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Common Health Care Beliefs and 

Practices of Puerto Ricans, Haitians 

and Low Income Blacks Living in the 

New York/New Jersey Area 


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A Training Module Developed For The 
Public Health Service Region II 
National Health Service Corps 

The Department of Health and Human Service 

Reprinted By The Office of Minority Health 
Public Health Service, Region II 


"- o 

Common Health Care Beliefs and 

Practices of Puerto Ricans, Haitians and 

Low Income Blacks Living in the 

New York/New Jersey Area 

I. Introduction to Cross Cultural Health Care 

II. Common Health Beliefs and Practices of Puerto Ricans 

III. Common Health Beliefs and Practices of Haitians 

IV. Common Health Beliefs and Practices of Low Income Blacks 

Public Health Service 

Region II 

26 Federal Plaza 

New York, NY 10278 

(Reprinted by the Office of Minority Health PHS Region II) 

John Snow Public Health Group, Inc. 

Under Contract with: NHSC/DHHS/Region II 

Contract No. 120-83-0011 



National Health Service Corps (NHSC) providers are frequently assigned 
to health centers serving large minority populations with socio-cultural 
characteristics quite different from their own and those of the majority 
population* These centers are usually located in communities where one or 
more ethnic group(s) predominate and often the center's support staff 
reflect the community's composition and culture. A major part of every 
culture is a health belief and practice system, i.e. , ideas about body 
ima ge and anatomical functioning, disease causation, symptoms, diagnosis, 
appropriate treatment and prevention of disease (Weaver & Sklar, 1980). 
Cultures differ in their medical belief systems such that what is perceived 
as illness, its causes and proper treatments and appropriate sick role 
behavior, varies widely from one culture to another (Weaver & Sklar, 1980). 

When members of one culture provide health care to members of another 
culture, conceptual misunderstandings are likely to occur (Weaver & Sklar, 
1980). The needs and expectations of both parties are not mutually shared. 
As a result, patients may receive medical care inconsistent with their 
world view and mainstream providers are often hindered in their attempt to 
provide care they consider effective and rational. 

Cross-cultural misunderstandings about health care are even more 
likely when patient and provider do not share a common language. This is 
often the case in multi-ethnic NHSC sites. Providers must overcome yet 
another major barrier to achieving an accurate diagnosis and treatment and 
convey this information to patients. All of these factors contribute to 
the likelihood of less than optimal outcomes when a patient and mainstream 
provider come face to face. In order to treat patients from 
socio-cultural lv different backgrounds and communicate effectively with 
them, providers must develop a special understanding of the health beliefs 
and practices of their ethnic patient populations. More importantly, they 
must also develop methods for optimizing the communication flow and 
treatment results of these encounters. 


The intent of this booklet is to provide an orientation for NHSC 
physicians to the health beliefs and practices of their ethnically diverse 
patient populations, to increase understanding of the health belief systems 
and to thereby facilitate better treatment outcomes in these cross-cultural 
encounters. It should be cautioned that by no means do all members of a 
particular ethnic group share the beliefs and traditional practices 
mentioned herein. There are different levels of belief in and adherence to 
all the practices mentioned, ranging from none at all to fervent practice. 


The information presented herein was obtained by The John Snow Public 
Health Group, Inc. (JSI) from three major sources: 1) discussion with 
researchers and health professionals working in multi-cultural settings; 
2) a review of the recently published relevant literature; and 3) 
discussion with patients, staff and nonpatients from multi-ethnic health 


centers. (JSI organized focus groups for the purpose of obtaining culture 
specific viewpoints about health care and consisted of patients, 
nonpatients or staff of NHSC sites in Region II. Separate groups were 
organized for each ethnic group: low income Blacks, Puerto Ricans, and 
Haitians.) JSI conducted the study between October of 1983 and March of 


Most folk medical systems have many conceptual similarities, and it is 
useful to look at these before studying the specifics of a particular 
culture's beliefs. 

1. Generally, folk healing systems divide the causes of 
disease into two types: natural and unnatural . The first 
type are those caused by the environment or natural 
inbalances in the body's physical, emotional or 
psychological state. The second are those due to the 
malicious desires of another person enacted through a human 
agent using witchcraft rituals or those due to the actions 
of displeased spirits, gods or ancestors (Weaver & Sklar, 

2. In conceptualizing disease causation, most folk healing 
systems do not have a mind-body dichotomy as does western 
medicine. Folk medical systems often have multi-causal 
explanations for a disease which frequently include an 
emotional, psychological or social component (Weaver & 
Sklar, 1980). 

3. Folk medical systems have specialized healing personnel . 
Often these personnel are distinguished by the types of 
illnesses they cure — i.e. , natural or unnatural. 

4. In folk healing, both healer and patient have active roles 
and share similar expectations in the healing process. 

5. Folk healers may have unquestioned power and authority and 
are expected to bring about cures in a relatively short 
period of time. 

6. Suggestion and hypnosis are used extensively in folk 
healing and are important elements. 

7. Folk healing usually provides a common idiom for naming the 
disease and an explanatory strategy which gives answers to 
and images of the disease and cure process. 

8. There are specialized healing behaviors in each folk 
system, that is, special expected behaviors for diagnosis 
and treatment. 

9. Each system also has generalized and specialized medical 
substances. Generalized substances are those commonly 


conceived of as "home remedies." Specialized ones are those 
prepared, prescribed, or used by healing specialists. 

10. Finally, folk medical systems also include some fee 
structure and arrangements for payment to the healing 

Many of these concepts are also common to western, scientific medical 
systems. Specifically, the U.S. mainstream medical system has specialized 
healing personnel, specific idioms and explanatory strategies for disease, 
expected diagnostic and treatment behaviors, generalized and specialized 
medical substances and arrangements for payment. These common features may 
help physicians in developing a framework for the many variations of 
traditional healing systems and provide a common ground for achieving 
desired treatment outcomes. 

These commonalities may bring one to oversimplify traditional belief 
systems and providers should be careful not to make this mistake. Although 
many belief systems share a common structure, they are not at all 
homogenous. There are multitudinous variations among cultures and even 
within one social group. The specific practices around the common 
framework are quite different from culture to culture and the specifics can 
be extremely important in treating any one individual. 


In working with persons of different cultures, it is important to keep 
in mind that there will be variations among individuals in their adherence 
to a traditional medical system. These variations will be due not only to 
personal belief differences but, with a cultural group that has recently or 
is still immigrating to the U.S., also to differing degrees of 

Immigrants have had substantial experience in a healing system of 
another country and culture and have learned to expect treatment to occur 
in certain ways and personnel to behave in a certain manner. Now, living 
in the United States, they must use the mainstream medical system or, if 
they believe in folk medicine, must fall back on folk healers and medicines 
available in their community. An example of this dilemma is evident in the 
account given by a woman from Trinidad who participated in one of the 
patient focus groups for this project. She was treating herself for a rash 
by rubbing honey and vaseline on it. It became worse. When she didn't see 
any change she went to the doctor and told him what treatment she was 
using. He told her she should "leave the treatment to the doctor." She 
told him that in Trinidad, there are no doctors so she learned to treat 
herself. She became very upset with the physician and left. 

Scott (1974) states that when subordinate groups are only partially 
assimilated into a dominant culture, they tend to be bicultural in their 
choice of alternative beliefs and behaviors. People from a different 
culture are caught between two worlds, often believing in the folk causes 


and treatments of disease, but now living in a country where these beliefs 
are not the norm and where a physician's medicine is viewed as more 

There is much evidence to support the fact that many persons who 
believe in folk healing systems use several healing personnel (both 
traditional and mainstream) simultaneously or sequentially. Mainstream 
health providers may be consulted to see what treatment they offer, to 
verify a folk healer's diagnosis, or to unknowingly confirm a "spell" or 
hex. Thus. appearance in a mainstream medical center does not 
automatically imply confidence or belief in that system. 

Due to the differences in acculturation there are also variations in 
belief systems through the generations. First generation and elderly 
members of a culture are more likely to follow traditional beliefs. 
Succeeding generations, however, are likely to recall and use some of 
"mother's remedies" when sick even though they may not have had the 
associated folk "training." 

In our pluralistic society, providers thus have a broad continuum of 
traditional health beliefs with which to contend. A variety of methods are 
available to these providers when communicating medical information to 
ethnic individuals. The physician's own personality and temperament will 
also come to play in formulating his or her own style. A provider may 
choose to "educate" the patient to bring them to understand the logic of 
the regimen, may (according to personal style) use his or her authority to 
establish a treatment regimen or may choose to work within the patients 
belief system. Each of these methods may be appropriate on occasion, but 
behavioral science shows that the most effective will be working within the 
patient's belief system (Harwood, 1971). 

Efforts to change a person's beliefs, attitudes and behaviors about 
illness and its proper treatment in a short time period are not likely to 
succeed, especially when the patient is surrounded by people who share his 
beliefs. The ability to make these changes is, of course, dependent on the 
particular individual, and providers must make judgements and adjustments 
to their particular methodology in each case. 



This booklet on the health beliefs and practices of Puerto Ricans 
living in the New York/New Jersey area is divided into four major sections. 
The first deals with concepts of disease and illness, the second with the 
use of home remedies and traditional healing practices, the third with 
attitudes toward and use of mainstream health providers and the fourth with 
implications for effective treatment of Puerto Ricans by mainstream 

As discussed above, information for the booklet was gathered from 
three sources; the booklet is an attempt to integrate the information 
gathered from these sources and to provide NHSC practitioners with 
information they can use to provide culturally sensitive health care to 
Puerto Rican patients. A caution is worth repeating at this point: 
providers should not assume that all, or even most, Puerto Rican patients 
ascribe to the beliefs and practices discussed in the following pages. 
Rather, the information should point to conditions that they might watch 
for. In addition, the results of the focus groups JSI held with NHSC 
sites' patients and staff members lead us to conclude that patients are 
more likely to follow the treatment recommendations of providers who have 
shown some interest in and consideration for their cultural beliefs and 


Puerto Ricans, like members of many other cultural groups, may have a 
holistic conception of health and illness. Many feel that the physical and 
mental functionine of the body cannot be separated; what affects one will 
affect the other. Thus, a person's health is subject to feelings, other 
peoples' actions, significant events, natural forces and spirits. A 
logical extension of this holistic approach is the belief that faith in God 
and the healer are vital to being healed. This belief was also confirmed 
by the members of the Puerto Rican patient groups convened for this study. 

Some Puerto Ricans believe that illness is the result of either 
natural or supernatural causes. A natural illness is caused by "cold," 
"empacho" or any other similar event, or is seen as having been permitted 
by God. A belief in the supernatural causes of illness, or spiritism, is 
based on a belief that spirits can enter the visible world and influence 
human behavior. A person affected by spiritism is not considered sick but 
is seen as suffering from a "causa" and is not blamed for the condition 
(Comas-Diaz, 1981). Witchcraft is a general term which covers a range of 
supernatural factors causing illness or some other negative occurrence. 
Jealousy frequently plays an important role in witchcraft, "dano" (harm) 
may be the result of another person's envy and is particularly important as 
a cause of "nervios." For example "mal de ojo" (evil eye) is explained as 
the rapid onset of an illness in children and is believed to be caused by 
an adult who covets an attractive or clever child. 


Discussions with Puerto Rican patients. nonpatients. and staff 
indicated that although beliefs in spiritual causes and cures of illness 
do exist to a certain extent and particularly among people who have 
recently arrived in the United States, they are not prevalent among Puerto 
Ricans living in the New York/Nev Jersey area. Providers should not assume 
that their patients believe in spiritual causes of illness or that patients 
are imagining their illnesses. 

Practitioners who deal with the effects of spiritism and with 
witchcraft will be discussed in Section B. In addition to the beliefs and 
practices that would be recognized both by holders of mainstream and 
traditional beliefs, the following theories and illnesses may be recognized 
by Puerto Ricans living in the New York/New Jersey area. 

1. The Hot-Cold Theory Of Disease 

The following discussion is based primarily on Harwood's 1971 article: 
"The Hot-Cold Theory of Disease." The Hot-Cold Theory of Disease is one 
which is considered to be prevalent in almost all Latin American cultures. 
It has been found among Puerto Ricans in the New York area and, for those 
who practice it, has significant health care implications. The hot-cold 
system is derived from the Hippocratic humoral theories of disease which 
were brought to Latin America by the Spanish and Portuguese in the 16th and 
17th centuries. According to the Hippocratic theory, there are four bodily 
humors (blood, phlegm, black bile and yellow bile) and these humors vary 
both in temperature and moistness. Health is considered to be a state in 
which all four humors are in balance in a wet and warm body. Disease is a 
state in which one or more of the humors are out of balance. Foods, herbs 
and medications are classified as wet or dry, hot or cold and are used 
therapeutically to restore the body to its natural balance. In the Puerto 
Rican variation of the Hot-Cold Theory, diseases are classified as either 
hot or cold, but food and medicines are categorized as either cold, cool or 

The classification of foods is not related to the temperature at which 
they are normally ingested. For example, lima beans and steaming hot 
linden tea are classified as "cold" foods. An ice cold beer, on the other 
hand, is considered a "hot" food. Temperature is important, however, in 
the believed etiology of the disease. Illnesses classified as "cold," for 
example, are often thought to be caused by the person being chilled. The 
common cold is often believed to be caused by drafts, and upset stomachs 
and may be attributed to eating too many "cold" foods which chill the 

The system can be individualized so that if a food or medicine that is 
typically classified as "cold" causes symptoms that are classified as 
"hot," the individual may classify it a "hot" food for himself /herself . 

Table 1 gives categorizations of illnesses, medications, foods 
according to the hot-cold theory and Table 2 elaborates on the expected 
behavior of patients who adhere to the hot-cold theory. 

Treating patients who believe in the hot-cold theory of disease can be 
a challenge for health providers. One dilemma that may arise is that 


1 1-3 

Illnesses or 
Bodily Conditions 

"Frio" (Cold) 



("Frialdad del 


Menstrual period 

Pain in the joints 


"Fresco" (Cool) 







Medicines and 
Herbs : 



Lima beans 
Sugar cane 
White beans 

Bicarbonate of soda 

Linden flowers 

("Flor de tilo") 


("Mana" de Manito") 

Mastic bark 


MgC0 3 

("Magnesia boba") 

Milk of magnesia 


("Yerb Mora") 

Orange-flower water 

("Agua de azahar") 


Barley water 

Bottled mile 










Castor oil 


Cod liver oil 

Fe tablets 





Chili Peppers 



Corn Meal 



Kidney Beans 




Reprinted by permission. Source: Harwood (1971), "The Hot-Cold 
Theory of Disease." Journal of the American Medical Association, 
216. Copyright 1971, American Medical Association. 

1 1-4 


Patient's Condition 

Common cold, arthritis, joint pains 

Diarrhea, rash, ulcers 

Requires a diuretic as part of a 
treatment regimen and has been told 
to supplement his potassium intake 
by eating bananas, oranges raisins, 
or dried fruit. 

Requires penicillin or any other hot 
medication, particularly on an 
ongoing basis. 

Infant requires formula, which 
contains hot-classified 
evaporated milk. 


Postpartum and during menstruation. 

Expectable Behavior 

Patient will not take cold- 
classified foods or medications, 
but will accept those classed 
as hot. 

Patient will not take hot- 
classified medications and 
uses cool substances as therapy. 

Patient will not eat these 
cold-classified foods while he 
has a cold or other cold- 
classified condition. (For 
female patients, this includes 
the menses.) 

Patient will stop taking hot 
medicine when he suffers any 
hot-classified symptom (e.g., 
diarrhea, constipation, rash). 

Mother will put baby on cold- 
classified whole milk or will, 
after feeding formula, "refresh" 
the baby's stomach with various 
cool substances, some of which 
are diuretic. 

Avoids hot medicine and hot 
foods and takes cool medicine 

Avoids cool foods and medicines, 
particularly those which are 

Reprinted by permission. Source: Harwood (1971), "The Hot-Cold 
Theory of Disease." Journal of the American Medical Association, 
216. Copyright 1971, American Medical Association. 


pregnancy may be thought of as a "hot" condition requiring the avoidance of 
items classified as "hot" and the frequent ingestion of "cool" items. 
Vitamins and iron pills are considered "hot" items and may not be taken by 
a pregnant patient adhering to hot-cold concepts. Another common problem 
is found in infant feeding practices. Evaporated milk, which is used in 
infant formulas, is classified as a "hot" substance. Rashes, which are 
common in young babies, are also classified as a" hot" condition and are 
attributed to the intake of evaporated milk. One study found that over 40 
percent of new mothers curtailed the use of evaporated milk upon coming 
home from the hospital. These mothers either switched completely to whole 
milk which is classified as "cold" or used the neutralization principle by 
giving their babies a cool substance along with the evaporated milk. Some 
of the cool substances used are barley water, magnesium carbonate (a 
cathartic) and mannitol (a diuretic). They are believed to neutralize the 
harmful effects of the evaporated milk. Providers might want to reinforce 
the use of harmless substances such as barley water to mothers who are 
using this principle. 

The neutralization principle is an important one because it can b e 
used by practitioners to improve compliance in patients who believe their 
prescribed therapy to be counter to the hot-cold theory. For example, 
providers might suggest that their pregnant patients take vitamin and iron 
tablets ("hot") with fruit juice or herb tea ("cool") to neutralize the 
"hot" effects. Puerto Rican patients do not refer to this as 
"neutralizing" but rather as "refrescando el estomago" — refreshing or 
cooling the stomach. 

Many principles of the hot-cold theory are in accord with orthodox 
medical practice and thus, the hot-cold theory need not be viewed as a 
major obstacle in patient care. In fact, the hot-cold system is, more 
often than not, consistent with the practice of good medicine. Examples of 
this are that the bland diet typically recommended for patients with ulcers 
fits into the hot-cold system very easily and aspirin ("hot") is a readily 
accepted treatment for colds and arthritis ("cold"). 

It is possible that, because of the influence of the hot-cold theory, 
Spanish speaking cultures in general tend to feel that diet is a very 
important component of any treatment modality. For this reason, they may 
often expect suggestions about the proper diet that persons with their 
condition should follow. The typical Puerto Rican diet includes rice, 
beans, fatty meats, salted fish, milk and limited amounts of vegetables. 
Iron, green vegetables and fruits may be lacking in the diet. "Tonicos" 
(tonics) such as eggnogs or malted drinks may be taken for extra strength. 
The Puerto Rican concept of a healthy diet may involve more calories and, 
as a result, a higher body weight than an American physician might 

2. Illnesses Specific To The Puerto Rican Culture 

There are several illnesses or conditions which researchers have found 
to be specific to the Puerto Rican culture (Harwood, 1981 and Azziz, 1981). 
Some of these are given below: 


a. Empacho (obstruction or upset stomach) is caused by 
excessive food intake, particularly heavy or starchy food. 
According to Azziz (1981) it is consistent with gastroenteritis. 

b. Mai aire (bad air) is the result of exposing an 
overheated body to a cold wind or to cold water. Symptoms 
include back pain, muscle contractions (spasmo ) . and eventual 
muscle paralysis. 

c. Caida de mollera (fallen fontanel) is caused by a 
"dislodgement" of the fontanel and results in a baby becoming 
anorexic and lethargic. The symptoms are consistent with the 
symptoms of dehydration which may be the result of excessive 
vomiting or diarrhea. 

d. Susto (fright) is the result of a frightening event 
that causes a person's spirit to leave his or her body. 
Symptoms include paleness, listlessness, withdrawal, anorexia 
and weight loss. 

e. Ataques (attacks) sometimes known as the Puerto Rican 
Syndrome is a type of hysterical reaction with symptoms that 
include seizures, acute stress and anxiety. 

f. Malhiimor (bad humor) is used in a number of contexts. 
It describes a blood condition that causes ongoing skin 
conditions. It is also said that menstruating women have 
malhumor and cause babies to have diarrhea if they handle them. 

Some terms for certain illnesses and conditions also have a high 
potential for being misunderstood in translations. Table 3 provides a list 
of these potentially misleading terms. 

One area of common medical concern and of high potential for confusion 
is blood pressure. Discussions of blood pressure problems can easily b e 
misunderstood when dealing with a Puerto Rican persons because thev have 
several terms which, when literally translated, are "high blood pressure" 
and "low blood pressure" though their meaning in the Puerto Rican culture 
is quite different than that intended by a practitioner of western 
medicine. Alta presion (high blood pressure) is generally interpreted as 
too much blood or polycythemia. Baja presion (low blood pressure) 
generally means anemia. It is important for the practitioner to carefully 
explain his/her meaning when diagnosing high or low blood pressure. Cancer 
and tuberculosis also evoke a strong emotional response in many Puerto 
Ricans. This has implications for how the practitioner should present the 
diagnosis to the patient and his or her family. Tuberculosis has a strong 
stigma attached to it and because of this, patients may sometimes refer to 
it by another name, such as anemia. 

3. Concepts of Mental Illness 

There appear to be two basic categories of mental illness in the 
Puerto Rican culture: locura (insanity, craziness) and nervios or 
enfermedad de los nervios (sickness of the nerves) (Harwood, 1981). Either 

1 1-7 



Spanish Term 
"Acidez en el (del) estomago" 

"Alta presion" 
"Anemia en los hue so s" 


"Ataque de alferecia" 

"Ataque cerebral" 
"Ataque de nervios" 
"Baja presion" 


"Deficienca en la sangre" 

"Falfayota" (also "farfayota") 
"Fatiga de ahogo" 
"Fiebre paludica" 

"Flu jo" 


English Gloss 

Stomach acidity, sour taste in 
mouth and throat after eructa- 

High blood pressure 

Literally, anemia in the bones, 
considered by many to be a form 
of tuberculosis. 

Asthma, can also refer to 
shortness of breath from any 

Convulsions in infants, thought 
to be caused by sudden fright 


Nervous attack 

Low blood pressure, anemia 

Cold, usually refers to one 
localized in the chest. 

Conjunctivitis, any inflammation 
of the eye with exudate. 

'Weak blood,' blood deficiency 

Upset stomach, nausea, 
attributed to a bolus of food 
in the intestine. 



Malaria, sometimes used to 
refer to yellow fever. 

Discharge, flow, particularly 
from vagina. 

Glands, swollen salivary glands 




Spanish Term 



"Mala circulacion" 

"Nube en los ojos" 
"Orisma" ("aneurisma") 

"Raquitis(mo) 1 * 



"Sangre gruesa" 


"Soplo en el corazon" 
"Tuberculosis en los huesos" 

English Gloss 

Small underarm tumor or cyst, 
said to occur in multiples. 

Very bad headache, sometimes 
accompanied by nausea; migraine. 

Bad circulation, may be caused 
by "sangre gruesa." 



Spasm of clonic or tonic 
variety, particularly facial 
paralysis. Thought to be 
caused by chills or drafts. 


Rickets; tuberculosis in 

Cold, usually refers to one 
localized in the nose. 

Rheumatism, used as a synonym 
for arthritis. 

Literally, "thick blood," blood 
overly rich in red corpuscles, 


'Pus,' or 'poison' in the blood, 
often associated with leukemia. 

Heart murmur 

Tuberculosis of the bone, some- 
times equated with rickets. 

Reprinted by permission. Source: Harwood, Alan, Ethnicity and 
Medical Care . Harvard University Press, 1981. 


of these conditions may be the result of biological or spiritual causes or 
of particular occurrences. People who suffer from locura behave 
unpredictably and/or aggressively (this includes homicidal and suicidal 
behavior) and may harm themselves; there is generally a stigma attached to 
suffering from this condition. Nervios is identified by a number of 
possible conditions including ongoing agitation, inability to concentrate, 
pacing, excessive crying or brooding and is best treated, according to 
tradition, by rest, relaxation, talking or medication. 

One research team (Gaviria and Wintrob, 1976) report that the causes 
of locura nervios can be divided into two categories: natural and 
supernatural. The natural biological causes include alcohol and drug 
abuse, heredity, malnutrition and head trauma. The natural psychological 
causes include "desgaste" (weakness of the brain) due to such factors as 
sexual excess, excessive worrying, thinking or obsessing, family problems, 
and social problems — such as poverty or difficult working conditions. 
Spiritism was found to be the most important supernatural cause of nervios 
and locura . Witchcraft, bad luck, fate, "dano" (harm) and envy were also 
found to be important factors. 


Our research indicated that there is a significant amount of variation 
in traditional health beliefs and practices among Puerto Ricans living in 
the New York/New Jersey area. Overall, it appears that home remedies and 
herbal medications are widely used and respected but that few people 
believe that spirits cause or can cure illnesses. As mentioned in the 
previous section, a very important distinction can and should be made 
between the "natural" and "supernatural" traditions in Puerto Rican 
culture. The two traditions are quite distinct; an individual can use 
home remedies and go to traditional healers for "natural" illnesses without 
believing in or practicing withchraft or sorcery. A mainstream provider 
should not assume that the use of home remedies or traditional healers 
means that a Puerto Rican patient is involved in witchcraft. 

1. Home remedies 

Home remedies are often used in conjunction with mainstream medicine ; 
mainstream providers should be aware that this is a possibility and should 
provide patients with an opportunity to explain what remedies they are 
using. Discussions with Puerto Ricans living in the New York/New Jersey 
area suggest that patients are likely to believe that doctors will 
disapprove of their use of home remedies; they may feel more comfortable 
being questioned by staff. Staff members, in fact, may be very 
knowledgeable about home remedies and traditional healers. In some cases 
they may be dispensing information to patients and in almost all cases they 
are a valuable source of information for the NHSC provider. 

Oils and herbs are frequently used for home remedies and in 
traditional healing practices. They may be obtained at a "botanica" or 
sent directly from Puerto Rico. Botanicas are neighborhood herb shops that 
stock herbal and spiritist remedies. The herbs sold for other than 


spiritist reasons tend to be used for nervios and digestive, respiratory, 

rheumatic, and genitourinary problems. The treatments supplied by 

botanicas are often used in conjunction with treatments supplied by 

mainstream providers. The following list includes commonly distributed 
herbs : 

Beneficial or neutral: 

a. Aqua de azahar: orange-flower water (for nerves); 

b. Tilo: linden tea (for nerves); 

c. Yerba buena: peppermint (for digestive disorders); 

d. Anis estella: star anis (for digestive disorders); 

e. Manzanilla: chamomile (for digestive disorders); 

f. Pasote: a laxative; 

g. Glycvrhva elabra: licouce (a laxative); 

Potentially harmful: 

a. Aienio artemisa: wormwood, mugwort; 

b. Laurel: laurel; 

b. Correquela. Sanguinaria: bloodroot. 

In addition to the herbs mentioned above, the following herbal 
remedies were discussed at the focus groups held by JSI as part of this 

a. A mixture of several types of oils and onions is used in a bath 
to cure a bad cold. 

b. Watercress, ground and mixed with milk and sugar, is used to 
treat tuberculosis; 

c. The peel of bitter orange is mixed with salt and cooking oil, 
left outside overnight, and eaten to treat malaria; 

d. Aqua Benditas with Flores Blancas is used in a bath for pains in 
the bones; 

e. Lukewarm water, salt, and sugar are mixed together to make a 
serum that is used to treat nerves ; 

f. A piece of grass or the leaf of a tree is moistened, sprinkled 
with salt and placed on a snake, spider or rodent bite; 

g. Cooking oil is used to massage away an empacho; 

h. A mixture of wheat flour, lemon, and sugar is used for "pujo" 
(abdominal cramps which are similiar to the pain that preceeds 
diarrhea) ; 

i. Oils are used for ear infections; 

j. Lemon and ginger teas are used to treat a cold; 


k. Palode carajkon is a herb used to treat empacho; 

1. A mixture of ground orange leaf, ginger, milk, and butter is used 
to treat colds. 

2. Traditional Healers 

There are two basic types of traditional healers, those who deal with 

supernatural illness and healing and those who treat natural illnesses. 

Within these two classifications, the following traditional healers can be 

a. Espiritista. bruieras and santeros treat illnesses that are the 
result of spiritual causes or some combination of spiritual and natural 
causes. Treatment may include purchasing candles, bathing with special 
solutions and using protective fetishes and herbs to ward off evil spirits. 
Most of the care provided by these healers is crisis oriented and lasts a 
relatively short time. Common reasons for seeking this type of care 
include insomnia, depression, nightmares, frequent crying, repeated 
ataques. suicidal tendencies, problems concerning puberty, marriage, 
menopause, chronic or terminal conditions, or other problems that another 
type of provider has not been able to cure. Although some researchers have 
drawn a parallel between psychotherapy and treatment by spiritual healers, 
an important difference is that traditional psychotherapy is based on the 
idea that individuals are responsible for and should take charge of their 
behavior while espiritismo is based on the idea that individual problems 
are the result of outside forces. Individuals effected by this type of 
illness are not responsible for their illness and are expected to be 
passive instruments of the treatment. Behavior that might appear to the 
psychotherapist to be the result of an inability to cope may be a 
culturally appropriate response for a Puerto Rican who has been influenced 
by traditional health beliefs (Comas-Diaz, 1981). 

b. Curandero is a general term used to describe healers who treat 
natural illnesses such as dislocations, empacho (indigestion, blockage), 
and mild digestive, respiratory, and rheumatic problems.. Curandero s use 
herbs (see above section), "ventosas" (cupping), and massage. Massage, and 
touch in general, are important healing technigues in Puerto Rican culture. 
Massage is used as part of home treatment and by traditional healers, often 
with special mixtures of oil. A skilled provider of care is said to have a 
gift for healing, or a way of touching that is particularly effective. 

c. Santiguadores are similiar to chiropractors in that a great deal 
of their activity is based on massage and other manipulations of the body. 
Although the word santiguador means "someone who blesses", the term has 
come to be independent of interactions with spirits. "Santiguadores" treat 
natural illnesses, particularly chronic and intestinal and orthopedic 
problems (Azziz, 1981). 


Discussions with Puerto Rican patients, staff, and nonpatients suggest 
that, not suprisingly, Puerto Ricans living in the New York/New Jersey area 


who seek care from mainstream providers would prefer to be treated by 
Puerto Rican or Hispanic providers. This preference is both because of 
language issues and because they feel that Puerto Rican or Hispanic 
providers are more likely to understand and accept their belief systems and 
use of home remedies. 

We found that language barriers are common, even when native speakers 
are available to translate . Misdiagnoses can occur because of 
mistranslations (support staff may not always know how to translate medical 
terminology) or because of cultural prejudices. Treatments may be 
improperly followed because the patient did not understand and 
prescriptions may be improperly used because the instructions were written 
in English rather than Spanish. 

There are a number of aspects of Puerto Rican culture which are 
directly related to how Puerto Ricans living in the New York/New Jersey 
area may view and utilize the mainstream health care system. 

The family plays a central role in health practices and healing in the 
Puerto Rican culture. Illness is a family affair and not just a problem o f 
the individual (Assiz, 1981). The family is an extended one including the 
grandparents, godparents, in-laws and even special friends. Decisions 
about whether a person is ill, what remedies they should use, whether they 
should seek the services of a traditional or mainstream healer, and whether 
they should follow that person's advice are all influenced by the opinions 
of family members. An example of this family influence is seen in the 
infant feeding practices of Puerto Rican mothers. The mother of a Puerto 
Rican woman who is expecting a child often plays a major role in the 
decision-making process surrounding infant feeding practices (Bryan, 1982). 
Oftentimes, the new mother will live with her mother during the perinatal 
period and the grandmother is the most important consultant in infant 
feeding matters. The use of advice about infant feeding from these 
individuals lessens with subsequent children. Still, a more subtle kind of 
communication and influence will occur. 

Another important aspect of the Puerto Rican culture is the concept of 
"respeto" (respect), although this idea is a pervasive one in the culture 
and is not important exclusively to health care. To treat others with 
respect and to be treated with respect oneself are deeply held values . The 
value of self is held very highly and lack of respect on the part of others 
may be taken very seriously and have more pervasive consequences than the 
offender would imagine. "Personalismo" is another related important 

concept in Puerto Rican culture. Personalismo in volves treating the 

patient as an individual and building rapport before begi nning the business 
of the medical encounter. Puerto Rican patients expect a provider to show 
his or her respect for them through the questions that are asked, the tone 
of voice used and the way the provider touches the patient. A touch of the 
arm, a pat on the back, or an embrace mav be highly valued, although warmth 
should not be exhibited in a casual or informal way. While most Puerto 
Ricans will respect a doctor because of his or her training and experience, 
they will also expect the doctor to project the image of a doctor. A 
provider should be well groomed and well-dressed and it should be obvious 
that he or she is a doctor (white coat, black bag). The image the 
physician projects should require and deserve respect. 


One area where it may be particularly important for a provider to show 
respect to the Puerto Rican woman is during exams for gynecological 
problems. Puerto Rican women may have great feelings of shame and 
embarrassment associated with sex and the female organs . In one study 
concerning the contraceptive methods of several ethnic groups, Puerto Rican 
women refused to label any parts of the female body between the navel and 
the thighs (Scott, 1975). Members of the Puerto Rican patient discussion 
groups held as part of this study reiterated this feeling of great shame 
and embarrassment when undergoing pelvic exams. They expressed 
appreciation for physicians who tried to put them at ease during the exam 
by explaining what procedures they were doing and the reasons for them. 

The same aforementioned study found that Puerto Rican women are more 
likely to be using no contraceptive method at all, and if they are, it is 
more often sterilization by tubal ligation. This use of tubal ligation for 
contracepton has been found by other authors among the New York Puerto 
Rican population and anecdotally by family planning personnel and 
researchers in the New England area. One reason given for the pervasive 
use of tubal ligation is that it is only "sinning" once, whereas most other 
methods involve sinning with each sexual act. The research of the 
contraceptive study also found that methods that alter the monthly flow, 
such as the pill and IUD, are not as acceptable because a normal monthly 
flow is believed to rid the body of "unclean" blood and is therefore 
healthy and desirable. An interruption or change in this flow is 
considered unhealthy and potentially harmful. 

Another way that mainstream providers can show their respect for 
Puerto Rican patients is to show interest in the patient's opinion about 
his or her illness. Mainstream providers may find that Puerto Rican 
patients have had and may be acting upon a preliminary diagnosis which is 
based on a family member's opinion or the advice of a traditional healer. 
Although Puerto Rican patients may expect providers to listen to their 
opinion, they will not necessarily expect the provider to agree with the 
diagnosis. A physician should work hard and earn the fee by ordering tests 
and medicines; asking questions is not enough. Conversely, some Puerto 
Rican patients will think that a provider who asks a lot of questions is 
incompetent. Most Puerto Rican patients often want to talk about a range 
of issues that may not be directly related to the problem that they are 
seeing the provider for but which are viewed as critical by the patient. 
The mainstream provider may feel that the peripheral issues are irrelevant. 
Nonetheless, if time is available, listening to the patient's concerns may 
increase the patient's respect for the provider and thus improve the 
patient's compliance with the provider's treatment plan. 

Some research ha6 shown that Puerto Rican patients and more generally, 
Hispanic patients, may experience and present symptoms differently than 
members of other cultures. When experiencing an illness, they may perceive 
more symptoms and express a greater diversity of complaints than do 
cultural groups of western and northern European origin (Weaver and Sklar, 
1980). The mainstream provider may view this behavior as dramatization of 
the illness and therefore as illegitimate illness behavior. The behavior 
may confuse a mainstream health provider who may think that the patient has 
an emotional problem when, in fact, the behavior can be attributed to 
cultural norms. 


A related issue that was raised in our discussion groups with Puerto 
Rican staff members was that Puerto Rican patients may have difficulty 
describing the type of pain that they are experiencing . This, of course, 
may make it difficult if not impossible for the provider to accurately 
diagnose the problem. The staff felt that the commumication problem went 
beyond a language barrier to a different perception of the various types of 
pain and of how that pain can be communicated. 


As previously stated, it would be inappropriate for a NHSC provider 
working with a Puerto Rican population to assume that all, most, or even 
the majority of his or her Puerto Rican patients' health beliefs and 
practices are described in the preceding pages. With this point in mind, 
and recognizing that each provider has an individual style of practice, the 
following list includes examples of situations or issues that might arise 
when providing health care services to Puerto Rican patients or working 
with Puerto Rican staff members. 

1. A Puerto Rican patient may be already treating an illness 
before coming to the mainstream provider and may continue to 
use a variety of providers while being treated by a 
mainstream provider. Treatment may be based on the opinion 
of family members or on a diagnosis made by a traditional 
healer. Information about other remedies should be 
solicited directly by the provider or with the assistance of 
a staff member. 

2. If a mainstream provider is hesitant or unsure about a 
patient's illness, that patient may seek care from a 
traditional healer. 

3. Mainstream providers should be aware that the family plays 
an important role in diagnosing and treating illness. It is 
likely that any diagnoses that are made and any treatments 
that are prescribed will be discussed and interpreted by 
more people than just the person being treated. In some 
cases it may be appropriate to include the important family 
member in the diagnosis and treatment sessions or to include 
traditional remedies such as massage or herbal teas in the 
treatment plan. 

4. Mainstream providers might make an effort to touch the 
patient several times during the medical encounter. A 
handshake and a touch on the shoulder may go a long way 
toward improving the quality of the encounter. In addition, 
learning and using a few words of Spanish will lead to 
greater rapport between the NHSC provider and the Puerto 
Rican patient. 

5. A Puerto Rican patient may expect that a thorough physical 
examination be given for any problem. 


6. Puerto Ricans may be distrustful if a lot blood tests are 
ordered. In any event, providers should explain what 
laboratory tests are being given, and why. 

7. The provider may want to make sure that instructions for 
treatment are given and written down in Spanish if the 
Puerto Rican patient is not fluent in English. 

8. A provider may want to determine whether an individual 
practices the hot/cold system. This may be particularly 
important for pregnant or lactating women. 

9. The provider should not assume that his or her Puerto Rican 
patients believe in the spiritual causes or cures of 
illness. In most cases, the provider should not raise the 
issue directly unless the patient has expressed such a 
belief. Staff members may play a useful role in acting as 
intermediaries in such cases. 

10. Providers should be aware that the way that they are dressed 
and their cleanliness will influence the seriousness with 
which their Puerto Rican patients take their advice. 



Aiken, Linda H. (1976). Chronic Illness and Responsive Ambulatory Care. 
In The Growth of Bureaucratic Medicine , ed. David Mechanic, New 
York, Wiley. 

Alers, Jose Oscar (1978). Puerto Ricans and Health. Findings from New 
York City . Monograph No. 4, Hispanic Research Center, Fordham 
University, Bronx, NY. 

Azziz, Ricardo (1981). The Hispanic Patient. Pennsylvania Medicine 

Bowering, Jeanet et al (1978). Infant Feeding Practices in East Harlem. 
Journal of the American Dietetic Association . 72 (February). 

Bryant, Carole Anne (1982). The Impact of Kin, Friend and Neighbor 
Networks on Infant Feeding Practices. Social Science and Medicine 

Comas-Diaz, Lillian (1981). Puerto Rican Espiritismo and Psychotherapy. 
American Journal of Orthophvchiatry 51, No. 4. 

Delgado, Melvin (1979). Herbal Medicine in the Puerto Rican Community. 
Health and Social Work 4, No 2. (May). 

Galli, Nicholas (1975). The Influence of Cultural Heritage on the Health 
Status of Puerto Ricans. The Journal of School Health 45, No. 1 
(January) . 

Garrison, Vivan (1977). Doctor, Espiritista, or Psychiatrist: Health 
Seeking Behavior in a Puerto Rican Neighborhood of New York City. 
Medical Anthropology 1 ,2. 

Gaviria, Moises and Ronald M. Wintrob (1976). Supernatural Influence in 
Psychopathology. Canadian Psychiatric Association Journal 21, No. 

Harwood, Alan (1971) The Hot-Cold Theory of Disease: Implications for 
Treatment of Puerto Rican Patients. Journal of the American Medical 
Association 216. 

Harwood, Alan (1981). Mainland Puerto Ricans. In Ethnicity and Medical 
Care . ed. Alan Harwood, Cambridge, Massachusetts: Harvard 
University Press. 

Haynes, R. Brian (1976). A Critical Review of the "Determinants of 
Patient Compliance with Therapeutic Regimens". In Compliance with 
Therapeutic Regimens , ed. David L. Sackett and R. Brian Haynes. 
Baltimore: Johns Hopkins Universtiy Press. 


(Bibliography/Puerto Rican, cont.) 

Leiberman, Leslie Sue (1979). Medico-Nutritional Practices Among Puerto 
Ricans in a Small Urban Northeastern Community in the United States. 
Social Science and Medicine. 138. 

Lubchansky et al (1970). Puerto Rican Spiritualists View Mental Illness: 
The Faith Healer as Paraprof essional. American Journal of Psychiatry 
127, No. 3. 

Mumford, Emily (1973). Puerto Rican Perspectives on Mental Illness. Mt. 
Sinai Journal of Medicine 40. 

Padilla, Elena (1958). Up From Puerto Rico. New York: Columbia 
University Press. 

Ruiz, Pedro and John Langrod (1976). The Role of Folk Healers in 
Community Mental Health Services. Community Mental Health Journal 
12, No. 4. 

Scott, Clarissa S. (1974). Health and Healing Practices Among Five 
Ethnic Groups in Miami, Florida. Public Health Reports 89, No. 6 
(Nov/Dec.) . 

Scott, Clarissa S. (1975). The Relationship Between Beliefs About the 
Menstrual Cycle and Choice of Fertility Regulating Methods Within 
Five Ethnic Groups. International Journal of Gynecology and 
Obstetrics 13. 

Weidman, Hazel H. (1978). Miami Health Ecology Project Report: A 
Statement on Ethnicity and Health. Department of Psychiatry, 
University of Miami School of Medicine (Mimeo). 

Wheeler, Madeleine and Sanober Q. Haider (1979). Buying and Food 
Preparation Patterns of Ghetto Blacks and Hispanics in Brooklyn. 
Journal of the American Dietetic Association 75 (November). 

Yohai, Fanny (1977). Dietary Patterns of Spanish Speaking People Living 
in the Boston Area. Journal of the American Dietetic Association 71. 


After you have had a chance to read and use the booklet, we would 
appreciate your comments about the usefulness of the booklet and the 
medical vocabulary guide. Please take a fev minutes to complete this 
evaluation and return it to: 

Regional Program Consultant, NHSC 

26 Federal Plaza 

Room 3302 

New York, NY 1027 8 

A. Common Health Care Beliefs and Practices of Puerto Ricans Living in 
the New York/New Jersey area 

1. Did the information in this booklet increase your 
knowledge about the health beliefs and practices of 
Puerto Ricans? 

2. If you have begun practice with a Puerto Rican 
population, have you found the information contained in 
this booklet to be useful to you? 

3. Which sections were of the most interest and/or use to 


4. Is the booklet too long, too short, or about the right 

5. How did you read the booklet? Did you read the entire 
booklet, selectively read the parts of most interest to 
you, only read the underlined statements, etc? 

6. Do you have any comments or suggestions for improving 
the format or content of this booklet? 

B. Que Paso? 

1. Have you used the booklet? 

2. If so, have you found the booklet helpful? 

Well organized? 


Easily understandable? 

3. Which sectionCs) are you most likely to use? 

4. How has using this book affected your relationship with your 

With the staff that you work with? 

5. Have you found other books of this type that are more 
appropriate for your setting? Please list them (include name 
and source). 



This booklet on the health beliefs and practices of Haitians living 
in the New York/New Jersey area is divided into four major sections. The 
first deals with concepts of illness and disease, the second with the use 
of home remedies and traditional healing practices, the third with 
attitudes toward and use of mainstream health providers and the fourth with 
implications for effective treatment of Haitians by non-Haitian, mainstream 

As discussed above, information for the booklet was gathered from 
three sources; the booklet is an attempt to integrate the information 
gathered from these sources and to provide NHSC practitioners with 
information they can use to provide culturally sensitive health care to 
Haitian patients. A caution is worth repeating at this point: providers 
should not assume that all, or even most, Haitian patients ascribe to the 
beliefs and practices discussed in the following pages. Rather, the 
information should point to particular questions that providers might ask 
and to particular symptoms or conditions that they might watch for. In 
addition, the results of the focus groups we held with NHSC sites' patients 
and staff members lead us to conclude that patients are more likely to 
follow the treatment recommendations of providers who have shown some 
interest in and consideration for their cultural beliefs and practices. 


Many Haitians believe that illness is the result of either natural 
causes or supernatural causes. Natural diseases occur frequently and are 
usually over with fairly quickly. They are caused by purely natural 
events: a person gets a cold; a worker is careless and cuts his finger 
with a machete; a market woman carries an excessively heavy load and has a 
miscarriage. Natural illnesses are divided into categories dealing with 
blood, gas, human milk, bone displacement, disease movement, and hot/cold 
disequilibrium. Supernatural diseases occur infrequently and appear 
without any warning. They are believed to be caused by angry voodoo 
spirits. Although many Haitian patients and staff members from New York 
and New Jersey health centers expressed knowledge of spiritual causes and 
cures of illness, few indicated a belief in or practice of witchcraft or 
voodoo. Many expressed resentment that American health practitioners 
assume that all Haitians believe in and practice voodoo, that they imagine 
illnesses, and that they are all "a little bit crazy." 

Irrespective of their belief in voodoo or witchcraft, belief in God 
and in the healing power of that faith seems to be an important part of 
Haitian culture. God can heal by working with the healer (the medical 
doctor or the traditional healer) or through the sick person's dreams. 
Faith in God and faith in the healer are both critical. 

Another health belief that has important implications for primary care 
providers is that many Haitians believe that a thin person is apt to be 
sickly and a heavier person (by mainstream standards) is more likely to be 


happy and healthy. The Haitian diet tends to be high in salt and fats; 
common foods include salted and fatty meats, rice, beans, cornmeal, 
potatoes, and plantain. Haitians may resist suggestions that they reduce 
or change the types of foods that they eat (e.g. reduce salt or fats). 
Haitian women may gain a considerable amount of weight during pregnancy 
because they are encouraged to "eat for two." Providers working with 
infants should be aware that babies may be given table food very young, 
often by their fourth month. 

In addition to the type of natural illnesses that would be recognized 
both by traditional and mainstream health practitioners, there are several 
illnesses and beliefs in the Haitian culture that do not have equivalents 
in mainstream medicine: 

1. Perdition 

Perdition is an illness where a woman has a fetus trapped in her womb, 
often for many years, before eventually delivering the child. Perdition is 
believed to be the result of natural causes such as walking barefoot on wet 
ground or carrying too heavy a load, although it can also be the result of 
a spell being cast on the unborn child's family. It is believed that at 
some time during pregnancy some force effects the child and its development 
is reversed until it is a tiny speck. The fetus still remains in the womb 
and the woman is considered pregnant. A woman who is in perdition will 
menstruate, although the flow will be less than usual. Haitian women who 
believe in perdition will insist that this is not a miscarriage, which they 
recognize as something different from perdition. As long as the woman is 
in perdition, the child remains inside her. When she clears up her 
problem, the same child starts growing again and will emerge nine months 
later, none the worse for the months or years spent dormant in the mother's 
womb. A female focus group participant asserted, with no hesitation and 
with no sense of inappropriateness, that she spent eight years in her 
mother's womb before being born. Her legal father was her mother's former 
husband, who had impregnated her mother and then left her eight years 
earlier. Other focus group participants knew of similar circumstances. 
The idea of perdition is apparently deeply rooted in Haitian culture and 
serves several purposes: 

a) It reduces the stigma of being barren or sterile; a woman 
in perdition is not infertile; her pregnancy is "on hold." 
A woman in perdition has a higher status than a non-pregnant 

b) A woman in perdition is more secure in her conjugal union. 
Sterility is grounds for dissolving a union; a woman in 
perdition is carrying a man's child and he is responsible to 

A Haitian woman who states that she has been pregnant for more than 
the usual number of months is not biologically naive or suffering from 
psychotic delusions. Rather. she is simply using a common, culturally 
acceptable explanation for her condition. It should not be assumed that 
she needs to see a psychiatrist. 

1 1 1-3 

2. Blood Classification 

Blood plays a central part in the Haitian concept of illness, which 
may explain why some Haitians are suspicious of a lot of blood tests. 
Haitians may feel that losing blood will make them weak or that the blood 
could be used for voodoo purposes. One focus group participant implied 
that doctors who order a lot of blood tests may be selling the blood for 
profit. The blood is believed to be the main determinant of whether a 
particular person's body is hot, cold or somewhere in between (see section 
below on hot/cold classification system). Table 1 describes the various 
types of blood and their causes and/or effects; information for this table 
is taken from Laguerre (1981). 

These concepts of blood also influence the choice of a method of birth 
control. Scott (1975) reports that Haitian women, as well as women from 
other cultures, are reluctant to use a method of birth control that effects 
menstrual flow. The IUD is an example as it often increases the flow, and 
the Pill because it often decreases the flow. Menstruation is viewed as a 
natural, healthy event and changes in the menstrual flow may indicate that 
something is wrong. 

3. Beliefs about Bad Blood. Rising Blood, and Insanity 

Bad blood, which is usually the result of blood mixing with some other 
substance, is a commonly believed cause of a variety of illnesses. A 
person who becomes violently angry is said to "make bad blood." It is 
believed that when a person loses his or her temper seriously, blood will 
rise up into a person's brain, perhaps causing insanity if the attack is 
sufficiently strong. Any violent emotion — anger, grief (e.g., at the news 
of a sudden death of a loved one), or sudden terror — is believed to cause 
blood to rise to the head and to be capable of damaging one's blood for an 
indeterminate period of time. This pattern of damaged blood appears to be 
especially frequent and of especially deleterious consequences in females. 
Many folk remedies applied during fits of violent emotion (e.g. , tying the 
head of the patient with a kerchief, pouring coffee on the crown of the 
head) have as their stated function the return of the blood to its normal 
position and the prevention of its spoiling. 

A patient may feel a non-specific illness which she tries to explain 
to a physician. It may very well be that the patient assumes that this 
illness may be related to a spell of anger, grief, or fear which she had in 
the past and which reduced the quality of her blood. 

4. "Rising Milk." "Spoiled Milk." and "Milk Mixed with Blood" 

Female milk is another substance believed vulnerable to displacement, 
improper mingling, and permanent, irreversible spoiling. There are 
particularly strong cultural injunctions against causing a lactating woman 
to lose her temper as she may harm either herself or her child. At worst, 
her milk may physically rise to her head and enter her brain, causing 
violent behavior and perhaps insanity. Somewhat milder in its consequences 
for the woman herself but perhaps not for her child is the danger that 
the milk may become mixed with the woman's blood and be permanently spoiled 




Blood Condition 

Sancho: hot blood 

















cold blood 

thin blood 
weak blood 

thick blood 

yellow blood 
dark blood 

dirty blood 

spoiled blood 


Cause and/or Effect 

high fever 
intellectual activity 
physical exercise 
after childbirth 

quiet rest 


physical weakness 
mental weakness 


bile flowing in blood 

patient will soon die of an 
incurable disease 

venereal disease 
skin eruptions 

venereal disease 
skin eruptions 


for the duration of that nursing cycle. It is believed that the spoiled 
milk would poison the child; a child is immediately weaned if the mother 
has had her "milk spoiled." 

Just as perdition (mentioned above) serves explanatory purposes for 
members of the culture, so also does the idea of "spoiled milk." In its 
earlier form in rural Haiti, this belief appears to serve as the rationale 
for giving the lactating woman 12 to 18 months of rest and special 
treatment. Spoiled milk also, quite conveniently, permits the mother to 
resume her economic activities without falling under public censure of 
being an irresponsible mother. 

5. The Wandering Womb 

The concept of a displaced organ causing problems is seen very clearly 
in the beliefs surrounding a woman's immediate postpartum experiences. 
Interview findings indicated the continued existence among immigrants in 
New York and New Jersey of a belief that has been observed in Haiti 
concerning the behavior of a womb from which a child has just been born. 

A physical and emotional attachment is believed to exist between the 
womb and the child. When the child exits the womb, the womb senses a 
sudden, radical, violent emptiness. In a panic the womb begins moving 
frantically all over the woman's body searching desperately for the 
occupant that has suddenly departed. The womb is believed on some 
occasions to make its way into one of the limbs of the new mother. 

The weakness, dizziness, confusion, and disorientation that many women 
feel after childbirth is generally attributed to the effect of a displaced 
womb that has moved about looking for the child. The situation can be 
remedied by the massaging of a skilled granny midwife. This massaging 
serves the dual function of, first, locating the position of the displaced 
womb and, second, gently easing it back into its proper position. 

Also of critical importance to the placating of the frantic womb is 
filling it with rich food. The one occasion on which a woman is pampered 
with abundant food in rural Haiti — including even the killing of a family 
animal (usually reserved only for cash sale in the market) — is on the four 
or five days immediately following delivery. The midwife will have 
restored the frantically searching womb to its rightful position. But it 
is the responsibility of the woman's husband and family to remove the empty 
feeling of the womb by filling it with food. 

6. Gas 

Gas is also important as a cause of illness, particularly pain and 
anemia. Gas can enter the body through the ears and mouth and lead to pain 
in the head. stomach, legs (rheumatism), back, and shoulder. Gas may be 
caused by eating leftovers. A woman who has just given birth may wear a 
tight belt around her waist to keep gas from entering her body. Gas may be 
treated with tea made from garlic, mint and cloves or by eating plantain or 


7. Hot-Cold Theory of Disease 

The hot-cold classification system plays a role in the Haitian system 
of health beliefs and behaviors, although it is unclear how strictly or how 
frequently the system is applied by Haitians living in the New York/New 
Jersey area. Essentially, the hot-cold theory divides illnesses, 
medications, and foods into hot and cold categories. Good health is the 
result of maintaining a proper balance between hot and cold states. The 
designation of "hot" or "cold" is not related to the temperature of the 
food or medication although temperature may be related to beliefs about how 
a person develops a particular illness. There may also be individual 
variation in the classification system, depending on how the person 
responds to specific foods or medications. 

In the Haitian hot-cold system, classification of body states is 
related to sex and reproduction. For example, females are always "warmer" 
than males and pregnant women or women who have recently given birth are 
"warmer" than other women. The first three months postpartum is the 
"hottest" state and may be a period of relatively severe dietary 
restrictions; only cold or cool foods (such as certain fruits, cashew 
nuts, and cassava bread) may be eaten during this period. 

One researcher (Weidman, 1978) has found that some Haitian mothers 
will give a type of milk of magnesia (classified as a "cold" remedy) to 
cure diarrhea with fever (classified as a "hot disease"). This treatment 
in many cases, will worsen the child's illness. In addition, Haitian 
mothers may resist giving children with diarrhea an oral electrolyte 
solution alone because they may feel that the baby will die without food. 


Our research strongly suggests that Haitians who use traditional 
healers and remedies are likely to simultaneously seek out the advice of 
traditional and mainstream providers and to use traditional and mainstream 
remedies together. Therefore, it is important that mainstream provider be 
aware of the types of providers and remedies their patients may be 
using . 

1 . Home Remedies 

Discussions with Haitian patients and staff from New York/New Jersey 
area health centers indicate that leaves, herbs and oils are commonly used 
for self treatment and for treatment by traditional healing experts. 
Leaves may be boiled, used for a bath, or placed directly on the injured 
areas. Oils may be used for massage. Traditional remedies may be 
purchased in botanicas or brought directly from Haiti. Some examples of 
traditional home remedies which were mentioned in our discussion groups 

a) asorousi : a tea boiled from leaves that will restore 
person's appetite. 


b) fev korosol : a child's head is bathed in this to cure 

c) a variety of leaves are used for gas or if a child's 
stomach is swollen. 

d) loks (purgatives) may be given to a baby as a first food to 
expel the meconium. Castor oil is frequently used; it is 
stirred into hot water with salt and sugar. This mixture 
is given to the baby once a day for three days. The lok 
works when the mother sees green stains; this means that 
the child is cleaned out. 

e) warm oils are used in combination with massage to solve a 
number of problems from aching or sprained bones to 
displaced organs. 

Table 2, based on information taken from Clerisme (197 9) includes 

substances that are used in Haitian folk medicine. There appears to be a 

fairly consistent use of the plants based on their perceived healing 

2. Traditional Healers 

There are four basic types of traditional healers in Haiti: 

a) Docteur-feuilles or bocars : leaf doctors who treat patients 
with medicinal plants, herbs and roots, occasionally along 
with mystical ritual. Leaf doctors are generally called on 
to perform certain standard services such as bone setting 
and burn treatment. One of his major theoretical tools is 
the concept of the "foulay" — an internal blockage of blood 
that forms clots which the leaf doctor can dissolve by a 
combination of massage and herbal medicines. Droquistis 
also fit into this category; they bottle and sell potions. 

b) Houngans/mambo s : voodoo priests/priestesses who practice a 
combination of magic and religion. Voodoo is a complex of 
religious beliefs, practices and specialists which assumes 
the existence and intervention of a number of spirits in 
human affairs. The major focus of voodoo in rural Haiti is 
the healing of illness. In the United States, the major 
focus of voodoo may be to make someone ill or "work with the 
left hand." Voodoo is, in effect, a folk medical system 
which differs from other systems in that the illness-causing 
agents are believed to be conscious, active spirits rather 
than natural forces. 

c) Sages-femmes/matrones/fam sai: lay midwives, wise women, 
usually women without medical training, who perform 
deliveries and other work with women. 

d) Piquristes : people who give shots and apply dressings. 
These healers usually have some technical experience and 











Swietemia Mahogani 

Bark, enriches 



Bambussa vulgaris 
vel Arundian 

An infusion of 
the leaves is 
used to control 
coughs and to 
cure colds. 

Bo is de Chene 

Oak tree 

Catapa longissimue 


Wild calabash Cressentia Cujete 

An infusion of 
the leaves is 
used to cure 
cramps and fever. 

A syrup made of 
the calabash pulp 
is used to melt the 
"deposits" in 
"foulaille." It 
is also used to 
prevent "foulaille" 
after a contusion. 

Avocat Marron 

Cresson Marron 

Wild avocado 



An infusion of the 
leaves that relieves 

A tea made from 
these along with 
the leaves of 
eayemite and papaya 
stimulate breast 
milk of a nursing 

Graine de 
Cotonnier Violet 

Cotton seed 


Roasted cotton seeds 
prepared like coffee 
stimulate breast milk 

Pistache Marron 

Wild peanut 


An infusion made 
of the leaves 
combined with those 
of laiteron is used 
to treat grippe. 
Alone, it is said 
to prevent 

I II- 9 

TABLE 2 (continued) 






Thym Grande s 


Thymus vulgaria 

Saf ran 


Curcuma longa 


Infusions of 
citronnella leaves 
are taken to cure 
gas or stomach 
cramps. The leaves 
are also used in 
soothing baths. 

An infusion made 
from 2-3 thyme leaves 
is good for all sorts 
of pain, fever, 
chills, grippe or 
cramps. To relieve 
a headache, several 
leaves are inhaled. 

A small piece of 
the root soaked in 
a glass of cold 
water is used in 
cases of fever, 
particularly when 
accompanied by 


tend to be the youngest of the traditional healers. It is 
interesting to note that Haitian focus group participants 
expressed a preference for injections and are suspicious of 
all the pills that are prescribed in the United States. 
They place a great deal of confidence in vitamins that are 
given by injection. 

There is some overlap in categories; many of the houngans , mambos, 
and sage-f emmes also work as docteurs-f euilles . In Haiti, the healers are 
respected and loved in their communities yet tend to be modest about their 
role in influencing the members of their community. Most are illiterate, 
over forty and poor, although some of the healers who specialize in magic 
may be quite wealthy in comparison with the other members of their 

Docteurs-f euilles and matrones generally learn their trade from 
relatives who pass the practice on to them. Most of the training is 
observational and consists of hands-on experience, although recipes are 
also passed along. Piquristes may receive training in missions or modern 
medical facilities, which increases their credibility and increases the 
probability that they will refer patients with serious illnesses or wounds 
to these facilities. Houngans start their practice by buying loas or 
spirits or by being claimed by the loas of an ancestor. The process of 
becoming a houngan is long and complicated and involves a succession of 
ritualistic ceremonies. Remedies are generally given to the houngans by 
the spirits although some houngans learn the recipes from their relatives 
with whom they apprentice. In such cases, the spirit of the relative is 
passed on to the new houngan in a ceremony after the relative's death. 

As mentioned above, the Haitian patients and staff members who 
participated in our discussion groups expressed some knowledge of voodoo or 
witchcraft but said that it was not widely practiced in their neighborhoods 
or among their friends and relatives. However, another type of 
traditional healer — the lay midwife or wise woman — was discussed to a 
significant degree by the participants. Although the participants were 
somewhat reluctant to say directly that there are unlicensed Haitian 
midwives who perform services in the New York/New Jersey area, it became 
clear from what was said and the way it was said that if a lay midwife is 
needed, she can be easily found. Midwives are highly regarded; they are 
believed to possess a significant amount of knowledge and skills . They 
are particularly skilled in areas related to childbirth, massage and the 
preparation of herbal remedies. Specific examples of lay midwifery skills 
are listed below: 

a) They can tell a new mother when her milk and blood have 
mixed and can give a special drink and ointment to solve the 

b) They understand perdition and under certain circumstances 
can release the child. 

c) A Haitian belief is that after birth a woman's womb can be 
dislocated which can give the woman swollen feet, among 
other problems; a midwife can solve this problem. 


d) Lay midwives are experts at massage for both diagnostic and 
healing purposes. Their fingers may probe deeply to receive 
signals about harmful gaps between two bones that should be 
joined, the absence of an organ that should be in a 
particular place, or the presence of an organ in one place 
when it should be in another. Once problems have been 
identified, massage is used to nudge the organs or bones 
back into place. 

e) Lay midwives may play an important role in the immediate 
post-partum period. Haitian tradition prescribes a long 
recovery period for a woman who has just delivered a baby . 
She may not be allowed to leave her house or undertake any 
activities for several weeks or months. The midwife may 
make special teas to clean out the woman's stomach, prepare 
special baths and massage the woman's body with special oils 
so that it returns more quickly to its pre-pregnancy state. 

Of particular significance to non-Haitian mainstream providers serving 
Haitian patients are the norms governing what is considered appropriate 
behavior on the part of Haitian folk healers, including lay midwives and 
leaf doctors. There is not an automatic assumption that the traditional 
healer is competent; it is known that some healers are more competent than 
others. It is also recognized that even competent healers may not be able 
to find the cause of a particular illness, although rarely will a healer 
admit his or her inability to diagnose and cure a problem. A healer is 
expected to appear confident of his or her abilities at all times. 

One common "test" which patients apply to their healers in Haiti and 
other parts of the Caribbean is to determine if the healer is able t o 
diagnose the problem with as little help from the patient as possible. The 
ideal diagnostic procedure is for the healer to examine the patient with 
no questions asked and to describe to the patient, after this examination, 
exactly what pain or illness motivated this visit by the patient, and what 
the underlying cause of this pain is. 

Conversely, a folk healer may be suspected of quackery if he begins 
soliciting detailed information from the patient concerning symptoms 
(although questions concerning diet seem to be appropriate). The patient 
may feel that he is "doing the doctor's job for him." 

Healers have several standard examination procedures. Mention has 
already been made of the massaging techniques of the midwife. These 
techniques have also been mastered by competent leaf doctors. In addition, 
a skillful leaf doctor is supposed to be able to examine a person's 
fingernails. There is a folk understanding of the human body by which all 
nerves running through the body are believed to have terminals in the ten 
fingernails. By examining irregularities in the texture or coloring of the 
fingernails, the skillful leaf doctor will be able to identify, for 
example, where a "foulay" (blood blockage) may be affecting the patient's 
body. Or a leaf doctor should be able to look carefully at a patient's 
eyes and detect signs of "febless" (generalized weakness). All of this is 
ideally done with as little questioning of the patient as possible. 



As can be seen from the preceding, Haitian patients expect certain 
behaviors from healers in the process of diagnosing an illness. The 
confidence-inspiring healer is one who receives the patient with several 
moments of conversation about the patient's life in general and who quickly 
proceeds to a straightforward, confident, hands-on examination of the 
patient. an examination that proceeds with minimum of suspicion-evoking 
questioning by the healer. It is the healer, not the patient, who is 
supposed to say what is wrong. 

Haitian patients may know in theory that modern physicians "are 
supposed to" proceed differently when they are diagnosing a patient. But 
comments that came out in several interviews indicate that at least some 
patients entertain misgivings about the competence of a doctor whose 
physical examination of a patient is cursory and whose main diagnostic tool 
seems to be a long series of questions posed to the patient, particularly 
questions about a patient's family history. A folk healer who makes 
diagnoses in this manner might be dismissed as a fake. 

Several comments in the interviews indicate that Haitian (and 
Hispanic) physicians practicing in the islands and in New York and New 
Jersey recognize these expectations and adapt their own behavior 
accordingly. Some are reported to be willing to prescribe traditional 
remedies if they seem to be appropriate and even to send the patient to a 
traditional healer if he, the physician, suspects a traditional malady. 
But even those who do not go this far, or who may even denounce folk 
healers as charlatans, apparently do at least adopt some of the 
confidence- inspiring diagnostic style of these popular folk healers. 

As mentioned in the previous section, Haitian patients may be 
simultaneously using traditional and mainstream health practitioners. As a 
partial explanation for the duality, the discussion group participants felt 
that most American, mainstream health care providers do not know about, 
understand, or accept Haitian theories of illness and traditional healing 
practices. In fact, many Haitians think that American-trained providers 
consider all Haitians crazy, think they imagine illnesses. As a result of 
this perception, Haitians may delay seeking care, may hide their use of 
traditional healing substances and practices from the mainstream providers, 
and may simultaneously seek the advice of a number of providers. 

Group participants also felt that only traditional healers have the 
knowledge and the skills to treat particular illnesses so that it doesn't 
make sense to take these complaints to a mainstream provider . 
Communication can break down between non-Haitian providers and Haitian 
patients both because of language barriers and because of their very 
different ideas about the existence and causes of particular illnesses. As 
with each of the cultural groups we included in this study, Haitian 
participants respected and appreciated mainstream providers who made an 
effort to learn about and respect their cultural beliefs and practices. It 
is not necessary for the providers to agree with the beliefs and practices , 
but it is important that they not criticize them. Similarly, providers who 
make an attempt to speak a few words of the patient's language are highly 
regarded. It is not as important that the providers be fluent in the 
language, -just that they try. 



As previously stated, it would be inappropriate for a non-Haitian NHSC 
provider working with a Haitian population to assume that all, most, or 
even the majority of his or her Haitian patients' health beliefs and 
practices are described in the preceding pages. With this point in mind, 
and recognizing that each provider has an individual style of practice, the 
following list includes examples of situations that might arise when 
providing health care services to Haitian patients. 

1. As with any cultural group, Haitians have a coherent system of 
health beliefs and practices. Without having to accept those 
beliefs as "true," mainstream providers should attempt to 
recognize and respect their existence and their influence on a 
Haitian patient's successful use of the mainstream health care 
system. A person who uses and responds to the mainstream health 
care system based on his or her cultural beliefs may behave in a 
way that is not understandable or appropriate to the mainstream 
provider. It is critical that a mainstream provider recognize an 
inappropriate "cultural fit" for what it is and not interpret it 
as craziness, stubbornness, or stupidity on the part of the 

2. Spiritual causes and cures of illness appear to be a sensitive 
issue among Haitians living in the New York/New Jersey area. 
Although most Haitians we spoke with are familiar with the basics 
of voodoo, few openly accept or practice it. Haitian patients and 
staff may be very sensitive to the fact that American health 
providers think all Haitians believe in voodoo and are "a little 
bit crazy." Providers should, of course, avoid this 
generalization; in most cases, it would be best if the health 
provider did not raise the issue at all unless the patient 
indicates some belief in voodoo. 

3. A Haitian woman who states that she has been pregnant for longer 
than the normal period may be expressing a belief in perdition. 
This will probably not come up directly as most of the women will 
recognize that American providers do not know about or accept the 
idea of perdition. 

4. Blood plays a central role in the Haitian health belief system. 
When ordering blood tests, the provider should explain why the 
test is being given. Also, Haitian women may be reluctant to use 
either the Pill or the IUD because of the effect of these methods 
on blood flow. 

5. A variety of traditional practices may influence a woman's 
treatment of herself and her child in the immediate post-partum 
period. Purgatives are commonly given to newborns and the 
mainstream provider may want to spend additional time explaining 
the danger of this practice or discussing substances that could be 
used instead of castor oil. 

6. The provider should realize that a woman who stops breastfeeding 
may do so because she believes that her blood has mixed with her 


milk and spoiled it. A mainstream provider may not be able to 
reassure the woman to her satisfaction, but knowing the possible 
reason may help the woman and the provider communicate better. 

7. A new mother may resent the suggestion that she resume normal 
activity soon after birth; Haitian tradition prescribes a long 
recovery period. Also, a woman may believe that her womb has been 
displaced, which may affect how the provider chooses to conduct 
the post-partum exam. 

8. Haitian patients may be seeing a variety of practitioners for the 
same problem. NHSC providers may want to ask patients about other 
medicines that they've tried to make sure that their prescription 
is not contraindicated. 

9. Teas are commonly used as home remedies. Discussions with Haitian 
staff members might provide useful information about home remedies 
that are potentially dangerous. More generally, staff can be 
excellent resources for the provider and their opinions and 
knowledge should be solicited. 

10. Traditional Haitian healers tend to rely more on physical exams 
and less on questioning than American-trained mainstream 
providers. In order to make their Haitian patients more 
comfortable and less suspicious, providers may want to emphasize 
the exam more and explain why particular questions are being 
asked. At the least, the provider should understand that 
hostility toward questioning may be culturally-based. 

11. Haitians may prefer injections to pills and may place a high value 
on vitamin injections. 

12. As with each of the groups studied, Haitians tend to appreciate 
and respect a provider who makes the effort to learn a few words 
of Haitian Creole and something about Haitian traditional health 
beliefs and practices. 

13. Providers should be aware that infants may be given fatty, salty 
table foods at a very early age. 

14. Pregnant women may need to have their weight gain closely 
monitored; special nutrition counseling might be necessary. 

15. Obese, hypertensive, or diabetic Haitians are likely to resist 
making changes in their diets. 

1 11-15 


Buchanan, S.H. (1982). Language and Identity: Haitians in New York City. 
International Migration Review 13, No. 2. 

Chen, Kwan-Hwa and Gerald F. Murray (1976). Truths and Untruths in Village 
Haiti: An Experiment in Third World Survey Research. In, Culture, 
Natality and Family Planning. ed. Marshall. Carolina Population 
Center, University of North Carolina. 

Clerisme, Calinte (1979). Recherches sur la Medecine Traditionnelle. 
Division d'Hygience Familiale, Department de la Sante, Publique et de 
la Population. 

Coreil, Jeannine (1983). Allocation of Family Resources for Health Care in 
Rural Haiti. Social Science and Medicine . 17, No. 11. 

Dempsey, P. A. and T. Geese (1983). The Childbearing Haitian Refugee, 
Cultural Applications to Clinical Nursing. Public Health Reports 98, 
No. 3 (May/ June). 

Jelliffe, D.B. and E.P. Patricia Jelliffe (1960). Prevalence of Protein 
Calorie Malnutrition in Haitian Preschool Children. American Journal 
of Public Health. 

Laguere, Michel S. (1979). The Haitian Niche in New York City. Migration 
Today 7. 

Laguerre, Michel S. (197 9). Haitian Americans, Ethnicity and Medical 
Care , ed. Alan Harwood, Cambridge, Massachusetts: Harvard University 

Leonidas, Jean Robert (1982). Depression a la Haitian. New York State 
Journal of Medicine . (April). 

Mathewson, Marie A. (1975). Is Crazy Anglo Crazy Haitian? Psychiatric 
Annals 5 (8). 

Murray, Gerald F. (1976). Women in Perdition: Ritual Fertility Control 
in Haiti in, Culture. Natality and Family Planning . ed Marshall. 
Carolina Population Center, University of North Carolina. 

Scott, Clarissa S. (1974). Health and Healing Practices Among Five Ethnic 
Groups in Miami, Florida. Public Health Reports 89, No. 6. 

Scott, Clarissa S. (1975). The Relationship Between Beliefs about the 

Menstrual Cycle and Choice of Fertility Regulating Methods Within Five 

Ethnic Groups. International Journal of Gynecology and Obstetrics. 

13. ~~ 

Stepick, Alex, et. al. (1982). Haitians in Miami, An Assessment of their 
Background and Potential. Dialogue #12, Occasional Papers Series. 
Latin American and Caribbean Center, Florida International University. 

(Bibliography/Haitian cont.) 

Weidman, Hazel H. (1978). Miami Health Ecology Project Report: A Statement 
on Ethnicity and Health. Department of Psychiatry, University of 
Miami School of Medicine (Mimeo). 

Weise, H. Jean C. (1976). Maternal Nutrition and Traditional Food Behavior 
in Haiti. Human Organization 35. 

Weniger, B. , (1982). Plants of Haiti Used as Antif ertility Agents. 
Journal Ethnopharmacology 6, No.l (July). 



Low income Blacks compose a heterogenous, ever-changing cultural group 
that has slowly been integrating into the mainstream culture. Of the three 
ethnic groups studied for this project (Haitians, Puerto Ricans and low 
income Blacks), Blacks appeared to have health beliefs least divergent from 
mainstream medical practice. This is not surprising since, of the three 
groups, they have been a part of the American culture for the longest time 
and do not have the language barriers experienced by the other two. 
Although these facts make it more difficult to identify their unique and 
important health care characteristics, many Blacks do hold traditional 
health beliefs and utilize folk healing practices quite different from 
modern medical practice. 

The information on low income Blacks in this booklet generally refers 
to those who are native Americans or who have lived almost their entire 
lives in the U.S. These are distinct from, for example, Haitians who are 
Black and also of low income. There is a paucity of research on the health 
beliefs of Blacks and much of what has been conducted was done in the 
south, southwest and midwest and it is uncertain to what extent the 
findings from these studies can be generalized to urban, eastern Blacks. 
One Black staff person of a Region II NHSC site stated that "a lot of times 
we don't understand what the patients are saying either. Southern Blacks 
have an altogether different culture from northern Blacks." Because 
physicians in a TTISC site may see Black patients originating from many 
regions of the U.S. and the Caribbean, and because these patients will 
have health beliefs varying not only by region but also by individual 
adherence to any one belief, it is important that physicians not stereotype 
Blacks by assuming that all Blacks hold any particular belief. 


There are a wide range of traditional health beliefs and medical care 
practices among low income Blacks. For many, ideas about illness and its 
causes result from a combination of folk, popular and biomedical ideas and 
each particular geographical or social subgroup of low income Blacks has 
its own special mix (Jackson. 1981). A large number have holistic 
viewpoints and make no distinction between science and religion or mind and 
body in their concepts about health and illness (Snow, 1978). Often 
illness is considered to be the result of conflicts between good and evil 
or between natural and unnatural forces. Events in life are believed to 
affect all aspects of a person's life including their job, family life and 

In this traditional system, the cause of the illness is the most 
important factor — not how that cause is expressed (symptoms). Many Blacks 
believe that the causes of illnesses are of two types: natural or 
unnatural. The decision about which type of illness a person has is 
pivotal because it has implications for the type of care initially sought. 
Depending on the believed cause, an individual may seek out a variety of 


cures from home treatment to folk healers to mainstream practitioners. An 

individual may interpret the same symptoms differently depending on the 

risks to which he or she has been exposed and on his or her beliefs 

surrounding the illness. This interpretation may change with further 

evaluation. In addition, it is believed that illnesses can be "cured" by 
spontaneous expulsion from the body en masse (Snow, 1974), therefore, 

individuals may not seek care or may use this for an explanation of its 

Women, the very young, and the very old are believed to be more 
susceptible to illness. For women, fairly specific techniques for personal 
care are defined which are conducive to good health. For example, 
menstruating women should never go swimming, they should never go to bed on 
a full stomach and hair should be shampooed at a defined frequency 
(Jackson, 1981). Black women may also reject contraceptive methods that 
alter the monthly menstrual flow (such as the IUD and the Pill) because a 
change in this may be viewed as a threat to health and well-being (Scott, 
1975). There are also many taboos associated with pregnancy. The thoughts 
and cravings of a mother during pregnancy are believed to affect the health 
and physical appearance of the baby. 

1 . Natural Causes of Illnesses 

Natural causes of illness are those attributable to either the natural 
environment or to God's punishment (Snow, 1978). Most illnesses may 
initially be seen as the result of acting foolishly by not following the 
basic tenets of good health and may be treated by a variety of home 
remedies, many of them herbal. It is the individual's responsibility to 
maintain his or her health by following a moderate lifestyle, protecting 
him or herself against excessive heat or cold, eating a healthy diet, and 
keeping his or her system clean. (Sometimes the latter necessitates taking 
laxatives fairly regularly to prevent "impurities" from building up.) 
Natural phenomena such as the phases of the moon and the seasons are also 
believed to affect the body (Snow, 1974). For example, some Blacks believe 
that hypertension is affected by changes in the weather or small changes in 
diet: therefore, to them, it may not make sense to take dramatic action to 
cure hypertension. 

Some natural illnesses are believed to be caused by a failure to 
"know, love, and serve God" as represented by going to church and praying. 
Long term illnesses are often believed to be the result of God taking 
action to give the person or family time to contemplate their weaknesses. 
Mental retardation and strokes leading to paralyses are examples (Snow, 
1978). For these types of illnesses, the individual or family will be 
cured only after making peace with God: recognizing the sin, feeling 
remorse for having committed it, vowing to improve and taking action to 

2. Unnatural Causes of Illness 

"Unnatural" causes of illness are those due to forces such a s 
"worriation, " stress from everyday living, evil influences, or sorcery. In 
some instances there is a fine line between the designation of a natural or 


unnatural cause. Illnesses resulting from "worry", "nervousness", or 
"stress" are classified as "unnatural" if the person is worrying about 
something over which he/she has no control. For example, many urban Blacks 
believe that stress (especially stress resulting from racism) causes 
hypertension (Jackson, 1981). Another common belief is that diabetes is 
the result of "worriation, " a belief with some basis in medical fact. 

An unnatural illness can also result from a natural illness if it was 
the result of God's punishment. This can happen if the person does not 
mend his ways, make peace with God and thereby prevent the removal of God's 
protection. This removal leaves the person at the mercy of the devil or 
other evil influences. 

Some low income Blacks believe that an illness can be caused by 
sorcery in the form of voodoo, hoodoo, rootwork, hexing, or witchcraft . 
These systems are largely based on the idea that associates, especially 
friends, neighbors, or relatives, can exploit and control you by using 
information about you to fix a spell. Usually an intermediary who has 
contact with the spirits is used to cast these spells. Envy often plays an 
important role in them: envy of success, beauty, or good fortune in the 
areas of love, business or politics (Wintrob, 1973) . A spell or hex may be 
put on an individual either to make him ill or to cause him to act in a 
certain way. For example, a husband who does not want his wife to be 
unfaithful to him may place a spell on her to keep her faithful. Potions 
for love purposes are common in some inner city neighborhoods. 

Spells are often cast by making a powder from something that belongs 
to or was part of the individual being "hexed" (e.g. clothing, hair, nail 
clippings, excreta, or soil that the person las walked over.) The powder is 
placed in the victim's food or drink (Snow, 1974). After eating or 
drinking the altered food the individual responds by having stomach cramps, 
vomiting, diarrhea, intense tremors or unusual behavior (Wintrob, 197 3). 
Because "poisoning" food is believed to be a common mode of casting a 
spell, gastrointestinal problems may be viewed as the result of a hex. 
Spells are not placed lightly because the person placing the spell is 
endangering himself due to the possibility that the person "hexed" can find 
a more powerful intermediary and turn the situation around. Thus, spells 
are usually actions of last resort after other means of solving the problem 
have been attempted (Wintrob, 1973). 

Unusual symptoms (i.e. symptoms no one has ever seen before or ones a 
physician expects to be able to cure but cannot) are likely to be viewed as 
the result of witchcraft. Losing weight while continuing to eat normal 
amounts is seen as a particularly ominous sign that may mean a spell has 
been cast. Unnatural illnesses are often viewed as the result of animals 
or reptiles (commonly including snakes, lizards, spiders, toads and frogs) 
being lodged somewhere in the body. They are assumed to be introduced into 
the body by putting either animal eggs or powder made from the animal into 
the person's food. The eggs hatch or the powder is reconstituted once 
inside the body. 

Normal symptoms might be seen as the result of witchcraft if the 
individual has been warned that he will have the symptom or if the 
individual has a guilty conscience. For example, a spouse who feels guilty 


about being involved in an extramarital affair is more likely to believe 
that symptoms are the result of a spell than a spouse who does not feel 
guilty (Snow, 197 8). 

Changes in behavior may also be believed to be the result of a spell. 
Depression, crazy behavior, anorexia, and inability to perform the usual 
tasks of life may all be seen as the result of a hex. There is evidence 
that hypnosis may be an appropriate method to use with patients who have 
the above mentioned symptoms and believe them to be the results of 
witchcraft (Snell, 1976). Folk healers may be particularly sought out and 
effective as psychotherapists because they have more time for the patient 
and more understanding of the patient's problems as they relate to his 
family life and social conditions (Jackson, 1981). 

Research findings are not consistent about the percentage of low 
income Blacks that believe in sorcery or related concepts and seek out care 
from these types of providers. However, regardless of the exact 
percentage, it is evident that these beliefs have influenced the culture's 
health concepts to some degree. As a result, "unnatural" illnesses are 
particularly frightening because they are seen as removed from God's 
influence and the healing abilities of friends, family and mainstream 

3. Perceptions About Cancer 

In a study of Black Americans' attitudes and knowledge about cancer 
(ACS, 1981) several interesting findings were discovered about Blacks' 
perceptions and behaviors with respect to cancer. Blacks may think that, 
among illnesses, cancer is the main preoccupation of white people, and that 
high blood pressure and sickle cell anemia are primary preoccupations of 
Black people. Blacks more often believed cancer to be fatal and treatments 
to be less effective than is actually the case. Futhermore, few Blacks 
could name cancer's warning signals and were less likely to seek medical 
care if they experienced any of these symptoms. They were, however, very 
interested in receiving educational programs about cancer prevention. 

About half of the Blacks studied believed that "surgery can expose 
cancer to the air" and cause it to spread. Also, approximately one-fourth 
said they would "feel uncomfortable" working next to someone who had 


Low income Blacks use a wide variety of home remedies. traditional 
healing practices and modern over-the-counter drugs. As is characteristic 
of the majority of the population, they seek advice first from friends and 
relatives, try home remedies and then if the illness is serious enough and 
still remains, they may seek mainstream medical care. 

IV- 5 

1. Home Remedies 

Members of low income Black patient groups of NHSC sites in Region II 
revealed significant experimentation with and use of home remedies. Often, 
different treatments for the same illness were given by various members of 
the groups. These remedies, summarized in Table 2, may be of particular 
interest to NHSC physicians serving this Region. 

As is evident from the above table, Black patients in Region II 
display a significant knowledge and use of home remedies. Herb teas were 
mentioned several times and are apparently used for many types of ailments . 
Also mentioned frequently was the solicitation and use of advice from 
health food stores. Several patients considered the personnel of these 
stores to be very knowledgeable about natural and effective treatments for 
illnesses. One Southern Black stated that castor oil was used for 
"everything" in the south. Also, Blacks may be suspicious of a lot of 
blood tests or feel that they are more harmful then beneficial. Some of 
the Blacks in the focus groups terminated treatment after being given 
several blood tests. 

Some of the home remedies found among low income Blacks in Louisiana 
include wearing garlic around the neck, for tuberculosis; drinking a tea 
made of sheep manure, for whooping cough; wearing a bag of asafetilda 
around the neck, for worms, and eating horehound root for diabetes (Webb, 
1971). These treatments may not be directly transferable to urban, eastern 
Blacks but they give some idea of the types of home remedies that may be 

Other harmful uses of home remedies found by researchers have included 
laxative abuse and oral use of kerosene, turpentine, moth balls and carbon 
tetrachloride (Snow, 1974). 

2. Use Of Traditional Healers 

A percentage of low income Blacks use traditional healers. 
Advertisements by these healers can commonly be found in low income Black 
communities. It is uncertain, however, how prevalent this use is and how 
it varies by geographic region. A great deal of secrecy surrounds the use 
of them so the distinction in the type of problems each deals with are not 
clear to the outsider. Some use roots, herbs, and patent medicines and 
some use massage with special oils. Others use candles, charms and 
amulets. Often healing takes place as part of a religious ceremony. 
Frequently, healers provide a substance that leads to some physical symptom 
(such as vomiting) which is an indication that the cure is working. Folk 
healers are confident in their ability to heal and unlike many mainstream 
practitioners are usually available •immediately and at all times of the 
night and day, and can often work cures through the mail or over the phone. 
They are also of the same economic class and cultural background as the 
patient and therefore better understand the patient's concerns. Their 
power to cure is considered to be given by God. 

Only certain individuals are believed capable of enacting or removing 
spells; these persons are intermediaries who have special knowledge of and 
relationship with supernatural forces. They are called by many names 




Illness or Condition Treatment 

Fever Slice a white potato and put it in a white sock 

under the bottom of the foot, then wrap a rag 
around the head. When the potato gets as if it 
were cooked, the fever will be gone. 

Fever Put turpentine in a pan and place under the sick 

person's bed. 

Fever Place a raw red onion on the body to draw out the 


Fever Warm gingerale, herb tea 

Fever Alcohol bath, then rub body with a green lime or 

coconut oil. 

Cold Honey and lemon 

Cold Cod liver oil to prevent a cold 

Asthma "Vicks" salve 

Castor oil with olive oil and sugar 


Formula 44 

Diarrhea Flour and water mixed together 

Herb teas 

Diarrhea Add corn whiskey to one teaspoon of white whiskey, 

strike a match on it and let it burn. Then take a 
piece of alum about half the size of a pea, put it 
on a spoon and put the spoon on something hot. 
Then mix it with the whiskey. Add a little milk 
to it and give it to the person (adult or child) 
with diarrhea. 

Gastroenteritis Boiled water 

Broth soups 
Herb tea 

Rash Herb tea 

Rub honey and vaseline on rash 

Chest pain Soda 

High Blood pressure Vinegar and garlic 


(TABLE I: HOME REMEDIES, continued) 
Illness or Condition Treatment 




Laxatives (patients were found to use laxatives to 
lose weight prior to a health care visit). 

Herbal teas 

Golden seal tea 


IV- 8 

including healer, herb doctor, root doctor, root worker, reader, advisor, 
spiritualist, conjure man or woman, houngan or papaloi (voodoo tradition) 
(Snow, 1978). Because each intermediary is considered to have unique 
strengths and skills, both the persons wanting to place spells and the 
persons wanting to remove them seek out the most powerful intermediary they 
can locate — the former in order to place a spell that cannot be broken and 
the latter with the hope of being able to break the spell. 

Sometimes this healing power can work against patients which may lead 
them to seek out mainstream care before resorting to the more dangerous 
folk medicine cures. Interestingly, if a sufferer is cured after seeing a 
traditional healer, no one is surprised and the traditional treatment is 
credited with the cure (Webb, 1971). However, if the sufferer does not 
improve, it is believed that it was because the individual was beyond hope, 
not because the cure did not work. The folk healing system is based on 
belief; successes have significantly more force than in mainstream 
medicine and failures are less serious a blow because there is always the 
possibility that the patient can be cured. Lack of knowledge or resources 
are not issues in traditional healing. Several of the patients in the 
focus groups expressed an awareness of witchcraft but stated that they 
neither believed nor participated in this type of activity. 


Most low income Blacks, particularly those in urban areas. see a 
physician at least once each year (Jackson. 1981) and there is little 
evidence that they have significantly different expectations about these 
encounters than the majority populations. They believe physicians should 
be treated with respect and also want courteous treatment in return. They 
expect the physicians to know what is wrong with them, to explain the 
illness in clear terms and to suggest an appropriate treament. One study 
(Scott, 1974) found that although Blacks are large users of the orthodox 
health care system, their contacts tend to be superficial. Symptoms and 
conditions which brought them in for care continued week after week, month 
after month and were rarely cured. This study also that a Black family 
will often use both private physicians and public clinics, sometimes at the 
sflme time. This was found among the Black patient focus group participants 
also. Participants stated that they use private physicians when they want 
to be served in a timely manner, when they want better treatment, when they 
need a form completed (such as a child's physical for school) or when they 
wanted continuity of care, i.e., to see the same doctor who will have their 
whole history in his files. Some patients may withhold information from a 
physician to test his or her intelligence and skill and similarly, some may 
believe physicians should be able to diagnose without any patient input 
(Jackson, 1981). 

Some Blacks may be distrustful of non-Black physicians after learning 
about or experiencing condescending, disrespectful, or otherwise 
prejudicial treatment. Most low income Blacks' primary concern is that the 
physician is competent. The race and sex of the practitioner are secondary 
to this, but may still be very important, i.e., many of the patients in the 

IV- 9 

focus groups expressed a preference for female physicians because they were 
more careful to explain information about the illness and treatment to 

The Black patients in the Region II groups displayed few conflicts 
with the expertise of health care providers. Many did, however, express 
the belief that faith in God and in the provider are important to the 
healing process. 

A feeling of nervousness or slight fear when seeing a physician was 
expressed by many Region II patients . This nervousness resulted in 
soliciting information from and giving more information to support staff 
than to physicians. Patients utilized staff to translate physicians' 
medical terms into "plain English" and to give information or pose 
questions that they expected would be passed on to the doctor. Patients 
felt more comfortable telling staff members about personal problems and 
home remedies. This trust in staff and reluctance to confide in doctors is 
due to many factors, including some of the following. At the centers where 
these patients were served, the staff were of the same culture as the 
patients whereas the physicians usually were not. The patients felt more 
comfortable with staff. Secondly, a number of Black patients feel many 
non-Black doctors are prejudiced against them. They are also afraid that 
doctors will get upset over the use of home remedies and feel the staff can 
"translate" this information so that the physician will not get angry. 
Fourthly, some Blacks hold to the traditional belief that a physician 
should be able to diagnose an illness without any information from them. 
Finally, some Blacks fear that physicians will "steal" their home remedy 
and transform it into an expensive prescription drug. 

Although most low income Blacks in urban areas see a physician at 
least once per year, some percentage of this group also use the services of 
a non-mainstream practitioner. At least one researcher has found that a 
number of Blacks use a variety of mainstream and non-mainstream 
practitioners simultaneously (Scott, 1974). The mainstream providers may 
be sought after other healing attempts have been tried and failed or they 
may be used to confirm the success of a folk cure. In other instances, the 
doctor may be seen to alleviate symptoms but the folk practitioner is seen 
to effect the "cure." Sometimes physicians may be seen as capable of curing 
only environmentally caused diseases, other times not (Snow, 1974). 

Persons who believe themselves to be victims of a spell may see a 
physician prior to, concurrent with, or after seeking help from a 
folk/magical healer. When dealing with patients who believe their symptoms 
to be the result of hexing, it is probably wise for a physician to 
determine the extent of the individuals belief in witchcraft. Otherwise, 
the physician may inadvertently confirm the patients fears about the 
seriousness of the ailment. Patients may interpret uncertainty about the 
cause of an illness or a request to wait a few days for test results as 
confirmation of a hex. In the patient's mind, this would reduce his/her 
likelihood of cure and he or she may not return. Although no members of 
the Region II patient group said that they used traditional healers, they 
knew of them and did admit to the use of traditional and home remedies. 

Once the Region II patients found a physician they liked, they were 
very loyal to him or her and would travel long distances to maintain the 

IV- 10 

1 . Characteristics and Training Blacks Consider Desirable in a Physician 

In general, most of the characteristics that Blacks feel physicians 
should have are ones relating to their personal qualities such as how they 
treat patients and their ability to communicate. Black patients felt that 
physicians should work to develop a good rapport with their patients, 
should be open in their communication and should take time to answer the 
patients' questions. Patients expressed the desire that physicians 
communicate with them in terms they can understand but at the same time 
treat them as if they have intelligence and not be condescending. They 
felt that physicians should be caring and interested in them, respectful 
and concerned. Patients felt it was important to see the same doctor at 
each visit so that a rapport and accumulation of knowledge about their 
medical history could occur. Some practical advice was also offered by the 
patients. They felt that whenever a change in physicians was to occur, the 
"old doctors" should introduce the new doctors to the patient in person 
rather than on paper. Also, they suggested that a physician should not 
pretend that he or she knows everything and should call in a colleague if 
he or she is unsure about something. 

2. Advice from Staff for Incoming NHSC Physicians 

To orient themselves to the clinic and community, staff of the Region 
II centers stated that physicians should learn about the culture of the 
community to gain a general idea of the context from which the patients 
come. Physicians should realize however that "not every person will fit 
that picture exactly." Staff felt it was important for physicians to come 
with a open mind, to learn as much about the system as possible and to 
accept the patients as they are. Staff also advised physicians to treat 
the patients as human beings, to say hello and introduce themselves to 
them. Aside from the courtesy of this, staff said it served a practical 
value as well because many patients did not know the name of the physician 
they saw at the last visit. 

To help in their orientation, staff felt that physicians should be 
given a thorough tour and explanation of the clinic and how the internal 
systems function, where supplies, instruments and equipment are kept and an 
introduction to staff with explanations as to their roles. To develop 
relationships, staff felt that physicians should make an effort to get to 
know them. 

Regarding the patients, staff had this advice for physicians: 
patients may be embarrassed and hesitant to tell the physician about some 
things such as bleeding, a discharge or giving a urine specimen. Staff 
stated that, because patients have seen them over a period of time, they 
trust the staff and view them as friends. The patients feel more confident 
in talking with the staff and relate to them more openly than with the 
physician. This perception was confirmed by the patient focus groups. 
Staff also warned that some patients are con artists and may present 
confusing information. In these cases, staff felt that the physician 
should trust the judgement of the staff. 


The staff also warned that their Black patients consume a lot of salt. 
The diet of Blacks, of course, varies within the population. Some Blacks, 
have a diet that consists primarily of "soul food" which includes a lot of 
pork. Those who are of southern origin may be relatively low consumers of 
fresh vegetables and citrus fruits but heavy consumers of flour, fat, 

rice, grits, cornmeal, sweet potatoes, and in small amounts, fish, poultry 
and meat (especially salt pork, bacon and fresh pork — Lowe, 1973). 


As previously stated, it would be inappropriate for a NHSC provider 
working with a low income Black population to assume that all, most, or 
even the majority of his or her low income Black patients' health beliefs 
and practices are described in the preceeding pages. With this point in 
mind and recognizing that each provider has an individual style of 
practice, the following list includes examples of situations or issues that 
might arise when providing health care services to low income Black 
patients or working with low income Black staff members. 

1. In treating a low income Black patient it would be wise for a 
physician to determine if the patient (or the parent if the 
patient is a child) is using a traditional or home remedy 
including any alterations in diet. 

2. If a patient seems to believe that an illness is due to 
unnatural causes, it would be wise for the physician to 
determine to what extent the patient believes in witchcraft. 
Any questioning about beliefs in witchcraft must be done 
carefully so as not to alienate the patient who does not 
ascribe to these beliefs. 

3. Some patients may not seek care for a very serious illness if 
they believe it to be caused by witchcraft. They may, 
however, consult a physician for another illness which they 
believe to be of natural causes — never telling the physician 
about the "unnaturally" caused ailment. Therefore, 
physicians might want to ask patients if they are 
experiencing any other pain or physical problems other then 
the one they came in for. 

4. Many cultural groups lack a concept of chronicity of illness 
or believe the idea that a physician's first therapeutic 
modality should be immediately successful or else nothing can 
be done. They may also view failure of a first treatment as 
a loss of face for the physician, should it be brought to his 
attention and therefore may not return if a condition 
continues or worsens. To avoid the situation in which a 
patient will not return if a condition worsens, a physician 
might want to explain the process and course of the disease 
in appropriate terms to the patient and encourage them to 
return if the condition worsens. 


5. Because patients are generally more willing to confide in 
staff, physicians might utilize staff to find out more 
information relevant to a patient's case. 

6. In giving explanations of an illness or treatment, it is 
important to use terms patients understand. This is 
especially important in achieving compliance from patients. 
Physicians can test patients' understanding by having them 
repeat instructions back to them. 

7. All patients are sensitive to a physician's manner and 
communication skills. Black patients may be particularly 
sensitive to disrespectful or brusque treatment by non-Black 
physicians and may interpret it as racism. Physicians should 
treat patients and their health beliefs respectfully. 

8. Non-Black physicians should learn some basics about the 
culture of low income Blacks so that behaviors of either 
staff or patients are not judged out of context. 

9. It is wise that physicians learn about the staff and their 
job functions and to use staff appropriately. 

10. Health centers should provide some training opportunity for 
their physicians to learn about the culture of the patients 
and the community. 

11. When possible, physicians might take and make opportunities 
to provide preventive education to Black audiences as most 
are desirous of this information and are not as likely to get 
it through typical mass media and social relationship 

12. When appropriate, physicians might question the use of salt 
and fat in the diet, as low income Blacks may be heavy 
consumers of both. 



Bryant, Carol Anne (1982). The Impact of Kin, Friend and Neighbor Networks 
on Infant Feeding Practices. Social Science and Medicine 16. 

Cappannari, Stephen C. et al (1975). Voodoo in the General Hospital, a Case 
of Hexing and Regional Enteritis. Journal of the American Medical 
Association 232. 

Coulehan, John L. (197 9). Hypertension Followup in an Urban Population. 
Public Health Reports 94. 

Fabrega, Horacio and R. E. Roberts (1972). Social-Psychological Correlates 
of Physician Use by Economically Disadvantaged Negro Urban Residents. 
Medical Care 10. 

Gylys, Julius A. and Barbara A. Gylys (1974). Cultural Influences and 
the Medical Behavior of Low Income Groups. Journal of the National 
Medical Association 66, No. 4 (July). 

Hall Arthur L. and Peter G. Borne (1973). Cultural Influences and the 
Medical Behavior of Low Income Groups. Journal of the National 
Medical Association 66, No. 4 (July). 

Harris, Rachel (1979). Cultural Differences in Body Perception During 
Pregnancy. British Journal of Medical Phvchology 52. 

Jackson, Jacquelyne Johnson (1981). Urban Black Americans, in Ethnicity 
and Medical Care ed. Alan Harwoood, Cambridge, Massachusetts: 
Harvard University Press. 

Krug, Earnest F. (1974). Folk Medical Beliefs. Annals of Internal Medicine 

Linn, Margaret W. et. al. (1980). Self Addressed Health Impairment and 
Disability in Anglo, Black and Cuban Elderly. Medical Care 89, No. 

Satcher, David (1973). Does Race Interfere with the Doctor-Patient 
Relationship? Journal of the AMA 223. 

Scott, Clarissa S. (1974). Health and Healing Practices Among Five Ethnic 
Groups in Miami, Florida. Public Health Reports 89, No. 6 
(Nov. /Dec). 

Scott Clarissa S. (1974). The Relationship Between Beliefs About the 
Menstrual Cycle and Choice of Fertility Regulating Methods Within Five 
Ethnic Groups. International Journal of Gynecology and Obstetrics. 

Snell, John E. (1967). Hypnosis in the Treatment of the "Hexed" Patient. 
American Journal of Psychiatry 24, No. 3 (September). 

IV- 14 
(Bibliography/ Black cont.) 

Snow, Loudell F. (1974). Folk Medical Beliefs and their Implications for 
Care of Patients: A Review Based on Studies Among Black Americans. 
Annals of Internal Medicine 81 . 

Snow, Loudell F. (1978). Sorcerers, Saints and Charlatans: Black Folk 
Healers in Urban America. Culture. Medicine and Psychiatry 2. 

Vail, Anthony (1978) Factors Influencing Lower-Class Black Patients 
Remaining in Treatment. Journal of Consulting and Clinical Psychology 
46, No. 2. 

Verbrugge, Lois, M. (1979). Medical Care of Acute Conditions, United 
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Health Statistics. 

Web, Julie Yvonne (1971). Louisiana Voodoo and Superstitions Related to 
Health. HSMHA Health Reports 86, No. 4. 

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Patterns of Ghetto Blacks and Hispanics in Brooklyn. Journal of the 
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