REVIEW

Folk Medical Beliefs and Their Implications for Care of Patients

A Review Based on Studies Among Black Americans

LOUDELL F. SNOW, Ph.D., East Lansing, Michigan

The folk medical system of low-income black Americans Isdescribed, from an ethnographic study of a blackneighborhood in Tucson, Arizona. Comparable beliefs amongMexican-Americans, Puerto-Rican Americans, and Southernwhites are traced, mainly from published sources. Thesystem is a composite of rare elements of African origin,survivals from the folk and formal medicine of a centuryago, and selected beliefs from modern scientific medicine.It includes beliefs about the prevention of illness, theclassification of illnesses into "natural" and "unnatural"categories, home remedies and preventives, and the rankingof healing practitioners, according to the perception of theirability, their modes of curing, and the types of illnesses theycan cure. Folk medical beliefs are at odds with scientificmedicine in many respects. Medical personnel should beaware of these differences and how they might affect patientbehavior.

IN 1967 a conference on the health status of black Ameri-cans was held. It was concluded that the gap betweenblack and white mortality and morbidity was widening andthat this was true for most of the important public healthindexes used in the United States (1). A 1968 survey re-ported that two thirds of urban blacks usually "feel sick"and that more than half believe that their health is worsethan that of their parents or grandparents (2). More re-cently, interviews with several hundred Harlem adolescentsshowed that three fourths of them believe an individualcan expect a lot of sickness during his lifetime, and morethan half think that there is not much to be done aboutit (3). Few would deny that, as a group, low-incomeblacks, rural or urban, have received little professionalhealth care until the last few years. The key word hereis professional, however, and it would be fallacious toassume that a lack of professional health care means nohealth care at all. Health is of prime concern in all so-cieties, and no group has yet been found that did not havesome systematized way of dealing with illness. It is notsurprising, therefore, that a viable folk medical system is

>• From Tucson, Arizona; Lansing, Michigan; Chicago, Illinois.

part of American black culture. Most of the informationin this paper is based on the ethnographic study of thissystem in a poor black neighborhood in Tucson, Arizona*.

Methods

A preliminary investigation of the neighborhood used his-torical sources, U.S. Census data, mapping techniques, andinformation from the Tucson City Directory (4-6) t. Theneighborhood is a small, residential backwater that has beensurrounded on all sides by the city's urban expansion. Mostof the inhabitants were at the lower end of the economiccontinuum, many on welfare. There were 223 households inthe neighborhood, 114 (51%) of which were headed bywomen, 38 (17%) by men, and the remaining 71 (32%) bymarried couples (6). In all, 47 individuals were interviewed,members of 29 separate families living in 37 households; 15%of each head-of-household category is represented.

The ethnographic portion of the study included the collec-tion of life histories, preparation of geneologies, and in-depthinterviews; additional data on each informant include dateand place of birth, length of time lived in Tucson, maritalstatus, household composition, rental or ownership of home,occupation, amount and source of income, education, andreligious affiliation. Informants were from 36 to 85 years old,and, with one exception, none were bom in Arizona. Mosthad been born and reared in rural areas of the border south,particularly Oklahoma, Texas, Arkansas, and Kentucky. Thelevel of formal education of informants was rather low. Onewoman has a college degree, and one other has had 1 year ofcollege training. Six other women have high school diplomas,and all other informants reported only some primary school-ing. None of the men in the sample had completed highschool. The occupations of neighborhood residents reflect thelow educational level, usually requiring few skills.

Persons formally interviewed were seen at least twice, andthese interviews were taped whenever possible*. Those in-formants with special knowledge of the health system wereinterviewed several times. Several neighborhood women areconsidered expert in home remedies, for example, and othersare thought to possess special healing power§. One women is aVoodoo doctor and thus able to cure diseases caused bywitchcraft. Although her office is not in the neighborhood,neighborhood residents sometimes consult her, so she too was

• SNOW L : The Medtcal System of a Croup of Urban Blacks. Un-published doctoral thesis, University of Arizona, Tucson, 1971.

t YANCY J: The Negro of Tucson, Past and Present. Unpublished M.A.thesis, University of Arizona, Tucson, 1971.

t Informants have been given pseudonyms to protect their identity.§ SNOW L : God Can Brtng You Up Out of Ftlth Just Like He Do A

Lily. The Life History of a Black Evangelist. Unpublished manuscript.Department of Anthropology and Department of Community Medicine,Michigan State University, East Lansing, 1971.

8 2 Annals of Internal Medicine 81:82-96. 1974

included in the sample (7). Some interviews were not taped,and in these instances notes were taken instead: those whodo some folk curing are aware of licensing laws, and somewere afraid of getting into trouble if "they" heard the tapes.

Information was also collected informally at such publicgatherings as Model Cities Neighborhood Task Force meet-ings. Religious services were attended at neighborhood churchesand, on other occasions, special ceremonies as well: healingnight at a Pentecostal church; message night at a Spiritualistchapel, where mediums bring word from loved ones in thespirit world; a revival; a baptism by immersion; and Mother'sDay services at a Voodoo temple.

Further information has also been collected in Lansing,Michigan, that has corroborated the Tucson study and in someinstances extended the findings to persons who are bothyounger and much better educated than the Arizona in-formants. Four individuals are working women, one a nurse'saide and the others in clerical positions at Michigan StateUniversity; six others (two women and four men) are eitherundergraduate students at Michigan State or medical studentsat the university medical schools.

A study of folk healers in the Chicago area is being carriedout at the present time, and a final report is not yet ready.Preliminary findings indicate, however, that beliefs concerningthe allocation of the ability to cure, who is able to cure what,and the techniques used are the same as those in the Tucsonstudy. A survey of the literature yielded further information,which is included where pertinent.

Folk Medical Beliefs as a System

In general, however, the information presented in thispaper is meant to illustrate the beliefs found amonglower-class blacks who have been socialized in the ruralSouth or maintain kin ties in the South, or both. Blackfolk beliefs concerning maintenance of health, the causesof illness, the allocation of the ability to cure, and thecuring techniques commonly used will be described. Al-though folk medicine is a fascinating topic in its own right,this report focuses on those areas where the contrast withorthodox scientific medicine might produce conflict. Knowl-edge of potential conflict does not guarantee its resolu-tion, of course, but practitioners should be aware thatpatients' behavior may be adversely affected by their com-mitment to a different belief system.

The system is a composite of the classical medicine ofan earlier day, European folklore regarding the naturalworld, rare African traits, and selected beliefs derivedfrom modem scientific medicine. The whole is inextricablyblended with the tenets of fundamentalist Christianity,elements from the Voodoo religion of the West Indies, andthe added spice of sympathetic magic. This mixture ofcultural elements has formed, in folklorist Richard Dor-son's phrase, "a rich complex of unified folklore whoseparts intertwine in a many-veined, dazzling filigree (8)." Itis a coherent medical system and not a ragtag collectionof isolated superstitions. If the underlying premises areaccepted, it makes just as much sense to the believer asthe principles of orthodox medicine do to the graduateof an accredited medical school.

The folk medical system under scrutiny here is not, how-ever, restricted to black Americans. Portions of it are tobe found among groups as diverse as the PennsylvaniaDutch, the Hutterites, the Amish, Appalachian whites,the Cajuns of Louisiana, Kansas farmers, Puerto Ricansin New York and the Midwest, and Mexican-Americans

wherever they are found (9-33). Similar beliefs are to befound from rural Florida through the Ozarks and fromCalifornia to the Upper Peninsula of Michigan (34-39).They are, therefore, characteristic of a great many peo-ple, and a secondary aim of this report is to compare andcontrast the beliefs of the different groups.

Three major themes emerge from the data, particularlythat collected from black informants—first, that the worldis a hostile and dangerous place; second, that the individualis liable to attack from external sources; third, that theindividual is helpless knd has no internal resources tocombat such attack but must depend on outside aid. Thatthe world is seen as hostile and dangerous for poor blackpeople has been reported in studies by anthropologists,sociologists, psychologists, and psychiatrists (40-47). Thebehavioral adaptations this produces are perhaps best seenin the fictional and autobiographical works of black au-thors, in poetry, and blues songs (48-54).

The individual as potential victim of attack must bewary of the world of nkture, of a punitive God, and of themalice of his fellow man. This latter is embedded in apessimism about the nature of human relationships and"the bedrock convictidn that most people will do ill whenit is in their interest, that doing ill is more natural thandoing good (42)." This distrust may be extended to friendsand relatives as well as strangers (41, 43, 55). Life is aconstant hustle, and success in interpersonal relationshipsmay be seen as the ability to manipulate others (49, 56).

Feelings of emptiness and helplessness are reflected inthe content of much religious music and a dependencyon supernatural aid*. The use of magic is also prominentand is commonly found when what is wished for is ofgreat emotional significance, the outcome uncertain, andother means to the end are not available (57-59).

There is a tendency to lump events as to whether theyare desirable or undesirable, resulting in a mixture ofconceptual domains confusing to the science-oriented pro-fessional. Good health is classed with any kind of goodluck: success, money, a good job, a peaceful home. Ill-ness, on the other hand, may be looked upon as justanother undesirable event, along with bad luck, poverty,unemployment, domestic turmoil, and so on. The attemptedmanipulation of events therefore covers a broad range ofpractices that are carried out to attract good, includinggood health, or to repel bad, including bad health (60).

Natural and Unnatural Phenomena

The folk medical system described here depends largelyon the classification of happenings as "natural" or "un-natural." This division of the universe into natural andunnatural phenomena is common among New Worldblacks. It has been reported in Haiti, in Trinidad, andwherever in the United States black people are found (58,61-66). It is also common to Spanish-speakers in Mexico,in the West Indies, and the United States (13, 28, 31, 67).Although the terminology is slightly different, this idea isexpressed by Southern whites when they differentiate

• SIMPSON R : A Black Church: Ecstasy in a World of Trouble. Un-published doctoral thesis, St. Louis, Washington University, 1970, page 62.

Snow • Folk Medical Beliefs 8 3

between the natural and the supernatural (20, 23, 35).Perhaps the simplest way to describe this division is to

state that natural events have to do with the world as Godmade it and as He intended it to be. Natural laws there-fore allow a measure of predictability for daily life. Un-natural events, in contrast, imply just the opposite: bytheir very existence they upset the harmony of nature.At best they interrupt the plan intended by God; at worst,they represent the forces of evil and the machinations ofthe Devil. They are frightening because they are not pre-dictable. They are outside the world of nature and, whenthey do occur, they are beyond the abilities of ordinarymortals to control.

Pertinent to this tendency to view phenomena in termsof oppositions such as good versus evil and natural versusunnatural is the belief that everything has its opposite.This is expressed in health terms by proverbs stating thatfor every birth there is a death, every illhess has its cure,every poison an antidote, every herb a healing purpose(36, 63, 68). This belief is largely responsible for the lackof acceptance of the chronicity of some diseases; mostinformants feel that all illnesses are curable. If everyillness has its cure, then what one must do is find it: anew medicine, another treatment, a different doctor, faithhealing perhaps—and the search is on.

Illnesses are also classified as natural or unnatural,whicji affects the type of cure or practitioner sought. Allillnesses represent disharmony and conflict in some areaof the individual's life and tend to fall into three generalcategories: environmental hazards, divine punishment, andimpaired social relationships.

NATURAL ILLNESSES

In this first category the individual has come up againstthe forces of nature without suitable protection. Dangerousagents are cold air, which may enter the body, and im-purities in the ̂ air, in food, and in water, which may enterthe body to cause illness; they will be more fully discussedlater. Such problems are considered natural because thesource is natural. For example,

"Well, in other words, it's exposure, that you getsometime when you're young in your body. Throughyour system as you get older, it take effect . . .danipness and not takin' proper care of yourself.Goin' out in bad weather and rainy weather, youexpose yourself. Pores are open. You're subject totakin' a complaint, in through the blood . . . kind ofgrows into the system, and as you get older it workswith you." *

Second, it is commonly believed that illness may besent by God as punishment for sin. It is believed in Trini-dad, where the "powers" may punish wrongdoing withsickness, in Haiti, when the loa send misfortune as a"chastisement," and death is the will of le bon Dieu (65,66, 69). Mexican-Americans see natural illnesses {malesnaturales) as God's will and, in some cases, as a directpunishment, or castigo (33). Among Appalachian whites"the wrath of God" may be the final explanation for sick-ness (20). Such illnesses may take any form but are often

sudden and severe enough to give the individual time toreflect on his or her transgression. A paralytic stroke, forexample, allows the sinner time to think over past be-havior and repent. Retardation in children is commonlycited as punishment to the parents, who then spend therest of their lives contemplating the result of their mis-deeds. The punishment of the parent by inflicting illness,injury, or death on the child is a common theme, and onewhich cross-cuts social class and educational level. Onecollege-educated informant considers a younger sister'sdeath from meningitis as a punishment to the father for"drinking and running around with women." t The bac-terial etiology was also fully understood but did not pre-clude the supernatural explanation as well. More often,when asked what sins are thought to bring on such retribu-tion, informants cite pride and "thinking you are betterthan other people." | Fear of such punishment thereforeoperates as a social leveler, that is, to insure that individ-uals do not blatantly exhibit feelings of superiority orflaunt material possessions. To do so is to invite divinedispleasure:

"So many time the Lord get vexed with us when wedo things. Like sickness I would say sometimes is awhup to us, just like whuppin' a child. So manytimes we have to be taught a lesson, a sickness some-time bring us down to make us serve the Lord's will.Sometime we don't know to say 'Thank the Lord,'and we don't know how to praise the Lord andthank Him for things He did for us. You can inviteit in yourself. If you live a real good life for God,it's just like children: if you got good children youdon't have to punish 'em. Sickness and different thingsis like a whuppin'. A reminder. The Lord would healall the people if they would ask the Lord to heal 'em.But the people, they forget God." §

Such punishment, whatever its nature, is considered naturalbecause it is the will of God.

It is believed that the doctor is unable to help the pa-tient whom God is punishing. Thus a Baptist minister ad-monishes his congregation that the doctors cannot curemany people because "Medicine cannot reach the mindinor a heart diseased by sin." ||

On the other hand, God may intercede in the favor ofthe individual—one woman, a Pentecostal evangelist,spends much time at a local hospital praying for the sick.She understands that there are illnesses caused by micro-organisms but believes that while she is making herhospital rounds God puts an invisible barrier around herthat germs cannot penetrate. Preventive measures mayalso be taken that illustrate the powerlessness of the in-dividual and the emphasis on possession of some tangiblesign of protection. Such measures range from the asafoe-tida bag worn around the neck to keep away illness to theprinted prayer given me by an informant to keep me safe,which assures that the possessor will never bum or drown,poison will have no effect, 82 accidents wUl be averted.

• Bertha A., Tucson, Arizona, age 67, bom Texas, 6th grade education.Excerpt from tape recording, December 1970.

t Alice L., Lansing, Michigan, age 22, bom South Carolina, 1 year ofcollege. Personal communication, January 1972.

t Lizzie L., Tucson, Arizona, age 47, born Kentucky, high schooleducation. Excerpt from tape recording, February, 1971.

§ Erma V., Tucson, Arizona, age 49, born Texas, 6th grade education.Excerpt from tape recording, January 1971.

II A phrase from a sermon entitled "The Sickness of Sin," heard in aBaptist church, Tucson, Arizona, April 1971. From field notes.

8 4 July 1974 • Annajs of Internal Medicine • Vo/ume 81 • Number 1

childbirth will be eased, and epileptic seizures precluded.It is an exact duplicate of one sent to William Blacknearly a century ago, as reported in his classic treatiseon folk medicine (70).

UNNATURAL ILLNESSES: EVIL

INFLUENCES AND WITCHCRAFT

In extreme cases the individual may be so grave a sinnerthat the Lord withdraws His favor. An unprotected personis easy prey to demons and evil spirits and in some in-stances may be possessed by them. The presence of suchbeings, which lurk about waiting to pounce on the sinner,is usually referred to as evil influence, or, among Spanish-speakers, malas influencias. If this does occur and theDevil takes over, the illness is no longer natural but un-natural. The following passage illustrates the feeling thatone may be buffeted by opposing external forces and theidea that alone one may do nothing.

"Evil influence mean the Devil which name is Satan.He is Evil, he can put evil thought in your mind.Also the Devil can work in the frame of anyonemind, cause you to do things you don't want to do.Our body is made up of Evil and of Good. If we arenot close to God in spirit, the Devil take control ofus. God guide me each day and teach me wisdom andknowledge how to cope with my problem and peoplearound me. Sometime I have so many burden on myshoulder I don't know which way to turn to. I learnto work them out by talking to Jesus and forgetabout them, and before long He work them outbecause I can't do anything for myself." *

Evil influences may be blamed for any sort of problem,from nightmares to tuberculosis (71). Like those illnessesthat result from divine punishment, the physician is unableto help the patient afflicted by evil because you cannotfight the Devil with drugs. This may create real treatmentproblems: a diabetic black woman in Grand Rapids, Michi-gan, for example, has consistently refused to inject herselfwith insulin because she believes her illness is one thatthe devil has "put on" her because of a sinful youth. Itis now 18 months since the initial diagnosis, and she iscalled on daily by a visiting nurse who gives the injec-tiont.

Most commonly, however, unnatural illnesses refer tothose caused by witchcraft. Here, too, it is believed thatthe physician is unable to treat such illness, and a primesymptom is that the more you go to the doctor the sickeryou get. Witchcraft is based on the belief that there areindividuals with the ability to mobilize unusual powersfor good or evil. The use of such abilities is based on theprinciples of sympathetic magic, and because they underlieso much of folk medical practice a brief description is inorder. Sympathetic magic is based on the assumption thateverything in the universe is connected and that eventscan be interpreted and directed by an understanding ofthese connections. There is a division into imitative andcontagious magic. Contagious magic has to do with the

premise that things once physically connected can neverbe separated and that what you do to the part you doto the whole. Many witchcraft practices are based on con-tagious magic, and an enemy need only obtain a lockof the victim's hair, fingernail clippings, worn clothing, ora used menstrual pad to do harm. Thus, says a coed, "I'ma little skeptical of letting just anybody use my comb orborrow too many of my personal possessions." t Imitativemagic depends on the assumption that iike follows like,and you imitate what you wish to achieve: a knife underthe bed will cut pain or the effect of medicine, or an evilcharm put on when the moon is waxing will increase withthe moon.

Belief in witchcraft as a cause of illness is widespread;it is found among Haitians, Trinidadians, Puerto-RicanAmericans, American blacks, and Mexican-Americans (13,27-29, 31, 33, 58, 61, 64, 66, 69, 72-75). It does not seemto be prominent in the folk nosology of Southern whites,although belief in nonmalign magic certainly is. It is esti-mated that one third of the black patients treated at aSouthern psychiatric center believe that they are the vic-tims of witchcraft, and a Spanish-speaking physician inCalifornia reports that this is true for one fourth of hispatients (39, 76).

Among blacks, the terms commonly used to describesuch occurrences are roots, rootwork, witchcraft, Voodooor Hoodoo, a fix, a hex, a mojo—the evU has been "puton" or "thrown at" the victim (75). Among Spanish-speakers, comparable terms are mal puesto (literally, "evilput on"), mal ojo, mal artificial, brujeria, hechiceria, orenfermedad endariada, the illness of damage. Regardlessof the term used, the idea is that someone has done some-thing to cause another illness, injury, or death. The fearof such attack is very great and may contribute to whatEngel has called lethal life situations (77) :j:. A classic caseat Baltimore City Hospital describes how such fear isbelieved to have contributed directly to a patient's death(78).

A recurring theme in witchcraft belief is that animalsare present in the body, introduced by magical means.Animal intrusion as a cause of illness has a long historyin European and American folklore, usually from acci-dental ingestion of the creature: spring water might con-tain a "spring lizard," river water contains eggs that canbe swallowed while swimming, a garden hose might harbora small reptile and should not be drunk from, and sleepingin the grass should be avoided lest a snake or lizard crawlinto the mouth (70, 79). In witchcraft, however, the magi-cal component is obvious, in that the animal has been driedand pulverized, sprinkled on food, and then reconstitutedin the body of the victim. Lizards, snakes, toads, and spi-ders are most commonly mentioned, and "Satanic worms"kept in milk, frog eggs hatching out in the blood, andcanned com or the victim's own hair turning to snakesor worms in the stomach have all been reported (15, 28,

* Lun«ll N., Chicago, Illinois, age 38, born Georgia, 11th grade educa-tion. From letter to author, January 1974.

t Personal communication, Elaine Yudashkin, M.S.W.; the StudentPrimary Care Clinic, Grand Rapids Campus, College of Human Medicine,Michigan State University, and the Grand Rapids Area Medical Educa-tion Center.

t Yvonne W., Lansing, Michigan, age 20, bom Michigan, collegefreshman. Personal communication. May 1972.

X One young woman, a secretary at Michigan State University, can-celed our scheduled interview when she found out I knew somethingabout root work. She said she was afraid of it and didn't even like tothink about it, let alone talk about It.

Snow • Folk Medical Beliefs 85

58, 64, 72). A Tucson informant told me that rival in alove triangle had placed an octopus egg in his beer; it hadthen hatched, and the baby octopus had to be removedfrom his bladder. The main symptom seemed to be hema-turia, and I have puzzled since as to what the problemactually was; whatever he was told, he interpreted it inculturally acceptable terms. Although the offending beastis almost always a reptile, amphibian, or insect, in onerare instance a gopher was reportedly served up in a dishof hopping John (75).

Symptoms of witchcraft are often described as reptilescrawling over the body or wriggling around in the stomach.

"I've heard of people with snakes in their body, howthey got in there I don't know. And they take 'emsomeplace to a witch doctor and snakes come out.My sister, she had somethin', a snake that was in herarm. She was a young woman. I can remember herbein' sick, very sick, and someone told her about thishealer in another little town. And I do know theytaken her there. This thing was just runnin' up herarm, whatever it was, just runnin' up her arm. Youcould actually see it. And we would have to holdher in the bed. And someone told her about thishealer, and my parents did take here there. And thisactually came out of her arm. You could actually seeit when she would go into one of her spells, it wasin her left arm. Some woman they said didn't likeher [had done it]." *

Because of the fear of adulterated food there is oftenanxiety about eating in other people's homes or in publicplaces, and some people refuse to do either. It is not sur-prising that presumed symptoms of unnatural illnessesare often associated with eating, so that the appetite islost, there are pains in the stomach, food doesn't tasteright, or that food eaten does no good. This latter is aparticularly frightening symptom, since it isn't naturalto lose weight while consuming the usual amount of food.As continued weight loss may be symptomatic of seriousillness, the observation here may be correct if the inter-pretation is not.

Perhaps more commonly, behavioral changes—anythingthat is perceived as "crazy"—will be seen as the sign of fixor hex. This idea is illustrated in the following passage, aswell as the idea of external control by another person.

"Well, I've heard people can take your clothes, takeyour underclothes or your menstruating [pads] oranything that you wear on your body. I heard thatthey could put stuff in your food, or they could cometo your house and put something down for you.Yeah, I hear talk of it. Yeah, I hear about a fewpeople, someone have control of 'em. They do actrather peculiar, they doesn't act normal or sensible.Well, for instance I've heard of men flxin' their wivesand wives fixin' their hus]3ands, stuff like that, youknow. Well, if this happen to you, they say you wouldbe the last person to suspect; anyone could tell youand you wouldn't believe it. Well, [lowers voice] Idon't know why, but I hate the thought of a persontakin' control of you if they want to." *

A Tucson informant who was hospitalized for "nerves"(professional diagnosis, acute anxiety state) was greatlyrelieved to afterwards dig up a pair of underpants buriedwith a snapshot of herself; the date she was to die wasprinted on the back of the picture. Finding it supposedlybroke the spell—but in a burst of eclecticism she startedattending church more regularly, continued to see herphysician, and began training classes at a Spiritualist tem-ple to learn to visualize herself "in the white light of pro-tection." t Rubel (32) also states that dramatic mania isthe one symptom nearly always attributed to mal puestoby Mexican-Americans, with the understanding that thevictim is controlled by someone else.

Any symptom that is seen as unusual may be frighten-ing, however, and the mere fact that an illness has notbeen cured may signal to believers that it is unnaturalin origin. In one recent instance in Lansing a man had askin rash that the physician was unable to clear up imme-diately. The rash reportedly occurred "only where itshowed," which was seen as being strange—the com-bination of chronicity plus the unusual symptom wasenough to make him call in a root doctorj.

Even when the patient does not think the illness is theresult of malign forces, the practitioner may inadvertentlyplant this fear. So simple an act as telling the patient toreturn in a few days when the results of tests are completemay be interpreted as uncertainty on the part of the physi-cian, and therefore the illness may be unnatural (58).

The most commonly cited reasons for witchcraft attackare sexual jealousy and envy, among both blacks andSpanish-speakers. It is dangerous to be one of the "higherups," or to have anything that someone else might want,a new car, money, a pretty face, a faithful husband. Likedivine punishment, fear of witchcraft can act as a levelingdevice—if you've got it, don't show it off. When I ac-cepted a teaching position in another state, one womanwarned me against going to and accepting refreshments atsocial gatherings:

"Witchcraft is real, it can be did; you can be hypno-tized. You hafta be careful where you eat and drink.Parties is not good; you know some ladies is lookingat that man of yours. You is new there so don't be sofast in going to parties and eating and drinking, itisn't good." §

Among Mexican-Americans the power of envy is believedto be so strong that the mere glance of an envious personcan kill pets or house plants. ||

Although such beliefs may be bizarre to the scientistthey are understandable in their cultural matrix. Witch-craft beliefs are the most extreme example of distrust andunease in social interactions. They are the magical expres-sion of the fear that strangers, friends, or relatives maywish you harm. In a survey in a federal slum housing proj-ect in St. Louis, 91% ot black respondents agreed with the

• Cassie S., Lansing, Michigan, age 46, born Arkansas, 11th gradeeducation and nurse's aide training. Excerpt from tape recording, October1973.

t Alma U., Tucson, Arizona, age 42, born Texas, high school educationand nurse's aide training. Excerpt from tape recording, March 1971.

t Bishop T., root doctor from Chicago called in to treat the patient.From interview in Lansing, Michigan, November 1973.

§ Anna P., Tucson, Arizona, more than 65 years old, born Texas, 4thgrade education. From letter to author, January 1972.

II KAY M: Health and Illness in the Barrio: Women's point of View.Unpublished doctoral thesis, Tucson, University of Arizona, 1972, p. 156.

86 •'"'y 1974 • Annals of Internal Medicine • Volume 81 • Number 1

statement, "It's not good to let your friends know every-thing about your life because they may take advantageof you," and 69% agreed that it was also unwise to trustyour relatives (42). As one man put it, "You know your-self, man, when you walk out in the streets you have gotto be ready. Everybody walking out there is game oneverybody else (42)." When the discussion shifts fromthe theoretical to the concrete, however, the malice ofunknown others is replaced by accusations of individualsin the immediate social network. In virtually every casereported in the literature and in my own data as well,the evildoer is specifically identified and is usually girlfriend or lover, husband or wife, a parent, a sibling, or anin-law. This is true for both blacks and Spanish-speakers,and there is no more graphic example of personal inade-quacy and the deep distrust and ambivalence that manyfeel in their social ties. The possibility of external controlis matched by the belief that magical means are neededto bring about desired behavior in others: charms mustbe used to get what you want, and to keep it*

The need for visible protection is also exhibited, and asilver dime is often worn somewhere on the body in thebelief that it will turn black if someone is attempting todo evil to the weairer (80). Oils, incenses, candles, andaerosol room sprays may be used to repel evil, and suchitems may be ordered by mail or purchased at specialtystores; in a Spanish-speaking neighborhood they are avail-able in the botanica (13, 60, 81-82).

Perhaps most individuals who believe themselves thevictims of witchcraft do not turn up in the clinician'sofiBce because they believe that only a person with specialpowers can remove the spell. Occasionally they do, how-ever, and there is a growing number of reports in themedical literature giving actual case histories; physiciansinterested in knowing how such a patient presents himselfin the clinical situation are urged to consult these (27, 72,73,74,77,83).

If illness is seen in terms of attack from without, curesmay be described in equally dramatic terms; demons canbe exorcised, the cold driven out, God can lift up thoseHe has struck down, and, if one can find a powerfulcurer, the fix or hex that was put on can be taken offagain. The view of illness as something that can be drivenout of the body en masse holds true for both natural andunnatural categories. Thus a white Southern mountainwoman reports, "Over in Kentucky, they prayed for awoman who had cancer of the stomach. They was holinesspeople and they prayed for her and anointed her with oiland laid hands on her, and before she left the church, shevomited that thing up (18)." This view of illness as athing that strikes the unprotected individual is clearlyexpressed in the following passage; the speaker, an evan-gelist in the Holiness Church, has given up praying forthe sick.

"I don't pray for 'em, though, cause I picks up theirailment. See, you could have something wrong with

you and I could pray for you, and I'd take it!""Would I get well [Author]?""Yeah, you'd be all right. But I'd be sufEerin' with it!It'd go in me! And then somebody's have to comealong and pray it out of me! Lots of times peoplewon't accept it; it's the way you have to pray for thesick people to keep from takin' it. Reverend ,he stopped me from prayin' for people down there.Ever' time I'd take it. Pick it up, take it like that.And they had to come right on and pray it oflE of me.And so tiey kiada stopped me." t

Although the separation of illness into natural and un-natural categories is useful as a descriptive device, inreality it is not always so clear-cut. Since the emphasis ison presumed cause rather than effect, illnesses that areidentical to the clinician may be variously interpreted: astroke may be blamed on divine punishment, on improperdiet, or on the entry of cold air into the body of amenstruating woman. Treatments, as will be seen, alsoreflect an intermingling of pragmatism, religious belief,and magical practice, so that a nosebleed might be handledby packing the nose with cobwebs, the recitation of abiblical verse, or placing broomstraws crosswise in the hairto cross up the flow of blood.

Although the physician should be aware of these beliefsregarding witchcraft and divine punishment, most healthproblems occur because the individual is no longer inharmony with the forces of nature. Good health isprimarily based on such harmony, and this requires thatthe rules of nature must be known and foUowed. If not,"Nature will kUl you, you won't kill it." t

The individual is responsible for knowing the rules ofnature that thus govern life, and if a lapse results in illnessit is his or her own fault. On the positive side, this createsan atmosphere in which preventive medicine can flourish,since people are necessarily concerned with monitoringtheir health. It may have negative repercussions, however,in that the wise individual is incessantly dosing himself orherself to prevent illness. Self-treatment for illness iscommon, and in one study nearly 40% of the people inthe sample reported treating aU illnesses at home in theprevious year (84). In another study every respondentdisclosed that they deliberately withheld use of "oldtimey" remedies from physicians (34). Some of thesepractices are extremely dangerous in the light of orthodoxmedical practice. Laxative abuse is legion, and other oralmedications include kerosene, turpentine, moth balls, andcarbon tetrachloride (76, 85, 86).

Attaining and Maintaining Good Health

There is safety in harmony and balance and danger inanything done to the extreme. It is bad for the body to eattoo much, drink too much, stay out too late at night, andso on (87). In a study in Harlem 90% of black adolescentsbelieve that good health is largely a matter of "lookingafter yourself (3)." The results of excess may not beimmediately visible but will certainly affect the individualsooner or later because the body has been weakened. Older

• SNOW L ; Mail Order Prevention and Cures for Witchcraft. Depart-ment of Anthropology and Department of Community Medicine, MichiganState University, East Lansing, Michigan. Paper presented at the 72ndAnnual Meeting, American Anthropological Association, New Orleans, 28November-December 2, 1973.

t Amelia L., Tucson, Arizona, age 64, bom Texas, 6th grade educa-tion. Excerpt from tape recording, December 1970.

t Wilson E., Tucson, Arizona, age 55, bom Kentucky, 9th grade edu-cation. From field notes, December 1970.

Snow • Folk Medical Beliefs 8 7

people in poor health usually attribute it to the rashbehavior of youth, whereas older people whose health isgood look back on a life of moderation:

"I feel that it's the care that they take of theirselves.That's what I think, I don't know. I feel like theyexposes theirselves too much, and don't take enoughcare of theirself like they should. That's one reasonthat I can get around and do things now at my age!Now I've worked hard all my life, ever since I startedat ten years old. But otherwise, I've taken care ofmyself. And I never was the goin' kind! I didn't workall day and then goin' half the night and all liket h a t . . . I taken my rest and taken care of myself." *

STRENGTH AND WEAKNESS DURING THE LIFE CYCLE

There is an age/sex differential associated with strengthand weakness, strength being correlated with greaterability to withstand illness and weakness with heightenedsusceptibility. There is an explicit correlation with strengthand sexuality, and the very young and the very old, seenas asexual, are constitutionally weak. Females are con-sidered weaker than males, and weakness is part of theideal female role for both Latin women and women inthe rural South (35). This sex-correlated weakness meansthat women are more prone to illness, primarily becauseof functional blood loss and anatomical differences:

"There's somethin' about a girl gets a disease quickerthan a boy. On account of her different sex. She's easyto catch or she's eager to catch ever'thing. Becauseshe'll get it in her breast. Different things comethrough the breast, through your vagina too, youknow. There are two things you have a man don'thave, that make you easily [get sick]." t

The unborn infant is the weakest of all, and the fetusis at the mercy of the mother's prenatal behavior. Harmonyand moderation are again the watchword, and the preg-nancy period is one of many behavioral prescriptions andtaboos. This doctrine of maternal impressions is nearlyuniversal, and in the United States is found amongSpanish-speakers, the Arriish, the Hutterites, and bothwhites and blacks in the South (9, 16, 88). The mother'semotional state may affect the baby, whether pity, fear,mockery, or hate is experienced. Feelings of hate for aparticular individual may cause the baby to resemble thatperson, one young mother told me, adding ingenuously,"It's usually the father."| A child may suffer seizuresbecause the mother saw someone having a seizure and feltpity; worrying about a loved one with a particular healthproblem may cause the infant to have the same problem.The theme of divine displeasure again appears for blacks.Southern whites, and Mexican-Americans; it is reportedthat if a pregnant woman makes fun of someone with aphysical affliction the baby may be born with the samething, punishing the mother for lack of charity (16, 33).Dietary cravings are also potentially harmful to the fetus,and if the pregnant woman desires a particular food she

must not touch herself until the craving is satisfied. Other-wise the b^by will have a birthmark resembling the foodshe wanted, located on the spot corresponding to whereshe touched herself.

The young infant is still prey to external conditionsbecause of its inherent weakness. Many of the folk diseasesunique to Mexican-American culture occur during child-hood, when the child is seen as being in delicate balancewith life. The folk illness mal ojo (evil eye), for example,occurs when an infant or small child is admired by anadult with "strong vision (28)." There is a widespreadbelief that a newborn child should not be handled by amenstruating woman; among black women the belief isthat it will cause the infant "to strain (89)." In Tucson,Mexican-American women blame umbilical hernia on thehandling of the new baby by a menstruating woman oranother new mother§. According to Foster, this belief isfound in some and perhaps all Spanish-American countries,from El Salvador to Peru (26). In accord with the prin-ciples of imitative magic, the cramping of the menstruatingwoman affects the baby in the same way, and strain orhernia is the result.

NATURAL FORClgg

Sympathetic magic is also incorporated in the notionthat there is a direct connection between fhe body and theforces of nature. Here the basic premise is that naturalphenomena, such as the phases of the moon, position ofthe planets, season of the year, and so on, directly affectthe human body and its processes. Since these phenomenaare observable, and man is a part of nature, the hiainte-nance of health is directly associated with the ability of theindividual to read "the signs." As one woman says, "Lottadoctors stand around on their butts laughin' at the sigris;they'd do better if they paid attention." || Dependence onthe signs to regulate behavior is found all over the ruralSouth among both blacks and whites, in northern andwestern cities where southerners have migrated, and inother parts of the country as well (17, 23, 24, 36, 38, 64).The clearest exposition of how the signs are read is to befound in The Foxfire Book (24).

A farmer's almanac is the repository of niuch of thisnature lore and is an instructional guide that reports thebest days to plant crops, to set hen's eggs, to destroy weeds,wean babies, and go fishjpg. The almanac is consulted forthe best times to have teeth extracted (during the increaseof the moon) or filled (during the moon's decrease). It isalso used to pick fhe optimal time to have surgical pro-cedures done, as will be shown. The almanac is not usedby rural people alone, and I recently purchased one in astore on Chicago's south side. The proprietor described itas a very popular item, pointing out that it had beenwritten by an M.D.; flrst edition, 1897 (90). Many peoplewho use the zodiacal signs to manipulate their own healthregimens do not mention this to health professionals for

* Olive P., Tucson, Arizona, age 85, born Oklahoma, 6th grade educa-tion. Excerpt from tape recording, November 1970.

t Erma V., Tucson, Arizona, age 49, born Texas, 6th grade education.Excerpt from tape recording, December 1970.

t Rena S., Lansing, Michigan, age 18, born Arkansas, high schooleducation. From fieid notes, October 1973.

§ KAY M: Health in the Barrio: Women's Point of View. Unpublisheddoctoral thesis, Tucson, University ofArizona, 1972. p. 146.

II Bertha A., Tucson, Arizona, age 67, bom Texas, 6th grade educa-tion. From field notes, January 1971.

38 July 1971 ' Annals of internal Medicine • Voiume 81 • Number 1

fear of being laughed at*. They are, however, the basisfor a constant and lively practice of self-medication, dietaryregulation, and behavioral modiflcations, and the physicianshould be aware of these beliefs. Some are harmless, someneutral; others, however, are potentially damaging, as willbe shown. Again, they illustrate how external forces arebrought to bear on the individual, who must learn tomanipulate them for his or her own well-being.

FAMILIARITY WITH THE BODY

It is imperative that the individual understand the work-ings of the body as it must be regulated throughout life.The understanding of the body reflects the old classicalhumoral pathology, in which the physical functions wereregulated by four "humors," blood, phlegm, and black andyellow bile. These, in turn, were cori-elated with prdjiertiesof heat and cold, wetness and dryness. Health dependedon the humors and theii" associated properties being keptin the proper balance. This system was promident inAmerican medicine into the 19th century and was doubt-less introduced into the slave cabins of the antebellumSouth, where the health of slaves was a prime economicconcern (91-93). In a classic article, Foster has tracedthe introduction of the humoral theory from Spain to theNew World, where it is still the basis for most illnessesconsidered natural, males naturales (26). The tendency toclass illnesses, foods, and medicines according to intrinsichot and cold properties is well known in Mexican, PuertoRican-American, and Mexican-American culture (14, 28,39, 67, 94). In the system of Americans of non-Spanishdescent, such a comprehensive classiflcation is not found,but heat and cold are still of prime importance: heat isassociated with blood, which ke§ps one warm during coldweather, and,with fevers and rashes. Cold is associatedwith water, damp air, and phlegm, prime symptom ofupper respiratory infections, common in the wintertime.The importance of bile as a bodily humor has disappeared,except for a; notion that the liver is an organ that must becleaned each spring. For all groups there is a generalconcern that the body will become internally dirty if notconstantly cleaned out. Phlegm, usually referred to as"slime," is a normal bodily component associated withuncleanliness. This is explained by the biblical referenceto man being fashioned of a handful of dust. "Jesus Christmade us of the slime and the dirt. A little [newborn] babyis slimy; all that stuff's iii you." t The body becomesdeflled by vaguely deflned impurities that occur outsidethe body and that are ingested in food or drink, or whichbuild up during the digestive process. They are nowfrequently associated with germs and, like slime, areconsidered a systemic cdntaminant. Germs were describedby informants in such terms as something nasty, badbreath, something like bedbugs, or defilement. Very fewinformants believe in contagion; more commonly, slime

•On a visit to western Kansas ift August of 1973 I learned, to myconsternation, that it is my own mother who is the iocal expert onreading the signs. She advises friends and neighbors about their gardensand the best dates for dental work, impending surgery, and the iike—when asked why this had never been mentioned before, the reply was,"Well, all those years you worked in the lab you thought everythinghad to be so scientific."

t Anna P., Tucson, Arizona, age over 65, 4th grade education. Fromfield notes, April 1971.

and impurities in the body are the cause of upper respira-tory infections, fevers, and rashes of all kinds. The ideathat illness will result if the system is not constantlycleansed is universal in American popular medicine, andthe necessity for regular evacuation has been the subjectof concern since the 19th century, when it was believedthat retained fecal matter would decompose and "corrupt"the system (95). It has been recently reported that 67%of the adult population of the United States believes thata daily bowel movement is necessary for good health (96).

The blood is the fdbus of most attention, however, andthere is concern with its generation and volume, the cir-culation, purity, and viscosity. Blood is spoken of as highor low, thick or thin, good or bad, clean or deflled, andso forth. If any general statement can be made about theblood—and therefore about the state of the system—it isthat it is in constant flux. The blood responds directly to anumber of internal and external stimuli, and this probablyalso explains inforihants' difficulty in grasping the chro-nicity of certain conditions, for example, hypertension.Since all one has to do to change the state of the blood isto wait for different weather conditions or to make amidbr dietary change, it makes little sense to be told thata condition will last a lifetime.

'Generation of Blood: It is believed that new blood isconstantly being formed, and used blood is eliminatedfrbm the body. This is accomplished during the mensesfor women, but it is sweated out by men. The monthlyblood loss of adult females contributes to their relativeweakness health-wise, since blood loss is weakening. Themoon affects blood generation, as it does many otherbodily functions, and new blood is mixing with the oldwhen the moon is waxing (97).

Blood Volume: The amount of blood in the body is notstatic but can increase or decrease. It is most prominentlyaffected by the diet, which causes the blood level to goup or down. Extremes are ill-advised, so that the amountof blood in the body can be dangerously reduced ("lowblood") or too much may be produced ("high blood").High blood (too much blood) is a recognized syndromefor blacks. Southern whites, and Haitians (34). It isterminologically confused with high blood pressure, andstrokes are believed to be caused by excess blood backingup into the brain|. High blood is thought to result fromingesting too much rich food, especially meat (98). Certainfoods and other substances are thought to have the prop-erty of bringing down the high blood to a more acceptablelevel; they do so by opening the pores and allowing theexcess blood to be sweated out. Astringent substances, suchas vinegar, lemon juice, pickles, and epsom salts, are usedfor this purpose. A century ago this was part of Americanmedicine, and the juices of citrus fruits and sassafras teawere recommended as blood diluents; both are in commonuse today (95). Low blood, on the other hand, is con-ceptually allied with anemia, and for blacks and Southernwhites is terminologically confused with low blood pres-sure. Low blood, or too little blood, makes it difficult for

t Scorr C; Haitian Blood Beliefs and Practices in Miami, Florida.Miami, University of Miami School of Medicine. Paper read atAmerican Anthropoiogicai Association annual meeting. New Orleans,29 November-2 December, 1973.

Snow • Foik Medicai Beiiefs 8 9

the heart to pump it through the body. In the Haitiansystem low blood is represented by the syndrome faiblesse,caused from lack of food. Mexican-Americans recognizesangre debil from not eating proper foods, but it is con-ceptually separate from low blood pressure, baja presion.Untreated sangre debil may result in anemia aguda (severeanemia) or tuberculosis*. Where low blood is confusedwith low blood pressure, dietary folly is also blamed: theindividual has eaten too many astringent foods or hastaken the remedies for high blood for too long. For allgroups, low blood can be brought up to normal by eatingand drinking certain items. Exercising imitative magic,these tend to be red: beets, wine, grape juice, red meat,liver, blood sausage, blood from a freshly slaughteredanimal, or water in which a nail has been allowed to rust(24, 25, 36, 88). Imitative magic is also obvious in therecommendation of yeast to make the blood "go up (99)."

Circulation: The circulation of the blood is affected byenvironmental conditions. Again according to the principleof imitative magic, the blood moves faster when environ-mental conditions are unsettled: when the moon is waxing,the tide is high, the weather stormy, or the seasons chang-ing. Turbulence in nature affects the whole body, and thehealth of the individual is particularly vulnerable duringtimes of seasonal change. "In the spring the seasons donemade their turn. When sap go up it make you sick. In thefall when sap go down, it'll make you sick." t Humanbeings may almost be viewed as innocent bystanders in theyearly battles of nature. The almanac reports that Marchis particularly dangerous for health because "The greatstruggle between Winter and Summer takes place thismonth and woe to the person who is taken sick at thistime, for they seldom recover" (90). The location of theblood in the body is also affected by the signs of the zodiac.Each zodiacal sign is associated with a certain part of thebody, and there is thought to be more blood at that pointwhen that sign occurs (100). Procedures that may producebleeding, such as surgery, should be undergone only whenthe signs show that the blood is correctly positioned in thebody.

When any kind of a surgical operation seems neces-sary have it done if possible during the increase ofthe Moon, then the solar influences are most power-ful, the wounds heal better and the vitality is greaterthan at the decrease of the Moon.

If the Moon is going through the sign which rulesthat part of the body where the operation is to beperformed, defer it for a day or two until the Moongets well into the next sign or past it. This willminimize the danger of complications and not in-frequently the symptoms change so that the operationis avoided [90].

The use of the almanac to read the signs for schedulingsurgical and dental procedures was reported by black in-formants in Arizona and Michigan, is currently used inmy hometown in Kansas, and has been described all overthe rural South as well (34, 36, 38). I have not seenreference to zodiacal signs in the literature on Latin-

* KAY M: Health in the Barrio: Women's Point of View, unpublisheddoctoral thesis, Tucson, University of Arizona, 1972, p. 150.

t Bertha A., Tucson, Arizona, age 67, bom Texas, 6th grade educa-tion. From field notes, January 1971.

American folk medicine, and I do not know if this beliefis extant there.

Purity: The blood is affected when the system is notclean, and, by the circulation, impurities are carried to allparts of the body. The idea that the blood is impure isreflected terminologically: "bad blood" is equated withvenereal disease and, according to one informant, occurswhen a woman "is with too many men and their stuffgets into her system." % The idea that sexual excess is theimportant factor is reflected in the Ozark belief that anywoman who has intercourse with seven men will acquire avenereal disease, even though none of her partners areinfected (36). "Poison blood" may refer to septicemia,but the term is an ambiguous one (35). It may also be asynonym for witchcraft, and any magical practice with evilintent may be referred to as "poison" (65, 97). It istherefore a term that should be used with care by physi-cians with a black or Spanish-speaking clientele.

Most commonly, though, impurities in the blood aremanifested cutaneously. Any sort of skin eruption, whetherurticaria, measles, diaper rash, chicken pox, or a syphiliticlesion represents the impurities in the body trying to comeout, and they should not be interfered with. For the groupsunder discussion here, the lifelong battle against systemicimpurities begins at birth, when the infant is given a teadesigned to drive out impurities built up during gestation;these are represented by a fine red rash (16, 25). Catniptea is a favored herbal for this purpose, and pharmacies inthe Lansing area catering to a black clientele purchasecatnip in bulk. If one thing isn't available another will betried, and Southern white mountain women now living inDetroit report trying commercial teas when they areunable to obtain catnip (23). One Lansing woman simplygave her new granddaughter warm water; she says it is theheat that counts, not the flavor.

The association of heat with rashes is also seen in Latinfolk medicine: rashes and hives are a "hot" reaction inMexico and among Puerto Rican-Americans, and a preg-nant woman should avoid hot foods lest the baby developdiaper rash (14, 39, 94). The viability of the folk systemis demonstrated by the inclusion of new substances intothe hot/cold dichotomy: penicillin, for example, is con-sidered hot because it can cause a rash (14). In ruralFlorida it is also believed by some that disposable diapersshould not be burned because this would cause the babyto have diaper rash (101).

Because of the effect of the weather on the circulatorysystem, symptoms caused by the presence of impurities areseasonally variable. It is believed that, just as the sap fallsinto the roots of trees during the winter, impurities sinkin the body and lie dormant until spring. "When springconges, birds start mating, flshes in the water start mating.The sap is rising and impurities start rising too. If yoursystem's defiled, why, you're liable to come up withanything!" | The almanac also advises spring as a time to"clean up," as "Malaria, boils, bilious attacks, blood dis-eases, catarrh and skin eruptions begin to show" (90).This time of the year therefore brings on several regimens

t Anna P., Tucson, Arizona, age over 65, born Texas, 4th gradeeducation. From field notes. May 1971.

90 •'"'y 1974 • Annals of Internal Medicine • Volume 81 • Number 1

based on the premise that the body is about to come backto life and had better be purifled, oiled, and generallytuned up. These are 9-day treatments, and ideally includesulfur and molasses for purification, castor oil to lubricatethe system and prevent stiffness, a commercial preparationto clean the liver, and miscellaneous other treatments, forexample, sassafras tea or poke greens to thin the blood.The numbers three and nine are exceptionally powerfuland are found over and over in both home remedies andmagical rituals among blacks. Southern whites, Haitians,Trinidadians, and Spanish-speakers. During those timeswhen the pores are open because of such treatments,bathing should be avoided lest the water and cold enterthe body and cause illness. Fortunately for the individual,the body is not strong enough to withstand these treatmentsmore than once a year: "You can't take a blood tonic allthe time; it would work in the blood too forcible, stripthings out that you didn't want out." * All the items usedin such home treatment are readily available in the backyard or garden, the pharmacy, or the corner grocery.Knowledge of how to use them is passed on both by wordof mouth and in publications (102, 103).

Viscosity: The blood is often described as being thick orthin, and this attribute is particularly affected by age, thesex of the individual, diet, and environmental temperature.Children and the elderly have thinner blood than thesexually active adult, and women have thinner blood thanmen. Blood loss caused by trauma or hemorrhage isweakening, and thin blood bleeds more rapidly thanthick blood. Alcohol and some foods are believed to thinthe blood, and one young man in Lansing offered the novelsuggestion that the real reason that the police don't wantpeople to drive while drinking is that alcohol thins theblood, and if there were an accident the individual mightbleed to death. Here, too, new substances may be addedto old categories, as when a midwife does not give aspirinfor postpartum pains because it would thin the blood andcause more flow (35).

Blood viscosity is also affected by outside temperatures;it thickens in the winter as a protection and thins downagain when outside temperatures rise. Blood can be eithertoo thick or too thin, however, and may be seen asbecoming "watery" by groups as diverse as Haitians,Mexican peasants, and Southern whites (25, 94). Becauseof its lessened protective capability, thin blood is associatedwith lowered resistance to the onslaught of cold damp airupon the body. The presence of cold in the body is blamedfor upper respiratory infections, for degenerative diseasesof old age, and for problems associated with the menses,childbirth, or abortion.

Any illness associated with increased mucus productionis attributed to the entry of cold into the body and thesubsequent mobilization of accumulated slime. This slime,if not periodically removed, collects in the kidneys and inthe region of the diaphragm. The cold in the bloodsomehow mobilizes it, it rises up into the chest, and oneis soon coughing, sneezing, and so forth. Of course, manytimes people "expose" themselves and do not fall ill; this

paradox is explained by the belief that the blood thinswith age and that present activity may not be fullyexpressed until the distant future.

"Now this here is winter time, isn't it? If I go outhere half dressed, half nekkid, catch a whole lottacold, won't try to do nothin' about it, you know I'mgonna be sick! I brought it on myself! Lookit thegirls today, walkin' around here with no clothes on.Their miniskirts up to here! I saw some with shortson yesterday. Shorts! Up to here! And pore me, Icouldn't stay warm with what I had on! All right!They don't feel it now! They young, blood's thick.But wait until they get up 25, 30 years old, maybe40. They gonna be crippin' along, got the rheumatism.'I'm hurtin'." They brings it all on theirselves! Theyjust goin' head on, just dressin', and you cain't tell 'emnothin'! More nekkid folks now than I ever seen inmy life! Walkin' nekkid in the street. And when theyget my age, mightn't get as old as I am, they gonnafeel it. Sumpin' gonna happen to 'em! If they don't gointo TB, they gonna have pneumonia; if they don't dothat, they gonna have arthritis, they gonna haverheumatism. They gonna pay for it. All that cold issettlin' in their joints. . . . When they get older theygonna feel it. They be to the place they be walkin'on crutches, sticks and ever'thing else!" t

The most feared problems associated with the cold,however, are those that involve menstruating, recentlydelivered, or newly aborted women. They are at riskbecause they are bleeding, and great care is taken that theflow of blood is not impeded. There are proscriptionsagainst going out or bathing, lest the woman be exposedto cold air or water. The idea is that the woman shouldbleed, cold thickens and stops the flow, it backs up, andthe result is death or hemorrhage. Suppressed menstrua-tion from taking cold is reported in 19th century Americanmedicine, and congestion of the chest is blamed on"suppression of eruptions or accustomed discharges" in ahomeopathic manual published in 1926 (95, 104). Acomparable explanation is still found in a booklet put outby the same company, whose homeopathic remedies arepopular with informants. The explanation for suppressedmenses reads, "Sometimes, in regularly menstruatingwomen, during the flow or just as it is about to commence,the flow stops or becomes suppressed from exposure tocold, especially damp cold" (105). Avoidance of bothbathing and "cold" foods during the menses is found inMexico, and among Mexican-American and Puerto Rican-Americans (14, 39, 94). Sterility, in fact, may be blamedon frio de la matriz, a cold womb (39). Among Southernwhites, bathing during the menses may be blamed forinsanity or tuberculosis (23, 38). The idea is equallyunsettling to black informants in both Arizona andMichigan.

"No, I don't think you should bathe. When I wasgrowin' up, my girlfriend she died from bathin' duringher menstruating period. They say it stops you, stopsyour womb up or somethin' up there, the water does.She was taking a bath during her menstruating periodand she died in the tub. Another reason I don't thinkyou should be in too much water is you'll catch cold.

* Anna P., Tucson, Arizona, age over 65, born Texas, 4th grade edu-cation. From field notes, May 1971.

t Amelia L., Tucson, Arizona, age 64, born Texas, 6th grade educa-tion. Excerpt from tape recording, January 1971.

Snow • Folk Medical Beliefs Q l

You'll catch cold because your veins are open." *

Puerto Rican-American women avoid "cold" foods in thepostpartum period lest the lochia back up to cause aspeciflc form of insanity, ptilga del parto (14). Finally,the almanac predicts the onset of "female troubles" inFebruary because it's the coldest month (90).

Heat, in contrast, opens the pores and veins and pro-motes bleeding; in northern Mexico one has to "heat thewomb" of a barren woman so that she may bear children(67). A Mexican-American woman may attribute herchild's nosebleed to the fact that the child is overheated,and in the South a midwife may wrap her patient's anklesin warm cloths to hasten labor (19, 39). For a latemenstrual period, the kitchen spice shelf may yield sage,ginger, or mustard for a hot tea, "if you're tryin' to getstarted, you drink you tea and it brings you through." *Like anything else, too much heat is dangerous, and veryhot weather may cause the blood to "ferment" (90).

Patients holding the sorts of beliefs that have beendiscussed in this section present treatment problems ofvarying signiflcance. The doctrine of maternal impressionsis responsible for several behaviors that are not those theclinician would like to promote. One example is the beliefthat a pregnant woman should not have dental work donebecause she might lose too much blood or cause her childto be born with a harelip. There may be undesirable dietaryrestrictions, such as a belief that pregnant women shouldnot eat fresh fruits or vegetables (23).

Treatment problems may arise because of ideas aboutwho has low blood and what should be done about it. Thecommon diagnosis of nutritional anemia among blackteen-agers does not make sense to some, because the bloodis automatically supposed to go up at puberty, not down(106, 107). Dietary suggestions for the treatment ofnutritional anemia in black and Southern white patientsmay be resisted because of a belief that red meat is toostrong and "virile" a food, during childhood, pregnancy,convalescence, or old age (99). For the patient who haseither high or low blood pressure, medication may not betaken because of the notion that dietary changes can makethe blood go up or down, and it is easier and cheaper tochange eating habits than take prescription medicine. Ifmedication is being taken, potentially harmful dietary ad-justments may also be carried out, as when the patientwith high blood pressure also drinks the brine frompickles or olives in the belief that it will help the bloodgo down.

Disbelief in the chronicity of certain conditions mayalso be a factor in noncompliance. I visited one womanwho had just had a light stroke and was recuperating athome. She was sitting up in bed as she had "blood on thebrains," and she thought that sitting up would make it godown more quicklyf. A physician had given her medica-tion and told her that she would always have to take it.Her reaction was, "Now that don't make no sense," andshe had thrown it away. She was instead trying to decide

• Cassie S., Lansing, Michigan, age 46, bom Arkansas, 11th gradeeducation, and nurse's aide training. Excerpt from tape recording,October 1973.

t Amelia L., Tucson, Arizona, age J64, bom Texas, 6th grade educa-tion. From field notes, Febmary 1971.

between two home remedies, epsom salts or vinegar andhoney in hot water to "bring down" the high blood to amore acceptable level. The same night she reported thatshe felt the stroke "leave" her when her minister put hishand on her head during a prayer meeting in her home.In any case, according to her niece, "The doctors didn'tdo nothin' for her, that's for sure." t

A further complication may arise if an individual isboth anemic and has high blood pressure: patients maychange physicians if they are told that they have both highblood (pressure) and low blood (anemia). In folknosology these are obviously mutually exclusive, so thephysician making such a diagnosis is thought a fool.

The idea that it is dangerous to interfere with naturalprocess also accounts for misunderstanding. A colleaguewho has practiced in Detroit's inner city reports that thelessened menstrual flow that may occur when a patienthas been on oral contraceptives for a long time is worri-some to many women. They think that, since the usualamount of blood is not coming out, that it must be col-lecting inside and will eventually cause problems §. Thefear that water can impede normal blood flow may makemenstruating or newly postpartum women resist efforts tomake them bathe while in the hospital. It is doubtful thatthe anxiety thus generated is worth any hygienic gain—ifresistance is great, a sponge bath might replace the showeror tub bath. One of Kay's informants solved this problemby turning on the shower but not getting under the water:hospital personnel thought she had bathed, she knew shehadn't, and everyone was happy. ||

Despite all precautions, iUnesses sometimes do occur,of course, and when household remedies fail medicalexpertise is sought. There is great contrast, however,between the informants' and professional practitioners'views of medical expertise and how it is gained.

The Art of Healing

The mixture of natural, magical, and religious domainsseen in ideas about illness causation, treatment, and pre-vention is also found in views on who has the ability tocure. Practitioners are classifled according to the methodsused in healing and how they received the ability to heal.

In the flrst instance it is said that "medical" doctors givemedicines, "surgical" doctors cut, "rubbing" doctors ma-nipulate the body, and so forth. It may not be generallyunderstood that surgeons are also trained in generalmedicine or that there is any real difference between thechiropractor and the M.D. or D.O., other than the typeof treatment used (21, 23, 36). In some instances thechiropractor is considered superior because he preventsillness, whereas the medical doctor can only cure it; inothers, the chiropractor is sought after other, orthodoxmedical services have been used without success (10)**.

t Ella T., Tucson, Arizona, age 50, bom Texas, 9th grade education.From field notes, February 1971.

§ George Gross, D.O., M.P.H., Department of Community Medicine,Michigan State University; personal communication.

II KAY M: Health in the Barrio: Women's Point of View. Unpublisheddoctoral thesis, Tucson, University of Arizona, 1972, p. 191.

•* COBB A: Chiropractic and the Division of Labor in Society: Processesof Health-seeking Behavior. Unpublished M.A. thesis, Lawrence. Uni-versity of Kansas, 1972, p. 72.

9 2 July 1974 • Annals of Internal Medicine • Volume 81 • Number I

In some cases, in fact, the physician may be consideredinferior to the nurse or pharmacist in health matters (34).Because the "medical" doctor gives medicines he or she isin the same class as the herb doctor, the housewife, or theneighbor who happens to know a lot of home remedies.This gives rise to a great deal of hostility toward profes-sional practitioners, and they are often seen as motivatedby cupidity; likewise, the feeling that doctors are not in-terested in having poor people as patients is very wide-spread (2, 25, 47). Southern mountain woinen in Detroitcomplain that doctors think they are "poor white trash"(23). Black people in New Orleans have even reportedbelief in the "gown man," or "needle doctor," characterizedas a student physician who lurks in dark alleys at night tofall upon hapless victims, kill them with an injection, andthen take them away to dissect at leisure (43, 89). ATucson woman who had just been released from thehospital noted bitterly that the physician just looked at herwithout touching her when he made rounds, which sheinterpreted as meaning he didn't want to put his hands ona black person. The behavior of the low-income patientis often just as frustrating to health persormel (21, 108,109). In an extreme case, medical personnel have cate-gorized Appalachian whites as abnormal, and "one group,the 'cultural primitives,' is described as characterologicallysimilar to schizophrenics and the other group, the 'tradi-tional farmers' as having character structures similar topsychoneurotics" (110).

The synthetization of medications in the past few yearsalso contributes to misunderstanding, and informants fre-quently mention items formerly available in the pharmacythat they cannot now obtain or that require a prescription.The pharmacist is blamed for collusion with the physicianin seeing that patients have to use prescription medicine;one woman complained that the pharmacist had laughedwhen she asked for buzzard grease. The fear of notknowing what is in prescription medicine has already beenmentioned. It is also believed to be quite strong, so thatif it is taken it should produce practically instantaneousresults. Another frequently mentioned complaint, there-fore, is that the doctor only gives you enough medicine tokeep you alive until the next office visit, implying that hecould give you enough to cure you if he wished butprefers to keep the patient returning until the money isgone.

The ability to heal is seen as being a gift from God,and the gift is differentially bestowed. Healing practitioners,that is, can be ranked according to how much "power"God has given them to cure. There are three ranks ofhealers graded in this way, the lowest including those wholearned their craft from others, whether one's grandmother,a talented neighbor, or a medical school—the M.D. orD.O., therefore, is classed along with the herb doctor andneighborhood healer. Above these are those individualswhom God thought fit to receive the gift of healing,during a religious experience later in life; evangelist OralRoberts is a well-known example of this kind of healer.The individual with the greatest ability, however, is theperson bom with the gift of healing, which is evidence ofspecial divine approbation literally from birth. The sorts

of illnesses dealt with are also correlated with the amountof power the individual healer is thought to command.

The conferring of expertise by education is, of course, aparticularly middle- and upper-class phenomenon, and isrelatively meaningless to those who have little educationor for whom education does not guarantee upward mo-bility. There is marked ambivalence on the part of in-formants concerning education. On the one hand, it ishighly valued and seen as the key to sliccess—realistically,however, most poor people do not have any expectationsof advanced training, and both envy and resent the"higher ups" who have it. For blacks the fact that most"higher ups"—including physicians—^with whom theycome in contact are white compounds feelings of helpless-ness and anger. Since such avenues to advancement arelargely closed, they fall back on the cultural system wherereligion and magic allow them to deal with a hostile world.This was succinctly expressed from the pulpit of a Pente-costal church one morning when the pastor, a janitorduring the week, stated, "Mrs. Snow is learning a lot ofthings from books. We didn't have that opportunity, soGod helps us and shows us the way." * Thus any ability,including the ability to learn, is seen as a divine gift. Iwas frequently told that an atheist would be unable tocure anyone, irrespective of the number of years in medicalschool. The gift is more important than the training,therefore, and the individual whose healing ability wasgained by training—whether M.D. or neighborhood healer—is only able to cure the simplest kinds of illnesses, thosenatural problems caused by the entry of cold or impuritiesinto the body. Such individuals are not able to deal withproblems resulting from divine punishment or those whichresult from witchcraft activity.

A more powerful practitioner is the man or woman onwhom God has bestowed the gift of healing during a reli-gious experience later in life. It is commonly stated that"the gift" was put into the hands, and curing techniquesare prayer and the laying on of hands. The cure seems,hke electricity, to flow directly froni God through thehands of the healer into the patient. It is obvious thateducation or training is completely irrelevant in this sortof situation.

"I was called by God! Darlin', He called me onemomin' and give me my position. To visit the sickand to preach and to help save the laws. And I heardthis and I didn't believe it! I went on back to sleep,and then He woke me up again. And this mellow-toned voice, you know, waked me again. And I wasn'tfrightened, it wasn't a frightenin' voice, it was aglorious voice! I don't know whether you ever felt theLord or not. When I felt the Lord, it just woke meout of sleep, just seem like it touched me all over.And called me by my name: 'Erma! Go ye there-fore!' I said, 'Yes, Lord.' . . . It was one momin' aforeday. God called me to a ministry. And to visit thesick and pray for the sick, and pray for the handsthat handles them and so forth. . . . That night whenHe called me to a ministry here, it meant somethin'in life to rhe. I mean it meant that, I couldn't stop,wherever I go. K I went to Kansas, I went in in thehospitals there, too. He gave me somethin' in my

* Pastor Jones, Pentecostal minister, Tucson, Arizona. From fieldnotes, January 1971.

Snow • Folk Medical Beliefs 9 3

hands that I could touch the peoples that they maybe healed." •

Such individuals are able to deal with all natural illnesses,including those caused by punishment for sin. Sincespiritual healing, as it is usually styled, gives the healeradditional power, such a practitioner may be sought outwhen a physician tells a patient that an illness is incurable.

"See, now, if you have cancer, the doctors can't curecancer! But if they go prayin' for you, and you havelots of faith, the Lord will cure that cancer! TheLord heals a whole lot of people of things the doctorsdone give up! While the doctor may give you up,the Lord can come in and deliver you! Put you onyour feet! Then whenever the doctor come back andexamine you for that particular thing and he don'tsee it, why, he'll say, 'Well, I know it was there, butI don't know what became of you now!' They'll beamazed theirself; they want to know what hap-pened!" t

Another good example of such magico-religious healingtechniques is the belief that bleeding can be stopped byreciting a charm or prayer. One informant who is such a"blood doctor" told me how she stopped the bleedingfrom a deep cut by reciting a passage from Ezekiel whilealso applying an ice packt. When I inquired as to whetherthe ice pack might have had something to do with thecessation of bleeding, I was reprimanded gently with,"God sewed it with His needle, darlin'." § Such treatmenthas been in use since the 13th century, and "blood-stoppers" or "blood doctors" are found from Florida tothe Upper Peninsula of Michigan among blacks. Southernwhites, and the Pennsylvania Dutch (11, 12, 23, 24, 35,36,37,70).

To be bom with the power of curing is a sign of God'shighest approval, a sign that the individual is to havespecial powers throughout life. It of course implies thatthe infant must be identifiable at birth as special. Thebirth order may be important, and special powers havebeen attributed to a seventh son or seventh daughter forcenturies, and today this accounts for special abilities forblacks, Southern whites, Cajun traiteurs, and Puerto Ricanhealers in the Chicago area (12, 26, 68, 70, 111). Thechild bom after a set of twins is powerful, a West Africanbelief found as well in Haitian Voodoo (65). A variationis that the child who has never seen his father can curespecific ailments. It is said, for example, that such a per-son can cure a child of oral moniliasis ("thrash" or"thrush") by blowing into the mouth; this belief is foundin the United States today among both blacks and whites(12, 23, 87, 89, 112). The birth itself may be seen asunusual—one centuries-old belief still extant is that thechild bom with a caul ("the veil") has special abilities.

* Erma V., Tucson, Arizona, age 49, bom Texas, 6Ui grade education.Excerpt from tape recording, February 1971. In this passage the in-formant goes on to say how she once cured five women of cancer in asingle morning by laying on hands; that they also subsequently hadsurgery was considered irrelevant. As a licensed minister, of course, shehas open entry to most hospitals.

t Amelia L., Tucson, Arizona, age 64, bom Texas, 6th grade educa-tion. Excerpt froni tape recording, January 1971.

t Ezekiel 16:6 And when I passed by thee, and saw thee polluted inthine own blood, I said unto thee when thou wast in thy blood. Live;yea, I said unto thee when thou wast in thy blood. Live.

§ Erma V., Tucson, Arizona, age 49, bom Texas, 6th grade education.Excerpt from tape recording, November 1970.

This has been reported worldwide since the Chaldeans andis found today in the United States among Louisiana Ca-juns, Appalachian whites, and blacks from the Sea Is-lands of South Carolina to Michigan. It may confer healingability, "second sight," or just good luck (12, 16, 23, 59,68, 112). In even rarer cases, the infant itself signals be-fore the birth his or her special ability.

"Some people say that I have the gift because I wereborn behind two twins. But I don't know, I alwayshad that urge that I could cure anything! I've alwaysfelt like that. But my grandmother knew it beforeI were born. I cried three times in my mother's wombbefore I were born. Then she said, 'That's the one.That's the one what's gonna be just exactly like me!'I was fortunate, I was born just exactly with the gift"[7].

The person born with power can cure all illnesses,natural or unnatural; they often report the ability to "see"or "hear" the diagnosis of illness, usually with spiritualaid (7). The cure may be sent by air, and, in some cases,the healer may not even have to see the patient; simplythinking about the illness heals it||. It is easy to see howsuch people outrank the ordinary physician in the assess-ment of curing ability.

ConclusionsThe folk medical system described in these pages reflects

a view of the world as a dangerous place. The individualmust be constantly on guard against the vagaries of nature,the potential hostility of his fellow man, and possiblepunishment from God.

It is a world view that teaches that the individual hadbetter look out for himself, that mistrust is wiser thantrust, and that safety lies in not calling attention to one-self. It is not, unfortunately, a world view in which thephysician is readily seen as the altruistic healer come todispense medicine to the poor.

The presence of an alternate medical system which atbest is different from and at worst is in direct conflictwith that of the health professional can only complicatematters. It is not simply a matter of offering health carein place of no health care at all, or even of offeringsuperior health care in the hope that such superiority willbe patently manifest to the clientele. Deeply ingrainedbeliefs about how to attain and maintain health affectbehavior whether or not the individual ever becomes apatient in a modern health setting. These beliefs about theintricate network linking man to the natural and super-natural world may greatly color the doctor/patient rela-tionship and influence the decision to follow—or not—the doctor's orders.

When a low-income black, Southem white, Puerto-Rican American or Mexican-American finally does arrivefor professional health care, it probably may be assumedthat every home remedy the patient knows about hasalready been tried. It is important that the physician

jl In a taped broadcast from Texas recently heard over the Lansing,Michigan, Spanish-language station, a Mexican curandero sent hiscures via the air waves. Invalids were urged to put their hand on theradio, or an item of clothing might be placed on the radio to "pick up"the cure. Jane Haney, M.A., Department of Anthropology, MichiganState University; personal communication.

9 4 July 1974 • Annals of Internal Medicine • Volume 81 • Number 1

know what the patient has been using to combat theillness—if it is harmless, it might be left in the treatmentplan and the physician's own suggestions added. A harm-ful practice might be more readily eliminated if thephysician simply suggests that since it has apparently notworked something else should be tried. Laxative use andchanges in food habits should be inquired into, and, ifpossible, the physician should make suggestions that canfit into the patient's belief system. The numbers three andnine might be used to advantage, for example, as they areimportant in the folklore of every group that has beenconsidered here.

As more and better health care is made available to thepoor patient, some of these beliefs will gradually begin todie out. Those intimately tied to religious belief willprobably not, however, and others, such as the belief inwitchcraft, may continue to be operative as long as thestatus of the Spanish-speaking or black American iseconomically and socially marginal. For some time tocome, therefore, physicians practicing in the inner cityor rural areas will need some knowledge of folk medicineto be able to assess how the diagnosis and subsequentadvice is likely to be interpreted by patients.

ACKNOWLEDGMENTS: The author thanks George Gross, D.O.,M.P.H., for his useful criticisms of this paper.

Grant support: Woodrow Wilson National Fellowship Foundation;the Danforth Foundation; and the College of Osteopathic Medi-cine, Michigan State University.

Received 30 July 1973; revision accepted 27 February 1974.

• Requests for reprints should be addressed to Dr. Loudell Snow,Department of Community Medicine, Michigan State University,East Lansing, MI 48824.

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9 5 July 1974 • Annals of Internal iViedicine • Volume 81 • Number 1