Immigration, Acculturation, And Health: The Mexican Diaspora (The New Americans: Recent Immigration and American Society)

The New Americans Recent Immigration and American Society

Edited by Steven J. Gold and Rubén G. Rumbaut

A Series from LFB Scholarly

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Immigration, Acculturation, and Health The Mexican Diaspora

Jill S. Reichman

LFB Scholarly Publishing LLC New York 2006

Copyright © 2006 by LFB Scholarly Publishing LLC All rights reserved. Library of Congress Cataloging-in-Publication Data Reichman, Jill S. Immigration, acculturation, and health : the Mexican diaspora / Jill S. Reichman. p. cm. -- (The new Americans: recent immigration and American society) Includes bibliographical references and index. ISBN 1-59332-132-5 (alk. paper) 1. Mexican American women--Health and hygiene--New Mexico-Santa Fe County 2. Mexican Americans--Medical care--New Mexico-Santa Fe County. 3. Health attitudes. I. Title. II. Series. RA448.5.M4R45 2006 362.1089'6872078956--dc22 2006009807

ISBN 1-59332-132-5 Printed on acid-free 250-year-life paper. Manufactured in the United States of America.

Table of Contents

List of Tables .......................................................................................vii Acknowledgments ................................................................................ix Foreword...............................................................................................xi CHAPTER 1. Mexican Immigrants, Health Care, and Acculturation ...1 CHAPTER 2. Modeling and Measuring Acculturation .......................15 CHAPTER 3. Methodological Considerations, Data Collection, and Analysis.......................................................................................33 CHAPTER 4. Sociodemographic Profile.............................................51 CHAPTER 5. Models of Health, Models of Illness.............................63 CHAPTER 6. Change over Time in Health Prescriptions ...................77 CHAPTER 7. Cognitive Models of How People Should Behave When Sick ................................................................................. 103 CHAPTER 8. Therapeutic Options: Awareness and Usage of Complementary and Alternative Medicine................................ 115 CHAPTER 9. Crossing Boundaries: Geographical, Political, and Religious ................................................................................... 135 CHAPTER 10. Diagnosis And Treatment Efficacy........................... 161 CHAPTER 11. Antibiotic Usage And Rate of Acculturation ............ 187 CHAPTER 12. Nervios, Stress, Sadness, Depression: The Evolution of a Mind/Body Discourse ........................................................ 209 CHAPTER 13. Conclusion ................................................................ 229 Endnotes ............................................................................................ 247 APPENDIX A. List of Sending Communities ................................... 259 APPENDIX B. Survey Questions...................................................... 261 Bibliography ...................................................................................... 269 Index .................................................................................................. 289 v

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List of Tables

Table 1. Age by percentage of respondents Table 2. Years lived in the U.S. Table 3. Education levels in the <5 years subsample Table 4. Education levels in the ≥5 years subsample Table 5. Type of sending community by years lived in the U.S. Table 6. Education level by type of sending community Table 7. Self-reported English language proficiency by years lived in the U.S. Table 8. Marital status by years lived in the U.S. Table 9. Type of employment by years lived in the U.S. Table 10. Mexican physician rating by years lived in the U.S. Table 11. Cognitive models of health by years lived in the U.S. Table 12. Cognitive models of health prescriptions by years lived in the U.S. Table 13. Cognitive models of treatment by years lived in the U.S. Table 14. Knowledge about or usage of T/CAM by years lived in the U.S. Table 15. Sending community by years lived in the U.S. for CAM familiars Table 16. Education levels of CAM familiars Table 17. Education levels of religious converts Table 18. Type of illness by number of subjects

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51 51 52 53 54 55 56 58 60 61 74 95 111 122 127 130 137 162

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Table 19. Diabetic/hypertensive diet narrative by years lived in the U.S. Table 20. Preferred physician characteristics by years lived in the U.S. Table 21. Reasons for stopping pharmaceutical treatment by years lived in the U.S. Table 22. Type of medication imported from Mexico by years lived in the U.S. Table 23. Percentage of illness subtypes by health care system ratings Table 24. Diagnosis type and associated rating of health care system by years lived in the U.S. Table 25. Use of emotion term by years lived in the U.S. Table 26. Belief in the curability of mental illness by years lived in the U.S.

171 182 193 197 201 203 222 225

Acknowledgments

During the five years that it took to plan, implement, and analyze the study on which this book is based, I met and worked with many people. The list of people I wish to thank is long and I have felt enormously supported by my family, colleagues, and friends. Funding from the University of Chicago as well as from the National Institute of Mental Health provided financial support. Mentors at Chicago include Richard Shweder, Dan Freedman, Sydney Hans, Bill Goldstein, and Richard Taub. Peter Guarnaccia, too, has been very supportive. Amadao Padilla, way back when, inspired me when he published the results of one of my first attempts at research. Members of the health care community in Santa Fe to whom I am especially indebted are Paula Devitt, Arturo Gonzales, Carlos Frias, Berna Chavez, Sylvia Ornelas, and most especially, Grace Pena. The team of interviewers who developed intimate bonds with and fondness for our interviewees included Maria Isabel Acosta Martinez, Marcela Diaz, and Adda Garcia. Maria Christina Lopez also aided the project in spirit. I am forever indebted to Rob Logan for his patient and insightful editing of this work as well as his friendly emotional support. Jane Kepp provided invaluable help in shaping my work into its present form and Kate Talbot did a tremendous job lightening my oftentimes ponderous prose. Kay Hessemer undertook an impossible task and succeeded in formatting all this verbiage. I am beholden to my family without whose patience and fortitude I could never have finished: Nanci Reichman, Cathy and Bill Hare, Jane Shea, John Oliver, and of course Michael, Sophie, and Will. Finally, I want to thank the women whom we interviewed. Their willingness to share their intimate stories—both the painful and the joyful—has humbled as well as enlightened me.

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Foreword

“That's Fascinating! Tell Me More.” From time to time, I conduct a seminar at the University of Chicago in which one primary aim is to teach prospective research scholars in the social sciences how to clearly formulate a research problem. I ask the students to imagine that they are at a dinner party with intelligent, inquisitive American citizens from different walks of life and that someone asks them about their research. The goal (and challenge) is to describe their work in a single lucid sentence such that the person who posed the question would respond, “Now that's fascinating! Tell me more.” Trying to boil down Dr. Jill Reichman's provocative research findings to a single sentence is certainly hazardous. When I picture her at that hypothetical dinner party, though, I imagine her saying something like this: Mexican immigrants to the United States modify their health beliefs and related practices far more rapidly than previously supposed. Within five to ten years of arrival in the Southwest, they shift their views of the causes of illness, learn about viral and bacterial theories of disease, reinterpret the Hispanic concept of “nervios” as “stress,” distance themselves from "traditional" Mexican healing modalities, and reconsider the types of therapies they should seek when they are sick. That is just the beginning. And I very much doubt that you can guess which factors best predict the speed with which they change their beliefs, attitudes, and practices concerning health. Now that's fascinating, and not just because 9 percent of the native-born Mexican population is now working in the United States or because providing appropriate health services for minority groups is a major public policy challenge. It is fascinating because a commonplace xi

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notion in the literature on immigration is that the young are more adaptive to changing circumstances and more open to new ideas than their elders. This idea is challenged in Dr. Reichman's book. Her research effectively marries the fields of medical anthropology and immigration studies and takes a close look at the process of acculturation from the point of view of sixty-two female Mexican immigrants who live in Santa Fe County, New Mexico. What types of therapies do they seek when they are sick? What are their beliefs about the meaning of health, about the causes of physical and mental suffering, about the usefulness of various medical therapies? Is poor health caused by a high-fat diet, lack of exercise, and heredity? Or is it caused by bad weather, inadequate sleep, and insufficient calories? When you are sick, should you “get up and around,” or should you stay in bed? In predicting the rate of acculturation for health beliefs, why is having a chronic illness (for example, hypertension or diabetes) far more relevant than age, education, the rural versus urban character of the Mexican sending community, or the degree of a person's religious commitments? Why is the rejection of certain healing modalities (curanderismo, in particular) strongly associated with Protestant conversion? And that's just for starters. I hope that every intelligent, inquisitive American citizen will want to learn more and will take the opportunity to read this detailed, well-written, and eye-opening book. Richard A. Shweder William Claude Reavis Distinguished Service Professor Department of Comparative Human Development University of Chicago

CHAPTER 1

Mexican Immigrants, Health Care, and Acculturation

With the advent of the twenty-first century, thirty-seven million Latinos make up roughly 13 percent of the United States’ total population. Of these, 58 percent, or twenty million, are of Mexican origin, either immigrants or first-generation U.S. born. Migrants from Mexico represented 57 percent of the unauthorized population in 2004 and thus constitute a powerful force in the Latinization of the country. They represent the largest migration flow in the history of the continent (Passel 2005; March 2004 CPS). One great concern of federal and state policy makers, epidemiologists, health care providers (both administrative and clinical), and U.S. citizens is how the U.S. healthcare system can handle the increase in demand posed by so many nonEnglish-speaking people. How can it possibly accommodate people who communicate in a different language, come from a culture with different expectations of care, have no insurance coverage, and little or no money to pay, and often delay seeking help until, acutely ill, they rush to the emergency room? This important question requires careful consideration. One widely held view is that this health crisis exists, in part, because Mexican immigrants resist change more than other immigrant populations and tend to regard American healthcare practices with suspicion. Moreover, in the past several decades, research on the rate of acculturation of Mexican immigrants purports that change in attitudes, beliefs, and behaviors does not occur intragenerationally. Rather, only secondgeneration Mexican Americans are thought to adopt beliefs—about health or otherwise—similar to those of native U.S. citizens. What is troubling about these studies is that they attempt to measure the rate of acculturation in Mexican immigrant populations according to whether 1

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the participants prefer to speak Spanish instead of English during the interview process. Many first-generation immigrants still prefer Spanish, which researchers have construed as evidence of a general resistance to acculturation. I discovered evidence to the contrary in female Mexican immigrants living in Santa Fe, New Mexico. From May 2001 to July 2002, I studied the health-related cognitions and behaviors of thirtynine women who had lived in the United States fewer than five years and of twenty-three women who had lived here longer. I questioned them regarding their beliefs about health and illness, which therapies they used for particular illnesses, and what sorts of experiences they had with Mexican and U.S. healthcare providers. Every interviewee chose to speak Spanish instead of English. The veteran immigrants, however, differed from the recently arrived in their cognitive models of health; their beliefs about how people should behave when sick, about the emotional and physical effects of stress, and about diet and exercise; their knowledge of alternative medicine; and their attitudes toward curanderismo, the traditional healing system in much of Latin America. Changes in health-related beliefs and behaviors appeared in subpopulations previously thought to resist change: elderly immigrants, immigrants from rural Mexico, and immigrants who intended to return to their country one day.

WHY STUDY THE HEALTH CARE BELIEFS OF MEXICAN AMERICANS? Given the size of the Mexican immigrant population in the United States and its influence on the country’s infrastructure, the ways in which the values and attitudes of recent Mexican immigrants evolve to reflect those of the native population have long been important areas of research. Working to understand change in cognitions over time, researchers have often commented on Mexicans’ slow rate of acculturation to mainstream U.S. culture in comparison with other immigrant groups. Speculations as to why include (1) a traditional rural background that is particularly resistant to change, (2) strong familial ties that impede the acceptance of different cultural ideas, (3) proximity to Mexico and the culture of origin and expectation of returning, and (4) institutionalized discriminatory practices that exclude Mexicans and Mexican Americans from participating as U.S. citizens (Padilla 1980:51).

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In a subsample of Mexican immigrant women, I found that the rate of acculturation in health ideology is much more rapid than previously thought. Factors that affect (either accelerate or decelerate) the rate of acculturation are not the ones commonly cited in the literature on acculturation in this immigrant population. Rural background, level of education, and degree of religiosity, among other things, are implicated less than are type of diagnosis (chronic or subacute), religious conversion, and the quality of the first encounter with health care in the United States. A greater understanding of the acculturation process, in and of itself, is desirable. But understanding the acculturation process as it relates to health ideology is imperative if health and educational services are to serve immigrant populations effectively. Insight into the processes of acculturation—the regularities, the permutations, the individual differences—can help us target services for recent Mexican immigrants in an efficient and meaningful manner (Rios-Ellis 2005; Abraido-Lanza et al. 2005; Magaña et al. 1996). Moreover, if we can better understand immigrants’ transition into mainstream U.S. society, we can help them cope with the psychological stress associated with migration and increase their sense of well-being, both of which lead to better health outcomes. More specifically, in the event of psychological maladjustment or physical disease, we must understand patients’ cultural backgrounds to develop therapeutic models that will attract those in need and keep them engaged in therapy. Researchers working in the domains of Hispanic physical and mental health have endeavored to discover client cultural variables or characteristics that must be considered when developing valid statements about the relationship between clients in treatment and the appropriateness of treatment models (Coatsworth et al. 2005; Szapocznik et al. 1978). Dana suggests that “knowledge of the multidimensional nature of acculturation, a focus on the components of the process, and a substantial research context are now necessary for ethical practice” (1995:322; Gamst et al. 2002). Since the turn of the twentieth century, health care researchers have posed literally hundreds of questions regarding Mexican immigrants. Current questions include the following: Do Latinos with acute and chronic health problems go most often to emergency rooms, county health clinics, or private doctors? How well do Mexican immigrant mothers adhere to the immunization schedule mandated for

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their infants? Do they understand the urgency of addressing chronic health problems, such as high blood pressure and diabetes? Are they seeking prenatal care? Do they comply with standard health directives? Is there a cultural component to self-assessment of health status? Are Mexican immigrants abusing drugs and alcohol more in the United States than they did in Mexico? Are they neglecting allopathic solutions to health problems in favor of traditional Mexican folk remedies?1 How do they define mental health and illness? What is the psychological impact of migration on Latinos’ mental health? Do Mexican men physically abuse their wives and daughters more than Anglo or African American men? How much do their health beliefs differ from the outset? How quickly do they adopt health beliefs similar to those held by the majority of U.S. citizens? My research focused on the last question, how quickly Mexican immigrants relinquish the old and adopt the new. That is, do they come to the United States with certain beliefs about health and illness that they eventually give up in order to accommodate new or different beliefs? Of course, belief systems are not monolithic entities, and I make no attempt to portray them as such. People and their belief systems are complex and contradictory, both implicit and emergent, embodied and, ultimately, flexible. Furthermore, all medical systems are pluralistic; they offer multiple treatment options from which to choose. Consequently, it is a mistake to speak of any society’s medical system as if it were unitary and static. Instead, medical systems are best examined as local social systems that may differ from one locality to another. Taking these points into consideration, I want to examine what Emily Martin, in her discussion of changing U.S. beliefs about the immune system (1994), termed “emerging sensibilities.” My research endeavor strives to reveal the health-related emerging sensibilities and the health ideologies already instantiated as “self-evident, universal and necessary” (Foucault 1991:76) in the recently arrived and the veteran Mexican migrant populations. In certain disciplines of the social sciences today, it is almost a caveat that Foucauldian webs of power are surreptitiously at work, so I do not reiterate this particular philosophical approach to understanding social phenomena here. What is of interest, however, is whether the sensibilities—the emerging worldviews of how bodies and minds function when healthy and ill—of recent Mexican immigrants differ from those of Mexican immigrants who have resided

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in the United States a long time. If so, how long did the process of change take? Do changes take place only generationally, as is commonly postulated? That is, do changes in beliefs, values, and behaviors occur only in the second generation or in those who arrive at a very young age? Are certain specific beliefs intractable? What nurtures change, and what impedes it? Do certain experiences accelerate the acquisition of new beliefs, and others hinder? Are specific demographic variables associated with these processes? These questions are not merely academic. Researchers have to learn how cultural categories of illness evolve in response to the changes in sociocultural milieu that migration necessarily entails. Health care workers and consultants who manage clinics, legislators who allocate funding for health care, and migrants themselves, whose health status and quality of health care lie in the balance, are all interested parties to this research.

IMMIGRANTS IN THE UNITED STATES Among Hispanics, acculturation is a timely subject. From 1980 to 1989, the Hispanic population increased by 39 percent to 20.1 million, not including an unknown number of undocumented migrants. This growth resulted primarily from immigration but also from an excess of births over deaths. In the 1990s, an immigration explosion took place with the arrival of an additional 13.3 million immigrants from around the world, accounting for almost half of the total immigrant population of 30.7 million. The United States Census Bureau calculated that, in 2000, a staggering 29 percent, or 8.8 million, of the foreign-born population came from Mexico. Fix and others (2001), demographers with the Urban Institute in Washington, have written that Mexico is now the single largest country of immigrant origin in U.S. history. Passel has discussed the converse of this statistic: that a stunning 9 percent of the native Mexican population is now living and working in the United States (2005). This trend may be changing, however. According to one study, migration to the United States peaked in 2000 and is down by about 25 percent in 2004, following the growth and contraction of the economy. “In 2004, migration bounced back to exceed 1.2 million. Whether or not this move portends further increases is impossible to predict. But even with this recent increase in migration, the most recent data show that immigration flows are at levels

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comparable with those of the mid-1990s and still significantly below the peak levels of 1999–2000” (Passel et al. 2005). During the past decade, the entire Hispanic population, both U.S. citizens and immigrants, grew by 58 percent (almost 20 percent more than the preceding decade) to reach a total of 35 million. These 35 million, the majority of whom come from Mexico, possibly have the highest labor-force participation rate in the United States today (Passel 2005; Marcy 2001). Traditionally employed in the agricultural and manufacturing sectors of the U.S. economy, Mexican migrant workers are now permeating the service sectors. Agriculture, to be sure, continues to employ large numbers of Mexican migrants. Although an estimated 50 to 80 percent of all U.S. farm workers are undocumented, only one in ten of the twenty-one million Mexicans and Mexican Americans (excluding Latinos from other cultures) living and working in the United States is undocumented. An estimated 85 percent of all Mexicans working in the United States work in the service sector. Another unknown percentage is starting to enter the commercial sector. According to a report on immigration published by Mexico’s National Population Council (CONAPO), Mexican immigrants to the United States in the past decade are more likely to work in commerce than in agriculture and are better educated and more urban (Campbell et al. 1999). They are also discovering or creating “receiving” communities for new arrivals. In spite of the infamous ballot measure Proposition 187, California continues to attract more Mexican workers than any other state. With an estimated 28 percent residing there (Marcy 2001), California is still home to 66 percent of all Mexican nationals and Mexican Americans in the United States. Yet, Mexican temporary workers are also moving to areas besides California, Illinois, New York, New Jersey, Texas, and Florida. According to the 2000 U.S. Census, 15 percent of temporary workers live outside these locales, a 50 percent increase in the past decade. Of note about this population is that the vast majority enter the country without proper documentation. The Bureau of Citizenship and Immigration Services (BCIS) and the Current Population Survey (March 2004 CPS) estimate the total number of undocumented immigrants in the United States at 10.3 million, with over half of them from Mexico.2 In 2001, the Urban Institute published an article stating that nearly four out of every ten attempts to cross the border succeeded. Arresting more than one million would-be entrants into the United

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States in 2002 alone, the BCIS simply cannot handle the continuous influx.

IMMIGRANTS IN NEW MEXICO Because of New Mexico’s proximity to Mexico, more than threefourths (78 percent) of the state’s legal immigrants are from Mexico. Other countries represented are Vietnam (2.9 percent), Mainland China (1.5 percent), and 1.5 percent each for the Philippines and India. National immigration studies place the illegal immigrant population in New Mexico between 50,000 and 65,000. Between 1997 and 1999, citizenship status was accorded to 92.9 percent of the immigrant population in New Mexico; 7.1 percent were defined as “non-citizens” (Senate Joint Memorial Report 2001). This number is high compared with the percentage of the population comprising undocumented immigrants in the United States in general. In the country at large, 93.5 percent are citizens, and 6.5 percent are thought to be non-citizens. Nationally, families with a non-native Latino householder have levels of poverty similar to those of families with native Latino householders. In New Mexico, by contrast, foreign-born Latino householders are more than twice as likely to have poverty status than those headed by a native-born Latino (INS Data on Immigration to N.M. 2000). Furthermore, although the number of Americans without medical insurance dropped from 39.3 million in 1999 to 38.7 million in 2000, the U.S. Census in 2000 and again in 2003 reported that New Mexico and Texas enjoyed no such reduction. They still have the two highest rates of medically uninsured in the nation, at 24.6 percent and 21.6 percent, respectively. Moreover, immigrants and native citizens alike are enmeshed in a web of social contextual constraints that impact their ability to access health care services. Not only is New Mexico noteworthy for its large immigrant population, but it is also ranked second in the nation for the percentage of its population living in poverty: 18 percent (U.S. Bureau of the Census 2003). For example, the average median income of households in the state is $35,265, the sixth lowest in the United States. In Santa Fe County, 12 percent of the total population lives in poverty, and 19 percent of those are under 18 years (U.S. Census 2000). In addition, New Mexico, in 2001, was classified as a “medically underserved state” by the Office of Personnel Management. Those most likely to experience disparities in health care outcomes are the Native

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Americans and Hispanics, who together constitute half the population of the state: Native Americans compose approximately 10 percent of the population, and Hispanics make up 42 percent. Recent scholarship in the field also uncovers the extreme difficulties encountered by practitioners in New Mexico who serve these populations (see special edition of Medical Anthropology Quarterly 19[1] 2005. See also Waitzkin et al. [2002]). Nativity and citizenship assessed by the 2000 Census illustrate that Santa Fe’s population increased to 62,203 from 57,605, an 8 percent increase since 1990. The city has grown another 7 percent since the 2000 census, with more people moving to the city environs from the rural edges of the county. In the previous decade, the percentage of foreign-born, non-naturalized persons residing in Santa Fe County jumped from 2,518 (4.4 percent of the population) to 9,488 (13.7 percent), an increase of 213.3 percent. Two thirds of the children under five are of Hispanic ethnicity and approximately 50 percent of families with newborns are Spanish speaking. Close to 37 percent of county residents over five years of age speak a language other than English at home, Spanish being the most common (U.S. Census 2000). The local health clinic that serves primarily the uninsured population delivered one third of the babies (600) in Santa Fe County in 2004, the majority of whom were born to immigrant families. As of November 2005, this clinic had approximately 1,000 women registered for prenatal care, most of whom are native Spanish speakers.

WHY SANTA FE? Mexican migrants come to Santa Fe for economic reasons, but they also come on vacation and decide to stay. Some women come to have their babies, thinking that their children will have a better life; others come simply to escape family or boyfriend problems. Some come to be close to their relatives and meet grandchildren born here; others prefer to migrate and work seasonally, keeping houses in both Mexico and Santa Fe. In terms of economic opportunity, Santa Fe is no different from hundreds of other receiving communities in the United States. Historically, and currently, it has a lower unemployment rate than the United States in general—4.0 percent versus 4.9 percent (preliminary U.S. D.O.L. Population Statistic, August 2005)—but Santa Fe supplies no better or higher paying jobs. It does present fewer barriers to health care and education, but migrants seem generally unaware of this before

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their arrival.3 They are not from any specific sending community in Mexico, nor do they appear qualitatively different from Mexican immigrants in many other locales around the United States. So why study immigrants in Santa Fe? Santa Fe has a manageable size relative to a propitious concentration of diverse health ideologies. One can easily canvass migrants’ health care options: the clinics they frequent, the health care providers they consult, the Mexican stores where they buy herbs, even the curanderas who treat them. The high per capita concentration of health food stores—a common place for neophytes to learn about new and different health ideologies (Baer 2001)—makes it obvious to even the most casual onlooker that health and health care products are popular commodities in the community.4 In addition, Santa Fe is home to many spiritual and other types of communities with varied health belief systems: ayurvedism (The Ayurvedic Institute and the Vedic Chant Center); acupuncture and Chinese herbology (the International Institute of Chinese Medicine and the American Academy of Chinese Medicine); hypnotism (the Hypnotherapy Academy of America); massage, cranial-sacral, and other types of energy and body manipulation (the New Mexico Academy of Healing Arts, the Scherer Institute of Natural Healing, and the Light Institute); psychological counseling (Southwestern College); and homeopathy (the University of Natural Medicine). Numerous members of the Native American Church live and practice their peyote healing rituals in Santa Fe. A displaced Tibetan community sponsors standing-room-only demonstrations and seminars by Tibetan physicians trained at the Tibetan Medical Institute in Dharamsala. Some have called Santa Fe a “tidewater zone,” where systems of thought, health and religious beliefs, languages, and people of differing socioeconomic backgrounds mingle, exchange, grow, and change. Many of Santa Fe’s private physicians and public clinic and hospital physicians are open to and even promote non-allopathic methods of healing, regardless of spiritual orientation. Complementary and alternative medicine (CAM) is promulgated by all manner of physicians in many contexts. The New Mexico State Legislature has even inscribed into law that health insurance companies working in the state must reimburse healing modalities such as massage and chiropractic. The 2003 legislature passed a law that compelled health insurers in the state to reimburse doctors of oriental medicine at the

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same rate, and without bias, as medical doctors. Naturopaths are fighting for the same recognition, an endeavor that did not get far in either the 2003 or 2004 sessions. Activists plan to revisit the topic in the 2006 legislative session. Combining biomedicine with CAM is not idiosyncratic to Santa Fe. The immigrant in virtually any U.S. community can come across these and other health ideologies. Although allopathic care dispensed by federally funded public clinics is usually less expensive, holistic care is increasingly available nationwide. According to a recent article in the Wall Street Journal, non-biomedical treatments are more commonplace than ever: “Now at a hospital near you: aromatherapy, meditation, and milk thistle tea. With a third of Americans trying alternative medicine, treatments that your doctor never learned in medical school are spilling into hospitals at a remarkable rate. In just the past two years, the number of medical centers with alternative clinics has jumped to almost 100, up from fewer than a dozen in 2000, according to integrative health experts and medical consultants” (Keates 2003). This phenomenon is not relegated to medical centers that are “off the grid.” Rather, research hospitals such as Beth Israel in New York City, Stanford University Hospital, and Northwestern Memorial in Chicago are getting in on the act. Of course, competition for health care dollars has something to do with the growing popularity of these programs. This interpretation notwithstanding, the administrators for these programs claim to be responding to patient needs. Santa Fe immigrants blend in well with the local population. They speak the same language (although the local variant of Spanish differs from Mexican Spanish), eat basically the same foods, and dress similarly. The herbs used in Mexican caseros remedios are so popular that the local grocery stores sell them. Well-known curanderas give lectures to promote their healing art and their book sales. Mexican migrants do not have to alter their health beliefs significantly and can pursue a path of cultural maintenance. Because of the many ideological options in Santa Fe, a researcher can witness the process of change over time in the health ideology of Mexican immigrant women. Do their beliefs in “traditional” Mexican methods of healing, notions of health and illness, disease etiology and prognosis remain firmly entrenched and unchanging, as currently theorized? Or do they adopt a more allopathic, less traditional belief system, relying less on Mexican herbal remedies and curanderos/as?

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Are they learning about and trying healing modalities such as ayurvedism, Chinese acupuncture, and chiropractic? Or are they integrating all of the above? If these women are open to new ways of caring for themselves, they will access and perhaps even permanently adopt one or more of these healing modalities.

WHY NOW? Latinos experience major health problems at a rate disproportionate to their numbers in the population (NCHS et al. 2002; CDC 2005). Major health disparities are documented in the following categories: cancer screening and management; immunization; diabetes; infant mortality; cardiovascular disease; HIV/AIDS; and smoking cessation (NCLR 2005e). For example, at the end of 2002, 20 percent of all AIDS infected persons were Hispanic. In the same year, the AIDS case rate among Hispanic women was over five times that of White women. And Latino children under 13 years accounted for 26 percent of all pediatric AIDS cases in 2002 (NCLR 2005a). Latino women have nearly three times the incidence of cervical cancer than non-Latino White women do, as well as the highest mortality rates from the disease. The five-year breast cancer survival rate for this population is 15 percent lower than the rate for U.S. Anglo women and its incidence is increasing faster in Hispanic women. Also, the rate of incidence for stomach cancer is more than twice in Hispanic women than non-Hispanic white women (NCLR 2005b). Mexican Americans in particular are 1.7 times more likely than Whites to have Type 2 diabetes; 25-30 percent of Hispanics older than 50 have diabetes and nearly half of Latino children born in the year 2000 are likely to develop diabetes in their lifetime (NCLR 2005c). As the general population enjoyed a decline in heart disease mortality rates—between the years of 1985 and 1991, its death rates declined by 13.5 percent—the Latino population experienced a decline of only 7 percent (USPHS 1996). Moreover, one in three Hispanics between 19 and 64 in the United States lack health insurance (NCLR 2005d). A sampling of health statistics for Santa Fe county reflect some of the disparities mentioned above. For example, only 30 percent of births are categorized as “healthy,” a “healthy” birth meaning that the mother is fit and the pregnancy intended (New Mexico Children’s Cabinet Report Card 2004). The rate of full and complete schedule of immunizations for toddlers between 19 and 35 months of age is only 68

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percent (compared to 71 percent in New Mexico and 81 percent in the U.S.). In the past decade, Santa Fe County’s low birth weight rate has climbed 1 percent to 7.8 percent (SFC Health Profile 2003). The county is designated a “health professional shortage area” for dentists and (as mentioned above regarding New Mexico in general) a “medically underserved area and population” (New Mexico Health Planning Council 2004). Six percent of pregnant women report having physical abuse prior to and/or during pregnancy (New Mexico PRAMS). This 6 percent places Santa Fe County and New Mexico as having the highest percentage of women reporting abuse by a husband/partner during pregnancy in the nation (Child Trends and Center for Child Health Research). During this same time and even preceding it, research on acculturation arrived at a methodological impasse in trying to determine the reason for so many documented health disparities between the Latino and general populations. Researchers are interested in acculturation because a resistance to it is hypothesized as contributing to health disparities. A lion’s share of the literature on acculturation is based on the theory that simple behavioral measures (e.g., language use) provide an adequate proxy for level of cognitive acculturation. In most instances, however, behavioral measures of acculturation have not satisfactorily predicted attitudes (Marie et al. 1996; Negy et al. 1992). Moreover, researchers criticize much of this research for being predicated on a “catalog” of stereotyped cultural traits and social relationships, which they claim is irresponsible (Guarnaccia et al. 1996). In contrast to many published studies, I based my research on the idea that language-based scales of acculturation do not often predict attitudes and beliefs, areas of great concern for health care researchers. For example, in the aggregate, Spanish speakers probably utilize emergency healthcare facilities more than those who are English dominant, but these statistics tell us very little about why this is so, about the Spanish speakers who utilize public clinics more often than emergency care, and about their specific health beliefs. Large-scale, language-based acculturation research in the health domain is rarely more than descriptive. It tells us nothing about causality, about how health beliefs influence behavior. For nearly two decades, theorists in the field have proposed that research in this area delve more deeply and comprehensively into the

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phenomenon of acculturation by means of a longitudinal study design and the collection of naturalistic, qualitative data. Few researchers have attempted this, because of time and money constraints, publication pressures, and problems with attrition, as well as the fear of the unknown that a longitudinal, qualitative methodology necessarily engenders. I am no exception. I, too, was stymied by problems in collecting longitudinal data. Nevertheless, I offer qualitative, narrative-based, context-rich information that affords an intimate glimpse into the processes of change—the antecedents, concomitants, and consequences— in the health ideology of a group of Mexican immigrant women. My research revealed attitudes toward and values about health that effectively distinguish Mexican immigrants who are still strongly identified with their culture of origin from those less strongly identified. Both popular belief and published studies of acculturation posit that change in cognitions and behaviors progresses by generation. That is, first-generation Mexican immigrants rarely alter beliefs, attitudes, or behaviors. In contrast, the majority of Mexican migrant women in my study are embracing new ideas about caring for themselves, changing their health care behaviors, and redefining the way they conceptualize the treatment and prevention of disease. They make many of these changes within five to ten years of arriving in the United States, regardless of their age, whether they emigrated from pueblitos or ranchitos in the country or from the city, and whether they achieved a high school diploma or other advanced degree. In sum, to build and improve upon previous research, I collected qualitative, text-based data instead of quantitative, number-based information. I used open-ended questions instead of closed. I examined belief systems in the context of actual illness episodes instead of just theoretical constructs of beliefs, and I focused on individual life histories instead of aggregate group data. In my research, I endeavored to avoid some of the problems that historically have plagued the field of acculturation research. Rather than assume, a priori, that certain beliefs or values are important to the Mexican immigrants under scrutiny, I called upon the migrants themselves to elucidate exactly which beliefs have meaning to them and how these are instantiated across different contexts. Through this dialogue, I learned how these migrants perceived, labeled, explained, and treated sicknesses before their arrival in the United States and how they have done so since.

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I learned from the immigrants whether they believe in and seek help from traditional healers (i.e., curanderos/as) or allopathic physicians. As they discussed their bouts with sickness, the immigrants told me about the specific ailments for which they treat themselves with herbs and those for which they seek help at emergency rooms instead of public clinics. They told me what being healthy means to them and how they know when they are sick. In their own words, the women in the study explicated the concepts and behaviors that should be useful in forming acculturation scales based on emic items that effectively discriminate between immigrants of Mexican descent who still refer to their culture of origin and those who refer to their host culture. In brief, the evidence I present shows that acculturation occurs in the following areas: (a) beliefs about diet and exercise; (b) cognitive models and/or images of health; (c) beliefs about how people should behave when they are sick; (d) knowledge about and actual use of complementary and alternative medical therapies; (e) belief in the traditional Mexican healing modality curanderismo; (f) English language use; (g) understanding of viral versus bacterial theory; and (h) the discourse on nervios, stress, and depression and related problems.

CHAPTER 2

Modeling and Measuring Acculturation

The phenomenon of acculturation commands great interest among behavioral scientists and anthropologists. Since the turn of the century, the literature on acculturation has grown exponentially. Today, “the serious scholar of acculturation has thousands upon thousands of books and articles which must be studied for a complete understanding of the work in the area” (Padilla 1980:1). Scholars began working with the concept of acculturation as early as 1880 (Berry 1980). The formal adoption of acculturation as an area of scientific inquiry, however, did not begin until the 1930s, when the Social Science Research Council appointed the Subcommittee on Acculturation to identify and define the parameters of this burgeoning field of study (Olmedo 1980). Scholars commonly recognize four classic formulations: Redfield et al. 1936; Herskovits 1938; Linton 1940; and the Social Science Research Council (SSRC) Summer Seminar 1954. Most lauded for its clarity and prescience, and therefore most often cited, is Redfield and others’ definition: Acculturation comprehends those phenomena which result when groups of individuals having different cultures come into continuous first-hand contact, with subsequent changes in the original culture patterns of either or both groups.…Under this definition acculturation is to be distinguished from culture change, of which it is but one aspect, and assimilation, which is at times a phase of acculturation. It is also to be differentiated from diffusion, which while occurring in all instances of acculturation, is not only a phenomenon which frequently takes place without occurrence of the types of 15

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contact between peoples specified in the definition above, but also constitutes only one aspect of the process of acculturation. (1936:149) An examination of recent literature reveals that research on acculturation has undergone two significant developments: (1) a shift in the cultures of interest, from culture contact between the Indians of North America and Euro-Americans, to the study of Asian/Pacific Americans and Latin American ethnic groups residing in the United States, and (2) an increasingly complex and multidisciplinary approach. The disciplines of sociology, psychiatry, and psychology have begun to treat acculturation as a relevant area of investigation: These recent developments have greatly expanded the scope of acculturation research, but have also increased its complexity. Each discipline has contributed its own interests as well as conceptual and methodological tools to the study of acculturation involving American ethnic groups. Thus, sociologists have, in general, conceptualized acculturation as a “group” process of assimilation and their primary interest has been within the context of minority group and race relations. Psychologists and psychiatrists, on the other hand, have conceptualized acculturation as an “intra-psychic” phenomenon dealing with changes in the perceptions, attitudes, and cognitions of the individual. This “differential psychology” perspective has focused on the wide range of individual differences in acculturation levels as well as the empirically demonstrable implication of these differences vis-à-vis stress and mental health, cognition and personality, and psychological/educational testing. (Olmedo 1980:28) In Berry’s seminal work, Acculturation as Varieties of Adaptation, he outlines three varieties of what he terms “adaptation”: Adjustment, Reaction, and Withdrawal. “These three varieties of adaptation are similar to the distinctions in the psychological literature made between moving with or toward, moving against, and moving away from a stimulus” (1980:12). Additionally, four varieties of acculturation may be identified: Assimilation, Integration, Rejection, and Deculturation. Assimilation (“moving toward” the host society) is characterized by relinquishing cultural identity and moving “into the larger society.” Integration, by contrast, implies holding on to or maintaining “cultural

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integrity” while becoming an integral part of the host culture’s structure. Rejection, considered by Berry to be a “negative” type of acculturation, refers to “the self-imposed withdrawal from the larger society.” Deculturation refers to groups’ being “out of cultural and psychological contact with either their traditional culture or the larger society. When imposed by the larger society, it is tantamount to ethnocide. When a result of being chosen for whatever reason [by the individual], it constitutes the classical situation of ‘marginality’” (1980:13–15). On the individual level, Berry identified six areas of individual psychological functioning that respond to second culture acquisition: language, cognitive style, personality, identity, attitudes, and acculturative stress. He proposed that there is a common course across all six psychological areas: a traditional (precontact) situation precipitates a gradual change in psychological characteristics until some hypothetical conflict or crisis point is reached, after which a variety of adaptations occur (1980:17). Moreover, Berry posits, the effects on psychological functioning are neither linear nor unidimensional. Since Berry, most studies have focused on and attempted to quantify one of three areas of individual functioning: (1) The behavioral includes verbal behavior or language development, customs, food preferences, and cultural expressions such as music choice (Cuellar et al. 1995b). These variables—language use, dress, technology—are incorporated at a more rapid rate, in general, than abstract or less tangible qualities such as sentiments and values (Mendoza et al. 1981). (2) The affective encompasses emotions that have cultural antecedents, such as the way one feels about ethnic identity, the symbolic systems one supports, and the “meaning one attaches to life itself” (Cuellar et al. 1995b:281). (3) The cognitive refers to beliefs, ideas, and attitudes, for example, about male/female roles and about illness, as well as what Marín describes as “values and norms …those constructs that prescribe people’s worldviews and interaction patterns.” He argues that “changes at this level can be expected to be more permanent and to reflect actual culture learning (or adoption)” (Marín 1992:238–39). Another research approach studies factors that inhibit, accelerate, or are correlated with the process of adaptation (Mendoza et al. 1981). For example, Weinstock’s (1964) work with Hungarian immigrants points to an acceleration of acculturation in those personality types that

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demonstrate high achievement and strong goal orientations. Work by Burriel (1975), Martínez (1977), and Ramírez and others (1974) found that faster rates of acculturation are associated with socioeconomic status, educational level of head of household, community type, and generation level. Yet another approach focuses on the psychological and physical manifestations that accompany or result from second culture acquisition, what one researcher has termed the “Lifestyle Model” (Salant et al. 2003). For example, this type of research studies rates of transient diabetes and alcoholism, “psychosomatic” disorders such as hypertension, and suicide and overall mortality rates, all of which tend to increase as a result of the acculturation process (Mendoza et al. 1981).

BICULTURALISM Redfield and others’ (1936) definition, quoted above, does not in any way constrain researchers to conceptualize adaptation to the host culture as a unidimensional process. Nevertheless, this has been the dominant theoretical underpinning of most acculturation studies. In practice, researchers have hypothesized the meaning of acculturation as complete assimilation of behaviors, beliefs, and values of the dominant group in the United States by immigrants or ethnic minorities. This adaptation process has been conceptualized in three basic ways, two of which contain a “moment” of biculturalism as the immigrant proceeds along the path toward assimilation. The third model represents biculturalism as it has most recently been conceived in the literature. The Single-Continuum Linear Model of acculturation posits the gradual relinquishing of traditional cultural traits simultaneously with the incremental subscription to Anglo American norms. (Trait, in this regard, generally encompasses behavioral, affective, and cognitive areas of functioning.) In this depiction, acculturation is measured along a line representing Mexican culture at one extreme and U.S. culture at the other. This linear definition of acculturation represents a functional relationship between two variables: y = x + c (Cuellar et al. 1995b). According to one version of this model, individual acculturation is a linear function of the length of time a migrant has been exposed to the host culture, and the rate at which acculturation progresses is a function of the migrant’s age and sex and other demographic variables (Szapocznik et al. 1980).

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The most prominent criticism of this depiction is that the two poles are not measured independently; this “mutual exclusion” bipolar model of acculturative change posits that involvement with one culture necessarily entails disengagement from the other (Rogler et al. 1991:586). Most items in these scales are worded so that an interviewee must choose between the two cultures. If a respondent happens to score in the middle range of most questions (e.g., asking to what extent the respondent speaks English or Spanish in a variety of situations—the choices ranging from “mostly Spanish” to “mostly English”), he or she is considered bicultural. According to Rogler and others, “items presented in this way constrain the respondent’s choice of alternative answers according to a model of a zero-sum competition between the two cultures” (1991:587). Because the two poles are not independently measured, “high” biculturals possessing strong characteristics in both American and Mexican cultures cannot be distinguished from those biculturals who possess “low” characteristics in both cultures (Cuellar et al. 1995b). Thus, the unidimensional, linear manner of assessment severely limits the types of biculturals that can be described. Numerous studies are theoretically based on this type of continuum (Cuellar et al. 1980; Márin et al. 1987; Burnam et al. 1987). Spindler’s (1955) study of the acculturative patterns of Menomini Indians graphically depicts the linear model of acculturation level: unacculturated, bicultural, and acculturated. Nearly two decades ago, Garcia and others (1979) proposed an alternative. Theoretically based on the assumption that cultural influences of both the original society and the host society are not mutually exclusive and that the two can be measured separately, the result was (apparently) a valid and reliable measure specific to Cuban culture (Rogler et al. 1991). This and other research projects (e.g., Szapocznik et al. 1980) gave impetus to the creation of a second model, the Two-Culture Matrix Model. In this conception, the two cultural systems are treated singly as two independently derived axes forming an orthogonal matrix. Each culture is conceived as an independent continuum, and the two cultures are hypothesized to intersect at right angles (see Appendix A, figure 2). According to this model, “individuals may vary in their acceptance of and adherence to the two cultures” (Keefe and Padilla 1987:16). Individuals who acquire behaviors/affects/cognitions from the new while retaining traits common to the native are deemed bicultural; those who do not fully

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accept either are considered marginal. The matrix model was first illustrated graphically by McFee (1968) and has been emulated recently by Cuellar and others (1995b). According to them, the model is truly multidimensional because it possesses two distinct axes with four quadrants, as indicated in Cartesian analytic geometry. The matrix model, however, has not been without its critics. Marín (1993) and Magaña (1996) have maintained that, despite attempts to expand the matrix model to a higher level of complexity, the outcome is often undermined by an adherence to individual item responses that require a unidimensional ordinal answer scale. Also, each culture is still portrayed as a monolithic entity to be accepted or rejected in its entirety. Thus, the matrix model treats each culture unidimensionally, even if it acknowledges the possibility of “possessing” attributes from both cultures. The Multidimensional Model, the third conceptualization of the acculturative process, postulates that the acceptance of the new and the loss of the traditional vary from trait to trait and from domain to domain. Because some traits are relinquished slowly and others are quickly replaced, “each aspect of culture change must be measured independently” (Keefe and Padilla 1987:16). The multidimensional model vastly improves upon the matrix model because it does not assume that biculturalism necessarily entails being highly adept in both cultures. Regarding the utility of the multidimensional model, Keefe and Padilla state that “the concept of selective acculturation has been used to describe the common tendency for immigrants and ethnic minorities to adopt certain strategic traits (especially those, such as learning English, which will improve their economic status), while retaining other traditional cultural values and patterns, including childrearing practices, family organizations, native foods, and music preferences” (1987:16–17). When it is desirable to investigate biculturalism (or multiculturalism) as a pattern of acculturation in its own right, biculturalism must be differentiated from assimilation. The customary ordinal-response format, used in conjunction with a scoring system that sums or averages responses across the scale items, loses its capability to tap biculturalism because the mean or sum does not always reflect the underlying patterns of responses. An individual may answer an equal number of items at the low and high ends of the response set and none in the middle. He or she may have a preponderance of scores in

Modeling and Measuring Acculturation

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the middle or a variety of responses spread across all the items. Although all situations could total the same means score, one would be comfortable claiming only that a single situation reflects a bicultural adaptation. As it is frequently interpreted, a subject who is bicultural has a lower score on the resulting scale than a subject who is assimilated. This circumstance suggests that one individual is more assimilated than the other, but it masks the fact that the two manifest distinctly different patterns of acculturation (Mendoza 1989:447). Mendoza avoids the unidimensional response-set problem by creating separate methods of scoring across dimensions. The result is a set of three bipolar scales measuring assimilation to a new culture (cultural shifting), retention of the old (cultural resistance), and biculturalism or the development of fluency in both cultures (cultural incorporation). According to Magaña and others, “this scoring method, which we term bidimensional scoring, avoids the problem of embedding bicultural scores in the middle of the range and provides the advantage that correlates of biculturality per se can now be investigated.” They continue: The domain sampling theory of scale construction and the need to achieve more power in statistical analysis require that psychometricians construct single continuous measures from sets of related discrete measures. There are various algorithms that can be employed to create a single scale score from a set of discrete items, but in some cases the choice can set an artificial limit on what can be learned with the scales that result. What we will term unidimensional scoring after the usage introduced by Marín (summing or averaging over ordinal response sets) is such a case when acculturation is the target construct. An alternative algorithm that we will term bidimensional scoring (counting the number of responses in a given direction to create multiple scales) avoids the limitations of unidimensional scoring in the case of acculturation….(Magaña et al. 1996:448) Although their instrument, the CLSI, uses the ordinal response set described above, “it is scored bidimensionally by treating the responses as though they were nominal rather than ordinal data. That is, to compute a subject’s score on the scale measuring cultural resistance, the number of items answered in a resistant direction are counted and divided by the total number of valid responses, yielding a scale score

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that ranges from zero to one” (1996:451). This may be a step in the right direction, but the CLSI takes the ordinal response set employed by many acculturation measures and treats it as though it were nominal data to achieve a bidimensional scoring system and regain the lost bicultural dimension. Thus, it leaves the psychometric properties of the new scales in question. For example, is the reliability of the scales produced from the ordinal items retained with a nominal scoring procedure? Future research that investigates these issues would be useful. Scoring controversies aside, the advantage of this sort of multidimensional model is that it is flexible enough to accommodate the novel social and cultural patterns inevitably created by migrants as a result of culture contact, a process termed “creolization” by Watson (1977). Creolization is a phenomenon studied by researchers interested in the Mexican American barrio, a locus of the pachuco lifestyle and language. Obviously, a model flexible enough to allow for the creation of such new cultural characteristics as those of the pachuco is highly desirable. This multidimensional model has been suggested by Pierce and others (1978) and Olmedo (1980) and has been utilized by Keefe and Padilla (1987) in their research on Chicano ethnicity. Elsewhere, this type of multidimensional model is named the Fusion Model (LaFromboise et al. 1993). The fusion model suggests that when cultures share a geographical, political, and economic “space,” they fuse, ultimately creating a new culture—the idea underpinning the “melting pot” metaphor of cultural evolution: “The respectful sharing of institutional structures will produce a new common culture. Each culture brings to the melting pot strengths and weaknesses that take on new forms through the interaction of cultures as equal partners…The fusion model is different from the assimilation or acculturation model in that there is no necessary assumption of cultural superiority” (1993:401). The fourth and final model is the Alternation Model. This model posits that a migrant can intimately understand two cultures; it also postulates that an individual can alter his or her behavior to fit a particular social context (LaFromboise et al. 1993:399). Like the matrix model, the alternation model assumes a bidirectional relationship between the individual’s culture of origin and the host culture. Like the multidimensional model, it hypothesizes that variation exists, from trait to trait and domain to domain, not in the sense that new traits are

Modeling and Measuring Acculturation

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acquired and others are relinquished, but rather in the manner and degree to which individuals choose to alternate (behaviors, etc.) between cultures. As with the multidimensional model, each aspect of culture change must be measured independently. At issue in the present case is how migrants integrate new behaviors and cognitions and differentially utilize them, depending on context. Postulated by the researchers working within this paradigm is the idea that an individual can and will choose the manner in which and degree to which he or she will affiliate with either mother or host culture. Also integral to the alternation model is the suggestion that an individual can have a positive relationship with both cultures and not feel forced to choose between them. Moreover, “this model does not assume a hierarchical relationship between [the] two cultures. Within this framework, it is possible for the individual to assign equal status to [each], even if he or she does not value or prefer them equally” (1993:400). Similar to the theories of code switching found in the literature on bilingualism, the alternation model is an “additive” model of cultural acquisition (LaFromboise et al. 1993:399). Just as certain literature on bilingualism points to the positive effects of fluency in two languages, the alternation model theorizes that individuals who are well versed in two cultures and comfortable alternating between them experience less anxiety than individuals undergoing the processes of assimilation or acculturation. Garcia (1983), Rashid (1984), Rogler (1991), LaFromboise (1993) and others have speculated that migrants who effectively alternate culturally appropriate behavior may demonstrate higher cognitive functioning and mental status than people who are monocultural, assimilated, or acculturated. The strength of the alternation model is that it frames the subject of acculturation in a positive light by focusing on the affective and cognitive processes that enable an individual to withstand the negative impact of acculturative stress. Additionally, it provides a framework for observing the migrant in the process of choosing how he or she will balance the culture of origin with the adopted culture. Aspects of the alternation and the multidimensional models provide much of the theoretical underpinning of the present research, outlined in greater detail below.

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ATTITUDE AND VALUE ORIENTATIONS Several past attempts to isolate an attitudinal component of cultural identity have relied on Kluckhohn and Strodtbeck’s (1961) values orientations (Clark et al. 1976; Szapocznik et al. 1978). The five orientations are Human Nature (the character of innate human nature); Man to Nature (subjugation to, harmony with, or mastery over); Time, Activity (being, being in becoming, or doing); and Relational (one’s relation to others). These orientations, however, are considered “too broad to generate measures of cultural identity and may be difficult to translate decisions in everyday life” (Félix-Ortiz et al. 1994:111). Moreover, these particular value orientations tend to depict Latinos unfavorably (Marín 1986). According to Kluckhohn and Strodtbeck (1961), the value of “familism,” along with key values such as fatalism, present-time orientation, and being rather than doing, are primarily responsible for the low rate of acculturation among Spanish-speaking Hispanic Americans in New Mexico (and this is considered a negative). This point of view assumes that familism (as a value and behavior pattern) is the independent variable controlling, in part, the rate and extent of the acculturation process (Keefe 1987:111). Assessments of values or attitudes that are more specifically related to the everyday life of Mexican migrants are in high demand. Just a few of the studies that stand out in their capability to assess values and/or attitudes validly and reliably in the Latino community are Keefe and Padilla’s (1987) assessment of ethnic identity and cultural awareness, Félix-Ortiz and others' (1994) Multidimensional Measure of Cultural Identity for Latino and Latina Adolescents, Domino and Acosta’s (1987) study of the relation of acculturation and values in Mexican Americans, and Jankowski’s (1986) analysis of political attitudes among Chicano youth. Despite these studies, the association between the possession of particular attitudes and specific behavioral patterns has not been established definitively, for acculturation research or for the field of psychology in general. A recent project examined the cognitive referents of acculturation. Included in its assessment was a scale designed specifically to measure ideas about health—what they call “Folk Beliefs” (Cuellar et al. 1995a). The main thrust of this study was to explore in the Mexican American population the empirical relationships between a wellestablished behavioral measure of acculturation (e.g., language use) and five theoretical cultural constructs composed primarily of cultural

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beliefs, ideas, and attitudes. “The five cultural constructs selected are those that have been hypothesized as cultural variables with the potential for influencing the experience of illness and/or help-seeking behaviors; the five cognitive cultural constructs, which represent aspects of Mexican-American culture, have been reported in the literature as factors which influence the delivery of mental health services”(1995a:340). The five constructs (which are partly based on Kluckhohn and Strodtbeck’s work mentioned above) are (l) Machismo, (2) Folk Illness, (3) Familism, (4) Fatalism, and (5) Personalismo, which is defined as a warm and personal way of relating to an individual or an orientation toward people rather than toward impersonal relationships. These five cultural constructs were measured by the Multiphasic Assessment of Cultural Constructs―Short Form (MACC-SF), a 60-item true/false scale. Interestingly, acculturation regressed on four of the five hypothesized constructs (Familism, Machismo, Folk Beliefs, and Fatalism) was significant at the .001 level. These four were found to be negatively correlated with acculturation (so the coefficients for these variables were negative). According to the authors, “the four scales combined accounted for 13 percent of the variance in acculturation as measured by ARMSA-II [a then relatively new multidimensional scale]. A stepwise regression showed Folk Beliefs to account for the largest percent of variance in acculturation” (1995:351). The authors conclude that cognitive referents of acculturation were found to change “concomitant with generational status and behavioral acculturation, thus validating four of the five cultural constructs while simultaneously validating Acculturation Theory” (1995:352). Acculturation theory postulates that psychological acculturation takes place at least along cognitive and behavioral domains. The authors’ claim notwithstanding, this study of cognitive referents as they relate to level of acculturation explained only 13 percent of the variance. In reality, this is not much of an explanation. Furthermore, it is unclear exactly how these results can be interpreted to aid in understanding causal relationships and predicting health-related behaviors. The significance of the above research for the present study is that it demonstrates, for the first and only time, that a change in traditional beliefs about health can be assessed empirically and directly. This is obviously preferable to validating indirectly, utilizing only behavioral (e.g., language use) indices. Yet, the literature criticizing such forcedchoice survey instruments is vast (e.g., Briggs 1986; Bradburn et al.

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1987; Tanur 1992). Survey methods produce reliable quantitative data for statistical analysis, generalization, and replication, but the gain in quantitative rigor is necessarily a loss in terms of historical depth, richness of context, and the intuitive appeal of people’s heartfelt stories. Furthermore, even though the study appears to show that ideas about health and illness do change over time and that there is a relationship between cognitions and behavior, it provides no insight into the catalysts or concomitants of change. Concerning the rate of change, this research reveals nothing more than that beliefs or cognitions change sometime in the second generation.

THEORETICAL UNDERPINNING OF THE STUDY The initial and most popular measures for assessing acculturation were behavioral measures of acculturation processes. More recent research has focused on the relationship of cognitive measures—values, attitudes, and beliefs—to level of acculturation (Cuellar et al. 1995b; Domino and Acosta 1987; Marín 1993). In general, there is a lacuna in the literature of empirical studies that relate psychological processes to acculturation (Cuellar et al. 1995b; Padilla 1980). In most instances, behavioral measures of acculturation have not satisfactorily predicted attitudes (Marin and Gamba 1996; Negy 1993). It makes intuitive sense that the rates at which individuals acculturate would vary, depending on which values, attitudes, or behaviors are being assessed, but cognitive referents of acculturation have been difficult to validate. Only a few studies have claimed to demonstrate quantitatively and convincingly the relationship between behavioral and attitudinal processes of acculturation (Cuellar et al. 1995a; Hazuda et al. 1988; Keefe and Padilla 1987). Ideally, researchers would like to be able to discern in a reliable, valid fashion whether an individual is, for example, cognitively bicultural (fluently speaks English and Spanish), displays “affective cultural shift” (holds some attitudes that reflect ideas of the dominant culture), yet acts “behaviorally unassimilated in terms of food habits and dress preferences” (Mendoza and Martinez 1981:75). This sort of granularity is appealing because true individual variation is possible. In the study mentioned above, Cuellar and others found that “some cognitive referents of acculturation change more rapidly than others, while still others are linked by varying degrees with such variables as age, grade, and socioeconomic status” (1995a:352). Similarly, in a study by Hazuda and others, researchers found that “although Mexican Americans…had

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experienced substantial degrees of acculturation to the dominant, nonHispanic white culture (primarily in their adult years), acculturation on adult language dimensions far exceeded that on value and attitude dimensions” (1988:702). Therefore, an isomorphism between the language spoken at the interview (the most common behavioral construct of acculturation), or other behavioral correlates, and adherence to “traditional” folk ideas about health or the centrality of the family (or whatever belief is being studied) is far from assured—although often assumed. Because English-language acquisition may proceed faster than change in beliefs about health and illness, one cannot assume that the language an individual chooses to speak in an interview indicates that individual’s belief systems. Moreover, problems persist in trying to define and measure the differences between values, attitudes, beliefs and behavior. Contrary to the literature based on secondary statistical analyses of large sets of cross-sectional data, I do not assume a simple, direct relationship between a particular acculturation level, as assessed by the various rating scales available, and an acculturating individual’s belief in and adherence to traditional notions of health and disease. Angel and Cleary (1984), Angel and Guarnaccia (1989), and Guarnaccia and others (1989) assume the opposite. The scales used in their surveys are most often predicated on behavioral variables having little to do with health behavior or attitudes (e.g., language choice). As a result, these do not often predict attitudes toward health care, much less health care utilization. For several decades, it has been a premise of the research based on secondary analyses of cross-sectional data, such as the Hispanic HANES, that specific language usage indexes the degree or extent of acculturation. Researchers interested in acculturation and how various levels of it affect the internal validity of health surveys consider a respondent who chooses to be interviewed in English not only adept at expressing himself in English but also more identified with the dominant English-speaking culture. Conversely, researchers regard an interviewee who opts for Spanish as less culturally assimilated and therefore more in tune with traditional (Latino) cultural ideas about health and illness (Gamst et al. 2002; Angel and Guarnaccia 1989; Guarnaccia et al. 1989; Angel and Cleary 1984). Additionally, these and other researchers posit that use of language of interview to tap degree of assimilation largely differentiates more recent immigrants from Mexican Americans of second and later generations” (Borrell 2005; Ramos 2005).

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The present Mexican American immigrant population is more urban and encompasses greater variation in socioeconomic background than past immigrants. Implicit in this research, however, is the assumption that a more traditional orientation toward medicine still exists and is most common among the recently emigrated, the impoverished lower class, and Mexican Americans coming to the U.S. from rural areas. These are the subjects more likely to request the Spanish-language version of the survey and to respond to health-related questions in ways researchers have interpreted as being traditional. Traditional, in this regard, implies that Spanish-speaking subjects are more likely to believe in curanderismo and the philosophical premises on which it is predicated (see Maduro 1983 and GangotenaGonzalez 1980 for comprehensive treatments of contemporary curanderismo). Also, they are more likely to endure chronic illness stoically and impassively, resulting in fewer reports of worry and pain, to disregard specific symptoms, and to avoid health clinics (Angel and Cleary 1984). Last, and most important for this discussion, Spanishspeaking respondents perceive their global health status differently than non-Spanish-speaking subjects: they tend to derogate their health status and exaggerate their feelings of somatic distress. In one published study, discrepancies between self-reports of global health status and “objective” physician assessments were found to be greater for the Spanish-speaking Mexican American population than for the Englishspeaking, so discrepant that the extent of agreement between physicians and respondents reached only 15 percent. That is, only 15 percent of Spanish-speaking interviewees agreed with physicians that their health was “excellent.” Rather than rate their own health as excellent, as physicians had rated 80 percent of the sample, Spanish-speaking subjects described their health as buena or regular, terms that are interpreted as corresponding to the English categories of “good” or “fair” (Angel and Guarnaccia 1989). Strong identification with traditional culture, measured by answering the questionnaire in Spanish, is rendered an explanatory variable powerful enough to elucidate significant statistical outcomes in the data: Trends indicate that Spanish-speaking Hispanics are culturally habituated to report worse overall health than are English-speaking Hispanics, non-Hispanic Whites, and Blacks. Since speaking Spanish in the context of the interview is associated with poorer self-assessed health and because those who took the interview in Spanish are

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postulated as being more culturally Mexican, these findings “reflect a culturally conditioned response pattern in addition to actual poorer overall health” (Angel and Guarnaccia 1989:1234). In general—and most likely, unintentionally—subjects are often portrayed as exaggerating the severity of their health condition (Reichman, 1997). Another common (and problematic) procedure has been the creation of items that are assumed a priori to measure a given acculturative dimension (e.g., language use, patterns of media use, and attendance at culturally appropriate celebrations). The score derived from these items is utilized as if they actually form a psychometric scale. In many cases, no information is available on the internal consistency of the a priori “scale,” and validity indicators (other than possibly face validity) are often missing. Other scales and indices have “included demographic indicators or correlates of acculturation (e.g., generation of respondents) as part of the acculturation scale or index, spuriously increasing the validity of the scales” (Marin and Gamba 1996:311). Although several researchers have recognized this limitation and have called for future research on the topic (Betancourt and Lopez 1993; Marin 1992; Rogler et al. 1991), little has been published since then that addresses how we can assess acculturation at a more profound level (Cuellar et al. 1995a). One problem with these surveys, according to Marín and Gamba, is the relative scarcity of culturally appropriate emic instruments to measure basic Hispanic values. “A proper understanding of acculturation requires this more basic analysis, and this is an area to which attention should be directed to move the field beyond its present status” (1996:310). Therefore, at this point in the history of culture contact between the United States and Mexico, “there is little doubt that the field of Hispanic acculturation needs to move beyond scale construction of mostly etic items.…” (1996:311). Attempts to illuminate the process of acculturation via closedended questions and statistical analyses have been only partially successful, and not just because of the problematic inclusion of questionable emic items on survey instruments. Rather, because acculturation is a process, not an event, it involves at least two points on any dimension (e.g., attitudinal and behavioral). Attempts to freeze culture—or level of acculturation (which, itself, is a cultural type or form of culture)—into a set of generalized value orientations or behaviors will consistently misrepresent what is both culture and

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acculturation. Dynamic, creative, and illuminated by the narrative form of particular life histories and evolving contexts, culture is what shapes and informs each individual’s tenacious adherence to the “traditional” as much as his tentative, or wholehearted, acceptance of the “modern.” Acculturation researchers should not be criticized unduly for the problems within anthropology of defining a core concept. What was once considered static and unchanging is now conceptualized differently. While not disregarding entirely the idea of the direct (i.e., unidirectional) cultural transmission of ideas, values, behaviors, and the like, recent transformations in the study of culture have attempted to understand the concept as a dynamic in which values, attitudes, and practices are reciprocally affected by social conflict, social transformation, power relationships, and migrations (Geertz 1973; Good 1994; Guarnaccia and Rodriguez 1996). Of late, approaches have focused on the emergence of culture from the daily social practices and life experiences of small groups and individuals. Therefore, it must be recognized and underscored that the process of acculturation is similarly long-term, fluid, and reciprocal. Many problems associated with the global assessment of cultural affiliation are due to having overlooked the dependence on context of behaviors, attitudes, and values, all of which are maintained and reinforced by certain personal experiences and social contexts or are ultimately disvalued and replaced by others (Guarnaccia and Rodriguez 1996). Cross-sectional (“snapshot”) survey data simply cannot glean information regarding the complexity of this process. As Herskovits (1938) and Siegel and others (1953) have previously noted, acculturation should be seen as a dynamic process rather than as an end result. It is also a “bidirectional phenomenon that can affect change at the individual and group levels” (Mendoza and Martinez 1981:79–80). In assessing progress in the field of acculturation research, Mendoza and Martinez lament the lack of sophistication: “In general, very little effort has been devoted to the development of empirical or theoretical models that attempt to describe the dynamic components of acculturation” (1981:72). One dynamic aspect, the rate of change, is still poorly understood. Most studies posit that change in cognitions progresses by generation. That is, first-generation Mexican immigrants rarely shift beliefs and attitudes; it is their children who readily adopt cognitive and behavioral aspects of U.S. culture. Numerous studies hypothesize various factors that affect the tempo of acculturation. For example, one needs to

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understand the circumstances surrounding the acculturating individual’s change of locus: Has the person voluntarily sought out the culture contact, or has it been forced upon him or her (i.e., is the person an immigrant or a refugee?)? Is the situation temporary and voluntary, temporary and involuntary, long-term and voluntary, or long-term and involuntary? Has the migrant relocated to a culturally plural or a culturally monistic society? Is a social network of other migrants available to the recently arrived immigrant? Is the host society tolerant of diversity, or do structural and cultural impediments preclude the individual’s participation? Age, gender, socioeconomic background, educational level, and so on, are factors that have been examined to determine their influence on rate of acculturation. Few (if any) studies, though, have attempted to study the process as it unfolds. The notions of assimilation and acculturation in early research in the field of acculturation were often unidimensional and conflated. In contrast, guiding my research was the fundamental supposition that an individual can be familiar with, understand, and choose to move between two cultures or cultural practices. Of course, level of acculturation varies, depending on the domain under scrutiny (as outlined by the multidimensional model, described above), but an individual can alter his or her behavior to fit a particular social or cultural context (e.g., the alternation model, LaFromboise et al. 1993:399). Ogbu and MatuteBianchi have argued similarly: “It is possible and acceptable to participate in two different cultures or to use two different languages, perhaps for different purposes, by alternating one’s behavior according to the situation” (1986:89). Ramirez (1984) also concludes that there are often multiple problem-solving, human-relational, coping, communication, and incentive-motivational styles, which vary by sociocultural context. Kleinman, though not writing about the context of culture change per se, has argued similarly for more than two decades. In the province of health, seemingly disparate ideas function as congeries of separate beliefs and practices without an overarching integration (Kleinman 1980:97). Berger and others (1973) describe health beliefs as individual packages of ideas, no two being exactly alike, made by assembling components from various systems of belief. Acting pragmatically, people tacitly pick and choose the behaviors and beliefs they think will aid them in maintaining or recovering their health. Kleinman explains: We can see that individuals are in contact with different belief and normative systems.… As they move between distinct

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Immigration, Acculturation, and Health clinical realities of health care, they carry with them their own cognitive and value orientations and encounter other cognitive and value frameworks. Contact with another system of meaning and norms may mean simply a shift between conceptual frameworks and behavioral styles the patient himself possesses or has had experience with and can negotiate with. Quite commonly, this contact is a more demanding and difficult experience, because it entails conflict between markedly divergent orientations. What is more, it occurs in situations (social interactions involving power differentials) that press upon the patient a particular view of social reality as the one he must accept: the clinical reality socially constructed by the professional or folk sectors of health care. Furthermore, a patient at times may be exposed to different explanations and value statements about his illness at home, among friends, and at work—all in the popular health sector—and again when he encounters the more formal explanations tended him by professional and folk practitioners. (1980:99)

Congenial to this study is the metaphor of developing expertise provided by cognitive studies. In this regard, the development of expertise is theoretically commensurate with the alternation model posited by La Fromboise and others (1993). In the health domain, becoming acculturated means learning new things and expanding one’s repertoire. The expansion of one’s repertoire does not mean necessarily that old ideas/beliefs/cognitions are lost or forgotten; it means simply that one has added new ones to the “tool kit.” Allegiances may shift and contexts may bring different beliefs and/or values, but the new does not ineluctably displace the old. What I illustrate here is that, at times, respondents merely add new ideas to their preexisting beliefs about health care, enabling them to alternate seamlessly between orientations. At other times, I show that actual cognitive shifts have occurred, shifts that entail changes in basic values (attitudes) and associated behaviors. In these moments, alternation was no longer possible. The two beliefs were completely incompatible, and the acceptance of the one meant the ineluctable relinquishing of the other.

CHAPTER 3

Methodological Considerations, Data Collection, and Analysis

Cross-sectional studies tell us what to expect on the average, but not what individual children do; they provide an envelope, but inside the envelope we may find individual differences. The only way to determine if individual minds follow the same course of development as the group mind is to track individual minds over a period of time… G. Miller, Spontaneous Apprentices: Children and Language Unlike quantitative, cross-sectional research, case-based narrative research provides an intimate glimpse into individual agency, or motivations and behaviors. It enables the researcher to induce or, better yet, understand “sequential and temporally ordered patterns of change” (Mishler 1996:79). The case-based methodology I used in this study also enabled me to understand the acculturative process multidimensionally. That is, I examined only one domain, health care, and independently measured separate aspects of culture change within that domain. A true longitudinal study, in which participants are queried several times over many years (i.e., there are numerous data-collection points) to ascertain change over time, was not feasible. I decided that the evolution of health beliefs could be inferred by questioning two subgroups of women (those who had lived in the United States fewer than five years and those with more than five years’ experience living here), using the same instrumentation about their attitudes, values, beliefs, and behaviors. Therefore, this research project could be loosely defined as a “non-experimental” and deductive one in which 33

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conclusions are based, in part, on correlational procedures reflecting the association between or among variables (Sproull 1995:134). Question by question, I examined the data and then “reconstructed” it in the manner discussed by Mishler (1996). That is, I rearranged it, by interview, in chronological order (Goodman describes this as “the order of the told,” as opposed to the “order of the telling” 1981:799). This revealed a series of event patterns or trajectories of experience and associated (or resulting) health ideologies. In other words, why some people adopted certain health-related beliefs and others did not, based on shared personal experiences, became obvious. In addition, placing the narratives in juxtaposition afforded the opportunity to ascertain the common or prototypal event sequences leading to changes in health ideology and associated behaviors. I then undertook consensus analysis to determine (a) whether these event trajectories and associated clusters of beliefs aggregated in a meaningful way in relation to time lived in the United States and (b) who espoused these ideologies and why. All aspects of this study—from data collection techniques to questionnaire design—were reviewed and approved annually by the Institutional Review Board at the University of Chicago (Protocol #99154).

RESPONDENT POPULATION I decided to canvass as many individuals (or “cases”) as possible. I needed at least 60 subjects in order to gather enough data to work with statistically at a future date. Also, “a minimum sample size of 30 for each group [is required so that] the probability of data distribution approaches a normal one” (Sproull 1995:121). In all, I collected data from 62 undocumented Mexican women between May 2001 and July 2002. Sixty-three percent of the sample population had been in the United States fewer than five years, and 37 percent, more than five years. I determined that female respondents would be easier to locate— fewer of them work outside the home, often delegated the tasks of housekeeping and childrearing. It is well documented that women use health care services more frequently than men do. In 2000, females made the majority of office visits—in terms of percentage and also visit rates (number of visits per year)—compared with male patients in the age group between 15 and 64 years (National Ambulatory Medical Care Survey 2002). Most studies show that pregnancy, childbirth, uniquely female diseases, and preventive and diagnostic needs are

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major factors behind women’s greater use of mainstream health services (Mustard et al. 1998). Also, women have a higher prevalence and incidence of many chronic conditions (Green et al. 1999). Gender roles and socialization, too, may affect women’s responsiveness to illness, causing them to be more active in seeking medical care (Green et al. 1999). These statistics refer, of course, to health care utilization by women in the United States; the exact rates of health care utilization for women in Mexico are unknown. I assumed that women there, like women here, even in the absence of a childbearing experience, visit health professionals more often than men do. In a study of biomedical practice and patient response in Mexico, Finkler (1991) found that women, four times more frequently than men, sought care and agreed to be interviewed. So that I could infer change over time in beliefs about illness and health, I determined that the sampling method would be purposive and stratified. It was purposive in that I mostly chose undocumented migrants for interviewing. Recently arrived undocumented immigrants are simply more prevalent. They are also more likely to impact local health care services in ways that are perceived as being negative. It was stratified in that I divided the immigrants into two subpopulations. This enabled me to maximize their intra-group homogeneity and increase the variance between groups, facilitating comparison along the prime variable of interest, time spent in the United States I decided to interview as many diabetics and pregnant women as possible. Diabetics are an important subgroup to study because of the disease’s prevalence and chronicity in the population. To improve my understanding of how beliefs and behaviors related to illness might change, depending on the context, I wanted to query women who had been diagnosed and treated for an illness in both Mexico and the United States. Similarly, an immigrant undiagnosed in Mexico and subsequently diagnosed and treated in the United States can reveal illuminating information about her implicit diagnostic categories, illness behavior related to her diagnosis, and her belief in and use of various therapeutic options in her home country and in the host country. Because many of a culture’s values, beliefs, and attitudes cluster around pregnancy, it is a perfect episode/event to study in the context of culture change. Healthy Mexican immigrant women also participated in the study.

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As mentioned above, the first subgroup consisted of recent émigrés to the United States (in the United States continuously or cyclically for fewer than five years). Short trips to Mexico to visit relatives or friends did not render the women ineligible to participate; continuous, uninterrupted residence in Santa Fe was not deemed necessary to understand how women make choices about diagnosis, self-care, healthcare service utilization, and so on. If anything, infrequent trips to hometowns or merely to cross the border into Juarez added depth, richness, and complexity to these women’s stories about their search for health care. Several crossed back into Mexico explicitly in search of treatment options they felt were unavailable in the United States. One defining characteristic of contemporary international migration is its circularity: “International migrants, documented and undocumented, are highly mobile, making multiple entries and exits before and after settlement” (Massey 1987a:1514). The second subgroup consisted of women who had been here more than five years at the time of the study. At the time of the interview, most of the women in both subgroups did not have permission to reside permanently in the United States; two women were exceptions to this norm.1

INTERVIEWERS I hired women of Mexican origin and native Spanish speakers as interviewers in order to dispel suspicion of and foster confidence in the project. Three interviewers worked on the project: a translator employed at an immigrant rights organization in Santa Fe; the executive director of the same organization, a second-generation Latina from Los Angeles with a bachelors degree from Columbia University; and a trained anthropologist (Escuela Nacional de Antropologia e Historia, Mexico, D.F.), who started working for the project in November 2001. The third interviewer had more than twenty years’ work experience in Mexico’s social health system and was a recently arrived, undocumented migrant. After losing a lucrative white-collar job at Seguridad Social in Mexico, D.F., she emigrated—with a passport but without papeles de trabajo (work permits)—to be near her children, two of whom lived in Santa Fe during the project datacollection period. The two interviewers who worked for the immigrant rights group were known in the community and were regarded as being trustworthy and having the best interests of the immigrant population at heart. They

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and the anthropologist from Mexico were quickly able to establish good rapport and intimacy with their interviewees (Warnecke et al. 1997). Bias unintentionally introduced by one or more of these interviewers is discussed in the Conclusion.

RECRUITMENT AND ADMINISTRATION OF THE QUESTIONNAIRE I made every effort to match the group participants along other demographic variables, but this was not always possible, and a certain amount of opportunism is evident in the sampling method. The interviewees themselves led me to friends, relatives, or acquaintances who met the sampling criteria in terms of age, specific illness, health condition (e.g., diabetes and pregnancy), or length of time in the United States. This method is sometimes referred to as a “snowball” sampling technique (Cornelius 1982). Although a small percentage of respondents were recruited by using the “snowball” technique, interviewers met most of the respondents while at work. The two employees of the immigrant rights organization came in contact with immigrants seeking legal advice about immigration status, civil rights, housing rights, and the like. The third interviewer (the recent immigrant) met women where she was employed, at Kmart and Big Lots. Both chain stores regularly hire undocumented immigrants with false social security numbers. In addition, we contacted 100 percent of the diabetic interviewees and approximately 31 percent of the pregnant interviewees through the local health clinic that treats mostly low-income, immigrant, and indigent patients. Some interviewees were recruited before their initial intake interviews. This is significant because several respondents had had very little or no prior contact with Santa Fe healthcare service providers. All but two interviewees were interviewed once; two were consulted twice. One hundred percent of the interviews were conducted orally in Spanish in the interviewees’ homes, the offices of the immigrant rights organization, or a comfortable location specified by the interviewee. Before administering the survey instrument, the interviewers explained the purpose of the research and reassured interviewees that their identity and responses would be kept confidential. Interviewees were told that the information they provided was intended to help improve health care services in the Santa Fe area for

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Mexican immigrants. The interviewers encouraged them to be candid. Both interviewers and interviewees were paid for their time.

QUESTIONNAIRE A preliminary interview schedule was pilot-tested in the community. All the women were asked the same core set of questions, although questions were also added midway through the interviewing process. The questionnaire consisted mainly of questions compiled from three published survey instruments created specifically for use with the Hispanic population. To ensure comparability with other research in the field, I decided to select existing instruments and modify them only slightly, if at all. Such modification included an attempt to avoid response categories such as “agree,” “strongly agree,” and “don’t agree.” It has been suggested in the literature that an extreme response style is characteristic of the recently emigrated subset of the population under study (Warnecke et al. 1997). All questions but one were in the open-ended, semi-structured response format so that interviewees would generate an original response and offer opinions or comments. If interviewees replied to a question with a simple yes or no, interviewers would probe for further detail with questions such as, Why do you believe that? The large segments of text produced by this method were ideal for affording new insight into specific health ideologies and for examining the organization of a respondent’s thought. Thus, it was possible to analyze (for content) settings/contexts, conditions, perspectives, processes, activities, events, strategies, relationships, and the manner in which each of these clustered or fell into discernible patterns. I chose the existing questionnaires because these would make comparison possible between the “new” data collected during this research and the “old” collected previously. Also, having been developed by anthropologists and psychologists whose cumulative experience in the field cannot be discounted, these questionnaires were considered to have strong “natural” validity (Miles and Huberman 1994:278). Rather than think in terms of “construct validity,” the gold standard for quantitative studies, Miles and Huberman find it more useful to think in terms of the different types of understanding revealed in a qualitative study: “descriptive (what happened in specific situations); interpretive (what it meant to the people involved); theoretical (concepts, and their relationships, used to explain actions and

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meanings); and evaluative (judgments of the worth or value of actions and meanings)” (1994:278). I did not attempt to find some sort of law or rule that purports to represent the relationship between the inner world of the research project and the outer “real” world. Instead, my goal was simply to question the plausibility and adequacy of the explanations offered by the immigrants themselves (Van Maanen 1988). In addition, I took steps to minimize the influence of intervening variables that may have affected the validity of the data collected: interviewer bias or a negative interaction between interviewers and respondents (discussed at length in the Conclusion). The first of the three questionnaires I adapted was one developed by Guarnaccia and Rodriguez (1996) as a guide for the sociocultural assessment of Hispanic clients in a mental health context (see Appendix B). The questions explore what they have determined to be critical concepts about six aspects of Latino culture: (1) language capabilities and preferences, (2) social connections in family structure, (3) social connections in social supports, (4) migration experience, (5) religious beliefs and practices, and (6) health care utilization. Although these particular questions had not been tested systematically, they were developed for an Hispanic inpatient bilingual/bicultural psychiatric program with which the authors worked. Subsequently, this instrument was adapted for use by the NIMH Group on Culture, Diagnosis, and Care and was published as an “Outline for Cultural Formulation” in Appendix I of the DSM-IV (1994:843–44). In this section of the interview, each interviewee provided basic demographic information such as age, birthplace, employment, number of people living in household, marital status, length of time in Santa Fe, length of time in the United States, and level of education. I decided not to ask about income, a sensitive topic and easily distorted. I wanted to ensure that interviewees would remain open rather than become suspicious or uncomfortable early in the interview. Although phone numbers were requested in case we needed to ask follow-up questions, interviewees were told to use a pseudonym in order to preserve anonymity. I took the second set of questions from an article by Nancy Scheper-Hughes and Stewart (1983). Scheper-Hughes worked with Taosenos in northern New Mexico to determine the extent and prevalence of their contact with curanderos/as. Her questions were influenced by her background in medical anthropology and therefore

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focused more on the phenomenological aspects of illness (e.g., How do you know you are not well?); the practical (Do you seek advice from anyone when you are sick?); the emotional (In terms of loss of health, what is your greatest fear?); and the cultural (How should a sick person behave?). She was also interested in understanding the extent of use of home remedies (caseros remedios) and the types of herbs and treatments used regularly. Included were questions aimed at understanding the utilization of medical care in Taos County (located 60 miles north of Santa Fe), but Scheper-Hughes also integrated questions regarding the evaluation of care received, a foresight that proved of inestimable importance to the present project. Her general questions (such as, What does being healthy mean to you? and What do you do to stay healthy?) provided much basic information, which I readily analyzed to conclude that beliefs do indeed change over time. Last, Scheper-Hughes included questions to establish the extent to which respondents retained the traditional belief in humoral medicine (i.e., the hot/cold qualities underlying illness and cure), whether they had come into contact with other healing ideologies (complementary or alternative), and whether the women had ever used, or would ever use, a midwife to deliver their babies. The third questionnaire I used was created by Arthur Kleinman to elicit patient explanatory models. One way to contextualize healthrelated belief systems and gain a deeper understanding is to ground them in actual illness episodes. A respondent’s beliefs about sickness, her decision a propos how to respond to specific episodes of illness, and her expectations and evaluations of particular kinds of care help researchers fashion a model of her personal belief structure (Kleinman 1980:6). Because beliefs about illness are “always closely linked to specific therapeutic interventions and thus are systems of knowledge and action,” they cannot be understood apart from their use (1980:34). To avoid the potential influence of bias on the responses to questions requiring retrospective evaluation (see the section on supplemental questions below for a discussion of another way in which this was addressed), methodology for this research project also focused on ascertaining a respondent’s ideas about health and illness at the time she was experiencing (or just after she had experienced) an illness episode. An illness episode is whatever a respondent regards as a physical or mental disturbance in daily functioning. Respondents themselves determine the definition of the term, which varies according

Methodological Considerations, Data Collection, and Analysis

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to each individual. The collection of ideas and explanations about specific illness episodes is what Kleinman terms an Explanatory Model (EM). He explains: “Explanatory models are the notions about an episode of sickness and its treatment that are employed by all those engaged in the clinical process….The study of patient and family EMs tells us how they make sense of given episodes of illness, and how they choose and evaluate particular treatments” (1980:105). Although EMs often lack structural organization or specificity, they do seek to address the etiology, time and mode of onset of symptoms, pathophysiology, course of sickness (including both degree of severity and type of sick role—acute, chronic, impaired, etc.), and treatment. EMs determine what is considered relevant clinical evidence, as well as how it is organized and ultimately used to indicate an appropriate course of action. Action, in this regard, refers to the means by which the patient lessens her physical or emotional suffering (1980:105). See Appendix B, section III, for a list of questions Kleinman uses to elicit the details of a patient’s EM. The importance of understanding the dialectical relationship between context and patient EMs is the primary reason for eliciting EMs in relationship to particular episodes of illness. A patient may be exposed to a range of value statements and explanations about her illness: family, friends, and colleagues (all in the popular sector) may provide vastly different EMs of the patient’s illness than do health care professionals (from the professional sector) and folk practitioners (from the folk sector [1980:99]). All these actors may operate in the context of either the home country or the adopted. How the individual patient integrates the EMs to which she is exposed and how the EMs change over time in relation to similar and different illness episodes—as well as other acculturative influences—to reflect one distinct (core) set of health beliefs are the focus of this project and the reason for using a methodology based on patient explanatory models.

SUPPLEMENTAL QUESTIONS It became clear that the women, when complaining about characteristics of U.S. doctors, were comparing their experiences here with their experiences in Mexico. I therefore added a question about encounters with medical professionals in their native country and also asked them to compare these with their experiences in the United States. In this way, what was implicit became explicit, so I could better

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understand why the women were happy or unhappy with doctor visits here. Thirty one respondents were asked these new questions. The answers provided invaluable data about perceptions of doctors’ competence in Mexico. Even more significant, by asking these and other retrospective evaluation questions, I created what Campbell and Stanley call a retrospective pretest, which determined whether the recalled observations of the two groups were similar (1963:66). This is extremely important because I based the research design utilized in this project, in part, on memory (or recall), which is notoriously inaccurate. If there was any distortion in recall, it should have been equal for both groups. According to Campbell and Stanley, because the two groups were similar in recall (see chapter four, Table 10), the findings of the research were strengthened (1963:66). Another supplemental question had to do with the migrants’ antibiotic usage. The women were often disgruntled because U.S. doctors did not prescribe antibiotics for illnesses that, in the women’s opinion, warranted such treatment. Therefore, they were asked whether they had brought Mexican medications with them to this country and, if not, whether they obtained them in some other way here. That is, did they continue to self-medicate, despite knowing that the prescription of such medication is tightly controlled in this country? As it turned out, the responses also clustered into patterns that relate to time spent in the United States. Of the questions added after data collection had begun (see Appendix B for a list of the additional questions), two others deserve mention. One focused on dietary changes since arrival in the United States. It has been reported in the literature on immigrant health status that a change in diet has a lot to do with the declining objective health indicators of this population. Therefore, the women were asked whether their diet had changed since arriving in this country and, if so, how. Interestingly, their responses were not as straightforward as I expected (on the basis of the literature), nor did they replicate the findings of other published research. Furthermore, beliefs about diet became a key indicator of change in this sample of women. Midway through the data collection process, I decided to add a question about whether the women felt that people from Mexico changed after living in this country. There have been much speculation and hypothesis testing related to this question, but few researchers, if any, have queried the immigrants themselves. The responses to this

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question were passionate and surprisingly consistent. That is, there was a high degree of consensus regarding the changes immigrants from Mexico undergo. Before being administered, interview schedules underwent a process of translation and back-translation. The two translators who worked on this were bilingual and bicultural, having lived in the United States more than 20 years. Currently, one teaches Spanish at the Santa Fe Community College. In addition, she is a founder and board member of a local, non-profit, immigrant rights organization. The other translator was also an employee of this organization at the time she performed the translation work. Both women worked gratis because they believed in the importance of the project’s stated goals. Last, concurrent with the administration of the survey instrument, I collected information in English from area physicians, nurses, and health education administrators. My purpose was to juxtapose the viewpoints of “outsiders,” those who administer health care, with the viewpoints of “insiders,” those who receive health care (Stebbins 1987:4). These interviews canvassed three general practitioners and four administrators: the executive director of the local health clinic that serves the most low income patients in Santa Fe, the head of health education there, the director of a religious based medical clinic, and a social work clinician at a Catholic Social Services Outreach program. I also interviewed one obstetrical nurse employed at both the local hospital (Santa Fe’s only hospital) and the first clinic mentioned above. At the hospital, she worked in labor and delivery; at the clinic, she was the intake coordinator for the prenatal program. The last two health providers interviewed worked as promotoras in the health education department of the clinic, teaching prenatal care and giving breastfeeding advice to new (mostly immigrant) mothers. There was no set format for these encounters; all questions were open-ended. These health care workers shared their perceptions of the immigrant patient population, the medical treatment they gave, and what they felt needed to change in administering health care to the migrants. In other words, the health care workers described the barriers to care and how these could be eliminated. Interviews with both health care providers and recipients averaged an hour and a half in duration; interviews of more than two hours were not uncommon.

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DATA PREPARATION AND ANALYSIS All interviews were transcribed verbatim and annotated by the interviewers who conducted them. Annotations consisted of interviewer impressions of how the process went, for example, how accurately the interviewee understood the questions and responded to them and how comfortable the interviewee appeared. Also included was anecdotal information about an interviewee’s home environment, emotional reactions, and relationships with family and friends. Transcriptions were typed in Spanish. The Spanish transcriptions were then translated into English. All three interviewers aided in editing a subset of the other translators’ work, thus “catching” and correcting inaccurate translations. Before beginning the process of data analysis, all interviews were read in both Spanish and English. At this point, I spot-checked the translations. When I discovered holes in the data, I tried to contact the interviewees again. I could not locate 60 percent of them. They had given false telephone numbers and addresses (the latter of which were expected, even during the initial round of data collection), had moved to a different location in Santa Fe or the United States, or had simply returned to Mexico for a visit or permanently. Interviews transcribed into English were imported in a computer program designed specifically for the storage, management, and analysis of qualitative data: NVivo, version 2.0.161, published by QSR International in 2002. After importing all 64 translated interviews into NVivo, I began the analysis by reading every interview closely. I then constructed an “attribute” (or variable) matrix, placing the names of the interviewees along the vertical axis and the variables of interest—demographic and other—along the horizontal axis. This matrix proved invaluable: it executed quick and efficient retrieval and assessment of descriptive data and visually displayed the variables of interest, thereby facilitating the perception of patterns in the data. Into this matrix I entered the following topics of interest: whether the interviewees believed in or visited healers and whether they had ever changed religion. The importance of this question lay in its ability to distinguish between those women who were more open to change, in general, and those who were not. I found this openness to have predictive capability in that it underscored a willingness to accept new health-related beliefs as well.

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Another variable entered into this giant matrix was whether the interviewees had remained in contact with their godparents, or compadres (and whether they themselves were currently acting enthusiastically in that capacity). This question is commonly thought to assess a tendency to remain in a family-oriented mind-set characteristic of those who are not acculturating quickly or are more conservative or “traditional” in their beliefs. Research by Cuellar, Arnold, and Gonzalez suggests that “adherence to the ideology of familism may affect the rate at which one acculturates and may, at least partially, play a role in the phenomenon of ‘acculturation gap’ within acculturating families” (1995:341). See also NCLR (1998). Also, I hypothesized at the outset that the more difficult the border crossing, the less open to acculturative influences the migrant might be, thus I coded the migration stories for degree of hardship. Another way of displaying one aspect of the descriptive health data was to note whether the woman’s primary health issue was non-lifethreatening “subacute” or “chronic.” Obviously, there was some overlap in these two columns. They are discussed in greater detail in chapter 10. The next fragment of data reduction focused on knowledge of complementary and alternative methods of healing (CAM) . Most of the women were asked whether they knew anything about four specific types of healing modalities: (1) “medicina naturista,” herbal medicine practiced by thousands of yerberos, or naturalists, in Mexico, (2) acupuncture, (3) homeopathy, and (4) chiropractic. Any of these that they had heard of or practiced were recorded in the matrix. English language ability was another variable in the matrix. Categories were as follows: “no ability” for women who spoke/ read/understood absolutely nothing or very little; “poor” for women who understood and spoke less than 30 percent; and “good” for women who understood 30 to 70 percent of what they heard or read. Women in the “good” category often claimed that they could speak well enough to be understood by the average English-speaking Anglo. “Very good” English speakers understood 70 percent or more of what they read or heard, and they could easily make themselves understood. The last category was “fluent,” and not one subject out of the whole data set was characterized in this manner. The terminology describing language fluency was suggested by one of the interview schedules (Guarnaccia et al. 1996). The percentages accorded to the various levels of fluency,

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however, were not arbitrarily assigned by the researcher but rather reflected the categories presented by the immigrants themselves. Thus, these proficiency levels were created inductively, using the women’s own categories for assigning meaning. An example is provided by Rocio, who had lived in Santa Fe 10 years at the time of her interview. When asked whether she understood English, Rocio gave a percentage: “Oh yes, I understand more. I understand about 70 percent.” Aurora, who had also lived in the United States 10 years, was asked whether she could understand when someone spoke English to her. She responded, “Only about 5 percent.” The women were asked specifically whether they and (in a separate question) their relatives had planned to come to and/or stay in the United States. It has been hypothesized that this intention, on the part of the immigrant or close family members, potentially creates a desire to assimilate aspects of the culture in the receiving community. In some cases, interviewees stated explicitly that they preferred to “travel back and forth.” This question was intended to gauge the negative type of acculturation called rejection. Recall that this refers to the immigrant’s withdrawal from the larger society. Undoubtedly, this mind-set would affect rate of acculturation. An important category for inferring rate of acculturation to U.S. health ideology turned out to be the rating the subjects gave to the U.S. healthcare system. Based on their experiences with health care workers, the women assigned a rating of 1, 2, or 3, with 1 being the highest/best rating and 3 being the lowest/worst. Level of religiosity was also placed in this matrix. Interviewees were rated as having a “high,” “medium,” or “low” level of religiosity, based on their answers to a series of questions relating to the frequency of church attendance; the placement and use of religious articles in their home; and, among other things, the frequency of praying or other personal expressions of faith (Levin and Vanderpool 1989). It became clear that the division between those characterized as having “low” or “medium” levels of religiosity was not as great as the divide between those two levels and the women in the “high” level. These women were extremely devout, often going to church four to six times a week, praying daily or even constantly, possessing numerous articles of religious faith, placing open bibles on the table during the interview, etc. Categorizing in this manner was important because I observed that being highly devout—especially among converts—is associated with significant shifts in health care

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ideology. Also, it has been hypothesized in the acculturation literature that a high degree of (Catholic) religiosity is correlated with a tendency not to acculturate or assimilate quickly. For the present research, thus categorizing a migrant made it possible to determine whether an intense level of religiousness was associated with the retention of other “traditional” beliefs, such as a belief in the efficacy of curanderismo, and with a fatalistic attitude toward sickness and life and death. I was also interested in how other aspects of the migrant’s life—her relationship with her compadres, education level, age—correlated with her religious and health beliefs. The last few attributes entered into the matrix were whether the women came from a rural or urban environment (thought to influence speed of language acquisition and rate of acculturation in general) and what type of social support they enjoyed in Santa Fe. The latter information was imperative, for the degree and type of social support has been hypothesized as influencing speed of language acquisition, cultural learning in general, and mental health status specifically. The last category of data recorded was whether the women subscribed to the cultural notion that, when sick, one should “move around and get out,” “go to see a doctor,” or “stay in bed.” This data proved extremely important in distinguishing those who had recently arrived from those who had resided in Santa Fe for numerous years. Displaying the data in this manner was an enormously effective way to search for patterns of beliefs and associations between demographic and other variables. It allowed for their systematic comparison and their partitioning into other categories of interest. Because the data analysis program was so powerful, I could search the records entered across any number of variables and using a variety of search operators: text, Boolean, proximity, co-occurrence, intersection, union, matrix intersection, negation, and so on. All examples were then retrieved as full documents. By moving from the one-word descriptive variables entered into the table to an examination of the interview contexts in their entirety, it was possible to see many themes working in concert, within the context of one interview and simultaneously across several interviews. In contrast, simply searching for paragraphs that are coded similarly (a function performed by some less powerful qualitative data-analysis tools) does little to aid in seeing the big picture, nor does it allow for easy assimilation of large amounts of data. In effect, this meta-matrix method of retrieving and examining

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information is a hybrid of variable-oriented and case-oriented methods of data analysis (Miles and Huberman 1994:174). After this process was completed, all interviews were re-read, and responses to each question were segregated into 165 subgroups—one for each question in the questionnaire—to facilitate examining the data cross-question. Only after segregating responses to all questions did the formal process of coding begin. Question by question, data were coded for ideas, beliefs, or topics that were repeated within the context of each question. That is, the range of responses to a particular question was determined, and then the frequency of responses was noted. At this time, measures of central tendency and variance were also calculated: both means and medians for response category by time spent in the United States were figured for all relevant questions. Reliability—that is, agreement among three coders—was established with a small subset of the data. Initially, there was an 85.5 percent level of agreement; a discussion of the items that posed a challenge for the coders resulted in an increase in the level of agreement to 90.5 percent. One could call this sweep of the data a “descriptive” endeavor. Responses were then grouped into two larger categories: those whose medians aggregated less than 5 years and those that added up to more than 5 years. Five is not a magic number of years that accelerates acculturative change. Rather, it is merely an arbitrary and convenient way in which to bisect the sample so as to accentuate the differences in beliefs. My sense is that the “magic” number of years—if it could be called that—would be closer to 4 than 5. As we shall see, many intervening variables affect rate of change, so trying to discover the exact moment when change occurs for the broadest range of people is not a constructive endeavor. During this process, themes began to appear that were not easily contained within the context of one question. That is, certain discourses seemed to emerge and submerge at different (seemingly random) times throughout each interview. During yet another sweep of the data, these themes were also given codes. Discerning and examining these themes turned out to be a more interpretive level of analysis. Themes that were coded at this more interpretive level included perceived discrimination; discourses on stress, depression, and illnesses localized in the throat; and diet and exercise. References to language (i.e., both miscommunication and good communication with health care workers), the cost of health care, and private Mexican doctors versus physicians working in the Mexican social security system, among others, were also noted.

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A final pass of the data allowed for true pattern coding. What followed was a process of identifying segments of the interviews that illustrated relationships between themes: between types of people (i.e., their associated demographic variables) and their particular health problems, their experiences in Mexico and the United States, their preferred treatment options, and their opinions about the U.S. healthcare system. These clusters of relationships were then examined for their affiliation with time spent in the United States. In an attempt to understand and develop causal networks, a preliminary hypothesis as to which factors logically influenced others, which ones were likely to appear together (and which were not), and which ones had directional influence (i.e., which had to happen first in order for others to happen later) was formulated (Miles and Huberman 1994:155). A type of sequence analysis ensued, combining an understanding of the process of change in health beliefs with knowledge of the demographic variables thought to be associated with change. The data were reexamined to count how many cases fit seamlessly into the hypothesized causal network. After this process, cases that did not—for whatever reason—fit the proposed causal network were noted and examined closely to determine the possible reasons for their disqualification. More often than not, specific demographic variables (e.g., socioeconomic status) or individuals’ idiosyncratic experiences were identified.

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CHAPTER 4

Sociodemographic Profile

The average age (mean) of the 62 women interviewed was 35.8 years. The youngest was a 16-year-old mother who had been in the United States a mere 2 weeks at the time of her first interview, and the oldest was 68. Thirty-nine of the women had been here fewer than 5 years, and 23 had been here more than 5 years. Because a longitudinal study was attempted initially, this data set is skewed toward women who had been here fewer than 5 years. The mean age for those who had been here fewer than 5 years was 34.3; the mean age for the women who had resided here for more than 5 years was 38.8. Of those who had resided in the United States fewer than 5 years, the mean time here was 1.8 years (median 1.5). The corresponding mean time spent in the United States for the ≥5 years group was 9.2 years (median 6).1 See Tables 1 and 2. Table 1. Age by percentage of respondents Age 16 to 30 31 to 45 46 to 81

Percentage of Population 41.3 28.6 23.8

Table 2. Years lived in the U.S. Years Percentage of population Average (mean) Average (median)

<5 Years 63% 1.8 1.5

51

≥5 Years 37% 9.2 6.0

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Interviewers posed two questions regarding time spent in the United States: How long have you lived in Santa Fe? and How long have you lived in the United States? In most cases, the women had lived a commensurate length of time in both; that is, the difference between their time in the United States and in Santa Fe was usually only months or a couple years. In rare cases (3), women had spent enough time in the United States to throw them into the ≥5 years subgroup, but only a year or two in Santa Fe. It was noted in their record that their responses to questions might not reflect immersion in Santa Fe culture per se (regarding awareness of alternative healing modalities) but that other aspects of U.S. biomedical health culture might still be relevant. Also, the women might have come into contact with and even adopted CAM in places other than Santa Fe. These issues are hard to untangle and are addressed in more detail below.

EDUCATION In terms of education, the samples were rather balanced. The subpopulation that had been here fewer than 5 years at the time of the interview comprised 1 who was college-educated, 8 who had begun or finished college preparatory studies (corresponding roughly to U.S. high school); 8 who had begun or finished the secondary level (U.S. junior high school), 6 who had achieved the primary level (U.S. elementary school), and 1 who had no formal education. Of those who had resided in the United States for 5 or more years, 5 had achieved some amount of schooling at the college preparatory level; 6 had started and/or finished the secondary level; 4 had finished the primary level; and, as with the other sample, 1 had no formal education (see Tables 3 and 4). Table 3. Education levels in the <5 years subsample Level University Preparatory Secondary Primary None Unknown

Number of Subjects 1 8 8 6 1 16

Percentage 2.5 20.0 20.0 15.0 2.5 40.0

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Table 4. Education levels in the ≥5 years subsample Level University Preparatory Secondary Primary None Unknown

Number of Subjects 0 5 6 4 1 7

Percentage 0.0 21.8 26.1 17.4 4.3 30.4

RURAL VERSUS URBAN Rural areas are defined as pueblos (pueblitos, ranchos, etc.) of fewer than 50,000; in the study, most averaged fewer than 8,000 residents. Medium-size cities range between 50,000 and 500,000 people. Urban environments have more than half a million inhabitants. (See Appendix A for the distribution of study participants by their sending communities.) All told, 48 percent of the sample was from a rural area, 42 percent from an urban area, and a mere 10 percent from a mediumsize city. (Data for one subject are missing.) The participants were from all over Mexico, with the largest cities sending proportionately more women. Proximity to the border also influenced the number seeking to emigrate; 6 women called the city of Chihuahua (in the state of Chihuahua) home, and 4 called Mexico D.F. home. By this logic, however, we would expect that most of the women would come from Juarez (in the state of Chihuahua), but this was not the case. Only 4 came to Santa Fe from Juarez, whereas 5 came from the city of Durango (in the state of Durango). On average, however, 23 women were from Chihuahua, the state closest to the U.S. border. Somewhat surprisingly, the sample included women from the far east of Mexico (Chiapas), as well as the far west (North Baja California). They came from as far north as Juarez and as far south as Veracruz, from the Sierra Madre Occidental in the state of Durango, to the interior city of Guadalajara. Interestingly, the distribution of subjects from rural and urban areas tended to cluster according to time spent in the United States. Of those who had been in the United States fewer than 5 years, 55 percent were from rural areas, 31 percent from urban areas, and 16 percent from medium-size cities. Conversely, most of those who had been in

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this country for 5 or more years came from urban areas: 67 percent were city dwellers, whereas only 33 percent came from the countryside. Ostensibly, people from rural pueblitos are in greater need of improving their economic situation, but city dwellers, more accustomed to a fast pace, seem to have the adaptability necessary to make a permanent move to the United States. Of course, whether some of the rural women who left Santa Fe went to other locations in the United States is unknown. In general, though, the urban dwellers found Santa Fe’s economic and cultural climate more propitious. At first glance, there appears to be a process of selective migration that favors inhabitants of urban environments in the country of origin. Testing this assumption statistically (chi-square), however, revealed no significant difference from expected distributions of rural and urban dwellers in relation to time lived in the United States (see Table 5). Table 5. Type of sending community by years lived in the U.S. Type Rural Urban Medium

Number of Subjects 30 26 6

Percentage of Total 48 42 10

<5 Years Percentage 55 31 16

≥5 Years Percentage 33 67 0.0

Because the result of this test tended toward significance, one might examine, for example, level of education to explain the differences in immigration levels by sending community. That is, the more educated a migrant is, the more economic opportunities available to her in the receiving community (Espinosa and Massey 1997). It seems intuitive that city dwellers must have more access to basic resources such as education. Tables 5 and 6, however, illustrate that levels of education in relation to the length of time lived in the United States do not appear to vary enough to explain why urban dwellers stay in Santa Fe in particular or the United States in general. If anything, recent migrants appeared to be slightly better educated than those who had lived here a long time. Approximately 39 percent of the recent arrivals had a college preparatory background or better, compared with only 31 percent of those who had lived here longer. Furthermore, Table 6 shows that those from rural areas were slightly better educated (e.g., more of them had completed college preparatory studies).

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Table 6. Education level by type of sending community

Level University Preparatory Secondary Primary None Unknown

Number of Rural Subjects 0 8 4 5

Rural Percentage 0.0 25.8 12.9 16.1

Number of Urban Subjects 1 5 9 5

Urban Percentage 3.1 15.6 28.1 15.6

2 12

6.5 38.7

0 11

0.0 37.5

A simple explanation for the women from urban areas in Mexico liking Santa Fe more than those from rural pueblitos could be that the former might find the environment in Santa Fe (a city of only 69,000 inhabitants) quite pleasing, with its beauty, relatively mild weather, little traffic, no air pollution, and long history of Spanish and Mexican cultural influences woven into the fabric of everyday life. In addition, there are social services that help with English language acquisition, health, housing, and immigration services. In all probability, immigrants from urban locales are more adept at discovering these services. Conversely, inhabitants of rural pueblitos and ranchitos might find the hustle and bustle of a city of 69,000 more than they can or want to handle. They might feel overwhelmed and have trouble locating basic resources, and they may not know as many people upon arrival as do those from large cities.

ENGLISH LANGUAGE PROFICIENCY As mentioned in chapter 3, interviewees were asked to rate their level of English fluency. To determine whether they tended to code-switch between English and Spanish, and their proficiency in doing so, each of the women was asked a series of ten questions regarding her ability to read, write, comprehend, and speak English. The women were also asked which language they spoke when talking to family members, to coworkers, and to physicians and when expressing strong (negative or positive) emotion. There was 100 percent agreement on the latter two questions; all stated that they preferred to speak their native language

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with physicians and during intensely emotional times. These two situations obviously overlap in many ways (see Table 7). Table 7. Self-reported English language proficiency by years lived in the U.S. Level Percentage Years (mean) Years (median)

Inadequate 33.9 1.8 1.0

Poor 33.9 5.9 4.0

Good 22.5 5.6 5.0

Very Good 9.7 6.8 7.5

Fluent 0.0 0.0 0.0

Note: There is a slight misalignment of the (generally) positive relationship between language ability and time spent here in that the mean number of years living in the United States for the “poor” English speakers (5.9) is slightly higher than that of the “good” English speakers (5.6). This is due to the inclusion of the 45-year outlier in the “poor” class of English speakers. In this case, the median as a measurement of central tendency is a more representative statistic.

In general, there was agreement that reading and understanding were easier than writing and speaking, with the last being the most difficult. Moreover, it was the consensus of the interviewers that the women did not exaggerate their abilities. In fact, they tended to downplay their language skills. With the exception of one interviewee—the college-educated, solidly upper-middle-class, white-collar worker from Mexico D.F., who may have exaggerated her comprehension and speaking ability (perhaps because she attended an English-only college preparatory school)—the women were quite humble when discussing this topic. Their self-assessments may be slightly skewed toward fewer English skills rather than more (Espinosa and Massey 1997; Delgado et al. 1999). By taking the mean and median for the length of time each woman had been in the United States, in relation to her speaking ability, we see a solid trend toward gaining competence in the new language as more time is spent here. The positive relationship between English language ability and time spent in the United States (i.e., with more time spent living in the United States, proficiency in reading, writing, comprehending, and speaking English increases) demonstrates that these women are adapting to life in a mostly English environment. Even though Spanish is spoken widely in Santa Fe (by bank tellers, store clerks, fast-food restaurant workers, and some healthcare staff), these immigrants still manage to pick up aspects of the new language.

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Contrary to the public perception that Mexican immigrants congregate in the large urban centers of the United States, refuse to learn English or to assimilate in other ways, the data reported here replicates what research based on cross-sectional census and survey data has found: there is a clear pattern of language assimilation among migrants to the United States from Mexico. Much of the social science literature on language acquisition assumes a “human capital model.” That is, learning English is perceived as an investment necessary to improve one’s economic standing in the host country (Massey 1997:29). Also, because many more workers coming to the United States are targeting jobs in sectors of the economy other than agriculture, the chances of their having contact with English speakers increase. It cannot be discounted, however, that there is a degree of probability (perhaps high) that migrants who had trouble learning English, the “linguistic failures,” returned to their homes, leaving the “linguistic survivors” (Massey 1997) in the host country. This could skew the data, and the interpretation of data, toward the conclusion that language assimilation proceeds seamlessly for most migrants. Nonetheless, it is notable that, with the disincentive to learn English (i.e., lack of proper documentation and a large community of native Spanish speakers), the women in the sample are, by their own account, acquiring English language skills, despite low education levels and relatively advanced ages. These results are congruent with Massey’s findings: “Consistent with hypotheses derived from human capital theory and the assimilation model, the odds of speaking English rise significantly as migrants’ total experience accumulates across U.S. trips, and they increase substantially as the total proportion of time spent in the U.S. grows” (1997:42). Marisol, a single 27-year-old who had lived in the United States (and Santa Fe) for 3 years, explained, “Sometimes there are things that I understand more in English. By reading, I understand more, when they talk to me. [Not] understanding is what costs me the most work.” Marisol knew from experience that understanding the English language was necessary to reach her economic objective, the reason she immigrated to the United States. This might be an intuitive conclusion, but it is one that contradicts the negative stereotypes about Mexican immigrants’ relative lack of interest in language assimilation.

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HOUSEHOLD CENSUS, MARITAL STATUS, AND EMPLOYMENT STATUS Other aspects of the sociodemographic profile of the group were as follows: the average (mean) number of people living in a dwelling with an interviewee (in this case, the interviewee is not counted) was 4.1, with 10 being the greatest number and 0 being the least (i.e., the interviewee lived alone). Broken down by time spent in Santa Fe, those with fewer than 5 years’ experience living here had a (mean) average of 4.7; 2.7 was the mean average for those in Santa Fe more than 5 years. (Together, the means total 4.1 years; see Table 8.) It is not surprising that the home censuses of those who had lived here longer started to resemble the home censuses of those who were born and raised here (Fields and Casper 2001). That is, the longer an immigrant resides here, the fewer people live in the house. As children grow up, gain an economic footing, and move out of their parent’s households, the number of people living in the original home necessarily shrinks. In addition, recent immigrants usually share living expenses upon arrival in the host country, moving into their own residences when they are able to manage on their own. The type of person with whom an interviewee lived also changed over time. The longer a resident had lived in Santa Fe, in contrast, the less chance she lived with anyone but members of her nuclear family. As already noted, some of the elder women lived alone, husbands and children long since gone. Table 8. Marital status by years lived in the U.S. Status Single Married Separated Divorced Widowed

Total Percentage 9.5 68.0 11.1 6.3 4.8

<5 Years Percentage 15.8 63.2 13.2 2.6 5.1

≥5 Years Percentage 0.0 70.8 8.3 12.5 4.3

One may interpret this data on marital status by examining the trends, which illustrate that young single women are migrating without their parents (they may or may not come with other close family members, such as brothers or sisters). More of these young women (than those who had been here longer) emigrated because they had

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recently separated from their husbands, or they had separated since their recent arrival in the United States. In the later arrivals, however, more of the women had actually divorced their husbands, most likely after their entrance into this country. Because data are scarce, however, it is not possible to prove or even correlate that an uptick in the rate of separation or divorce resulted from spending time in the United States, although women did claim that changes in family composition of this sort did occur (see the conclusion for more on this topic). The information on employment status was incomplete because it was not collected for 16 of the 62 interviewees (25 percent). Of the data gathered, the types of jobs ranged from housewife and housecleaner to retail clerk (the latter job usually encompassing stocking duties only, with little or no customer contact), babysitter, and dishwasher. Bisecting the data by length of time in the United States shows that more of the recent arrivals were employed in jobs outside the home (see Table 9). Fewer were retired, and fewer were housewives. This part of the sample population was relatively more employed, reflecting the needs of most recent immigrants to hold jobs. According to research by Chavez (2003), recent arrivals hold mostly part-time jobs in order to take care of their children at home. Similar to the trend discussed above, in which household size decreases with time spent in the United States, female partners or household members were less employed as more time was lived in the host country. As the immigrant family becomes more established, it appears, female members are required to work less, as is generally the situation in Mexico. In several cases, when husbands had died or had retired, female household members were taken care of by their children, who contributed to their upkeep and maintenance. It was not uncommon for recently arrived elder women to have been brought over by their children. Already established here, the children had made arrangements for their parents’ transportation across the border. In these cases, the women were not necessarily employed. Instead, they chose to call themselves “housewives,” taking care of their grandchildren, grandnieces, and nephews.

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Table 9. Type of employment by years lived in the U.S. Type of Employment Mom/housewife Housecleaner Store clerk Unknown position Restaurant dishwasher/ bus person Retired Nanny

41.1 27.5 9.8 8.5 5.9

<5 Years 35.7 28.6 14.3 10.7 7.1

≥5 Years 45.8 25.0 4.2 4.2 4.2

4.3 2.1

3.6 0.0

8.3 4.2

Total Percentage of People

RETROSPECTIVE EVALUATIONS OF MEXICAN PHYSICIANS The results of the retrospective pre-test mentioned in chapter 3 confirmed that the two groups were remarkably similar in the quality and texture of their memories of experiences with doctors in Mexico. Of the 31 participants who were administered this question, 17 had lived in Santa Fe fewer than 5 years, and 14 had resided there for more than 5. Trends in associations between ratings of doctors encountered in Mexico and time spent in the United States were not evident in the following responses. Mexican doctors were rated as okay when the interviewee’s response to the question How would you describe the doctors in Mexico? contained both positive and negative descriptions. An example of such a response came from Nohelia (21 years old and 7 months in Santa Fe): “You tell them what is wrong, and they give you some medicine, and that is it. I would describe them as regular. They don’t attend to you well, but they don’t ‘not attend’ to you. For that reason, they are okay.” Of the entire sample who had been in Santa Fe fewer than 5 years, 2 rated their doctors in Mexico as okay, compared with 2 of the women who had lived in the United States more than 5 years. As one can tell from Table 10, most respondents, both the recently arrived and the “veterans,” simply rated their Mexican doctors as “good.” Dora (35 years old, 18 months in Santa Fe) explained: “They are good. They treat you well. They are concerned that one is sick. Then they have tests done, to find out what illness you have.” Eladia (27 years old, 4 years in Santa Fe) answered: “Good. I always had good

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luck. They were good. They treated me well.” A total of 64.6 percent of the sample rated their Mexican physicians “good.” The ratings were evenly balanced between each subgroup. Table 10. Mexican physician rating by years lived in the U.S. Time Lived in the United States Mexican physician rating: OK Mexican physician rating: Good Mexican physician rating: Very good

<5 Years 6.5 32.3 9.5

≥5 Years 6.5 32.3 12.9

Most of the “excellent” or “very good” ratings were reserved specifically for doctors whom the patients saw in their private offices. As far as these patients knew, their doctors worked only in private practice and did not work for the social security health system in Mexico. Although the patients might not know it, it is quite common in Mexico for physicians to work for the National Institute of Social Services (IMSS), the Institute for Social Security for State Workers (ISSTE), or the Department of Health (SS), as well as in private practice. Whereas doctors’ prestige and power come from association with government bureaucracies, their primary source of income is private practice (Finkler 2001). As with physicians in the United States, those who work for HMOs or other sponsored health programs appear to have less time to see and treat patients than those in private practice, although this is often debated (Schappert and Nelson 1999). An example of an “excellent” rating for a Mexican physician or, at the least, “very good” came from Contreras, a 53-year-old woman who had lived in the United States for 6 years. When asked to describe the doctors she remembered visiting in Mexico, she stated, “Well, for me, they were expert/outstanding (una eminencia). First, God. And then, after God, the doctor’s science. Very good, very attentive with me. I never had a bad impression of them.” Jacqueline (16 years old), a recent arrival (2 weeks), remembered the physician who delivered her son: “I have always seen private doctors in Mexico, and they are very good. He was really nice and understanding with me. When I had my son, he helped me a lot in everything. And when my time came, he was already there. And whether there was anyone there or not, he saw me, and he was always really good with me.” Of the recently arrived subsample of Mexican immigrant women, 9.5 percent rated their physicians in Mexico “excellent” or “very

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good”; 12.9 percent of the veteran group did so. In absolute numbers, this percentage difference represents one additional interviewee in the veteran subgroup who rated her doctor “excellent.” Because the two groups showed no obvious differences in ratings of Mexican physicians based on recall—in fact, the data were uncannily balanced—it is presumed that the other data based on memory were not egregiously distorted because of inherent differences in quality of memory or recall ability between the two subpopulations. If there had been observable trends or clusters of all-positive or allnegative ratings associated with time lived in the United States, then the women’s responses to other questions, based on recall, would be entirely suspect. For example, one could imagine that the longer the time since visiting a doctor in Mexico, the more one might idealize him or her. Thus, a preponderance of responses from the veteran subgroup would be skewed towards the “outstanding” and “excellent” categories. Conversely, one could make a case for the opposite effect: the more a migrant comes into contact with the U.S. healthcare system, the more she acclimates to the different way she is diagnosed and treated and the more she retrospectively reevaluates her treatment by physicians in Mexico as being of poor quality and (possibly) backwards technologically. Neither of these patterns was perceptible, so it was presumed with some confidence that other responses relying on recall were valid and reliable. Of note about the distribution of these ratings is that an “extreme response bias” does not seem to be evident in this subsample of Mexican immigrant women. They did not demonstrate a propensity to rate their doctors as either very bad or very good, a finding that goes counter to the large-survey methodology literature on cross-cultural differences in response styles (Marin and Marin 1989; Kirkman et al. 1991; Fullerton et al. 1993). Rather than give extreme responses or ratings, all the women provided ratings predicated on “qualified information” (Warnecke et al. 1997).

CHAPTER 5

Models of Health, Models of Illness

A good place to begin the discussion of how Mexican migrants’ healthrelated beliefs change over time to reflect U.S. ideology is with what it means to people to be healthy. For some researchers, the concept of health is indeterminate, culturally constructed, and subject to considerable variation (Joseph and Shweder 1995; Shweder 1996). Beliefs, for example, that one should eat certain foods, that physical health should impart a feeling of energy, and that the body should be a smoothly running engine “are presupposed, taken-for-granted models of the world that are widely shared (although not to the exclusion of other, alternative models) by the members of a society and that play an enormous role in their understanding of that world and their behavior in it” (Holland and Quinn 1987:282. See also D'Andrade and Strauss, 1992; D’Andrade 1993). The central concept of a cognitive model, also called a “schema,” is known by other names as well: “mental model” (Johnson-Laird, 1983), “idealized cognitive model” (Lakoff, 1987), “folk model” (D'Andrade, 1987), “script” (Schank and Abelson, 1977), “scene” (Fillmore, 1975), and “frame” (Minsky, 1975). Although these implicit cognitive models are not perfectly bounded and intransigent— that is, they can be conceptually fuzzy, and people can subscribe to a variety of them over the course of a lifetime—they can be made explicit in order to understand how they influence people’s health beliefs and health care decisions in a particular context. To tap into the differences (if any exist) between how health in general is socially constructed in Mexico and in the United States, the following questions were posed: What does it mean to be healthy? and What do you do to stay healthy? These questions enabled me to draw out and make explicit the implicit cognitive representations that 63

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potentially influenced the respondent’s help-seeking behavior. To demonstrate how these ideas evolved with time spent in the United States, the mean and median numbers of years for each cluster of beliefs were reported. That is, for all the women with a particular response, the number of years lived in the United States was tabulated and averaged. I report both the mean and median to offset the effect of outliers (especially the woman who had lived 45 years in Santa Fe). It should be noted that the lower means suggest that, collectively, the women who supplied a particular response had been Santa Fe residents for less time than those who had a higher average and therefore whose cluster of responses reflect more time spent in the United States, in general, and Santa Fe specifically. Reliability among the coders of these responses was established at a 90.5 percent level.

HEALTH AS FREEDOM: BEING ABLE TO TAKE CARE OF YOUR CHILDREN To the question, What does it mean to be healthy? a range of responses were liberally sprinkled among the subsamples. An often-cited response was that the women regarded health as being able to take care of their families. Of the 57 women who responded to this question, 9 who had been in the country fewer than 5 years expressed this as the first thing that came to mind; 4 from the other subpopulation shared this concern. It is possible that the small disparity in percentages is due to the veteran immigrants’ greater financial wherewithal and therefore reduced worry about who would care for their children if they, or one of their family members, became ill. Related to this idea was a concern about not being able to work outside the home and contribute to the family’s upkeep and maintenance. Elizabeth G., (age 25, 5 years in Santa Fe), stated, “To feel well. I am well to take care of my baby and my husband, my house, and I can work.” Maria N. (age 41, 3 years in Santa Fe) commented, “It has a lot of meaning because you feel you have the freedom to do many things, to do chores with more freedom, to go out and work, to see your kids, or, even better, play with them, to chat, to teach them a little. Because sometimes you feel so bad that you don’t even help them with their homework.” Being sick is a physically and morally constraining experience. The desire to do chores in the house, work outside the home, and take proper care of children is thwarted by sickness.

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The linkage of health with freedom of action was reported by Joseph and others in their quest to understand the phenomenological experience of depression in a small sample of Mexican respondents. They found that feeling loss of freedom causes physical ill health, as well as depression. Their respondent stated, “Perhaps if the possibility…exists, of having more freedom of action like in Mexico, we would be more healthy, not only physically but mentally also” (1995:31). In the present data set, Yolanda (age 29, 10 months) did not speak of freedom to act per se, but she underscored the notion that being healthy means having the liberty to work: “It means that I like having good health because that’s how I raise my children. And if I get sick, who’s going to look after my children? I have to go on. I like being healthy [enough] to work. I like to work to raise my children.” Jacqueline (age 16, 2 weeks), like Maria N., conceived of health as enabling her to do everything she wished. She related, “[Health] means everything to me. It’s to be able to eat everything, to be able to do everything, to be able to care for your son, to be able to talk with your husband, to be able to play basketball, everything that is to live well, that without health you couldn’t do.” Health, then, is characterized as liberty, autonomy, and freedom. Last, Gabriela (age 34, 10 years) viewed good health as being able not only to take care of one’s family but also to “perform” one’s duties. One cannot help wondering whether the extreme orientation toward action and performance in U.S. culture had affected her. Gabriela explained, “Well, [health] means performing better as a mother, as a human being, as a wife.” For the 13 women who suggested that an inherent connection existed between being healthy and having the freedom to act, the average number of years lived in the United States was 2.9 (median 1.8 years). See Table 11 for a compilation of all the results from this section.

HEALTH AS PROSPERITY: BEING ABLE TO MAKE ECONOMIC PROGRESS Being healthy also symbolizes the possibility of “getting ahead” economically, the primary reason for most migrants’ journeys to the United States. Berta (age 43, 1 year in Santa Fe) underscored the relationship between being healthy and becoming more prosperous: “It means a lot because when you are well and healthy…you can work, look after your kids, move forward. You can do many things”

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(emphasis added). Neli (age 55, 5 years) also believed that good health is intimately related to the economic reasons for which she emigrated: NELI: It is the most beautiful thing in my opinion. Health is very beautiful. ENTRE: What are the characteristics of good health? NELI: Not to go through economic hardships. That, for me, is to be healthy. Not to be in need of everything. That, for me, is health and peace.1 Having suffered with clinically diagnosed depression for several years, Neli articulated the cause of her ill health: economic duress. Very directly relating adverse life circumstances to her health condition (something that, we shall see, is common in Mexican etiological belief systems), she blames the material condition of being poor on her depression. In a similar vein, Ivone (age 38, 1.5 years) echoed the common desire of migrants to better their living conditions. For her, health meant “to be stronger, to have more life…to be able to work and get ahead.” Guadalupe G. (age 25, 3 years) imparted a similar message: “To have good health is to have the energy to work. That is the main thing. Because without work, you can’t live here. To have the energy to get ahead, that is everything.” The testimony of these immigrant women appears to highlight the fundamental relationship between a quest for income stability and a subjective sense of well-being. Furthermore, of the 5 interviewees who felt that good health means being able to get ahead economically, only 1 had lived 5 years in the United States, suggesting that economic progress preoccupies the recent immigrant more than the veteran. Their recent arrival status is reflected in the mean number of years they had lived in Santa Fe: 2.1 (median 1.5 years).

HEALTH AS STRENGTH: HAVING ENOUGH ENERGY Besides emphasizing the ability to work, Guadalupe (mentioned above) invoked a trope common in many cultures, that being healthy means having a surplus of energy (Joseph and Shweder 1995). Women from both subsamples agreed that a surfeit of energy is a reliable predictor of health. For example, Teresa V. (age 38, 1 year in Santa Fe) explained that health means “feeling well, having energy to work, to take care of my home, my children….” Rosario M. (age unknown, 3 months) agreed: “To have energy, to always have energy.” Gloria R. (age 22,

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5 years) stated similarly, “To eat well, to feel good, to have energy to do anything you want to do. Sometimes you get tired quickly [when you are ill].” The opposition of energy and fatigue is also mentioned by Maria M. (age unknown, 4 years): “To be in good health means to have energy…and not to be weak. That is what it is to have good health. Energy, a lot of agility, to never be tired, and to not be sleepy.” The concept of “energy” comes in diverse cultural incarnations. Those who subscribe to or are familiar with any variants of complementary and alternative medicine) know that energy gives vitality and vigor. The energies of chi, or ki, are primary in traditional Asian therapies based on the tenets of Chinese and Japanese healing philosophies. In all, 5 respondents cited a surplus of energy as the meaning of health; the mean number of years they had lived in the United States was 3.1 (median 4 years).

HEALTH AS AUTONOMY: LIVING INDEPENDENTLY, FREE OF DISEASE The differences between the implicit models of health for the <5 year and ³5 year subsamples were subtle, but cognitive models more obviously differed, depending on the age of the subject. Uniformly, those to whom good health meant being able to perform their duties as wives, mothers, and breadwinners were younger. Conversely, those beyond the family-raising years were more concerned about illness and the resulting diminution in their ability to take care of themselves without the aid of doctors, family members, medicines, and the like. Magdalena, a 65-year-old diabetic with hypertension who had lived in the United States for a total of 45 years, explained, “It means a lot. If I had good health, I wouldn’t have, I would say, so many illnesses. I would like to feel good and not have to go to the doctor, at least not so often. Because sometimes I think it bothers them, that I’ve never gotten over it. But, of course, I don’t want to have illnesses.” Imputing to her doctors an impatience that they may or may not feel, she expressed dismay at her body’s failure to be free of disease. Ana Marie (age 68, 13 years in Santa Fe) agreed: “What is it imagined that it [health] means to me? I am 68 years old. I have been diabetic for about 32 years. Having good health is having everything. I am an active woman. I like to work. I liked to walk even when I was good and healthy. I can’t do all that now. There are moments it torments me, that, before, I

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could go to stores and I didn’t get tired as I do even in my house, and in the patio and the gardens. And now I can’t do all that….” Independence, mobility, and regeneration are more regularly the cognitive models of health for older women of all cultural backgrounds. Freedom from diagnosable (and often chronic) disease is the foundation, indeed, the ultimate definition, of health for older women. An older person’s conception of health is not focused solely on energy levels or the absence of illness, however. Underlying it is the hope that there is still much more life to live. This idea—a cognitive model of health usually held by an elderly person or a degeneratively or chronically ill one—is expressed by Concepcion (age 53, 6 years). She had been recently diagnosed with severe osteoporosis, a condition that, according to her doctor, was caused by her having too many babies (6) in rapid succession. She stated, “For me, good health means you still have life ahead of you. And if you have life ahead of you, you have to fight, to see a doctor. Because the doctors help you with their medicines and help you move forward [with your life]” (emphasis added). For these 3 women, who perceived a relationship between health and autonomy, the mean number of years lived in the United States was 21.3 (median 13 years).

HEALTH AS THE ABSENCE OF PAIN: SEEING THE BODY AS A SMOOTHLY FUNCTIONING FACTORY Uniformly, young and old alike—in both subsamples—defined health as a lack of pain. Some were quite specific. Rocio (age 32, 10 years in Santa Fe) stated, “That everything feels well, that I don’t have a headache. That is the most important thing.” Likewise, Claudia (age 30, 2 years) explained, “To want to work, walk, and eat, and do everything that one can do, I think we are well. Nothing hurts me. So far, I haven’t been looked over really well, but I am well. I feel well.” San Juana (age 17, 5.5 years) gave a very specific explanation of what made her feel unhealthy: “Well, feeling good in every sense. It means a lot because I’m practically always sick with pain in my throat. I can’t go walk about when there is a little wind. I have to be inside because I get sick right away.” Josefina (age 44, 13 years) combined lack of pain with adequate functioning of the body when she stated, “That nothing hurts you, not even your head, because if it’s not your head…that your arms don’t hurt, that your feet don’t get swollen, that you do your necessaries well—pee and poop—I don’t know how they say it now,

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that you are well. When you are well, as I say, you are well in all ways.” A global wellness is associated with a body that does not hurt and that functions as it should. This method of determining health is basically a phenomenological one, defined as the peaceful lack of intrusion on one’s subjective awareness of the body (Joseph and Shweder 1995:18). Eight more women also invoked absence of pain as a way to determine whether the body is healthy. The mean number of years associated with these 12 responses was 5.1 (median 4.8 years). Images of the body as a functioning mechanical system have been commonplace in the western hemisphere since the early part of the twentieth century (Clark and Cumley 1953; Engel 1977; Osherson and Singham 1981; Martin 1994:28). In this cognitive model, the body that works as a machine contains parts that occasionally break down, cause pain, and need to be “fixed” by physicians. The body as factory is homeostatic and therefore dichotomous: either it is healthy and all the parts function smoothly, or it is diseased and one or more parts must be restored or replaced (Martin 1994:269). Health, in other words, is a fragile state of equipoise. Finkler (2001) writes that the cognitive model of the body as a machine with parts is traditional in allopathic medicine as practiced in Mexico and understood by the popular sector.

HEALTH AS A PRECARIOUS BALANCE: SEEING THE BODY AS A COMPLEX SYSTEM The only narrative that was very obviously influenced by emergent health discourse in the United States was provided by Delia (age 65, 2 years in Santa Fe), a diabetic for whom being healthy is a state in which she waits to discover when she is ill. Very surprised by her Santa Fe doctor’s diagnosis of diabetes, Delia stated, “Well, [health is] to feel well. Because one can be sick and feel well and not know that you are sick and feel bad. For me, good health is to not be sick yet, to be in control and feel well.” Using the discourse she likely learned from the health educators at the local health clinic, Delia believed that being healthy means being in “control” of her sugar levels; to be out of control is to enter the state of illness. Although she realized that she was already chronically diabetic, she perceived another level of wellness, ultimately promoted by her maintaining the proper insulin levels. Her discourse echoes that promulgated by Pender (2001) in what she terms “The Health Promotion Model.” This model, rather than stress preventive behaviors that merely react to the threat of disease,

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emphasizes well-being, personal fulfillment, and self-actualization. Examples of health-promoting behaviors are routine exercise, rest, pleasurable leisure activities, stress reduction, and optimal nutrition. (See also Whitlock et al. 2002.) For Delia, bad health was a precariously balanced condition constantly threatened by the vagaries of daily changes in diet, exercise, and stress levels; wellness, however, was promoted by the same constituents. Having been in close and constant contact with the diabetes education team at the clinic, Delia had adopted the diabetic discourse that emphasizes being in command and striving for wellness. It is a discourse that reaches far beyond the local world of the diabetic and his or her diet. When a patient embarks on the path of diabetes education, she is, perhaps unwittingly, becoming embedded in a culturewide discourse about the body as a complex system (as opposed to a homeostatic machine). Complex systems are enormously sensitive to differences in input (i.e., the famous “butterfly effect”): a little more stress here, a few extra cookies there, and suddenly a diabetic’s insulin levels are raging and she must be rushed to the hospital. Martin writes about how this cultural model of the body as complex system affects the psyche of a sick person: “If you see everything about your health connected to everything that exists but also accept the possibility of managing and controlling at least some of the factors, the enormity of the ‘management’ task, of controlling one’s body and health, becomes overwhelming. Who will manage all this? Is anyone in control?” (1994:123). Although Martin wrote specifically about the body’s immune system, several of the diabetics interviewed expressed anxiety about their responsibility as “managers” of their precarious health condition (none as eloquent as Delia). Indeed, they were very aware that their condition allowed no respite from vigilance, no potential for homeostatic balance. Similarly, intrinsic to the cultural model of the body as a complex system is the knowledge that “catastrophic eruption or collapse can, and indeed eventually will, occur” (1994:125). Contrary to motorized systems, there is no state of smoothly running equilibrium, no reprieve from the influence of environmental inputs. Delia, the only interviewee to conceptualize health in this manner, had lived in Santa Fe 2 years at the time of her interview.

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HEALTH AS A STATE OF ENCOURAGEMENT: ENJOYING THE RICHNESS OF LIFE For 5 of the women, the cognitive model of health included a vision of wellness that encompassed their emotional world. A discussion of what it means to be healthy for a member of the Mexican community would not be complete without considering the affective aspects of health. The following explains how health is associated with an energetic enthusiasm for life. Specifically, health, as conceived phenomenologically, means that a person has strong desires and enthusiasms. Ivone (age 38, 1.5 years in Santa Fe), whom we met above in the discussion relating health to economic progress, also suggested that health has to do with a state of desire. When she is healthy, she feels “more desire to live and be well [sentir deseo]” (emphasis added). Similarly, Reyna (age 40, 5 years), whom we encountered in the discussion relating energy to health, explained that feeling healthy is commensurate with being in a general state of “encouragement.” She commented, “For one to feel encouraged (alentado) is the most important, to feel good in your health.” The Spanish verb alentar has two meanings when used in its past participle form: “to be in good health” and “to be encouraged.” The intertwining themes of “desire” and “encouragement” were also expressed by Delfina (age 61, 10 years), who explained that health means what she calls “the state of encouragement—for me, it means richness.” (“El estado de animo…para mi es una riqueza.”) In this context, animo as in “el estado de animo” can be interpreted as meaning a state of “intention,” or “will.” Animo in other contexts means spirit, soul, mind, courage, and fortitude. For Delfina, the sense of intentionality and hope that results from having a healthy body is the very essence of a life rich with meaning and purpose. Margarita (age 54, 2 months) agreed with this assessment when she stated that being healthy is “to feel well, to have the desire to do things.” Ana Maria, whom we met above in the section on health as an absence of disease, continued her reply: “Now I can’t do all that [I used to]. My ambitions that I wanted to have…and to work and to learn to drive, to buy myself a car—they are already gone. I don’t drive, so it’s like all that hurts you. But, for me, the principal thing is to be healthy.” Being and feeling healthy are an actual emotion state for these women. To be healthy is to experience the positive feelings that accompany the pang of desire, the thrill of encouragement, the ache of

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ambition. In a way, health is also an image of “energy,” but an energy that goes far beyond mundane vitality or vibrancy. Feeling encouraged does not give one the energy simply to carry out daily responsibilities. It enables one to embody longing aspiration and extend the body and mind into the unknowable future. When one is healthy, one feels that one can manifest desires, relieve the twinge created by want, act with intentionality and spirit. Perhaps this healthy sense of willfulness, intentionality, and fortitude is what propels immigrants over the border to fight for their dreams. Many of the “models” of health outlined above have been discussed elsewhere vis-à-vis the Mexican population, as well as other groups. In my experience, however, imagining health as a “state of encouragement” is singular. Whether this is a truly Mexican cultural model of health, a pan-Latino cognitive representation of health, or merely a linguistic (or translation) artifact remains to be seen. The mean number of years lived in the United States for the women who suggested that being healthy means “El estado de animo” was 4.1 (median 4 years). A subset of the phenomenological experience of the healthy body is the perception that it is a “calm” (tranquila) body. Olaya (age 23, 18 months) explained that she knows when she is healthy because she is tranquila, as well as able to care for her family: “Well, that I am well and I can attend to my family, to my children, to my husband, that I feel happy, calm.” Eva (age 49, 4 months) agreed, suggesting that her feeling of calm also extended to her family: “When I feel well and I feel calm with my family, with my husband, with everyone. Because when I’m sick, I get very agitated [aguitada].” Blanca (age 32, 5 years) was yet another interviewee who mentioned that feeling calm is the hallmark of health: “To be healthy and not get sick, to feel good, to be good, to be calm.” Like Blanca, Yolanda (age 40, 5 years) regarded calmness as an intrinsic value of health: “It is very important. It is to feel good, to feel relaxed, calm, my children are also good and I feel calm.” Six of the subjects offered “feeling calm” or “relaxed” as their cognitive model of health, representing an average of 3.3 years (median 4 years). Interestingly, the images of desire and tranquility—seemingly contradictory yet complementary in many respects—implicate for the obverse, for feeling sick, a phenomenological sense that to be ill is to feel empty, listless, constrained, tired yet agitated, discouraged, and

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without desire. As we shall see below in the discussion on depression, anxiety, and nervios (chapter 12), these categories of emotion often indicate a phenomenological understanding of the body when diseased, one that the women utilized regularly in diagnosing illness in themselves, as well as others.

HEALTH AS FAMILY WELL-BEING: EMBRACING THE ENTIRE FAMILY Another model of health begs quick attention, if nothing more than for its similarity to models held by members of other cultures (Asian Indians in particular, Joseph and Shweder 1995:6). It is the belief that health is distributed through and is intrinsic to a complex web of related persons. Rather than view the person atomistically, as North Americans acting and thinking in a biomedical context (and in practically every other domain) are wont to do, 3 interviewees could not conceive of their children’s illnesses without considering how these would affect themselves as well. Regarding other domains, this tendency has led some researchers to call Latinos highly contextual people (Alegria et al. 2004; Mikhail 1994); that is, they think and make decisions in the context of an environment that includes family, religion, socioeconomic conditions, and so on. Like Eva (mentioned above), who conceived of health as feeling calm in herself and with her family, Maria R. (age 65, 2 months) underscored this tendency: “Good health means a lot. Health is everything. [To be] content, very happy. That my children have good health too. Because if I have good health and my children don’t, well, it would not be the same.” Thinking “contextually,” Maria incorporated information about her family’s health when discussing her own sense of well-being. She understood that she was embedded in a world of complex relationships and that these could not be discounted. In contrast, biomedicine, as practiced in the United States, places focus solely on the patient with the diseased body and on the medical encounter between the physician and the patient. This all-embracing principle of individualism (Dumont 1971, 1977; Shweder and Bourne 1984; Waitzkin 1993) effectively segregates the patient from the family and society and conceives of him or her as the sole sufferer. The limitations of excluding the family have been discussed elsewhere (Cicourel 1981:71; Hahn et al. 1988). The mean number of years spent in Santa Fe for these 3 women was 8 months (median 4 months).

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HEALTH AS BOTH PHYSICAL AND MORAL WELL-BEING: FEELING COMFORTABLE Last, Anahy (age 30, 10 years in Santa Fe) provided an interpretation of health as multidimensional: “It has a lot [of meaning] because of my kids. To take care of myself physically, morally, economically, spiritually. I have to take care of my health in many ways.” A devout Catholic who once asked her priest for an intercessory prayer to help her newborn son overcome jaundice, Anahy believed intimately in the connection between body, mind, and spirit. Having migrated to escape impoverishment, she also understood the important connection between economic well-being and physical well-being, discussed previously. Similarly, Sylvia (age 20, 2 years) commented, “First of all, that I feel good physically and morally, that I feel comfortable with all of my family.” The average number of years Anahy and Sylvia had spent in Santa Fe was 6 (median 6 years). See Table 11. Table 11. Cognitive models of health by years lived in the U.S. Cognitive Model Healthy family body Economic progress Freedom to care for family Complex system Energy State of encouragement Calm; relaxed body Absence of pain; machine Physical and moral Absence of disease; autonomy

Percentage of Samplea 3.5 8.8 22.8 1.6b 8.8 8.8 10.5 21.1 3.5 5.3

Mean Years 0.6 2.1 2.9 2.0 3.1 4.1 3.3 5.1 6.0 21.3±

Median Years 0.3 1.5 1.8 2.0 4.0 4.0 4.0 4.8 6.0 13.0±

a

The numbers representing percentages of the entire sample do not add up to 100 percent because there was significant overlap in responses. b This response was provided by only 1 interviewee. ± – The presence of 1 respondent who had lived in the United States for 45 years skews this mean and median.

I want to emphasize again that because these models or images of health were liberally sprinkled throughout the sample, it was difficult to locate the lines between the recently arrived and the veterans of more than 5 years. Intuitively, it makes sense that older people would conceive of health in manifestly different ways than younger people.

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Similarly, those who are very recently arrived in the United States would be, in general, concerned more with economic survival and “getting ahead” than the veterans, who might conceptualize health more multidimensionally (and perhaps solipsistically) as “energy,” a “state of encouragement,” or even as “tranquility.” It appears that, after living 4 or 5 years in the United States, the economic situation of veteran migrants is not dire, freeing them to focus on other aspects of their lives—individual health as opposed to familial needs. This is a significant revelation: a migrant who is less preoccupied with securing financial stability and who possesses, for example, a model of health predicated on a tranquil body, free from pain, will likely seek care earlier rather than later. Of note is that other researchers have found that Hispanic seniors invoke the health models of “tranquility,” “absence of pain,” and “physical, moral and emotional balance” (Ailinger and Causey 1995). Also, in their study there is no mention that these elders equate health with economic stability or being able to take care of one’s family. Although Ailinger and Causey do not mention the length of time their elder Hispanic subjects had lived in the United States, their data underscores the basic thesis of this research: over time, changes in beliefs about health or in conceptions of health are possible, and indeed probable, in the Mexican immigrant community. The longer they are here, their minds turn more to conceptions of health based on a sense of phenomenological well-being and less on physical impoverishment. We need more research to untangle the relationships between cognitive models of health and actual health behaviors. Sharing Margarita’s (age 54, 2 months) beliefs about health might aid in summing up the salient ideas of these immigrant women—no matter how long they had lived in the United States. She explained that being healthy means “to feel well, to have the desire to do things, to feel strong enough to do things, to feel well physically and emotionally, to be happy, content, calm, without pain, without concerns. Getting along in my job, getting ahead, my normal life.”

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CHAPTER 6

Change over Time in Health Prescriptions

One of the main points about cognitive models of health in chapter 5 is that they do not fall into as easily discernible time-sensitive patterns as other health-related beliefs. This chapter focuses on what the migrants thought that they should do to keep their bodies healthy. The change over time in their prescriptions for good health is more readily apparent here. Discussion of the proper diet (and exercise, in the United States) to maintain or recover good health is intrinsic to medical encounters between patients and physicians. But diet and health tips are not the sole province of medical practitioners. How to achieve a healthy body is medical knowledge usually encountered in the “popular” and “folk” sectors of the health care system and is therefore particularly contextsensitive. Information on these topics is offered in the nightly news, radio advertisements, and daily periodicals. The importance of diet and exercise is taught in schools and in the home and debated in legislative sessions and among friends. In fact, in the United States, it is difficult to avoid the onslaught of opinion about what we should eat. The data discussed below illustrate beliefs about proper diet, which become increasingly specific the more time a migrant spends in the United States. Table 12 illustrates this data.

IDIOSYNCRATIC RESPONSES One distinctive response was offered by Rafaela (age 65, 1 year in Santa Fe), a diabetic. Rafaela stated that, to stay healthy, she tried very hard to avoid falling, something she learned about at the local health clinic. Another health prescription, “Eat a lot of calories,” was provided by Jacqueline (age 16, 2 weeks in Santa Fe) and Ivone G. (age 38, 1.5 77

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years). It seems to be a persistent and tenacious belief—especially among the poor and chronically undernourished in Mexico—that eating a lot is the road to good health (Finkler 2001). Although these two women are the only ones who phrased their health prescription in this way, others spoke of eating “well.” One interpretation of well in this context could be “amply” or “adequately,” as opposed to “nutritionally balanced,” the other meaning of well. Most likely, the former interpretation pertains more directly to the recently arrived. Other prescriptions for good health included (a) sleeping/resting a lot, not working too much, and eating on schedule; (b) taking vitamins; (c) drinking a lot of water; (d) taking care of oneself without going to the doctor—doctors do more harm than good; (e) work; and (f) controlling one’s nerves. (The concept of nerves as it relates to the health of these Mexican immigrants is addressed in much greater detail in chapter 12.) In addition, taking medication was the key to staying healthy for two diabetics who were absorbed with their need to inject insulin in order to maintain their health.

RELIGIOSITY Responses started to show less idiosyncrasy and more tendency to cluster with those interviewees who were Catholics, Pentecostalists, Jehovah’s Witnesses, or Baptists. These interviewees contributed health advice most likely learned in their respective churches. When queried as to what they did to stay healthy, 35 percent of those categorized as “highly religious” or devout and whose time in Santa Fe ranged from 2 weeks to 10 years responded that they did not smoke or drink, and they referred to such activities as “vices,” most likely a churchinfluenced discourse. Jessica (age 35, 10 years in Santa Fe) explained, “I eat a lot, but I don’t have any vices, like smoking, drinking. And I don’t like it, but to avoid them [is] to maintain good health.” Of 6 interviewees who spoke to the health benefits of avoiding drugs, smoking, and alcohol, Brenda (age 24, 4 months in Santa Fe) stated that she stayed healthy by not “smoking and drinking” and, when sick, she and members of her family called upon a traveling Catholic priest to heal them. Of course, the negative effects of smoking, drinking, and doing illegal drugs commonly appear in public health messages, at least in the United States. The use of the word vice (el vicio) to describe these, however, suggests that church doctrine had influenced these women’s health beliefs.

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In a related vein, two other respondents who considered themselves devout (that is, they attended church weekly, read the Bible regularly, and prayed daily) commented that they “go to church” or “talk to God” to become healthy. One of the two had converted to the Baptist religion after moving to Santa Fe; both women had lived in Santa Fe for more than 5 years. A different interviewee, Martha (age 24, 6.5 years) invoked churchgoing as a way to stay healthy. She, too, had changed religion. At the time of the interview, she was a member of Christiana Yo Soy, a Protestant church. Martha attended services three days a week and prayed daily but, interestingly, did not consider herself religious. Voluntary service was also one of the ways in which she took care of her health: “I think [volunteering] also helps.” Responses such as “go to church” and “do voluntary service” refer implicitly to the emotional or even moral dimensions of health, discussed in chapter 5. Praying to God or performing ministrations in God’s name produces a subjective sense of well-being and peace. Although some women stressed the importance of being “right” or “good” with God, they did not see God as a vengeful being who takes away good health from a supplicant who does not perform her daily or weekly rites. Depending on the women’s understanding of Catholicism, as well as familiarity with curanderismo, they might attribute this spiteful behavior to their neighbors rather than to God. Whether they prayed did not directly affect the way God treated them in general, or their health specifically. Instead, being “right” or “good” with God meant that they had the peace of mind that comes from initiating and maintaining a constant dialogue. God allows sickness and suffering not because one does not pray but rather because these are simply part of life. This idea is explicated by Martha (age 24, 6.5 years): “According to the Bible, [sickness] is necessary, that all of this takes place.”1 In all, 9 people who responded to the question, What do you do to stay healthy? offered a health dictum related to the religion they practiced. Not surprisingly, all but 1 were coded as being of medium or high religiosity. Further bisecting the responses by time lived in the United States showed that the “vice” discourse was more common with the recently arrived; those who had lived longer in the United States more frequently promoted the “go to church,” “talk to God,” and “voluntary service” advice. Together, the mean number of years for any religiousbased health maxim was 3.8 (median 3 years).

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FAMILY COHESION Similar to the emotional well-being produced by prayerful contact with God, “get[ing] along with family” was an answer provided by 2 of the women. Elizabeth and Guadalupe (5 years and 3 years, respectively, in Santa Fe) felt that peace in the home would also aid emotional and physical health. Although neither mentioned the family when answering the question, What does it mean to be healthy? both referred to family when explaining what they do to stay healthy. The average number of years they had lived in Santa Fe was 4 (median 4 years). What is interesting about these relatively high averages is that they may reflect the tendency—after 3 or 4 years living in the United States—for the family to begin to disintegrate, because of divorce or separation, children moving out of the house, and the like. The conclusion discusses this topic at greater length.

A POSITIVE ATTITUDE Responses to the question also start to cluster (that is, more than 2 women provided them) around the idea that staying “positive” or being “strong” has a constructive effect on health. The following quotations serve to initiate the discussion. Ivone (age 38, 1.5 years) related, “I try to control my nerves (trato de conservar mis nervios), to not say that I am sick or that I feel bad. Because if I think that I am sick, I get sick. I try to be positive.” Veronica (age 23, 7 months) suggested a similar sentiment, albeit in a different manner: “I take care of myself as much as possible, but at times…that is, I don’t get sick much except for at times from the flu. But I don’t pay much attention to the flu…what I do is not be so delicate.” Fortifying oneself in the face of sickness, trying not to be fragile, these reflect the belief in staying “positive.” Paola agreed: “I take medicines and keep my spirits up.” She was 53 years old and had lived in Santa Fe 1 month. Together, their responses were more emblematic of recent migrants. For these 3, the mean number of years lived in the United States was 0.7, or 9 months (median 7 months; range, 1 month to 1.5 years). Maintaining a positive attitude, keeping one’s spirits up, and trying not to be delicate were health maintenance techniques cited (in relation to this one question) only by the recently arrived, who most likely lacked the wherewithal to visit a doctor.

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A REGULAR SLEEP SCHEDULE The next, most oft-cited method of staying healthy was recommended by 5 of the migrants (range, 4 months to 10 years in the United States): keeping regular sleeping hours. Diana M. (age unknown, 10 months) told how she stayed healthy: “I live a normal life. I don’t smoke. I don’t drink. I don’t stay up all night. I try to take care of myself” (emphasis added). Maria R. (age 41, 2 years) agreed: “What I do is take care of myself. For example, I don’t stay up all night. I eat well. I make sure we get our milk, tortillas for everyone” (emphasis added). Brenda (age 24, 4 months) responded in the following manner: “I eat well. I don’t smoke. I don’t have sleeping disorders.” When asked what she thought was most harmful to health, Brenda replied, “Alcohol, cigarettes, insomnia [las desveladas].” Gabriela, whom we have met before (age 34, 10 years) and whose complete response straddles the divide between more acculturated and less, told her interviewer that, to stay healthy, one must have “good food, good sleeping habits, exercise.” Without exception, interviewees supplied multiple ideas for ways of staying fit, but the mean number of years for those who believed in good and regular sleeping habits was 2.9 (median 1 year).

EXTREME TEMPERATURE CHANGE (THE HUMORAL THEORY) In addition to good sleeping habits, more of the recent arrivals emphasized the importance of guarding against extreme temperature changes. This is not an uncommon attribution; in fact, it is a popular etiological explanation for all manner of minor illnesses, among both urbanites and those from rural areas (Keefe 1997; Finkler 2001). Eight subjects out of 41 mentioned that a person should avoid large variations in temperature. For example, Jacqueline (age 16, 2 weeks in Santa Fe), who had stated that one must “eat a lot of calories” to be healthy, also suggested that it is important to dress properly when venturing outside: “Take care of ourselves…eat things that don’t hurt you, dress properly when you go out, eat a lot of calories, things you don’t do, out of laziness” (emphasis added). Maribel (age 23, 1.5 months) echoed Jacqueline’s caution about the weather and added a dietary restriction: “I take care of myself with changes in temperature, sometimes with food. Chile hurts me. I shouldn’t eat it.”

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During fieldwork in a large hospital in Mexico D.F., Finkler also discovered that various foods and inclement weather are thought to affect health: “Diet and climactic changes are part of the etiological folk [ideology] for both physicians and patients. Many physicians associate poor diet with the overall poor health state of the population they treat. Often they attribute specific gastrointestinal dysfunctions to the spicy Mexican diet and to the eating of pork, which is considered an irritant to the stomach” (2001:79). Almost identical to Finkler’s findings about “folk” or “popular” diagnoses in Mexico is the one Maribel reports having received before leaving her home in a rural pueblito in the state of Zacatecas, where she was diagnosed with gastritis. The doctor told Maribel that she had become ill because she “ate chili and drank a lot of cola.” San Juana, who was 17 and had immigrated to Santa Fe with her father when she was 11, concurred with the recently arrived immigrants. Her sole prescription for avoiding colds that cause throat pain (a chronic problem for her) was to stay inside: “When the weather is cold, I stay inside as much as I can.” Despite having lived 5 years in the United States, San Juana retained more “traditional” or “Mexican” beliefs, in health and many other respects. This was due, perhaps, to her extreme bitterness at having to emigrate with her father when she was a pre-teen, leaving behind her mother and much of her nuclear and extended family: ENTRE: Why did you leave Mexico? SAN JUANA: Because they brought me, my father brought me. I didn’t want to come. ENTRE: Why did you come to the United States, and specifically, why to Santa Fe? SAN JUANA: Because my father had been here for a long time and he didn’t like any other place. That’s why I’m here. He’s already a citizen. ENTRE: Describe your trip to the United States to me. SAN JUANA: By car, from La Perla to Juárez in one night and from Juárez to here in 5 hours. Seventeen hours. We didn’t have any problems because I already had papers because my father had already asked for them for us. I traveled with my father and a sister. My mother stayed there.…I’ve been back to Mexico, when I wasn’t married yet.

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I went back with my father in December. In June, we went to visit my mother.2 Like San Juana, Raquel (age 35, 6 years in Santa Fe) retained the belief that a sudden change in temperature would affect her health, especially her throat:3 RAQUEL: I make sure not to go to cold places or eat something frozen, so I don’t get the flu. ENTRE: Do you think there’s a relationship between temperature and the flu? RAQUEL: I think so, because if I go out of my house here and it’s hot and outside it’s cold, my throat is going to hurt. ENTRE: And ice? Do you think if you drink drinks with ice, it’s going to affect you? RAQUEL: Yes, because it’s cold. Any change in temperature—sudden or not—can precipitate illness, according to Raquel. To guard against this, wearing the proper clothing outside was a particular concern of the recent migrants. Cold drinks, too, must be avoided because they lower the body’s internal warmth and precipitate illness. Illustrating the virtue of asking questions in different ways, it is interesting to note that the women responded differently to the more specific question, Do you believe that heat or cold affects illness or medical treatment? when posed after the question, What do you do to stay healthy? The number who claimed that extreme temperatures or swift temperature changes were responsible for some illnesses increased from 8 subjects, to 29 subjects. These sorts of beliefs have been noted elsewhere in this population (Mikhail 1994) and have been categorized as belonging to the special category of humoral medicine. The humoral theory of disease etiology is common to many culturally distinct societies, and the foundations of this theory can be traced back more than four thousand years to the ancient medical traditions of China and India. The Greeks, Hippocrates and Aristotle in particular, borrowed from and advanced the theory of humoral medicine. In Hippocrates’s conception, health exists when the four body humors— blood, phlegm, black bile, and yellow bile—are in balance. In the 1500s, the Conquistadores introduced this health ideology, along with Catholicism, to the New World.

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Central to humoral theory is the belief that one’s health can be lost or restored by the effects of hot and cold upon the human body. Hot and cold refer not only to actual temperatures but also to their symbolic power, which is inherent in most substances. Everything from foods and herbs to mental states, illnesses, and medicines are categorized as either hot or cold. A prescription for good health is the maintenance of the proper balance in the body by avoiding prolonged or extreme exposure to either hot or cold forces and/or substances. For example, Mikhail (1994) and a host of others have reported that Hispanic mothers suggest that a change of weather or temperature, walking with bare feet, cooling or chilling of the chest, being improperly dressed for the weather, getting wet, drinking or eating cold things, and hot weather make an individual susceptible to contracting a cold. In the event of an unbalance, the goal of therapeutic intervention is to restore the body’s temperature equilibrium by selection and consumption of items that possess the opposing quality. For a more elaborate discussion of humoral medicine in the Mexican and Mexican American populations, see, for example, Trotter and Chavira (1981), Young (1996) and March et al. (2005). Although in some regions of the world—and in some southern areas of Mexico—humoral theory also dictates treatment options, this aspect of the humoral belief system did not appear to be important enough to the women to note with any regularity. Most of the women who mentioned climate changes and the need to avoid ice in drinks or exposure to extreme cold weather did not refer to the necessity of eating particular hot or cold foods when sick, during recovery from a surgical procedure, or after childbirth. In response to the question, Do you believe that heat or cold affects illness or medical treatment? only 3 women (out of 29), 2 of whom had been in the United States less than a year and 1 who had been in the United States 4 years, believed that heat and cold could affect treatment, as well as the onset of illness, but they were not specific about how this occurs. One example is Araceli (age unknown, 4 months in Santa Fe), who was from a rural area and had visited curanderas in Mexico. She explained, “Yes, heat can affect you. For example, they operate on someone, and he has an infection or something, and heat hurts him. And the cold too. For example, children [go] out in the cold, and their throat hurts.” Araceli, in her response, spoke of an attribution of illness and a treatment prescription, both of which are based on humoral theory. Mireya (age 24, 1 year) espoused a

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similar notion. Her interviewer asked her, “Do you think that the cold or heat affects sickness or medical treatment?” Mireya answered yes. When asked how, she responded, “Because there are many sicknesses that people have which get worse after being exposed to heat. When they have an infection, they need to stay cool. And the cold affects people with a cold.” Maria G. (age 49, 4 years) stated simply, “Yes [cold and heat affect one], when you are in treatment, yes.” The beliefs associated with humoral ideology regarding the onset of illness appear to be retained in this subset of early migrants, even though the manner in which many or most illnesses are cured does not appear to be inspired by humoral theory. More common was an explanation such as Dora’s (age 35, 18 months) regarding simple etiology. When asked whether heat or cold affect illness or treatment, she replied, “Yes, because with my mom, the heat raises her blood pressure. She gets sick. And with the cold, her bones hurt. It doesn’t affect the treatment.” Concepcion (age 53, 6 years) answered, “Yes, the cold affects you a lot, because many times the kids’ bronchial tubes are sensitive—the lungs—and they catch everything in the air. And first thing you know, they have bronchitis or pneumonia.” Berta (age 43, 1 year), with only a third grade education and from a rural area, gave a detailed answer about the relative effects of heat and cold: “The cold not so much, because you can take the cold away with clothing. But heat affects people more, [especially] little children, with dehydration. Not with a medical treatment, because if you are getting better, if they are taking care of you, I don’t think it affects you.” Although a robust number of people (29/41) subscribed in some manner to the idea that extreme temperatures affect the onset and duration of illness (especially in the event of continued exposure to cold weather when one is already sick), their combined mean number of years spent in the United States was only 2.1 (median 11 months). The one outlier who had been in the United States 10 years and had answered this question in the affirmative, Anahy, had not acculturated to many U.S. allopathic beliefs as quickly as other interviewees. She and others like her are discussed at greater length in chapter 11, which addresses the relationship of acute illnesses, antibiotic usage, and rate of acculturation.

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DIET AND EXERCISE The next cluster of responses to the question, What do you do to stay healthy? focuses on the actual components of dietary intake, which, judging by the percentage of respondents who invoked diet as a causal factor in promoting salutary health—56 percent—is of paramount importance. Worldwide, people have a basic sense that what goes into the body affects its proper functioning. What is revealed about the specifics of dietary intake is that this notion of the “proper” or “best” diet shifts with more time lived in the host country. People do not, of course, fit neatly into one schema or the other. Some recent arrivals gave answers resembling those of ten-year veterans, and the obverse was also true. What distinguishes the recently arrived from the veterans is the specificity with which they explained their views on how diet affects health. Whereas a newly arrived immigrant might simply say that she “eats well” to stay healthy and not provide any details, a seasoned migrant describes exactly what she eats, what she should eat more of but does not, and what she has learned to avoid eating altogether. The women who had, on average, spent more than 4 or 5 years in Santa Fe explained, or at least alluded to, the need for a “balanced” or “nutritious” diet. They also discussed the need to reduce fat in the diet, to eat lots of fruits and vegetables, and to exercise. According to one researcher, these topics are noticeably absent in the discourse between doctor and patient in a preponderance of medical encounters in Mexico D.F. (Finkler, 2001).4 In contrast, the National Center for Health Statistics report for 1997–2000 states that counseling or education related to diet occurred in 15.4 percent of all reported physician visits (National Ambulatory Medical Care Survey 2000). An example of how recent migrants’ discussions of food intake lack specificity is supplied by Maria R. (age 41, 2 years in Santa Fe). (Her belief that regular sleep habits are important for maintaining good health is mentioned above.) She said, “What I do is take care of myself. For example, I don’t stay awake late. I eat well, make sure there is plenty of milk, and tortillas for everyone.” In the present context, her belief that she “eats well” points to her being a recent arrival. Similarly, Nohelia (age 21, 7 months) discussed diet in a general way: “I eat well to avoid getting sick, and all of that. Nothing else.” Araceli (age unknown, 4 months) concurred, commenting that she “eat[s] well, drink[s] water.” Another recently arrived immigrant, Claudia (age 30, 2

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years), offered the following explanation: “I try to eat on my schedule, to eat well, not work much, to rest and sleep a lot.” The intertwining of diet and work as illness attributions—as when a regular eating schedule becomes impossible because of irregular work hours—was also noted by Finkler (2001) during her work at the public hospital in Mexico D.F.5 Olaya (age 23, 18 months) offered the same general advice as the other recent arrivals: “Eat well. Stay calm.” Guadalupe (age 23), who responded to many questions more like a new arrival, despite being a 6year veteran, answered plainly, “I eat well.” To illustrate the simplicity and generality of recently arrived interviewees’ responses, here are a few more. Eva (age 49, 4 months) stated, “I’m always doing something, work. And I take care of myself, in what I eat, and I try to keep calm.” Reyna (age 40) had lived in Santa Fe off and on for 5 years. Despite her 5 years, her diet-related discourse was as general as that of the newly arrived: “I take care of myself. I dress warmly and eat what I like to eat. Yes, because one is encouraged [alentado] [when] they eat all they like to eat. And when they are ill, they don’t eat anything.” Lucero (age 20, 2.5 years) summed up her health care regimen when she commented that she “live[s] well, eat[s] well.” As noted above, the most probable interpretation of the word well (bien) is “ample” or “sufficient,” indicating that adequate caloric intake was extremely important to these recently arrived immigrants. This sort of generalized health advice was attributed to 14 (out of 57) women who responded to the question, approximately 25 percent of the total sample. Taken together, the mean number of years that their experience in the United States represented was 2.4 (median 2 years; range, 4 months to 6 years). In contrast to the recent arrivals’ very basic philosophy about proper diet, the later arrivals (approximately 30 percent of the entire sample), those who had, on average, resided in the United States longer (mean 4.7 years; median 4 years) offered very specific counsel. Rather than simply state that they ate “well,” they explained in detail how they watched their “diet” (la dieta). For example, Eladia (age 27, 4 years in Santa Fe), who had seen a physician about her blood pressure during pregnancy, explained, “I try to not eat fatty things, because of the blood pressure too.” Similarly, Martha (age 24, 6.5 years in Santa Fe) said, “I try to eat a balanced diet.” Delfina (age 61, 10 years) stated that she strove for “an adequate nutritional balance,” a reply that does not do justice to the enormous changes—both dietary and religious—she had

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made in the 10 years since her arrival. Later in the interview, in response to the questions, Have you changed your way of being since you arrived here? If so, how? she responded, “Yes, I have changed in some aspects. I changed to become a vegetarian in the human sense. I live more sensibly, and I try to be more humble.” When answering the question, Have you changed your way of eating since you came to this country? veteran immigrants provided details suggesting that they had heard about and were even trying to incorporate diet dictums and related cooking suggestions prevalent in the United States. For example, Rocio (age 32, 10 years) stated, “I am the one who cooks, and I almost always make food that is from there [Mexico]. But before, I did not eat much salad. I did eat vegetables. There they are different. There is strictly lettuce with tomatoes and here, broccoli, cauliflower. We did not use ranch dressing there. We have always greatly enjoyed fruits. Here, I eat more meat. There, we did not have enough money to eat meat, only two times per week, but now we no longer want to eat too much red meat because it is unhealthy.” When asked whether she had changed her way of cooking, Rocio replied, “Yes, well, I told you that we did not eat broccoli and cauliflower and that, and here I learned how to make them steamed and all of that.” Martha (age 24, 6.5 years) had also changed her diet after coming to this country: “Yes, well, in Mexico I did not eat much fruit, vegetables, and here I do eat balanced foods, and I don’t eat a lot of grease. In Mexico, I ate a lot of grease.” When asked whether she thought that she was healthier here, Martha said yes. Blanca (age 30, 5 years) related: “There in Mexico, I was not so accustomed to eating vegetables. Here, yes, I do it because I know they are good for my children.” Those women who had resided in Santa Fe for a longer time also discussed the importance of exercise. For example, Rocio (age 32, 10 years) said that she tried to eat a balanced diet and to “exercise, try not to go crazy with the children, to have patience.” Martha G. (age 24, 6.5 years., who had talked [above] about trying to eat a balanced diet) also tried to get “a little exercise” in order to stay well. Gloria R. (age 22, 5 years), high school educated, an urbanite, a believer in curanderismo, and pregnant, commented, “I don’t exercise much, to tell the truth, but I eat a balanced diet.” Although Gloria R. was vague about what she ate, the mere use of the word balanced and the mention of taking exercise

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to maintain her health suggest that she was a veteran immigrant. Similarly, Anahy (age 30, 10 years) discussed the importance of exercise: “In the mornings I go outside to walk a while, and later in the afternoons I get my son, and at night I walk for ten or fifteen minutes here where I live.” Maria M. (age unknown, 4 years) was pregnant at the time of her interview: “Well, what do I do? Well, I eat a little more healthily. Once in a while I exercise and do activities in the house. This is what I do.” Last, Gabriela (age 34, 10 years) expressed beliefs that are characteristic of both newcomers and veterans: ENTRE: And what do you do to maintain your health? GABRIELA: Good food, good sleeping habits, exercise. ENTRE: What sort of exercise do you do? GABRIELA: Walk in the mornings, two or three times a week, about twenty minutes. ENTRE: Do you walk near your house? GABRIELA: Yes, around where I live. Although vague about her actual diet, like the more recently arrived, Gabriela differed from them in her endeavor to improve or maintain her health by exercising. The attribution of good health to a specific diet is exemplified best by Josefina. She was 44 and had lived in the United States 13 years (10 in El Paso and 3 in Santa Fe). She had also spent nearly 30 years in Juarez (a border town), which may have affected the rate of acquisition of health ideology. Educated through the sixth grade, she claimed to read, write, and speak English reasonably well. Josefina was very savvy about health care options (she requested city shuttle service when her family was unavailable to transport her to the health clinic) and financial options (she said that she would go to a bank for a loan if she needed money). She was also very open to trying new things in general (she became a Jehovah’s Witness after moving to Santa Fe). Josefina shared her beliefs about proper diet at great length: “Well, [you] try to take care of yourself, not eating cheap things, getting rid of certain foods from what we eat. Because I think that how you eat is how you feel. Because to say if you put a lot of things in your stomach, it will reject this. You’re going to load yourself up. You’re going to have gas. You’re going to get sick in the stomach. They say that if your intestines are good, all your body’s health depends on that. Clean

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intestines, good health.” When asked what things are most harmful to health, Josefina replied, “All refined things, like sugar, flour, rice, because it’s already refined too. But the worst thing you can put in your organism that many people here like is pepper, and that’s what the iridologist told me. Yes, well, refined sugar. I don’t know, but I believe her. Sugar, it’s very bad, the refined sugar.…Every time I go to Juarez, I bring brown sugar, and that’s what they use in my house, and not much of it.…I have honey in my house. And right now I’m trying to feed my children. Of course, you’re not going to be able to change your ideas of how to feed yourself from one day to the next, because, unfortunately, we have hamburgers, pizzas, all that, that the kids love. But you can include some things to make them healthier.” Josefina had recently returned from a visit to her sister (in El Paso), who had recommended the iridologist. Because this woman had cured Josefina’s sister of rheumatic fever and helped her to lose more than 30 pounds in 4 months, Josefina wanted to see whether the iridologist could identify why she felt unwell. Told that she was suffering from “too much stress” and that her “liver is a little damaged,” she was instructed to begin a diet composed of, among other things, “half a glass of natural spinach juice, with half a glass of lemon juice, but it all has to be natural.” Josefina explained in detail how the iridologist from El Paso diagnosed her: “They give you the diabetes test, the urine test, and the blood pressure test, and everything else. They see in the iris of your eye, and without saying a word…she tells you what you have. It seemed very interesting to me. Because I’d already seen people who see what you have in the soles of your feet, because all the organs of your body are there, or here in your hands. They also see in your iris, and what they always got out of me was stress….Because my organism isn’t making all of the B complexes, which are for the nerves. But now I feel very well.” When asked what she did to control this, Josefina said, “I’m taking a ton of vitamins, cat’s claw, to clean the liver. Large quantities of vitamin C, many things. There are even vitamins that serve to—if your organism wants to develop cancer—this vitamin encapsulates that for you and doesn’t allow the cancer to form, to grow. I learned with the doctor that cancer, if you detect that you have cancer, then you begin to eat everything natural. You stop eating canned things, sausages, sugar, flour, all that. And if you eat pure vegetables, you shrink the cancer. It dries up, because what makes it grow is what we

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eat….” The interviewer queried, “Now you don’t have any worries, any symptoms, nothing?” Josefina said, “See, it’s almost getting shameful.” Josefina comes up again in discussions of the data because her experience presents an interesting confluence of demographic and other factors that influence her health care decisions in ways that are both obvious and difficult to untangle. Exactly what in Josefina’s life opened her to experimenting with complementary and alternative medical ideologies? Was it her urban background, where multiple healthcare options were available? Was it her proximity to El Paso when she was living in Juarez, itself a rather cosmopolitan city? Was it her sixthgrade education, or her socioeconomic status, which gave her the wherewithal to afford different types of healers and physicians? During her interview, Josefina indicated that she had had experience with naturalist healers (even working with one in Juarez for a time), curanderos, medical doctors, and, as described above, the iridologist. Moreover, after moving to Santa Fe, unyielding and debilitating shoulder pain motivated her to start seeing a chiropractor. Later, because it was less expensive, she traveled to Juarez for the treatments. Although Josefina represents the apex of acculturation in the present sample of Mexican immigrants—at least, in her discourse on diet and her knowledge about complementary and alternative medicine—she may be idiosyncratic in general. Not all Mexican immigrants end up experimenting with different healing modalities, diets, body and energy manipulation therapies, and so forth. Josefina did make an important contribution to this project, however, for her very presence proves that rates of acculturation vary with each individual and that great changes in belief systems and behavior are both possible and likely. Josefina herself spoke to this possibility (“Of course, you’re not going to be able to change your ideas of how to feed yourself from one day to the next”). Given the will and the time, she implied, one just might change.

DIABETICS AND PREGNANT WOMEN A special subcategory of the women had not spent much time in the United States but nevertheless possessed very specific ideas about diet and exercise: those who had visited the local health clinic for diabetes treatment or prenatal visits. Maria N. (age 41, 3 years in Santa Fe) had been diagnosed with hypertension in Mexico but felt that the treatment—including advice about diet—she received in Santa Fe was better: “I make sure to follow the diet that my doctor gave me. I

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remember what they have told me not to eat, or if I eat them, I tell myself that I like these things but that they aren’t good for me. I think that I feel better when I do the things that the doctor recommends.” Rafaela (age 65, 1 year) also specified what her physician had told her about how to care for her diabetes: “Yes, I do have a special diet. I eat lots of vegetables. I cannot eat flour, or soda, or sugar. I also walk a lot.” Teresa (age 38, 1 year) was pregnant and going to prenatal classes for the first time: “Well, right now, I try to eat vegetables, fruits, teas. I make natural juices, and I like to walk. Now I just walk.” Delia (age unknown, 2 years) was a diabetic: “Diet. Walking. What they’ve told me what I have to do. The only thing I haven’t done is quit smoking.” I placed the women who had diabetic or prenatal education in a special subcategory because, in general, they had resided in the United States less time yet their health ideology—concerning diet and exercise—consistently resembled that of the women who had lived here longer. That is, they spoke with great specificity about what they should be eating and how much exercise their doctors had prescribed. The chronically ill and the pregnant responded to the questions in a manner comparable to the veteran immigrants because they had come into close, continual contact with workers in the health care system.6 Diabetics and pregnant women, every time they go in for an eye, foot, or blood pressure exam or a prenatal visit, see the same healthcare personnel. Not only do they hear the diet and exercise discourse more often,7 but they also develop a deep, satisfying rapport that is unusual for those who visit the clinic merely for subacute illnesses. Massey speaks of a similar causal factor in accelerating the acquisition of English among immigrants: “A migrant’s access to social capital… plays an important role in structuring the process of language acquisition. The odds of English proficiency…are also higher for those who have more extensive contacts with members of U.S. racial and ethnic groups” (1997:45). In the present context, repeated contact with medical personnel accelerated the process of health belief acquisition. Mentioned above, Delia, in her sixties, was a diabetic who had been in the United States only 2 years when she was diagnosed and began treatment. She explained why she was so pleased with the local clinic that caters to the immigrant population: “The people in charge of the diabetics, they speak to you really nicely. They raise your spirits. They teach you that it’s not an illness as severe as you hear. Before, when you didn’t know, you just heard ‘diabetes is bad.’ But learning

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how to take care of yourself, you learn a lot of things, and you know that it’s not so serious. It depends on the person. But they teach you, and they have made me feel a lot better.” Similarly, Magdalena (age 65, 45 years) claimed that she had been diagnosed with hypertension in Mexico when she was 18, but was not informed that she had diabetes until moving to Santa Fe a few years before the interview. During the time she visited the U.S. clinic for treatment and health education, she met and became friendly with an educator there, “Leo.” Magdalena described her relationship with him: “With the diabetic staff, sometimes I talk to a guy there. His name is Leo. I really like him. I feel a lot of affection for all of them, but a lot for him because he makes us feel so good. They are all really friendly, those in that department. But this guy, sometimes I greet him. On friendship day I brought him a rabbit. I feel, maybe because I’m so far away from my family, I feel like he is a son, very special. And I like the girls, too, but he is very sweet. I feel as if he is someone I really love a lot.” Later in the interview Magdalena described what she had learned about her hypertension and diabetes from the physicians, nurses, and health educators at the clinic. Having completely internalized their diet and exercise discourse, she repeated it like a mantra for the interviewer: I am trying to—all the doctors recommend exercise. For blood pressure, exercise. For diabetes, exercise. To relax, for [old] age, you should get around as much as you can, but you have to move. We have a gym here in the apartments. We go every morning. And even though my knees bother me, I have to walk. Because if I don’t walk, I’m going to get worse. We do a fifteen-or twenty-minute walk every morning. Because we have to go with the older folks. I am doing everything I can. But, like I said, it hurts sometimes to the point that I want to cry. Like when I get up from here, I’m going to feel bad, but I have to do it because of my health, to feel better. And those that live with me are also going to feel better. May God leave me until the day I can’t do everything for myself, that I never have to depend on anyone, that I would be in a bed and not be able to get up from that bed, or a chair, and not be able to move to take care of myself. I don’t want to be a burden on anyone, not for my kids, not for my family, because that is sad. I would hate to see my daughter sacrificing herself for me

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because I can’t do anything. I am not there yet, and I don’t want to get to that extreme. When asked what it means to have a good life, Magdalena replied, “It’s very important to try to have a good life. Taking care of yourself. Doing all that your doctor advises. Trying, above all, to do what I’ve just said. Exercise is very important. Diets are very important. Trying to do everything as best as you can. And taking care of yourself like they tell you to.” Although the question order undoubtedly had something to do with Magdalena’s response to the “good life” question, coming right on the heels of a long discussion about diet and exercise, it is interesting that she equated a good life with following the proper diet and exercise regimen to lessen the ill effects of her diseases. The emphasis she placed on these two activities might be due to her fear and consternation at the failing of her body. It also reflects the length of time she had spent in the United States, where diet, exercise, health, and longevity are obsessions. Clinic visits and a 45-year immersion in the body- and healthfixated U.S. culture, however, are not all that impelled Magdalena to place diet and exercise at the top of her health care “list.” Her advanced age and desire for autonomy also motivated her. These important factors hasten shifts in health care beliefs about exercise and diet for diabetics like Magdalena and are common themes in the discourse of elder Hispanic women (and men) in general (Magilvy et al. 2000). Pregnant women, too, are hypothesized as adopting diet and exercise beliefs more readily, because of their desire to deliver a healthy baby. It has been documented elsewhere that Mexican women commonly come to the United States believing that a healthy baby is a fat baby: “Dame gordura y te dare hermosura,” or “Give me plumpness and I’ll show you beauty” (Haffner 1992). “Eating for two” is a prevalent health maxim for these immigrants, one that prenatal care promotoras in the United States feel the need to confront and change, especially because this population experiences higher rates of gestational diabetes than other ethnic groups. Even though the recommended diet is often more expensive, because it contains fresh fruits and vegetables, Mexican immigrants readily comply with it. According to Haffner, “the surprising result is that there are fewer compliance problems than would be expected, even with all these frustrations. Having a baby is important to Hispanic women, so most of them overcome their

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reluctance and comply with the recommended diet or at least try their best within their limited resources” (1992:57). Haffner’s interpretation is that, in Latino culture, women are “supposed” to sacrifice for the family, even to the point of eating a lot of vegetables. Taking the two findings together, it appears that pregnancy is a time in which immigrant women are particularly open to new or different ideas about health; they readily adopt novel beliefs and new behaviors in order to care for themselves and their unborn children. This idea is treated at greater length in chapter 10, which discusses the relationship between rate of acculturation and specific diagnoses, including pregnancy. The mean and median number of years associated with those pregnant and diabetic interviewees who suggested that diet and exercise are particularly salient health topics were 2.1 and 2, respectively. By way of contrast, the mean and median number of years lived in the United States for the rest of the sample (including the diabetics and pregnant women) were 4.7 and 4, respectively. It is obvious in comparing these statistics that the diabetic and pregnant women were encoding the discursive practices related to diet and exercise more rapidly than the women who were not facing similar health issues. Table 12. Cognitive models of health prescriptions by years lived in the U.S. Cognitive Model Positive attitude Avoidance of changes in temperature Regular sleep schedule Low-fat diet (diabetic or pregnant) Good diet No vices Exercise Family cohesion Low-fat diet

Percentage of Sample 5.3 70.7 8.8 12.3 26.4 15.8 29.8 3.5 29.8

Mean Years 0.7 2.1 2.9 2.1 2.4 3.8 4.5 4.0 4.7

Median Years 0.7 0.9 1.0 2.0 2.0 3.0 3.5 4.0 4.0

THE INFLUENCE OF PLACE OF ORIGIN AND SES The last two categories of interviewees comprise those whose responses were rarely commensurate with the length of time they had spent in the United States and who were not diabetic, hypertensive, or

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pregnant. That is, even though they had lived in the United States only a short time, their responses most often resembled those provided by the veteran immigrants. Both socioeconomic background and urban residence before immigration appear to confound the neat clustering of responses that correspond to time lived in the United States. A long digression into the particulars of 2 interviewees’ lived experiences is important at this point to illustrate a principle that influences the shape and character of their responses and others’ across all the questions. This factor explains—if not rate of acculturation—why some immigrants from Mexico espouse ideas that greatly resemble those of the majority in the United States, who adhere to the tenets of allopathic medicine. Rosario came from Carlos Acuario, a small rural town in Vera Cruz, without a passport or her parents and was living with her brother, sister-in-law, and friend. Her thoughtfulness, intelligence (she claimed that she already—after only 3 months—understood a fair amount of English and spoke some too), and articulate responses belied the stereotype of a rural upbringing and sixth-grade education. Because her answers were not easily explained by associating them with variables such as “rural,” “level of religiosity,” or “education,” Rosario stood out. Here is her response to the question, What do you do to stay healthy? ROSARIO: I take vitamins. I try to take vitamins. My father speaks to me and says, “Did you already buy your vitamins?” ENTRE: Which ones do you take? ROSARIO: Now I am taking a one-a-day. This is the one I am taking. ENTRE: Do you have many? ROSARIO: Yes, a woman needs many. ENTRE: And what other things do you do? ROSARIO: I like to exercise. I love it. But since I have arrived here, it is like I have gone to the other side, and I want to go back to exercising. ENTRE: Do you run? What do you do? ROSARIO: I like aerobics better. ENTRE: Then you are going to have to find a gym to join. ROSARIO: Yes, I already have a videocassette.

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On the one hand, Rosario's discourse on vitamins distinguishes her from other recent arrivals. None of the recently arrived discussed taking vitamins as a way of acquiring or maintaining good health. Taking vitamins, however, is not uncommon as a treatment in Mexico, especially for a non-specific malaise or anxiety (“nerves”). Nerves, as well as anemia, are usually treated with injections of large amounts of vitamin B. According to Finkler, who observed in the Internal Medicine outpatient clinic of a public hospital in Mexico D.F., “in Mexico, as in the United States, there is a popular cultural belief that vitamins have a special potent force. Physicians variously prescribe a variety of vitamins and tonics” (2001:87). What is uncommon about Rosario’s response is her claim that she took them daily as a prophylaxis against sickness rather than as a remedy. On the other hand, Rosario’s discussion of physical exercise also places her in close association with the less recently arrived immigrants. As mentioned above, it is not at all common for physicians to prescribe physical training as part of a preventative or treatment regimen (Stebbins 1987; Finkler 2001). Elsewhere in her interview, Rosario explained that when she was little, she attended the local social security health clinic, which was available to her because her father was a union member working in a sugar factory. While she was growing up, Rosario saved money so that she could visit a private doctor in Mexico, a decision prompted by her mother’s death from cancer. Rosario’s fear of developing cancer impelled her to visit the private doctor, whom she thought provided better care. There was a general consensus among the women that, in Mexico, private physicians are of superior intellect and possess better diagnostic abilities and understanding of treatment options: ENTRE: On a scale of one to three (one being the best), how would you rate the medical attention that you have received this year or in the past six months? ROSARIO: I went to a private doctor in Mexico. The private doctor was always a number one, but the insurance was always a number ten. ENTRE: Why did you go to the private doctor? ROSARIO: I went for the same reason. Cancer scares me. I am going to get a cancer test, also to have them check my breast. I am going to a private doctor.

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Immigration, Acculturation, and Health ENTRE: What qualities do you think are important when you need a doctor or nurse? ROSARIO: Most importantly, that I can trust them. Much trust. Because there are doctors that you arrive—well, the ones from the insurance are like this—you get there and they don’t [turn] to see you. Or rather, you are telling them where it hurts, “This is swollen.” The doctor did not [turn] to see me. He is writing and says, “Aha.” And writing. But he didn’t say what was wrong, and he didn’t seem to know his job. It is the worst. I don’t like the doctors like that.

That this young woman frequented private physicians for strange pains in her chest and ovaries (but not for colds and mundane illnesses—these are better ignored, she and other recent migrants claimed) explains why her responses, across many questions, resembled those of veteran Santa Feans. Most likely, the private doctor (oncologist?) who treated her or her mother in Vera Cruz suggested vitamins and physical exercise as a way to prevent cancer (in herself) or treat it (in her mother). Although not the case for every subject vis-àvis every health topic (e.g., antibiotic usage), the data do illustrate that some women with the wherewithal to access private care show a resemblance in their responses to those who had more contact with allopathic physicians or health care educators in the United States. It is possible that those who arrive with health beliefs most like the U.S. population’s have had the economic means to access the private healthcare system in Mexico, a system that resembles (was fashioned after) that of the United States. (This is particularly curious given that many physicians in Mexico work in both the public and private health care sectors.) Like the U.S. healthcare system it tolerates some aspects of complementary and alternative medicine.8 Immigrants can be from the country, illiterate, devout Catholics, or believers in curanderismo. Despite all these variables, which are thought to be associated with more traditional health beliefs, if they have saved the money for highquality private health care, their responses to certain questions posed by this research may start to resemble those of the veteran immigrant. All in all, the most influential factor seems to be the degree of training and clinical experience of the physician consulted in Mexico. Because of the great range in quality of doctors, both private and public, however, this linkage between having visited a private doctor in Mexico and

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holding health beliefs similar to those promulgated in the United States is not a given. The second migrant, Margarita, exemplifies the influence of socioeconomic background and urban residence before immigration. Recently arrived (2 weeks at the time of her interview) from Mexico D.F., she had come to Santa Fe to be with her granddaughter, son, and daughter and to search for temporary work until the job market picked up in Mexico (she had lost her job 6 months previously and was having trouble replacing it because of, she claimed, her advanced age of 54). Margarita’s response, like Rosario’s, contained explicit prescriptions for good health: ENTRE: What do you do to stay healthy? MARGARITA: I walk an hour every day. That’s the best way. The other is avoiding red meat. I eat red meat, but not much. The other is combining raw vegetables with cooked vegetables. I watch my nutrition. I exercise. The only thing I don’t do is stop smoking, which is really bad. I cut back. This is a great country to stop smoking. Smoking here is a stigma. When asked which of her family members had been sick in the past year (a standard question that was intended to urge recall of how the interviewee handled illness episodes), Margarita replied that no one had been ill in a few years: ENTRE: In the last few years, no one has gotten sick? MARGARITA: No. Now that I think about it, my family is very healthy. There’s no one that’s sick. ENTRE: Why do you think that is? MARGARITA: Look, I come from an upper-middle-class family in Mexico. The food from the day we were born has been healthy food. The environment has been pleasant, good schools. I’m speaking about my siblings. Good schools. Good food. An environment of peace, tranquility. So you have grown up with studies, with a superior level of life. This lets you have access to the doctor, to good food, to exercise, to have access to recreation, to have access to everything that a human needs to live healthy. It’s very important to understand that health is a response to environment. If the environment is adequate, health will be adequate. That’s why it’s worrisome

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Immigration, Acculturation, and Health that immigrants that come here are generally poor people. Genetically, they bring problems of poor diet from generations back. And they come here to a hostile environment, and besides that environment, they bring this negative genetics of bad nutrition for generations. They come here to work and be exploited for hours in hard work and labor, with a lot of stress because of not having documentation. Obviously, their health is going to worsen. That is, the result is logical. But when you come here without that background, the environment attacks, but you have more strength. In general, the people that live here don’t have that strength. It’s likely that these people will be very affected in their health. And not just mentally, physically.

Margarita was unaware of the studies claiming that Mexican immigrants’ health worsens in the second generation. That is, immigrants remain relatively healthy, but their children often suffer the ill effects of migration (Zsembik and Fennell 2005; Abraido-Lanza et al. 2005; Cervantes and Castro 1985). She does speak to the relative influence of wealth on the access to care. This is an obvious point, perhaps, but one that seems to carry less weight in the literature and the lore about undocumented Mexican migrants and their monolithic “traditional” and “unacculturated” beliefs about health and illness. Studies that conclude, for example, that culture influences firstgeneration Mexican immigrants to exaggerate their somatic symptoms may be indexing beliefs that are usually attributed to the disenfranchised and impoverished (Reichman 1997). These are not the only undocumented Mexican immigrants in this country, as Margarita’s presence in Santa Fe illustrates. An interesting observation of how the economically stable citizens in Mexico resemble the insured well-off in the United States was attributed to a Mexican physician working in both private practice and a social security hospital in Mexico City. He commented that, in his experience, the poor tend to minimize their symptoms, and the wealthy exaggerate them (Finkler 2001:44). If this doctor’s observations are correct, then it is the wealthy Mexicans who are migrating to the United States and not the economically unstable! Indeed, if Margarita were to seek medical care at a local health clinic in Santa Fe, she, too, would fit, at least economically, the stereotype of the impoverished immigrant whose only recourse is to seek publicly funded health care.

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Another important caveat provided by the examples of Rosario (born and raised in a rural pueblito) and Margarita (born of an uppermiddle-class family in Mexico D.F.) is that one must not make the facile assumption that a simple dichotomy in types of health beliefs and behaviors exists between rural and urban populations. Rather, the health care advantages found in many urban areas are enjoyed disproportionately by a privileged minority, as Margarita explained about her own upbringing. Although alternatives to standard medical care (e.g., homeopathy and acupuncture) do exist mainly in the large urban centers (Mexico D.F. and Juarez), relatively few benefit from them. This imbalance in access to quality health services leaves a vast urban population no better off than their compatriots in rural pueblitos (Chavez 1992; Lopez 1980). To clarify the confounding factors of urban-versus-rural residence and low-versus-high SES, the dichotomy that carries more weight is the one that exists between poor Mexicans (whether in urban or rural areas) and prosperous Mexicans living mainly in urban areas (Stebbins 1987:5).9 Moreover, it is misleading to suggest that a clear-cut division exists between urban and rural populations, because Mexico’s rural population visits frequently or lives periodically (even for extended times) in urban areas (Stebbins 1987:23). Viewed through this lens, the data for this study show that the immigrants with lower SES status who come from urban locales and end up staying longer, on average, than those from rural areas are most likely adopting health ideologies and emergent sensibilities of the native U.S. population rather than arriving here with these beliefs already intact. (See chapters 10 and 11 for more on this topic.) Finally, the inclusion of informants such as Margarita and Rosario in ethnographic studies is important because they add social class diversity and therefore shed light on at least one of the potential reasons why some of the health beliefs of recent migrants closely resemble those of the U.S. biomedical establishment. Anthropologists working along the Mexican-U.S. border have called for the inclusion of social class diversity in ethnographic studies of Mexican migrants because of what is perceived as a dearth in the literature addressing the differences (instantiated in cognitions and behaviors) between the socioeconomic backgrounds of immigrant subgroups (Hirsch 2001). For the most part, migrants are impoverished in Mexico and, because they often must pay a high price to coyotes, arrive in the United States even more so. They are not uniformly from poor backgrounds, however. The mere fact that

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a large number of immigrants in this study crossed with passports, which are available to all yet not inexpensive, indicates that people do have choices. Simply being able to save up the money to pay a coyote suggests a degree of financial wherewithal that one must presume is not available to all Mexican residents. In a related vein, research by Bagley and others purports to show how immigrants who arrive in the United States impoverished may, over time, come to enjoy the benefits (and not only the oft-reported negative health-status effects) of acculturation and structural assimilation (through which one enters the economy of the host society). These may have independent effects on health beliefs, as well as physical health. Bagley and others argue that “it is likely, in fact, that individuals and groups who are successful in gaining economic success will have health and functional capacity profiles similar to those of middle-class Americans regardless of their cultural orientation, whereas those who remain in poverty will suffer the greatest detriments in health status as a function of less successful structural assimilation” (1995:636; Chavez 2003). The present discussion focuses on the effects of migrating from a rural versus an urban community and of coming from a poor or middleclass socioeconomic background. In reality, however, it may not matter how large the migrant’s sending community is, how much education she has had, or even whether she had access to a private doctor in Mexico. What may influence her health beliefs and outcomes most is whether she or her family can assimilate into the workforce and gain health insurance and therefore access to quality health care in the United States (Chavez et al. 1992).

CHAPTER 7

Cognitive Models of How People Should Behave When Sick

The following discussion focuses on what people think others should do when ill. To tap into a shared, emergent sensibility about the proper set of behaviors when a person is ill, we posed the question, What do you think people should do when they are sick?1 The intent was to gain information that dovetails with the many published studies on the helpseeking behaviors of recently emigrated Mexicans. See, for example, Chavez et al. (1992); McVea (1997); Jackson-Triche et al. (2000); Salant et al. (2003); Bratter et al. (2005); and Zsembik et al. (2005). These studies claim that help seeking in this population is delayed and that delay in seeking primary health care is associated with higher rates of emergency room visits.2 I had anticipated that the women’s responses would shed some light on these hypotheses. To this end, 55 responses to the question were recorded. The responses clustered into three core categories. Subjects suggested that when others are sick, they should (1) try to get outside the house (or, more specifically, out of bed) and move around as much as possible; (2) go to the doctor, and get medicine; and (3) stay in bed, rest, and relax. Interestingly, the responses were easily segregated into those offered by the recently arrived and those who had lived in the United States, on average, 4 or more years. Of course, certain interviewees did not fit neatly into either the under-4-year subset or the over-4-year subset. As we shall see, there was some degree of overlap between those who responded that a sick person should “get around” and those who qualified that response with “go to the doctor,” a finding that may have been influenced by the manner in which the question was worded.

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A SICK PERSON SHOULD MOVE AROUND AS MUCH AS POSSIBLE It turned out that there is some truth to the claim that immigrants who have spent less time in the United States (i.e., who are less “acculturated”) delay accessing health care providers in the event of trifling aches, pains, and illnesses. The recent immigrants expressed a belief in trying to overcome their (mostly minor) illnesses with mental perseverance. This tenacious control of their mental attitude was fueled, in part, by a fear of succumbing to negative, unproductive thought patterns that they felt would lead to even worse health. For example, Maria G. (age 49, 4 years in Santa Fe), who came from a medium-size city (Gomez Palacio in the state of Durango) and had a sixth grade education, stated, without explaining why, that when one is sick, one should “get around as much as possible, because bed is worse.” Malorena (age 28, 4 years in Santa Fe), from a rural background, expanded on Maria G.’s idea that staying in bed is worse: “Well, it depends. If they truly can’t move, they should stay in bed. But if they can, they should get around as much as possible so as not to feel bad.” Rosario (age unknown, 3 months) agreed: “Unless it is such a serious illness that the person can no longer move on their own. But if it is something lighter, the worst thing one can do is stay in bed.” Another example is offered by Paola (age 53, 1 month): “Well, I think that they should get around as much as possible. Because if you don’t make an effort, you end up in bed, and that’s not good.” What exactly do these recent arrivals find so objectionable about staying in bed when sick? Maria N. (age 41, 3 years) explained: “Well, I think that they should get around. Working is what takes away stress.”3 Olaya (age 23, 1.5 years) said that she, too, felt nervous when sick. Regarding what people should do when sick, she said, “Well, it depends on what sickness they have. If it is a serious illness, well, they have to rest. And if not, they should go about their normal life, keep working, so they don’t become more agitated.” The agitation may arise from (as some of the women elucidated previously) fear of not being able to take care of their families or from the fear of the unknown that illness often engenders (an existential fear). Reyna (age 40, 5 years) underscored the need for a sick person to remain active: “I think to walk, mobilize. At times, you can get better by walking.” Rafaela (age 65, 1 year in the U.S.A.) said, “To motivate and mobilize as much as possible. One gets worse in bed. When I get sick, I get up, walk, do a

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little, but never stay in bed. Because the bed is bad.” Delia (age 65, 2 years) gave a detailed and interesting response: “I think that, sick or not, one always has to do as much as possible, right? But if you’re sick and in bed, I see that you get more sick. I think that one always has to do things, to not be useless. The day that we become useless, it’s like a really bad illness.…I no longer have this eye problem. Like right now I feel that my eyes are really tired. I see okay, but they feel tired, as if they were going to close. But otherwise, I have always thought that if you pay attention to it, it’s worse” (emphasis added). Delia was alluding to the intrinsic connection between the mind and body, in which the mind’s unbounded power influences the way, and the degree to which, the body manifests or embodies sickness. One might call this a “mature understanding of the mental side of somatic experience and of the whole person as a psychological and social person” (Shweder 1996:9). More simply, paying attention to or thinking about one’s sickness or disease amplifies its importance in one’s own mind and consequently one’s bodily perception of it. When asked the question, How do you react to pain? Delia replied, “I tolerate it.” When her interviewer asked the question, What do you do when you cannot tolerate it anymore? she explained, “Then I say that I’m going to take something, but I try to put up with the pain.” Yolanda (age 40, 5 years in Santa Fe) also believed in ignoring pain. In reply to the question about how she reacts to pain, she said, “I just try to control myself, but at times it feels bad. I go outside to get some air. And if something hurts, I take pills that I know are for that pain” (emphasis added). One last quotation exemplifies how Delia―and possibly others who share her belief that paying attention to infirmity augments its ill effects—handled a recent diagnosis of diabetes. Offering her the chance to provide her own (perhaps culturally influenced) name for her disease, she was asked the question, What do you call your actual problem? She replied, “Diabetes. What do I call it? I don’t have a name.…My whole life I have never been in the hospital, because I am not one of those people who go for any little pain.…I don’t give my illness a name like it’s something that slowed me down. I’m not saying I’m happy having it, but I haven’t gotten all caught up in it. Me being really sick, no.” Interestingly, what could be termed Delia’s “lay” or “folk” theory is not far removed from current medical sociological research

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indicating a direct correlation between negative subjective health assessments and morbidity and mortality rates (Nicholson et al. 2005; Arcia 1998; Reichman 1997). Delia is right. Perceiving oneself as ill does affect one’s actual level of morbidity, and it can have an impact on mortality as well. A different migrant, Neli, had relatively more experience living in Santa Fe (5 years) yet, she concurred with Delia about what staying in the home does to one’s emotional experience of disease and added her own details: “A person who feels like that, the best thing to do is to walk and walk. Try to go out to the park, see other things―even the birds. Don’t be alone in your house, because this makes you feel more depressed.” The discourse on denying aches and pains or avoiding them altogether, as well as fears, anxieties, or depressive thoughts, is augmented (in 5 replies out of 55) by a parallel discourse on the importance of maintaining positive ideations when already sick or about to succumb to sickness. (Recall the women, in chapter 6, who suggested that staying positive affected their health outcomes.) This is illustrated by Ivone (age 38, 1.5 years): “I try to control my nerves, to not say that I am sick or that I feel bad. Because if I think that I am sick, I get sick. I try to be positive.” Ivone reiterates the significance of optimism when she affirms that, for her, the good life means “trying to live positively.” Neli (age 55, 5 years), who is mentioned above, stated that most damaging to one’s health are “things that are negative.” Guadalupe (age 25, 3 years) underscored her belief that the power of the mind influences health outcomes when she talked of her experience with medicina naturista (natural or herbal medicine). When asked the question, Do you know what medicina naturista is? Guadalupe answered, “Yes. Once I went to see a doctor, and he made me better. Maybe because you get it in your head that you are going to get better and you do.” Coming from a very religious Catholic upbringing and a rural village in Mexico (two demographic variables that, in themselves, might be interpreted as influencing her belief in “traditional” medicine), Guadalupe nevertheless had a sophisticated understanding of what biomedicine or allopathy would call the “placebo effect,” the initiation of biological processes via the power of belief. Catholic religious doctrine, one could argue, teaches that faith (in saints, martyrs, etc.) heals. But Guadalupe’s understanding of the influence of mind over bodily health came from a different, meta-level of understanding. She was not talking about placing her faith in a third

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party with the power to heal the believer. Rather, she had located the power to heal within herself; it is a faith in the power of the mind and in the healing connection between the body and the mind, a selfreflexive healing. The third example is provided by Rafaela (age 65, 1 year), the diabetic who was anxious about falling. Rafaela liked to stay healthy by “do[ing] something to make myself happy, and to make my children happy. At times, I dance and sing with them and we all laugh.” The last interviewee who believed that a positive attitude was a requirement for maintaining superior health was Ana Maria, 1 of only 2 interviewees in this subset who had lived in the United States for more than 5 years. She was 68, diabetic, and diagnosed with heart trouble. Ana Maria claimed, as did the recent arrivals, that getting out and about was good for one’s health. She also considered herself very religious (Catholic) and had visited a curandero from Sonora during her last trip to Chihuahua (her birthplace). Ana Maria’s positive attitude was of a different nature than Guadalupe’s, however. Ana Maria said that she was optimistic about health outcomes because she placed her faith in God: “And I’m going to tell you something: what I can assure you is that there are few positive people like me. I’ve been positive in all my operations. I go to the surgeon, they put me to sleep, and before I lose consciousness, I say, ‘Lord, here I am. I put myself in your hands. If it is your Holy Will, I will return. If not, do your Will.’” What is interesting about Ana Maria’s words is her equation of a positive attitude with what in the literature would be called “fatalismo,” a tendency to relegate responsibility for one’s physical health and disease to a higher power. U.S. biomedical providers most likely would not agree with Ana Maria’s assessment that relegating responsibility to someone else (even God) is a positive way to enhance one’s health (although non-traditional healers might be in complete accordance). In other studies, fatalistic thought patterns have been associated with less acculturated immigrants. In this regard, despite living 17 years in the United States, Ana Maria may resemble recent arrivals. In the present sample of migrants, however, few, if any, of the young and recently arrived espoused these beliefs. If anyone demonstrated fatalistic beliefs about health, it was the older generation of adherents to Catholicism and the veteran sojourners who had converted to a Protestant denomination.

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All these permutations on the theme of getting out of the house, staying physically active, and maintaining a positive attitude could be interpreted as a causal factor in delaying help seeking, a behavior that, some claim, characterizes less acculturated Mexican immigrants (Chavez et al. 1992). Believing that ignoring nagging symptoms or chronic warning signs is good, immigrants may be doing harm by delaying care. Proclivity to put off visiting a physician is, in fact, common in Mexico.4 The percentage of the sample who responded with “Move around” or “Stay positive” was 49.1. The mean number of years they had lived in Santa Fe was 3.2 (median 2 years). See Table 13 which sums up all the data from this chapter.

A SICK PERSON SHOULD GO TO THE DOCTOR As mentioned previously, there is an overlap between those interviewees who claimed that they tended to ignore minor aches and pains and those who suggested going to the doctor even for minor illness. For example, Guadalupe (age 25, 3 years in Santa Fe) qualified her remark that, when sick, one should get around as much as possible: “I think they should get around, no matter how hard it is. When you are really sick, you should go to see a doctor.” Nohelia (age 21, 7 months in Santa Fe) also combined the two discourses, stating that a sick person should “mobilize as much as possible, go see the doctor.” Dora (age 35, 18 months) suggested that a sick person should “get around as much as possible and get help.” Claudia (age 30, 2 years) qualified her response to include staying out of bed and, in the event of worsening symptoms, going to the doctor, stating that one must “get out of the bed and get help.” Last, Jessica, who had lived in Santa Fe 13 years, said, “Move around to cure yourself. Go to the doctor. Take medicine that benefits you.” Out of a total of 55 documents coded, 8, or 14.5 percent, recommended combining these two ways to cure the body. The mean number of years lived in Santa Fe for those who responded thus was 3.3 (median 2.2 years). The rest of the subjects who mentioned going to the doctor stated explicitly that a person should go to the doctor exclusively when ill. Those who responded to the question in this manner numbered 7, or 12.7 percent. Teresa (age 38, 1 year) suggested simply, “I think he should see a doctor soon,” and Maria S. (age 29, 3 years) said, “Move around to the doctor.” Maria R. (age 41, 2 years) agreed: “They should

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get around as much as they can.” When asked where sick people should go, Maria R. replied, “To see a doctor.” San Juana (age 17, 5.5 years) qualified the proper behavioral response to illness: “It depends. If he’s very ill, he should go see a doctor.” As it turns out, the mean number of years that correlates with these types of responses does not differ significantly from those who responded that one should “get out and move around.” Whereas the mean for the latter subgroup was 3.2 years (median 2), the mean for the “go to the doctor” subgroup was 3.5 years (median 3). Therefore, at least 27.3 percent of the sample who were recently arrived claimed that it is important to visit the doctor when sick. These women might not delay seeking care, or they might have provided socially sanctioned responses (because they have come to understand that seeking prompt medical care is of cultural importance in the United States), or at one time they might have sought care only to be rebuffed by overburdened medical staff. As a consequence, they might not return readily in the future. As we will see below, the third scenario may explain why so many migrants claim that it is important to seek timely medical care but they do not actually do this.

A SICK PERSON SHOULD STAY IN BED AND REST Where there does appear to be a large difference in the mean number of years associated with the various response categories is between those who responded, “Get out and move around” or “Go to a doctor” and those who responded, “Stay in bed.” For example, Rocio, who had lived in Santa Fe for 10 years, stated, “I say you should stay in bed.” Rocio, 32 and employed as a housecleaner, spoke very good English despite having achieved only preparatory-level schooling in Mexico (she claimed that she could understand, read, and speak at a level of 75 percent proficiency). She planned to stay in Santa Fe, and her relatives hoped to make the journey to the United States to live as well. Because Rocio was still in touch with her compadres (a purported index of her intent to maintain traditional family ties) and still a Catholic, one might suspect her beliefs about health to resemble those of the recently arrived. Her comment about staying in bed, however, distinguished her from this subsample. Elizabeth (age 25, 5 years in Santa Fe) advocated the same: “They should stay in bed.” Yolanda (age 40, 5 years in Santa Fe) provided more detail: “It depends on the illness. If it is necessary to stay in bed,

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then stay in bed. And if one can move and you know with that illness it is possible to move, then move. Stay in your house, calm. Watch TV, however the person feels relaxed.” Although Yolanda did refer to moving around if you already are familiar with the type of illness, her emphasis—and the reason for even segregating these responses—was on relaxing at home, staying in bed. This is diametrically opposed to the advice given by recent arrivals, which distinguishes their beliefs and perhaps their behaviors. Blanca (age 30, 5 years) agreed with Elizabeth and Yolanda: “I think the best thing to do is to take a rest and stay in bed.” In many respects, Anahy (age 30, 10 years) thought more like the recent arrivals than others of her cohort who had lived in the United States for 10 years, at least in her understanding of viral theory and biomedical discourse vis-à-vis antibiotic usage (see chapter 11). In the context of this question, however, she falls into the same category as those who had lived in the host country for 5 or more years: “It depends on the illness, because sometimes you can have an illness where you have to rest and not be stressed. If it’s a serious illness, it’s best to get moving as soon as possible and go to the doctor. And if it’s…it depends…to relax and sleep a while.” Not only did she emphasize rest and relaxation—something the recently arrived Mexican women felt would worsen illness, or at least their perception of it—but she also displayed her cultural knowledge of the discursive rules surrounding the concept of stress. Another veteran sojourner, Gloria R. (age 22, 5 years) as well appeared to have internalized a cultural sensibility to stay in bed and relax when ill. Her thinking mirrored that of the others: “They should stay in bed if they can’t continue with their schedule.” She offered no guidance on when one should suspend one’s schedule, but the bar does not appear to be very high, in view of her nonchalant response. Gabriela (age 34, 10 years) concurred: “It depends on the illness. If it is a cold, you need to stay in bed at least for a day…to get better quickly.” Raquel (age 35, 6 years) believed the same: “I think they should rest.” Interestingly, only 1 interviewee who responded similarly had lived in Santa Fe for fewer than 5 years: Sylvia. She had come from a medium-size city, spoke good English after only 2 years in the United States (she had a high school education in Mexico), and was diagnosed with a chronic illness (irregular menstrual cycles with attendant ovary pain). The illness, which caused her to have more than

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the usual contact with clinicians at the local clinic, might be one reason her response resembles that of the women who had lived more time in the United States. Finally, Josefina (age 44, 13 years) gave a detailed answer, as usual: “I don’t know if you know, with chicken stock they make Teramycin.…Every time I got a throat illness, twenty-four hours of liquids and rest, it works.” Of the 13 who responded, the mean number of years lived in the United States associated with the response of staying in bed was a relatively high 6.2 (median 5 years). This number must be seen in context of the means calculated for the other two responses: 3.2 years (median 2) for “Get out of the house” and 3.5 years (median 3) for “Go to the doctor.” It is obvious that the length of time spent in the United States associated with the responses differs and therefore reflects the dissimilarities in attitudes toward sickness behavior. Table 13. Cognitive models of treatment by years lived in the U.S. Cognitive Model Get out and move Go to the doctor Stay home and rest

Percentage of Sample* 42.9 23.8 20.6

Mean Years 3.2 3.5 6.2

Median Years 2.0 3.0 5.0

*Note that 12.7 percent of the sample did not answer this question.

What is interesting about the discrepancies in these responses is that staying in bed to cure minor illnesses is a curious cultural belief for a nation obsessed with working. Yet, it is part of U.S. health discourse: to prevent illness, we are to avoid stressful working (or other) conditions that weaken the body’s immune system (Martin 1994; Kaplan 1991). It is doubtful that these migrants have read in great detail about the body’s stress response and its relation to the hypothalamopituitary-adrenocortical (HPA) axis, but they have (as discussed in chapter 12) definitely entered the discourse on stress, in general, and have assimilated its discursive practices to varying degrees. Moreover, stating that a person should stay in bed and rest reflects an implicit understanding of viral theory. When one is sick with a virus, neither ignoring it nor taking medication will help. Only bed rest and fluids will hasten the body’s recovery.

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Research has shown that with more time lived in the United States, the chances of having health care insurance increase. There is also a relationship between having health care insurance and increasing visits to non-emergency sources of care such as health care clinics and private physicians (Chavez 1992) . This is particularly true of immigrants whose children are U.S. citizens. Whereas recent migrants are rarely granted “sick days” with pay, immigrants who have lived in the United States longer may more regularly find jobs that offer health insurance, paid days off, and the like. Although the question was not asked directly, approximately 10 percent had medical insurance, for themselves or through their husband’s work. Many undocumented immigrants have children who are either U.S. citizens or qualified immigrants and are therefore eligible for public assistance programs (i.e., Medicaid), despite the status of the parent(s). Some migrants who have resided longer in Santa Fe (or the United States, in general) are finding ways to become insured, and being insured is directly related to more frequent usage of clinics. As discussed already (in chapter 6), people learn many of their health care beliefs through their doctor/nurse encounters. This is especially the case for recent migrants who do not understand English and cannot glean information from print or television media. In general, the greater a migrant’s social connections to the medical personnel of the U.S. healthcare system, the more likely her emergent sensibilities will reflect those of the native population than those of the recently emigrated or native Mexicans. Related to this is an experience that many of the migrants claimed to have had when visiting the local health clinic for relief from the flu or other viruses: they were told that they should take a Tylenol and go home and rest. In the context of these encounters (and increasingly via periodicals), people are learning new ways in which to care for themselves and displaying shifts in beliefs about how sick people should behave. Magdalena (age 65, 45 years) was one who was lucky enough to have social security. She spoke quite movingly about her gratefulness to the U.S. government for the benefits granted to her after living in Santa Fe for some time: “Before learning of this place or having contact with the people here [the local clinic], I never thought that they would lend this service that they are giving me. Doctor Padilla has had all these tests run. When I started here, I paid for my visit, and they gave me the medicines if they had them. But they sent me to a social

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worker because I didn’t have any insurance. Now I come, and they don’t charge me anything. Of course, if I have to go to a specialist, it will be different. And thank God for the government here. I have to thank them because they started to send me supplements. My social security wasn’t enough to give me the social services. But this week they sent me a year’s supplement. I have to be grateful to them too. I still don’t have enough, but in case I need a specialist, then I will turn to them.” Alternatively, for those without health insurance, the veteran immigrants’ prescription to “stay in bed” when sick might simply reflect a more stable economic situation. After 5 or 6 years in the United States, they might be in a position financially to take a day off now and then. Already armed with a similar Mexican cultural health belief that working too hard causes sickness (or alters “nerves”), perhaps only when immigrants gain financial stability in the United States can they act on a previously embedded cultural health prescription. This health dictum, in reality, is not all that different from that which is already espoused in the United States.

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CHAPTER 8

Therapeutic Options: Awareness and Usage of Complementary and Alternative Medicine

One reason for locating this research endeavor in Santa Fe, New Mexico, is the city’s dense concentration of schools, clinics, and individual practitioners dedicated to complementary and alternative medicine, or CAM. In fact, Santa Fe stands out as proof that the holistic health movement has become a mass phenomenon (Baer 2001). The healing practices discussed here are considered complementary, alternative, and holistic in relation to allopathy, or western biomedicine. The holistic health movement encompasses an extremely varied assortment of medical therapies and practices: aspects of humanistic and psychosomatic medicine, parapsychology, folk medicine, herbalism, nutritional therapies, homeopathy, yoga, massage and other forms of bodywork, meditation, and martial arts (Baer 2001:106; Berliner and Salmon 1980). Various types of healers are associated with these belief systems: acupuncturists, chiropractors, osteopathic physicians, naturopaths, spiritual or psychic healers, and M.D.s who practice holistic medicine. All types of healing belief systems can be found in Santa Fe: ayurvedic medicine, Chinese herbal medicine and acupuncture, chiropractic, healing energy techniques (reiki, cranial sacral, etc.), Tibetan medicine, and curanderismo. Also in Santa Fe are schools that train psychotherapists and hypnotherapists, who are often called upon to alleviate insomnia, anxiety, and panic disorder. These educational institutions offer therapeutic services to the community at greatly reduced prices as part of their student training. Furthermore, because most of these healing centers readily offer treatment with lowcost options, there are few structural barriers to health care access. 115

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Even language poses less of a problem than in other locations; more than 40 percent of N.M. physicians canvassed for 1 study claimed that they spoke Spanish fluently (Sleath and Rubin 2002). I hypothesized that the Mexican immigrants who immersed themselves in this context—if they were interested in or open to learning about different health ideologies—would, at the very least, recognize CAM names and associated therapeutics. I also postulated that the longer the immigrant lived in Santa Fe, the greater the chance that she would try one of these healing modalities. It is a great irony that these healthcare ideologies are considered “alternative” in the United States, for the number of visits to CAM providers far exceeds the number of visits to primary care physicians (Fink 2002). In addition, in 1997 an estimated $27 billion in out-ofpocket expenditure went to therapies or treatments considered “alternative”—defined as interventions neither widely taught in U.S. medical schools nor broadly available in hospitals. Also, the results of a nationwide telephone survey of more than 2,000 households showed that 42 percent had used at least 1 of 16 of these therapies or treatments, an increase of 8.2 percent from the data gathered in 1990 (Barret et al. 2004; Eisenberg et al. 1998). Another irony is that people in industrialized nations are only now turning to these healing modalities for a mounting array of perceived health problems but the rest of the world—the less industrialized nations—has counted on these very therapies for primary care. (See also the World Health Organization’s Traditional Medicine Strategy 2002–2005.) Despite the fact that people everywhere, living in nations in all stages of development, utilize CAM, “the widespread use of these [belief systems] in both the developed and developing world contrasts with its lack of integration into the health care systems of most countries” (Fink 2002). A further irony is that CAM is perceived as marginalized and denigrated in the United States, in general, but even more so in some of the developing countries where these therapies are thought to have originated, despite their widespread use for primary care. This is the situation Ted Leon, a physician working with an NGO, found in a developing African country: The gap between traditional and allopathic medicine in developing countries is often even wider [than in the United States]. Animosity toward traditional medicine dates back to colonial times, when healers—powerful leaders in their

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communities—were forbidden by law from practicing. Many continue to work underground and in secrecy.…It became clear to me that there were 2 systems integrated only by the patient…. Perhaps the best analogy is like having a wife and mistress. There’s not a lot of interaction between the two. The patient zips back and forth between the traditional healer and the medical doctor. (Fink 2002:1736)

BIOMEDICINE, MEDICINA NATURISTA AND CURANDERISMO IN MEXICO In the United States, a prevalent stereotype of Mexican immigrants is that they utilize traditional Mexican healers (curanderos) as primary care providers or as secondary providers in tandem with biomedical healers, as Leon indicates is done in Madagascar. In reality, this may not be the case. Because curanderismo has been so widely reported in the literature, its importance in the everyday lives of Mexican men and women may have been inflated. What is otherwise reported in the anthropology (as opposed to the medical sociology and general periodical) literature is that “biomedicine, differentially accessible to various segments of Mexican society, is the dominant treatment regimen in Mexico. It is well entrenched and might even be regarded as the formal state ‘religion,’ analogous to the position it occupies in the United States and other industrialized societies” (Finkler 1994:41). Four other therapeutic options (besides curanderismo) are available to indigenous Mexicans, both rural and urban populations. One option is self-diagnosis, coupled with self-treatment, usually in the form of herbal teas and analgesics or some other medicine bought overthe-counter at the local tienda or open market. A second is selftreatment with pharmaceuticals purchased at pharmacies. Pharmacists, who often possess only a sixth grade education, frequently help diagnose, prescribe, and even, for a small fee, administer injections of antibiotics, steroids, vitamins, and other medicines. As a third option, herbalists found at the weekly open-air markets readily diagnose and prescribe local herbs to treat all manner of ailments, including nerves, diabetes, hypertension, male impotence, and female infertility. Usually, this option is considered one of the least expensive. From these dispensers of medicina naturista, “persons may inquire for an herb appropriate to their self-diagnosed condition, or they may consult an anatomical chart displayed by herb vendors indicating the proper herb

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for each anatomical part…herbal cures are very popular among all social sectors and are usually regarded as safer than pharmaceutical preparations” (Finkler 1994:44). A small subset, usually women, also seek out spiritualist healers because this incurs no cost and is thought to address the maladies that biomedicine cannot cure, for example, chronic infirmities or culturally embedded illnesses such as susto, nervios, and aire. Local biomedical health clinics offer a relatively inexpensive fourth option. The state provides 3 healthcare options to Mexican citizens. The Mexican Institute of Social Security (Instituto Mexicano de Seguro Social—IMSS) covers approximately 80 percent of all beneficiaries who work in the private sector. The Institute of Security and Social Services for State Workers (Instituto de Seguridad y Servicios Sociales para los Trabajadores del Estado—ISSSTE) grants health care coverage to government workers and accounts for 17 percent of the total number of beneficiaries. Various other state business entities granting coverage to their workers include the Secretariat of National Defense (Secretaria de Defensa Nacional), the Secretariat of the Navy (Secretaria de Marina), and Mexican Petroleum (Petroleos Mexicanos, or PEMEX). Contributions from the government, employers, and employees fund IMSS health organizations; ISSSTE is funded solely by the government and employee donations. For citizens who do not hold formal-sector jobs (usually those who live in remote or rural areas and are therefore outside the social security network), government agencies supply health care services. This socalled “open” population is approximately one-third of the total population. These people utilize the state’s third major healthcare option: IMSS-Opportunity (IMSS-Opportunidad), the successor to the IMSS-COPLAMAR (and later IMSS-Solidaridad) plan implemented in the late 1970s.1 As of June 2005, Mexico’s social security program provided health care to 54,224,903 workers and their families or 51.2 percent of the national population. IMSS Opportunity program covered 10,534,354 people, an increase of 2.89 percent from the previous year. The statistics having to do with health services utilization are similar to those of the United States in that those citizens of Mexico who were fortunate enough to have social security (as previously defined) had greater access to health care than those whose only option for biomedical care was to visit the pasantes working at the IMSS-

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Opportunidad clinics. (In rural regions, the health centers are staffed with inexperienced physicians [pasantes] who are completing their first year of practice by fulfilling a federal requirement to work in underserved rural regions.) Accordingly, those beneficiaries of social security were nearly two times as likely to have consulted a doctor and to have had surgery than those in the “open” population, whose only recourse for allopathic care from licensed medical doctors was to visit the Opportunidad clinics. It was not reported, however, exactly how many of the “open” population opted to visit private physicians instead of the government clinics, which do not have superlative reputations with a large percentage of the immigrants. Relatively impoverished people commonly save their money to visit private physicians in the hopes that they are better trained or more experienced. As a fifth option, people go to the traditional healers who practice curanderismo. Contrary to stereotype, these healers are by no means gratis, charging fees that sometimes rival those of private physicians. Most, however, are reasonably priced. Curanderismo has been described in the anthropology literature for decades. Resources include Adams and Rubel (1967); Rubel (1993); and Trotter et al. (1997). According to Finkler (1994), who worked in a rural area of Mexico researching the prevalence and influence of spiritualist healers, people continue to visit curanderos/as, but their (secular) influence is waning and they do not appear to be refreshing their ranks with young curanderos/as. The reason, she claims, is the increasing appeal of spiritualist healers who purport to have the sanction of supernatural figures such as Jesus Christ and the Virgin Mary. In our study, a healthy 25 percent of the interviewees (16 of 62) indicated that they had visited a curandero/a. Of these, at least 3 claimed that they had gone only to have their cards read, not to be cured. Another 10 percent stated that they were ambivalent about curanderas; these women were uncomfortable with discounting curanderas’ healing capabilities because they had heard many success stories. They had never visited one, however, preferring biomedicine to heal their minor physical ailments. The average (mean) number of years lived in the United States for those who had visited a curandero was 2.8 (median 1 years).

CAM USAGE IN MEXICO The purpose of discussing the healing modalities available in Mexico is to provide the background necessary to examine the data on

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immigrants’ knowledge about and usage of complementary and alternative therapies in Santa Fe. The indigenous Mexican population is somewhat aware of the various healing therapeutics available, but socioeconomic or even sociocultural background may determine which immigrants visit these healers and how regularly. Finkler (1994) claims that there is a positive relationship between the number of years of education and the solidity of belief in the biomedical model. In the present sample, however, some of the women with the most education actively sought out CAM, both in Mexico and in the United States. According to the results of her assay of treatment options solicited by her subject population in Mexico D.F., the vast majority sought the care of private physicians first, if they did anything at all (Finkler 2001). Smaller percentages visited government health centers, selfmedicated, or tried various types of herbal remedies.2 Forty-two percent had never attempted to treat the ailments for which they sought treatment at the public hospital in Mexico D.F. Finkler states, in consonance with her previous work in rural Mexico, “I have found that biomedicine was the first and foremost resort to health care among the majority of people.…When biomedical treatment failed, then other modalities, homeopathy, acupuncture, and folk healing were sought, or herbal medications administered” (2001:52). In her study group, approximately 12 percent resorted to alternative treatments, principally, herbal medications in tandem with biomedical treatment. Of the total number of study participants (205), only 2 were prescribed or sought acupuncture treatments. None were treated by a chiropractor, and an unknown number visited homeopaths or were treated homeopathically by one or another of the hospital physicians. All in all, such a small percentage (1 percent) visited these sorts of healers in Finkler’s data set that, extrapolating the results to the present population of immigrants, only 0.63 people would have had experience with these healers in their native country. The following results show that a much larger percentage of the immigrant population know of and/or have used one or more of these healing modalities.

CAM USAGE IN SANTA FE Using Finkler’s findings as a departure point, a large percentage of the present sample did claim to have either heard of or tried medicina naturista, translated as “naturalist” or even “herbal” medicine. Rural and urban dwellers alike were conscious of this healthcare ideology and

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associated treatment regimen so prevalent in Mexico. What is significant, however, is that very few of the recent arrivals, whether from urban or rural locales, had any basic knowledge of, or experience with, medical alternatives such as chiropractic, acupuncture, or homeopathy. The data collected supports the claim that those Santa Fe immigrants who had lived in the area for 5 or more years had become aware of and even utilized CAM since their arrival in the United States. Of course, as in all categories of interest, certain study participants do not fit neatly into one compartment or the other. Some of these exceptions are discussed below. Of the 43 study participants who responded to the question, 23 women (53.5 percent) either had heard of acupuncture, chiropractic, or homeopathy or had both heard of and visited a practitioner of one of these. By contrast, 16 women had only heard of or practiced naturalist medicine. One subject stated that she had heard nothing about any of the healing modalities about which she was queried. Presumably, she had visited only biomedical healers in Mexico. Thirteen women (30 percent) claimed to know of or to have utilized a combination of naturalist therapies and other alternatives, such as chiropractic, acupuncture, and homeopathy. This number of 53.5 percent not only represents a much larger percentage of people who had heard about and/or utilized CAM in the U.S. sample than in Finkler’s Mexican sample but also represents a 10 percent increase in the number of people (42 percent) who reported using CAM in the United States in 1998 (Rafferty 2002). To be sure, knowing about or having heard about a medical technique or belief system is not the same as actually utilizing it. Nonetheless, the veteran immigrant population canvassed by this study did appear to be hypercognizant of CAM compared with the recently arrived. In addition, they appeared to be taking advantage of Santa Fe’s medically pluralistic environment by trying the “new” therapies of chiropractic and acupuncture. To illustrate these relationships numerically, the mean number of years calculated for those study participants who had heard about or visited only Mexican naturalist healers was 2.2. The median was even lower, 1.5 years. The range for those responding to the question regarding alternative healing usage was between 2 weeks and 5.5 years (see table 14). These means (medians) contrast sharply with the mean and median number of years spent in the United States associated with those

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subjects who responded affirmatively to having heard of and/or utilized healers in traditions other than that of biomedicine and curanderismo. For example, the mean number of years lived in the United States was 5.3, and the median was 5.0. The years interviewees had spent in the United States ranged: 1 woman had lived in Santa Fe only 1.5 months, and several women had spent 10 years in the United States. The discrepancy between the simple means and medians is large enough to infer that these migrants were increasing their awareness—and, in some cases, use—of different health ideologies and therapeutics. In Table 14, note that because these categories are not considered mutually exclusive, the percentages associated with them do not add up to 100 percent. Table 14. Knowledge about or usage of T/CAM by years lived in the U.S. Type of T/Cam Curanderismo Medicina naturista Acupuncture/chiropractic/ homeopathy

Percentage of Sample 25.4 37.2

Mean Years 2.8 2.2

Median Years 1.0 1.5

53.5

5.3

5.0

Note: The T in T/CAM stands for “traditional,” which, in this instance, refers to curanderismo.

CAM USAGE AMONG IMMIGRANTS First, we will turn to those recent immigrants who had heard of alternative healing only via herbal remedies of the sort sold by naturistas. In response to the question, Have you ever heard about medicina naturista? several interviewees’ very simple responses were akin to Nohelia’s (age 21, 7 months in Santa Fe): “Yes, but I have never been.” Many responded with just a yes. Ivone (age 38, 1.5 years in Santa Fe) gave a little more detail about the extent of her knowledge: “Yes, those are the ones who give pure teas or natural things.” Dora (age 35, 18 months) provided more detail: “Yes, yes, I know of it. I have never consulted one. If I were to get sick, I would go to a hospital doctor and not the naturista.” Maria (age 49, 4 years), from the large city of Juarez, had never heard of acupuncture, chiropractic, or homeopathy, but she had visited a naturista and had good results: “Yes,

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I went to one in Juarez. When I got bad with asthma, they recommended one to me, and it was good.” Some of those who had heard of a few or all of the CAM therapies besides herbal ones responded similarly, without detail. For example, Maribel (age 23, 1.5 months) stated that she had heard of acupuncture but did not know much about it: “I’ve heard of it, but I don’t know.” Socorro (age 41, 6 years) said that she had heard of chiropractic but “I have never consulted one.” Concepcion (age 53, 6 years) shared an interesting mixture of actual experience and limited knowledge of CAM. She claimed that she was a healer (a sobadora, or one who specializes in massage) and described her work: ENTRE: When you or someone in your family gets sick with something simple like a cold or diarrhea, do you use home remedies? CONCEPCION: Yes, it’s the first thing you do. If it’s a stomach ache, I give them a massage so that the stomach relaxes. I make them an hierba, an estafiate, which is what you use in Mexico to cure diarrhea. That’s what I give them. ENTRE: And you only massage your kids, or do you massage other people? CONCEPCION: Many people come to me. I don’t know if it’s faith or ignorance. They bring me many kids and I massage them. I take away their indigestion. The only thing I do is massage their tummy, and later I tell them [the mothers] to lay them on their stomach and stretch them out from behind. And I tell them what hierba they should use, which is estafiate. They get better, because later they come back and thank me. I never wanted to charge them. People leave me five or three pesos, but I have never charged for anything. The only thing I know how to cure is indigestion. One could postulate two theories about how Concepcion’s personal experience with healing might have affected her accumulation of knowledge about other healing alternatives: (1) it made her more open to and curious to learn about other kinds of health ideologies or therapeutics, or (2) she might have become resistant to learning about alternative healing modalities, convinced that her therapy was the most effective. Neither of these seems to have occurred. She went on to inform her interviewer that she knew nothing about acupuncture or

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homeopathy and that she had heard of naturalist medicine but had never engaged in it. She added more specifically, “A chiropractor is one who dedicates himself to taking care of people with bone problems.” Therefore, there is no salient patterning to her knowledge about or utilization of the various health belief systems about which she was queried, although she had lived in the United States longer than others who had absolutely no knowledge of chiropractic. From responses such as these, it is extremely difficult to infer that these women had learned about alternatives to biomedicine since their arrival in Santa Fe. This is not the case for responses such as Rocio’s (age 32, 10 years in Santa Fe), who claimed that she could understand and speak English well. ENTRE: Do you know what acupuncture is? ROCIO: I received a book on that. It is the practice of curing with needles. I have not read it. ENTRE: Do you know what homeopathy is? ROCIO: It is a type of medicine that does not contain so many chemical substances. When the kids get colic, there are chochitos and drops. ENTRE: Do you know what a chiropractor is? ROCIO: Yes, it is a doctor that studies, that…I do know, but I don’t remember what they do. ENTRE: Do you know what natural medicine is? ROCIO: Yes, it is like herbs. Rocio had received a book about acupuncture but had not yet read it. It is probable that she had heard about acupuncture and anticipated learning more about it while living in Santa Fe, but we don’t know for sure. Furthermore, the specificity of her answers may serve as an indicator that she was living in Santa Fe when she learned about these healing modalities. Recall the greater detail and precision of the longtime Santa Feans’ answers to the question about what people do to stay healthy. Analogously, the women who had resided in the United States longer provided more comprehensive responses to the question about their knowledge of CAM. Regarding Rocio’s answer, it should be noted that she is 1 of only 7 who had even heard of homeopathy, let alone used it, despite other researchers’ contention that homeopathy is

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common in Mexico because it is basically a state-sanctioned alternative to biomedicine (Finkler 2001:50). Even more helpful are the interviewees who provided precise responses and said that they had learned about acupuncture, chiropractic, or some other healing modality after arriving in Santa Fe. For example, Ana Maria (age 68, 17 years), who was a diabetic with a heart condition and had recently been diagnosed with rheumatoid arthritis, claimed to have learned about acupuncture in Santa Fe 5 years before the interview, when she had fallen: I want to talk to the doctor because I have a lot of faith in acupuncture. I have a lot of faith because in Mexico, I, about five years ago, I fell three times. One time I was being followed by some dogs and I fell, twisted, and I hurt my waist. Then I came here [the United States] and in Rosa’s bathroom I fell again, very injured. Then the godfather of a niece of mine went to say hello to me, and he told me to go to Doctor Garcia. “He’s an acupuncturist. I know he’s going to help you.” And I said to him, “Wouldn’t he hurt me?” And he said, “No, he is not going to do, pull on anything. He’s going to send you to get some X-rays, and then they tell you to get needles and the little massages.” Carefully, it was like that, and I got a lot better. Later, another dog knocked me down there in the house and completely unbalanced me, and my leg, one larger than the other. I ended up very bad. I went to the doctor.…He gave me the same treatment. It lasted a while, like four months. And now I want to use it for the arthritis. With only a second grade education, a belief in Catholic religious healing (she had visited a famous Catholic church in Chimayo, New Mexico, to rub its healing dirt on her aching joints), and a selfprofessed “good” command of English, Ana Maria had seamlessly integrated an alternative healing therapy into her healthcare regime. One must also note, by way of providing background, that Ana Maria had had a very bad experience with a cardiologist in Mexico. After being brought to the United States to be treated by a cardiologist in Albuquerque, she completely renounced Mexican medicine, and especially the Mexican Social Health Service. This and other positive experiences with the U.S. biomedical healthcare system might have inspired her openness to new health beliefs. Although her experience is by no means idiosyncratic, it is not necessarily emblematic of the

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“immigrant experience.” That is, few of the sojourners claimed to have experienced biomedical or other types of healing in the United States so superior that they felt impelled to discredit Mexican physicians or Mexican health care in general. Rather, most of the women who came to the United States with a negative assessment of Mexican healthcare services and providers developed this attitude in Mexico during actual illness episodes and interactions with Mexican health professionals.

PLACE OF ORIGIN AND CAM USAGE It must be noted that these results appear to be confounded by the place-of-origin factor. There is a strong association among the following: coming from an urban environment, knowing about one or another of the CAM therapies, and having lived in the United States or Santa Fe for more than 5 years. Recall the discussion in chapter 4 about how most immigrants who remain in the United States more than 5 years come from large urban centers (e.g., Juarez, Durango, Chihuahua, and Aguascalientes). Because of this phenomenon, all results that point to certain responses clustering in the veteran subgroup are associated with urban place of origin. Even though the conclusion that significantly more Mexican urbanites stay longer in the United States was ultimately discredited (by the non-significant chi-square result mentioned previously), it is especially important to be cognizant of this potential confounding issue in the discussion of CAM usage in Santa Fe. The women from urban environments may have already heard about these health beliefs before they arrived in Santa Fe. One example is Aurora. Her response, like Rocio’s, fits into the category of responses that demonstrates how problematic it is to declare definitively the existence of a direct relationship between time spent in Santa Fe and knowledge about and usage of CAM: ENTRE: Do you know what acupuncture is? AURORA: The medicine of needles. I have heard of it and I have seen it, but I have never used it. ENTRE: Do you know what homeopathic medicine is? AURORA: Yes, I have used chochitos de arnica in the past to cure internal wounds and also chochitos for children, for the teeth. I have not been in Santa Fe, however, because I do not know anyone.

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ENTRE: Do you know what a chiropractor is? AURORA: Yes. ENTRE: Do you know what natural medicine is? AURORA: I don’t like it, because I am particular and I don’t like to take liquids and I dislike smelly medicines even more. Aurora (age 49, 10 years in Santa Fe) was from Mexico, D.F. She had only a secondary level of education, yet she knew about all the healing techniques associated with the various health ideologies. She had an impossible-to-diagnose chronic illness that did not start until menopause (in the United States), which may have led her to seek out alternatives to biomedicine. Although Aurora stated that she knew about and even utilized homeopathy and medicina naturista in Mexico D.F., we do not know (because the interviewer did not ask) where she learned of the other health treatments. As a result of incomplete narratives such as Aurora’s, one can hypothesize that the data on CAM usage are confounded by place of origin; nearly 61 percent who knew about or had utilized one or more of the healing therapies came to Santa Fe directly from an urban location. By contrast, only 39 percent who knew of these treatments came from rural pueblitos. The mean number of years those from the rural areas had lived in Santa Fe was 4.3 (median 4.2 years), and the mean number of years those with urban backgrounds had stayed in the United States was 6.3 (median 6.1 years). Judging by the means alone, however, one could conclude from the relatively high number of years (4.3 and 6.3) lived in Santa Fe for those who knew about or had utilized CAM that, compared with the mean number of years (2.2) of those who had not, the veterans had learned of these healing therapies while living in Santa Fe. See Table 15. Table 15. Sending community by years lived in the U.S. for CAM familiars Sending Community Combined Rural Urban

Percentage of Sample 100.0 39.1 60.9

Mean Years 5.6 4.3 6.3

Median Years 4.0 4.2 6.1

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Conversely, an example of an immigrant who had spent little time in the United States yet knew much about (and had tried or even trained in) many health ideologies was Margarita. She had been in the United States only 2 months and was 54 years old. (Recall from chapter 4 that she had a college degree and came from Mexico D.F., where she owned a house.) The following are her responses to questions about her knowledge of alternative therapies: MARGARITA: They [alternative health systems] have increased in an impressive number, including at the university in Albuquerque. There is a school of traditional Chinese medicine where many people learn acupuncture, massage, herbs, etc. And I should tell you that my daughter was there. ENTRE: And do you see this as positive or negative? MARGARITA: I see it positively. Alternative medicine has always been positive. Above all, because you can’t deny what you don’t know. There are many people who refuse acupuncture because they don’t know how it works and what marvelous reactions it has. Herbs, for example. Aromatherapy and energy stones—these things are pure fiction, right? But alternative medicine I think is a good option. Now many institutions in the world are adopting it. Not everything is done with medicine and chemicals. There are many other ways to treat people’s health. Diet, for example, is a very good therapy. Diabetes, ulcers, there are many illnesses that can be treated through a good diet and exercise as a way of life. Traditional medicine has not been adopted strongly. A response as detailed as this obviously belongs to a well-educated person who has had exposure to a variety of health beliefs. Exposure such as this is probably obtainable only by a person who has financial wherewithal and is living in a large city. Margarita also worked for the Mexican Department of Health for quite a few years, an experience that undoubtedly increased her awareness of varied health beliefs. Those from Mexico D.F. stand out more in this regard than those from other urban areas; 3 of the women from Mexico D.F. (out of 4) had heard of all these alternatives to biomedicine. One had heard only of acupuncture and homeopathy. To confuse the interpretation of the data even more, being from a large city was not necessarily associated with knowledge of these

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therapies. Five migrants from urban areas had no knowledge of health beliefs other than those associated with herbs (medicina naturista). Most of the latter women came from the cities mentioned previously (Juarez, Durango, Chihuahua, etc.), not from Mexico D.F. Conversely, only 2 women knew of all the health options and came from a rural area. They had lived in the United States 2 years and 4 years, respectively. That rural residents know of these modalities at all may be significant, for Finkler (1994) did not report that Mexicans living in rural areas had any access to acupuncture or chiropractic services. Of course, it is entirely possible that these 2 migrants visited the largest city in Mexico at some point, but we are not privy to this level of detail about their lives. What needs to be underscored is that living in a large urban center—particularly Mexico City—does increase the chances that an immigrant has heard of or utilized CAM but it is not a given. As mentioned in chapter 6 in relation to beliefs about diet and exercise, the influence of urban versus rural sending communities may be mitigated by the effects of socioeconomic background. That is, those with financial stability can access health care alternatives other than biomedicine; those who are less stable cannot and do not. What does stand out about the data collected is that the 64 percent with urban backgrounds who knew about CAM represent a much larger percentage than the people other researchers indicated knew about (or had tried) these therapies in Mexico D.F., arguably the most cosmopolitan and multifaceted city the immigrants could come from. This suggests that Mexican immigrant women are using CAM. Because the populations are not matched in any way, however, more work needs to be done to prove unequivocally that subsets of Mexican women are learning about and adopting complementary and alternative beliefs about diagnosis, prognosis, and treatment.

CHRONIC ILLNESS AND CAM USAGE Another way to look at the data is to examine how many of the women who had tried CAM also considered themselves to have chronic illnesses. In this formulation of “chronic” I did not include pregnancy because there was no indication that immigrant women sought these sorts of healers during their pregnancies. This proved to be complex because 4 of the rural dwellers claimed to have a chronic illness (1 was diabetic) and 5 of those from urban areas claimed to have chronic

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problems (2 of these were diabetic and/or had high blood pressure). Together, 9 out of 22 (41 percent) who had experience with CAM also had chronic or otherwise untreatable illnesses. The association between having a chronic condition and using CAM is common in the United States (Baer 2001) and, to some extent, in Mexico as well (Finkler 1994; 2001). This finding in the current study might be noteworthy, but considering the context of the interviews and what the women said about their diagnosable chronic health conditions (especially diabetes and hypertension), it does not appear to be significant. Seldom was there mention of trying to heal themselves biomedically and, after that failing, seeking out alternative medicine. More work needs to be done to determine conclusively whether Mexican immigrants with undiagnosable chronic conditions are turning to CAM in search of relief and remedy.

OTHER VARIABLES In addition, with the exception of Margarita, who had a college degree and worked in the health care sector in Mexico, I found no salient relationship between level of schooling and knowledge of alternative health beliefs (see Table 16). Table 16. Education levels of CAM familiars

Level University

Number of CAM Familiars 1

Number of Total Population 1

Percentage 4.0

Preparatory

5

20.0

13

21.0

Secondary

6

24.0

14

22.0

Primary

6

24.0

10

16.0

None

2

8.0

2

3.0

Unknown

5

20.0

23

36.0

Percentage 2.0

As with the population as a whole, there is a fairly even distribution of levels of education among the women who used CAM, so the case cannot be made that only the more educated venture to find alternatives to biomedical treatment. If anything, it appears that those with less education are seeking out biomedical alternatives; nearly onethird more interviewees with only a primary level of education claimed

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to have heard about or used some form of alternative medicine or therapy. Upon arrival in the United States (assuming no prior knowledge of CAM), which variant does a Mexican immigrant “discover” first: acupuncture, chiropractic, or homeopathy? The data were probed to ascertain whether there was any cultural patterning to the sequence in which an immigrant tries CAM. A case can be made that acupuncture is the first alternative therapy that migrants in Santa Fe come into contact with (the one that is the most common in Mexico, according to ethnographers of the Mexican healthcare system). A statistic to bolster this assertion is that the average (mean) number of years an immigrant had lived in Santa Fe who said that she knew about acupuncture was 4.5 (median 3.5 years; range, 2 months to 17 years). The mean number of years a subject had lived in Santa Fe who knew of or utilized chiropractic was 5.1 (median 5 years; range, 2 months to 10 years). Those who knew of acupuncture averaged fewer years living in Santa Fe than those who knew of or had tried chiropractic. Of course, this finding could be due to the prevalence of acupuncturists in Mexico and scarcity of chiropractors. A case in point is Reyna (age 40, 5 years), who came to Santa Fe from a rural area of Mexico (Chiapas), where she was raised without a formal education. Although she had no chronic problems, she nevertheless learned about acupuncture after her arrival in Santa Fe. Her response to the question, Do you know what acupuncture is? was this: “Yes, I have heard of it here, and it is very good in Santa Fe.” Another respondent, Maria R. is one who, conversely, first learned of and sought out chiropractic (not acupuncture) soon after her arrival in Santa Fe. She came from a small village (Tuxtepec) in Oaxaca, was 41 years old, and had lived in Santa Fe only 2 years. When asked the question, Have you ever gone, here in Santa Fe, to see one of these [CAM] doctors? she responded, “I went to the chiropractor and it worked out really well.” Next, she was asked whether she knew about chiropractic in Mexico, to which she replied no. ENTRE: How did you find the chiropractor who cured you? MARIA R.: I went to a shop and I saw a doctor there, or I don’t know what she might have been, with a skeleton. And I showed her the part of my back that was hurting me. It was in a supermarket where she was. She had the skeleton where people could show her, and I made an appointment with

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her…and I went, and yes, thanks to God, I got good results. I don’t know what she did to me, because I felt that they didn’t do anything to me [laughs]. She didn’t do more than you get there and you lay down in a special bed and she plays some very smooth music for you to listen to. And from time to time, she gives you a massage, she touches your back or makes some movements like this. And she has you for like half an hour or so, and that’s all she did to me.… ENTRE: How many times did you go? MARIA R.: Like four times. ENTRE: Why did you keep going if she didn’t kneed/massage you? MARIA R.: Because I wanted her to treat me, to relieve me of that pain. ENTRE: Did you believe in her? MARIA R.: Yes, I believed in her. ENTRE: Did you feel that she was a half witch or what? Since she was doing a cleansing with music? (laughs) MARIA R. (laughing): Yes, but a cleaning of my purse, because I was left without money. ENTRE: But she did cure you? MARIA R.: Yes, it didn’t hurt me, and the back pains have not returned since then. ENTRE: Since how much time? MARIA R.: It’s been a year and four months since I went to see her. The healer’s actions, according to Maria’s description, sound more like healing by modifying the energy fields surrounding the body. According to Baer (2001), the holistic heath movement has taken hold among a large percentage of the U.S. population as a result of “the widespread dissatisfaction with the bureaucratic and iatrogenic aspects of biomedicine” (2001:109). Dissatisfaction with (or fear of) the U.S. healthcare system probably affects both natives and immigrants similarly. As Maria’s case demonstrates, the holistic health movement has also gained prominence, in large part, because of the pivotal role played by health food stores in disseminating relevant information. It is

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common for both natives and immigrants to encounter new health ideologies during the mundane activity of grocery shopping.3 In addition, Maria’s comments stand out in the context of her second interview (she was 1 of only 2 who were interviewed twice) because, at that time, she recounted how “terrorized” she had been by her mother-in-law, whose health care beliefs caused her to caution Maria against performing certain activities at certain times. For example, Maria was warned against bathing in hot water on cold mornings and eating combinations of specific foods, beliefs associated with the humoral theory of medicine and considered extremely traditional in rural Mexico, particularly Oaxaca, where they lived. Maria recalled: Before I was afraid of bathing, because before, my mother-inlaw, my first mother-in-law, she put things in my head. She told me all these negative things. They practiced a lot of witchcraft. They used to pray the prayer of death for me. They did things to me. I’ve been traumatized because when I got married, I was a free, young girl. I never had malice—in my head, I mean.…For example, my mother-in-law said to me, “What are you doing? You shouldn’t do that, because that’s bad.” For example, with food, “Don’t eat this. Don’t eat that fruit with this other, because that is venom and you can die.” And this is how I was traumatized. When I gave birth, I didn’t eat avocado or milk. I couldn’t eat. You didn’t eat anything. You almost died from the hunger. This hurts the child. It hurts the egg, what else I don’t know. I left there completely bad, with my mother-in-law. I lived around ten or eleven years with her. (Emphasis added) Maria’s comments appear in their entirety here to illustrate how much her beliefs about health and illness had changed since she arrived in the United States to begin a new life with a different husband. The first alternative to biomedicine and curanderismo she encountered in Santa Fe was chiropractic. We do not know why she no longer believed in her mother-in-law’s ideas, which had “traumatized” her, nor in visiting curanderas for healing (which she had done several times in Mexico to address her concern over how thin and depressed she had become since her mother’s death 15 years earlier). One could argue that the similarity between the work of sobadores and chiropractors made the transition easy for Maria. Adjustments and massage are closer to the techniques of sobadores than acupuncture needles. This may indeed be the case

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and deserves further study. The data collected for this project, however, provides no way to determine definitively whether there is a sustained (and/or culturally influenced) pattern of “discovery” (e.g., first acupuncture and then chiropractic, or vice versa) of CAM techniques among the immigrant population. The discovery of CAM appears to be based on opportunity rather than cultural propensity.

NON-SECULAR HEALING AND CAM USAGE Following Maria’s example, one might postulate that immigrants who believed (or continue to believe) in curanderismo might be more likely to accept any allopathic substitute simply because they are already accustomed to an alternative and therefore marginalized medical system in their countries of origin. This latter point has no real validity, however, because there is no perceptible relationship between believing in curanderismo and knowing anything about or trying one or another biomedical alternative. Only 3 of those who knew about CAM (out of 23, or 13 percent) were also believers in curanderismo, and another 2 were ambivalent about it. Moreover, 12 users of CAM did not believe in any religious or spiritual healing. Although there is no predictable relationship between believing in curanderismo in Mexico (or the United States) and knowing of or adopting CAM ideologies, there does appear to be an association between changing religions and exploring alternative health ideologies, in general. The data reveal that a full 12 out of the 23 interviewees who claimed to know about and/or to have tried CAM therapies had changed religion either before or after moving to Santa Fe. These 12 subjects represent 52 percent of the total who knew about and/or used CAM. Even more significant, these 12 represent 80 percent of the entire subgroup of 15 immigrants who had changed religion (or who were exploring conversion and were still ambivalent). These migrants had changed from Catholicism to one of three Protestant denominations: the Baptists, Jehovah’s Witnesses, or the Pentecostals, the three churches that are currently conducting extensive outreach campaigns among the recently arrived Mexican immigrant population in Santa Fe. In chapter 9, I discuss the intimate connections among crossing the U.S.-Mexican border, converting to a new religion, and adopting new or different health ideologies.

CHAPTER 9

Crossing Boundaries: Geographical, Political, and Religious

The historical backdrop of religious conversion in Latin America, as well as among Latino groups in the United States, is one of exponential growth in non–Roman Catholic religious movements since the 1950s (Espinosa 2005; Bastian 1993). In fact, evangelical Christianity and Pentecostalism are thought to be the fastest-growing segment of Christianity. It is estimated that worldwide adherents number around 150 million and that approximately 33 percent of them are located in or come from Latin America. Moreover, “In a huge cultural transformation that is changing the face of religion in the United States, millions of Hispanic Americans have left the Roman Catholic Church for Evangelical Protestant denominations. This may be the most significant shift in religious affiliation since the Reformation and represents a 20 percent loss of Catholic Hispanic membership in as many years,” (NYT, 24 August 1998). Two recent studies based on nationwide surveys examined the growth rate and correlates of Protestantism in the U.S. Latino population. According to the data published by Greeley, there was an 8 percent “defection rate” from Roman Catholicism to one or another form of Protestantism (1994).1 Moreover, “fully threefourths of all Spanish Origin Protestants identified themselves as Baptists or Fundamentalism” (Hunt 1999:1603). In the United States, the major evidence for recent increases in fundamentalist Protestantism is largely confined to the Mexican American community in the 1990s (Espinosa 2005). Tangential is a published enumeration of American religions revealing that only 59 percent of “Mexican origin” high 135

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school seniors surveyed declared Catholic allegiance and 17.4 percent identified themselves as Protestant (Leon 1997).

WHY PROTESTANTISM? Because the patterns recorded in the past are linked to first-generation Hispanics, researchers must determine whether conversion occurred in the United States or in the country of origin. There are two hypotheses. If conversion occurred before arrival in the United States, the disproportionate number of women converts among first-generation Hispanics in the United States would seem to reflect what many observers have noticed, namely, that women are usually the first in their native communities and families to convert to Protestantism (Brusco 1995; Mariz 1996). Alternatively, if conversion occurred after migration to the United States, the gender-based conversion differences might be linked to distinctive gender experiences central to the migration experience (Hagan 1998). It has been postulated that women before migration, but especially after, have greater need of the social and moral support offered by church-based social networks. The data collected indicate that 15 women converted to Protestantism. Specifically, 4 became Baptists; 3 converted to Pentecostalism; 3 joined the Jehovah’s Witnesses (and 1 was studying with them, trying to decide whether she wanted to make the commitment); 4 switched to one or another “Christian” church; and 1 was a Seventh Day Adventist. These 15 women represent approximately 24 percent of the entire sample. When compared with standard census data on the percentage of the population that claims to be Protestant in Mexico—4 percent in 1990, 7 percent in 2000—Mexicans apparently are not converting to evangelicalism or another form of Protestantism in significant numbers until they enter the United States. Protestant conversions “must therefore be implicated in processes of immigration and conversely, immigration must therefore figure into the trajectory and discourse of conversion” (Leon 1997:370). This is the scenario in the present sample; 66 percent of those who had converted stated that they had done so after arriving in the United States. Moreover, the mean number of years lived in the United States by those who had converted to Protestantism was 5.4 (median 5 years). See also Campo-Flores 2005. Anthropologists have noted the predominance of women in evangelical churches, particularly Pentecostal congregations, and have

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hypothesized that organized religion might be the most common way women develop new relationships within socially prescribed boundaries (Gill 1990:708). Because they are often relegated to the home and engaged in child-rearing activities, women encounter more difficulties than men when seeking emotional support and economic security after moving outside their kin networks and zone of familiarity (Gill 1990:712).2 Protestant churches create an island of peace amid the uncertainties of daily life. By forging closer ties and providing economic and emotional sustenance, these small churches are countering the “disintegrating” effects of economic crisis, social dislocation due to migration, and anomie. In addition, strained marital and familial relations exacerbate immigrants’ sense of alienation. Not surprisingly, a full 47.4 percent of the subgroup who converted had divorced or separated from their husbands. One should note, too, that these women appear to be better educated than the population as a whole (see Table 17). See Marin and Gamba (1993) who reported a similar finding. Table 17. Education levels of religious converts Level University

Total Population 1

Percentage 2.0

Number of Converts 1

Percentage 6.7

Preparatory

13

21.0

4

26.7

Secondary

14

22.0

3

20.0

Primary

10

16.0

2

13.3

None Unknown

2

3.0

0

0.0

23

36.0

5

33.3

One of the most interesting findings of the research on genderbased conversions is how evangelical Christianity works as a “strategic” women’s movement, “reforming” machismo and enhancing women’s position in the household. “Evangelicalism redraws and redefines the boundaries of public (male) and private (female) life. It curbs male aggression, violence, pride, self-indulgence and… individualistic orientation in the public sphere and directs men’s attention and energies to the preservation of the household, women’s traditional province” (Vasquez 1999:4).3 This factor is not to be discounted, for there are numerous published studies about the elevated level of domestic violence in migrant households, the increase in drinking and

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smoking behaviors, and the allure of gang life for immigrant children, all of which are associated with heightened stress levels of immigrants (Hernandez and Charney 1998; Rogler et al. 1991). Jacqueline (age 16, 3 months), who moved to Santa Fe with her husband and their son from Oaxaca, discussed this type of violent behavior. Feeling betrayed by the American Dream, she recounted the story of her husband’s physical and emotional abuse: ENTRE: And has he hit you since you’ve arrived? JACQUELINE: Just once….We hit each other and it was really ugly. And I told him, “Of course you don’t care, because I’m here now and my mom is here and I don’t mean anything to you.” I said to him, “You know I love you and I’m not going to tell the police, but one day it will be the last straw. I will turn you over to the police, and they will take you away. You have no reason to hit me.” ENTRE: Are you sorry you came here? JACQUELINE: Yes, very. ENTRE: Why? JACQUELINE: Granted that we were poor there, but he has changed a lot here. There we fought, yes, but he was very understanding. But now he’s got a car, and he’s never been like this before. He’s gotten really bad with me, very stingy. He doesn’t give me money, not one cent. With my salary, I buy what I want or send it to Mexico. I pay my rent and bills. ENTRE: He doesn’t pay the child’s expenses? JACQUELINE: Sometimes not. I’m the one who buys. Sometimes I borrow because I don’t have enough, and I go and buy diapers. But sometimes, very rarely, he will buy diapers, but sometimes, no. Since we’ve been here, he has changed a lot with me, for the worse. Obviously distraught about the disintegration of her relationship with her spouse—a familiar discourse of both immigrant women and men—Jacqueline, or a woman in her position, might begin searching, consciously or unconsciously, for support from others in a similar position. Welcomed into the modest storefront churches of the evangelical or fundamentalist congregations, Jacqueline and converts like her can find new friends and validate emergent identities. After

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severe emotional crises, religious ideology can be an important part of the acculturation process. Furthermore, these Protestant churches offer women an institutional base for developing important and enduring social relationships and provide the rituals to validate these emerging bonds, which help to create a shared sense of community.4 “They create an experience of opposition to the prevailing norms and practices of the dominant society (i.e., drug usage, gang membership, etc.), serving to establish a sense of order and to instill feelings of hope in persons living in a social environment characterized by uncertainty and alienation” (Sider 1980:21). At the same time, church doctrine replicates or underscores the philosophical structural underpinning of American society with liturgy that emphasizes individual agency instead of blind submission to the interpretive mediation of priests. Disciples are taught “to reject…the priesthood, or the role of religious specialists. Rejection of sacramental mediation allows [them] to become agents in their own salvation…and success is proven through ‘bearing religious fruit,’ and implicitly, through economic achievement” (Leon 1997:374). Conversely, why does Catholic doctrine, or sense of community, or the quality of succor offered by Catholic institutions not address immigrants’ needs? One reason may be that immigrants perceive that they are not welcome in the institutionalized Catholic bastions, particularly in Santa Fe, even though it is nearly 50 percent Hispanic and several Catholic churches offer Spanish-language masses. Traditionally, the Hispanics of New Mexico have not welcomed Mexican immigrants, whom they see as a threat to their livelihood and cultural identity. In New Mexico, social class encompasses more than economic standing. Local Hispanics trace their blood lines back to colonial Spain and not Mexico: Mexican immigrants, with their “impure” mestizo blood, destabilize the locals’ sense of entitlement, which is also under siege by the large population of Anglos who moved into northern New Mexico in the 1980s and 1990s. Another reason may be that, although fundamentalist Protestantism is a clear departure from the official forms of Catholic religious community among Hispanics, “it may not be dissimilar to folk Catholicism, an enduring tradition that has long existed outside official Catholicism. Consequently, it may reinforce traditional forms of community rather than create the new social networks that the classic version of the Protestant Ethic presumes critical: either secular mobility

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and/or acceptance into the American mainstream” (Hunt 1999:1619– 20). In effect, the various Protestant religions to which recent migrants convert may be practicing a form of Catholicism, albeit without the priests. Converting to Protestantism is, then, what Stoll refers to as “a reorienting (or rechanneling) of the popular religiosity of folk Catholicism” (1990:112–13). Bastion refines this concept even further when he argues that “the expansion of ‘Protestant’ societies and new religious movements corresponds neither to a ‘reform of popular Catholicism’ nor to a ‘renewal internal to Protestantism’ but rather to a patchwork kind of renewal of popular religion and by the historic Protestant groups’ adopting the practices and values of popular Catholic culture” (Bastian 1993:43–4. See also Martin 1990).

HEALTH BELIEFS AND RELIGIOUS CONVERSION In discussing religious change among Mexican immigrants, it is hard not to postulate a symmetry between the motivations for crossing geopolitical borders and those for crossing boundaries of religious ideology. According to Leon, who worked for four years as a participant observer in a Pentecostal church in East Los Angeles, “ethnic Mexican religious movements are typified by the confluence of religious and national border crossings” (1997:389). He argues that the motivations for both religious and national border crossing are analogous. Both can be considered modes of survival in a state of emergency.5 How does this process work? How do people relinquish their first religion and embrace a new one? Inherent in at least one local variant of Pentecostalism, although it is true of other variations of Protestantism as well (i.e., Baptists and Jehovah’s Witnesses), is the theme of making a “break with the past” (Meyer 1998). In the United States it can be interpreted to present the Mexican immigrant with a sense of community, an “us” versus “them,” a “now” versus “then,” and even a “modern” versus “traditional.” To Mexican-American conversos, making a break with the past means, among other things, disavowal of the priests’ prestige and power to interpret the word of God.6 One is also taught that idolatry of religious iconography (iconolatry) is forbidden.7 Implicit in this discourse is the idea that, by forgoing priestly interpretation and the worship of religious imagery, the born-again understand the Bible better. In this manner, they gain

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greater proximity to God, which, in turn, enhances proper, moral, Christ-like behavior.8 Before, one was not as close to God as one should be (in effect, the priests stood between the congregants and God); now that one is a Baptist, Jehovah’s Witness, Pentecostal, or the like, one can bask in the glory of closeness to God. Inherent in this process is a disavowal of or “break with” the previous Catholic self, which was inevitably attracted to the work of Satan or inhabited by Satan and allowed to do Satan’s work (because that Catholic self was not close to God). Although most Mexican immigrants do not necessarily want to let go of their cultural customs, a discourse such as this one may effect a more rapid release of all manner of cultural beliefs, not just religious doctrine directly pertaining to the Catholic religion. Meyer concludes that “indeed, in practice, the ‘complete break with the past’ amounts to a break with one’s family, and [the notion of] progress translates well into individualist patterns of production, distribution and consumption” (1998:192). Interpreting through this lens, Mexican immigrants not only become immersed in a discourse that affords them emotional stability even as they relinquish cultural and familial ties, but also find a doctrine that implicitly espouses the American Dream, the primary pursuit of which was the motive for immigrating in the first place. The immigrant situation is even more complex than this, however. Hernandez, discussing conversion to variations of Protestantism, cautions: “An alternative explanation to the culture-denying hypothesis can involve two parallel arguments. Initial attraction and connection to another religious ideology has nothing to do with a desire to reject one’s cultural roots. In fact, quite the opposite takes place. There is a redefinition of one’s ethnic identity, or rather the symbolic expressions of that identity. What is really going on is not cultural abandonment but rather abandonment of practices and traditions that appear to go against the desire to maintain what is judged to be a purer…religious experience” (1999:11). In the present sample of Mexican immigrants, both processes appear to be operating. On the one hand, the women were not relinquishing every last aspect of their Mexican cultural heritage; in fact, the churches welcomed them by demonstrating sensitivity to these traditions. On the other hand, aspects of Catholicism that engendered belief in the healing power of the traditional Mexican health ideology—curanderismo—are scorned. In fact, the first belief system that

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Mexican immigrants who have converted are told to relinquish, or “break” with as the work of the devil, is curanderismo. In this scenario, the manifestation of the devil’s work is the healing cure provided by a curandero/a. Even though some good may come of it (that is, people may actually be cured of their ailments), curanderismo as a form of healing is not sanctioned by the Protestant churches to which nearly 24 percent of the interviewees belonged. The Mexican women were not always sure how to resolve this dilemma; they had often witnessed or experienced “cleansings” by curanderos/as.9 At the same time, however, they were acutely aware that curanderos/as are often remunerated for reading cards or one’s palm, in effect, foretelling future events. The women were mostly in accord that this type of prophesizing is the work of the devil, and most were not unhappy about giving up this aspect of curanderismo. Margarita (age 54, 2 months), although she changed religions while living in Mexico City, explained her movement away from such practices: ENTRE: Have you heard of people who can heal by means of spirits or saints? MARGARITA: Of course I’ve heard of it. ENTRE: And do you believe in that kind of person? MARGARITA: No. ENTRE: Have you ever consulted a curandero? MARGARITA: Of course, before I became Christian. ENTRE: And when did you convert to this type of Christianity? MARGARITA: I’ve been a Christian for ten years. ENTRE: And before that, you went to a―? MARGARITA: I occasionally went to have my cards read. I went so they could do a cleansing. Esoteric things like that that I believed in before, but now I don’t believe in that… ENTRE: And when you, at one point in your life, went to this kind of person―? MARGARITA: I didn’t go for cures. ENTRE: Just for curiosity? MARGARITA: Exactly. I had a problem and I got my cards read, or something like that. That they do a cleansing to take

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away bad spirits—pure fiction. But in hard times in your life, you can believe in something like that, in magic, right? It’s valid, right? Margarita is quoted extensively because her explanation of why she no longer frequents curanderos echoes that of other immigrant women, such as Aurora (age 49, 10 years in Santa Fe). When asked whether she believed in curanderismo or had ever consulted a curandero, Aurora responded, “When I was Catholic, I even had my cards read, and they read my palm. But no, I did not like it.” Both speak dismissively about their past behavior.10 Margarita, a few moments later in her interview, went so far as to wish out loud that she had found Christianity earlier in her life so that she would not have had to experience years of searching and wandering and experimenting with “magical” forms of healing. Similar to the Pentecostals of Ghana (Meyer 1998), Margarita and other subjects feared “the past” because it was, for them, a source of personal disturbance instead of a source of pride. Another interesting inference to be made from Margarita’s remarks is that, even though she calls a “cleansing,” “pure fiction,” she simultaneously attests to the comfort such a “fiction” can be to one who is experiencing “hard times.” Perhaps this was her way of excusing her behavior while distancing herself from her history with traditional Mexican healers. Araceli (age unknown, 4 months) described her visit to a curandera to heal her high blood pressure, illustrating how cleansings are integral to the curanderos’ art of curing: ENTRE: Have you ever consulted with this type of person, like a spiritualist, a curandero, or a santero? ARACELI: Yes, I’ve done that. I went to see woman there in Mexico who does cleansings, and she has cured people. And she cleansed me and I felt good. ENTRE: She cleansed you or something like that? ARACELI: Yes. I felt bad and she made me feel better. I had high blood pressure and she gave me some herbs. I took them and didn’t feel bad anymore. ENTRE: How long ago was that? ARACELI: It’s been about five years now. ENTRE: This person cures illnesses? ARACELI: Yes.11

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Despite Margarita’s disavowal of the curandera’s healing art, those who had not relinquished their belief in curanderismo continued to consider it and, indeed, expected to receive cleansings to be cured.

A PERMANENT SHIFT IN HEALTH BELIEFS What is remarkable about conversions—and why so much space is devoted to discussing them—is that they precipitate the only permanent shift in health ideology away from curanderismo. Many subjects could simultaneously believe in both allopathic medicine and curanderismo. In fact, this is reported extensively in the literature on the Mexican immigrant population, namely, that few believe exclusively in curanderismo. This is true of the present sample as well; 11 subjects (17.5 percent) stated explicitly that, their visits to allopaths notwithstanding, they believed in curanderismo. Another 6 (9.5 percent) explained that they were ambivalent; they had witnessed or had experienced healing but—possibly because of a cure or two that failed—were not sure what to believe.12 For these 17 interviewees (27 percent) and many others like them, there was an express pattern of dual resort. One type of medicine was tried first, followed by a different treatment or practitioner, or both were tried simultaneously.13 Even immigrants who had lived in the United States for more than 10 years sought healing cures from both biomedical doctors and curanderos. Moreover, a persistent stereotype of Mexican immigrants is that their refusal to relinquish their belief in curanderismo is responsible for their neglect of potentially serious medical conditions, conditions which ultimately impact the U.S. health care system. In contrast are those migrants for whom a momentous shift in both ideology and patterns of usage came after they had come into contact with a Protestant doctrine and discourse that explicitly forbids the health belief system of curanderismo, calling it the work of the devil. Therefore, it is not simply time spent in the United States (i.e., the more time an immigrant lives here, the more likely she is to give up her belief in curanderismo) or the persuasiveness of the medical model that influenced these immigrants. Rather, they voluntarily relinquished their belief in the healing system so intimately associated with a Mexican cultural identity, because of a simple religious conversion. The stereotypical “conversion tale” has been that when traditional, rural immigrants come into contact with Western biomedicine and experi-

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ence its superlative healing efficacy, they inevitably relinquish their belief in curanderismo. This was not born out by the narratives collected for the present project.

SHIFTING BELIEFS AND MEDICAL TECHNOLOGY What is fascinating is the pervasiveness of the stereotype of rejecting curanderismo and/or medicina naturista in favor of new and advanced technology. Margarita’s response to her interviewer’s question regarding why Mexicans visit curanderos in their native country echoes this “conversion tale”: There are two things that happen. One, that culturally Latinos have chamanes in their historic roots, hechiceros, brujos, right? The other thing is that this is combined with poverty. That is, these peoples’ lack of opportunities or medical insurance makes them look for the easiest thing, and the cheapest is to go to a chaman, an hechicero, a yerbero. It has to do with the culture. And that’s why, for example, in my country its importance has gone down a lot, because they have extended services in an important way throughout the country. Even in the little villages there is a health center. They first go to the yerbero to be cured. And when they see that it’s not getting better and that the yerbero didn’t cure them, then they go to see the doctor. This has made the people have a greater outlook on going to see the doctor, at least the people of really tiny and really poor villages and towns, that the doctor cures them. And the medicines are almost free. They aren’t free, but they are really, really cheap in the health centers. And I think that the health system in my country is a good system and that it serves as an example for Latin American countries like El Salvador, like Honduras. And this has allowed the medical culture to gain importance with Mexicans, unlike Central American countries. From an historical perspective, Margarita may be right about the relative acceptance of biomedicine (versus medicina naturista) on the part of Mexican citizens compared with inhabitants of Central American countries. What is interesting about this discourse is that even as it points to a shift in patterns of belief away from yerberos to highly advanced medical technology, it does not fit precisely the

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paradigm (outlined previously) of conversion to Protestantism and rejection of curanderismo or medicina naturista by immigrants in the United States. What does ring true is its ability to describe in part what happens as a subset of immigrants spends more time in the United States. In this scenario, 7 interviewees (or 11 percent) discussed how, over time, they came to appreciate the technology and specialization of the North American biomedical system. This does not mean, however, that they renounced their belief in curanderismo. It only means that they had come to distrust herbal remedies. The mean number of years spent in the United States for those who had turned away from both medicina naturista and biomedicine as it is practiced in Mexico was 11 (median 10 years). At first, many were stunned by the U.S. physicians’ lack of “charisma” and complained that the doctors did not “attend” to them well. Over time, though, some came to appreciate the myriad diagnostic tests, as well as the quality of the surgeons and friendliness of health educators. For example, Magdalena (age 65, 45 years in the U.S.A., diabetic with high blood pressure) responded to a question asking whether she tried to cure herself by using home remedies: “Sometimes I try. Usually, I go straight to the doctor. Now they tell me to go there immediately, when it’s higher than normal. Because I could have a stroke or something. Imagine having an embolism and waiting for them to make up an herb” (emphasis added). Even after spending so much time in the United States, Magdalena, who was diagnosed with diabetes in Mexico, was still outraged that her Mexican doctor prescribed herbs and did not give her a glucose monitor so that she could check her blood sugar levels. Ana Maria (age 68, 15 years) also had a story about the physicians in Mexico not explaining that she needed to monitor the glucose levels in her blood. Having heard “on the street” that insulin was dangerous to the body, when she came to the United States and the physician who detected her diabetes explained to her that she needed to inject herself with insulin, she got mad at him. In the beginning, she thought that he was very incompetent. She also told a story about a botched heart surgery in her native country and how that experience changed her opinion of U.S. physicians: ANA MARIA: I was there for about three months and I had a serious heart attack. My children all went and I didn’t want to come [back to the United States]. They looked after me. They

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took me out of the hospital, but later, with time, I began to understand that I was very far and they were very behind. ENTRE: How long ago was the heart attack? ANA MARIA: Two years ago. It was in May. And in November of that year my daughter brought me to the doctor for a checkup, and they told me that I had to go to Albuquerque to have an open heart operation, because he said that my heart was bad. And I realized that the work they did on it in Mexico wasn’t done very well. (Emphasis added) Ana Maria had believed, for many years, that the medicine practiced in Mexico was superior to that in the United States. Not until she had heart surgery, radiation treatments for cancer, and diabetes care in the United States did she realize that not only could she avail herself of advanced medical technology here but also the knowledge and expertise in treating various diseases were superior. As discussed before, there is a relationship between having lived in the United States a long time (recall that the mean number of years these women had spent in the United States was 11) and having health insurance, the latter demonstrated by Ana Maria’s better-than-average health care options. This access is hypothesized as positively influencing her opinion. The reason for discussing these women’s experiences is to illustrate that they may reject taking herbal remedies for serious illnesses but they are not necessarily rejecting curanderismo for hightech biomedicine as it is practiced in the United States. Their experience in the United States does not reflect what Margarita claims happens regularly in her country. In fact, of the 7 women who mentioned their approval of the advanced medicine available in the United States, 3 also claimed to believe in curanderismo. The most important revelation from the data is that biomedicine holds absolutely no sway over traditional beliefs in curanderismo or patterns of resort. Rather, it is rejection of Catholicism in favor of some form of Protestantism (what the women call “Christianity”) that makes permanent the shift in health care ideology, that is, the shift away from believing in curanderismo.

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SIMILARITIES BETWEEN CURANDERISMO AND PENTECOSTAL HEALING TECHNIQUES I did not focus on the subtle similarities and differences between the health ideology and therapeutics of curanderismo and those promulgated by Pentecostalism or other forms of Spiritualist healing (at the outset of data collection, the relationship between religious conversion and shift in health beliefs was unknown, so no Pentecostal or other types of churches were visited), but I will discuss some of their prominent similarities. It should be noted, too, that there was no indication that interviewees rejected Catholicism simply because they were displeased with the healing efficacy of curanderismo techniques or practitioners (although some were disappointed by curanderos/as). On the contrary, women converted for reasons having little to do with health care ideology.14 For example, they cited their desire to find a welcoming community, to be in the company of exemplary Christians who comported themselves well, and to hear a Spanish-language service. The most oft-cited reason for converting was that people simply wanted to learn more about the Bible and live more within its teachings. See Espinosa 1999. The more common scenario was that the migrants discovered the faith-based healing methodologies associated with the Pentecostals and the Seventh Day Adventists as they spent more time at these respective churches. The most obvious similarity is that followers of all the mentioned religions are familiar with faith-based prayer associated with healing. Catholics request a “healing” novena or special prayer by a priest to help cure a family member. For example, Anahy (age 30, 10 years in Santa Fe) recounted how she went to the priest at Guadalupe Church for consolation when her baby was ill. Asked by her interviewer whether she had ever consulted a religious guide about health problems, Anahy responded thus: Yes, a priest, when my son was born at six months and two weeks later he got really sick. His liver didn’t work. He had bilirubin problems. They had to take all his blood out and give him new blood, and he was really sick. He only weighed about two pounds, and the doctor told me that my son probably wasn’t going to live. So I went to Guadalupe [church], and I was crying and the priest came out.…I don’t remember the priest’s name. And he told me that I had to believe in God,

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that God was going to make him better, that God is great and for me to remember that God gave his life for us, that I remember his mother, who is the Virgin of Guadalupe, that I ask Him many times, and that I tell the Virgin that she suffered for her son on the cross and to not take my son from me. And the priest told me all this, and he and I prayed to God a lot. I commended myself to all the saints, and to this day my son is still here. He is now nine years old. This sort of spiritual involvement with the Catholic trinity was common among the immigrants—several women discussed their conversations with or prayers to God and the Virgin of Guadalupe. What other types of Catholics, Charismatic Catholics, do to connect with God might be more akin to the rites the Pentecostals perform when asking for God’s intervention in healing the sick and afflicted (except, perhaps, the quintessential Pentecostal rite of speaking in tongues). An example is provided by Brenda (age 24, 4 months), who considered herself a Charismatic Catholic. She explained to her interviewer how a traveling Catholic priest came to her village and healed her sister of a “nerves” problem: ENTRE: In what way do you see a connection between religion and health? BRENDA: Let’s see, look, I have a sister that suffers a lot with her nerves. So there was a priest that visited the homes of the parishioners, and he did cures. ENTRE: Where is this guy? BRENDA: I think he is Chihuahua now. ENTRE: He is a Católico Carismático? BRENDA: Yes. ENTRE: Are you Católico Carismático? BRENDA: Yes. ENTRE: Let’s see. Please explain to me how this priest did the cures— BRENDA: He goes and prays for the people who are sick. It’s God that cures through him. (Emphasis added) Brenda did not discuss whether her sister sought help from a curandera, but there is also no mention of a lack of compatibility

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between the actions of the charismatic priest and other sorts of healers. Moreover, the intercession on the part of the priest and his ability to “channel” God are very similar to the interventions performed by the “dons” in the Pentecostal churches. By way of comparison, Maria (age 24, 6.5 years) related how the Pentecostal church to which she belonged required that she shift beliefs from one form of religiousbased healing to another. Maria and other immigrants who had chosen the Pentecostal church spoke explicitly about how they availed themselves of the healing powers of the church dons, who are thought to channel God’s healing power for the congregants: ENTRE: Have you been to see a church don? MARIA: Yes. ENTRE: Is it a treatment that you use, or is it only prayer, or how does it work? MARIA: It is prayer and fasting. I practice prayer and fasting. It is not that you have to do them both for much time. And then the don comes to you, and in accordance, he will put the will of God in whom he wants. ENTRE: You have gone directly to a don, and they have helped you with your illness? MARIA: A brother from church has the don of health. In my case, I had epileptic attacks. They began when I was a little girl. In Mexico they gave me drugs, such as cortisone—very strong drugs—to control me. They said that when I had children, the attacks would cease, and the problem continued. Then, on one occasion a brother said a prayer for me—and it has been five or six years—and since that day until now, I have never had another attack. My son also had a problem with his knees. I don’t know what it was, but his knees always hurt him in a manner that would make him cry. And again, a brother—it is a brother of my husband—he had that don say a prayer for him, and his knees never hurt him again. He even went to the hospital, and they always told him that he did not have anything. ENTRE: When you or someone in your family becomes ill, do you go directly to a don from church, or do you do other things before going?

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MARIA: Usually, if there is an illness, we try using natural medicine. But when it is something serious, we do go directly to a don, and we all unite in prayer. ENTRE: In the past, before coming to the U.S., in Mexico, have you consulted with an espiritista, curandero, or santero? MARIA: Yes, with my epileptic attacks we tried everything and nothing worked. ENTRE: And whom did you go see? MARIA: Well, with different people, with espiritistas, with curanderos. ENTRE: Do you believe in the powers of these people? MARIA: Now I do not, but in those times I did. They told me the cure and nothing cured me. ENTRE: What type of treatment did they give you? MARIA: Well, they were different. On occasions, it was the classic treatment, such as a cleansing with a hard-boiled egg. It was the herbs and things. I don’t know if they were oils or aromatic waters and prayers that they had, but, no, nothing worked. ENTRE: And now you do not believe in those things? MARIA: No, only in God. One can readily see the similarities between the rituals of the Catholic priest and the Pentecostal don. After converting to the Pentecostal religion five years before the interview (a year after she came to Santa Fe), Maria looked to the local church for many of her healing needs. It has been illustrated here and hypothesized in the literature on Protestant conversion in the Latino community that the similarities between the two variations on the worship of the trinity make for the seamless transition from one to the other (see Cox 1995). The data from this study reveal that healing rituals are another similarity between the two religions. Two more examples will illustrate the pervasiveness of the belief in the healing efficacy of the Pentecostal dons. Raquel (age 35, 6 years), who was meticulous about getting her children immunized and taking them for bi-annual checkups at the dentist, felt that the don at her church was the proper person to heal her, even in the event of

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subacute illness (as opposed to the chronic problems Martha discussed). She related the story of how her don channeled the healing power of God and cured her of a severe headache (he also cured her husband of the flu): ENTRE: Do you think there are people who can heal or cure other people through the medium of saints or spirits or supernatural powers? RAQUEL: No. ENTRE: You don’t believe in those people at all? RAQUEL: No, the minister heals. The minister asks for healing, but not a saint. They’ve healed me many times. ENTRE: Then you do believe in those people? RAQUEL: It’s that he’s not a healer. He is a spiritual person who is full of God, and he has healed people in the church. ENTRE: Like who, for example? RAQUEL: Like, for example, the children who are sick, the flu. ENTRE: And have you had an experience? RAQUEL: Yes, one time with myself. Because I passed before him and my head hurt. And I told him I felt bad, and they made me go up front. And, yes, afterwards I began to feel better and my headache, as strong as it was, went away. ENTRE: And how does he do it? He doesn’t use objects? RAQUEL: He doesn’t use anything. He just puts it in the oration. ENTRE: And has he healed your son too? Of the flu, or what? RAQUEL: Yes, he healed him of the flu, of a cough. ENTRE: Does your husband go to that church too? RAQUEL: Yes, as well. ENTRE: And has he healed him? RAQUEL: Yes. ENTRE: Of what? RAQUEL: He was sick from the flu, and then later he asked for the oration so that his mother could arrange her

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immigration papers so she wouldn’t have problems arranging her papers. In fifteen days, they have his mother’s permission, and they resolved them all, and his mother could then come here. Now she’s here legally. ENTRE: And if you are sick or someone in your family feels bad, what is your first instinct, to go to church or to go to the doctor? RAQUEL: To go to the church, to the minister. It’s that he’s God’s medium. God works. He’s just an instrument. ENTRE: Have you consulted a religious guide about your health problems? RAQUEL: Just the minister. ENTRE: But you don’t consider him a healer? RAQUEL: No. ENTRE: God just uses him? RAQUEL: Yes, he is an instrument of God. He is not a healer. He is not anybody. God uses him. Raquel was not averse to biomedical healing in general (although she did have a sour experience with a physician at the local hospital her first year in Santa Fe). She still made an effort to take her kids to be vaccinated and would, mostly likely, resort to the clinic or hospital if she or one of her family became acutely ill. It is not unlikely that perceived gravity of illness affecting patterns of resort in native Mexicans similarly guides the subject immigrant population. For subacute illnesses, however, including upper respiratory ones that Raquel might have treated with antibiotics, she now sought the healing energy channeled by her minister. Although not a Pentecostal, Teresa (age 38, 1 year), who converted to the Baptist faith while living in Juarez, also claimed that healing can be effected through “people,” but not with the aid of images of saints, “objects” often used by curanderos and the Latin American Catholic laity to achieve healing. Intercession on the part of saints or priests is also forbidden by the Baptists, who claim that this distinguishes them from Catholics and aids them in becoming even closer to God. Confused as to where she could go for cures sanctioned by God, Teresa discussed a preconversion experience with one such healer: “No, not with saints…from an image. No, but there could be people whom the

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Lord uses to heal other people, but not in an image, not from a saint.” Asked whether she had consulted a spiritualist, a healer, or saint-healer, Teresa answered, “Yes, I went for my husband because he was drinking and he told me to go, because they had done something bad to him. And I went, but I didn’t like it because they asked me for a lot of money that I didn’t have, and that gave me doubts. It didn’t help anything.” Most likely, because the healer asked for money, Teresa was referring to a curandero and not a church-based faith healer. Thus, by denigrating the experience (1) because the cure was ineffective and (2) because it cost a lot of money, Teresa, like Raquel, broke with her past and denounced the healing cure she once sought. She no longer blamed others for her husband’s problems with alcohol and looked to her new church for guidance on these issues.15 Last, Dolores (age 32, 6 years), also a Baptist, claimed that she had not been to a doctor in a whole year because of her faith in praying to God for health: “I pray to God to heal me, and before I knew to do that, I went to the doctor. Now I don’t go to the doctor. God cures me. I don’t go to the doctor anymore. God has cured me, cold, cough, or weak body. I don’t ask anyone’s opinion. It’s been a year since I’ve gone to the doctor.”

HEALTH BELIEFS AND THE JEHOVAH’S WITNESSES The similarities between Catholicism—especially the charismatic kind—and various Protestant religions probably make it simple to leave the former and convert to the latter, but one variety of Protestantism espouses a health doctrine that 2 of the 4 immigrants who had converted, or were thinking about converting, had a hard time accepting. The Jehovah’s Witnesses’s conviction that blood transfusions are bad for the body confounded the Mexican women, and they cited it as a reason not to become a Jehovah’s Witness, even if many of the other doctrines were appealing. Recall Maria R. (age 41, 2 years), who was studying with the Witnesses to see whether she wanted to join them. Asked whether her religion dictated any specific, health-related prohibitions, she stated, “Yes, the Jehovah’s Witnesses don’t allow the blood, and I don’t agree with them. I think that the first thing is my son’s life or that of my family.” Similarly, Rafaela (age 65, 1 year) had become interested in the Jehovah’s Witnesses: ENTRE: In what religion were you raised? RAFAELA: Catholic.

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ENTRE: Have you changed religion? RAFAELA: No. ENTRE: And do you plan on changing religion? RAFAELA: Well, I have liked the way they pray and how they read the Bible and how they study. I have been to the churches. ENTRE: To what churches? RAFAELA: I have been to the Jehovah’s Witnesses and to the Christian Church. ENTRE: Then, you are planning on changing your religion? RAFAELA: Yes, I am thinking [of] changing. ENTRE: To which? RAFAELA: I don’t know if I want to switch to the Christian or to the Jehovah Witnesses. Later in the interview, during a discussion about her belief in spiritual healing, Rafaela related a story of visiting a curandero in Mexico to help heal her son, who was in a coma from a car accident in the United States: ENTRE: Do you believe in spiritual healing? Have you heard of people who can cure by means of saints or spirits? RAFAELA: Yes, I have heard of them. ENTRE: What do you think of them? RAFAELA: But I don’t believe. ENTRE: Have you gone with a curandero, santero, much? RAFAELA: Yes, yes I went to one once recently with what happened to my son, but I proved that it was lies because they told me he would walk in two months—and it has been half a year. ENTRE: You went to one here? RAFAELA: No, there in Mexico. ENTRE: In November? RAFAELA: Yes. ENTRE: With whom did you go? RAFAELA: I went with a Chal from there in Casas Grandes.

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Immigration, Acculturation, and Health ENTRE: And you had to pay? RAFAELA: Yes. ENTRE: How much? RAFAELA: Two hundred dollars. ENTRE: What did he tell you? RAFAELA: That in two months my son would get up, that he would start walking, and that I did not have to worry. It has already been half a year and I yell at my son, I talk to him, and nothing. ENTRE: Is he paralyzed? RAFAELA: Yes. I yell at him and he takes great pains to open his eyes, but nothing else. It is not like the man said [the curandero], no. ENTRE: And he did not give you any treatment? RAFAELA: Yes, he gave me a water to put on his head and on his wounds. Well, nothing. He did not get better. ENTRE: Why did you decide to go with this curandero? RAFAELA: A friend of mine—there in Albuquerque, where my son was—told me about that man. ENTRE: Was this the only time that you consulted with someone like this? RAFAELA: Yes, it was the only time. ENTRE: And the water did not help? RAFAELA: He is the same. ENTRE: Have you spoken with a religious guide about your health problems? RAFAELA: No. ENTRE: Does your religion have any beliefs that could affect your treatment? RAFAELA: This is what I don’t like about the Jehovah’s Witnesses. Because they do not allow blood transfusions. But in the Catholic Church, no. ENTRE: Do your children need blood transfusions? RAFAELA: Yes, both of them do.

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ENTRE: Then, do you think that this will be an obstacle for you [to change religions]? RAFAELA: Yes, but only for that, right. I am thinking about it for that reason. Because at times someone gets sick, and they do not believe in that. Although Rafaela was obviously frustrated with both the biomedical healthcare system (the doctors in Albuquerque told her to take her son off life-saving equipment because he was going to die anyway—and he continued to live) and the ineffectual curandero in Casas Grandes, it is not clear that she was turning away from Catholicism because of her bad experience with Catholic faith healing. She might just be seeking a supportive, tight-knit community to assuage her emotional or psychic pain. At any rate, she expressed quite plainly her concern about the Jehovah’s Witnesses prohibition against blood transfusions. In contrast, Josefina (age 44, 13 years) another convert to the Witnesses, indicated that she would unequivocally refuse a blood transfusion were she to need one: ENTRE: Does your religion have any beliefs that could affect your treatment, for example, not being able to use certain kinds of medication or not being able to accept blood transfusions? JOSEFINA: Of blood, yes, I wouldn’t accept it. ENTRE: And in extreme cases? JOSEFINA: No. ENTRE: And why? JOSEFINA: Because it’s also a biblical belief. Supposedly, blood is life. Why would you take someone else’s life so they can give it to you? There are various biblical texts where God says we shouldn’t transfer blood. Now science is so advanced that there are other substances that can replace the blood and still save you. For example, if you don’t speak with your doctor beforehand to say that you don’t accept blood.…Of course, it’s for my religion, but you see that some people can get hepatitis because the blood is contaminated, or even AIDS. Then it’s beneficial to you so that later you don’t get other illnesses. ENTRE: No circumstance is okay for transfusion?

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JOSEFINA: No, and not because my religion prohibits it, but because it’s a command from God, so we should obey all God says in his word. The last religious conversion that merits mention is Delfina’s (age 61, 10 years), who left Catholicism to embrace the teachings of Takhar Singh, a spiritual guide who teaches a technique of meditation called “Science of Love” internationally. One aspect of this spiritual path consists of existing in silence, attentive to the inner sounds of love and of the spirit, to relax and achieve inner peace. Delfina, a former nurse from Veracruz and previously very amenable to the biomedical paradigm, was frustrated with the physicians in Santa Fe, which, coupled with her conversion to this Eastern spiritual practice, impelled her to lose faith in Western biomedicine. After becoming a vegetarian, she began healing herself by using only natural substances and therapies. ENTRE: Has there been an instance when you or someone in your family stopped seeing the doctor, even though you knew it was necessary to see him? DELFINA: Well, recently, when I had a cough and cold, they asked me why I didn’t go. And I told them, all they were going to do is give me Tylenol and there is no reason to go to the doctor if they only give you Tylenol. ENTRE: Besides medical doctors or nurses, what other people do the members of your community turn to when they are sick? DELFINA: Yes, doctors of natural medicine. Yes, I do know. I have friends who only know how to cure themselves with natural medicine. ENTRE: Is there any medical treatment with which you have not been in agreement? DELFINA: Well, Tylenol. Delfina’s aversion to Tylenol as a form of medical therapy serves as a metaphor to illustrate how Mexican immigrants’ religious proclivities shape their health-related belief in ways that are—if not unexpected—unexplored in the literature on the acculturation of this population. It is noteworthy that folk treatment practices that immigrants have resisted changing solely via the provision of information by

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health care educators are being discarded if associated with religious conversion. Much has been written about the sociopolitical implications of rejecting Catholicism in indigenous settings. In fact, the majority of the literature deals with historical changes in the demography of Protestant groups in Latin America and the attendant changes taking place in working-class sectors of various Latin American economies. Little attention has been paid, however, to how health ideologies evolve as a result of religious conversion. Because there is such a pervasive hope that immigrants, or more generally, inhabitants of traditional societies, eventually relinquish the “old” and adopt the “new” simply by virtue of an epiphany, realizing that the “new” is better, the phenomenon reported here—that these Mexican immigrants turned away from curanderismo only when they simultaneously turned away from Catholicism, and not when they began to respect Western allopathic technology—merits further study.

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CHAPTER 10

Diagnosis And Treatment Efficacy

I want to offer the hypothesis that there is a causal relationship between presenting with a particular kind of disease in the U.S. healthcare system and the speed with which the immigrant adapts to the allopathic theories connected with that particular disease. This causal relationship holds, as well, for health prescriptions that come into play secondarily (see chapter 6). More specifically, for those who enter the U.S. healthcare system looking for relief from chronic health problems, the road to understanding and adopting beliefs and behaviors appropriate to allopathic care is relatively smooth and seamless. Conversely, those who seek relief from subacute (and even some acute) health problems find themselves on a rocky and precipitous path that often leads to distrust, financial peril, and cognitive intransigence. This hypothesis that a chronically ill person is more amenable to adopting new allopathic beliefs may seem counterintuitive because it is usually those with chronic health conditions who are “chronically” unsatisfied with the care they receive from allopathic physicians. This is the population that is hypothesized as leading the CAM revolution in this country, often changing health ideologies and patterns of resort in the quest to find relief from chronically debilitating health conditions. Although this pattern of resort is apparent for a few interviewees with chronic and usually undiagnosable conditions, it is not the primary discourse that emerged from the narrative data. The health conditions that are labeled, for present purposes, “chronic” and “subacute” may or may not be categorized as such in the medical literature. They are designated thus for the convenience of the reader. “Chronic” disease in the context of this research means both diagnosable and undiagnosable medical conditions, treatment of which necessitates continual contact with nurses, doctors, and health educators. Examples include ulcers, depression, menopause, backache, 161

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arthritis, and gastritis. Although each of these were mentioned by women in the study, the most commonly mentioned conditions were diabetes, hypertension, and pregnancy. Note that the terms chronic and diagnosable also imply “treatable,” but not necessarily “curable.” In this chapter, I show that those who were properly diagnosed but did not receive satisfactory treatment found themselves in the same (subjective) position as those who visited health care practitioners for chronic undiagnosable conditions. That is, both subsets of patients were dissatisfied with their care and therefore did not acculturate at the same accelerated rate as those with chronic diagnosable conditions. Examples of diseases that were classified as “subacute” are bronchitis, angina (a Mexican term for throat-related diseases), colds and flu, pneumonia, ear infection, stomach infection, rash, and postpartum bacterial infection. Table 18 displays the distribution of the various subcategories of illness among the sample population. Table 18. Type of illness by number of subjects Illness Chronic—other Subacute Diabetes/hypertension Pregnancy No experience with U.S. health care

Number of People 12 19 9 13 10

Percentage 19.0 30.2 14.3 20.6 15.9

DEVELOPMENT OF THE HYPOTHESIS To develop the hypothesis about the causes affecting rate of acculturation, I analyzed the transcripts in two ways: (1) I examined them, by interviewee, for differences in migrant experiences with the doctors and the respective healthcare systems (i.e., Mexican and North American). Interviewees were queried as to how they learned of their illnesses, the type of treatment they sought for each illness episode, the type of medication or treatment they were prescribed, and the manner in which they interpreted and carried out the prescribed medication, diet, or therapy. I also determined each migrant’s own assessment of the diagnosis, prescriptions, treatments, and therapies, as well as their efficacy. Usually, they provided reasons for their decision to comply, or not, with their doctor’s suggestions. (2) I analyzed the responses to one

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particular question in the survey relating to the experiences reported by each interviewee: how did she rate the health care system in the United States.1 This turned out to be such a hot-button issue for the migrants that, if they had not already done so, they told stories based on their personal experiences or others’ to justify their rating. As a result of this exercise, I had ample material to analyze and therefore shed light on individual relationships with the Santa Fe healthcare system and the resulting assessments of it. The outcome of the data analysis process showed a high degree of association between an immigrant’s rating of the U.S. healthcare system and her openness to new or different health beliefs. That is, those who rated the health care system as a 1—the best rating—had a higher subjective sense of satisfaction and were more willing to listen to their doctors or health educators. Those who rated the system a 3— the worst rating—demonstrated a high measure of negative affect and consequently were not as open. In most cases, when a woman rated her experience as a 3, she felt that she had been discriminated against or otherwise treated unfairly, misdiagnosed, or prescribed the wrong medicine. Interestingly, these ratings varied not only by type of illness—chronic or subacute—but also by amount of time lived in the United States. Those chronic illness sufferers who had lived in the host country longer and, presumably, had interacted more with health providers often gave a rating that was neutral, a 2. Moreover, the ratings of veteran immigrants who had suffered from occasional subacute diseases and had interacted with the clinics and the hospital in Santa Fe for years demonstrated another shift, to a rating of 1, indicating a highly positive assessment of their U.S. physicians and their biomedical care in general. After living in the United States for 10 or more years, they had come to approve of what they had initially rejected upon arrival. The best way to begin illustrating this web of relationships is by examining what the women had to say about their experiences with health care providers in Santa Fe. Those diagnosed with chronic conditions are discussed first, followed by those who suffered from subacute diseases. It should be noted that a total of 437 illness episodes were analyzed. For the purposes of the present discussion, however, the data were “reduced” to illness episodes that were the most critical, produced the most verbiage, or most influenced ratings of the U.S. healthcare system (e.g., “I rate the health care system a 3 because when

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I got here, they treated me very badly.”). Usually, the women who had had no contact with doctors or nurses in Santa Fe rated their experience with health professionals in Mexico. Alternatively, several new arrivals shared their preconceived ideas about the Santa Fe healthcare system, having heard about others’ (friends and relatives) experiences with U.S. health care. Because these preconceptions did not constitute actual illness episodes or reflect actual experience with U.S. healthcare providers, they were not considered part of the data subset.

CHRONIC ILLNESS: DIABETES As one can determine from Table 18, 9 women were diagnosed with diabetes, hypertension, or both, either in Mexico or in the United States. Their discussion of their experiences with the health educators and physicians at the local clinic where the majority of immigrants end up for diabetes treatment illustrates how an extended, positive experience with American healthcare workers can accelerate the process of acculturation to U.S. allopathic health ideology. Maria C. (age 55), for example, who maintained a home on a ranchito in Mexico and visited her children in Santa Fe every year, was diagnosed in Mexico with diabetes three years before the time of her interview. She commented on the treatment she had received for her diabetes in Santa Fe: ENTRE: How do you know that you don’t feel well, that you are sick? MARIA: When my pressure or sugar goes up, I feel desperate and sometimes my head hurts. And, thank God, now that I am here, that they are taking good care of me, I am happy with the attention that they are giving me. Because when I got here, I was really sick and they hospitalized me for two days. And when I left, they gave me medicine and I have been well. They hospitalized me because my sugar rose to 400, but now it’s under control. I have had this illness for three years. ENTRE: How do you compare the treatment they are giving you here in the clinic to the treatment in Mexico? MARIA: Much better. I have felt safer with this treatment, with the medicine. I take pills. They wanted to inject me, but I went Wednesday to the doctor and now I don’t need it. Because insulin injections are really hard.

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ENTRE: How do you react when you have pain? MARIA: Now that I am here, I take something and control it. I have little pills and I take them. My head hurts, I get desperate, but I control it. I don’t use home remedies. (Emphasis added) Three or four times, Maria C. distinguished between the management of her diabetes in Mexico and the treatment from the clinic physicians. She obviously preferred the latter. Given her cyclical migration, she could easily have sought treatment (and might have done so at one time) in Mexico. Emphasizing her diligence about controlling her condition, she stressed that she did not take home remedies to treat her disease (or pain). This assertion perhaps indicates how important it was for her to demonstrate to her interviewer that she had learned a lot about treating her disease (herself) since going to the clinic. It also might be a tacit admission to using home remedies when she was in Mexico, possibly in an attempt to avoid self-administering the dreaded insulin. The main point is that Maria emphasized her eagerness to comply with her physicians’ directives regarding sugar monitoring and insulin self-administration. Additionally, in response to a question about whether she generally followed the treatment regimen prescribed by the doctor, Maria claimed, “Yes, I agree with everything that they tell me. If I don’t feel well, I would tell him so that they could change my treatment.” This seemingly innocuous statement is significant because one of the distinguishing marks of a migrant who has lived in the United States for 5 years or more is an acquired assertiveness in handling illness. That is, those who had spent fewer than 5 years in Santa Fe were, in general, more desirous of their physicians’ asking many questions to help them describe their phenomenological experience (i.e., their somatic symptoms), whereas those who had lived in the country more than 5 years claimed that they preferred doctors who were good listeners.2 Presumably, those in the latter group had developed a vocabulary for expressing how their symptoms related to what they thought was the proper diagnosis for their condition. This process of becoming assertive and participating more in the health care encounter (e.g., asking questions rather than waiting to be asked) is accelerated in the group categorized as having a chronic condition.3 Delia (age 65, 2 years in Santa Fe) is another respondent who, despite limited time in Santa Fe, had accepted very different ideas

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about how to treat her illness since seeking care at the clinic. Recall, she was quoted previously as saying that she liked to stay positive and refused to give her illness a special name so as not to “get all caught up in it.” Here she discussed how she had felt and acted since she was diagnosed: ENTRE: Your problem was different in your country? DELIA: They diagnosed me here. Maybe that’s why I’m sicker—there was no control [there]. I didn’t know what I had. I hadn’t realized, no. Here I get along well. I’m not happy I have diabetes, but I am learning a lot of things. I feel cleaner about everything. Shortly after this, Delia’s interviewer asked whether she was “managing” her sickness. Delia responded, “I know that if I do something bad, I will get sick…but otherwise, I have always thought that if you pay attention to it, it’s worse.” Overcoming a lifelong tendency to minimize or deny physical symptoms so that the illness would not “control” her, Delia had, since arrival in the United States, learned to identify the symptoms of diabetes and hypertension. She felt that she was the one in (limited) control. She had assumed agency, a propos her own health care behaviors, and her beliefs about how to best care for herself had shifted. In response to a question about the care she had received since her diagnosis and whether she had taken any home remedies, she commented, “The only thing I have taken is teas. And I have taken the same medicine since they diagnosed me. But, yes, the diet is the base of this illness. Walking. I walk a lot.” ENTRE: And whom do you ask for advice about your illness? DELIA: I ask the doctor. One reads, and that helps a lot. (Emphasis added) Not only had Delia started exercising since her diagnosis, but she had also changed her diet. Even more interesting, especially for a woman with only an elementary school education, Delia wanted to read and hear more about her disease. This tendency is illustrated by her response to the following question about her prognosis: ENTRE: How severe is it? Will it affect you in the long or short term? DELIA: I don’t know. Here, the doctor told me that I have diabetes [type] 2. I was just hearing yesterday that 2 is more

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severe than 1. It’s shorter, that one lasts less and everything. And they hadn’t told me that. I heard it yesterday on TV. I have very little knowledge of illnesses. Delia is quoted at length from various sections of her interview because she had obviously gone to great effort to learn more about her illness and treatment. In some ways, she is a model diabetes patient: attentive, assertive, curious, and hardworking. What underscores her shift in health beliefs is the fact that her daughter was a working curandera. Delia did not reveal any attempt to cure herself with her daughter’s aid (nor did her interviewer probe on this topic). Delia did, in another section of the interview, indicate that she believed in curanderismo. She had sought the advice of one on occasion (this is when she revealed that her daughter was a healer), but we do not know what prompted her. Nevertheless, Delia’s background of belief in curanderismo had not hindered in any way her adherence to her doctor’s prescribed diet, exercise, and pharmacological regimens. Paola (age 53, 1 month) went to the clinic for a problem with seasonal allergies, at which time they also discovered that she had been diagnosed with diabetes in Mexico but remained untreated. The text of her transcript reveals how different she felt about the health care providers who diagnosed and treated her in the two countries: ENTRE: This year or in the last six months, how many times have you had to consult a doctor? PAOLA: The only place they’ve been seeing me is here [at the clinic]. I’ve had three visits. ENTRE: And why did you come? For a checkup, for your allergy, or why? PAOLA: In April I came because the allergy was acting up, and afterwards I came because they made appointments about the diabetes. ENTRE: They found the diabetes here? PAOLA: No, in Mexico they had already diagnosed it, but they hadn’t been treating it. Then, when I came here, I felt bad and now they are taking care of it. ENTRE: And did they teach you how to monitor your sugar? PAOLA: I have a machine. They gave me a machine.

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ENTRE: And there they didn’t treat it. They didn’t take it seriously? PAOLA: The doctors never told me anything, that it was serious. And here they have talked with me a lot, in this clinic too. ENTRE: So there they diagnosed you with diabetes but didn’t put you on a special diet? PAOLA: Right. ENTRE: Or medicine? PAOLA: Nothing. Contrary to stereotype, given the chance to be involved in her health care, Paola was quite willing to learn how to use her monitor, change her diet and exercise habits, and listen to what the U.S. physicians and health educators told her about her condition. She was very pleased with the type and quality of care she was receiving from the clinicians in Santa Fe and planned to continue her treatment with them. Rafaela (age 65, 1 year) is another recent arrival who demonstrated significant shifts in health beliefs, due to being treated at the local clinic for diabetes, hypertension, and, significantly, depression. Although she had felt sick in Mexico, she had only treated herself—on the advice of neighbors—with herbal tea. ENTRE: Do you try to cure yourself at times or use home remedies? RAFAELA: Yes, I used it at one time, but it did not balance my sugar. Only with medicine. ENTRE: What type of home remedy did you use? RAFAELA: I used the tea of Seven Flowers (Siete Flores). They said it was very good. ENTRE: Who told you? RAFAELA: Well, there my neighbors did. Yes, I did feel good the first days, but later I didn’t. ENTRE: Then, after that, you decided to go see a doctor? RAFAELA: It’s that I became very sick [when I came here].…I went to the hospital. When I got to the hospital, my sugar was at 600. There they began to inject me and they

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began to control it. Now I don’t use the injection, just pills. I had very high blood pressure too. All the medications I am taking are for diabetes, blood pressure, and for depression. Rafaela’s emergency encounter with the hospital clinicians and subsequently the clinic health educators propelled her along an acculturation trajectory characterized by dramatic shifts in her health schemas. Not only did she abandon using herbs to treat her diabetes, but she also cared for her high blood pressure (which had not been diagnosed in Mexico). Most important was her recognition that she was depressed. Coming from a rural background and with little education, an older immigrant such as Rafaela might be characterized as resistant to treatment for an emotional disorder. Contrary to stereotype, Rafaela discussed it quite openly and with a complete stranger. Although the stories told by Paola, Rafaela, and Delia show that radical changes in health ideology and behavior are possible—even for the elderly, the less educated, and, most important, the recently arrived—it must be underscored that major shifts in health ideology do not occur within neat boundaries. Clusters of beliefs that are sometimes inconsistent or even incompatible are more common. This point is illustrated by Delia. Despite experiencing a shift in her beliefs regarding how to respond behaviorally to illness (that is, she responded quickly by changing her diet or phoning her physician instead of ignoring her symptoms), she retained a more traditional belief in the etiology of her diabetes. Asked the question, Why do you think your problem started? she explained: “From grief, sorrow. Anger. [Por penas. Corajes]. The doctor told me that I have had the illness for around three years. And if I think back to what was happening back then—they put my son in jail, and many things like that—I think that is when I started to get diabetes.” Diabetes researchers are starting to discuss the relationship between high stress levels and the activation of dormant genetic conditions such as diabetes, but the specific notion that sorrow or anger could precipitate diabetes is a particularly Mexicanculture causal ontology.4 Rafaela and other interviewees who had hypertension, diabetes, or both and were treating these conditions with insulin, diet, and exercise also subscribed to the belief that anger or a fright (susto) precipitated these illnesses. Rafaela discussed her belief that her hypertension (and her depression) started when her son almost died from the car accident and she had to attend to him daily in the hospital. Here are her

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responses to questions intended to elicit details about how she understood her illnesses: ENTRE: What do you call your actual problem? RAFAELA: The diabetes and high blood pressure and depression. They are three different things. ENTRE: Why do you think your problems began? RAFAELA: They began now with these accidents—I got worse, I was so frightened. Because I spent time with my son in the hospital and I got very sick. I was with him there alone, and later the way he complained, the way they injected him, everything. I got sick from high blood pressure and depression. I cried for any little thing. The doctor at the clinic told me I was very depressed—that it was depression. She told me she would help me with my children so that I wouldn’t worry. ENTRE: And with the diabetes, when did you have the coma? RAFAELA: It was about five years ago. ENTRE: Before that, did you know you had diabetes? RAFAELA: No. ENTRE: But you said all the people in your family have it? RAFAELA: They have all died of diabetes. My mother and my father too. ENTRE: Why do you think your problem with diabetes began? RAFAELA: It was inherited. It is not known where or when Rafaela picked up the attribution of heredity for her diabetes.5 Nonetheless, she mixed several types of attributions for her three illnesses, a tendency she shared with other diabetes and hypertension sufferers. As mentioned above, her accelerated pace along the health ideology trajectory was also exemplified by her using the term depression. A last example of a particularly Mexican-culture illness attribution is Estela (age 50, 3 years), whose diabetes, she claimed, was still not under control. She ascribed her disease to an unexpected pregnancy when she was 43 years old: “I found out about it there. My son was

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born when I was almost 43. Two years later I became diabetic. He is 10 now. I didn’t know why. That is, I don’t know.” ENTRE: You don’t know why you became diabetic? ESTELA: Well, they say from being pregnant at that age. ENTRE: Did you go to a doctor to be looked at over there? ESTELA: Yes, they ran tests. These women had radically altered the way they behaved. But illness attributions are particularly “sticky”—they do not shift as readily as beliefs and behaviors regarding diet, exercise, and pharmacological regimens. This finding underscores Kleinman’s conception of explanatory models. He wrote that explanatory models are plastic enough to cover a wide range of experiences and imprecise enough not to be refuted by specific happenings. It is also characteristic of explanatory models to evolve somewhat frequently. In this subsample of 9 diabetics and hypertensives, 5 had lived in the United States for fewer than 5 years, and 4 had more than 5 years under their belts. Of the 5 who were recently arrived, every single one talked at length about her medications, glucose monitor, diet, and exercise regimes. All spoke of the need for low-fat/low-sugar diets, discussed how often they exercised, and even commented on how much they appreciated the attention they had received from the clinic’s nursing and health education staff. The mean number of years they had lived in Santa Fe was only 1.6 (median 1 year). Recall that the mean of those in the entire sample who spoke with an equal amount of precision and verbiage regarding the diet/exercise topic was 4.7 years (median 4 years), illustrating how much acculturation was accelerated in this group (see Table 19). Table 19. Diabetic/hypertensive diet narrative by years lived in the U.S. Diet/Exercise Narrative Diabetic/hypertensive (<5 years subsample) Entire sample

Mean Years

Median Years

1.6

1.0

4.7

4.0

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CHRONIC ILLNESS: PREGNANCY The acceleration of change in health beliefs is also evident in the subcategory of women who were pregnant. Although not as pronounced, it is nonetheless discernible. One example is Malorena (age 28, 4.5 years in Santa Fe), who discussed how much more attention she received when she was pregnant in Santa Fe than in Mexico, a factor in her greater appreciation of the U.S. healthcare system. In turn, her positive regard for her caregivers in Santa Fe favorably affected her ability to believe in and observe the health dictums offered by the promotoras and physicians at the local clinic. (Recall that the promotoras are responsible for getting the pregnant Spanish-speaking immigrants to their prenatal appointments, teaching them to breastfeed, and communicating the importance of post-natal care, especially immunization schedules.) When queried about the difference between the care she received in Mexico and in Santa Fe (where she was also enrolled in a prenatal education program), she answered, “Well, it’s better here. They pay a lot of attention to you. They are constantly checking up to see how you are doing, your diet, exercise, the temperature, a hemorrhage, something like that. Just like, if you feel bad, you are to return immediately to the emergency room, and there is someone there to help you.” Similarly, Elizabeth (age 25, 5 years), when asked how her pregnancy differed from her mother’s, said that because she lived in a large town (Santa Fe), she was able to take advantage of the available health care: “I think it was really different, because I lived with my mom in a village and she didn’t get the same attention that I have gotten here. I had a lot more, during the whole pregnancy, all kinds of attention, but not her.” Maria M. (age unknown, 4 years) concurred with Elizabeth about the quantity and quality of care she received when pregnant. She was obviously pleased with her caregivers: ENTRE: This year, in the last six months, how many times did you have to consult with a doctor, a nurse, or some other kind of medical professional? MARÍA: Just when I was pregnant. I went every month. You have to go for the baby checkup. I went to the clinic. There they attended to me. And in the last three months, for example, in October and November, I went urgently because I

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felt a little bad because of the child. They were childbirth pains, but they were able to control them quickly. ENTRE: And besides this, there were no more complications? MARÍA: No, it was born well. There were no more complications. Nothing else. They anaesthetized me in the clinic. They put me on a serum, and that regulated me. I think that it was nothing more than sudden pains you get when you are close to birth. They were contractions, but soon they relaxed and didn’t continue. ENTRE: And to make an appointment, do you have to wait months? MARÍA: No, we ask for the appointment, and if it’s for a pregnancy, they will give you an appointment much sooner. But when it’s for a general checkup, then, yes, they give it to you after a month. ENTRE: Are there differences between Mexico and Santa Fe? MARÍA: You will have one or two differences. Here they are more attentive to you. Here they will even call you to remind you of your appointment—the nurses. If it’s because you want to see the doctor urgently, then the doctor lends…or at times even the doctor will call you on the phone if you have any doubts. This would be the difference, as in Mexico it wouldn’t be like that. Your doctor can’t attend to you this way. (Emphasis added) The caring support of the local healthcare providers would, undoubtedly, establish a foundation of trust upon which Maria (and they) could build. In turn, giving Maria this foundation facilitated her accommodating new or different health beliefs. She herself contrasted her experiences with clinicians in Mexico and in Santa Fe. Her narrative of comparison continued with a story of how women in Mexico without cash to pay are shut out of the local clinic by the nurses, forcing them to deliver in the clinic doorway, in the street, or back in their homes.6 As discussed previously, behavioral changes in diet and exercise are hypothesized as being related to the greater quantity and higher quality of care the women received in Santa Fe when pregnant. Maria S. (age 29, 3 years in Santa Fe) is one example. When asked by her

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interviewer whether she had changed her eating habits since becoming pregnant in the United States, she responded, “No, well, yes, in the general sense. Just the fast food here, hamburgers and all that.” ENTRE: Tell me some things you didn’t eat before that you eat here now. MARIA: What I eat every day is vegetables and fruit, and I eat more because of the pregnancy. Similarly, Patricia (age 27, 1 year) shared how her diet had changed since her arrival in Santa Fe and her pregnancy. When asked to describe foods she ate in the United States that she did not eat in Mexico, she answered, “Milk. Yes, I used to have milk, but here a lot of milk. Fruit, a lot of fruit, also juices.” Teresa (age 38, 1 year) changed her diet in the same way after discovering that she was pregnant. Asked whether she had changed her eating habits, she responded, “No, because even though some foods don’t taste the same, I try to make things the way I made them in Juarez. Right now I’m adding more yogurt to my diet, which I didn’t eat before. And for me, it’s hard to drink milk, and now I drink it, milk, because I need it for the pregnancy.” It is possible that Teresa, because of her proximity to the border, had picked up this idea of needing to increase her calcium intake in Juarez. Also, one could argue that these three were tailoring their answers to satisfy the expectations of their interviewers. This is a potentially powerful causal factor that must be considered and may indeed have influenced outcomes. Approximately 18 other respondents, however, did not provide as much specificity as these pregnant women did when queried about their eating habits and what they did, in general, to stay healthy. It appears, then, that these 18 were not as concerned with social approval. Moreover, one might expect answers such as Jacqueline’s (age 16, 2 weeks) to questions about diet if these women had not been receiving prenatal care in the United States or home visits from promotoras. Recall, Jacqueline (whose baby boy was just a few months old when they arrived in the United States) suggested that to stay healthy, one had to eat many calories on a strict timetable. Finally, even if the pregnant women’s behavior was not influenced by the pregnancy diet discourse—it is impossible to prove that their behaviors changed—their beliefs, like those of the diabetic women, most likely had been affected. Behavioral changes are harder to

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document—requiring home visits and such. Also, numerous barriers to behavioral change in diet have been documented (Martinez and Himmelgreen 2002; Haffner 1992; Mikhail 1994). In a different vein, Olaya (age 23, 18 months), pregnant with her third child but her first to be delivered in the United States, had decided not to take prenatal classes, although she was seeking monthly prenatal care. North American cultural norms had influenced her behavior in an interesting and unexpected way: she anticipated, for the first time, to have her husband present at the birth. Olaya’s interviewer asked her, “Do you want the father of your baby to be present when it is born?” Obviously open to trying new ways of being or experiencing, she responded, “Well, yes, that’s how it is here. Let’s see if he doesn’t faint [laughing].”

SUBACUTE ILLNESSES AND RATE OF ACCULTURATION Unlike the diabetics, hypertensives, and pregnant women, who interacted more often with health care workers in Santa Fe, the women who presented in these same clinics with subacute sicknesses such as colds, flu, angina, and bronchitis did not, in general, exhibit an enthusiasm for learning new ways to care for themselves or their children. In contrast, they were cognitively intransigent, preferring the advice of doctors, relatives, and friends from Mexico. Reasons for this deceleration or stasis of the rate of adoption of U.S. health ideology included a pervasive sense of being discriminated against, a conviction that the doctors practicing in the United States are incompetent or are merely indifferent about their work, or a belief that the medicine in Mexico is superior to that prescribed in the United States. The discussion of those who suffer from subacute illnesses begins in the same manner as that of chronically ill immigrants. I will present excerpts from transcripts that demonstrate how unhappy the migrants were with the health care they had received (in contradistinction to how content the diabetics and pregnant immigrants were)—especially the recent migrants, who had yet to become accustomed to medical care in the United States. These excerpts reveal the relationship between the interviewee’s perception that she is receiving inferior care and her disregard for her health care practitioners’ advice. What will be provided, then, are causal ontologies that illustrate reasons for lack of “compliance” or acculturative change in the population interviewed.

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The first example is Lucero (age 20, 2.5 years in Santa Fe). When asked which members of her family had been sick in the preceding six months, she replied, “My son got sick, and I took him to the doctor. They gave him medicine, but it didn’t do anything for him. So I was giving him home remedies. I took my little son, too, because he had a cough, and the doctor told me that this cough was normal. Imagine that.” Incredulous that a doctor would tell a sick child’s mother that being sick is “normal,” Lucero was not sure what to make of her experience. Believing now that they will not treat her children, that they will not “do anything” when her children are sick, she is uncertain whether she will seek care in the clinic again. In a similar vein, Jacqueline (age 16, 3 months) in her second interview shared a terrifying story of her experience with the staff at the local hospital, where she brought her son when he was feverish. Quite outspoken for a 16 year old, she commented on the differences between the doctors she visited in Mexico and those she had encountered in Santa Fe: ENTRE: Tell me five of the main differences between the care the doctors gave you in Mexico in comparison with the ones in Santa Fe. JACQUELINE: I don’t like the ones in Santa Fe. They are, to put it bluntly, rude. They don’t do anything for you, for us Mexicans…you never have anything…because you get there and it’s English, always English. There are many who don’t speak Spanish. And now I’ve been to two or three, and when I took my son, they didn’t do anything for him, and the bill was really expensive. ENTRE: What happened to your son? JACQUELINE: He was dehydrated. They tried to give him saline solution, but they couldn’t. They really jabbed him, and my son twisted all around and cried. And in the end I wouldn’t let them do this to him. ENTRE: How long did they try to give him the serum? JACQUELINE: For about three hours. They stabbed his arms, wrists, little feet. They looked everywhere but couldn’t find a vein. In Mexico, when you go and are really sick like that, they take care of you. And I’ve seen it. The doctor finds the vein really fast. Here, no one could. Everyone tried, but no one could do it. There they take care of you fast, and besides, it

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costs less and the doctors are better. I don’t think the doctors here are good. Upset that the hospital staff caused her son to suffer unnecessarily, she was angry, too, at their inability to explain to her the results of tests they ran on her son—or, better still, diagnose the nature of his sickness. She explained how she felt when she had to take her son to a doctor in Santa Fe: Well, for one thing, I’m nervous because I don’t speak English and you almost never run into anyone who speaks anything but English. And another thing is that they tell me, “Take this,” and they give me a prescription and tell me to go have it filled, but they don’t go over anything.…I took him to a clinic, but they didn’t tell me what he had. They just said something about an infection, but they didn’t tell me where the infection was. And I even went to the hospital. They told me that the infection was in his ear, not his stomach, and that was why it wasn’t getting better. And now I have to take him again so they can make his ear better. I have to go back because of that ear. Jacqueline might not have understood the health care workers’ Spanish or their instructions in English. Regardless, communication broke down, and her son’s suffering (and hers) was not ameliorated as it should have been. After only 3 months in the United States and 3 medical encounters, she felt angry, distrustful, and fearful of getting sick in this country. Mireya (age 24, 1 year) told a tale similar to Jacqueline’s. She was upset by what she felt was the inferiority of the medical practitioners at the hospital. The following is her response to a question regarding the number of consultations she had had with a doctor, nurse, or other medical professional in the preceding six months: MIREYA: My son got very sick in his throat. We took him to the hospital—at times, the boy could not breathe. They gave him medicine, but it did not do anything for him. We no longer gave it to him. Instead, we made him better with home remedies. ENTRE: Do you feel satisfied with the medical attention you are receiving?

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MIREYA: I have never been to the doctor here, but my son, yes. And the truth is that it is not good, because the medical attention is bad. How could it be that we took him to the doctor for his throat and the doctor said it was normal? Like Lucero, who could not believe that a medically trained physician could call disease “normal,” Mireya expected treatment for her son’s throat illness (angina) that the attending physician did not prescribe. In the United States, and Santa Fe in particular, allopaths claim they are increasing community awareness of the difference between viral infection and bacterial infection, letting the former run its “normal” course and treating the latter with medication. In Mexico, few such health education campaigns have been introduced.7 The Mexican immigrants interviewed for this study were convinced that throat pain is symptomatic of a serious infection— which they call “angina” and treat with antibiotics. Contrary to common practice in the United States, they also treat bronchitis and symptoms of childhood asthma with antibiotics (JAMA 1998). Being told that a cough is “normal” shocked Mireya, who was accustomed to treating such a symptom aggressively. She concluded from this episode that the doctors in Santa Fe are incompetent or, at the least, indifferent. Therefore, she stated, when queried as to what qualities are important in a physician, “The doctor should pay more attention to his patients. They should check you very well, not just on the surface.” The result of her conclusion that the doctors evaluate their patients superficially is revealed in the following: ENTRE: Do you already have a doctor? MIREYA: No. ENTRE: Has there been an occasion when you or someone in your family stopped seeing a doctor, knowing that you needed to go? Why? MIREYA: Yes, I needed to go see one, and I have not gone. Although Mireya did not answer the “why” part of the interviewer’s question, it is not hard to detect that she, like Jacqueline, had developed a distrust of the doctors who did not appear to do their jobs well. The significance of Mireya’s discussion cannot be underestimated. There is a well-established relationship between having a regular source of care and achieving better health outcomes (Karliner et al. 1998; Chavez et al. 1992; Chavez 2003) .

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Evidence that recent migrants are dissatisfied with Santa Fe physicians and nurse practitioners’ ability to diagnose and treat subacute illnesses effectively is preponderant. Maria R., for example, who was 41 at the time of her interview and had lived for 2 years in Santa Fe, eloquently expressed her terror about not being able to get her son an appointment at a local clinic to treat his symptoms of angina (she had had to wait a month). She was also concerned because when he was seen by a doctor, he was not diagnosed with any specific disease: ENTRE: Are you worried about your health or safety? MARIA: Yes…for my health. Also because if you get sick, they don’t take care of you. The other day a child of mine got sick, and I went to several clinics and no one could see us. And the poor thing got better on his own. He had a fever and his throat was inflamed. It wasn’t too severe, but he felt bad and no one could wait on us. ENTRE: In comparison to the doctors here, what is the biggest difference that you find? MARIA: I don’t know if there is a difference or if there’s just a conspiracy that you might have here in the United States against the Hispanics. Because, is it possible for you to go to see a doctor here and he takes X-rays of you and does four blood tests to treat and diagnose a sickness or to discover what the patient has, and at the end of it all, all the tests show nothing? And they tell you that you have nothing, and the patient is boiling with fever or vomiting, and they tell you that you’re okay? That isn’t right. They could only tell that to an idiot, and I don’t think they’ll find one by me…the patient is sick, they have a high temperature, and is vomiting. Why say that they are okay? And I have seen two cases like this. My friend the Jehovah’s Witness’s daughter just got over being sick. She had bad diarrhea, was vomiting, and had a temperature, and she took her to the hospital and they did analyses. They did everything, and they told her that the girl was fine. She had to go to Juarez City, and there the girl [was diagnosed with] dysentery, many infections, a swollen throat, and as a result the bad fever that she had. And there was the

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only place she could discover what the child had. She had to run to Mexico to be able to be diagnosed properly! ENTRE: Therefore, the differences between one doctor and the other are—? MARIA: The races, discrimination. ENTRE: Do you think that they treat the gringos, or North Americans, well? MARIA: I think so. I am not sure. But how can it be possible that with us they find nothing, that we are fine even though we are sick? They are seeing that we are dying, and they say that we are fine? Refusing to believe that the doctors were as incompetent as they seemed, Maria resorted to an explanation of discrimination to explain why her son was not diagnosed properly. Finkler (2001) discussed the tendency of the Mexican physicians in her study to diagnose, on average, between 2.1 and 4.3 diseases per patient. She found that most physicians, after conducting exhaustive personal medical histories and performing extensive physical examinations, will, at the very least, prescribe an antiparasitic treatment because most are under the impression that an inadequate diet and lack of sanitation are responsible for the majority of symptoms in their patients. In her study, infectious or parasitic disorders were diagnosed for between 25 and 54 percent of all patients seen by the eight physicians she worked with in Mexico D.F. She also reported that physicians prescribed between 1.7 and 5.5 medications per patient. Stebbins (1987) reported that 47 percent of patients in rural areas are given an injection as part of their treatment. As Maria R. testified, and as we have witnessed in testimonials by other immigrants, the unwillingness on the part of U.S. health providers to provide a concrete diagnosis seriously undermines Mexican immigrants’ confidence in their healing abilities. Aurora (age 49), even after living in the United States for 10 years, still recalled what she liked most about Mexican doctors. When asked what the medical providers in Mexico did to make her feel good, she replied, “Well, that they gave me a complete checkup and listened to everything that I had to say about how I felt. Because here, many times they will only come and look at your face and listen to your heart with the stethoscope and later give you the prescription. I do not like that. But when they checked me from head to toe to make sure I was okay and later gave

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me my diagnosis, this was better. They would say, ‘If you don’t get better with this medicine, return at this date for a follow-up.’” Marisol (age 27, 3 years in Santa Fe) shared the widely held belief among recently arrived immigrants that U.S. doctors do not perform their duties with precision and care. This conviction, moreover, appears to be implicated in recent immigrants’ refusal to seek help. It provides a causal link between the belief that the doctors are inferior and avoidance behavior toward U.S. health clinics. Marisol was requested to describe the doctors she visited in Mexico: MARISOL: Now I think that they were good doctors, maybe the best, in comparison to the doctors that I have seen here. The truth is that many times I have needed to go to the doctor here, and I haven’t liked it. I feel that here they are very superficial and they don’t give you good treatment. Sometimes you feel very bad, and they think that you are fine. And they give you a certain medicine, and at times you get to your house and you get worse. You return, and it’s like they are guessing what sickness you have. And in Mexico I had the luck of whenever I went, they always cured me. They cured me. There are good doctors, very good doctors I would say. And not just in my case, my brothers and sisters as well in the times that they got sick. They had very good doctors. They always attack the sickness quickly and precisely and effectively every time. There are good clinics [there], a difference from here. I don’t completely trust them. ENTRE: What was it that you most appreciated about that doctor in Mexico? MARISOL: My doctor, the way in which she inspected me, the way in which she checked me and asked lots of questions. The last time that I got sick in Mexico was in ‘91. I got sick in both of my lungs, and I had to take out my tonsils. But she checked everything. She opened my ears, my nose, my mouth, my lungs, my pulse, and everything. I appreciated that very much, but it was very expensive. But it was worth it to pay her. I remember that last year I got sick and I couldn’t even leave the bed. And I went to the doctor [in Santa Fe], and the doctor told me that, no, it was nothing serious. “Take this”…that’s it. It’s like they don’t give you importance. But I

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feel like they give a lot of importance to pregnant women. I feel like that there is a lot of protection and good attention made to pregnant women. (Emphasis added) Marisol mentioned at least three reasons why she did not like to seek care from medical practitioners in Santa Fe: (1) They inspect the body superficially, as opposed to the private doctor in Mexico, who “checked everything” and “asked lots of questions.” (2) They do not take illness seriously, that is, they do not give it the “importance” it merits. (3) The medicine they prescribe does not always work well because they have not properly diagnosed (of course, related to the first point). A tangential belief is that, in some cases, medicines prescribed in the United States are inferior to Mexican medicines. Among the recently arrived, giving a proper inspection (i.e., making the right diagnosis), taking the patient seriously (i.e., “attending” to her well, asking questions, being personable), and giving “good medicine” are the three most important characteristics of first-rate doctors. The mean number of years lived in the United States (or Santa Fe) for those who wanted a doctor who “attended them well” was 4 (median 3 years). For those who thought that a doctor should be a good diagnostician first and foremost, the mean number of years in Santa Fe was 3.9 (median 3 years). Finally, for those who specified that a doctor should give “the right medicine” (las medicinas adecuadas), the mean number of years in the United States was 3.9 (median 1.8 years).8 See Table 20. Table 20. Preferred physician characteristics by years lived in the U.S. Preferred Physician Characteristics Dispenses the “right” medicine Attends well Diagnoses accurately Explains well Is interested/concerned Speaks Spanish Listens attentively Female

Mean Years Median Years 3.9 1.8 4.0 3.0 3.9 3.0 4.6 4.5 8.0 4.8 5.3 5.0 5.5 6.0 5.6 6.3

The characteristics that distinguish good doctors from average ones are obviously of great importance to the immigrants in the context of their becoming open to new ideas about caring for themselves,

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changing their patterns of resort, and so on. This theme is, in fact, of such magnitude that, as we shall see in the next chapter, there is a direct relationship between their experiences with Santa Fe physicians and nurses, their assessments of the system, and their readiness to change the way they believe that they should be diagnosed and treated for their colds and flu, bronchitis, and the like. A fourth significant theme discussed by Marisol is her belief that those who present with the aches and pains of colds and flu are not treated the same as those who present with a new pregnancy. She underscores the main point of this section, namely, that those with chronic conditions such as pregnancy and diabetes—conditions with a diachronic element that are nonetheless diagnosable and treatable with medication or therapy—are treated differently, receiving more care and attention than those with subacute conditions such as viral infections. In turn, rate of change in health ideology is influenced by the quality and frequency of early encounters with the health care system in the United States. Although chronic illness sufferers more rapidly adopt health ideology learned in the United States, some plagued by subacute illnesses do eventually come to peace with the quality of the health care they receive here. The following excerpts from the transcripts of veteran immigrants shed light on how their ideas about the U.S. healthcare system have evolved since arriving in the United States. For example, Dolores (age 32, 6 years in Santa Fe) underscores the point that, over time, migrants come to accept and even embrace the care they receive for subacute illness: ENTRE: Which members of your family (or the people who live with you) have been sick in the last six months or in the last year? DOLORES: My kids and my husband too. My husband has varicose veins on his legs, and they hurt him a lot. Also the flu, he gets it really bad. I prayed and thanked God. I took him to the doctor. They took good care of him. Dolores made no mention of receiving a superficial examination, being denied the proper medication, waiting too long in the waiting room, or being discriminated against. Perhaps after 6 years in the country, she and her husband had health insurance; this fact alone would dramatically increase their satisfaction with the medical care

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they receive. In the absence of this information, however, one must infer that time had afforded these immigrants the opportunity to acclimate to the U.S. biomedical cultural milieu. Anahy (age 30, 10 years in Santa Fe) discussed how her opinion about the care she had received from doctors had evolved over the years: ENTRE: How do you feel about going to a doctor here in Santa Fe? ANAHY: Well, it depends. Because where I go now, they have taken good care of me. I quit going to the clinic many years ago. I never liked it because they never took care of me. We always went round and round, they had lost my file, they only gave my kids Tylenol, just take your money. And these women who work there…oh, they’re horrible. They treat the immigrants really badly. But now where I go is called…and there they have taken good care of me. They have a woman there who speaks Spanish [and] who is really nice and humane, and she has helped me a lot with the doctors, to send me to the type of doctor I need and things like that. First of all, I more or less feel okay now because the doctor I have speaks Spanish a little and he sends me to have tests done, analyses. The doctor I have now is a very good doctor. Before, I went to the clinic, but not now. After 10 years in Santa Fe, Anahy, whose husband was able to provide insurance for the whole family through his work, was quite pleased with the care she received. She had found a health practitioner who, on every other level, satisfied her health care needs, most specifically because he examined her thoroughly (i.e., he had many tests performed) and gave her pain medication other than Tylenol. She is also one of the veteran immigrants who used alternative healers in Santa Fe. Rocio (age 32), like Anahy, had lived in the United States for 10 years, and she echoed Anahy about finding a practitioner in Santa Fe whom she liked: ROCIO: Well, now I am pleased with him…the doctor at the clinic treats me well. Before, it was not to my satisfaction. Before, I did not like it very much. Once, I felt discriminated against in the hospital—in the clinic, not so much—by a female doctor over there. They yelled at me while I was giving

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birth. They tell you to go if you complain, but what about when they were…giving birth.…The woman (the nurse) was very despotic…but now they treat me well, very nice. It was eight years ago when they treated me poorly. It was only one person. Emphasizing the trajectory of change she had endured, Rocio’s story vividly illustrates—especially her use of the word despotic (era bien déspota)—how persistent and tenacious are first impressions of U.S. doctors and nurses. Significantly, the word despotic was used in the same context (early encounters with U.S. medical providers) by 4 other immigrants. These first experiences can have a lasting, negative impact on the immigrants’ subsequent patterns of resort. What requires mention, too, is that even those immigrants who had no contact with U.S. practitioners would often assess the quality of health care in Santa Fe as poor simply because they had heard stories from family and friends. Rumors can have a devastating effect on patterns of resort and can encourage the tendency to delay care until a sickness is acute. Of course, not all immigrants fit into these neat categories. For example, there are those who have chronic undiagnosable diseases, such as Diana (age unknown, 10 months in Santa Fe). She received care from caregivers at the local clinic for a miscarriage she had suffered 6 months before her interview. Upon arriving at the clinic, worried about heavy bleeding during her pregnancy, she was informed that her baby had died in the womb. After checking her blood to determine that she did not have a bacterial infection that could have caused the death of the fetus, her doctor sent her home and told her to wait for a spontaneous abortion, an event that did not occur for another three months. Worried that the dead baby had remained too long in her womb and caused permanent damage (she continued to feel pain in her uterus), Diana was not at all content with the health care she received: ENTRE: What type of treatment do you think you should receive from the doctors here? What did you want or hope for? DIANA: I wanted a treatment…with the emergency visit I had in the hospital. I imagine that she should have done a cleaning for me at that moment. They, after telling me that I had lost the baby, that it was a miscarriage, they should have done a cleaning for me and given me a treatment with antibiotics to prevent infection. They told me that my blood did not have an

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infection, because they gave me an analysis and all of that. But I am not sure because the amount of time that the baby was inside me dead. I am not comfortable because of that. Because, yes, everything could have come and gone and I could have remained clean, as could have a piece of placenta remained inside of me…I am insecure. What I want to know is if I am fine like the doctors here have told me, that I am normal, that my womb is normal. ENTRE: And do you think it is normal? DIANA: No, I don’t think so. I need to have a sonogram done so that the doctor knows for sure that I am fine. Not comfortable with asking for the extra attention (the sonogram) and certainly not in a position to pay for it, Diana suffered silently with her fear. Especially for those with chronic, undiagnosable, or untreatable illnesses but also for those who feel that they are generally less healthy than they could be (were they to receive the type of care they deem proper), there is a documented relationship between the subjective dimension of health assessment, morbidity rates, and perceived treatment efficacy (Gee 2002). Finkler (2001) also found in her sample of Mexican subjects a significant relationship between those who considered their general health status poor and the likelihood they would not perceive improvement even after adequate treatment. In sum, I have shown that rate of acculturation, or change in health ideology, for Mexican migrants is influenced by early encounters with the U.S. healthcare system. I also demonstrated that that the type of illness with which a migrant suffers influences the acculturation rate as well as the type and quality of her subsequent encounters with health care workers. What merits more attention is the set of psychological variables associated with preventing immigrants who perceive that they have been discriminated against or treated poorly from seeking health care altogether. Conversely, what characterizes the migrants who are able to overcome these early negative experiences and find sources of health care they trust and appreciate?

CHAPTER 11

Antibiotic Usage And Rate of Acculturation

The flashpoint for dissatisfaction with the U.S. healthcare system is related to the dispensing (or lack thereof) of antibiotic medication. A variation on this theme—namely, that Mexican immigrants are accustomed to self-prescribing antibiotics and resort to transporting them illegally over the U.S.-Mexican border—has been written about extensively in the literature (Corbett et al. 2005; McVea 1997; Stebbins 1987). What has been neglected in this literature, however, is an examination of the temporally ordered sequence of events that result from dissatisfaction with treatment regimens in the United States. This dissatisfaction leads, in turn, to the deceleration of the rate of acculturation in health ideology regarding viral infection. Conversely, those who are being treated for diabetes or hypertension (or, in some cases, pregnancy) demonstrate an accelerated learning of the health maxim that antibiotics are for bacterial—not viral—infections. They also demonstrate an increased awareness that taking the prescribed amount of medication is a necessity. I hope to show that beliefs about antimicrobial treatment are more comparable between the recently arrived diabetic and hypertensive immigrants (often older, less literate, and from rural backgrounds) and those who had resided more than 5 years in Santa Fe, than between the recently arrived diabetics and the episodically sick recent arrivals (i.e., the subacute illness sufferers who had spent, on average, fewer than 5 years in Santa Fe). More specifically, I show how those who present with chronic diagnosable illnesses and subsequently enter into the health education program at the local clinic consistently rate their care (and the system in general) higher than those who seek help from clinicians for subacute transitory illnesses. Those in the latter group, by contrast, consistently rate their 187

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care as poor. A high rating, in turn, is associated with an accelerated rate of acculturation, and a low rating, with a slower or even static acculturation rate. Furthermore, I argue that the purported tendency on the part of Mexican immigrants to exaggerate their physical symptoms is a strategic deployment of affect to counter what is perceived as the indifference, discriminatory behavior, and even incompetence of U.S. physicians working within the biomedical paradigm. What I provide in this chapter is a persuasive account of the “dynamic force of temporal processes, the structuring impact of earlier on later events” (Mishler 1996:89). In other words, I present a type of case- or narrative-based sequential analysis largely neglected in the research on acculturation.

ANTIBIOTICS ARE “RIGHT” AND “GOOD” MEDICINE Yes, I brought penicillin, Naproxen, and I brought other little things [from Mexico]. My sisters bring me antibiotics too, for pain, colds. They always bring me some for the stomach, for when the girl gets sick. Because there they say that the medicine [in Mexico] is better than here. —Dora (age 35, 18 months in Santa Fe) Perhaps the primary reason Mexican immigrants bring antibiotics and other types of medication from Mexico is their belief that these are necessary for fighting upper respiratory and abdominal infections. Anahy (age 30, 10 years in Santa Fe) told her interviewer that she continued to import drugs from Mexico: “Yes, sometimes they bring me medicines, like for the cold or flu, or for the throat, because here you can’t get Pentrexil, strong antibiotics. Here you have to go to the hospital to get a prescription.” Monica (age 40, 3 years) agreed: “Here I am well stocked, and when someone comes here from Mexico, I order penicillin, for when I get the flu, antibiotics.” Maria R. (age 41, 2 years) described her incredulity and anguish at an attending physician’s lack of understanding that the best way to treat her sick child is with strong antibiotics: ENTRE: How have you felt in clinics here in Santa Fe? MARÍA R.: I feel sad. Because the last time that I went, I carried my son. No one wanted to attend to him because I didn’t have his social security number. I asked God if he

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would make my son better, because they said nothing more than “He’s fine.” Nothing more than “juices and drinking lots of liquids…that will make him better.” And if his throat is closing, do you think that liquids are going to pass through and this will make him better? No, we are accustomed to having antibiotics to counteract the throat pains or the swelling of the throat, or I don’t know. And so just giving him juice, just juices to make him better? I don’t believe that. (Emphasis added) Besides confirming that Mexican immigrants feel that they are getting better care when they are prescribed aggressive antibiotic drugs, she also described the comfort that receiving a specific diagnosis gives a patient. Putting the disease—angina—into the Mexican context might shed some light on how Maria interpreted generalized throat pain, coughing, swollen glands, and all the other symptoms associated with diseases that originate in the throat. Although the term is used very loosely in the respondent population, it is used much more specifically in the Mexican medical community to refer to a streptococcus infection, a serious bacterial condition that can lead to rheumatic or kidney disease. Interestingly, a full 24 percent of the interviewees cited throat illness as a concern and, almost without exception, associated any throat condition with angina, hence their overwhelming astonishment that the U.S. medical community does not take all throat ailments seriously enough to treat them with antimicrobials. Veronica (age 17, 1 year in Santa Fe) explained the ease with which one treats throat illnesses in Mexico: “There in Mexico you can buy medications without a prescription, and here, no. In Mexico, if you have a throat illness, you can buy antibiotics and you don’t even have to go to the doctor.” Whether the mothers were worried about an infection evolving into a more dangerous condition (e.g., strep) is not known. In McVea’s (1997) research on the propensity of Mexican migrants to inject antibiotics, she cited minor infections such as fevers, colds, sore throats, toothaches, and headaches as the primary reasons those in her subject pool self-injected. Tangential to this firmly entrenched idea that strong antibiotics are necessary to rid the body of most infections, but particularly infections located in the throat, is the conviction that drugs made in the United States and dispensed by physicians are inferior in quality and do not

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perform the job for which they are intended. Claudia (age 30, 2 years) illustrated this point. When queried as to whether she imported medicine from Mexico, she said, “The medicine they give doesn’t work.” ENTRE: Did you ever try to buy Mexican medicines and bring them here for when you were sick? CLAUDIA: Yes, I tried once, penicillin, and other antibiotics, mostly. Because exactly one year ago I got sick and they gave me liquid medicine and I felt like it did absolutely nothing. I couldn’t send for them to bring the medicines, unfortunately. But one knows that penicillin is really good for things like colds and that it’s not bad for you. They couldn’t bring it, and I got better, but it took about a month in bed, like twenty days. Unaware of viral theory (that antibiotics are ineffective for most minor viruses and that the body heals on its own in two to three weeks), Claudia worried that she had not received good medicine to hasten her recovery. Similarly, Josefina (age 44, 13 years) told how because she could not get help in the United States, she bought a drug in Mexico, Diprospan, for her husband’s allergies, starting shortly after their arrival here. As it turns out, Diprospan, which Josefina’s husband was self-administering without doctor supervision, is a corticosteroid used to alleviate, among other diseases, rheumatoid arthritis, osteoarthritis, atopic dermatitis, eczema, lupus, and schleroderma. It is also indicated for some types of bronchial allergies. After “trying everything” they could find in the United States, a friend of hers from Mexico suggested this particular drug, and now they bring or import some every year to be taken during allergy season. Another reason the migrants continue to import all manner of medications from Mexico is that these are less expensive. Anahy explained: “And it’s very expensive [here]. It’s cheaper when they bring it here from over there. We buy them. When someone goes, sometimes they bring back medicines. People that go bring back medicine for people.” Examples of medications other than antibiotics that migrants transport from Mexico are gout medicine that is no longer sold in the United States, injectionable vitamin B, blood pressurelowering medication (Cartopril), insulin, and medicines for asthma, gastritis, and ulcers. Rafaela, sixty-five years old, from a rural ranchito, had lived in Santa Fe for only 1 year when she was diagnosed with high

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blood pressure. Keen to care for her condition by taking her medication regularly, she was nonetheless timid about taking her prescription to the local pharmacy. It also cost more to buy it here. Instead, she summoned the help of friends back home, who were sending it to her in Santa Fe.

VETERAN IMMIGRANTS AND ANTIBIOTIC USAGE The following illustrates that spending more time in the cultural milieu of the United States relates to an increased awareness—if not complete understanding—of viral theory and, tangentially, proper administration of antimicrobials. Yolanda (age 40, 5 years) described her most recent encounters with medical providers in Santa Fe, in response to her interviewer’s question about which of her family members had been sick in the preceding six months: YOLANDA: No…well, my children, only colds, a virus that they got once of vomiting and stomach aches, but nothing else. ENTRE: What did you do that time to cure them? YOLANDA: When it is a cold and I cure them, I give them hot chamomile tea and I give them Tylenol. And if they have a strong cough, we buy them an antibiotic. And the time they had the stomach virus, we called the ambulance because my son was throwing up and complained that his stomach hurt very much. And the paramedics checked him and told me that it was a virus, to give him pure saline, and he saw a doctor too. After a few days, my other child got sick and we spoke to the doctor again. He told me the same, that it was a virus and to give him pure saline, and my daughter too. (Emphasis added) Yolanda’s calmness suggests that she was satisfied with the paramedics’ explanation, which was seconded by her physicians. In striking contrast to the recently arrived migrants, she did not complain that they had given the wrong advice or medication. Her satisfaction with being told to simply provide liquids signifies only a partial understanding of viral theory, however, for she continued to believe that all types of coughs are best treated with antimicrobial therapy. Apparently, no one had taken the time to explain to her, nor had she herself discovered, that coughs are often due to viral agents, not bacterial. Yolanda appeared to be on the cusp of discovering why viruses are treated differently from diagnosable bacterial infections and

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why prescriptions for antibiotics are strictly regulated in the United States. At the very least, her children recovered from a stomach virus without taking “strong” antibiotics, an experience that may well inform her future decisions about therapeutic options. Similarly, those who had lived even longer in the United States seemed to understand antibiotic usage better than those who had arrived more recently. Although this does not always mean that they subscribed to viral theory and realized that they should not selfdispense drugs, it often means that they had a better understanding of how to administer antimicrobials. For example, Aurora (age 49, 10 years) acknowledged that one must continue taking antibiotics even after symptoms begin to abate. Asked how she determined when she no longer needed medication, she replied, “Well, one thinks they know everything, and it’s not true. For example, when I am in treatment and I have taken half the bottle of medicine but I am already feeling better, you say, ‘I am not going to take anymore.’ But one should not do that.” Aurora, like Yolanda, was also in transition regarding her understanding of viral theory: she knew that she should finish her medication for it to work properly, but she continued to believe that getting drugs from Mexico is fine: “Sometimes I do because—antibiotics and also penicillin—because it is good to fight off any infection and here they don’t give it to you.” Reyna (age 40, 5 years) was not asked specifically whether she brought drugs from Mexico, but she did demonstrate her understanding that the exact dosage of prescribed medication should be taken: “When the medicine has finished and I feel better.” Martha (age 24, 6.5 years) echoed these ideas: ENTRE: How do you determine when you need to be receiving medical attention? MARTHA: Well, when I feel good…when I don’t have any health problems. If I have a health problem, I look for medical attention, I continue the treatment, and later I try to have a follow-up appointment. Josefina (age 44, 13 years) also specified that she does not consider herself well until “they say I’m better.” Finally, Jessica (age 35, 10 years) provided one of the more detailed answers: “Because they always put on the medicine if it’s for one week. Even if there is a lot left, I don’t use it again, or two weeks, it depends.”

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The responses provided by the veteran immigrants contrast distinctly (because of their specificity) with those of the recently arrived. When answering the question about how they know that they are better, the latter stated ambiguously, “When one doesn’t feel bad anymore” (Araceli, 4 months in Santa Fe) or “When I feel well. When I don’t feel like I did when I got sick anymore, that I’m well and my body no longer feels bad” (Dora, 18 months). Monica (age 40, 3 years) readily admitted that she takes an antibiotic for only a few days: “When I know I am sick and I don’t go to the doctor because I can’t, because I have to make an appointment and they will give it to me many days later, many times I take antibiotics that I have here in the house for two or three days, and with that I recover.” Guadalupe (age 25, 3 years) offered the archetypal response of a recently arrived immigrant when she stated that she knows she no longer needs treatment when “nothing more than that I feel better and you haven’t even finished the medicine yet and you feel better.” Having been told that she needed to finish all the medicine in the bottle, she was pleasantly surprised that just a couple days’ worth cured her. Based on the specificity of the response (i.e., the respondent indicated an awareness of the need to finish the prescribed amount of the antibiotic) or, alternatively, the extent of verbiage, the mean and median number of years the 54 migrants had lived in Santa Fe were calculated (see Table 21). Table 21. Reasons for stopping pharmaceutical treatment by years lived in the U.S. I Stop Treatment When… I feel better. They tell me that I am okay. The medicine is finished.

Mean Years 2.3 5.6 7.4

Median Years 1.3 4.0 6.3

For those immigrants who responded that they are no longer sick when they “feel well again,” the mean number of years lived in Santa Fe was 2.3 (median 1.3 years; range, 2 weeks to 5.5 years). Those who responded with “when they tell me I am better,” thereby forgoing what their bodies are “telling” them (i.e., that they feel fine) and placing responsibility for this assessment squarely in the hands of their caregivers, had spent a mean average of 5.6 years in the United States (median 4 years; range, 7 months to 13 years). Last, interviewees who

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responded with “when the treatment is finished” averaged (mean) 7.4 years in Santa Fe (median 6.3; range, 1 to 17 years). This trajectory of responses is remarkable because it represents an evolution from a more phenomenological decision-making process, or one based on embodied subjective assessment, to one predicated upon information processing of external (learned) knowledge. Proceeding along the evolutionary trajectory of this discourse on antibiotics, we come upon those veterans who not only understood that antibiotic medicine is to be finished (or, at least, taken for the specified number of days) but had also renounced importing it from Mexico. Martha (age 24, 6.5 years) spoke very articulately about why she does not order medicines (especially antibiotics) from Mexico, preferring to take them only when prescribed by her Santa Fe physician. After 6 years in Santa Fe, she had become not only a proficient English speaker but also a savvy consumer of health care services and medications. Citing the differences between the health care systems in Mexico and the United States, she commented that, “one, in Mexico it is very typical, that in Mexico they always give you penicillin. Here they give you Tylenol. Here, there is a lot of control with penicillin, and it is good because I understand that this medicine takes away the red blood cells. And in Mexico anyone can buy it, without a prescription, and here you cannot. There they give you medicine, and they send you to your house. Here, they look for the problem. If they cannot determine it, they send you with other doctors.” It is a curious assertion that penicillin destroys red blood cells, yet Martha had come to accept and endorse the United State’s strict regulation of antimicrobials. Her depth of understanding extended even further; she proceeded to discuss the iatrogenic, or “secondary effects,” of particular medicines, mentioned by only one other interviewee (Delfina, the interviewee who had converted to the Sikh religion and had lived in the United States 10 years).1 Martha claimed that the chemicals she used to do her job, cleaning houses and offices, had caused her to develop asthma, as well as a sensitivity to all chemicals. She first described three bad encounters with the emergency room staff at the hospital, in which they misdiagnosed her with bronchitis when she had asthma. As a result of these negative experiences, she now chooses to see her private physician: MARTHA: For an illness, I go to the doctor, and they always give me the prescriptions. I always ask for them in Spanish to

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understand them better, and I always look at the secondary effects. Depending on what the effects are, I will take it. And because the asthma medication had secondary effects, I usually go with the natural medicines. ENTRE: So for you, it is very important to see what are the secondary effects? MARTHA: Yes, because usually the first thing they prescribe is Benadryl. And if you are an active person who works, Benadryl will always put you to sleep, so it does not help you much. Interestingly, and perhaps significant, Martha (like Delfina) had left the Catholic Church: she had chosen to become a “Christian” (her term for Protestant). As discussed in chapter 9, openness to adopting another religion signals a general willingness to learn about and test new health ideologies. Other demographic variables are that she was from the state of Sinaloa, had only an eighth grade education, and claimed that she spoke English well, none of which elucidate a compelling reason for her acculturated biomedical discourse. Another example was Gabriela (age 34, 10 years in Santa Fe), who spoke “good” English, had two children, and was divorced. She illustrated in three ways that the veteran immigrants do, based on their individual histories, eventually pick up on and then reflect U.S. allopathic beliefs about the importance of heeding physician advice regarding dosage. First, when queried about how she determines that she is no longer in need of medication, she answered, “When the treatment they give you ends and at times when you see better results. But they always indicate that you follow the treatment until it ends.” Not only did she understand the importance of finishing the prescribed amount of medication, but she also protested that physicians do not provide complete information on antibiotic usage to their patients. Asked whether she generally followed the treatment prescribed by her doctor, Gabriela responded, “Well, yes, I follow it. But lately I have been working with a nurse, and she told me that there are things that the doctors don’t tell you. I don’t know why. Like when you are taking medications that have penicillin. The nurse told me that if I have to take that, that I combine it with yogurt for my stomach, so it doesn’t irritate you. It was something that surprised me a lot because it is something that the doctors should say.”

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Gabriela had recently learned the importance of ingesting food simultaneously with an antibiotic, a medical tip to which no other immigrant referred. Communicating basic information about how to increase a patient’s tolerance of any drug—but especially an antibiotic—is integral to a physician’s job. Omissions such as this make it easy to infer that the migrants are not being given adequate information regarding viral theory and related themes. Gabriela also demonstrates the commensurability of her understanding of proper antibiotic usage with that of her health providers by her reason for not buying Mexican medicines. When asked whether she ordered medicine from Mexico, she replied, “No.” ENTRE: Why not? GABRIELA: Because to use some medications, you need a prescription. And some, you don’t know, there could be danger. Two months ago a man died intoxicated by his Mexican medicine. Not that Mexican medication is bad, but it was not what he needed. He was taking different medicines, and his heart stopped and he died. Note that this thought is not expressed in the narratives of recent migrants. Not one voiced a modicum of concern that the medications she self-prescribed might cause unforeseen injury or iatrogenic effects because they are not the most precise treatment for a particular physical ailment or, alternatively, because they do not mix well with other medications. Illustrating how change in health ideology does take place within the context of one generation, another veteran immigrant, Maria N. (age 68, 17 years), spoke of a time when she did import drugs from Mexico. Asked whether she had ever acquired or had continued to “order” antibiotics from her country, she said, “No, not now. It’s been a long time since I have. Before, I did, at the beginning. I brought the medicine for blood pressure from Mexico, nothing else.” Combined, responses like these clarify the differences between the recently arrived and the veteran immigrants in their understanding and usage of medicines that cannot be obtained in the United States without a prescription.

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ANTIBIOTIC USAGE AND TIME SPENT IN THE U. S. To show numerically the difference in the responses of the interviewees by time lived in the United States, the mean number of years spent in the host country by those who continued to order any type of prescription medication was 2.6 (median 2.5 years). Breaking out those who continued to engage in the importation of antibiotics specifically, the number of years lived in the United States is 4.3 (median 3 years). Last, the mean and median number of years represented by those interviewees who never resorted to ordering U.S. regulated medications (antibiotic or other) were 5.3 and 5, respectively. Significantly, not one diabetic, and only 1 hypertensive interviewee, claimed to import medication to treat her disease(s) or periodic infections. The orderly progression higher of the means and medians that represent time lived in the United States demonstrates again that cultural learning of what is self-evident, universal, and necessary (Foucault 1991) was occurring in this population of recently emigrated Mexicans. Note, however, that the mean and median number of years that correspond to the tendency to import Mexican antibiotics are relatively high. That is, even veteran migrants with as many as 10 years experience living in Santa Fe continued to import drugs illegally. As already discussed, this is undoubtedly due to the tenacity of the belief that aggressive antimicrobials are necessary to fend off all infections. Also, the migrants who even after many years continued to import and self-administer antibiotics were usually those who suffered from subacute illnesses, as opposed to chronic diseases. Finkler contends (contrary to the evidence presented here) that etiological beliefs are more amenable to cultural and idiosyncratic influence but that biomedical treatments “seem almost invariant” cross-culturally. She continues: “Significantly, people the world over usually demand pharmacological treatments, including pills and injections…” (2000:27). On the contrary, once whetted, this “appetite” is difficult, but not impossible, to quell. See Table 22. Table 22. Type of medication imported from Mexico by years lived in the U.S. Type of Medication All types Antibiotics None

Mean Years 2.6 4.3 5.1

Median Years 2.5 3.0 5.0

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CHRONIC ILLNESS AND ANTIBIOTIC USAGE One of the main theses of this book is that being diagnosed with a chronic illness is associated with an accelerated pace of acculturation along certain health ideology trajectories. In the present chapter, it is the recently arrived diabetics and hypertensives who support this thesis, demonstrating a greater understanding of proper antibiotic dosage schedules than their recently arrived, subacutely ill compatriots. For example, Maria C. (age 55), who crossed back and forth with a passport between a ranchito called la Quemada and Santa Fe and had been diagnosed recently with diabetes, answered her interviewer’s query about when she decides that she no longer needs to discuss a physical problem with her doctor: “I agree with everything that they tell me. If I don’t feel well, I would tell him so that they could change my treatment.…Well, when they let me stop, when they tell me that I am completely better. I only take the medicine that they give me at the clinic.” Delia (age 65, 2 years), the diabetic whose daughter was the practicing curandera, spoke eloquently about the difficulty she was having following her medical provider’s requirement that she finish all the medication he prescribed. ENTRE: After seeing a doctor, do you generally follow the treatment they recommend, or is there a treatment that a doctor has given you that you don’t agree with? DELIA: No. I try to follow it and finish it. With the kids and with my daughters, one tries. But at times, I tell family members, any one of them, “Take your medicines until they are finished,” but they don’t do it. But I try. ENTRE: But, generally, you agree with the treatment they give you? DELIA: Yes. ENTRE: How do you decide that you don’t need to be under medical attention? DELIA: Me? Well, when I feel good, no? When one feels like they need it or don’t need it and they take the medicine. There are times that you stop taking it early because you say that “it’s been days that I feel well…so why?”

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After only 2 years in the United States, Delia had learned the importance of finishing her antibiotic medication, most likely because of continual (monthly) contact with the local health clinic. The specificity of her response alone separates her from most of the recently arrived subjects. Although she may not have been cognizant (yet) of the reason she must finish the appropriate dosage, Delia appears to have developed a good enough rapport with her provider that she could trust his advice about antibiotic usage. She also attempted to convey his advice to her children. At the same time, she understood the confusion and ambivalence her children experienced taking what they (and she) perceived as a surfeit of medication when they felt healthy. Ana Maria (age 68) had lived in the United States 17 years at the time of her interview, so one cannot conclude definitively that she was not already aware of the need to take the prescribed amounts of medication. A diabetic, like Delia, Ana Maria specified that her doctor gave her a prescription directive she must follow: ENTRE: And you go every month to the clinic? ANA MARIA: Sometimes it’s every month, or different, because I have been having a urine infection because I don’t drink much water. And since I’m giving myself insulin and diabetic people should drink a lot of water and I can’t, I don’t pass it. And he told me to finish the pills he gave me for the infection and that I should go to get a prescription to avoid the infection. By sharing her doctor’s medical advice about finishing her prescription, Ana Maria is indicating that she did learn this information from him. One could infer that she went many years living in the United States without understanding its importance and that her monthly interactions with her doctor sped up the educational process. This finding is similar to McVea (1997), who found in her work on lay injection practices in the Mexican immigrant community, that some migrants discontinued use of antibiotic and vitamin injections because of repeated interaction with the health care system.

CHRONIC VERSUS SUBACUTE ILLNESSES AND RATINGS OF THE U.S. HEALTHCARE SYSTEM The positive relationship between the increased contact a chronic illness sufferer has with her health care providers and the accelerated

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rate at which she adapts to or adopts U.S. biomedical health ideology has been thoroughly discussed. This section focuses on how subjects’ ratings of their experiences with practitioners reflect this increased contact. The rating question is interesting because it may provide a subjective index of the patient’s experience with the health care system and also tap into a particularly “cultural” lens through which the judgment is made. According to Warnecke and others, “when the task requires a judgment to be formed about information that has been retrieved from memory, the task becomes more complex and is likely to be affected by racial or cultural background” (1997:336) What Warnecke and others mean, in the context of a questionnaire that requires a respondent to “rate” or judge a past experience, is that research has shown that those with specific cultural backgrounds have a tendency to answer this sort of question with an extreme response (See also van de Vijver and Phalet 2004; Marin and Gamba 1996.) In the present scenario, this would mean that the interviewees would utilize the response categories of 1 and 3 more frequently when rating their experiences with health care providers in Santa Fe. How, then, is it possible to interpret the uniformly positive ratings of the health care system by chronic patients? Are they merely reflective of a (Latino) cultural tendency to extreme response bias, or are they more directly related to subjective satisfaction with the quality of care? This satisfaction, in turn, is hypothesized to accelerate rate of acculturation or, at least, contribute to a migrant’s openness to learning new ways of caring for herself. The former hypothesis does not pan out because those migrants who had lived in the United States the longest (and most of whom had subacute illnesses) also frequently cited an extreme rating. After spending time here and learning how the health care system works, they rated their care a 1. It is not merely increased contact with medical practitioners that impels people forward along a trajectory of acculturation, but also frequent visits characterized by a salutary, friendly, respectful, and productive attitude. Recipients of this type of health care rated the health services they had received and the personnel with whom they had interacted since immigrating to Santa Fe a 1, or the best. Significantly, every single diabetic who was requested to rate the health care in Santa Fe rated it a 1. Similarly, 77 percent of the pregnant women queried also rated the prenatal care they had received a 1; the others rated their care a 2. Those suffering from chronic diagnosable

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diseases such as gastritis and osteoporosis and symptoms related to depression (58.3 percent) also rated their health care in Santa Fe a 1. What is interesting about both the chronic diagnosable and chronic undiagnosable categories of people is that even though they were suffering from illnesses that may not be treatable or may not abate naturally with time, they still rated their U.S. health care as either a 1 or 2 and never the lowest possible rating. On the other hand, those who presented in the local clinic or hospital with undiagnosable (i.e., viral) subacute respiratory and abdominal infections were not at all happy with the care they had received in the preceding year. Uneducated, discriminatory, negligent, or indifferent, at the least, is how these migrants characterized the health care workers they had seen at the local clinics and hospital. Believing that they themselves knew the best treatment for their particular diseases, the interviewees in this latter subsample rated their care a 3. Of the subjects who rated the health care system a 3, 91 percent listed the lack of quality treatment for subacute illness as the main reason for that rating. The one person who used a different rationale and rated the health care system a 3 cited the local hospital providers’ inability to diagnose her asthma properly, prolonging her suffering. As a result, she preferred to ingest “natural” medicines and claimed that she would not willingly seek care from practitioners in Santa Fe again. See Table 23. Table 23. Percentage of illness subtypes by health care system ratings Type of Illness Chronic: Diabetic Chronic: Pregnant Chronic: Diagnosable Chronic: Undiagnosable Subacute

Health Care Rating 1 100.0 76.9 58.3 0.0 35.5

Health Care Rating 2 0.0 23.1 41.7 100.0 20.0

Health Care Rating 3 0.0 0.0 0.0 0.0 44.5

Raquel (age 35) is an example of one who, even after living 6 years in Santa Fe, would not return to the local clinic or even the hospital for primary care, because of her very first encounter with the health care system. In response to the question, You haven’t gone to the doctor have you? she said, “No, because I had a bad experience when I

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gave birth to my baby. It was such a bad experience that now I don’t want to go back to the clinic or to the doctors. I don’t want to know anything at the clinic.” After a lengthy description of how the incision from her caesarian section became infected, she answered her interviewer’s rephrased question about her lack of reliance on the local health services: ENTRE: And do you have a doctor now? RAQUEL: No. I don’t want one anymore. ENTRE: Not even to do your annual examinations? RAQUEL: No. It’s already been a long time since I’ve gone. I don’t stop in the clinic. The only clinic I go to is the one at…for my children, because I think it’s important to follow the immunizations. But not for me. ENTRE: Because you got scared with the others? RAQUEL: Yes, I didn’t like it. I don’t know if they do it because I’m Mexican…I think it’s because of that. As already mentioned, these early, negative experiences with health providers leave a lasting impression, so negative that the immigrants preferred to forgo receiving medical attention rather than submit to another frustrating encounter with a health professional. In addition, the ratings of veteran immigrants like Raquel, who based her evaluation of the health care system (3) on her first encounter years before, suggest that the stories these immigrants relate are complex and cannot be summed up in the simple statement that Latinos tend to give biased or extreme responses. Because Raquel did not have further encounters with the health care workers in Santa Fe, she was stuck with her negative assessment. Noteworthy was the mean number of years lived in Santa Fe for the 11 women who rated their health care a 3 and who presented with a subacute condition. This average was only 2.9 years (median 1 year; range, 3 months to 10 years). In contrast, the 9 women who presented with similar types of subacute infections (including bacterial) and rated their health care in Santa Fe a 1, the highest, had lived, on average (mean), 12.6 years in the United States (median 6; range, 1.5 to 10 years).2 These women, having met with health care providers for subacute illnesses since their arrival in Santa Fe, had come to accept established allopathic diagnoses and treatment practices—including the

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withholding of pharmaceuticals for viral infections. Their rating of 1 for the treatment of their subacute infections directly reflects their acculturation; they had accepted and even preferred U.S. illness management. Notable also is that the diabetic and hypertensive immigrants who rated the health care system in Santa Fe a 1 had lived in the United States an average of only 6.7 years (median 2.5 years; range, 1.5 months to 45 years). Obviously, those in the latter group had learned to accommodate the changes in health schemas and behaviors required of them by their providers in less time, hence their satisfaction with their care after such a short time in Santa Fe. Furthermore, the number of years spent in the United States by those who rated the system a 2 turned out to be directly in between recent arrivals who rated their subacute care a 3 and veterans who liked their health care and rated it a 1: for the 12 interviewees (with subacute illnesses) who rated the quality of health care in Santa Fe a 2, the mean number of years spent in the city was 4.5. The median was 5 years (range, 4 months to 10 years), a statistic that is almost exactly in the middle of the other two. One reason why others rated their experiences with Santa Fe practitioners a 2 instead of a 1 was that 4 of them were suffering from chronic undiagnosable conditions and felt frustration with their inability to get a specific diagnosis, let alone relief from their physical ailments. Other reasons included lack of satisfaction with treatment for chronic diagnosable conditions such as pain in the ovaries and recurring throat-related infections that, despite their being identified, were not cured. It merits mention again that not one sufferer of a chronic diagnosable or even chronic undiagnosable illness rated her health providers—or the system in general—a 3, the worst rating. To put the ratings in perspective, recall that all the women with diabetes and hypertension and the majority of the pregnant women (the “chronic” illness sufferers) rated their experiences with Santa Fe health providers a 1. See Table 24. Table 24. Diagnosis type and associated rating of health care system by years lived in the U.S. Diagnosis Subacute Subacute Chronic Subacute Chronic

Rating 3 2 2 1 1

Mean Years 2.9 4.5 4.9 12.6 6.7

Median Years 1.0 5.0 5.0 6.0 2.5

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EXAGGERATION OF SOMATIC SYMPTOMS It has been reported in the literature that Latino immigrants tend to exaggerate their symptoms and self-assess their health as worse than physicians might. Researchers for years have documented discrepancies between self-reports of health status by Hispanic patients and physician reports. For example, Arcia (1998) found that, whereas in the general population approximately 4 percent of children were rated as having fair or poor health, 14 percent of Mexican American mothers ascribed this rating to their children. Thus, the perceived health status of Mexican American children is poorer than that of children from the general population. (See also Finch et al. 2002.) San Juana (age 17, 5 years in Santa Fe) expressed her concern that doctors from the United States do not readily dispense the proper medication for children’s illnesses (an anxiety she shared with numerous other immigrants). She also is aware that only if one is very sick will American healthcare providers prescribe strong antibiotics. Her interviewer requested that she provide five important differences between the doctors in the respective countries: SAN JUANA: Here, they don’t give you medication for all illnesses. There they do. There, there are more medications, and here in Santa Fe they’re not as worried, as if you get rid of illnesses without…that is to say, if you’re very ill, no. They will give you good medicine. But usually, here it’s “Take this, take that, take Tylenol” and that’s it. And there, no. They worry more. That is, if you’re very ill or if you feel bad, they examine you. Here, no. I don’t see much good about the doctors here.… ENTRE: When you go to see the doctor at the clinic what feelings are you left with in your heart? SAN JUANA: Anger, but I feel more for the child that I bring with diarrhea, fever. They say it’s nothing, that it’s normal…it makes me angry.…My God, why are the doctors here like that? Knowing that in Mexico they give you something quick…if you only lived here, you’d resign yourself right, but you know that in Mexico there are always medications. It’s the consolation that medicine gives you. You know they’ll give you medicine to make you…here, no…just Tylenol. It makes me very angry, and then I have to pay.

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ENTRE: How do you feel when you go to visit a doctor in Santa Fe? SAN JUANA: Without any desire to go. Why should you go if they don’t tell you anything? (Emphasis added) Although it has been documented that Mexicans tend to put off going to the doctor, the present and other published research indicate that they do want to be treated (in Mexico and in the United States) for symptoms of fever associated with upper respiratory or abdominal distress (Corbett et al. 2005). In so far as they are characterized as delaying clinic visits, a delay that may lead to dangerously acute problems, they may believe—based on past experience—that they will not be taken seriously, that they will be discriminated against, or simply that the doctors provide inferior care. Thirteen of the women stated specifically that they did not bother going to a clinic anymore because it would take too long to get treated or because they would not be given anything but Tylenol. This constitutes 21 percent of the sample of 62 subjects. Furthermore, San Juana’s discussion also reveals why some migrants who present in health clinics with subacute upper-respiratory or gastric distress (or any sick immigrant who is unhappy with the quality of the medical care she is receiving) may not readily absorb or adopt the tenets of viral theory: they know that better therapeutic options are available, and not that far away. Although San Juana did not plan to return to Mexico, she still had one ideological “foot” in her mother country, tenaciously holding on to her belief that antimicrobial treatment is the proper, indeed superior, method by which to cure certain diseases. As others have illustrated, these migrants will return to Mexico at times to seek what they perceive is better-quality health care. San Juana also, quite rightly, alluded to the “consolation” that taking medicine affords the sick. It almost does not matter, one could infer from her narrative, whether the drug is the best one to remove the cause of the problem. What matters is the symbolic healing that takes place when a patient ingests an agent that she thinks (or hopes) will alleviate her suffering. It is obvious from reading these narratives that, for these immigrants, Tylenol is not invested with the symbolic healing power to which San Juana refers; it does not carry the symbolic muscle to effect any relief on a physiological level. “Strong” antibiotics do, however, and they are demanded by the immigrants. In essence, San Juana was referring to the placebo effect: the measurable, observable, or felt improvement in health not attributable to treatment. The

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literature on this topic is enormous. Just a few of the available resources are Engel and others (2002); Hrobjartsson and Gotzsche (2001); and Harrington (1999). Thus, the lack of communication between patients and their physicians regarding viral theory and the problems associated with prescribing antibiotics in some cases is directly responsible for underusage of health clinics and even—possibly because of delay in help seeking— overutilization of hospital emergency rooms. San Juana gave voice to her rationale for not seeking help from U.S. clinicians: her knowledge that in Mexico she could quickly relieve her physical and emotional distress. Implicitly, as mentioned above, it may also be this belief that inhibited her from learning more quickly why North American healthcare providers distribute antibiotics only when they are positive that an infection is bacterial. San Juana’s discussion also illuminates a possible reason why Latino immigrants are characterized as exaggerating the severity of their health condition: ENTRE: In the last six months, how many times have you had to consult a doctor? SAN JUANA: About four times, because I have problems with my throat. And when I’ve gone, at times they give me a medicine…but when they don’t think I’m very sick, they don’t give it to me, until it’s very swollen. ENTRE: What reasons would lead you to choose a certain doctor for consultation? SAN JUANA: I already have a doctor. I didn’t choose him. They gave him to me…because he looks after you well, because he gives you something to make you feel better. He doesn’t say, “I’m not going to give you anything because what you have isn’t serious,” and you honestly feel bad. Based on discourse such as San Juana’s, I postulate that immigrants, because they are not educated by health providers about viral infection—that is, they do not know that antibiotic drugs have no effect on a viral infection and that the body heals most viruses naturally over time—perceive instead that they and their suffering are not taken “seriously.” As a result, they may deploy strategically an exaggerated level of affect in order to convey more effectively the intensity of their distress. In other words, they may knowingly or innocently amplify

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their level of distress in order to make an American health provider take proper notice of what they perceive is their seriously diminished health condition. Finkler witnessed this strategic deployment of the sickness role by young mothers living in the rural area where she worked: “A young mother may unwittingly attribute illness to an infant for secondary gain in order to attract attention from her husband, who may otherwise be very inattentive. Husbands become very attentive, however, when one of their offspring becomes even slightly indisposed” (1994:68). In a similar fashion, San Juana implied that if she presented herself to a physician as “very” sick, she would be given the treatment she sought. Most likely, she even felt sicker than she might have if she had been given what to her was the “proper” care in the first place. Indeed, she was happier after discovering a provider who “takes her seriously” and implicitly validates her self-assessment of her physical condition. After being educated in her country (both by the popular sector and the physicians who so readily dispense antibiotics) about the dire importance of treating throat symptoms quickly and properly, she was not going to relinquish this belief simply because a North American physician refused to prescribe strong antibiotics. On the contrary, such behavior on the part of the medical provider may reinforce her conviction that self-treatment with antimicrobials is the appropriate therapeutic response to upper respiratory infections. McVea, working to understand Mexican immigrants’ injection practices, found this to be the case, that “the practice styles of U.S. physicians may paradoxically encourage the use of lay injectionists” (1997:96). These are findings that obviously need more study. A hypothesis suggesting that the migrants may be exaggerating their physical distress needs to be tested in the field for appropriateness; otherwise, it may offend the population it is intended to understand and ultimately help. See Reichman (1997) for an alternative hypothesis as to why Mexican immigrants convey more negative subjective assessments of their health than non-Hispanic White populations.

SUMMARY Together, the immigrants’ narratives, their experiences, and their ratings of the Santa Fe healthcare system illustrate the relationship between the types of illness they present with, the quality of care they receive, and their assessment of that care. Subjective ratings of care, in

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turn, affect psychological symptomatology and physical patterns of resort. More work needs to be done, however, before concluding that there is a strong relationship between perceived discrimination and objectively worse health status (see Gee 2002). From these narratives, an image unfolds of a U.S. healthcare system that places more emphasis on diagnosis and treatment of chronic conditions associated with high morbidity and mortality rates and less emphasis on care for subacute conditions that, left untreated (or regardless of treatment strategy), usually subside with time. It is unknown how much extra financial burden is placed on the healthcare system in the United States due to this resource allocation strategy. Perhaps a few extra minutes of a health care provider’s time spent explaining viral theory to a recent immigrant would allow for a significant cut in the amount of the country’s health care budget earmarked for the care of the indigent.

CHAPTER 12

Nervios, Stress, Sadness, Depression: The Evolution of a Mind/Body Discourse

The mind and body are one and the same thing, conceived at one time under the attribute of thought, and at another under that of extension. For this reason, the order or concatenation of things is one…and consequently the order of the actions and passions of our body is coincident in nature with the order of the actions and passions of the mind.…So that it follows that when men say that this or that action of the body springs from the mind which has command over the body, they do not know what they say, and they do nothing but confess with pretentious words that they know nothing about the cause of action, and see nothing in it to wonder at. —Spinoza, Ethics Spinoza is in vogue of late, popular again after having lost the philosophical battle to Descartes over which entity—mind or body— exerts primary control or, in Spinoza’s own words, is the “cause of action.” Damasio’s work (1994, 1999, 2003), which is responsible for resurrecting and perhaps vindicating the seventeenth-century philosopher, is germane to the present discussion on the relationship of the mind and body because he proposes that the mind is not necessarily, in Aristotle’s words, the first or primary “mover” when it comes to reason. Instead, he argues that consciousness is best conceived as an indivisible mind-body system and that “reason” and “passion” are far from separable. Emotion and cognition, rather, are thought to work in concert with the same goal: preservation of the human organism.1 209

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The theory positing the inseparableness of the mind and body bears mention because, for decades, research on the Latino population, in general, and the speed with which Latinos acculturate, more specifically, has directed a large amount of energy to understanding and explaining this very phenomenon. In most cases, the literature has focused on and postulated reasons for Latinos’ tendency to “somatize” affective disorders such as depression and anxiety (Ringold 2005; Scheper-Hughes 1992; Markides 1986; Kleinman 1985, 1986). Individuals who somatize emotional distress have physical discomfort instead of overt psychological symptoms. Medical anthropologists perceive this discourse to be uncomplimentary and slightly patronizing, privileging the mind over the body, and oftentimes, the industrialized world over the non-industrialized. They claim it implies that people in the industrialized world are more aware of their emotional life and have a vocabulary to describe it whereas people from the non-industrialized world are unaware and inarticulate regarding their emotions. They are less conscious, less “advanced,” and therefore more liable to express their emotional life via the soma. Scheper-Hughes has observed: [There is a] tendency in biomedicine, psychiatry, and conventional medical anthropology…to standardize our own socially constructed and culturally prescribed mind/body tactics and to understand and label the somatic tactics of others as deviant, pathological, irrational or inadequate. Here I am referring to the exhaustive and generally unenlightening literature in medical anthropology on “somatization.”…[It is understood] as a generally maladaptive and fairly primitive defense mechanism involving the deployment of the body in the production or exaggeration of symptoms as a way of expressing negative or hostile feelings. (1992:185) Damasio’s research provides an interesting and enlightening metaphor for what is consistently noted of the Latino population, namely, that members of this ethnic group tend to privilege the perceptions of the soma over the psyche. It is Damasio’s contention that feelings are representations of the soma, or body (as opposed to products of the mind, which are sometimes instantiated in the body). “Feeling,” Damasio writes, “in the pure and narrow sense of the word was the idea of the body being in a certain way.” He continues:

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My hypothesis, then, presented in the form of a provisional definition, is that a feeling is the perception of a certain state of the body along with the perception of a certain mode of thinking and of thoughts with certain themes. Feelings emerge when the sheer accumulation of mapped details reaches a certain stage.…Feeling is a consequence of the ongoing homeostatic process, the next step in the chain.…The particular state of those body components [i.e., chemical molecules], as portrayed in the brain’s body maps, is a content of the perceptions that constitute feelings. The immediate substrates of feelings are the mappings of myriad aspects of body states in the sensory regions designed to receive signals from the body. (2003:86–7) Spinoza asserted that the body and the mind work in concert. Damasio underscores this idea but goes one step further. Turning the Cartesian causal chain of events on its head, he posits instead that a set of homeostatic reactions gives rise to feelings, not necessarily emotions proper, that are responsible, in turn, for a response from the soma (what Huxley [1894] terms “epiphenomenalism”). Damasio’s image is of a person who knows that he is frightened because he trembles, instead of a person who trembles because he perceives something as frightening. Reinterpreting somatization theory through this lens, those who are categorized as somatizing (that is, emphasizing the bodily sensation of sickness or disease as opposed to the mentalist feelings of depression or anxiety) may be more sensitive to their primary bodily reactions to external stimuli than those who infer and interpret them through a psychological or mentalist framework. In this tri-partite scenario, the first stage is a “state of emotion” that can be “precipitated nonconsciously”; the second is a “state of feeling” that can be “represented nonconsciously”; and the last is the “state of feeling made conscious” (1999:37). Representatives in the population under study might stop at the second stage and not go on to process their feelings consciously. They were subconsciously aware, however, of the first link in a chain reaction whose advent is the altering of the body’s homeostatic balance in reaction to (in this scenario) negative external stimuli. They may be, in effect, skipping altogether the “mind” or interpretive part associated with lack of homeostatic balance. Damasio explains how this might be possible:

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Some readers may be puzzled by the distinction between “feeling” and “knowing that we have a feeling.” Doesn’t the state of feeling imply, of necessity, that the feeler organism is fully conscious of the emotion and feeling that are unfolding? I am suggesting that it does not, that an organism may represent neural and mental patterns, the state that we conscious creatures call a feeling, without ever knowing that the feeling is taking place.…Neither the feeling state nor the emotion that led to it have been “in consciousness,” and yet they have been unfolding as biological processes. (1999:36) Damasio goes on to suggest that emotions happen of their own volition and often cannot be controlled willfully. One may discover that one is suddenly happy or sad yet be unable to discern why. One may hypothesize reasons for the feeling state, but, he cautions, one may not always know with certainty the basis for it. Alternatively, one may realize that there is a certain omnipresent precursor to feelings of anger or sadness, and one may, in turn, attempt to remove that precipitating or causal factor in order to prevent the feelings of anger or sadness. Again, he claims, one can be only partially successful at turning off the expression of emotions: The actual [cause of the emotion] may have been no image at all, but rather a transient change in the chemical profile of your internal milieu brought about by factors as diverse as your state of health, diet, weather, hormonal cycle, how much or how little you exercise that day, or even how much you had been worrying about a certain matter. The change would be substantial enough to engender some responses and alter your body state, but it would not be imageable, i.e., it would not produce a sensory pattern of which you would ever become aware in your mind.…Emotions can be induced in a nonconscious manner and thus appear to the conscious self as seemingly unmotivated. (1999:48) Vis-à-vis the discussion of somatization, Damasio’s contention that emotional responses to external or internal stimuli may not be controllable effectively vindicates the populations who are accused of somatizing. Their bodies do what they need to do to survive, regardless of how somatic feelings are interpreted and managed. Latinos, then, are not necessarily less evolved in terms of their ability to create the “right”

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mental images or “cognitive appraisals” of their bodily distress; they simply tell different stories about what their (inevitable) bodily sensations mean to them. Moreover, they might be, on some physical level, hypercognizant of homeostatic changes in the body, what Damasio terms “background emotions.” An organism’s interaction with the environment causes responses in the soma (background emotions), which, in turn, can induce, for example, “a feeling of tension or relaxation, of fatigue or energy, of well-being or malaise, of anticipation or dread” (1999: 52). He continues: In background emotions, the constitutive responses are closer to the inner core of life and their target is more internal than external. Profiles of the internal milieu and viscera play the lead part in background emotions. But although background emotions do not use the differentiated repertoire of explicit facial expressions that easily define primary and social emotions, they are richly expressed in musculoskeletal changes, for instance, in subtle body posture and overall shaping of body movement. (1999:53) Perhaps it is awareness of the subtle internal changes in homeostasis, a sense of tension, a feeling of dread, expressed externally via body posture that Latinos cite as physical distress and that biomedically trained physicians have difficulty discerning. Maybe Latinos do have an increased awareness of the alternation of the “body map” caused by external stimuli. An alternative hypothesis would be that there is no actual mechanism that differs in this population. Rather, what is different is imposed by the veneer of culture, what anthropologists have claimed all along. Damasio includes this explanation as well: I am calling attention to the fact that regardless of the degree of biological presetting of the emotional machine, development and culture have much to say regarding the final product. In all probability, development and culture superimpose the following influences on the preset devices: first, they shape what constitutes an adequate inducer of a given emotion; second, they shape some aspects of the expression of emotion; and third, they shape the cognition and behavior which follows the deployment of an emotion. (1999:57)

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Obviously, more work needs to be done to untangle the relationship between the biological substrate of the “feeling” human body and the veneer of culture that imposes meaning on physical sensations. Damasio’s theories, however, provide a refreshing metaphor for a creative reimagining of what is happening in the bodies and minds of a large subset of the world’s population.

NEGATIVE EMOTIONS AND EMBODIED DISTRESS: THEORIES It has been written that Mexicans attribute embodied distress to negative emotions; that is, the body is considered to be an extension of daily events, which are often anxiety- or anger-producing (Finkler 2001). This anger is hypothesized as causing a number of physical insults on the body, resulting in physical illness (as opposed to depression). Imputations of this sort are thought to be outside the discourse of mind/body dualism; they are thought to neglect or misunderstand the effects of the mind on the body when they interpret adverse social conditions as potentially disease-producing. In light of not so recent theories that reveal the negative effect of external stressors on bodily functioning, however, one might go so far as to say that the Mexican theory of disease etiology is absolutely correct: there is an intimate connection between perceived social or even physical (e.g., hunger) stressors and disease. In fact, this is the primary tenet of Behavioral Medicine as it is practiced in the United States. Refusing to see disease as merely biological or physical, Behavioral Medicine posits a paradigm that incorporates the subjective experience, including the “personal meaning, and cultural and interpersonal contexts of illness and healing, as well as the associated behavioral responses to physical illness” (Schrodt and Tasman 1999:444). The precursor of subjective experience, according to Damasio, can be fluctuation in bodily homeostasis, which in turn is directly influenced by environmental factors. Another piece of evidence to support one aspect of illness attribution in the Mexican population is Martin’s exegesis of the understanding and role of the body’s immune system in daily discourse. She points to this very relationship between perceived emotional insults (perception can occur either at the bodily level or at the mental level) and corresponding—in this case, immunological—responses. She writes that it is “increasingly clear that scientists are coming to

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understand the immune system as playing a central role in the body’s network of causally linked systems.…This link explains how stress, which affects the nervous system, thus affects the immune system and can then lead directly to the onset or worsening of [physical] conditions” (1994:186–87). Regardless of whether biomedicine can detect actual disease states in the organs and tissues of the body, stressful events that are “perceived” as disturbing the homeostasis of the body may be doing just that, albeit on a more subtle level. Moral indignation, hunger, physical hardship, and existential angst may indeed be inscribed directly and catalogued by the immune system. In a related vein, working to “assess the relationship between presenting symptomatology of the self-labeled Hispanic popular diagnosis of ataques de nervios and the specific co-morbid psychiatric diagnoses,” Salman and others have hypothesized that “as psychiatry moves more and more to a biopsychosocial model, the concept of biologically mediated thresholds for emotional dysregulation gains increasing plausibility” (Salman et al. 1998:242). Exactly how these groundbreaking immunological, neurobiological, and biopsychosocial theories explain the traditional concept of somatization is yet to be determined, but the metaphor of the event patterning of somatic signals first and feelings second is significant in relation to the present research. The narratives of the immigrants put an unusual twist on the standard somatization discourse.

DISEASE AND DEPRESSION: THE IMMIGRANT’S VIEWPOINT The literature has characterized Latinos as being unaware of the psychological dimension of their physical ailments, but the present research discovered quite the opposite. Rather than neglect the psychic component of physiological distress, the Mexican immigrant women tended to invoke it as an intimate bedfellow of their physical pain. Yolanda (age 40, 5 years in Santa Fe) illustrates this point: ENTRE: How do you know that you aren’t feeling well, that you are sick? What are the symptoms that indicate to you that you are sick? YOLANDA: It is when I feel very depressed and I start to have great despair and I become very short-tempered with my

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children. It starts like that, with desperation. It is the depression and it alters my nerves. Citing a trajectory of affect that began with a homeostatic imbalance in the body (disease) that she experienced as depressed affect, it continued on a course that caused her to feel desperate and irritable. The “feedback” loop, in turn, directly affected her physical, embodied nervous system, negatively impacting her “nerves.” Instead of locating solely in the body what is or might be embodied psychological distress, Latinos may perceive somatic distress as psychological distress. Damasio provides an interesting potential explanation for this pattern of events: The [body] maps associated with joy signify states of equilibrium for the organism.…The maps related to sorrow, in both the broad and narrow senses of the word, are associated with states of functional disequilibrium.…There is pain of some kind, signs of disease or signs of physiological discord—all of which are indicative of a less than optimal coordination of life functions. If unchecked, the situation is conducive to disease and death. In most circumstances the body maps of sorrow probably are reflective of the actual organism state.…Feelings are the mental manifestations of balance and harmony, of disharmony and discord. (2003:138– 39, emphasis added)2 The phenomenon of perceiving sadness as an indicator that the body is diseased or discordant occurred so regularly that we asked a second question, What does it mean to you to be sick? Twenty-three respondents (37 percent) said that it meant that they felt depressed or sad or weak. (Of the 23 who responded to the question in this way, 15 of them had lived in the United States fewer than 5 years, an average of 2.5 years. This suggests that the proclivity towards equating physical distress with lowered affect may also change with more time spent in the United States.) What may have been uncovered is a mere linguistic effect instead of a true tendency to equate sickness with depression and sadness (i.e., depression actually signals physical distress), but the following examples of responses to the question, How do you know that you aren’t feeling well, that you are sick? underscore this point. Rocio (age 32, 10 years) answered, “Weakness, tiredness, to be depressed, all of that.” Asked what sickness meant to her, she replied,

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“To be weak, sad, depressed. To be healthy is to be happy.” Echoing Rocio’s sentiments, Aurora (age 49, 10 years) said that she knew that she was sick by what she characterizes as the typical symptoms of disease: “The symptoms are depression, headaches, stomachaches, or toothaches.” Yet another migrant who tended to place sickness and sadness on equal footing—indeed, the latter seemed to herald the arrival of the former—was Ivone (age 38, 1.5 years): “It depends on what I have but, in general, being tired and sad. My stomach bothers me. It’s my intestines. They get inflamed when I have problems. I have to go all day without eating, and I think it’s nerves.” Sylvia (age 20, 2 years) had a slightly different “take”: “When I’m sick, I feel sad. I feel I miss my mother. When I feel alone, depressed. That’s how I feel the illness.” Sylvia’s response provides insight into what may actually be happening. Rather than a perception of disease or physical distress first as sadness or depression, there may be instead a socially or culturally prescribed response (sadness) to sickness. This places the negative affect second in the chain of experience. In this scenario, being physically ill induces sadness or depression for any number of reasons: missing work when one needs to support the family; being far away from family when one needs comforting; losing energy or drive; missing out on the normal activities of family life. There are more examples. Araceli (age unknown, 4 months) responded to her interviewer’s query, What does it mean to you to be sick? with “One gets sad.” Claudia (age 30, 2 years) offered the most dramatic equation of physical and psychic distress. To her, sickness meant “to not sleep well, not be hungry, and not have any desire for anything. To spend the day thinking about things you shouldn’t think about. To be mentally ill, to want to kill yourself, to want to die. Many things.” It is not known whether her response to sickness is inflated because migration took her away from family and things familiar or this was also the way she responded to illness in her home country. Nonetheless, she dramatically described the psychic dimension of her physical distress. The question of how these events are patterned deserves more study, but what is of interest is how frequently negative affect is invoked verbally by the immigrants as an intimate component of their perception of physiological imbalance. This appears not to be the case in published research that promulgates the popularly held view that this population somatizes. Because no one has undertaken a serious study of

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the differences and similarities in the wording, translation, word order, and administration of the various published survey instruments utilized, it is not known exactly why the present research uncovered such a wealth of material relating to negative affect and other research projects have not. Referring again to Salman and others, who worked to understand nervios reactions in a Latino sample, the biopsychosocial explanation of depression as an indicator of homeostatic imbalance in the body may be due to “individuals’ lack [of] ability to contain certain emotional reactions” (1998:242). This is precisely what Damasio posits as the “body-map” of sorrow, which is not susceptible to complete conscious control. Of more importance is the relation of this data to published reports on the tendency of Latinos to somatize. Instead of minimizing the affective component of illness, respondents instead invoked emotion as a necessary companion to disease. Furthermore, addressing the widely held belief that this population exaggerates symptoms of ill health, evidence provided here suggests that the stated presence of elevated negative affect when sick (e.g., depression or sadness) may influence negative subjective assessments of physical health. This has been suggested before in the literature (Reichman 1997), and the data collected for this project lend credence to this hypothesis.

THE EVOLUTION OF SADNESS TO DEPRESSION In the preceding discussion on the intimate connection between depression (sadness) and sickness, those who had spent less time in the United States (e.g., Sylvia and Ivone) used the word sad, or triste and tristeza, to describe how they knew that they were sick whereas Aurora and Rocio, both of whom had lived in Santa Fe for 10 years, used the word depression. Specifically, Aurora stated, “Los síntomas son depresión,” and Rocio offered, “Está uno deprimida.” From narratives such as these, I discerned that the immigrants who had spent more time in the United States incorporated the word depresión, replacing the word triste to describe their response to both physical sickness and emotionally jarring experiences. Another veteran immigrant used the word depression to describe the symptoms of illness that worried her the most, Concepcion (age 53, 6 years in Santa Fe): “Those of my body, because there are days that I feel really weakened and a lot of depression. But apart from my illness is that lack of support in the family, because they have pulled away

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from me.” Ana Maria (age 68, 17 years) shared with her interviewer how she became depressed shortly after her heart attack: But I wasn’t really well yet. They [her children] left me a girl to look after me [in Mexico] and help me, but the girl left with her boyfriend and I was a little depressed from the heart attack. I had her since she was 13 years old, and I even put her in school. It was a hard blow for me because I loved her like a daughter, because she was a very good girl. But love showed up for her and she left me alone in the house, and I started to feel worse. When she left, I couldn’t sleep in my room anymore, because she slept with me. And I began to sleep in the chair in the living room, and I began to think, “I’m getting depressed here, and my children are so far away and I’m here alone.” (Emphasis added) To underscore the point that invocation of the word depression increases with time spent away from Mexico, the mean number of years lived in the United States for those who mentioned, in the context of any question, the word depression was 8.1 (median 5 years; range, 1 year to 45 years). Furthermore, not only did the veterans use the word in their narratives more frequently, but also 3 of them had been diagnosed with and were being treated for some form of depressive disorder by medical doctors or other providers in Santa Fe. By way of contrast, those respondents who never mentioned the term depression, using instead the words sad, weak, or desperate, had lived, on average, only 1.7 years in the United States (median 1.3 years; range, 2 weeks to 5 years). See Table 20.

THE EVOLUTION OF NERVIOS TO STRESS A corollary to the evolution of the understanding and use of the word depression was a similar progression in understanding and usage of the word stress. Migrants who had been in Santa Fe less time tended to, on average, use the term nervios to describe all manner of health conditions with an emotional component; those who had spent more time used the word stress. An exhaustive account of how this term is understood and used in the Mexican population has been provided elsewhere and is not the primary goal of this research. For background purposes, though, here is a general overview. According to these informants, “nerves” are typically curable, with herbs, injectable vitamins (usually

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B), or treatment by a curandero to cleanse (limpiar) the victim of nervios. In the recently arrived subgroup, sadness and depression (if the latter was mentioned at all) were often described as being a condition, or result, of nerves. Nerves—which can provide a physical or psychological explanation or attribution for illness and also be the outcome of some other psychological or physical condition (see Yolanda’s comments in the previous section)—serve as a catch-all category to explain any number of physical and/or emotional conditions. For example, nerves are implicated in high blood pressure (presión alta or hipertensión), gastritis, mental illness, and diabetes. In general, they cause ill health. Jacqueline (age 16, 2 weeks in Santa Fe) expressed this belief when she told her interviewer that sickness is caused by “not taking care of ourselves—eating poorly, getting angry, nerves.” Alternatively, environmental pressures cause nerves (both physical and emotional), as do big surprises and anger.3 Nerves are sometimes treated with teas, at times with soporifics such as valium (one woman claimed that her doctor in Mexico got her hooked on the drug). The opposite of nerves—estar tranquila (to be calm)—is health. Nervios is a complex, nebulous, and inconsistent concept. ScheperHughes discovered this during the course of her work in Brazil. She writes that “nervios is an elastic category, an all-purpose complaint” and, earlier, “here, an analysis of ‘epistemic murk’ and contradiction is the task at hand” (1992:175–76). It is also a sticky illness attribution in that the veteran respondents do not appear to give it up readily. Therefore, the mean number of years lived in the United States for a person who had used it was 6.7. The median number of years, however, was only 3.0 (range, 1 month to 45 years).4 To show how usage of the term nervios became encoded in the word stress, here are examples of recent immigrants who attributed disease to “nerves,” followed by the narratives of veteran migrants who spoke instead of their various sicknesses being caused by “stress.” Maribel (age 23, 1.5 months) told her interviewer that nerves had caused her gastritis: ENTRE: How do you know that you don’t feel well, that you are sick? MARIBEL: Because my stomach hurts, I get nauseous, I feel weak, my hands sweat. My nerves, I want to run, I want to cry. I don’t know what to do, and all these nerves give me

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gastritis. In other words, my nerves provoke the pain easily. That is what the doctor told me. When queried as to whether she tries to cure herself, Maribel answered, “Just with Maalox, without consulting the doctor, that’s what I took. Maalox, hierbitas like la prodigiosa for pain, and I took siete flores for nerves. If, as I told you, my nerves attacked me, if I took various hierbitas, I felt better.” Later in her interview, Maribel used the same causal ontology of disease, claiming that her parents had visited a doctor in Mexico because “my dad also has nerves and is on medication. My mom gets really affected by big surprises.” Furthermore, in the recently arrived population, nerves and depression were often conflated. Dora (age 36, 5 years in Santa Fe) described an “attack of depression” (un ataque de depresión): “Once I had an attack of depression, and that day I was so scared. It was horrible. I had a strong pain in my chest and a strong feeling of suffocating, strong, strong. I couldn’t breathe. They had to call an ambulance. That was here, after I got here, about eight months later. Suddenly, you get depressed and suffocate here [pointing to her chest].” In a similar fashion, Yolanda (age 40, 5 years) also attributed her nerves to depression. Her interviewer asked her what principal problems depression had caused her and she replied, “Well, the nerves, and sometimes I cannot sleep.” An actual glimpse of how a recent immigrant may have learned and ultimately utilized the word stress instead of nervios was afforded by Rafaela (age 65, 1 year). The interviewer took the initiative to ask Rafaela questions that were not part of the standard interview schedule (e.g., For you, what causes stress?). The following illustrates how the very concept of stress was foreign to some recent immigrants: ENTRE: For you, what causes stress? RAFAELA: I don’t know what it is. ENTRE: Anxiety, what causes a lot of anxiety? Pressure, what causes that? RAFAELA: One is very weak from the nerves. ENTRE: Is it something physical? RAFAELA: Yes. ENTRE: Do you think that the problems of life, to have few resources, to be poor, these are things that also affect stress? RAFAELA: Yes, many times that is it.

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ENTRE: What causes personal stress for you? RAFAELA: For example, when I don’t locate one of my children, I get very nervous. It makes me feel like something is going to happen. I walk in and out until they arrive. Having translated el stress into an idiomatic term she understood (los nervios), the interviewer asked Rafaela to describe a scenario in which she might experience los nervios. Presumably, after this encounter with her interviewer, she understood that the terms el stress and los nervios are comparable. Interesting, too, is her interpretation of what her interviewer suggested was a physical disease or illness state—stress. For Rafaela, stress was a physical, embodied reason (i.e., weak nerves) why one is affected by external situations that have the potential to be anxiety-producing. Apparently, if not afflicted with “weak nerves,” one does not experience negative external stimuli as stressful. But stressful situations also cause weak nerves. To some extent, for Rafaela the concept of stress took on the labile quality of the term nervios. In contrast to those recently arrived immigrants who more frequently invoked nerves as both the cause and outcome of disease, the average (mean) number of years lived in the United States for those who utilized the word stress in any context was 9.1 (median 7.5 years). Recall that the mean and median for immigrant usage of the term nervios were 6.7 and 3 years, respectively, a large difference (see Table 25). A total of 18 out of 63, or nearly 29 percent, mentioned the word stress in their narratives. Contexts in which women said that they felt stress ranged from general problems and worries to concern about their diabetes, hypertension, or cardiac illness. This is yet another indication that those with diagnosable chronic illnesses were acculturating more rapidly. Mental illness (e.g., caused by too much stress); time management (e.g., feeling rushed); physical pain; mundane occurrences or “house stress”; and not getting along with family were also discussed. Table 25. Use of emotion term by years lived in the U.S. Emotion Term Sad Nervios Depressed Stress

Mean Years 1.7 6.7 8.1 9.1

Median Years 1.3 3.0 5.0 7.5

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Anahy (age 30, 10 years in Santa Fe) is an example of a veteran migrant who used the word stress in her interview. She told her interviewer that she did not need to resort to self-administering home remedies (she did not get sick often) because her life was relatively peaceful: “The thing is, I don’t have a stressful life. I live well. I live well, since my husband treats me well, I live well. I take my medicines and try to get better. Sometimes, when I have a really bad cold, I drink manzanilla tea or other herbal teas.” Maria M. (age unknown, 4 years) attributed her infrequent headaches to stress: ENTRE: How do you know when you are not feeling well? What symptoms indicate to you that you are sick? MARIA: The only things are the headaches that I get at times. I think that it’s because of the everyday stress. It’s the only thing that I suffer from. ENTRE: These headaches. Do you consider these migraines or no? MARIA: Well, no, I don’t really consider them to be migraines. They’re just from the house stress. Sometimes it’s just being here all day. Time goes by very quickly. Looking after three children so close in age, and then the one that still has not left the bib or Pampers. Yes, all this at times gives me headaches. You have to feed them. And each one doesn’t eat the same. All of this has you flustered. I think this is fatigue. Josefina (age 44, 13 years in the U.S.A.), whom we met in chapter 8 on CAM, also connected her stress with embodied pain. She told her interviewer about the symptoms that worried her most: “When my head hurts, when it hurts here on your upper back, that’s a lot of stress. When I go to Juárez, I take advantage of it and have them give me a massage to relax the stress. And here I had to go to a chiropractor because a shoulder was hurting me a lot, but I’m okay now.” Of course, these narratives do not fall into seamless, bounded categories, and more than a few subjects utilized both terms interchangeably. Based on the evidence provided by the mean and median number of years associated with the use of each term, however, there does appear to be a shift over time in usage and understanding of the two terms, reflecting that a type of cultural learning was occurring in this subpopulation of Mexican immigrants. Moreover, the immigrants did not just exchange the word nerves for the word stress. Rather, it

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appears that the latter does not implicate the body as much as the former. That is, stress does not affect the nervous system in the same way; the “neurasthenic” quality of one who is weak from nerves does not appear to translate directly into the concept of stress for some of the veteran immigrants. Instead of citing “weak nerves” as an attribution for other illnesses, veteran immigrants such as Josefina and Maria M. discussed everyday “stress,” which simply causes headaches, backaches, and even depression, but no organic damage to the nervous system. Also, one can develop weak nerves (an illness that causes other problems) because of various physical or emotional insults, but there was no mention that one can develop a disease state called “stress” that precipitates other physical or emotional problems.

BELIEF THAT MENTAL ILLNESS IS CURABLE Not only did the encoding and usage of the words stress and depression evolve with time spent in the United States, but also opinion regarding whether “mental illnesses” (las enfermedades mentales) are curable. I detected no overt patterning (it was more subtle) in the types of attributions for the onset of mental illness: they ranged from a mean number of years spent in the United States of 2 to 3.5 for attributions of nervios, inbreeding, “parents don’t understand you,” drugs, and parental alcoholism, to means of 5 years and more for family physical violence, stress/pressure, and rape. Interestingly, there was a robust patterning to the responses elicited by the question, Do you think mental illness is curable? Perhaps the pattern was more obvious because subjects simply supplied a one-word answer (yes or no) or “I don’t know” so no judgment was required to code them. Nevertheless, the data suggest that change in beliefs about whether mental illness is curable did occur over time.5 Those who had spent less time in the United States believed that mental illness was not curable. The mean number of years associated with this negative response was 1.9 (median 1 years; range, 1.5 months to 4 years). Similar in terms of time lived in the United States were those respondents who said that they did not know whether mental illness was curable. The mean number of years reflected in this response was 1.4 (median 1 years; range, 2 weeks to 2 years). Conversely, the interviewees who believed that mental illness was curable averaged a mean number of years lived in the United States of 5.9 (median 5 years; range, 3 months to 45 years). It should be noted that the vast majority (30) of the interviewees said that mental

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illness was curable, only 9 thought that it was not, and 6 said that they did not know. See Table 26. Table 26. Belief in the curability of mental illness by years lived in the U.S. Curability of Mental Illness Do not know No Yes

Mean Years 1.4 1.9 5.9

Median Years 1.0 1.0 5.0

What can be gleaned from these statistics is that the Mexican immigrant population is not naïve about the existence of treatment for mental illness and the possibility of curing it. In fact, of 54 subjects who were queried about whether they knew anyone who was or had been sick with a mental illness, 33 said yes and only 21 said no. What they may not be as adept at, however, is identifying the signs and symptoms that North Americans consider integral to the affective disorders of depression and anxiety. Recall that these two concepts, or their (imperfectly mapped) corollaries, sadness and nerves, were often used interchangeably by the recently arrived immigrants.6 Also, they do not appear to categorize depression (and anxiety) as mental illness, reserving that diagnosis for something more serious, necessitating incarceration in an institution (or, as some suggested, chains). This tendency to conceive of mental illness as something dramatic and intractable that happens to other people was illustrated by Neli (age 55, 5 years in Santa Fe). Her husband left her after they immigrated to Santa Fe. She told her interviewer that she had been diagnosed with depression and was being treated for it—with antidepressants and therapy (she paid more than one hundred dollars a month for her medications). Yet, she did not consider herself sick with a mental illness. The following narrative suggests that ideas about what constitutes mental illness are not easily changed: ENTRE: What would you call your actual problem? NELI: Depression. There has been so much stress. ENTRE: Why do you think your problem began? NELI: Well, personal problems with my marriage. ENTRE: Before you were married, you did not have many problems with depression or stress?

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Immigration, Acculturation, and Health NELI: Yes, ever since I was very young. ENTRE: How severe is this depression? NELI: Almost on a daily basis. ENTRE: Is this going to affect you in the short or long term? NELI: I wouldn’t know. I hope it is short-term. ENTRE: What is it that scares you most about your illness? NELI: Well, to feel like this, depressed, sad, weak. At times, I feel very tired. It is what affects me most. ENTRE: You already told me what type of treatment you are taking. You are taking antidepressives, right? NELI: Yes. ENTRE: You are also speaking with two counselors at a clinic in Santa Fe? NELI: Well, with…[names her first counselor] it has easily been six months. Then later I switched .…to…[names her second counselor]. I have had little time with him. But, yes, both counselors have helped me. ENTRE: How long have you been taking the medicine? NELI: Close to two years. ENTRE: This is the only treatment that you are taking? NELI: Yes. ENTRE: Have you talked with a priest about your problems? NELI: No. ENTRE: In the past—because you said when you were little, you had stress and depression—whom did you turn to? Were there counselors in Mexico? NELI: No. ENTRE: Medicine? NELI: No. ENTRE: What did you do there? NELI: I talked with my friends. ENTRE: Do you consider depression or anxiety a mental illness? NELI: No, not a mental illness

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Conceivably, it does not matter whether Neli conceptualized her depression as a mental illness, for she was receiving therapy and medication. That she even sought care may be due to her having lived in the United States for so many years, where she learned that extreme and unrelenting sadness—even if she does not call it a mental illness— is a reason to consult a medical doctor. The need to understand how immigrants—Mexican or other—conceptualize and treat emotional disturbances has been addressed in the large literature on nervios and other “cultural idioms of distress.” Some studies have even reported that after adjusting for demographic variables (particularly gender and income), few statistically significant differences in prevalence or severity of depression were found among ethnic groups. SES was a more significant factor than ethnicity in determining risk for depressive disorder (Bratter et al. 2005; Bagley et al. 1995; Vega et al. 1991). What future studies need to investigate, in light of the data mentioned above, is the precise relationship between depressed affect and homeostatic imbalance: Is depressed or anxious affect associated with physical distress a precursor to and therefore an indicator of homeostatic imbalance, or is it a result? Did a mere linguistic effect of the word order or translation produce these findings? Or are they due to what some have written about in this population? That is, culturally, little division exists between experiences of mind and experiences of body (Interian et al. 2005; Congress and Lyons 1992).

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CHAPTER 13

Conclusion

Researchers working in the fields of psychology, epidemiology, and sociology have sought to discover the set of variables that will distinguish recent arrivals from those who have lived longer in the United States. After several decades of research, many theorists hypothesize that rate of change in beliefs, attitudes, and behaviors occurs by generation. That is, the recently arrived or first-generation immigrants continue to resemble their compatriots in the sending communities of Mexico more than they do the naturalized citizens of the United States. Furthermore, many, if not most, of these studies are predicated on the belief that language use (i.e., Spanish versus English) acts as an adequate indicator of level of acculturation. Respondents who choose to speak Spanish during their interview are more often categorized as possessing cognitions and behaviors representative of Mexican culture than those who choose to respond in English. My research tested the assumption that change in beliefs occurs by generation only and by those who acquire proficiency in English. Specifically, I hypothesized that for undocumented Mexican immigrant women, change in health-related cognitions and behaviors would occur more rapidly, that is, intragenerationally, with discernible shifts taking place after only a few years living in the United States. Changes over time in ways of conceptualizing health and illness, preventing disease, perceiving sickness and wellness, and treating illness were examined. Because “social reality happens in sequences of actions…it is a matter of [identifying] particular actors, in particular social places, at particular social times” (Abbot 1992:428), I wanted to understand the process of acculturation as it unfolded. A useful methodology is called “sequence analysis,” and although the debate rages on about the proper way to analyze sequences of actions (see Elzinga 2003 and Abbot et al. 2000), the usefulness of attempting to understand sequence similarity, 229

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and even causality, is not so fiercely deliberated. Another constructive methodology for examining phenomena that “are fully enmeshed in social time and social space” and that involve “social process” is what Abbot calls “interactional fields” (Abbot 1998:176). In the end, however, what matters most are reliable and compelling stories. “The main desiderata of explanation are consistency and interest. First, even though disciplines grow in fits and starts…our knowledge becomes great only when it has internal consistency. Our theories, our explanations, our methods, and our research programs should resonate with and support one another. In addition to this consistency, our knowledge of society should meet a second standard: It should produce… a comprehensive, interesting, and compelling account of social life” (Abbot 1998:173). To this end, I utilized case-based narratives to enable an intimate glimpse into individual agency, motivations, and behaviors. Because I was interested primarily in people’s ordinary experiences and knowledge, this methodology gave me a means by which to induce or, better yet, understand sequential and temporally ordered patterns of change. I examined the data, question by question, and then “reconstructed” it in the manner discussed by Mishler (1996), by rearranging each interview in chronological order. The outcome was a series of event patterns or trajectories of experience and associated (or perhaps resulting) health ideologies. In other words, consistent and compelling reasons why some people adopted certain health-related beliefs and others did not became readily visible. The 62 Mexican immigrant women who were interviewed imparted interesting and important information that shed light on both the process and rate of acculturation in the health domain. Regarding their conceptual models of health and illness, the recent arrivals thought of health as indicating the ability to “take care of the family” or make “economic progress,” among other things, whereas the veterans had entered the U.S. discourse that envisions the healthy body as a homeostatic factory or a precariously balanced, functioning system or complex of systems. The veterans also conceptualized health in a more phenomenological manner, associating health with tranquility, and a state of “desire” or “encouragement.” Beliefs about the causes of ill-health were different for the recently arrived and the veteran immigrants. Those who had spent little time away from Mexico cited the weather, extreme temperature changes, inadequate sleeping and eating schedules, and a deficit of calories as

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causing ill health, whereas the veteran migrants blamed a high-fat diet, insufficient exercise, and heredity. The obverse of these causes of ill health are the prescriptions for good health. Among the newly arrived immigrants, avoiding extreme temperature changes, sleeping well, and eating an adequate amount of calories on a rigid schedule afforded good health whereas eating a low fat diet, getting exercise and having good genes afforded good health for those immigrants who had lived in the United States longer. Cognitive models of proper illness behavior were markedly different between the two populations. Recent arrivals cautioned that people should “get up and get around” (i.e., perform their normal routine) in order to avoid the (ineluctable) sadness associated with disease, a sadness which in turn causes illness to worsen, whereas veterans thought that people should “stay in bed” and “drink fluids” when they are sick with subacute illnesses. Knowledge about and actual utilization of complementary and alternative medicine increased with time spent in Santa Fe, too. More veterans had heard of and visited acupuncturists, chiropractors, iridologists, and the like, than recent arrivals. One of the more notable findings was that even though faith in the traditional Mexican healing modality curanderismo decreases somewhat with time lived in the United States, the determining factor in the complete renunciation of this belief is conversion to a Protestant belief system (e.g., Pentecostal, Baptist, and Jehovah’s Witnesses). Another important finding is that adoption of U.S. allopathic beliefs was accelerated in those diagnosed with chronic illnesses (i.e., diabetes, hypertension, heart disease, and pregnancy) because of their continual contact with health care providers. This subset of respondents tended to understand and adopt more rapidly U.S. allopathic beliefs about diet, exercise, follow-up care, and so forth, than those who presented in clinics with subacute viral infections. The latter group’s rate of acculturation was much slower because they perceived their providers as racist, incompetent, or negligent. Consequently, they tended to avoid clinics and did not establish a regular source of care. Diagnosis type was more relevant for predicting rate of acculturation than were type of sending community (rural or urban), degree of religiosity, level of education, and age. Tangential to the above, understanding of viral (versus bacterial) theory was most pronounced in the recently arrived immigrants

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diagnosed with chronic illnesses. This subpopulation also learned more rapidly the importance of following directives to complete a course of antibiotics. Understanding of viral theory did increase with time lived in the United States, and some veterans understood why U.S. health practitioners limit the prescribing of antibiotics for viral diseases. The belief that antimicrobials can heal all manner of illnesses better and faster, however, is a tenacious one. Both the recently arrived and a number of veterans continued to self-administer antibiotics and believed that they were not prescribed these because of discrimination or incompetence on the part of health providers. Last, a majority of recently arrived respondents stated that they knew that they were sick when they felt “sad,” “depressed,” or “weak,” in effect allowing emotion states to act as proxies for the perception of a diseased body. Over time, the term nervios evolved into a narrative on the harm to body and mind caused by “stress.” A similar development took place in the understanding of negative affect: recently arrived migrants spoke of being “sad,” “weak,” or “desperate,” whereas veteran immigrants described feeling “depressed.” More veteran immigrants were in treatment (pharmaceutical and therapeutic) for depression than were the recently arrived. Finally, more veteran immigrants thought that mental illness is curable than did the recently arrived.

METHODOLOGICAL REFLECTIONS What might undermine or call into question these conclusions is that the survey instrument was flawed in some manner and/or that the interviewers who questioned the respondents introduced some undetected bias that diminished the veracity with which the immigrants represented themselves, their actions, or their beliefs. Both of these are possible, despite measures to prevent or counteract them. Mention needs to be made of the potential ways in which the information may have been compromised. Interviewers with the same cultural background were chosen deliberately to pose the questions to the immigrants. Published studies and those working in the field generally agree that interviewer characteristics can have a large effect on response bias (Wilson et al. 2002; Warnecke et al. 1997), especially for sensitive topics. In the present study, the immigrants felt much more comfortable speaking with the Latina interviewers who shared their cultural background. All

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the interviewers working on this project felt that they had developed good rapport with their interviewees, but one human factor may have induced slight permutations or bias in the information presented by subjects: the socioeconomic background of one of the interviewers from Mexico. Coming from an upper-middle-class background, she was well educated, and her Spanish reflected this. It is possible that the women she interviewed picked up on this class distinction and withheld certain information as a result. Even though she herself was living the immigrant experience—reduced funds, moving from apartment to apartment, working two jobs to pay rent—her class background was apparent even to someone not from her culture. One piece of evidence pointing to the possibility that she may have unwittingly introduced bias is that she received fewer reports (based on the percentage of interviews each interviewer conducted) of visits to curanderos than did the other two interviewers. Her interviewees might have been uncomfortable telling her about their visits to curanderos because, in Mexico, this sort of behavior is often looked down upon by those from higher socioeconomic backgrounds. Another concern is that this population is characterized in the literature as having a tendency to provide socially sanctioned or desirable responses, what is otherwise known as an “acquiescent” response style. Warnecke and others have written about this phenomenon: “Socially desirable response patterns may be compatible with the commonly observed pattern of social interaction in Hispanic cultures referred to as simpatía, the expectation that interpersonal relationships will be guided by harmony and the absence of confrontation” (1997:336). If the results of this research are viewed through this lens, then what has occurred over time in this subject population is a type of cultural learning. For example, I discussed that recently arrived immigrants had different beliefs from veterans about what constitutes a healthy diet. The veterans may simply have picked up on a discourse about diet and exercise in this country and provided responses they deemed to be culturally appropriate; whether their behaviors had changed remains to be discovered. Whether social desirability may have been influential in determining response patterns is unclear. An argument that would contradict this assessment is that both recently arrived and veteran immigrants answered affirmatively to the very sensitive question about antibiotic usage, thus attesting to their willingness to admit to committing a federal crime. This is obviously a

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highly sensitive topic and therefore a contradiction to the argument that they are unwilling to provide socially undesirable information. It is a great concern to those who construct health-related (as well as other types of) questionnaires that question order and wording (or, in this case, translation) may negatively affect the type and quality of information provided by respondents. Because the questions used in this study were taken from other published studies, it is assumed that only imperfect translation into Spanish might be a causal factor in the collection of data that does not accurately reflect the migrants’ experiences. Another fear about collecting valid data in the Mexican immigrant population is what has been described as a culturally influenced bias toward providing extreme responses to questions involving judgment. An extreme response style would cause a respondent, when asked to form a judgment or “rate” an event or experience, to pick either extreme of the rating categories provided. In the present study, the results of the rating question regarding the health care system, then, would have been (culturally) influenced such that recently arrived respondents would choose to rate their experiences with U.S. health providers as either a 1 or 3. What was discussed previously vis-à-vis the veteran population’s assessments of the U.S. healthcare system might be interpreted as a type of cultural learning having to do with an increased usage over time of modifiers when performing a task of judgment. That is, using qualifiers when making judgments is something non-Hispanic Whites are postulated as doing more frequently than Hispanics (Warnecke et al. 1997). However, it is easy to show that recent immigrants weren’t the only ones providing responses in the 1 and 3 categories because the majority of responses (12) fell into the 2 rating category. The number of years represented by those with subacute illnesses who rated the health care system in Santa Fe as only a 2 was in the middle, 9.5 (median 5 years), compared with 2.9 (median 1 year), the average for those who rated the system a 3, and 12.6 (median 6 years) for those who rated the system a 1. These medians contradict the argument that cultural learning and extreme responses are incompatible.

LOOKING FORWARD Case histories or narrative data based on individual interviews, such as those collected for this study, can provide a basis for explanatory

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analysis and induction (Massey 1987). Productive observation and study of individuals can lead to the creation of typologies that may be of theoretical and heuristic value. The specifying of typologies has played a prominent role in psychological theorizing, especially in the domain of personality theory. From Sheldon’s personality types based on body build to Eysenck’s psychometric separation of individuals on the basis of extroversion/ introversion, behavioral typologies are useful insofar as they may be utilized in the process of scale construction (the “bottom-up” approach)—the ultimate goal, not of this project, but of much acculturation research. Patterns of theoretical importance not readily deducible from prior theory often emerge in the compilation of this type of data (Massey 1987). Theoretically, a sound understanding of the acculturative process will yield information about individual differences that can assist in interpreting the psychological and social impact of the meeting of cultures at the level of the individual (Padilla 1980:66). Practically, typologies are important because they help specify the dynamics of individual psychological and behavioral functioning (Padilla 1980:66–7). Moreover, by trying to understand how the immigrants’ ratings of the health care system influenced their purported behavioral outcomes, I attempted to address both the issue of psychological acculturative stress (which Berry [1980] claimed decreased over time) and the “lifestyle model” that attributes a decline in physical health due to acculturation (Salant 2003:72). The mean and median number of years immigrants had lived in the United States were reported in their relation to themes and event sequences in order to support the conclusion that change in health ideology was occurring in this population of Mexican immigrants. This is integral to the research endeavor, for an important contribution of dynamic developmental models of temporal processes is that they can provide the building blocks of conceptual understanding for other researchers. What is more, these event sequences provided “greater clarity about the relationship between acculturation and health by permitting side-by-side comparisons of different outcomes in the same population” (Salant et al. 2003:87), something that researchers have deemed necessary to further the field of acculturation research. It is only a first step, however. Other medical anthropologists can take this information, these “elicited themes,” and begin to make better sense of how they are distributed in the immigrant population by conducting types of consensus analysis such as free lists, rankings, and pair sorts.

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Some anthropologists have taken to using scenario interviewing to determine the extent of cultural sharing of health ideology and other cognitive domains, what Dressler calls “cultural consonance” (1996:7). As Chavez and others have noted in their own work, however, “consensus analysis was designed for use by anthropologists and is superb for analyzing levels of agreement among relatively small samples. To tease out the influence of cultural beliefs on behavior, especially relative to other variables such as gender, income, education, and medical insurance, [what is typically required are] large samples and the use of random sampling” (2001:1115). Well-funded, statistically oriented social scientists can use the information reported here to create survey instruments that are sensitive to and can detect these or other event patterns associated with cognitive shifts in health ideology and, importantly, changes in health behaviors. In addition, what needs to be tested further is the hypothesis that rapid shifts in health beliefs are associated with increased access to material resources and services. Examples of resources in the present context could be mechanical insulin monitoring devices, financial assistance via the county and state indigent health programs, and, of course, health care personnel who have been instructed to take the time to explain the relationships between disease, treatment options, and health outcomes. Increased access is certainly a factor in the speed with which immigrants learn and use English (Espinosa and Massey 1997), and it is hypothesized as being a significant factor in the acceleration of shifts in health ideology. In the conclusion to their study, Palinkas and Pickwell (1995) hypothesized about what I found to be valid in the present study, namely, that chronic disease hastens the acculturative process by facilitating increased contact with the U.S. healthcare system. See also Berkman and others, who argue that not enough attention has been paid to researching the effects of differential access to material goods, services, and resources that might act as a mechanism through which social networks operate (2000:849). These networks, in turn, act to hasten the process of acculturation. A similar result was reported by Finkler (2001), who noted that the Mexican patients who suffered from hypertension and were recalled for visits with physicians were much better at maintaining treatment regimes than those who were sent off with a diagnosis and not requested to return to see the doctor. Those in the latter group tended to neglect taking their medication, causing them to relapse into bodily

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distress. Unfortunately, increase in access also implies the necessity for structural changes, to which those in positions of responsibility for the U.S. healthcare system (legislators and the citizens who elect them) may not be amenable. As discussed previously regarding structural barriers to care, Chavez (1992) also found that economic and political constraints shape the use of health care by low-income, undocumented immigrants. Some Mexican interviewees who had lived in Santa Fe longer had managed to acquire jobs that provided medical insurance and had, for the most part, learned to use the health care system effectively. This contrasts sharply with the common characterization of undocumented migrants as primarily temporary residents in jobs that do not provide medical insurance. Insured interviewees generally utilized health services, indicating the importance of medical insurance to overcome the barriers that may exist because of a lack of immigration status. Moreover, the insured tended to use clinics rather than more costly hospital services. This suggests that when the financial barriers to health care are reduced, undocumented immigrants are more likely to acquire timely and ultimately cost-effective (for both individuals and society) health care. Important is Chavez’s conclusion that when the financial barriers to health services are reduced, research will be better able to ferret out the effects of differences in beliefs and language, as well as various forms of miscommunication or bigotry. Increased access needs to be defined more specifically. Precisely what is being accessed that both accelerates acculturative shifts in health ideology and behavior and potentially improves psychological and physiological outcomes? To understand how this process works, it is necessary to delve into the vast literature on the impact of social relationships and their affiliation on physical and mental health. Berkman and others (2000) have created a persuasive model of social networks and their relationship to behavioral, psychological, and physiological outcomes. In their conception, the upstream factors of socialstructural conditions (the “macro” level) and social networks (the “mezzo” level) provide opportunities for and therefore influence the downstream factors of psychosocial mechanisms (the “micro” level) and what they call the “pathways” of behavioral, psychological, and physiological outcomes. What is compelling about their model is its ability to explain precisely how increased contact with health services affects health outcomes in manifold ways. In fact, utilizing their

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categories of social support, it becomes clear that a clinic such as that in Santa Fe affords its chronically ill patients four types of support: emotional, instrumental, appraisal, and informational. In the emotional realm, the health promotoras provide care, sympathy, understanding, and esteem. The diabetic, hypertensive, and pregnant patients receive instrumental support in the form of financial aid and assistance with their bills, help with getting to the clinic for appointments, and such. They receive appraisal support of their health conditions in the form of help with decision making about pharmaceutical or lifestyle therapy and feedback on treatments undertaken. Last, informational support is provided by the promotoras, who communicate about health conditions and give advice about successful treatment options. Of great importance is that health promotoras provide the Mexican immigrant women support not only on the individual level but also via their connection to the “brick and mortar” of the clinic itself. That is, they also supply neighborhood and community connections, which, in turn, enable the immigrants to form strong bonds and attachments. Both the community and individual support provided by the clinic health personnel are of paramount importance in this equation because, as will be discussed below, these women do not always benefit from the support of what is called in the sociological literature on migration “immigrant networks.” Conversely, quite a few of the women discussed how they did not receive as much help from their compatriots and family members as they would have liked. Instead, other Mexican immigrants refused to suggest where good jobs could be found; they denied material support in terms of housing and money for necessities; and they even refused to speak to recent migrants, pretending that they did not speak Spanish. In this context, it is no wonder that the recently arrived, chronically ill find succor in the friendships with healthcare service providers. These friendships positively affect the immigrants’ willingness to entertain new or different health beliefs and behaviors. But this is not the case in all health care contexts involving immigrants. An interesting finding published by McKee and Cunningham (2001) found that social support was not associated with increased physical or emotional well-being in a group of female Hispanics. Obviously, more work needs to be done to untangle these relationships. But health care personnel are neither the sole nor sufficient material resource required to aid in catalyzing (positive) change in the health beliefs of the Mexican immigrant community. The diabetic,

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hypertensive, and pregnant women who were afforded access to these resources made significant cognitive and behavioral adaptations in order to better their own health and that of their babies. Perhaps what happens in the health domain is a process of “selective acculturation” (Keefe and Padilla 1987). Interpreting through this lens, immigrants, especially chronically ill ones, strategically choose to acculturate more rapidly in terms of health ideology because they have a physical imperative to do so. Rather than stick their proverbial heads in the sand (as some undoubtedly will in response to a diagnosis of chronic disease), they open themselves up, seeking advice from those whom they realize they must trust. Indeed, they become willing participants in and directors of their own health care. It must be underscored that, in general, acculturation is a complex, non-linear, multidimensional process and the teleology of biculturalism (or even neoculturalism) cannot be ruled out. What is presented here is but one aspect of the multidimensional phenomenon that is acculturative change. Finkler, speaking generally about the “social constructivist” perspective on medicine, has called for ethnographers to demonstrate the “specific aspects” of its construction. She continues, “It is not enough to speak of the cultural construction of a particular system of knowledge in the absence of empirical evidence that demonstrates specific permutations of that knowledge and practice within a given society” (2000:26). I hope that the reader will agree that the present research project has succeeded in illustrating the specific variations, as well as the antecedents and consequents, of the female Mexican immigrant trajectories of health ideology.

BUILDING BRIDGES Perhaps the most important message of this work is its attempt to create a bridge between the fields of medical anthropology, acculturation research, and the disciplines of epidemiology and immigration studies. Medical anthropologists reading this book might not find it at all surprising that patients’ explanatory models or idioms of distress would change during the course of culture shift. After all, patients are thought to do this on a regular basis even within the context of their own cultures. “The change from old to new social forms holds the same profound implications for health care systems as for other cultural systems. In such modernizing societies, one finds social realities that are a strange amalgam of modern and traditional beliefs, values, and

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institutions, held together in varying patterns of assimilation, complementarity, conflict, contradiction. Since modern medical ideas and practices are often at the tip of the wedge of technology introduced during the modernization process, it is not surprising that health care systems provide some of the sharpest reflections of the tensions and problems of social development” (Kleinman 1980:37). The same can be said of acculturation in general: as a person leaves behind the old to embrace the new, odd fusions of health (and other) beliefs are possible and indeed likely. Medical anthropology has a story to tell about how health-related cognitions are plastic, imprecise, and ambiguous. Decisions about health care options, beliefs about etiology, understanding of pathophysiology, and so forth, are fashioned from complex semantic networks, systems of symbolic meanings that are inherently fluid and adaptive. As I have already discussed, classic, static, “snapshot” cross-sectional survey data of folk health beliefs cannot impart the malleability, complexity, and evolutionary quality of popular health ideology. Cross-sectional acculturation measures used in physical health, sociological, and psychological studies are often predicated on indices (e.g., age at immigration, place of birth and/or generational status; cultural participation, social relations etc.) or psychometric scales that, lacking granularity, are not able to detect a true cognitive and behavioral shift that proceeds more quickly than by generation. Moreover, “the diversity of specific measures and the disciplinary models upon which they are based make comparisons across… health domains extremely difficult. Acculturation measures in physical health studies generally conform to models derived from sociology and behavioral epidemiology while studies in mental health and health services use frequently borrow psychometric scales from the psychological literature.…This analytic separation of health domains belies their interrelationships; patterns of health services use inevitably effect the outcomes of both mental and physical health while poor psychological health…impacts physical well being” (Salant et al. 2003:86). Furthermore, varying degrees of English language proficiency in the Mexican immigrant population pose a problem for acculturation researchers who base one of their outcome measures on “language of interview.” One hundred percent of the respondents who participated in this research would have preferred to answer questions on survey

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instruments in their native language, despite the great amount of variation in their English language fluency, their health care ideologies, and other beliefs. The problems caused by basing level of acculturation on language of interview were discussed at great length in chapter 2 and are published elsewhere (Reichman 1997; see also Cabassa 2003). The data from this project contradict the results of most survey data, which purport a direct relationship between level of acculturation as assessed by Spanish language use and belief in folk health ideology. This research has revealed instead that there is no simple isomorphism between low levels of acculturation and belief in “traditional” health ideology. Better understanding of Mexican immigrant health beliefs, as well as true reform in health service delivery, may be possible with the marriage of medical anthropology theory and qualitative data collection methods, and other types of research that have acculturation as a component. All researchers interested in acculturation processes can benefit from learning about and adopting the assumptions, weltanschauungen, and methodologies promulgated by those working in other research domains.

WHERE TO BEGIN Researchers in the field of acculturation are desirous of developing accurate instruments to reflect both the process of and the reliable and valid measurement of the phenomenon, but seemingly few have stopped to ponder what the people who are doing the acculturating have to say about the topic. One of the questions I asked illuminated whether and how the immigrants perceive themselves or their compatriots to be acculturating: do you think people change when they come to this country? Of the 22 women who were asked this question, a startling 20 said yes. They claimed that Mexican immigrants definitely undergo major cognitive, affective, and behavioral changes. For those who responded affirmatively, time spent in the United States ranged from as little as 2 months to more than 10 years (mean 6 years; median 5.3 years). The low end of this range (2 months to 1 year) indicates that interviewees, in responding to this question, were drawing on a discourse that probably pre-dated their arrival in the United States. Therefore, their responses were not dependent on actual personal experience of change. Rather, they came expecting to change themselves or to witness a change in their family and friends.

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This is particularly fascinating in light of the widely perceived notion that Mexican immigrants are resistant to the process of acculturation, usually attributed to their lack of interest in learning English. According to the immigrants themselves, not only do Mexicans change when they come to the United States, but also some come to this country hoping for and anticipating transformation! This belief or discourse was articulated by Diana, who had lived in Santa Fe only 10 months at the time of her interview. When asked whether she thought that she had changed since coming to the United States, she said, “I think I am still the same. It has been too little time for me to change.” Implying that change is inevitable but that enough time had not passed for her to undergo it, Diana gives voice to one aspect of the “immigrant” discourse on acculturation. In the same vein, Dolores (age 32, 6 years), who had lived in the United States 5 years longer than Diana, asserted that she had changed since coming to live in Santa Fe: “Yes, my religion. I have changed the way I dress, think, act. I think better than before…the clothing changed a lot.” Another aspect of the immigrant discourse on acculturative change is that 77 percent of the 22 who responded to this question professed that they had not, themselves, undergone significant personal changes, but others whom they knew had. Aurora (age 49, 10 years) is one who felt that she had not changed her way of being since arriving in the United States: “No, I still remain the same, as a naca, and of Mexico, like the cactus.” Respondents were not quick to admit that they had undergone significant personal, lifestyle, or philosophical changes, but they did share some of the ways other Mexican immigrants had changed: (a) They pretend not to know Spanish so that they do not have to speak to and possibly help recent arrivals: “Sometimes [people change], yes. For example, there are people who arrive here the same as you, without anything, and because they already know how to speak a little English and because they already have a good job…they pretend like they don’t know Spanish, or that they are from here, or that they don’t know how to help” (Aurora, age 49, 10 years). (b) They become conceited, materialistic, less humble, more individualistic, selfish: “Yes, I have seen people who have changed, that forget about their kids, about their families, or their country and convert to life here…how can I say this…individualistic and selfish (Monica, age unknown, 3 years in Santa Fe). (c) Women’s roles change—women become less submissive:

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MARTHA (age 24, 6 years): They change in many ways, because in Mexico, as a result of the economic situation or tradition, the woman is very submissive. Here, the woman is more open. When one comes here, they get more freedom because you have the options to choose what you want to eat, how you want to dress, where you want to put the kids in school. In Mexico, because of the economic situation, you do not have those options. If you want to have a good diet and you don’t have the economic resources, well, you have to eat what you have. You have to take the children to public schools because there are no resources. Here, I think there is more liberty. In Mexico, it is not typical that the woman works. ENTRE: Have you changed your way of being? MARTHA: Yes. I was very submissive. I did what my husband told me to do. He was the one who made the rules in the house, the one who paid the bills. Now I can work. I can go out. I decide what we are going to eat, for the well-being of us all. I have the possibility of seeing different places for a better education for my son. Before, I could not. Several immigrants blamed the newly found freedoms for both men and women on (d) the breakdown of the family (divorce, separation, etc.): INES (age 32, 6 years): If you stay here very long, you get used to the customs here. And when you go back to Mexico, you don’t want to be there. The people that I have met become more confident, insolent. They stop being humble. And they separate because they want to be here more than to live in Mexico, and the family breaks down. Yes, they change. For example, the women there do not go out. They are very reserved. They do not walk. Here, they buy cars and walk wherever they want, and they don’t even tell their husbands where they are going. (e) Immigrants have to adjust to the fast pace of life in the United States: “Yes, their way of living changes. It is more different here…here, life is more rapid. There is not a lot of time for family. There is a lot of work, a lot of running around, the manner of eating, beans with pizza, potatoes with hamburgers” (Maria S., age 29, 3

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years). (f) People change their religion. (g) People change the way they eat and dress. It is naïve to think that the immigrants do not have generations of experience on which to base a cultural “discourse of change” or “acculturation.” The present research provides a fascinating glimpse into the world of acculturation from the vantage point of those who are doing the changing. As such, it deserves more study to illuminate the ways in which people perceive change in themselves and in others. The relationship of personal expectations of acculturative change to actual cognitive, behavioral, and affective shifts is also of great interest. Research that attempts to untangle these factors would be welcome. In sum, little thought is apparently given to the importance of building relationships of trust early on during the immigrant experience of subacute diseases, relationships that would facilitate the process of acculturation along health ideology dimensions. Trust, in turn, would help immigrants cope with their transition into mainstream U.S. society and mitigate the psychological stress associated with migration. Both of these would increase their sense of well-being, leading to better health outcomes. Better outcomes, in turn, would positively affect the U.S. healthcare system in terms of cost. Some of the costly changes that would lessen health disparities include training and placement of Spanish-speaking staff in the emergency rooms, health care clinics, and shelters that treat immigrants; education for health care providers on the “disease” terminology used most often in health and mental health contexts by Spanish-speaking populations; and funding for services for migrants who lack health insurance and who are unable to pay for diagnosis and treatment. Thinking realistically, instead of large structural shifts in health care delivery, perhaps some small steps can begin to eliminate the communication problems between providers and their Mexican immigrant patients. Providers often do not speak Spanish well enough or have enough time to explain the differences between bacterial and viral infections. Marketing strategies to educate immigrants and their communities about health issues (e.g., proper antibiotic use, signs and symptoms of diabetes, and the importance of proper diet and exercise) would be a small first step. Pamphlets written in simple Spanish could describe these differences, reassuring patients and allaying their anger at not receiving strong antibiotics. The problem of bacterial resistance to antibiotic medicines could also be explained. If recent immigrants

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can gain a better understanding of these issues, they might not avoid returning to clinics. Explanations as to why treatment at a hospital emergency room is not an efficient, speedy, or inexpensive process would be helpful, as would a discussion as to why the emergency room is not the best place for a subacutely ill child to be treated. Ways to determine whether a child is dangerously ill and ways to help a sick child regain health could also be outlined. These basic pamphlets could be given to new mothers as they depart the hospital with their babies, as well as to adults seeking treatment for subacute problems at the hospital. Addresses of local clinics would be included. Importantly, more and more communities are cognizant of the need for home visits to help new mothers establish breastfeeding and immunization schedules, as well as to ascertain whether the home is a context for domestic violence. The topics mentioned above and others could easily be addressed during these home visitations. Enlisting the aid of immigrants to help lessen the workload of the local clinics and hospital emergency room (by treating basic viruses in the home) might be possible if they come to understand that this helps everyone in the community.

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Endnotes

Chapter 1 1.

2.

3.

4.

I use the term traditional to denote beliefs about health and illness that are conceptually distinct from those associated with the type of allopathy espoused by the American Medical Association. Please note that I essentially agree with Shweder that a more appropriate way to conceptualize the two health approaches is not by placing them in opposition and implicitly denigrating one or the other, but rather viewing them side by side as “traditions of medicine” (Shweder 1996:5). The INS, with the reorganization of government structure that took place post 9/11/01, was renamed the Bureau of Citizenship and Immigration Services (BCIS). In 2003, New Mexico became the first state in the union to recognize identification cards issued by Mexican consulates. Immigrants with no other form of identification, such as a visa or residency permit, can use the cards to obtain a New Mexico drivers license. In early 2005, Governor Bill Richardson signed legislation giving some illegal aliens the right to lottery scholarships and in-state tuition rates at public universities. However, in late 2005, he appeared to change his tune, declaring a “state of emergency” in four New Mexico border counties due to “a chaotic situation involving illegal alien smuggling.” His office has pledged $1.75 million for stepped-up law enforcement. It is unknown how these zig-zag shifts in policy toward undocumented Mexican migrants may affect future levels of immigration to the state. Interestingly, Whole Foods, one of the largest health-food grocery stores in the Santa Fe area, until August 2005, regularly hired unauthorized Mexican immigrants to work in its on-site kitchens. In August 2005, however, the BCIS began comparing the names and social security numbers of Whole Foods workers. Discovering at least twelve discrepancies, BCIS informed the managers of Whole Foods that they had no choice but to terminate these workers.

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Chapter 3 1.

Forty-four percent of subjects claimed to possess authorized documentation at the time of their first crossing. In some cases, fathers who had been working in the United States arranged for their children or wives to cross; in other cases, respondents were old enough to apply for a passport. The women who had applied for their own passports two or more years before attempting to gain entry into the United States had the least amount of trouble getting six-month tourist visas. The women, before their visas expired, simply traveled back and forth, entering and exiting the country legally. Most who possessed passports overstayed the permitted time. Another 3 percent acquired permanent resident permits when they married Americans. Sixty-six percent of the interviewees claimed to be sin papeles (without papers) at the time of their first crossing. Lacking authorized entrance permits, these women crossed the established BCIS border checkpoints between Mexico and the United States with documents purchased on the black market, or they passed through a non-standard border region where there were no BCIS agents or checkpoints.

Chapter 4 1.

According to INEGI (Instituto Nacional de Estadistica Geografia e Informatica), in a report published on its web site (www.http://www.inegi. gob.mx) in February 2005, the divorce rate in Mexico was 77/1000, or 7.7 percent. It appears that more women in the study were getting divorced than those who stayed in Mexico.

Chapter 5 1.

“Entre” is short for the Spanish word, “entrevistador,” which means “interviewer” in English.

Chapter 6 1.

2.

Martha’s commentary on why God allows sickness and suffering in the world demonstrates what some researchers have termed fatalism (fatalismo) in this population, a concept that has been studied and commented on extensively since the early part of the twentieth century. Although in-depth data were collected on this topic and there is some evidence that the degree or extent to which a migrant adheres to a fatalistic belief in health (and other) outcomes changes with time spent in the United States, I do not discuss this here. For more on this topic, see Cuellar et al. (1995a); Deyo et al. (1985); Cervantes and Castro (1985); McKee (1992); Keefe (1980); Antshel (2002); and Saunders (1954; 1968). San Juana fits a paradigm of acculturation proposed by other researchers (Berry 1980, 1986, 1994, 1997; Padilla 1980). Because she was an unwilling migrant, she resisted, wittingly or unwittingly, adopting many of the health ideas and behaviors associated with time spent in the United

Notes: Chapter 6

3.

4.

5.

6.

7.

8.

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States, ideas promoted by migrants who have lived at least as much time as she had in the host country. In this regard, she fits the model of the reluctant or involuntary immigrant. San Juana was therefore one of those interviewees who, because her ideas were more akin to those of the recent immigrants, continuously skewed the means and medians higher because she was almost always included in the subsample of recent migrants. Regarding disease etiology specifically, San Juana was actually not that different from a larger subset of the migrants—both recently arrived and veteran—who subscribed to humoral theory. Approximately 25 percent of the entire sample made reference to throat illnesses, or anginas. Of these 16, 11 (68 percent) were from urban areas, and 5 (31 percent) in the subsample had been in the United States fewer than 5 years. In Finkler’s (2001) work, she noted that only 1 of the 8 physicians she accompanied on a total of 400 patient visits somewhat regularly prescribed diet and exercise as a means to improve health. Bad diets are often thought to consist of food that is purchased on the street, that is spicy, or that is eaten at irregular times, causing gastric distress. Inadequate caloric intake was also a cause for concern among the patients. Finkler also discusses illness attributions in her work on spiritualist healers in Mexico: “Appropriate nutrition is believed to mitigate illness. Dysfunctions are imputed to irregularity of food intake, when meals are not taken on time or when too much or too little food is consumed. Importantly too, it is believed that nutritional deficits stimulate emotional reactions, especially anger, to which a wide array of illnesses are ascribed” (1994: 49). In Santa Fe, there are a variety of special outreach and home visiting programs for pregnant women. The largest, Promotora Outreach Program, attends to the needs of 600 to 1,000 pregnant women and lactating mothers (on average) yearly. The local health clinic, which sponsors the promotora program, also has a special diabetes education program, which serves the needs of over 1,000 diabetics yearly. See O’Malley and Kerner (1999). In their study, they identified the health and cancer information sources used by a multi-ethnic population and determined whether information sources differed by ethnic group, age, gender, and SES. Their data show that all ethnic and age groups cited a health professional as the most common source of health information, 40 percent overall. Finkler (2001) discusses CAM options such as homeopathy, acupuncture, and, increasingly, chiropractic in Mexico D.F. Despite their availability in the city and official sanction by the state, these options are almost always more expensive than treatment by biophysicians. It is not apparent that the data collected for this project reflect an awareness of CAM on the part of

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Notes: Chapter 7 residents of urban centers other than Mexico D.F. and Juarez (e.g., Guadalajara and Durango). Stebbins explains that rural villagers in Mexico are very familiar with biomedicine. They are often not convinced, however, that they have as much access to good care as the more economically stable citizens of Mexico. They wonder whether their medicine and their health care providers are as effective as the ones in Mexico D.F. and other large cities (Stebbins 1987:22).

Chapter 7 1.

2.

3.

4.

The question, What do you do when you are sick? was also asked. I hypothesized that discrepancy might exist between what people actually do to care for themselves when sick and what they think that others should do: the ideal versus the real. The former question was intended to glean much greater detail than the latter, leading to the following: Do you ask anyone for advice? Do you try to treat yourself? What home remedies, if any, do you use? Any discrepancies between the replies to these two questions were noted. Interestingly, Finkler noted of her subject population that more than half regarded the public hospital as providing primary care services but “for the majority of the patients, the hospital is [still] a last resort, used after seeking treatment either from private physicians or Health Ministry clinics” (2001:52). In Santa Fe, too, it was noted that immigrants often ended up at the hospital emergency room only because they were turned away from overburdened and understaffed health clinics. Chapter 12 demonstrates a very direct relationship between the migrant’s objective physical illness with fever or pain and a phenomenological experience of nervousness, agitation, or sadness (depression). In the context of this question, Maria N. did not provide an etiological explanation for the onset of illness. Rather, she explains that for her, being sick causes stress. Getting out of the house and working prevent this agitation. Finkler’s experience collecting ethnographic information at a public hospital in Mexico D.F. sheds light on the present discussion because she discovered during this process that “despite the discomforts patients were experiencing, 53.1 percent of the women and 41.8 percent of the men chose to seek treatment on the particular day they did because ‘they had time’; only 22.6 percent of the men and 27.5 percent of the women came because ‘they were feeling sick or feeling worse than usual.’ The rest of the group…came at that time because they accompanied someone else who had an appointment at Salud Hospital. This suggests that for many people, seeking treatment is independent of experiencing pain and discomforts. In fact, patients in the study group reported they had experienced their symptoms for an average of 2.2 years. Only 25.8 percent

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of the men and 14.1 percent of the women reported that they had been recently incapacitated by their illness to a degree that it impeded their daily functioning. In this study, I found that the day-to-day functioning was a poor measure of sickness in Mexico since people claim, and I observed, that they continue to carry on their daily chores irrespective of their professed state of ill health. Usually, only when people had a fever did they cease to carry out their daily obligations” (2001:167).

Chapter 8 1.

2.

3.

In the early 1970s, the Mexican government began to take notice of the discrepancies in the availability of biomedical healthcare options for rural populations compared with those who lived in urban areas. By the late 1970s, the COPLAMAR program (Coordinacion General del Plan Nacional de Zonas Deprimidas y Grupos Marginados, or the General Coordinating Board for the National Plan [to aid] Depressed and Marginal Groups) was implemented. As early as 1980, the results could already be seen: 2,105 new rural health clinics. According to Stebbins, “each clinic was designed and located with the expectation that it would ‘cover’ a population of roughly 5,000 ‘marginal people’ living in Mexico’s most ‘deprived zones.’ Thus, over ten million rural Mexicans were said to have recently become ‘covered’ by these new health clinics” (1987:6). For more contemporary information on the IMSS programs see the Instituto Mexicano del Seguro Social website at: www.imss.gob.mx. This was not the case in the present data set. Far fewer had visited private physicians than government health centers. Of the 59 women who responded to a question about their regular healthcare experiences in Mexico, 32 visited doctors in the social security system, 12 regularly went to private doctors, 8 self-medicated, 6 went to the hospital to receive primary care, 1 regularly visited her local pharmacist, and 1 saw a traveling partero, who helped her deliver her babies at home. Hufford and Chilton discuss the relationship between and the simultaneous rise of the holistic health and health food movements: “In the United States, the health food movement has had the greatest influence in developing and disseminating natural healing ideas throughout the twentieth century. It has provided for an accessible model within which herbalism, nutritional therapy, environmental protection, a variety of lifestyle factors, including exercise, and spiritual concerns could be integrated and explored. Today the widespread availability of health food stores and the appearance of health food language in supermarkets both reflect and continue to advance public attention to natural healing ideas” (1996:64).

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Chapter 9 1.

2.

3.

4.

5.

Bastian (1993) cautions against the facile deployment of the term Protestantism, which is often used in the literature reductively to indicate a plethora of non-Catholic religious movements. Despite this caveat, the more generic term Protestant is used here to refer to the Baptists, the Pentecostals, the Jehovah’s Witnesses, and other Protestant groups, unless otherwise specified. For example, Blanca (age 32, 5 years in Santa Fe) discussed her loneliness after moving to the United States. When asked what attracted her to the Jehovah’s Witnesses, Blanca explained, “What happened was, when I entered the Jehovah’s Witnesses, in that time, I lived in the apartment. I lived very alone, very empty. It was me and my kids, no one else. I did not go out because I had recently arrived. Everything scared me. When they came to the door, many times I would hide. Many times, I did not open the door. But one day I said, ‘I am going to do it. There’s nothing to lose.’ They started to come. We started to study the Catholic Bible, because I told them I was Catholic. There were many things that they made me see differently.” This point is illustrated by Magdalena (age 21, 3 years), who indicated how much she was indebted to the Protestant church for helping her husband stay away from drugs and alcohol: “Yes, I realized that [being a Baptist] is better, because my husband…he was really lost, and in this church, thank God, God saved him. He was doing drugs and alcohol. He [still] drinks—I’m not going to lie—but not like before. He almost never drinks in the house.” Jacqueline’s mother-in-law, Maria R. (age 41, 2 years in the U.S.A.), recounted what attracted her to the Jehovah’s Witnesses when she first arrived: “The Jehovah’s Witnesses carry themselves so well. When you go to the temple, they all greet you even if they don’t know you. They talk to you. If there is anyone who can help you, they do it willingly, and I don’t know, you feel very good with them.” Asked whether she felt less alone and more protected, Maria replied, “Yes, less alone, because when I arrived here, I remember that they gave me clothes as gifts. I didn’t bring almost any clothes. They helped us with what they could. They gave us blankets and all those things.…They gave me courage to go forward, because I had left my children and all that, and that helped me a lot. They supported me.” Hunt suggests that there is a statistically significant relationship between being geographically mobile and converting to some form of fundamentalist Protestantism: “This pattern for [Hispanic] fundamentalists runs parallel to dynamics in the African American experience where mobility of various types is predictive of movement from historically established churches to more sect-like affiliations” (1999:1614).

Notes: Chapter 9 6.

7.

8.

9.

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An example of this was provided by Maria M. (age unknown, 4 years), who described her displeasure with the priests who performed mass in Mexico. Asked when she had switched religion and why, she replied, “Well, it will be just fifteen days since I’ve changed. Why? Because there was a church seminar that I was invited to and I liked it. And I felt that I should be even closer to God. In Catholicism, because there were so many things that, at times, I just could not understand, I have come to understand these things here, so this is why I like this religion.” When asked about Bible passages, she said, “At times they don’t explain Bible passages to you. Partly because of the churches and the priests that don’t even understand them. So I said, ‘Good. Let us see what happens.’” Asked whether she was happy, Maria replied, “Yes, I am happy here.” Maria R. commented on religious iconolatry. Asked what she had found in the Jehovah’s Witnesses, she said, “I found that they told me…I had a Catholic Bible and they had their Bible, and they told me, look for such chapters. I mean Mathew or something. And I saw that mine and theirs were the same, and we began to talk about what it was saying. For example, we, the Catholics, praise idols. We idolize the idols, and that shouldn’t be. You shouldn’t kneel down where there are idols made by man. And this is what I went looking for, to know more about the Bible. I want to know more about the Bible.” An example of how the Protestant discourse affects the lapsed Catholic’s feelings about herself was provided by Dolores (age 32, 6 years): “I think that in the Catholic Church…I don’t know how to say this….I feel closer now than in the Catholic Church. In the Catholic, I went to mass, let’s say, and the following day I carried on as usual, sinning, things that don’t…now I am closer to God because, thanks to God, I’ve stopped sinning so much. I was one of those people that wore a lot of makeup, wore tight pants, and now I feel good, being Christian. Also, because I have had serious, grave illnesses, and, thanks to God, he has kept me from dying, not just once but many times. Also, when I had my kids, I was on the point of dying, and, thanks to God, he saved me. And I thank God for being here.” Ana Maria (age 68, 17 years) expressed her confusion regarding her belief in curanderismo and her church’s disapproval of curanderismo. Asked whether she had been to a healer, she replied, “Yes, I have been. Why would I lie to you? But after, I regretted it.…Because I know it’s not good. In the Bible it says that. But, yes, I’ve been. The temptation is very hard.…There, I don’t know anyone here. It’s that I’m a little confused in that sense, because the cards, they’ve told me.…True things have come out. That’s why I’m so confused, because things have come out that have happened to me.” Asked whether she had been to psychics, Ana said, “No, to a man there in Chihuahua who is a healer. He’s very young. He’s from Sonora.…I went for health questions. I had bad legs, and he healed me.…With an egg. He washed my whole body with eggs. With the whole

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egg.…He is very young. He says he started healing during secondary school because his grandmother was a healer and his parents too.…When he finished cleansing me, he broke the egg in a glass of water, and he emptied it. And it was like it was cooked when it was emptied into the water, and many things started to be raised upwards like little points. They say this is the illness. And he cured me three times, and I could even run.” 10. Ana Maria spoke of her fear regarding her past transgressions in consulting a curandero. Asked whether she planned on going in the future, Ana replied, “No, now I’m afraid. It’s like a fear has entered me. I’m not afraid of them doing anything to me, but fear of God, because they don’t allow that in my religion. There are skillful people who heal us. Like there are people who have that power that God gave them [dons]. But wizards [devils] existed in the Bible.” Josefina (age 44, 13 years) provided more detail about how the “wizards” heal, describing a curandero she had visited: “So he did it truthfully, with all his heart, but now I’m sure that behind him was Satan. Because the Bible says Satan dresses himself as an angel of light to fool the people so that they continue believing in things we shouldn’t believe in. He exists. As good exists, so does evil. And there are people who devote themselves to doing evil.…It’s that now that I’m studying the Bible, I see that behind all that is the work of Satan, that Satan gives abilities to people.” Her interviewer asked whether the curandero did a good thing but had bad motives. Ana said, “Well, yes. Who should you have more confidence in? In God, who created us. And if in the Bible these things aren’t acceptable, then they shouldn’t be done.” 11. According to Finkler, high and low blood pressure “provide an especially good example of the structuration of typical symptoms that intertwine a biomedical construction with embodied day-to-day life experiences and emotional states.…It occurs when one feels either crestfallen or agitated and angry…when one is dejected one’s pressure is low, and when one is agitated and angry one’s pressure is high. People associate high and low blood pressure with familial conflicts, the death of a child, the loss of a spouse, economic problems, coming to live in Mexico City, and [any sort of] adversity that is considered quite intense" (2001:35). 12. Magdalena (age 65, 45 years) is one who had not visited a curandera but had seen the results of a healing performed by a curandera on her daughter: “I have seen it just like everyone else, on the TV, that it’s done and through the spirits. Look, I don’t personally believe. But I always don’t doubt it, because I have had a case with my daughter. That’s why I went to Mexico. It’s been a while that she’s been sick. So I went, determined to take her to a doctor. So that they could examine her and see her and all that. When I got there, I found out that she was seeing a woman that in Mexico we call a curandera.” Asked whether her daughter got better, Magdalena said, “Much better. I don’t believe. But I also don’t doubt it, because I saw it myself. She was walking the way I am now, like

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ducklings. And she had some other things. And with this woman, she was very happy and she got better.” 13. Finkler discusses the patterns of resort in a rural Mexican population who habitually sought out spiritualist healers (instead of curanderos/as or biomedically trained personnel). She comments that “the pattern of resort of habitual temple users follows cultural notions bearing on the gravity or the non-gravity of a set of symptoms. Grave illness refers to lifethreatening afflictions, illness episodes requiring confinement to bed, and sundry conditions involving fever. While fever alone, in the absence of additional symptoms, is not regarded as grave, fever is assessed as a grave symptom if associated with diarrhea, vomiting, or pain in other parts of the body.…” The findings on spiritualist temple users suggest that patients seek out temple curers not only out of commitment to cultural illness and not only during cultural illness episodes (i.e., susto, empacho), but also because of traditional notions of which illnesses are serious and which are not” (1994:59–60). In effect, patients go to both types of healers to treat the same (grave) illness and especially in the event of chronic illness that is incurable by allopathic medicine. This pattern of resort is discussed again in chapter 11 on antibiotic usage. 14. Finkler (1994) comments that the rural Mexicans she queried during her tenure in the spiritualist temple looked for alternatives to biomedical healing because, more often than not, they had suffered a serious trauma, for example, the death of a child, a life-threatening disease, or extreme alcoholism. This scenario was not salient in the present sample of Mexican immigrants, however. Only 3 out of the 15 who had converted mentioned a traumatic life event. In fact, only 1 of the 3 discussed, at length, a specific life experience that influenced her decision to leave Catholicism; the other 2 merely alluded to burdensome life events. 15. On this issue, Finkler explicates how the spiritualist healers, who espouse a doctrine similar to that of the Protestant churches being discussed, “impute affliction solely to impersonal spirits…[they attach] great importance to amiable social relations, shifting the onus of responsibility for an illness from [witchcraft practiced by] one’s neighbors, friends, or relatives to impersonal spirits. By so doing, they eliminate emotional discharges aimed at individuals in close relationships, discharges that might otherwise be instrumental in producing future illness episodes” (1994:53). Teresa’s husband, by claiming that his alcoholism was due to a hex placed on him, is an example of how a Catholic who adheres to curanderismo might understand the etiology of his illness.

Chapter 10: 1.

See Joseph and Shweder (1995) for a discussion of how the word rate may be misinterpreted by various ethnic community members. The interpretation problems cited in that article did not occur in the study population.

256 2.

3.

4.

5.

6.

7.

8.

Notes: Chapter 10 Finkler discusses the expectations of native Mexican patients vis-à-vis the doctor-patient relationship: “Not unsurprisingly, patients welcome the physician’s questioning, which assures them the physician will learn [more] about their malady.…” (2001:224). Guadalupe (age 25, 3 years in Santa Fe) illustrates the point that recent arrivals preferred their doctors to ask many questions, when responding to her interviewer’s query as to what characteristics she preferred in a physician: “When you go to see the doctor, there isn’t one who [stops to think]…that the doctor asks me, because at that exact moment I can’t tell him how I feel…so many things, and they ask me. I like for them to ask me, ‘Do you feel this? Do you feel that?’” This issue is examined in greater depth in the next section, on the relationship between subacute illness and rate of acculturation. Finkler describes her findings about attributing specific illnesses to anger: “Negative emotional discharge of anger is probably the most widely attributed generalized explanation for sickness. Anger provokes sickness in general, but it can also cause facial paralysis…bloating, heart palpitations…shortness of breath, and diabetes.…[Anger] emerges in all people out of failed social relations, or from a sense of injustice” (2001:37, emphasis added). Similarly, recent work by Daniulaityte (2002) explored twenty-one causal explanations for diabetes provided by Mexican respondents, fright (susto) being the most often cited, with anger coming in second. Finkler (2001) discusses how the biomedical attribution of heredity is often intertwined with a “folk” notion of the inheritability of certain diseases, such as cancer, and other health problems, such as those caused in the child by the exhaustion or “anger” of the mother during pregnancy. Finkler’s interviewees ascribed to susto symptoms such as a jabbing sensation in the heart or chest, hypertension, bloating, dry mouth, diabetes, and abortion (2001:39). Many of the immigrant women were shocked at the high cost of U.S. health care (23 out of 63, or 36.5 percent, saw the cost as prohibitive), yet 5 of the 23 (21.7 percent) were pleased to discover that U.S. hospitals and clinics arrange payment terms/schedules, which is unheard of in Mexico. In May 2001, the Alliance for the Prudent Use of Antibiotics (APUA), the Pan American Health Organization (PAHO), the Pan American Society for Infectious Diseases (API), and the Mexican Association for Infectious Diseases and Clinical Microbiology (AMIMC) held a joint conference in Guadalajara, Jalisco, and issued the Declaration to Combat Antimicrobial Resistance in Latin America. It is unknown how much progress has been made in educating the public on this issue since then. The reported means and medians are significant only in that they are distinctly lower than the means and medians associated with those who had lived more time in the United States. That they are as high as 3 or

Notes: Chapter 11

257

more years indicates that recent immigrants avoid health clinics in their first 2 to 3 years in the United States. The following are examples of some of the preferred doctor characteristics associated with longer residence in the United States: (1) The doctor should explain things well. (2) The doctor should show interest in the patient and concern for her. (3) The doctor should speak Spanish. (4) The doctor should listen well. (5) The doctor should be female. See table 20.

Chapter 11: 1.

2.

Sennott-Miller and others (1998) reported that the Hispanics in their study “never” asked about the possible iatrogenic effects of the medication they were prescribed. On a related note, Finkler states that in her study “those born in Mexico City were more likely to experience alleviation than those who migrated to the city.…This finding, while unanticipated, is not surprising considering the fact that unlike well-ensconced natives of the city, migrants to the city may experience subjective and objective pressures that impact on their general health state and perceptions of recovery” (2001:186). Her finding is significant in the present discussion because it was determined that relatively more city dwellers than rural inhabitants remained long-term in Santa Fe. These two findings may be related in that the urban dwellers who manage to commit to long-term living in the United States may also be those who are able to achieve symptom alleviation more readily via the U.S. healthcare system. The urban dwellers appear to have adapted to and even appreciate “the way things are” in the U.S. biomedical health delivery system.

Chapter 12: 1.

2.

3. 4.

A New York Times review of Damasio’s most recent book quoted The Chronicle of Higher Education as noting that “academics are throwing themselves into the study of emotion with the rapturous intensity of a love affair” and went on to cite a list of twenty-five recently published, scholarly books, “from philosophy and history to literature and political science, all devoted to affect in one way of another” (NYT, “Arts & Ideas,” April 19, 2003). To emphasize his point, Damasio cites work by Charlton (2000), who describes depression as sickness behavior. See, too, Churchland (1988) for a comprehensive discussion of the mind/body problem. Finkler found that in Mexico “making an anger” is “probably the most widely attributed generalized explanation for sickness” (2001:37). Literally hundreds of articles on the topic of nerves have been written in the past century. For an interesting historical overview of how the concept has been understood and utilized cross-culturally, see Davis (1988) and Davis and Whitten (1998). Other useful information is provided by:

258

5.

6.

Notes: Chapter 12 Nations and others (1988), V. Nelly Salgado de Snyder (2000), LewisFernandez and others (2002). If we were to summarize these rather disparate and untidy results, we might posit that, for the recently arrived, mental illness was something that was organic, began at birth or was caused by drinking or drugs, and basically incurable. After the women had been here approximately 5 years, mental illness was conceived as something that was not necessarily organically based but rather caused by inferior social conditions (e.g., relationships). They began to hear about or, in some cases, were actually treated with some sort of talking therapy and/or pharmaceuticals. The word therapy as a means to influence mental health outcomes was mentioned by those subjects who had lived in the United States an average of 8.7 years (median 5.5 years). In contrast to the United States, several subjects said that, in Mexico, depression is treated with B vitamins and no therapy. The reason for this is that depression is often diagnosed as anemia or a weakened nervous system that needs bolstering via vitamins. Finkler also noted a dearth of diagnoses of psychological disturbances. What was diagnosed, instead, were neurological anomalies. Patients were referred to neurology, reflecting, she states, “the influence of European theories of etiology. In the event a patient was given a psychiatric diagnosis, they were offended and angry because they did not consider themselves ‘crazy’” (2001:67). Nations and others (1988), Jenkins (1988), and V. Nelly Salgado de Snyder (2000), among others, discuss the relationship between the concepts and phenomenology of nervios, anxiety, and depression. See also Guarnaccia and Farias (1988) for a discussion of the social meanings of nervios. For a discussion of the first empirical analysis of a cultural syndrome (ataques de nervios) in children, see Guarnaccia et al. (2005).

APPENDIX A

List of Sending Communities

Sending Community Aguascalientes, Durango Anahuac City, Chihuahua Bachimada, Chihuahua Bella Vista, Chihuahua Cajulichi, Municipio de Ocampo, Chih. Carlos Acarria, Veracruz Chihuahua, Chihuahua Chipancingo, Guerrero Cocomora, Chihuahua Cordoba, Veracruz Cuahtemoc City, Chihuahua Durango, Durango Gomez Palacio, Durango Gran Morelos, Chihuahua Guadalajara, Jalisco Jiménez, Chihuahua Juarez, Chihuahua La Quemada, Chihuahua Las Varas Barbiquora, Chihuahua Lazaro Cardenas, Chihuahua Madero, Chihuahua Mexicali, North Baja California Mexico, D.F. Nahuat, Chihuahua Namiquita, Chihuahua No city, Chiapas 259

No. of Interviewees 2 1 1 1 1 1 6 1 2 2 1 5 1 1 1 2 4 1 1 1 1 1 4 1 1 1

260

Appendix A

Sending Community No city, Michoacán No city, Sinaloa Ojo Caliente, Zacatecas Parral, Chihuahua Paso Nacional, Durango San Francisco Mezquital, Durango San Luis del Colorado, Durango Santa Lucia, Chihuahua Tacaszcuaro, Michoacán Torreón, Coahuila Torreón, La Perla Nasas, Durango Veracruz, Veracruz Yanga, Veracruz

No. of Interviewees 1 1 4 1 1 1 1 1 1 1 1 1 1

APPENDIX B

Survey Questions

I.

Social and Cultural Assessment of Hispanic Immigrants A. Language Capabilities and Preferences 1. Basic skills in Spanish and English: Speaking, Understanding, Reading, Writing: (fluent, very good, good, poor, no ability). 2. What language(s) were you raised in? 3. What language(s) did you speak and learn in school? 4. What language(s) do you currently speak with family; friends; work associates; shopkeepers? 5. Levels of language ability a. languages the interviewee understands b. languages the interviewee functions in for day-to-day routine c. languages the interviewee expresses emotions/feelings in d. language in which the interviewee feels most comfortable interacting with a physician. B. Social Connections: Family Structure 1. Who is the core family? --nuclear, extended, family of origin or marital family? 2. Where is everyone living?--is family separated between U.S. and home country? 3. How long has family been separated? Are there plans to reunite the family? How soon? 4. How often are you in contact with the family?--in person, by phone, by letter? 261

262

Appendix B 5. 6.

How difficult is it to maintain contact with family? Do you have compadres? How often are you in contact with them? C. Social Connections: Social Supports 1. If you needed_____________, do you have someone you could ask? Who? Have they helped in the past? a. Ride to the doctor/hospital b. Loan of money c. Care of children d. Someone to talk to e. Place to live f. Use of telephone g. Help translating 2. Who helped you get around when you first came to the United States? 3. Who do you turn to for advice about where to shop or to go for health care and how to get services? 4. Who do you turn to when you just need to talk to someone? 5. Who do you celebrate holidays with? 6. Who should we contact if there is an emergency? D. Migration Experience 1. Where were you born? Where were your parents born? 2. How long have you lived in the United States? How long have you lived where you live now? 3. Why did you leave your home country? 4. Why did you come to the United States? Why did you come to Santa Fe? 5. Describe your trip to the United States a. How did you travel? b. What countries did you pass through? c. Who helped you on your way? d. What problems did you encounter? e. Where did you sleep? eat? wash?

Appendix B 6.

263

Did you travel alone or with others? Who did you come with? 7. Have you gone back to your home country. Why or why not? 8. Do you still have family and relatives in your home country? Who? Do they plan to come to the United States? Are you worried about their heath or safety? 9. Do you plan to remain in the United States or return to your home country? E. Religious Beliefs and Practices 1. What religion are you now? In what religion were you raised? If you changed religions, why did you change? 2. Do you consider yourself a religious person? 3. How often do you attend services and meetings of religious groups? 4. How often do you pray? Do you have an altar at home? 5. Beliefs in spiritual healing: a. Have you ever heard of people who can heal through the use of spirits or saints? b. Do you believe people can heal with the help of saints or spirits? c. Have you ever consulted such a person, such as an espiritista, curandero, or santero? d. Has the treatment helped? e. Are you currently consulting such a person? 6. Have you or your family consulted a religious leader about your health problems? A healer? 7. Does your religion have any beliefs that might affect your treatment? [i.e. not using certain medicines; not accepting transfusions, etc.] F. Health Care Utilization 1. When you were sick in your home country, what did you do? Who delivered your babies? Where did you go for medical treatment? Whom did you talk to about what to do?

264

Appendix B 2.

Since coming to the United States, what health problems have you had? Where did you go for treatment? (Note: Questions adapted from Guarnaccia and Rodriguez 1996.) II. General Health Questions A. Stages of Illness 1. How do you know that you are not well (what symptoms tell you that you are sick?) 2. Once you know you are not well what do you do? a. Do you seek advice from anyone first (spouse, relatives, neighbors?) b. Do you attempt to treat yourself first (how? any home remedies?) c. What kinds of symptoms concern you the most? d. In terms of loss of health, what is your greatest fear? (Is there any particular kind of sickness, disability, affliction that you particularly fear?) e. How would you say you usually respond to pain? 3. How should a sick person behave? (stay in bed? try to work as much as possible? try to get around as much as possible?) B. Illness Episodes 1. Has anyone in your family or household been sick over the past year? (who was sick, what was the illness, what did you do about it?) How about in the past few years? (same questions) C. Utilization and Evaluation of Medical Care 1. In the past year (past six months) how often has someone in the household seen a doctor, nurse, or other health professional? (explain circumstances) 2. On a scale of 1 to 3 (1 is the best) how would you rate the medical attention you have gotten this year (last six months)? 3. When looking for a doctor (or a nurse) what are the qualities you think are important?

Appendix B 4. 5.

265

On what basis do you finally decide which doctor to use? Do you have a family doctor? (how do you get to his clinic, office?) 6. Have you ever not seen a doctor when you thought that you or a family member should have? (why?) 7. Are there any people other than medical professionals that people in the community consult when they are ill? (who?) 8. After you see a doctor do you generally follow the prescribed treatment? (are there any kinds of treatment you particularly object to?) 9. When do you know that you no longer need to be under a doctor’s care? D. Cognitive Models of Health Questions 1. What does being healthy mean to you? 2. What do you do to stay healthy? 3. What kinds of things are most harmful to people’s health? 4. What does being sick mean to you? 5. Why does God allow sickness and suffering in the world? 6. What, in your own words, is the definition of a good life? 7. Do you have any views on death? (should people die at home? hospital?) 8. What does it mean to say that somebody is “crazy?” (or loco?) Do you think it is an illness? 9. Have you ever known anyone who was loco or mentally ill? 10. What do you think are some of the causes of mental illness? (can it be cured?) do you think such people should be hospitalized? PROBES: Inquire about: herbal cures and home remedies; hot / cold qualities underlying illness and cure; religious beliefs and practices related to health, illness and healing; attitudes about other “alternative” medical systems in northern New Mexico: medicina naturista; homeopathy; acupuncture; chiropractic; lay midwives. (Source: Scheper-Hughes and Stewart 1983).

266

Appendix B

III. Kleinman’s (1980) Questions to Elicit the Details of Patient Explanatory Models 1. What do you call your current problem? What name does it have? 2. What do you think has caused your problem? 3. Why do you think it started when it did? 4. What does your sickness do to you? How does it work? 5. How severe is it? Will it have a short or long course? 6. What do you fear most about your sickness? 7. What are the chief problems your sickness has caused for you? 8. What kind of treatments do you think you should receive? What are the most important results you hope to receive from the treatment? 9. Since your current problem started, what kinds of care have you received? a. Have you done anything yourself? (i.e. home remedies, teas, over-the-counter medicines); b. Whom did you talk to for advice? c. What are your expectations of treatment? d. Are you seeking any treatment from other providers? e. Have you talked to your priest or minister about your health problems? 10. Have you suffered from your current problem before? What did you do about it? Was the problem different in your home country? IV. Questions Added to the Interview Schedule 1. How would you describe the doctors you consulted in Mexico? 2. Recall the last doctor you consulted in Mexico. What did you like most about him or her? 3. How did you get to the doctor? Bus? Car? Truck? Walk? 4. How much time did you have to travel to see this doctor? Did you have difficulty seeing him or her? How much did it cost?

Appendix B

267

5.

How much time did you have to wait to see the doctor in Mexico? How much time do you have to wait to see a doctor in Santa Fe? When you went to the doctor in Mexico, what did he or she do to make you feel good? State five differences between doctors in Mexico and those you have visited in Santa Fe. How do you feel when you consult a doctor in Santa Fe? What feelings do the doctors in Santa Fe leave in your heart? Did you bring from Mexico, or buy in Santa Fe, Mexican medicines that are usually only obtained by a prescription in the United States? What kind of medication? Have you changed your manner of eating since you came here? Name five foods that you did not eat in Mexico that now are a part of your diet. Do you think that when people come to the United States they change their way of being? If so, how? What changes? Have you changed your way of being?

6. 7. 8. 9. 10.

11. 12. 13. 14.

15.

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Index

angina, 162, 175, 178, 189 antibiotics, 42, 117, 178, 187, 188–99

access to health care services, 54, 98, 101, 102, 115, 118, 237 acculturation acceleration/deceleration, 17, 187 attitudinal, 24, 26, 29 behavioral, 12, 17 behavioral measures of (indices), 26 cognitive, 17, 26, 32 generational, 1, 13, 18, 25, 29, 136, 229, 240 immigrant discourse of, 48, 141, 242, 244 psychological, 17, 235 rate of, 1, 18, 188, 200, 230 scales, 12, 14, 21, 24, 27 sequential and temporary order patterns, 33, 230 stress, 3, 17, 23 survey instruments, 25, 29, 38, 43, 218, 232, 236, 241 acupuncture, 9, 45, 101, 115, 120, 121, 122, 128, 131, 134 age of respondents, 51 allopathic medicine, 4, 10, 69, 96, 144, 161 alternative medicine. See complementary and alternative medicine (CAM)

bacteria antibiotics and, 178, 187, 232. See also antibiotics infection with, 191, 244 theory of, 231 Baptists. See religion Berry, John, 16–17 biculturalism, 18–23 bilingualism. See English language proficiency and Spanish language biomedicine, 73, 117, 132, 145–47 cancer screening and management, 11 cardiovascular disease, 11 caseros remedios, 10, 40 causality, 12, 230 causal networks, 49 Chavez, Leo, 59, 101, 102, 103, 108, 178, 236, 237 Chavez, Leo., 112 chiropractic, 45, 115, 121, 122, 131 chronic illness. See illness, chronic

289

290 complementary and alternative medicine (CAM), 9, 45, 52, 67, 115–34, 231 curanderismo, 2, 28, 79, 119, 122, 134, 146, 148, 231 curanderas/curanderos, 9, 39, 117, 142, 233 Damasio, Antonio, 209–14, 216, 218 data, qualitative, 13, 44, 241 data, quantitative, 26 depression, 209–27 diabetes, 11, 37, 67, 69, 77, 92, 95, 162, 164–71 diet and exercise, 2, 42, 48, 70, 77, 81, 82, 86–95, 88, 233 calories, 77, 81, 174, 230 high fat, 86, 95, 231 education level, 39, 52, 55 emic, 14, 29 employment status, 59–60 English language proficiency, 19, 28, 45, 55–57, 92, 229 epidemiology, 229, 239 etic, 29 evangelicalism, 135, 138 extreme response bias, 62, 200 Foucault, Michel, 4, 197 fundamentalism. See religion Guarnaccia, Peter, 12, 27, 29, 30, 39, 45 healers, traditional. See curanderismo health clinics, 3, 8, 28, 37, 43, 69, 77, 91, 112, 181, 199, 205 in Mexico, 97, 118 health disparities, 11, 244

Index health outcomes, 3, 7, 102, 106, 178, 236, 244 heart disease, 11, 231 herbal medicine, 45, 106, 115, 118, 122, 146. See also medicina naturista high blood pressure. See hypertension homeopathy, 9, 45, 101, 115, 120, 121, 122, 124, 127, 128, 131 homeostasis, 213–15 hospitalization, 146, 164, 168, 176, 237 humoral theory, 40, 81–85, 133 hypertension, 117, 130, 162, 187, 203, 231, 236 illness behavior, 35, 103–13, 231 illness episode, 13, 40, 126, 163 illness, chronic, 4, 28, 129, 161– 75, 198, 199–201, 231 illness, subacute, 92, 152, 153, 161, 163, 175, 183, 199–208, 231, 244 immigrant networks, 238 immigration studies, 7, 12, 17, 19, 32, 100, 101, 103, 107, 227, 229, 232, 239 immigration, undocumented, 5–7, 34–37, 112, 229, 237 infant mortality, 11 insurance, health care, 11, 102, 112, 183, 236 Jehovah’s Witnesses. See religion Kleinman, Arthur, 31, 40, 171 marital status, 58 Martin, Emily, 4, 69, 70, 111 medical anthropology, 39, 117, 119, 239 medical sociology, 117

Index medicina naturista, 45, 106, 117, 122, 145. See also herbal medicine mental health/illness, 4, 209–27 methodology consensus analysis, 34, 235 event patterns, 34, 230, 236 interactional fields, 230 life/case histories, 13, 30, 234 scenario interviewing, 236 social processes, 230 survey instruments, 38, 43 typologies, 235 Mexican physicians, 60–62, 126, 146 migration. See immigrant networks nervios, 209–27 Pentecostalism. See religion placebo effect, 106, 205 poverty, 7, 102 prenatal care, 8, 91, 172, 174, 200 promotoras, 43, 94, 172, 174, 238 proxy, language use as, 12 psychometric scale, 29, 235, 240 questionnaires, 38–40, 48, 234. See also appendix B reliability, 22, 48, 64 religion Baptists, 78, 135, 136, 140, 153 Catholicism, 78, 83, 135–42, 149, 153

291 fundamentalism, 135, 138, 139 Jehovah’s Witnesses, 78, 136, 140, 154 Pentecostalism, 78, 135, 136, 140, 148–52 religious conversion, 134, 135–59, 231 rural vs. urban, 47, 53–55 self assessment (of health status), 162, 207 sobadores, 133 social networks/support, 31, 39, 47, 136, 236 socioeconomic status, 95–101 somatization, 210–12, 215 Spanish language, 10, 19, 28 stereotype, 57, 96, 101, 117, 144, 168 stress, 209–27 subacute illness. See illness, subacute traditional healers. See curanderismo traditional medicine. See curanderismo validity, 29, 38, 39 virus antibiotics and, 178, 190, 192, 206. See also antibiotics infection with, 190, 191 theory of, 111, 192 years in U.S., 59–60