind of failing (Bailey, Erwin, and Belin 2000: 139). In general, these present-day African American women showed a commonality of belief with African American women of the past that certain diseases are naturally caused whereas others, like cancer, are unnaturally caused by a supernatural entity such as God. CONCLUSION To truly understand the growth and presence of alternative medicine and alternative health practitioners today among African Americans, we must examine the cultural history of the people and the major sociocultural factors that influenced their use. From this brief cultural historical review, we can see that alternative medicine and alternative health practitioners played a vital role in the health maintenance and well-being among both the African American communities and mainstream society. In fact, many of today’s mainstream alternative health care practices and medicines are a result of the earlier practices of African and African American alternative practitioners who established the foundation and strategies for treating illnesses and diseases from the African American perspective. In essence, this is what all alternative medical therapies are

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about—attempting to treat illnesses and diseases with therapies stemming from the patient’s belief system. POST-EVALUATION QUESTIONS 1. Are African Americans still using alternative medicines today regardless of the improvements of the health care system from earlier time periods? If so, why? 2. Is causation of certain diseases still perceived to be naturalistic and/or supernaturalistic in the African American community? 3. Do you use the home remedies from your parents’ and/or grandparents’ generations? If so, why, and how often do you use these remedies?

BIBLIOGRAPY Bailey, E., D. Erwin, and P. Belin. 2000. “Using Cultural Beliefs and Patterns to Improve Mammography Utilization among African American Women: The Witness Project.” Journal of the National Medical Association 92: 136–142. Bankole, Katherine. 1998. Slavery and Medicine: Enslavement and Medical Practices in Antebellum Louisiana. New York: Garland Publishing, Inc. Berry, Mary, and John Blassingame. 1982. Long Memory: The Black Experience in America. New York: Oxford University Press. Botkin, B. A. 1989. Lay My Burden Down: A Folk History of Slavery. New York: Delta. Dixon, B., and J. Wilson. 1994. Good Health for African Americans. New York: Crown Publishers. Ewell, J. 1813. Planter’s and Mariner’s Medical Companion. Philadelphia, PA: Scholarly Press. Fontenot, Wonda. 1994. Secret Doctors: Ethnomedicine of African Americans. Westport, CT: Bergin & Garvey. Franklin, John, and Alfred Moss. 1988. From Slavery to Freedom: A History of Negro Americans. New York: Alfred A. Knopf. Goodson, Martia. 1987. “Medical-Botanical Contributions of African Slave Women to American Medicine.” The Western Journal of Black Studies 2: 198–203. Harvey, William. 1988. “Voodoo and Santeria: Traditional Healing Techniques in Haiti and Cuba.” In Modern and Traditional Health Care in Developing Societies, edited by Christine Zeichner, 101–114. New York: University Press of America. Hill, Carole. 1976. “Folk Medical Belief System in American South: Some Practical Considerations.” Southern Medicine 69: 11–17. Jordan, Wilbert. 1979. “The Roots and Practice of Voodoo Medicine in America.” Urban Health 8: 38–41. Morgan, Marjorie. 1996. “Prenatal Care of African American Women in Selected USA Urban and Rural Cultural Contexts.” Journal of Transcultural Nursing 7: 3–9. Piersen, William. 1996. From Africa to America: African American History from the Colonial Era to the Early Republic, 1526–1790. New York: Twayne Publishers.

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Staples, Robert. 1971. “Towards a Sociology of the Black Family: A Theoretical and Methodological Assessment.” Journal of Marriage and Family 33: 19–138. Washington, Forrester. 1920. The Negro in Detroit: A Survey of the Conditions of a Negro Group in a Northern Industrial Center During the War & Prosperity Period. Detroit: Associated Charities of Detroit.

WEB SITES OF SIGNIFICANCE About Alternative Religions: altreligion.about.com/cs/african.religions Hoodoo Medicine: http://www.hoodoomedicine.com University of California–Los Angeles–Folklore & Mythology Archives: http:// www.humnet.ucla.edu/humnet/folklore/ethnic

Part III

How to Do Applied Medical Anthropological Fieldwork In general, medical anthropological fieldwork involves observing, listening, asking questions, analyzing, and summarizing patients’ and/or health care professionals’ thoughts and behaviors as they relate to a specific and/ or general health care or medical issues such as alternative and complementary medicine. A step-by-step approach to medical anthropological fieldwork is described for the first-time student, researcher, practitioner, and the general public. Qualitative methods such as participant observation, focus groups, and in-depth interviews are emphasized. The procedure for completing a medical anthropological fieldwork project consists of four phases: (1) preparing and adapting to the field; (2) medical anthropological fieldwork techniques; (3) ethnographic fieldwork data analyses; and (4) reflective comments. In addition, Part III discusses ethical issues of research as they relate to an African American researcher.

Chapter 5

Strategies for Collecting Qualitative Alternative Medicine Data CRITICAL THINKING QUESTIONS 1. What are the particular strategies for collecting alternative medicine data? .

2. Why is the field of anthropology the most appropriate research discipline for learning this type of data-gathering technique? 3. What can nonanthropologists learn from using applied medical anthropology health research strategies?

INTRODUCTION Ethnographic research has a long and continuing history of investigating human behavior as a part of cultural anthropology. To understand and to describe a cultural and/or ethnic group, anthropologists engage in ethnographic fieldwork. Fieldwork refers to firsthand observation of human societies as a means of gathering data and testing hypotheses generated by theories. This means living with people, eating their food, learning their language, listening to gossip, examining the items they produce, asking questions, recording answers, and, above all, simply watching people’s daily routines and interactions. Those who conduct this type of research are referred to as ethnographers (Bailey 2000). Ethnographers study how people live and how they communicate and interact with one another. Material and nonmaterial goods are of interest to the ethnographer, as are the folktales, symbols, rituals, and expressive arts (Leininger 1985a: 36). As ethnographers pay close attention to how people live, social structural features such as politics, religion, kinship, education, and technology become apparent to the researchers. Thus, a general ethnographic study is the principal means for obtaining a holistic

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view or total perspective of people in their physical and sociocultural environments (Leininger 1985a; Spradley and McCurdy 1972; Spradley 1980). The use of ethnographic methods in the health care field continues to open new doors of opportunity for applied medical anthropologists. Yet, bringing the new and growing awareness of health professionals closer to ongoing and expanding applied medical anthropology and the use of ethnographic methods is more likely to occur if we can show that anthropology can make a cost-effective contribution (Chrisman and Maretzki 1982). The continuing challenge is to build bridges between the clinical and public health fields with the applied medical anthropology field. Kleinman (1980), Fabrega (1974), Eisenberg (1977), Leininger (1978), and Schreiber and Scrimshaw (1979) are considered as the early bridge builders who pioneered anthropology in the fields of medicine, nursing, and public health. For example, in the field of public health, ethnographic methods such as the Rapid Assessment Procedures (RAP) have been used to address a variety of public health problems. Rapid assessment procedures are ethnographic methods for quickly gathering social, cultural, and behavioral information relevant to specific health-related problems and prevention programs (Harris, Jerome, and Fawcett 1997: 375). RAP has been used to solve problems with the World Health Organization Global Program on AIDS (Scrimshaw et al. 1991), agricultural public health issues of northeast Thailand (Subhadhira et al. 1988), and other international health programs. Distinguishing features of RAP include: 1. Formation of a multidisciplinary research team, including a member indigenous to the cultural group of interest; 2. Development of materials to train indigenous team members; 3. Use of several data collection methods to verify information through triangulation; 4. Iterative data collection and analysis to facilitate continuous adjustment; and 5. Completion of the project quickly, usually in four to six weeks. (Harris, Jerome, and Fawcett 1997: 375)

Ethnographic techniques used in RAP include in-depth key informant interviews, behavioral observation, and focus groups (Manderson and Aaby 1992; Scrimshaw and Hurtado 1987). Data generated from the RAP are analyzed using standard techniques developed for qualitative data, including content analysis and ethnoclassifications (Pelto and Pelto 1987; Scrimshaw et al. 1991). Internal validity and reliability of conclusions drawn from RAP are strengthened through triangulation (using multiple team members and/or research methods to gather similar data). Data are

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compared to verify both the accuracy of information and conclusions that are drawn (Harris, Jerome, and Fawcett 1997: 376). In a community-based public health initiative, Braithwaite, Bianhi, and Taylor (1994: 412) discovered that the rapid ethnographic assessment procedures proved effective in documenting community health concerns and in providing data for people of color and their participation in coalition partnerships. This community-based initiative involved two local health departments, a medical school, a school of public health, and three communities (two suburban and one inner-urban). Needs assessment profile reports served to educate indigenous citizens about their communities and provide them with information to make or argue a point with agency policy makers. In summary, the ethnographic techniques were the integral tool for galvanizing and mobilizing communities for social action relative to generating a health promotion and disease prevention agenda. In the clinical setting, ethnographic methods have been shown to be very effective in providing a better understanding of a patient’s illness perception. In particular, Blumhagen (1982), who explored some of the illness beliefs of mainstream Americans attending an outpatient clinic at the Seattle Veteran’s Administration, found that the use of the explanatory model interview helped to facilitate communication between practitioner and patients. A nineteen-item semistructured interview schedule based on Kleinman’s (1980) explanatory model questions was developed and pretested on six individuals who were not part of the study (Blumhagen 1982: 304). Blumhagen revised the interview schedule and administered it to 117 patients in the clinic. Among his findings: A knowledge of what the popular beliefs are around a common illness condition can lead to more intelligent questioning. Thus, for example, a person with hypertension could be asked, “Some people think that nervousness is associated with this illness. How do you see that applying to yourself?” A person who was delivering a biomedical model can sometimes be shifted to a deeper, more significant layer of illness belief explication by this type of question. (Blumhagen 1982: 316)

Thus, by using the ethnographic method such as the explanatory model, interviews can lead to improved patient adherence. The following sections describe the applied medical anthropological strategies that I used for my particular applied medical anthropological studies. PREPARING AND ADAPTING TO THE FIELD In any fieldwork project, the first issue is the “topic” of the project. That is, the researcher should “brainstorm” for a period of time about potential

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topics of the project. This brainstorming process consists of developing a list of at least ten potential projects and determining whether the project will be descriptive, explanatory, or exploratory. Once the researcher arrives at a conclusion in this area, the project can progress to the second stage of “preparing and adapting to the field.” This stage involves background research of the topic: conducting preliminary research through a variety of outlets such as library research, newspaper and magazine articles, Internet Web sites and news groups, and personal connections to the focus of the study. The primary purpose of conducting background research is twofold: (1) to reduce the researcher’s culture shock, and (2) to recognize one’s personal biases. Culture shock is an event that places the health researcher in an uneasy situation in which he or she feels uncomfortable, nervous, anxious, and embarrassed. The health researcher feels this way primarily because of unfamiliarity with the cultural patterns of informants. If some type of background research is completed prior to conducting the field research, the health care researcher can be better prepared for the encounters in the field. Second, once health researchers truly admit their own biases to themselves and to others, a better understanding of their informants’ health care issues can be appreciated. Thus, recognizing their biases helps health researchers realize their own personal preferences for certain health care issues and helps them move closer to the role of an “objective” health researcher. The third step of preparing and adapting to the field is called the “researcher’s effect.” It is critical for health researchers to be aware that their presence in the field may affect the behavior of their informants. In order not to change the behavior of or information shared among informants, health researchers must try to be as inconspicuous as possible when collecting field data. Sitting off to the side or staying out of the direct line of sight when informants are sharing detailed information may help when collecting field data. Thus, when preparing to collect field data, it is significantly important to plan ahead on how and where the health researchers will situate themselves. The fourth and final step of preparing and adapting to the field is referred to as “ideal versus real cultural patterning.” Before reaching the field and before collecting field data, the health researcher will often glean from key informants their “ideal” standards or views of their health cultural pattern. The ideal cultural pattern is what people say they do; yet, in fact, it is often different from what they really do. It is crucial for the health researcher to recognize the difference between what people say versus what they really do. In other words, people will complete surveys and participate in focus group sessions and say that they practice a certain health care pattern, while they actually practice an alternative health

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care pattern. For the health researcher, determining the difference between “ideal versus real cultural patterning” is of critical importance to the foundation of every applied medical anthropology study. MEDICAL ANTHROPOLOGICAL FIELDWORK TECHNIQUES One element that has remained constant throughout the history of anthropology is the use of qualitative methods to collect field data. Distinguished scholars such as Hurston (1942; 1995), Boas (1928; 1943), Malinowski (1929; 1954), Kluckhohn and Murray (1954), and Mead (1928; 1955) established the foundations for qualitative research methods. Their early fieldwork studies provided the framework for qualitative research in the future. Qualitative research refers to the methods and techniques of observing, documenting, analyzing, and interpreting attributes, patterns, characteristics, and meanings of specific contextual features of the phenomenon under study (Leininger 1985a: 5). Leininger states that with this research method, the focus is on identifying the qualitative features, characteristics, or attributes that make the phenomenon what it is. This includes documenting and fully describing major features of the phenomenon such as human events, life situations, health care issues, and other aspects under study. In general, the use of qualitative methods helps to discover cultural health patterns, to witness the actions of informants/clients, and to understand the informants’/clients’ perspectives. Observation The first phase of qualitative research is observation. This is particularly important to any qualitative health care project primarily because it allows the researcher to view the health care problem from a uniquely insightful perspective. Often, observation has been taken for granted. As most anthropologists recognize, observation is the key to any quality fieldwork project. Critically observing the behavior of individuals or interactions between health care professionals and patients provides an opportunity to witness the “real cultural” patterning that exists. Whether the observation is of a waiting room of an outpatient clinic, the interaction of a nurse practitioner with a patient who needs special assistance because of a disability, or the reactions of patients to one another in a busy emergency room clinic or a free public health fair, observation is a significant research tool in providing the researcher with “direct evidence” of a health problem. Leininger (1985a) states that the researcher obtains a broad view of the situation and gradually makes detailed observations. Allowing some time

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to make detailed and documented observations is essential before interacting or participating more directly with the people because it permits the researcher to establish what is occurring before influencing the situation as a participant. It also permits the people some time to observe the researcher at a distance and to “size up” his or her behavior as a stranger (Leininger 1985a: 53). Thus, researchers who use observation as a research tool must develop their own particular style and approach. Health researchers need to become aware of their own strengths and weaknesses in observational style. Pelto and Pelto (1978) state that one should practice observing and recording events in order to discover observational biases and to develop more systematic techniques of recall. One should find out how extensive note taking must be in order to ensure accuracy of recall. One must learn to direct attention to features that tend to be neglected (Pelto and Pelto 1978: 70). Thus, the key to successful critical observation is practice, practice, and practice. Participant Observation The second most important phase of a qualitative health research project is participant observation. Participant observation is a method by which an observer maintains a presence in a health care situation for the purpose of scientific investigation (Fitzpatrick 1981). The observer participates in the daily life of the people under study, either openly in the role of researcher or covertly in some disguised role, observing things that happen, listening to what is said, and questioning people over a length of time (Becker and Geer 1957: 28). By participating, the researcher learns from the people and feels, experiences, and learns by direct involvement in activities (Leininger 1985a). For example, my participant observation as a volunteer in the Hypertension Clinic of Henry Ford Hospital in Detroit provided an opportunity to feel and to experience what it was like to be part of the staff at a major urban hospital. A majority of the people with whom I worked treated me as though I were a regular staff member. Although they knew that I was a doctoral student at Wayne State University and conducting a study on patients’ health beliefs as they relate to hypertension, I obtained a degree of acceptance within the hospital culture and a better appreciation of those who work in clinical hospital settings. Therefore, using participant observation can significantly enlighten the health researcher on a number of social and cultural health issues that are often neglected. Informants Through participant observation, the health researcher notes which persons are most involved in the actions—usually those with the great-

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est amount of firsthand information. These persons are referred to as “informants” (Pelto and Pelto 1978: 74). Working with informants is the hallmark of ethnographic fieldwork and involves an ongoing relationship (Spradley and McCurdy 1972: 41). The informant plays a vital role for the health care researcher. Informants are representatives of the cultural and ethnic group who show the potential to reveal substantive data in the domain of study (Leininger 1985b:47). Informants are different from “respondents.” Informants provide descriptions of the group or research setting as a whole, whereas respondents provide the investigator with personal accounts—what they thought, saw, and did during some event or about some issue. Spradley (1979) and Spradley and McCurdy (1972) state that in many ways informants can be thought of as narrators, knowledgeable about the setting and its actors, who provide the researcher with insight into what is going on. Informants, therefore, are the spokespersons for the group about any particular health care issue in the community. Type of Interviews Generally, there are three types of interviews. The first type is the informal or open-ended interviews (Bailey 1982; Leininger 1985b; Spradley 1979; Spradley and McCurdy 1972). Informal interviews are ideal to elicit emic (insider’s perspective) data and get “inside the head” or obtain the worldview thoughts and experiences of the informant (Leininger 1985b: 54). Leininger states it is truly an art and skill for the interviewer to listen actively and patiently after posing an open-ended question to the interviewee. The second type of interview is the semistructured interview, which is a combination of both informal and structured types. It is designed to elicit both definitive and unexpected kinds of information from the interviewee (Leininger 1985b:55). The third type of interview is the structured interview, designed to elicit specific responses to specific questions. This type of interview is more often used to control responses to fit specific variables and to ask the same questions of all sampled individuals. Examples of structured questions are: (1) How many times have you used the local health clinic? or (2) How many times did you participate in prenatal health care classes before the birth of your child? With each interview strategy, there are obvious advantages and disadvantages. For instance, the advantages of using structured interviews are that: 1. They are standardizable; 2. They provide a frame of reference;

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3. They clarify dimensions of concepts; and 4. They allow less chance for interviewer variability.

Although these advantages provide the researcher with quantitative results and well-defined categorical findings, structured interviews have a number of disadvantages (Wagenaar 1981): 1. They may force statement of opinion even when the informant knows nothing about the topic; 2. The researcher may overlook a possible alternative; and 3. The informants may make different interpretations of the questions.

Informal interviews or unstructured interviews also involve a number of advantages and disadvantages. As stated earlier, informal interviews are much like a casual conversation between the researcher and the informants. The casualness and flexibility of the interview allow the researcher to ask many more in-depth and personal questions. The major advantages of using informal/unstructured interviews are that (Wagenaar 1981): 1. They provide better indicators of whether the informant is telling the truth or knows what he or she is talking about. 2. They are appropriate for intensive study of attitudes. 3. They suggest hypotheses. 4. They clarify response alternatives. 5. They allow data to emerge—grounded theory at work.

Although the advantages of using informal interviews may outweigh the disadvantages, there are two areas of concern: (1) analysis is difficult and costly, and (2) comparability is difficult (Wagenaar 1981). Often these two issues influence many health researchers to opt for a different and more structured style of interviewing. As stated earlier, semistructured interviews combine the informal and structured interview approaches. That is, semistructured interviews elicit specific categorical responses from the informants but also include opportunities for the informants to elaborate on as many concepts or issues as they desire. Therefore, the semistructured interviewing approach is best for the researcher who requires categorical, quantitative data and insightful, in-depth qualitative data. Focus Group Interviews Focus group interviews are a qualitative research method that provides rich data on dynamic attitudes of individuals interacting in a group about

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a designated topic. Focus group methodology uses a standardized series of questions to elicit individual responses within the context of a group. This method benefits from both group interaction and group dynamics. In this environment, participant responses include the interplay of group members, which allows for greater depth of response, social context, and emotion. In addition, focus groups allow the researcher to hear directly from participants, using their own vocabulary, language, and communication patterns—essential components when working with differing ethnic and cultural groups. The focus group leader participates to guide the group in addressing the cultural attitudes and values that the group has about the specific health care topic in question. The group leader also provides further feedback concerning group interaction. An ideal focus group leader is comfortable and familiar with the group process and is able to exert a mild, yet unobtrusive, control over the participants (Nyamathi and Shuler 1990: 1285). Moreover, the focus group leader must be able to communicate clearly and be adequately knowledgeable about the topic of conversation. It is critical that the focus group leader walk a fine line between following the focus group questions to assure that the purpose and objectives for the group will be achieved and maintaining group enthusiasm and interest (Nyamathi and Shuler 1990: 1285). Focus Group Studies The use of focus groups in gathering qualitative health data on various segments of the African American population continues to be a new area of enlightenment for health care researchers. Specifically, a number of focus group studies have been very effective in researching critical health care issues in the African American population. For instance, Nyamathi and Shuler (1990) used focus group interviews to develop a culturally sensitive AIDS education program for African American women. As part of a larger study designed to provide counseling and HIV testing for the at-risk group, African American women who were (1) homeless, (2) intravenous drug users (IVDU) or sexual partners of IVDUs, (3) diagnosed with a sexually transmitted disease, or (4) prostitutes were invited to participate. The women participated in six focus groups. All groups were held in private rooms in one of two homeless shelters or one of two drug rehabilitation programs (Nyamathi and Shuler 1990: 1286). All sessions were conducted by two African American nurse researchers who were thoroughly trained to provide guidance and direction. All women who participated in the focus groups and signed an informed consent received ten dollars at the completion of the two-hour session (Nyamathi and Shuler 1990: 1286). A sample of 66 African American

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women who participated in the six focus groups ranged in age from 18 to 68; 64 women (97%) were under 50 years of age. The qualitative data from the focus groups suggested that in order to provide useful assistance, health care professionals need to fully understand the concerns and stresses these women experience and attempt to devise strategies that enhance feelings of control. One way an element of control may be obtained is by assisting the women’s active participation in seeking needed resources. A thorough assessment should include the individual’s perception of the situation and the needs experienced. More important, an assessment of how their needs can be met without usurping control from the client is imperative (Nyamathi and Shuler 1990: 1287). In general, Nyamathi and Shuler contend that the qualitative information obtained from the use of focus groups has been invaluable in tailoring an education program to the needs of a select population. Focus group methodology was also used to ascertain answers to the issue of what cultural barriers impact African American women’s participation in breast and cervical cancer screening. Williams, Abbott, and Taylor (1997) conducted three focus group sessions involving a total of 32 African American women from Flint, Michigan. Most of these women were older than 45 years (51%); single, divorced, or widowed (69%); had a high school education or better (65%); reported household incomes of $20,000 or less (66%), and were employed (47%) (Williams, Abbot, and Taylor 1997: 48). Transcripts were analyzed for trends and themes that emerged as a result of the questions asked. Williams, Abbott, and Taylor (1997) stated that the results of the focus group discussions with low-income African American women indicate that intensive recruitment efforts were needed to increase utilization of breast cancer screening services. Interpersonal contacts such as telephone calls reminding them of regular checkups and providing transportation to doctors’ offices were two methods of encouraging preventive care, thereby making these women feel that hospitals were caring places and that the women were not just another face in the health facility (Williams, Abbot, and Taylor 1997: 54). Focus group discussions with African American women also indicated that health promotion messages should be culturally sensitive and acknowledge the role of spirituality in their lives. Finally, Williams, Abbott, and Taylor (1997) stated that focus group discussions provided important information that would not have been obtained through telephone surveys or personal interviews. In fact, they stated, “The group dynamics created an atmosphere where many ideas and feelings were expressed that would not have come out if participants had been interviewed individually” (Williams, Abbot, and Taylor 1997: 55). Focus group methodology was also used to gather qualitative data in recruiting African American women at risk for noninsulin-dependent dia-

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betes mellitus into exercise protocols (Carter-Nolan, Adams-Campbell, and Williams 1996). Five of the focus groups were comprised of 39 African American women less than 45 years old (mean age: 27.9). The remaining focus group was comprised of 18 African American women older than 45 years (mean age: 50.9 years). The mean age for all 57 women was 34.6 years. Content was analyzed within each group, and ranges of attitudes, beliefs, and barriers were determined across all groups. Carter-Nolan, Adams-Campbell, and Williams (1996) found that several barriers toward physical activity exist and tend to be more prominent in the African American population. The barriers included low income, safety concerns, time management, low motivation, lack of social support, and inaccessibility of exercise facilities. Addressing these barriers, the researchers contend, will prove beneficial in increasing the likelihood of African American women participating in exercise protocols. Moreover, with regard to the advantage of the focus group methodology, the researchers suggested that it was a useful technique for reaching minority populations: Focus groups may be used to increase participation of black women in physical activity programs because: 1) the women share a common problem and are more likely to discuss it openly with each other, and 2) the women, with consistent encouragement from the moderator, will have a sense of ownership of the solutions being provided. (Carter-Nolan, Adams-Campbell, and Williams 1996: 561)

Finally, focus group methodology was used to assess attitudes associated with the willingness of African Americans to participate in prostate cancer clinical trials. Robinson, Ashley and Haynes (1996) conducted focus group sessions among 46 men, 40 years of age and older, in south central Los Angeles. The sessions were moderated by an African American research team, and all sessions were audiotaped for transcription, then analyzed with the assistance of the Ethnograph Qualitative Analysis Program. Robinson, Ashley, and Haynes found the following qualitative results: Most stated that they would be willing to participate in prostate cancer clinical trials. Many preferred entering a trial that was conducted at a black facility. They would want to know if the hospital had enough funds to conduct the trials. They would request information about the track record of the medical center’s research activities. (Robinson, Ashley, and Haynes 1996: 83)

In addition, the focus group data revealed that major obstacles to entering prostate cancer clinical trials were the lingering memories of the Tuskegee trials, lack of trust in the medical establishment, and fear of adverse reaction to the experimental drug or therapy. Moreover, too much monetary compensation would increase concerns with respect to the

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safety of the experimental protocol (Robinson, Ashley, and Haynes 1996: 83). In general, Robinson, Ashley, and Haynes felt that their study will be invaluable in laying the foundation for future investigations and interventions aimed at increasing participation of minorities in clinical trials. Focus Group Procedures and Guidelines Focus group sessions vary with each research topic. However, there are general procedures and guidelines for focus group sessions. For researchers who are unfamiliar with the procedures and guidelines for conducting focus group interviews and for those researchers who want the best results, the following points are suggested: Preparing for the Focus Group 1. Review the questions the day of or several hours before the focus group session. 2. Practice asking the questions to a friend or a colleague before the focus group session. 3. Determine where and how to arrange the seating for the focus group session. 4. Arrange the seating in a semicircular or full-circle fashion (depending upon the number of participants). 5. Establish the best place to arrange the audio- and/or videotape in the room (usually off to the side or out of the way of participants). 6. Review the questions again with the local community facilitator (key informant). 7. Bring refreshments to the focus group sessions. 8. As participants arrive, introduce yourself to them and invite them to have some refreshments. (This helps to establish immediate rapport.) 9. Be patient about starting the focus group session. (Allow 5 to 15 minutes for individuals to arrive at designated time of focus group session.)

Conducting the Focus Group 1. At the start of the focus group session, welcome all participants and state the general purpose of the study. 2. Allow participants to ask as many questions as possible about the study. 3. After all questions are answered, restate that there are no right or wrong answers and that “we are here to learn from you.” 4. Pose the first focus group question. 5. If one person responds, encourage others to share their stories. 6. If several individuals respond, encourage a one-at-a-time discussion. 7. Learn to respect each response from all participants. 8. Ask for clarification for terms or phrases not familiar to you. (“Can you explain that term further?”)

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9. Do not demean or talk down to any participants regardless of their vocabulary or speech pattern. 10. Ask for assistance from your community facilitator to keep the conversation at a steady pace. 11. Keep long, elaborate examples to a minimum. (Some participants may want to share very long cases with the group. Tell them that you would want to hear these cases after the session.) 12. Focus group questions do not have to be asked consecutively. (Allow for flexibility; the flow of the focus group will determine which questions to ask.) 13. Keep your biases and opinions to yourself! (This allows for participants to speak freely on very critical topics.) 14. After the final focus group question is answered, thank the participants again and restate what will happen to their answers. 15. Assure all participants that they can receive a copy of the study results when completed.

Individual In-Depth Profiles The individual in-depth profile is a special way of obtaining individuals’ ideas and experiences from their particular viewpoint. The individual in-depth profile yields insightful information that is usually not obtainable by the structured questionnaire or the setting of a focus group. The following questions are examples of the individual in-depth profile investigation that I used: 1. I would like to hear your view on what it’s like to be an African American in this country and how you believe that your home setting and cultural values have helped (or hindered) you in successfully living a quality life. 2. If you could do it all over again, what stage of your life would you have changed since living here in this area?

In general, the purposes of the individual in-depth profiles are: (1) to obtain intimate and detailed knowledge about the person; (2) to gain a comprehensive view of the individual’s sociocultural environment and lifestyle; and (3) to generalize from the individual about the rest of the particular cultural and/or ethnic group. For those researchers who are unfamiliar with the procedure and questions and for those researchers who want the best results from individual in-depth interview session, the following points are suggested: Procedure for Individual In-Depth Profiles 1. Practice asking the questions to a friend or a colleague before the individual in-depth interview session.

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2. The individual in-depth interview session should be arranged immediately after a focus group session or entirely separately from the session. 3. Ask the community key informant (facilitator) who would be a good candidate to participate in the individual in-depth interview. 4. Select at least two potential individuals (of those who participate in a focus group) for the individual in-depth interview (male/female). 5. As the facilitator discusses the format of the focus group session with community residents, ask for volunteers to participate in a one-on-one, individual in-depth interview session following the focus group session, or arrange a special time to meet. 6. Once the individual in-depth volunteer is selected, discuss with the individual the goals of the individual in-depth interview. 7. Answer as many questions as possible pertaining to the purpose of the individual in-depth interview. 8. Once the session begins, maintain a relaxed and informal atmosphere. 9. The facilitator can determine how long (minutes/hours) the individual indepth session will last. 10. Always tape record the session in order to recall detailed information shared with you. 11. Always ask for clarity of key cultural terms or meanings of words/phrases. 12. Always thank the individual for sharing such important information with you in order to understand their point of view.

Types of General Individual In-Depth Questions 1. Could you please share with me a little bit about yourself? (probe—current lifestyle situation) 2. Let’s talk about where you were born and what you remember about your early days/years of growing up. (probe—family patterns, community, and childhood experiences) 3. I would like to hear your view on what it’s like to be an African American growing up in this area and your or your family’s experiences in seeking health care. (probe—cultural adaptation to the local health care system) 4. I would like to hear your general thoughts on keeping yourself well or healthy. (probe—cultural practices of preventive therapy) 5. Have you or any of your family members used the local health care system for your current health problem? What was it like? (probe—specific health care incidents) 6. Have you or any of your family members used the local health care system for any other type of care? What was it like? (probe—differences of emergency care vs. preventive care) 7. I would like to hear your thoughts on how you would improve the local health care system as it relates to your community. Are there any improvements that need to be made, or is the local system fair to all people? (probe—perception of health care system to local community)

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Sampling One of the most often asked questions about conducting applied medical anthropological research is: How many people should be a part of my study, and what particular group should I study? The response is, what is your topic? You can have as many or as few people as you want in your study. This is the advantage of conducting applied medical anthropological research. Although applied medical anthropological studies are more flexible in research design than in other fields of study, there are a number of commonalities. Sampling is one of these commonalities. Four type of sampling procedures often used in applied medical anthropological studies. They are: (1) random, (2) stratified, (3) convenience, and (4) snowball. Depending on factors such as funding, time schedule, and design of the study, the researcher has the option to use one or several of the sampling procedures. Bailey (1982: 91–100) describes the sampling procedures as follows: 1. Random—each person in the universe has an equal probability of being chosen for the sample. 2. Stratified—separating the population into non-overlapping groups, called strata, then selecting a simple random sample from within each stratum. 3. Convenience—the researcher chooses the informants by chance. 4. Snowball—the researcher meets and interviews key informants who in turn select other key informants.

Each sampling procedure has its advantages and disadvantages. The researcher must determine to what degree the advantages outweigh the disadvantages in using a certain sampling procedure. Ethnographic Fieldwork Data Analyses Depending on the type of ethnographic fieldwork method used, health researchers have the option to analyze their data through either a qualitative or quantitative approach, or both. In each case, the major objective of health researchers is to reduce or to “make sense” of all the observations and interviewing that they completed during the study. Analyzing data, whether quantitative (statistics) or qualitative (words), can be one of the most difficult and confusing stages or one of the easiest stages of the study. Quantitative Analyses In all of my studies, I have selected the easiest and least complicated approach in analyzing my field data. Often, I have had to blend basic

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quantitative analyses with basic qualitative analyses in order to obtain a “balance” of the information being gathered. For example, statistics are a tool for understanding data. The purpose of statistical analysis is to reduce data to some manageable form so that conclusions of various sorts can be drawn (Wagenaar 1981: 281). I have used basic statistical analysis for establishing a “foundation of consistency of information” gathered from my informants. Standard parametric statistics such as t-test, Pearson correlations, and multiple regressions may provide results to highlight similarities or differences between groups being compared. Whether these comparative statistical data support or disprove a hypothesis, they provide me with additional evidence to support the qualitative findings. Qualitative Analyses Simply put, qualitative data are categories or labels that describe a behavior, action, thought, or group of people. Categories are ways to classify and organize experience (Spradley and McCurdy 1972: 61). Basically, the use of qualitative data analysis helps the researcher to classify and organize the observations and interviews into specific “categories.” Although there are a wide array of qualitative data analyses used—such as content analysis, ethnoscience analysis, grounded theory analysis, componential analysis, symbolic analysis, and structural functional analysis— I have used primarily four different analyses: (1) ethnographic data, (2) life history profile, (3) individual in-depth, and (4) thematic and pattern (Leininger 1985b). Ethnographic Method The ethnographic method of analysis primarily focuses on the use of ethnographic (emic) cultural data obtained directly from the people, mainly through the participant observation method (Leininger 1985b: 58). The method includes also etic (outsiders’ perspective) and other generational observational data obtained while studying people over a short or long period of time (Leininger 1985b: 58). Life History Analyses The life history method focuses on analyzing normal and abnormal life history events, patterns, and their relationship to health maintenance. This method helps to identify longitudinal patterns of living related to wellness, caring, health-care seeking, and sociocultural barriers of the health care system (Leininger 1985b: 64).

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Individual In-Depth Analyses The individual in-depth analysis focuses on a particular individual’s mode of maintaining health, dealing with patterned illness, or other styles of survival through long or short spans of time in different or the same environmental contexts. This method of analysis is important to: 1. Obtain intimate and detailed knowledge about the individual; 2. Identify health, care, and illness patterns; 3. Identify actual and potential factors leading to illness; and 4. Gain a comprehensive view of the individual’s environment and lifestyle over short or long periods of time. (Leininger 1985b: 64)

Theme and Pattern Analyses Theme and pattern analysis focuses on the different cognitive and identifiable themes and patterns of living or of behavior. Raw data are analyzed by identifying and bringing together components or fragments of ideas or experiences, which often are meaningless when viewed alone. Patterns are generally small units of behavior that contribute to themes. Themes are large units of analysis derived from patterns that can explain multiple aspects of human behavior (Leininger 1985b: 60–61). In summary, each type of qualitative data analysis attempts to synthesize the words, actions, and behaviors of people into simple categories of meanings. Reflective Comments Reflective comments “look back” thoughtfully to recapture the situation and total process of what happened and how the people responded to you, the researcher (Leininger 1985b: 53). Leininger (1985b) states that understanding what transpired between researcher and the people being studied is essential to get an accurate and full account of the situation or event. Reflective comments provide the researcher with direct and immediate interpretation of the particular site visit or key informant interview. After leaving the field, it is especially important for researchers to document immediately their reflective comments in their fieldwork notebook. These reflective comments, thoughts, and feelings actually start the process of qualitative analysis primarily because they help the researcher to focus on certain categories of behavior. In other words, if the researcher uses theme and pattern qualitative analysis, the themes and patterns of the particular group or individual begin to formulate in the thought processes of the researcher. Once the actual qualitative analysis of the data begins, the researcher will already

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have developed categories of cultural domain, thereby making the qualitative analysis much easier and more understandable. ETHICS OF HEALTH CARE RESEARCH: PERSON OF COLOR ISSUES In any research, there is always an array of ethical issues one must attempt to follow. Depending on the topic, the institution, or area of the country, ethical guidelines of health care research can be a matrix of mass confusion. When studying people of color, such as African Americans, there are additional ethical issues to follow. As an African American health care researcher, I have been told for years that there are two major disadvantages of studying your own people: (1) objectivity will be compromised, and (2) subjectivity to informants will influence data findings. From graduate school to my position as an associate professor, these ethical issues have always been brought to my attention. Both of these research issues are legitimate ethical statements that can affect the outcome of any research, particularly when an African American is studying his or her own ethnic population. However, the aforementioned disadvantages are far outweighed by the advantages. I contend that being an African American conducting health care research on African Americans has allowed me to see, feel, experience, and analyze health care data (qualitatively and quantitatively) in a more in-depth way than my non–African American health care researchers. The specific advantages include: 1. Understanding cultural sensitivity health care issues; 2. Developing rapport and trust at an early stage of the research project; 3. Understanding past discriminatory health care issues and their effects on African American perceptions and health seeking; 4. Recognizing my role as an “ethnic cultural broker”—a person of color who has obtained trust from the community and trust from the health care system; 5. Attempting to make applied health care projects “ethically” responsible for the community being studied.

To reiterate, there are more advantages than disadvantages to being a person of color (African American) who studies the applied medical anthropological issues related to African Americans. The data gathered by African American researchers often provide an in-depth perspective into the qualitative cultural health and social issues associated with the African American population. Nonetheless, one must be cautious and not assume that all African American researchers are best suited to study the African American population. Some African American researchers may have no connection to the

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African American community. Moreover, some African American researchers may not desire to focus any of their health care research studies on the African American population. It is often assumed by non– African American and African American researchers that all African American researchers (persons of color) are naturally adept at researching African American health issues. In other words, just because you’re an African American does not mean that you automatically relate to the African American community. Although there are definite advantages in being an African American medical anthropologist and conducting research on African Americans, health care research has more to do with the individual—not his or her ethnicity. CONCLUSION Medical anthropological research strategies provide health care researchers and clinicians with an additional tool to learn more about the populations they research and serve (Hazuda 1997). As discussed in this chapter, qualitative research offers all those who learn how to use it effectively an opportunity to learn not only more about their clientele and their research subjects, but also more about themselves. The added advantage of qualitative research is that it allows us to truly appreciate the in-depth, innermost feelings an individual has about his or her particular health problem. When more health care researchers, public health administrators, and clinicians incorporate qualitative research strategies into their retraining seminars and courses, then perhaps more answers than questions will ensue with regard to why the general public, and in particular the African American population, continues to use alternative and complementary medicine for preventing and treating various severe illnesses. POST-EVALUATION QUESTIONS 1. Discuss which applied medical anthropological research strategies you would select for your study. 2. Which qualitative strategy appears to be most utilized for researching in the African American population? 3. Discuss the advantages of using qualitative research strategies in the clinical and public health setting. 4. Describe and explain additional ethical issues that a person of color may encounter when conducting applied medical anthropological research.

BIBLIOGRAPHY Bailey, Eric. 2000. Medical Anthropology and African American Health. Westport, CT: Bergin & Garvey.

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Bailey, Kenneth. 1982. Methods of Social Research, 2nd ed. New York: Free Press. Becker, Howard S., and Blanche Geer. 1957. “Participant Observation and Interviewing: A Comparison.” Human Organization 16: 28–32. Blumhagen, Dan. 1982. “The Meaning of Hypertension.” In Clinically Applied Anthropology: Anthropologists in Health Science Settings, edited by Noel Chrisman and Thomas Maretzki, 297–324. Boston: D. Reidel. Boas, Franz. 1928. Anthropology and Modern Life. New York: Norton. Boehm, S., P. Coleman-Burns, E. Schlenk, M. Funnell, J. Parzuchowski, and I. Powell. 1995. “Prostate Cancer in African American Men: Increasing Knowledge and Self-Efficacy.” Journal of Community Health Nursing 12(3): 161–169. Braithwaite, Ronald, Cynthia Bianhi, and Sandra Taylor. 1994. “Ethnographic Approach to Community Organization and Health Empowerment.” Health Education Quarterly 21(3): 407–416. Carey, James. 1993. “Linking Qualitative and Quantitative Methods: Integrating Cultural Factors into Public Health.” Qualitative Health Research 3(3): 298– 318. Carter-Nolan, Pamela, Lucille Adams-Campbell, and Jerome Williams. 1996. “Recruitment Strategies for Black Women at Risk for Noninsulin-Dependent Diabetes Mellitus into Exercise Protocols: A Qualitative Assessment.” Journal of National Medical Association 88(9): 558–562. Chrisman, Noel, and Thomas Maretzki, eds. 1982. Clinically Applied Anthropology: Anthropologists in Health Science Settings. Boston: D. Reidel. Crane, Julia, and Michael Angrosino. 1992. Field Projects in Anthropology. A Student Handbook. Prospect Heights, IL: Waveland Press. Dignan, Mark, and Patricia Carr. 1992. Program Planning for Health Education and Promotion, 2nd ed. Philadelphia: Lea and Febiger. Eisenberg, Leon. 1977. “Disease and Illness.” Culture, Medicine, and Psychiatry 1(1): 9–23. Fabrega, Horacio. 1974. Disease and Social Behavior. Cambridge: MIT Press. Fitzpatrick, John. 1981. “Reflections on Being a Complete Participant.” In Readings for Social Research, edited by Theodore Wagenaar, 118–129. Belmont: Wadsworth. Harris, Kari, Jerome, Norge, and Stephen Fawcett. 1997. “Rapid Assessment Procedures: A Review and Critique.” Human Organization 56(3): 375–378. Hazuda, Helen. 1997. “Minority Issues in Alzheimer Disease Outcomes Research.” Alzheimer Disease and Associated Disorders 11(6): 156–161. Hurston, Zora Neale. 1942. Dust Tracks on a Road. Philadelphia: Lippincott. ———. 1995. Folklore, Memoirs, and Other Writings: Mules and Men; Tell my Horse; Dust Tracks on a Road; Selected Articles. New York: Library of America. Kleinman, Arthur. 1980. Patients and Healers in the Context of Culture. Berkeley: University of California Press. Kluckhohn, Clyde, and H. Murray. 1954. Personality in Nature, Society, and Culture, 2nd ed. New York: Knopf. Knafl, K., M. Pettengill, M. Bevis, and K. Kirchhoff. 1988. “Blending Qualitative and Quantitative Approaches to Instrument Development and Data Collection.” Journal of Professional Nursing (January–February): 30–37.

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Kutsche, Paul. 1998. Field Ethnography: A Manual for Doing Cultural Anthropology. Upper Saddle River, NJ: Prentice-Hall. Leininger, Madeleine. 1978. Transcultural Nursing: Concepts, Theories, and Practices. New York: John Wiley. ———. 1985a. Qualitative Research Methods in Nursing. New York: Grune and Stratton. ———. 1985b. “Ethnography and Ethnonursing: Models and Modes of Qualitative Data Analysis.” In Qualitative Research Methods in Nursing, edited by Madeleine Leininger, 33–72. New York: Grune and Stratton. Malinowski, Bronislaw. 1929. “Practical Anthropology.” Africa 2: 23–38. ———. 1954. The Science of Culture and Other Essays. Garden City, NJ: Anchor Books. Manderson, Lenore, and Peter Aaby. 1992. “An Epidemic in the Field? Rapid Assessment Procedures and Health Research.” Social Science & Medicine 35(7): 839–850. Mead, Margaret. 1928. Coming of Age in Samoa. New York: William Morrow. ———. 1955. “Effects of Anthropological Field Work Models on Interdisciplinary Communication in the Study of National Character.” Journal of Social Issues 11: 3–11. Nyamathi, Adeline, and Pam Shuler. 1990. “Focus Group Interview: A Research Technique for Informed Nursing Practice.” Journal of Advanced Nursing 15: 1281–1288. Pelto, Pertti, and Gretel Pelto. 1978. Anthropological Research: The Structure of Inquiry. 2nd ed. New York: Cambridge University Press. Robinson, S., M. Ashley, and M. Haynes. 1996. “Attitude of African-Americans Regarding Prostate Cancer Clinical Trials.” Journal of Community Health 21: 77–87. Schreiber, Janet M., and Susan C.M. Scrimshaw. 1979. “Anthropologists in Schools of Public Health.” Medical Anthropology 3(3): 309–338. Scrimshaw, Susan, M. Carballo, L. Ramos, and B. Blair. 1991. “The AIDS Rapid Anthropological Assessment Procedures: A Tool for Health Education Planning and Evaluation.” Health Education Quarterly 18(1): 111–123. Scrimshaw, Susan, and E. Hurtado. 1987. Rapid Assessment Procedures for Nutrition and Primary Health: Anthropological Approaches to Programme Improvement. Published jointly by the UCLA Latin American Center, the United Nations University (Tokyo) and UNICEF. Spradley, James. 1979. The Ethnographic Interview. New York: Holt, Rinehart and Winston. ———. 1980. Participant Observation. New York: Holt, Rinehart and Winston. Spradley, James, and David McCurdy. 1972. The Cultural Experience: Ethnography in Complex Society. Prospect Heights, IL: Waveland Press. Subhadhira, S., S. Simaraks, and G.W. Lovelace, eds. 1988. Rapid Rural Appraisal in Northeast Thailand: Case Studies, Introduction, 3–19. KKU-Ford Rural Systems Research Project, Khon Kaen University, Khon Kaen, Thailand. Wagenaar, Theodore. 1981. Readings for Social Research. Belmont, California: Wadsworth. Williams, G., R. Abbott, and D. Taylor. 1997. “Using Focus Group Methodology

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African American Alternative Medicine to Develop Breast Cancer Screening Programs that Recruit African American Women.” Journal of Community Health 22(1): 45–56.

WEB SITES OF SIGNIFICANCE The Qualitative Report: http://nova.edu/ssss/QR/index.html Society for Applied Anthropology: http://www.telepath.com/sfaa

Part IV

Disease-Focused Alternative Treatment Practices: Research Including African Americans This section highlights a number of studies that examine alternative and complementary therapies associated with specific diseases among African Americans. Case studies are presented to show the reader the types of alternative and complementary medicines used for specific diseases and to determine whether the alternative and complementary therapy was effective. In addition, the cultural perception of the specific disease is presented to provide the reader with reasons why African Americans tend to use the particular alternative and complementary medical therapy for the disease. In general, this section will investigate the following alternative and complementary medicine issues: • Biomedical definition and epidemiology of the disease; • Cultural perception of the disease; • Conventional treatment methods for the disease; • Clinical testing of an alternative medical treatment regimen; • Implementation of a culturally oriented alternative medical treatment therapy.

Chapter 6

Hypertension and Alternative Treatment Therapies CRITICAL THINKING QUESTIONS 1. Why is hypertension a major health care problem in the African American community? 2. How would you describe hypertension and what are the best methods to treat it? 3. How do cultural factors relate to hypertension and the use of alternative medical treatment therapies?

BIOMEDICAL DEFINITION AND EPIDEMIOLOGY OF HYPERTENSION Hypertension is the generic term for blood pressure above defined parameters correlated with age. Currently accepted standards defining normal, borderline, and high blood pressure are: (1) Normal—up to 138 (systolic)/ 88 (diastolic); (2) Borderline—140/90 to 158/94; (3) High—160/95 and higher. The probable causes of hypertension include heredity, age, sex, stress, excessive weight, high sodium intake, alcohol intake, excessive cigarette smoking, and lack of exercise. Uncontrolled hypertension contributes to death and disability from stroke, coronary disease, and kidney failure (Comprehensive Health Planning Council of Southeastern Michigan 1981). The prevalence rate of hypertension among African Americans (38.2%) is still substantially higher than among European Americans (28.2%). African Americans, for example, show rates of moderate hypertension that are two times those of European Americans and rates of severe hypertension that are three times greater. This difference in relative frequency is

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more marked in African American males, among whom the rate of severe elevations (2.2%) is over four times greater than in European Americans (0.5%). Moreover, African American females show the highest prevalence of isolated systolic hypertension (2.4%), which is predominantly seen in the elderly (U.S. Department of Health and Human Services 1986). A disheartening aspect of this health problem in African Americans and other high-risk groups is that adherence to an effective treatment regimen and/ or an increased utilization of health screenings can prevent approximately 50% of the deaths associated with hypertension. The most perplexing attribute of essential hypertension is that there are usually no symptoms associated with it; it is asymptomatic. According to hypertension clinicians, a person cannot tell what his/her blood pressure is by how he or she feels. The only way to know one’s pressure is to have it measured. However, most people are unaccustomed to thinking about illness in asymptomatic terms, because symptoms provide the starting point for speculation about illness. Snow (1974) and Blumhagen (1982) contend that individuals develop “common sense models” or “cultural definitions” of hypertension in an attempt to treat the disease. Such symptoms as headaches, dizziness, tiredness, flushing sensations, and nervousness or anxiety are commonly associated with hypertension. These symptoms, therefore, help to formulate the individual’s “cultural definition” or “ethnomedical belief system” of hypertension (Bailey 1991). CULTURAL PERCEPTIONS OF HYPERTENSION Alternative and complementary therapies that have been promoted as beneficial for the prevention and treatment of cardiovascular diseases such as hypertension are numerous and varied. They include vegetarian diets, dietary supplements, herbal remedies, stress reduction/relaxation, and both Western and Eastern approaches (Haskell 1999). While claims have been made and numerous clinical observations or case studies have been reported, few studies have examined the alternative health and treatment practices among African Americans as it relates to hypertension. This chapter will highlight two studies that show the impact of African American alternative and complementary treatment therapies on their adherence or lack of adherence to the mainstream medical treatment therapies for hypertension. Brown and Segal’s (1996) study examining the relationships between health beliefs and the use of both prescribed medication and home remedies among a group of African American and Caucasian hypertensives is an excellent example of how health perceptions influence use of alternative and complementary therapies among African Americans. In their study of 300 individuals who were residents of northern and central north-

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ern Florida counties, Brown and Segal established the following criteria for their sample: 1. The individual must have been diagnosed by a physician as having high blood pressure; 2. The individual patient must have had high blood pressure for at least one year; 3. The individual must have been prescribed at least one antihypertensive medication; and 4. The individual must not have experienced or currently be experiencing complications (e.g., kidney disease, stroke, heart attack, blindness) of uncontrolled hypertension.

Although data were collected via telephone interviews, Brown and Segal (1996) stated that the initial phase of this project involved the development and validation of the survey instrument. The questionnaire development process began by conducting in-depth pilot interviews with a convenience sample of seven African American and Caucasian American hypertensives. All interviews were tape-recorded, content-analyzed, and coded so that the identified domains could be captured in scale items. Pretesting of the questionnaire occurred among groups of hypertensive patients and re-examination by an expert panel of researchers and practitioners (Brown and Segal 1996). Brown and Segal’s (1996) study sample exhibited the following sociodemographics: • A total of 300 hypertensive individuals were involved. • The sample primarily resided in the northern section of Florida. • A total of 56% and 69% of the respondents were African American and female, respectively. • Mean age of respondents was 60 years. • Respondents had hypertension an average of 14.6 years with African Americans having hypertension slightly longer than Caucasian Americans. • Most (56%) participants were above the poverty level and had at least a high school education. • African Americans were poorer and had relatively less education than the Caucasian Americans. • A majority (80%) of the African American respondents lived in metropolitan counties, and 58% of the Caucasian American respondents resided in nonmetropolitan counties.

Interestingly, the quantitative data gathered from this sample of 300 hypertensives (167 African American and 133 Caucasian Americans) found some remarkable differences. Regarding the use of home remedies,

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most respondents reported that they did not use home remedies to treat their high blood pressure. However, African Americans were more likely to be users of home remedies than were Caucasian Americans (p = 0.00). Thirty percent (N = 50) of the African American respondents used home remedies compared to 12% (N = 16) of Caucasian American respondents. Examples of home remedies included vinegar, garlic cloves and capsules, aloe vera juice, multiple vitamin therapy, and various combinations of these products. Respondents used these products in many different ways. For example, vinegar was ingested pure or mixed with water to thin the blood, and it was also used in cooking to reduce the toxicity or richness of foods such as pork products (Brown and Segal 1996). Other home remedies (Brown and Segal 1996: 917) used included: • Garlic—drink/eat (clove) or mix with water; cook with it; or take as tablet or capsule; • Teas—drink/eat alone or mix with water; • Multiple vitamins—take as tablet or capsule; • Combinations of above—mixture of garlic and vinegar; mixture of honey and vinegar; • Mixture of apple juice, grape juice, and apple cider vinegar; and • Other—aloe vera juice and lemon juice—drink/eat alone or mix with water.

Overall, Brown and Segal’s (1996) study found that African Americans were more likely to be users of home remedies compared to Caucasian Americans in this sample. In fact, when all the modifying factors contributing to the different use of home remedies were re-analyzed, African Americans were 3.3 times more likely to be users of home remedies than Caucasian Americans (p = 0.00). This finding indicates that African Americans make concurrent use of both the formal mainstream health regimen as well as the informal alternative health regimen. If this pattern is true for all African Americans, then this concurrent use of alternative and mainstream antihypertension medication has both medical and pharmacy practice implications for enhanced patient care. The implications of Brown and Segal’s study are that it represented an attempt to broaden our knowledge concerning the role of alternative medicines in the treatment decisions of African American and Caucasian American hypertensives. Understanding how different illness and treatment beliefs relate to different aspects of antihypertensive medication behavior may be important in devising strategies to improve patient outcomes in culturally diverse populations (Brown and Segal 1996: 915). African Americans often engage in the use of informal treatments, oftentimes to supplement formal medical treatment, when trying to manage chronic illnesses such as hypertension. In fact, African Americans’ use

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of home remedies is a function of individual demographic characteristics, perceived benefits, and reduced costs of home remedies, and in particular their cultural perception of high blood pressure. Another study that highlights the use of alternative and complementary treatment therapies associated with hypertension was conducted by Bailey in 1991. To address the issue of African American preventive health care practices, I investigated the health care treatment pattern among 285 African Americans in the Detroit metropolitan area. In the case of hypertension, for example, individuals develop “common sense models” or “cultural definitions” of hypertension in an attempt to treat the disease (Blumhagen 1982; Dressler 1982; Garro 1986; Snow 1993). Such symptoms as headaches, dizziness, tiredness, flushing sensations, and nervousness or anxiety are not only commonly associated with hypertension but also with changes in lifestyle pattern. These symptoms, therefore, help to formulate the individual’s “cultural definition” of hypertension. This discussion allows us to comprehend how an individual’s explanatory model (particularly this study’s sample) influences his/her choice of alternative treatment options (Bailey 1991: 228). The major objectives of my study were as follows: 1. Investigate the health beliefs and preventive health care practices of African Americans. 2. Examine the alternative belief and alternative treatment therapies associated with high blood pressure. 3. Determine how African Americans’ alternative belief system with regard to hypertension influences their pattern of health care seeking. (Bailey 1991: 288)

Utilizing a local health care organization’s facilities for interviewing, I conducted a two-phase study during the 1985 and 1986 Project Health-ORama health screenings. The total sample consisted of 312 African Americans and 178 Caucasians. A series of investigative questions inquired about the sample’s alternative medical beliefs regarding hypertension. Individual beliefs about hypertension were probed by such questions as: “Once you became aware that your blood pressure was high, what did you do about it?” A statistically significant number of African American men and women chose a different option for care than did Caucasian men and women. For example, more African American men tended to implement a home remedy and/or diet/regimen or do nothing about their high blood pressure than did Caucasian men. Caucasian men (33%), on the other hand, were more likely to seek a physician to treat their high blood pressure than were African American men (10%) (p = .008) (Bailey 1991: 292). A similar relationship was found between African American and Caucasian women. More African American women (41%) than Caucasian women (14%) stated that they were likely to use an alternative treatment

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therapy. African American women also indicated that the clinic (11%) and an alternative folk health practitioner (6%) would be their choice for consultation and therapy. More Caucasian women (32%) than African American women (11%) stated that they would seek a physician to treat their high blood pressure (p = .000). Overall, the differences in alternative therapy between African American men and women and Caucasian men and women remained significant across income levels. These results showed that more African Americans than Caucasians tended to follow and rely on an alternative medical therapy than the traditional/Westernized medical treatment regimen. In addition to these quantitative results, qualitative (in-depth individual health profiles) data verified the adherence to alternative treatment therapy among African Americans. As indicated in Chapter 1, I identified a number of my key informants who shared their thoughts about the causes and treatment of hypertension. Informants indicated that alternative treatment therapy for high blood pressure varied from altering one’s activity to consuming such astringent substances as garlic tablets, vinegar, epsom salts, sassafras teas, lemon juice, aspirin, and cream of tartar. These substances were purchased from grocery stores as well as from alternative health practitioners such as herbalists and magic store vendors. Although the alternative health practitioners had various ideas about the promptness of the prescribed herbs on lowering one’s blood pressure, they did agree on the effectiveness of their remedies. The reasons my informants consulted the various alternative health practitioners for treating their high blood pressure were: (1) their attempt to cope with their high blood pressure within the context of their own resources and social environment; (2) their belief that the alternative health practitioner has some control over the forces that cause anomalies in a person’s life, whereas mainstream practitioners cannot heal certain cases of illness and misfortune; and (3) lower monetary expense associated with such treatments. Finally, in most cases informants used various alternative treatment therapies prior to medical consultations and continued alternative therapies along with the physician’s prescribed medications, even though the informant did not tell the physician of this fact. The inability of some informants to participate actively in the discussion of their illness affected not only the quality of care but also their adherence to prescribed treatment regimens. CONVENTIONAL TREATMENT METHODS FOR HYPERTENSION According to the National Heart, Lung and Blood Institute (NHLBI) at the National Institutes of Health (NHLBI 2001), the following medications are the main types of drugs used to treat high blood pressure:

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• Diuretics • Beta blockers • ACE inhibitors • Angiotension antagonists • Calcium channel blockers (CCBs) • Alpha blockers • Alpha-beta blockers • Nervous system inhibitors • Vasodilators

A brief description for each medication follows. Diuretics Diuretics are sometimes called “water pills” because they work in the kidneys and flush excess water and sodium from the body. This reduces the amount of urine in the blood. There are different types of diuretics that are often used with other high blood pressure medications (NHLBI 2001). Beta Blockers Beta blockers reduce nerve impulses to the heart and blood vessels. This makes the heart beat slower and with less force. Blood pressure drops and the heart works less hard (NHLBI 2001). ACE Inhibitors Angiotensin converting enzyme (ACE) inhibits the formation of a hormone called angiotensin II, which normally causes blood vessels to narrow. The inhibitors cause the vessels to relax and blood pressure goes down (NHLBI 2001). Angiotensin Antagonists Angiotensin antagonists are a new type of high blood pressure drug. They shield blood vessels from angiotensin II. As a result, the vessels become relaxed and blood pressure goes down (NHLBI 2001). Calcium Channel Blockers (CCBs) Calcium channel blockers keep calcium from entering the muscle heart and blood vessels. This causes the blood vessel to relax and pressure goes down (NHLBI 2001).

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Alpha Blockers Alpha blockers reduce nerve impulses to blood vessels. which allows blood to pass more easily, causing blood pressure to go down (NHLBI 2001). Alpha-Beta Blockers Alpha-beta blockers work the same way as a beta blocker but also slow the heartbeat, as beta blockers do. As a result, less blood is pumped through blood vessels and blood pressure goes down (NHLBI 2001). Nervous System Inhibitors Nervous system inhibitors relax blood vessels by controlling nerve impulses. This causes the blood vessels to become wider and the blood pressure to come down (NHLBI 2001). Vasodilators Vasodilators directly open blood vessels by relaxing muscle in the vessel walls, causing blood pressure to go down (NHLBI 2001). CLINICAL TESTING OF AN ALTERNATIVE MEDICAL TREATMENT THERAPY The relationship between nutrition and disease outcome has been investigated for many years, and the majority of researchers have concluded that an individual’s dietary and nutritional regimen can greatly influence his/her health status. In fact, observational and experimental studies have clearly demonstrated a strong relationship between certain nutrients and blood pressure (Simopoulous 1990; 1992). Nutritional factors involved in the control of blood pressure include calories and energy expenditure, specifically, the imbalance between energy intake and energy expenditure that leads to obesity; alcohol; the electrolytes potassium, sodium, and chloride; calcium and magnesium; and omega-3 fatty acids (Simopoulos 1999). Artemis Simopoulos, MD, president of the Center for Genetics Nutrition and Health, contends that the Dietary Approaches to Stop Hypertension (DASH) Clinical Trial is the only study that investigated the effects of three different diets on lowering blood pressure. The study enrolled 459 adults, aged 22 years and older, with body mass index (BMI) of less than 35, systolic blood pressure of less than 160 mmHg, and diastolic pressures of 80–95 mmHg. About half were women and nearly 60% were African

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Americans, who tend to develop hypertension earlier and more often than Caucasians. Simopoulous (1999) stated that for eight weeks, participants were fed one of three diets: a control diet, a fruit and vegetable diet, or a combination diet. DASH was designed to test whether blood pressure in randomly assigned subjects in four clinical centers would differ between those on the control diet and the fruit and vegetable diet, or between those on the fruit and vegetable diet and the combination diet. Simopoulous (1999) stated that the greatest lowering of blood pressure occurred between the control and combination diets. The nutrient composition of the control diet was typical of the diets of a substantial number of Americans. The combination diet was rich in fruits and vegetables and had reduced amounts of saturated fat, monounsaturated fat, total fat, and cholesterol and greater consumption of fish (0.2 control vs. 0.5 combination). The combination diet included 10g less of saturated fat than the control diet, but was similar in the content of polyunsaturated fatty acids, and higher in protein, carbohydrates, and fiber. Whereas the control diet did not include any servings of nuts, seeds, or legumes, the combination diet included 0.7 servings per day (Simopoulos 1999). Overall, the combination diet reduced systolic blood pressure by an average of 5.5 mmHg and diastolic by an average of 3.0 mmHg. The fruit and vegetable diet also reduced blood pressure, but only by an average of 2.8/1.1 mgHg. For those with hypertension, the combination diet reduced systolic blood pressure by an average of 11.4 mmHg and diastolic by an average of 5.5 mmHg, which is similar to reduction of drug monotheraphy in patients with mild hypertension. The fruit and vegetable diet reduced blood pressure by 7.2/2.8 mmHg for hypertensives (Simopoulos 1999: 98). Simopoulos (1999) stated further that among the 326 subjects without hypertension, the corresponding reductions were 3.5 mmHg (p = 0.001) and 2.1 mmHg (p = 0.003). The surprise of the DASH study is that it lowered blood pressure in the absence of weight loss and with 3g of sodium per day. Because blood pressure reductions were seen in normotensives, Simopoulos suggested that the combination diet might be an effective nutritional approach to preventing hypertension. IMPLEMENTATION OF A CULTURALLY ORIENTED ALTERNATIVE MEDICAL TREATMENT THERAPY For clinical testing of alternative treatment therapies for hypertension to be truly effective (both short-term and long-term), there needs to be programs designed specifically for the African American population. One such study by Ard, Rosati and Oddone (2000) was successful in reducing weight, blood pressure, and cholesterol among a sample of African Americans.

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Ard, Rosati, and Oddone (2000) designed a culturally sensitive diet intervention based on the Duke University Rice Diet that addresses these deficiencies. The Duke University Rice Diet was used as the diet intervention because it has been shown to produce significant weight loss, in addition to providing tools for lifestyle modification. The Rice Diet uses staple foods found in the homes of most Americans. This allows for a very flexible program that can be easily adapted to most ethnic dietary patterns. Other key components of the Rice Diet program include daily dietary counseling, nutritional education, and a recommended exercise regimen. The program is also physician-supervised, which has been shown to improve patient outcomes (Ard, Rosati, and Oddone 2000: 516). Thus, they contended that their culturally designed diet intervention would decrease weight, serum cholesterol, and blood pressure in African Americans. The study’s design utilized a randomized, modified-crossover study. Subjects were recruited from Durham, North Carolina and surrounding areas through advertisements in a Duke University employee newsletter. All African American subjects interested in participating were considered eligible to enroll in the study if they received clearance from their primary physician. The cultural modifications made to the Duke University Rice Diet included decreasing the direct and indirect cost of the diet program, using ethnic recipes in cooking classes, changing ideas about exercise, and including patients’ family members in weight loss efforts. Class sessions were also held after work hours for most participants. Familiar foods were used during cooking classes, and patients were instructed on how to prepare traditional African American dishes using low-fat and low-salt cooking techniques. Additionally, all patients were encouraged to share information with their families. The study results from the 62 African Americans (35 randomized to immediate intervention and 27 to delayed intervention) were that after eight weeks of the modified diet intervention, participants lost an average of 14.8 +/- 6.8 pounds (p < 0.01), or 6.5% of initial body weight. None of the subjects gained weight during the intervention. Additional results were as follows: • Body mass index (BMI) decreased by 2.5 ± 1.2kg/m (p < 0.01); • Cholesterol decreased by an average of 13.7 ± 27mg/dl (p < 0.01); • Four hypertensive subjects were treated with lower doses of medication, with blood pressure ranging from 135–112/90–74 mmHg; • Six subjects who were hypertensive at baseline were normotensive without medication by the end of the eight-week diet therapy; • Other areas showing statistically significant improvement included physical functioning, physical role limitation, and mental health;

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• 90% of African Americans agreed or strongly agreed that they thought the modified diet therapy was suited for their needs.

Overall, Ard, Rosati, and Oddone (2000) found that by implementing four key culturally oriented strategies their diet program was successful for the African American participants. The first cultural modification was to decrease the direct and indirect cost for patients participating in the intervention. This allowed them to recruit the needed volunteers to study the diet intervention. Prior to this program, only 10 African Americans per year participated in the Rice Diet Program. The next modification dealt with the use of culturally sensitive recipes and foods. By using familiar foods, patients were able to comply easily with the dietary guidelines. The third modification included changing ideas about exercise. Specific steps were taken to educate subjects about the role of increased activity in weight loss. This modification helped to increase compliance with exercise recommendations. Last, efforts were made to involve family members in the support group, which has traditionally consisted of peers. This gave subjects the opportunity to involve family members firsthand who otherwise may not have been supportive, given their beliefs about body size and weight loss (Ard, Rosati, and Oddone 2000). Culturally oriented dietary treatment therapy programs can help to decrease the number of overweight African Americans. These types of therapies are necessary given cultural differences in perception of weight and dietary patterns. Ard, Rosati, and Oddone (2000) emphasize that a culturally appropriate approach to weight loss for African Americans can lead to safe weight loss and risk-factor modification. This alternative medical treatment therapy was an effective means in reducing the mortality and morbidity related to hypertension. POST-EVALUATION QUESTIONS 1. Is it important to be aware of African Americans’ cultural perceptions of hypertension? If so, why? 2. Which clinical testing of an alternative medical treatment therapy shows the best results as it relates to hypertension among African Americans? 3. What type of culturally oriented alternative medical treatment therapy program would you develop for hypertensives in the African American community?

BIBLIOGRAPHY Ard, J., R. Rosati, and E. Oddone. 2000. “Culturally-Sensitive Weight Loss Program Produces Significant Reduction in Weight, Blood Pressure, and

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Cholesterol in Eight Weeks.” Journal of the National Medical Association 92: 515–523. Bailey, Eric. 1988. “An Ethnomedical Analysis of Hypertension among Detroit Afro-Americans.” Journal of the National Medical Association 80: 1105–1112. ———. 1991. Urban African American Health Care. Lanham, MD: University Press of America. Blumhagen, Dan. 1982. “The Meaning of Hypertension.” In Clinically Applied Anthropology, edited by Noel Chrisman and Thomas Maretzki, 297–324. Boston: D. Reidel. Brown, Carol, and Richard Segal. 1996. “The Effects of Health and Treatment Perceptions on the Use of Prescribed Medication and Home Remedies among African American and White American Hypertensives.” Social Science & Medicine 43: 903–917. Chrisman, Noel. 1977. “The Health Seeking Process: An Approach to the Natural History of Illness.” Culture and Medical Psychiatry 1: 351–377. Comprehensive Health Planning Council of Southeastern Michigan. 1981. Regional Profile 1980. Detroit. Dressler, William. 1982. Hypertension and Culture Change: Acculturation and Disease in the West Indies. New York: Redgrave Publishing. Garro, Lynda. 1986. “Cultural Models of High Blood Pressure.” Paper presented at the 85th American Anthropological Association, Philadelphia, Pa. Haskell, W., F. Luskin, F. Marvasti, K. Newell, E. DiNucci, and M. Hill. 1999. “Complementary/Alternative Therapies in General Medicine: Cardiovascular Disease.” In Complementary/Alternative Medicine: An Evidence-Based Approach, edited by J. Spencer and J. Jacobs, 90–106. St. Louis: Mosby. Jones, Paul. 1993. The Black Health Library Guide to Heart Disease and Hypertension. New York: Henry Holt. National Heart, Lung and Blood Institute (NHLBI). 2001. Your Guide to Lowering High Blood Pressure.Web site: www.nhlbi.nih.gov. Simopoulos, Artemis. 1990. “The Relationship Between Diet and Hypertension. Complementary Therapy 16: 25–30. ———. 1992. “Dietary Risk Factors for Hypertension.” Complementary Therapy 18: 26–30. ———. 1999. “The Nutritional Aspects of Hypertension.” Complementary Therapy 25: 95–100. Snow, Loudell. 1974. “Folk Medical Beliefs and Their Implications for Care of Patients.” Annals of Internal Medicine 81: 82–96. ———. 1976. “High Blood Is Not High Blood Pressure.” Urban Health 6: 54–55. ———. 1993. Walkin’ Over Medicine. Boulder, CO: Westview Press. U.S. Department of Health and Human Services. 1986. Black and Minority Health: Report of the Secretary’s Task Force: IV. Washington, DC: U.S. Government Printing Office.

WEB SITES OF SIGNIFICANCE American Heart Association: americanheart.org National Heart, Lung, and Blood Institute: www.nhlbi.nih.gov

Chapter 7

Cancer and Alternative Treatment Therapies

CRITICAL THINKING QUESTIONS 1. Why is cancer a major health care problem in the African American community? 2. How would you describe cancer and what are the best methods to treat it? 3. How do cultural factors relate to cancer and the use of alternative medical treatment therapies?

BIOMEDICAL DEFINITION AND EPIDEMIOLOGY OF CANCER Malignant neoplasms (cancer) refer to an abnormal growth of new tissue. The actual cause of neoplasms is not known. Neoplasms may be benign or malignant, depending on their growth pattern. A benign tumor is one that remains circumscribed, although it may vary in size from small to large (Professional Guide to Diseases 1998). A malignant tumor, or cancer, spreads to other cells, tissue, and other parts of the body through the bloodstream or lymphatic system. The spreading process is called metastasis. In summary, cancer is a general term for more then 100 diseases, all of which are characterized by the uncontrollable growth of cells (Professional Guide to Diseases 1998). According to the American Cancer Society, about 1,268,000 cancers were expected to be diagnosed in the United States in 2001, and 553,400 Americans were expected to die of the disease. Overall, African Americans are more likely to develop cancer than persons of any other racial and ethnic group. During 1990–1997, incidence rates were 444.6 per 100,000 among

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blacks, 402.1 per 100,000 among whites, 272.9 per 100,000 among Hispanics, 279.3 per 100,000 among Asian/Pacific Islanders, and 152.8 per 100,000 among American Indians. Reported incidence rates of female breast cancer are highest among white women (114.0 per 100,000) and lowest among American Indian women (33.4 per 100,000). Black women have the highest incidence rates of colon and rectum (45.2 per 100,000) and lung and bronchus cancer (45.8 per 100,000) followed by whites, Asian/Pacific Islanders, Hispanics, and American Indians, respectively, for both cancer sites. Moreover, black women are more likely to die of breast (31.4 per 100,000) and colon and rectum cancer (19.9 per 100,000) than are women of any other racial and ethnic group. Black and white women have similarly high mortality rates of lung and bronchus cancer, compared with American Indian, Asian/ Pacific Islander, and Hispanic women (American Cancer Society 2001: 29). Recent reports, however, show that breast cancer risk in African American women can be reduced by strenuous physical activity. AdamsCampbell, Rosenberg, Rao and Palmer ’s (2001) analysis of the Black Women’s Health Study, which consisted of 64,524 black women aged 21 to 69 years, found that high levels of strenuous physical activity during young adulthood are associated with reduced risk of breast cancer. The women were from all parts of the United States, with the largest numbers residing in California, Georgia, Illinois, Indiana, Louisiana, Maryland, Massachusetts, Michigan, New Jersey, New York, South Carolina, Virginia, and the District of Columbia. The median age of participants was 38 years, and 97% of the women completed high school or a higher level of education. The exercise data assessed were the responses to questions on the 1995 questionnaire about hours per week of participation in strenuous activity (such as basketball, swimming, running, aerobics) during high school, at around age 21, at around age 30, and at around age 40, where the response categories were