Hispanic Health
This page has three sections: "Useful Websites," "Hispanic Health Problems, Inter-related Cultural Issues," and "Cosmology, Space, Time." The latter was written for "La Charla" a language-and-culture course designed by Alan Archibald for students of "The Allied Health Professions" at UNC - Chapel Hill.
Useful Websites:
Center for Disease Control --- Bilingual, Spanish/English site
The CDC's Spanish language site is very well designed and offers a tremendous amount of useful information. In addition to being an excellent source of Spanish language medical information, use of the site also facilitates Spanish language learning.
National Institute of Occupational Safety and Health --- Bilingual Spanish/English site: http://www.cdc.gov/spanish/niosh/
Cross Cultural Resources (UCSF) - http://medicine.ucsf.edu/resources/guidelines/culture.html
More Cross Cultural Resources (Merced, California) - http://www.gvhc.org/cultural/Resources%20&%20Links.htm
"Tools For Conviviality," Ivan Illich (Illich's most pertinent book is "Medical Nemesis." Lacking an on-line version of that text, I'm including "Tools for Conviviality," Illich's investigation of those characteristics that constitute life-enhancing technologies.)
Spanish Language Medical Sites:
Información médica de NOAH: http://www.noah-health.org/es/about/index.php
Web de información médica: http://www.infodoctor.org/rafabravo/
Web de información médica: http://www.fonendo.com/noticias/18/2001/12/1.shtml
Servicios Internacionales (Sitio Metodista): http://www.methodisthealth.com/cgi-bin/hmdim/home/showIntlHomepage.do?action=SP
MedSpain - Comprehensive Spanish language medical site: http://www.medspain.com
Portal de Salud de Cuba - "FitoMed "(plantas medicinales y más): http://www.sld.cu/fitomed/
Información sobre los medicamentos: http://www.infomedicamento.net/
Latin American Resources:
Latin American Network Information Center (LANIC): http://lanic.utexas.edu/
Great site for Latin American journalism access: Periodista Digital (Vastos recursos periodísticos): http://www.periodistadigital.com/
Online Spanish (and world) Newspapers - http://www.onlinenewspapers.com/
Exploration of Spanish language and latin culture - http://www.unm.edu/~engdept/spanresrc.htm
Terra --- Spanish language search engine: http://www.terra.es/
Hispanic Health Problems
Inter-related Cultural Issues
(The following information describes in schematic form the cross-cultural environment in which English-speaking service providers operate.)
What are the major health issues facing Latina women in the U.S.?
· Health care access. There are more uninsured Latina women than any other race/ethnic group (30%) even though many of them are employed or live with someone who is employed. Only 26% have private health insurance, 27% receive Medicaid coverage, and 7% are covered by Medicare. Difficulties with language, transportation, child care, immigration status, or cultural differences act as further barriers to health care services.
· Diabetes, including gestational diabetes, is two to three times more common in Mexican-American, Cuban American, and Puerto Rican adults than in non-Hispanic whites.
· Obesity is 1.5 times more common in Mexican American women than in the general, female population-reaching 52%.
· HIV/AIDS. The rate of HIV infection is seven times higher in Latina women than in white women, highlighting the need for greater prevention and treatment in this community.
· Prenatal care. Many Latina women do not get timely prenatal care (in the first three months of pregnancy). The rates are 89% (Cuban American), 74% (Puerto Rican), 73% (Central and South American), and 69% (Mexican American). Yet Latina women have infant mortality rates comparable to those of white women (7%) and far lower than those of African American women (17%) and Native American women (13%).
Diabetes:
NEW YORK (Reuters Health) -- Hispanic adults in the United States and Puerto Rico are twice as likely to be diagnosed with diabetes as non-Hispanic white adults, according to the Centers for Disease Control and Prevention (CDC).
Hispanic individuals in Puerto Rico and the West and Southwest are at greater risk than those in the Northeast, Midwest and Southeast, and diabetes is more common in those with less than a high school education than those with higher levels of education.
Overall, about 6% of Hispanics have been diagnosed with diabetes, but "possibly another 6 percent have diabetes but have not been diagnosed," according to the report.
Diabetes incidence increases with age. In the Hispanic population, it occurs in 2.3% of those aged 18 to 44 years, 12% of the 45 to 64 age group, and 21.4% of those aged 65 years and older. Type 2 diabetes mellitus, or "adult-onset" diabetes, increases the risk of blindness, heart attack, and stroke. Obesity is a major risk factor for type 2 diabetes.
"There are many things people with diabetes can do to prevent these serious complications and improve their quality of life," said the author of the report, Nilka Rios Burrows, in a statement issued by the CDC. "We must ensure that Hispanics know they are at higher risk for diabetes and how they can manage the disease if they are diagnosed."
The 1999 fiscal budget recently approved by Congress contains provision for $65 million in funds to "combat these disparities; including $5 million for a community-based, culturally relevant diabetes education and prevention program conducted by the CDC," according to a statement issued by the federal agency.
SOURCE: Morbidity and Mortality Weekly Report January 16, 1999.
Communication between Providers and Clients
Verbal and nonverbal communications from Hispanics usually are characterized by respeto (respect) and communications to Hispanics should also be respectful. There is an element of formality in Hispanic interactions, especially when older persons are involved. Over-familiarity, physical (touch by strangers) or verbal (casual use of first names), is not appreciated early in relationships (de Paula, Lagana, & Gonzalez-Ramirez, 1996). It is uncommon for Hispanics to be aggressive or assertive in health care interactions. Direct eye contact is less among Hispanics that among Anglos. Direct disagreement with a provider uncommon; the usual response to a decision with which the patient or family disagrees is silence and noncompliance. A brusque health care provider may (1) not learn of significant complaints or problems and (2) find the patient unlikely to return. Despite a lack of public complaint, Hispanics tend to have an acute sense of justice and often perceive failures in communication to be due to prejudice.
Communications and the relationship between patient and health care provider are key to providing quality care. Trust and interpersonal comfort is a critical component of the relationship between the person who is ill and the healer. In large part, it is this relational aspect of care that places folk healers in a place of importance among Hispanics living in the U.S. (Zapata & Shippee-Rice, 1999). Note that quality care as seen here is not just correct diagnosis and treatment, but also the way in which the treatment is provided.
The use of interpreters is often necessary, and ideally these should be of the same gender. Family members or friends are sometimes pressed into service as translators, but this may result in problems (personal, sexual, etc.) not brought up. The use of family or friends to interpret also presents difficulty in communicating and assessing the accuracy of vital communications such as medication regimes, side effects the patient must understand, and informed consents. Using children to translate puts the parent and child in a difficult reversed power and authority position, hence using a child to translate for a parent should be a last resort. In general, it is best to have Spanish-speaking staff or volunteers to translate. When there are staff whose primary function is translating, care should be taken that the position does not become an opportunity to wield power or make an additional profit from non-English speaking persons.
Communications about family planning are especially sensitive. Most Hispanics are Catholic, but increasing numbers of Latinas are using contraception without informing their husbands. Depo-provera seems to be the contraceptive of choice.
Implications: It is vital to have Spanish-speaking staff. In most cases it is best to use staff to interpret; and in nearly all cases it is best to avoid using children to interpret. Interactions with patients and families should be formal and concurrently warm, at least early in the relationship. Formality may decrease over time, and warmth increase. Use formal terms of address; a firm, slightly longer handshake than is customary among Anglos; and avoid prolonged eye contact. While written instructions (on medications, treatments, etc.) are important, personal instruction that is directive, active, and visual is most effective. Do not rely on brochures! Close personal space and brief, non-intimate touch makes compliance a personal favor. Emphasize present time orientation with short-term goals. Most patients ask few questions. To assess learning, ask questions; use directive active, visual instructions; self-disclosure is appropriate. Emphasize present time orientation with short-term goals. Family planning discussions should be completely private (Lieberman, Stoller, & Burg, 1997).
Social Relations
Familism, the valuing of family considerations over individual or community needs, is a strong, almost universal value in the Hispanic community (Juarez, Ferrell, & Borneman, 1998; Lieberman et al, 1997). The nuclear family is the most basic and common social unit, but many extended families also present. It is common for several family units to live in close proximity to one another and there is usually a strong reliance on family in day to day functions and crises.
The father or oldest male (direct relative) holds the greatest power in most families and may make health decisions for others in the family. Men are expected to provide for and be in charge of their families. Though increasing numbers of women work outside the home, homemaking is the expected role. At least publicly, women are expected to manifest respect and even submission to their husbands. Privately, some women will hold a greater degree of power. However, in too many marriages, the threat of physical violence is real and under-reported (de Paula et al, 1996). Two specific gender roles should be noted here:
· Machismo or macho is stereotypically viewed as a kind of foolish male pride in which men are depicted almost as buffoons driven to folly by male hormones. To the contrary, machismo is a defined sense of honor that is vital to the Hispanic sense of self, self-esteem, and manhood.
· Women are idealized in some respects and oppressed in others. Family violence is not uncommon. The woman is expected to be the primary force holding the family and home together through work and cultural wisdom, the primary caregiver, and responsible for most parenting. The Virgin of Guadelupe is a powerful symbol (dark-skinned Mother of Christ) and model for Mexicans and Mexican Americans.
Upward mobility, education, and other societal forces are changing the above; yet in isolated communities and among new immigrants, little has changed. Gender roles are important to the sense of culture and al least in public, are likely to be followed. Also see childbirth and related below.
Implications: Many patients seeking medical care will have already sought help from family resources (also see Lay Healers below). Family involvement in health care is common and health care providers are strongly advised to encourage such involvement and to include the family as a resource and focus of care in health planning, whether for individuals or a community. Showing respeto to all adults is important. Health providers should understand and comply with patient and family gender roles.
Health Beliefs and Practices
Physical or mental illness may be attributed to an imbalance between the person and environment. Influences include emotional, spiritual, and social state, as well as physical factors such as humoral imbalance expressed as too much "hot" or "cold" (de Paula et al, 1996; Spector, 1996). It is important to understand that belief in the concept of balance does not in any way obviate a concurrent belief in biomedical theories or practices (Zapata & Shippee-Rice, 1999). Hispanics who follow these beliefs may not express them to health professionals.
"Hot" and "cold" are intrinsic properties of various substances and conditions, and there are sometimes differences of opinion about what is "hot," what is "cold." In general, cold diseases/conditions are characterized by vasoconstriction and low metabolic rate. "Cold" diseases/conditions include menstrual cramps, frio de la matriz, coryza (rhinitis), pneumonia, empacho, and colic. "Hot" diseases/conditions are characterized by vasodilation and high metabolic rate. Pregnancy, hypertension, diabetes, acid indigestion, susto, ojo, and bilis are examples of hot conditions (Neff, 1998).
Folk illnesses are health problems associated with members of a particular group and for which their culture provides etiology, diagnosis, prevention, and regimen of healing; and which also have psychological and/or religious overtones (Neff, 1998). Folk or ethnomedical illnesses or conditions one might encounter in a Hispanic patient (de Paula et al, 1996; Lieberman et al, 1997; Neff, 1998; Spector, 1996) include:
· Antojos are cravings in a pregant woman. Failure to satisfy the cravings may lead to injury to the baby, including genetic defects.
· Barrevillos are obsessions.
· Bilis is thought to be bile flowing into the blood stream after a traumatic event, with the end result of nervousness.
· Caida de la mollera is the presence of a sunken fontanelle in an infant.
· Decaimientos is fatigue and listlessness from a spiritual cause.
· Empacho is intestinal obstruction and is characterized by abdominal pain, vomiting, constipation, anorexia, or gas and bloating. Post-partum women and infants and children are most susceptible.
· Mal de Ojo is the "Evil Eye" may affect infants or women. It is caused by a person with a strong eye (especially green or blue) looking with admiration or jealousy at another person. Mal de Ojo is avoided by touching an infant when admiring or complimenting it.
· Nerviosimo is "sickness of the nerves" and is common and may be treated spiritually and/or medicinally.
· Pasmo is paralysis or paresis of extremities or face and is treated with massage.
· Susto is fright resulting in "soul loss." Susto may be acute or chronic and includes a variety of vague complaints. Women are are affected more than men.
"Cold" conditions are treated with "hot" medications and "hot" with "cold" medications, thus bringing the individual back into balance. Problems that are primarily spiritual in nature are treated with prayer and ritual. However, few Hispanics who use folk means of treating illness are troubled by simultaneously using cosmopolitan treatments such as antibiotics, antihypertensives, and so on.
A common hierarchy of seeking relief from lay healers begins with home remedies or seeking assistance from relatives or neighbors (especially female). A common home remedy is a tea made from various herbs, spices, or fruits; and prepared in a specific and prescribed manner (Zapata & Shippee-Rice, 1999). If the home remedy or consultation with a senora/abuela does not bring relief, and depending on the problem, help may be sought from a yerbero (herbalist), sobador (massage therapist), or partera (midwife who may also treat young children). In most cases, it is only after these are not helpful that help is sought from a cuarandero total (lay healer who intervenes in multiple dimensions, e.g., physical and spiritual) (Neff, 1998). Cuaranderos are not used or are not reported as used as much in the U.S. as in countries of origin (Neff, 1998; Zapata & Shippee-Rice, 1999). Cuarandero use may be diminished because of increased access to care or the more cosmopolitan nature of those living in the U.S.; or under-reported because of fear of misunderstanding or prosecution (of the cuarandero).
At any point in this process, help may also be sought from cosmopolitan sources such as a clinic or physician. A naturalist doctor or doctor naturalista may also be utilized. The doctor naturalista prescribes "natural" remedies, but does not usually provide the spiritual component of care the patient would expect from a cuarandero.
Note also that medications, including prescription, are shared within social networks. There are instances in which a sick person may simultaneously be using prayer, folk and/or herbal medicine, prescription medications obtained from a friend, and prescription medications prescribed by a nurse practitioner or physician. Regardless of the source of care, the patient (and family) are likely to include faith in God as a vital component of understanding of the problem and the cure (Zapata & Shippee-Rice, 1999).
In the excellent article, Folk Medicine in Hispanics in the Southwestern United States, Neff (1998) presents the below information:
Folk Remedies Everyone Should Know (+ indicates yes, with + being least and +++ being most; - indicates no, with - being least and - - - most, i.e., - - - in the safety column indicates the treatment is dangerous)
Spanish Name English Name Uses Efficacy Safety
Ajo Garlic Hypertension, antibiotic, cough syrup,tripaida + + + +
Azarcón/Greta Lead/mercury oxides Empacho, teething - - - - -
Damiana Damiana Aphrodisiac, frio en la matriz, chickenpox 0 +
Estafiate Wormwood Worms, colic, diarrhea, cramps, bilis, empacho + purgative - -
Eucalipto Eucalyptus (Vicks VapoRub) Coryza, asthma, bronchitis, tuberculosis + respiratory ?? Gobernadora Chaparral -- Arthritis (poultice); tea for cancer, venereal disease, tuberculosis, cramps, pasmo, analgesic
Gobernadora Chaparral -- Arthritis (poultice); tea for cancer, venereal disease, tuberculosis, cramps, pasmo, analgesic + as a poultice 0 as a tea Gordolobo Mullein Cough suppressant, asthma, coryza, tuberculosis + + + + (if right species)
Manzanilla Chamomile Nausea, flatus, colic, anxiety; eyewash + + + + (if no allergy)
Orégano Oregano Coryza, expectorant, menstrual difficulties, worms ? + +
Pasionara Passion Flower Anxiety, hypertension + + + sedative + + (if right species)
Rodigiosa Bricklebush Adult onset diabetes, gallbladder disease ? ? ? ? ? ?
Ruda Rue Antispasmodic, abortifacient, empacho, insect repellent ? ?
Saliva Sage Prevent hair loss, coryza, diabetes + - - (chronic use)
Tilia Linden Flowers Sedative, hypertension, diaphoretic + sedative - - (chronic use)
Tronadora Trumpet Flowers Adult onset diabetes, gastric symptoms, chickenpox ? ? ? ? ? ?
Yerba buena Peppermint Dyspepsia, flatus, colic, susto + + + +
Zábila Aloe Vera External - cuts, burnsInternal - purgative, immune stimulant External + + + Internal + Safety: External + + Internal - - -
Safety: External + + Internal - - -Zapote blanco Sapodilla Insomnia, hypertension, malaria ? ? ? ? ? ?
Diet: The diet of Hispanics in the U. S. is variable, but certain traditional Mexican foods are common. These include rice and beans, usually prepared with lard. In many homes, tortillas are eaten at most meals, and these too usually include lard as an ingredient. Although some references (e.g., de Paula et al, p. 208) report that Mexican-Americans consume "traditionally, fresh natural ingredients," our observation in inner-city barrios in Texas is occasional fresh foods are consumed, but processed foods are more common.
Pregnancy, childbirth, and child-rearing: As noted earlier, increasing numbers of Latinas are practicing family planning. Pregnancy is viewed as natural, and despite a tendency to seek prenatal care late in pregnancy or in some cases, not seeking care until delivery, birth outcome statistics for this population are good (de Paula et al, 1996). The extended family and community exert a strong influence on health practices related to pregnancy and childbirth. Women who work outside the home usually continue to do so only if absolutely necessary. When going to clinic for prenatal care it is relatively common for women to be accompanied by their husbands; and more common for them to be accompanied by a sister, mother, or other female relative. Female relatives tend to play a significantly supportive role throughout pregnancy and into the post natal period or la cuarentena.
Some Latinas moan during delivery and there is no effort to be silent. Breastfeeding is more common among new immigrants, but our observation is that breastfeeding is increasingly popular among those who have lived in the U.S. for extended periods of time or second or third generation Latinas.
Child-rearing is primarily the woman's responsibility in most families. Both female and male children are encouraged to be stoic from an early age. (There is little crying or fear shown in immunization clinics in Hispanic communities.) Paradoxically, many Hispanic homes are warm and protective toward the children. Familism is a thread throughout Hispanic life, including in child-rearing. Older children often have significant responsibility for younger siblings or relatives, and from all outward appearances, do not find this burdensome. Among Hispanics, children seem generally to be enjoyed and even treasured across generations.
Dying and Death Practices: The family (except for pregnant women) is often significantly involved in caring for a family member who is dying. Women tend to do most of the actual care, while men seem to stay in another room or outside but still, are always there. In addition, many parishes have an active auxiliary, and members may be involved in caring for the person who is dying or supporting the family in the care. Autopsies and organ donations are usually resisted, especially by Catholics, but also by others. Public expression of grief is expected under some circumstances, especially among women (de Paula et al, 1996), but stoicism is also valued.
Disease prevention and health promotion: Traditionally, neither prevention nor promotion are valued; and this contributes to higher prevalence of chronic illnesses such as diabetes and hypertension, as well as waiting to seek care until illness has progressed (Neff, 1998). However, in recent years there seems to be increasing acceptance of these concepts. For example, it is increasingly common for new immigrants or visitors from Mexico to come to a community clinic reporting diagnosis and treatment for these disorders in Mexico. Still, the presence of chronic illness and risk factors such as obesity coupled with the overarching problem of difficulty accessing services, result in preventable morbidity and mortality (DHHS, 1998; Neff, 1998).
Implications: Some Hispanics have unique traditional health beliefs and practices and these are practiced to varying degrees. Having an understanding of these is helpful in assessing and understanding Hispanic patients and communities. Some traditional practices are helpful and some are harmful. Many persons who follow these practices are reluctant to share their beliefs with nurses or physicians, hence building trust and resisting judgment is essential to practice in these communities. Disease prevention (and detection) and health promotion need to encouraged and promoted in Hispanic communities. Assessment of health beliefs and practices is facilitated by use of a brief tool such as that developed by Tripp-Reimer, Brink, & Saunders (1984):
Brief Assessment of Patient/Family Perceptions of Health Problems
· What do you think caused your problem?
· Do you have an explanation for why it started when it did?
· What does your sickness do to you; how does it work?
· How severe is your sickness? How long do you expect it to last?
· What problems has your sickness caused you?
· What do you fear about your sickness?
· What kind of treatment do you think you should receive?
· What are the most important results you hope to receive from this treatment?
Immigrant communities may be at risk for the following problems, some of which are not yet documented.
· Malaria
Cysticercosis (masquerades as migtraine. Can be istinguished by brain scan or observing pressure on retina.)· Intestinal parasites (helminthic, amebiasis, giardiasis)
· Hepatitis B
· Low immunization rate (risk for measles, mumps, rubella, diptheria, pertussis, tetanus)
· Chagas disease (trypanosomiasis) May present with cardiomegaly.
· Filariasis, leishmaniasis, onchocerciasis, lymphatic filariasis, cysticercosis (which easily masquerades as intractable migraine headache), schistosomiasis, echinococcosis
· Typhoid fever
· STDs, including HIV
· Dengue
Recommended Laboratory and Other Tests for Immigrants from Latin America
· Nutritional assessment
· PPD (Note that having had a BCG vaccination [1] may confound the Mantoux/PPD by causing variable results and [2] does not contraindicate PPD as is sometimes thought [Uphold & Graham, 1998].)
· hematocrit
Latin American Rural Practices
Curanderismo is a folk system used in Latin America and among many Hispanic-Americans in the United States. Hispanic-American refers to Americans of Spanish or Spanish-American descent; in the United States most trace their roots to Mexico (63 percent), Puerto Rico (12 percent), and Cuba, but increasing numbers of immigrants are arriving from Central America (Wright, 1990). The population of Hispanics is rapidly growing in the United States, and today about 25 million people call themselves Hispanic. More than half of this population lives in Texas and California: large populations are also in North Caroina, Colorado, Arizona, Florida, Illinois, New Jersey, New Mexico, and New York.
Curanderismo typically includes two distinct components, a humoral model for classifying activity, food, drugs, and illness; and a series of folk illnesses such as "evil eye," "fright," "blockage," and "fallen fontanelle." Curanderismo as described herein is most characteristic of Mexican-Americans, especially those who are little assimilated; variants on the humoral component typify most of Latin America, while the folk diseases and the treatment modalities reflect national background. Thus the Cuban-American folk system is not curanderismo, but santeria, and it is African influenced.
Although no formal effectiveness studies seem to have been done on this system, its wide popularity and the research suggesting the relevance of the folk diagnoses for biomedical practice indicate the need for further demographic and effectiveness studies.
In the humoral component of curanderismo things could be classified as having qualitative (not literal) characteristics of hot or cold, dry or moist. (Harwood, 1971; Messer, 1981; Weller, 1983). According to this theory, good health is maintained by maintaining a balance of hot and cold. Thus, a good meal will contain both hot and cold foods, and a person with a hot disease must be given cold remedies and vice versa. Again, a person who is exposed to cold when excessively hot may "take cold" and become ill.
While this model is simple in theory, how people perceive in practice the hotness or coldness of substances varies greatly by region. Thus, while most can be expected to classify chili peppers as "hot" and milk as "cold," the classification of pork or penicillin is not so predictable.
The second component, the folk illnesses, is actively in use in much of Mexico and among less educated Hispanic U.S. citizens (Rubel, 1960, 1964; Rubel et al., 1984; Young, 1981). Trotter (1985) did more than 2,000 clinic interviews in Texas, Arizona, and New Mexico and found that 32 percent to 96 percent of Mexican-American households (more frequent in the less Americanized communities) treated members for Hispanic folk illnesses. Baer and colleagues found similarly high use patterns among Mexican migrant workers in Florida and Mexico (Baer and Penzell, 1993; Baer and Bustillo, 1993).
Four important Mexican-American folk illnesses are mal de ojo, susto, empacho, and caida de mollera.
Mal de ojo, or evil eye, is a worldwide disease concept in which a person can make another sick by looking at him or her. The one who gets sick, typically an infant, is usually "weak." The one who causes the illness is usually thought not to do it on purpose--the person just has the misfortune to have a "piercing" glance. Typical symptoms of mal de ojo include fussiness, refusal to eat, and refusal to sleep. Infants are protected from evil eye with amulets or by having their faces covered in the presence of strangers. Treatment is primarily symbolic.
Caida de mollera, or fallen fontanelle, is an illness of infants before the anterior fontanelle (crown of the head) closes. Common symptoms include diarrhea, excessive crying, fever, loss of appetite, and irritability. Usual folk treatments focus on raising the fontanelle by, for example, pushing up on the palate.
Empacho is thought to be caused by something getting stuck in the intestines, causing blockage. Common symptoms are diarrhea, constipation, indigestion, vomiting, and bloating. The commonest treatment is massage along with herbal teas; the former is for dislodging the blockage, and the latter is for washing it out.
Susto, or fright (sometimes called magical fright), develops when a person has had a sudden shock--a mother may develop fright if she sees her child nearly drown, or someone may experience fright after participating in an unusually intense argument. The sick person experiences such symptoms as daytime sleepiness combined with nighttime insomnia, irritability and easy startling, palpitations, inability to stop thinking about the shocking event, anxiety that it will be repeated, and sometimes a sense of loss or a sadness that will not leave. The mild form is treated with herb tea; more severe cases are treated with ritual cleansings (barridas) to restore the harmony of body and soul.
When mild, these folk illnesses are commonly treated at home, but if they persist, the help of specialists--curanderos (men) or curanderas (women)--is sought. The training of curanderos and curanderas varies widely. Most practice a combination of shamanic healing and herbal or practical first aid healing. Most are also astute at manipulating symbols and "reading" the prevailing psychological and social indicators. Some curanderas specialize in midwifery and infant care. In some areas, becoming a healer is a matter of inheritance; the skills are passed from mother to daughter or perhaps aunt to niece. In some areas it is a matter of being called. Typically, curanderos and curanderas spend several years in apprenticeship; their subsequent reputation depends on the number of their patients and how successful their patients judge them.
Treatment techniques, usually a combination of the shamanic and the naturalistic, vary widely; interested readers should consult specialist texts. An issue of concern is that some curanderismo treatments, particularly for empacho, involve feeding lead-or mercury-based remedies. Investigators' efforts to test whether the amounts ingested were causing medical complications were inconclusive. Although curanderas were found to be largely aware of the danger of the remedies and used them sparingly, intervention programs to limit use of these remedies were begun (Baer et al., 1989; Trotter, 1985).
Trotter (1985) collected symptomatology lists from more than 2,000 interviews and submitted symptom clusters to medical doctors for "blind" diagnoses. He found, for example, that caida de mollera appears to be symptomatic of serious dehydration secondary to gastroenteritis or respiratory infection. Trotter also found that people who are sicker than average are more likely to be diagnosed with susto. Baer and Penzell (1993) similarly report that migrant workers most affected in a pesticide poisoning incident were also those most likely to report suffering from susto. Susto fits the pattern of "soul loss" (Ingerman, 1991), a shamanically recognized disorder known worldwide that resembles several serious psychotherapeutically recognized conditions, including depression and posttraumatic stress syndrome. Therefore, people being treated for folk diseases could be considered to have conventional illnesses that are being treated outside the conventional biomedical health care system.
Mexican-Americans
Folk medicine is still popular among large groups of Mexican-Americans in New Mexico, Colorado, Arizona, California, and especially in West Texas. Their healing system, based on pre-Columbian indigenous lore,reflects a degree of isolation and unwillingness to assimilate Anglo-Saxon culture. Moreover, the inability of scientific medicine to offer relief for various categories of folk illness further enhances the usefulness of these practices. Five types of folk illness are most prominent:mal de ojo (evil eye), empacho (gastro-intestinal blockage due to excessive food intake), susto (magically induced fright), caida de la mollera (fallen fontanel, or opening in or between bones), and mal puesto (sorcery). Prominent among Mexican-American folk healers is the curandero, a type of shaman who uses white magic and herbs to effect cures. In the cosmic struggle between good and evil, the curandero, using God-given powers, wards against harmful spells and hexes. As in other folk systems, faith in the curandero's abilities is the essence of the healer's continued success.
Hot-Cold Theory
The hot-cold theory of disease ranks among the most popular systems of contemporary folk medicine in the United States. In health, the human body displays a balanced blending of hot and cold qualities. Sickness will ensue if an excess of hot or cold foodstuffs is ingested. The basic scheme was introduced into Latin America by the Spanish during the 16th century. Reinforced by native cultural values, it became firmly embedded in popular Latin healing traditions. The hot-cold scheme is applied to foods, diseases, and remedies. The terms hot and cold do not necessarily refer to the temperature of foods or remedies. Qualities are assigned on the basis of origin, color, nutritional value, physiological effects of the food or remedy, as well as therapeutical action. Among New York Puerto Ricans, for example, bananas, coconuts, and sugar cane are considered cold, whereas chocolate, garlic,alcoholic beverages, and corn meal are hot. Cold-classified illnesses such are arthritis, colds, and gastric complaints must be treated with hot foods and remedies. Their hot counterparts --constipation, diarrhea, and intestinal cramps--require treatment with cold substances.
Concept of Disease
Intrinsic to an understanding of why people choose folk medicine is an understanding of how the ordinary person defines disease. The term "disease" generally signifies any organic illness. All cultures have systems for classifying diseases on the basis of etiology, signs/symptoms and treatments. Many cultures-modern and ancient, have felt that when one's system is out of balance, one will become ill. Physicians have often seen patients who, when they feel well, believe they are well, leading to a denial of or delay in diagnosis and treatment of early stages of diseases such as diabetes mellitus, hypertension, and tuberculosis. The concept of disease prevention is completely alien in this belief context.
Origins of Hispanic Folk Medicine
People tend to look for reasons why they become ill. From the ancient Greeks came the concept that disease occurs when there is an imbalance of the four humors, or, what has survived into Hispanic folk medicine today, that disease is caused by an imbalance between hot and cold principles. For health maintenance, avoidance of exposure to extreme temperatures is important. Vasoconstriction and a low metabolic rate signify one has a "cold" disease while "hot" conditions are characterized by vasodilation and a high metabolic rate. Examples of "hot" diseases or states are pregnancy, hypertension, diabetes, acid indigestion, susto, ojo and bìlis. Some "cold" disease examples are menstrual cramps, frio de la matriz, coryza, pneumonia, empacho, and colic. Most people do not think about hot and cold principles unless they have been stressed by illness or are in another vulnerable state. The goal of treatment is to restore harmony and balance. Thus, "hot" diseases are treated with "cold" remedies, and "cold" diseases are treated with "hot" remedies.
The Meso-American Indians had a very sophisticated system of health, disease, and treatment. They established the first medical schools in Mexico fifty years before Jamestown was settled, and used a pharmacopeia of over 5,000 well studied and efficacious Indian herbal medications that have been categorized in the Badiano Codix (1552). In that native system of medicine, a strong connection between religion and health existed.
Utilization of Lay Healers Among Hispanics
Studies have shown that 90% of folk medicine adherents do not use the services of a curandero, or lay healer, but obtain their remedies from a hierarchy of lay healers.
Hierarchy of Lay Healers in the Barrio
Senora/Abuela (Matron/Grandmother)
Yerbero (herbalist) Sobador ("massage therapist") Partera (midwife)
Curandero/a (Traditional healer of shamanic type)
Neighbors and relatives are valuable sources of information. Those whose conditions cannot be treated by a senora/abuela are usually referred to a yerbero (herbalist), sobador (massage therapist), or partera (mid-wife, who also treats problems with young children). If these (specialists) cannot handle the problem then the patient is referred to a curandero total (the lay healer who may use multiple modalities). These people are highly respected in the local community and they may come from either a family with a tradition of curanderisimo or receive the gift of healing (el dón) later in life. Two of the most highly revered lay healers in South Texas and Mexico, Niño Fidencio and Don Pedro Jaramillo, lived in the late 1800's and early 1900's; they both have active followers who venerate them at shrines today. There is no direct remuneration for services rendered by the curanderos, but most of them do accept gifts. While the curandero has clear expertise in folk illnesses, 80% of the folk remedies are for medical problems. Most curanderos know what they cannot handle and will refer severe health problems to the medical profession, including their own.
HYPERTENSION
Hypertension is defined as a hot illness. In 60% of the cases the etiology is thought to be due to corajes (anger) or susto (fear); the remaining 40% are felt to be due to "thick blood". Cool remedies such as bananas and lemon juice are popular as well as teas of passion flowers (pasionara), linden (tilia), or zapote blanco.
Diabetes Mellitus
Diabetes mellitus is also a hot illness. While the curanderos will no doubt encourage consultation with a physician, various remedies may also be used. Nopal (or cactus), aloe vera juice, or bitter gourd can be taken. In some areas in Texas and Mexico treatment is started with maturique root infusion for approximately one week if the person is extremely hyperglycemic. Subsequently for maintenance therapy, trumpet flower-herb or root infusion (tronadora), brickle bush (prodigiosa) tea, or sage tea (salvia) are used. The proven safety and efficacy of maturique, trumpet flower, or bricklebush preparations are not known. Aloe vera juice is reasonably safe but aloe vera latex is a powerful purgative. Sage tea taken chronically can lower the seizure threshold and has been reported to cause mental and physical deterioration because it contains thujones and tannins.
Working in a context of prevalent folk belief.
Since folk beliefs are wide-spread to varying degrees, the effective health care provider would do well to heed the following recommendations:
· Understand (and be sensitive) to the role folk medicine may play in patients one encounters;
· Practice delivering messages of tolerance and respect - "the art of medicine";
· During the interview, ask "What do you think caused your illness?", and "We all have favorite remedies that we use when we are sick. What have you done to treat this condition?"
· When appropriate, and not contraindicated, incorporate some benign folk medicine remedies into one's advice to the patient to improve the compliance and trust;
· As an example, when encouraging liquid intake for colds and flu, considering suggesting te de manzanilla (chamomile tea) with other electrolyte replacement as part of the therapeutic regimen.
Family Structures
· Familismo. Hispanics/Latinos tend to view the family as a primary source of support. Families are broadly defined, close knit, and emotionally and financially supportive. Family often includes non-blood-related persons, including compadrazgos (when a couple baptizes the child of another). Some non-Hispanics interpret these family characteristics negatively as over-involvement or dependence.
· The eldest male is typically the authority figure, and gender roles are traditional.
· Important decisions are made by the whole family, not the individual.
· Elders often provide childcare so that children and spouses can work.
· In traditional Colombian families, children are highly protected and very dependent on their parents. They are expected to live with their parents until they marry. Punishment is often emphasized over positive rewards. Children are taught to avoid confrontations with their parents and older persons, and to be obedient, respectful, and shy.
Communication and Social Interaction
· Personalismo - This refers to the tendency of Hispanics to place utmost value on individuals as opposed to institutions. They tend to trust and cooperate with individuals they know personally, and many dislike impersonal and formal structures. Hispanic customers may identify a health worker by name rather than by job title or institution. In a professional situation, many expect formality in address (Mrs. X), but also personalismo (how are your kids doing in school?). The quality of a social interaction is often seen as more important than length.
· Respeto - The special consideration and respect that should be shown to elders and authority figures within the community. When speaking Spanish, elders should be addressed as usted, not tu.
· Simpatía - This describes many Hispanics' preference for smooth social relations based on politeness and respect, as well as avoidance of confrontation and criticism. Overt disagreement is not considered appropriate behavior. Some expect offers of gifts or food to follow a pattern of offer, refusal, insistence, and final acceptance, so receivers do not appear greedy or givers insincere.
· Many Hispanics are characterized by warm, friendly, and affectionate relationships. Personal space is close and frequently shared with family members or close friends.
· Some Hispanics may get agitated or emotional when nervous or frightened. They may communicate intense emotion and appear quite animated in conversations a behavior that is sometimes misperceived by non-Hispanics as being "out of control". Latinos' voice pitch and inflections are sometimes misinterpreted as confrontational. Many are very loud and outspoken in expressing pain.
· Many Hispanics, particularly if they were not raised in the US, may avoid direct eye contact with authority figures or in awkward situations.
· Many will nod affirmatively but not necessarily mean agreement. Silence may mean failure to understand and embarrassment about asking or disagreeing.
· Many may understand English better than they can speak it, especially under stress.
· Modesty and privacy are important. Stigmatized health issues should be discussed through an interpreter and not family members. When a family member is used as interpreter, if the issue is personal, try to use a family member of the same gender. Sexuality issues are hard to discuss. Often the word for sex (sexo) is not even used - tener relaciones (to have relations) is used instead.
Time Orientation -"Tiempo latino"
· Time and punctuality may be flexible. Social gatherings are often expected to start later than the announced time.
· Many Hispanics are averse to a hurried pace, especially given the expectation of personalismo.
Concepts of Health
· Health is generally viewed as: being and looking clean; being able to rest and sleep well; feeling good and happy; having the ability to perform in one's expected role as mother/father, worker, etc. In Puerto Rico, the phrase llenitos y limpios (clean and not too thin) is used.
· A person's sense of bienestar (well-being) is thought to depend upon a balance in emotional, physical, and social arenas. Imbalance may produce disease or illness. Some attribute physical illness to "los nervios", believing illness results from having experienced a strong emotional state. Thus, they try to prevent illness by avoiding intense rage, sadness, and other emotions. Depression is not talked about openly; a person may say, "I am sad" (triste).
· Eating well and drinking fruit juices are common health promotion practices. Exercise is often not perceived as a health promotion practice and is discouraged during illness. As with other issues, this will vary by educational level.
· Individuals may not seek help until they are very sick.
· Hispanic cultures view illnesses, treatments, and foods as having "hot" or "cold" properties, although how these are ascribed may vary by country. Some consider health as the product of balance among four body humors (blood and yellow bile are "hot", phlegm and black bile are "cold"). One would balance a hot illness with cold medications and foods, etc. This might result in not following a doctor's advice to drink lots of fluids for a common cold, if one believes such drinks add more coldness to body. Instead, hot liquids (teas, soups, broth) could be recommended. Colombians often use meat broth instead of chicken soup when sick; also drink agua de panela (unprocessed sugar and water) for respiratory/flu symptoms.
· Prevention strategies could build on this concern for balance e.g., adopt a balanced diet to prevent diabetes and other diseases associated with overweight.
Some common illnesses and their accepted causes:
Ataque - severe expression of shock, anxiety, sadness
Bilis - vomiting , diarrhea, headaches, dizziness, migraine, nightmares, loss of appetite, inability to urinate, brought on by livid rage and revenge fantasies. Believed to stem from bile pouring into bloodstream in response to strong emotion.
Empacho - lack of appetite, stomachache, diarrhea, vomiting, caused by poorly digested or uncooked food. Treated by massaging the stomach and drinking purgative tea, or by azarcon or greta, medicine that has been implicated in some cases of lead poisoning.
Mal de ojo (evil eye) - Vomiting, fever, crying, restlessness, brought on by an admiring or covetous look from a person with an evil eye. Children susceptible. Preventable by wearing particular jewelry.
Pasmo - tonic spasm of voluntary muscle; chronic cough or stomach pain; arrest of child's growth and development, all brought by exposure to cold air when body is overheated.
Susto (fright) - anorexia, insomnia, hallucinations, weakness, painful sensations, brought on by traumatic experiences. Treatment may include a barrida (spiritualistic cleansing by sweeping body with eggs, lemons, bay leaves), herb tea, prayer.
Asthma may be called fatiga by Puerto Ricans.
Health promotion, prevention, and treatment
· Preventative medicine is not a norm for most Hispanics. This behavior may be related to the Hispanic "here and now" orientation, as opposed to a future-planning orientation.
· Some commonly known Hispanic sayings suggest that events in one's life result from luck, fate, or other powers beyond an individual's control.
Que será, será (What will be will be);
Que sea lo que Dios quiera (It's in God's hands);
Esta enfermedad es una prueba de Dios (This illness is a test of God);
De algo se tiene que morir uno (You have to die of something).
· Persons with acute or chronic illness may regard themselves as innocent victims of malevolent forces. Severe illness may be attributed to God's design or bad behavior or punishment. Genetic defects in child may be attributed to parents' actions.
· Family and friends may indulge patients, allowing them to be passive a stance that may conflict with the view that active participation is required to prevent or heal much disease.
· Other Hispanic sayings support health promotion, and illustrate the considerable status given to health and prevention:
La salud es todo o casi todo (Health is everything, or almost everything);
Es mejor prevenir que curar (An ounce of prevention is worth a pound of cure);
Ayúdate que Dios te ayudará (Help yourself and God will help you).
· "Helping yourself" may lead to placing responsibility for cure with the entire family. The challenge for health professionals is to assess the amount of control patients believe they have over their health and to design interventions that build on traditional support systems.
· Vaccination is very important and adhered to for children.
· Western medicine is expected and preferred in case of severe illness, but some Hispanics may also use native healers. Curanderos utilize prayers, massage, and herbs to treat physical, spiritual, and emotional ailments. Espiritistas are believed to have spiritual or psychic powers to cure illness by communicating with dead souls.
· A "botanica" is a resource store for herbs and other traditional remedies. Some Hispanics may go there before going to a physician or clinic. In many Latin American countries, pharmacists prescribe medications, and a wider range of medications is available over the counter. People may share medicines, or write home for relatives to send them medications. Individuals may discontinue medication if doesn't immediately alleviate symptoms, or after their symptoms abate. Many believe taking too much medicine is harmful.
· Due to history, some Hispanics may distrust the health system (many Puerto Rican women experienced involuntary sterilization, or were adversely affected by birth control pill trials), or view it as an extension of a repressive government (Central Americans), or fear it as a point of contact with immigration authorities. Some may confuse public health programs with welfare and avoid them due to stigma.
Health Status - Causes of Death
· The five leading causes of death for Hispanics in Rhode Island are: cancer, heart disease, homicide, AIDS, and unintentional injuries. For the general population they are: heart disease, cancer, stroke, chronic lung diseases, pneumonia and influenza.
· Nationally, Hispanics are about twice as likely to have non-insulin dependent diabetes than are non-Hispanic whites, and are more likely to have undiagnosed diabetes.
· Hispanic men are more likely to have undiagnosed, untreated, or uncontrolled hypertension than the national average.
· Incidence of AIDS among Hispanics was 4 times more likely in RI than among the general population. Cases of gonorrhea were 2 times more prevalent.
· The incidence of tuberculosis for Hispanics in RI was 5 times greater than for the general population (17.5% vs. 3.5). Some patients may mistake the tuberculin test for a vaccine, and not realize the importance of medical follow-up. Some authorities recommend arranging for the reading of results of the test at work or school, for the client's convenience. Also, the use of the Bacillus Calmette-Guerin (BCG) vaccine in many Latin American countries may complicate the clinical detection of tuberculosis infection among Hispanics.
Behavioral Health Risk Factors
· Hispanics are less likely than the general RI population to smoke (20.3% vs. 22.4%). Some authorities attribute this to the low incidence of smoking among Hispanic women. One researcher states that Hispanics are more likely to smoke in social settings rather than in response to "need" or nicotine addiction.
· Hispanic Rhode Islanders are less likely than the general population to be overweight, but more likely to be obese.
· Hispanic Rhode Islanders are a third less likely than all Rhode Islanders to exercise regularly (30.4% vs. 45%), and engage in less leisure-time physical activity. One researcher notes that a high percentage of Hispanics work in manual labor that does not contribute to aerobic fitness.
· Hispanics were more likely than other Rhode Islanders to eat 5 servings of fruits and vegetables per day (29% vs. 24%). This is not true nationally.
· Hispanic Rhode Islanders are nearly 50% less likely to drink alcohol than the general population.
· Hispanic Rhode Islanders are more likely than the general population to use safety belts or child safety restraint (81% vs. 76%). I have no national statistics concering seat belt use. In Latin American countries, seat belts are routinely "cut out" of cars and very few people use them. Here in the United States, where many Hispanics are undocumented, seat belts are frequently worn in order to deprive police of the "probable cause" needed to stop and search a vehicle
Relatively few Hispanics know how to swim, making drowning a widespread risk.
Health Screening
Women participate in more screening activities than men. Women's breast and pelvic cancer screening procedures may be seen as intrusive and embarrassing, thus may be delayed or not done. In Rhode Island, the percentage of women ages 40 and over screened for breast cancer and the percentage of women screened for cervical cancer is higher in the Hispanic population than in the general state population.
· Many Hispanic men are resistant to the concept of health screening. Wives may be very influential in men's screening decisions. Elderly might be influenced by children. Health screening recommendations for children are generally followed.
Maternal and Child Health
· The birth rate of Hispanics in RI is about twice as high as for the general population (116.4 vs. 57.5 per 1000 women ages 15-44).
· A greater percentage of Hispanic mothers than all mothers in RI delivered babies without prenatal care in the first trimester. (14.8% vs. 10.3%). Yet the rate of low birth weight babies was only slightly higher in the Hispanic population in RI (6.8% vs. 6.3%)
· Hispanic teenagers ages 14-18 were over 3 times as likely to give birth than all teenagers in the state.
· Hispanic babies are over 3 times as likely to be born into poverty (78.1% vs. 25.5% for general population).
· Breast feeding is less common among Hispanic women than among non-Hispanic whites. Many Latin American women believe colostrum is harmful for babies. In Colombia, breast feeding is expected in low to middle socioeconomic groups.
Diet and Food Practices
· The typical diet is high in fiber, relying heavily on beans and grains (rice) rather than on meats for protein.
· Leafy green vegetables not a usual part of the diet.
· Relatively little intake of dairy products. Milk is consumed in coffee.
· Generally eat a lot of tropical fruits, fruit juices, and starchy root vegetables (e.g., potatoes, cassava, plaintains). Sofrito (blend of spices) is used to season stews.
· Puerto Ricans do not typically eat tortillas. More than 100 varieties of herbal teas are used to treat illness and promote health. For colds, flu and viruses, many use a mixture of honey, lemon and rum as an expectorant and antitussive. Egg yolk, sugar, and milk, malta, or fruit juices may be used as nutritional support for illness.
*******
(I'm listing the following passage on Evil Eye as a postscript because -- although the topic is significant worldwide and elicits a high degree of academic interest -- it is not as important as the voluminous literature seems to suggest.)
EVIL EYE
AN ORAL HISTORY OF EVIL EYE CUSTOMS ALONG THE TEXAS-MEXICO BORDER
The following collection of evil eye stories was made by Soledad Perez among "the Mexican people of Austin, Texas" in the fall and spring of 1948 and 1949. The commentary is hers as well. This material appears in "The Healer of Los Olamas and Other Mexican Lore."
The evil eye is an ailment common among small children. It is believed that it is caused by excessive affection. If a woman or a man sees a child with physical attributes which he admires, he must touch the child and invoke God's protection so that the baby will not suffer from the evil eye.
Children seem to be most susceptible to this ailment, although adults may suffer from it occasionally. Babies suffer the direst consequences. They have a very high fever, a lack of appetite and sleep, and usually a swelling on some part of the body. So if a woman casts an evil eye on a child's hand, it will be swollen and red.
In most instances, the cure for evil eye is simple. It consists in passing an unbroken egg over the face and body of the victim, sweeping him, or transferring three mouthfuls of water from the mouth of the person casting the evil eye to the mouth of the victim.
After the cure, precautions must be taken in the disposal of the egg or eggs used. They must be thrown out in a shady place or buried. If the sunÕs rays strike them, the evil eye will attack the victim anew. (For evil eye cf. D2071 and D2064.4 in Thompson's Motif-lndex.)
EVIL EYE (1)
When a person suffers from the evil eye, he says, "I was given the eye." To cure this an unbroken egg is passed over his face. Afterwards, the egg is broken in a saucer, and it is placed under the bed.
Another remedy is to find the person who cast the evil eye and force this person to give the victim three mouthfuls of water.
In order to decide whether a person is suffering from the evil eye, the egg placed under the bed must be examined after the cure has been administered. If a white membraneous film appears over the egg, it means that the person who gave the evil eye is a man. If only an eye appears on the egg, it means that the person who cast the evil eye is a woman."
(Informant 3.)
EVIL EYE (2)
When Chita was small, I took her down town on one occasion. She was a pretty little girl, and people admired her. While I was standing at the counter of one of the de- partment stores, a little Mexican woman approached me and wanted to touch Chita. She said, "What a pretty baby! Won't you let me touch her hair and eyes?"
I didn't like for people to be touching the baby; so I said, "No, please don't touch her!"
The little woman left, and I didn't believe in the evil eye; so I thought no more about it.
The next day Chita became ill. She had a very high fever and was flushed and uneasy. I called the doctor. He came and looked at her. Two or three days went by, and Chita didn't improve. She just seemed to get worse. We went from one doctor to another, but it didnÕt do any good.
Finally one day my comadre Mrs. Ramos came over, and she looked at Chita and said, "This child is suffering from the evil eye. I can cure her if you will let me try."
I told her to go ahead; and she did. She asked for two eggs and a cup. One of the eggs she passed over Chita's whole face. Then she took the egg, broke it, put it in a cup stirred it, and made a cross with some of it on Chita's fore- head. While doing this she pronounced several prayers. The other egg she placed on the mantelpiece in the living room and asked that no one touch it.
The next day Mrs. Ramos came back. Chita's fever was gone, and you could tell that she was better. Mrs. Ramos then took the egg from the mantelpiece and broke it. If I hadn't been there, I wouldn't believe it, but my husband and I both saw it. The egg looked as if it were hard-boiled. Mrs. Ramos said, "Chita will get well now. The evil eye has gone into the egg; that's why it looks like this."
Chita got well.
(Informant l.)
EVIL EYE (3)
In my home, whenever anyone became ill my aunt was called.
On one occasion it was believed that my little brother had the evil eye. My aunt came and passed an unbroken egg over my little brotherÕs face. Then she broke the egg, and taking some of it, she made a cross on his forehead. After that she said several prayers and swept my brother from head to foot. She took another egg, broke it, put it in a saucer, and left it under the bed. Later, when my aunt took the egg out from under the bed, she said that she could tell my brother had been suffering from the evil eye because an eye had formed in the egg.
(Informant 17.)
Both Perez's introduction and the second collected story accord with the notion that *touching* the child dispels the eye or prevents it from being cast. In story #2, the mother all but admits that it was her mistake in not letting the admiring woman *touch* her daughter that led to the child coming down with the evil eye.
A SUMMARY OF EVIL EYE BELIEFS WORLD-WIDE
PERPETRATORS
Envious people
Those who praise children
Those who suffer from covetousness
Those with blue eyes (xenophobia among brown-eyed racial groups)
Childless women
People born with the unfortunate propensity to inadvertently project the eye
ETIOLOGY
"Overlooking" (old British term; means gazing too long upon coveted item or child)
Praising without touching or spitting to void the damage
Projection from eye (Sicilian term for one who gives mal occhio is jettatura, from the same root-word as ejaculation and projection)
VICTIMS (AND SYMPTOMS)
Nursing infants (they sicken and cry; their mother's milk may dry up)
Young children (they sicken and cry; they may vomit or become listless)
Milk cows and milk goats (they dry up)
Fruit trees (they wither and die or they do not bear fruit)
Adult men (they become impotent)
(Note: as Prof. Dundes points out, all of these symptoms involve the loss of FLUIDS.)
APOTROPAIC CHARMS and GESTURES
Refusal to accept praise on behalf of child
spitting on child
Spot of soot or dirt on child so child will not look pretty
Protective hand gestures
Eye amulets (e.g. wadjet eyes, blue-eye charms, ojo de venado)
Eye-in-hand amulets
Hand of Power and Powerful Hand images
Hamsa hands or hands of Fatima
Eye-agate amulets or jewelry
Cat's-eye shells
Blue beads
Cord Charms that decay and release a blue bead
Amulets that replicate protective hand-gestures
Red coral horns and twigs
Buckle of Isis amulets
Horseshoes
Crescent-shaped objects
(Note: Some of these involve reflective imagery, others are protective.)
CURES
Olive oil dripped into water with prayer
Wax dripped into water with prayer
Coals or match heads dropped into water with prayer
Passing a whole raw egg over the face, then breaking it.
Breaking an egg in a dark, shadowed place, unseen
Breaking an egg and drawing a cross on the victim's forehead
Throwing an egg into the bushes or against a tree (if tree is victim)
Placing a broken egg in dish beneath victim's bed
Piercing a lemon with iron nails
Victim drinks three sips of holy water
Victim is bathed in holy water
Victim spits at giver of evil eye three times
Water or spittle from inadvertent perpetrator is passed to mouth of victim
Collection of spittle from group (anonymous donation); victim drinks spittle in holy water
(Note: As Dundes points out, these involve use of fluids and/or eye-shaped objects (egg, lemon) which contain fluid within them)
******
Health Risks of Hispanics in Colorado, the largest minority, 13% of the population.
· Among Hispanics respondents, 28% reported no health care coverage compared to 16% of the statewide survey.
· Only 20% of Hispanics reported being in excellent general health compared to 28% of the statewide respondents.
· Hispanic respondents reported an overall prevalence of diabetes of 7% compared to the statewide sample at 3%.
· Among Hispanic respondents, 29% reported being overweight (according to Body Mass Index) compared to 21% statewide.
· There were no significant differences between Hispanic and statewide estimates of current smokers or chronic drinkers.
· On the Hispanic survey, 53% responded that they did not always wear a seat belt when riding in a car, compared to 37% of the statewide survey.
· Diabetes is about twice as common among Hispanics as among Anglos. (Some estimates contend that the incidence of diabetes among Hispanics -- if accurately measured -- could approach 4 times the Anglo rate.)
· Obesity is more common among Hispanics (especially women) than in the general population.
· Latinas with breast cancer tend to have larger tumors and/or (more?) metastatic disease than do Anglo women.
· Causes of death nationally among Hispanics are (in decreasing order) heart disease, cancer, injuries, stroke, homicide, liver disease, pneumonia/influenza, diabetes, HIV infection, and perinatal conditions (Spector, 1996).
· Difficulty in accessing and utilizing the healthcare system may be viewed as both a singular health problem and a highly significant etiology in or contributor to other health problems. Factors contributing to difficulty accessing services include language barriers, low rate of medical insurance coverage, low incomes, and limited knowledge of health services (Chavez, Hubbell, & Mishra, 1999).
***Three final notes:
For Hispanics, "illusion" is a positive trait. The world is full of irremediable harshness. In consequence, Hispanics "pad" this harshness with illusion. In Gabriel Garcia Marquez' novella, "El Coronel No Tiene Quien Le Escriba," the colonel's long-suffering wife asks how he can continue to believe -- week after week, year after year -- that the mail boat will finally start delivering his pension check. The colonel answers, "Illusion may not nourish, but it can be eaten."
Unlike gringos, Hispanics are fully aware that "the death rate is one per person." Ironically, we gringos use mortality statistics somewhat "magically," tending to assume we always belong to the percentage of the population that is not affected by the disease in question.
The liver is transcendenatlly important in the latino view of health. If only to capitalize on the power of faith to heal, it will not hurt -- and may well help -- to say that any medicinal intervention "es bueno para el hígado."
***
Cosmology, Space, Time
"What is sickness in one culture might be chromosomal abnormality, crime, holiness, or sin in another. For the same symptom of compulsive stealing one might be executed, tortured to death, exiled, hospitalized, or given alms or tax money." Medical Nemesis, Ivan Illich
Medical Nemesis, Ivan Illich "Mexicans are different from you and me. Any attempt to deal with them as if they were the same would be shortsighted, maybe even disastrous. If Americans are going to deal with Mexicans we must deal with them on the basis of who they are... Mexicans place more emphasis on magic than on logic. They have more regard for fantasy than the truth. They laugh at death and sometimes show little respect for human life. They are resilient beyond explanation. Their humor is blacker than most. Mexicans can be exasperatingly fatalistic and uninterested in making their lot better. They drive visiting do-good reformers wild. They can be inspiringly heroic." This passage is from the last page of Patrick Osler's "The Mexicans." (Harper and Row, 1989)
Most summaries of ethnic traits inspire debate. Osler's view of Mexicans is no exception.
"More emphasis on magic than logic..."
In an age of progress and logical positivism, can anyone expect to "get ahead" by believing in magic?
While Americans continue to build "rational" constructs, there is growing concern over the proliferation of social, personal and
ecological "box canyons" --- apparent "dead ends" created by the relentless logic of our "systems." We sometimes wonder if
"the logic of progress" is compatible with a viable biosphere.
Interestingly, the Latin American authors who are most popular in the United States belong to a literary school called "magical
realism." Perhaps a sizeable dose of "magic" is tonic, antidotal, or even salvific.
"More regard for fantasy than truth..."
Many will argue that "regarding fantasy more highly than truth" indicates a refusal to confront reality, a negation of reality "as it
is." Curiously, this inclination to indulge fantasy reveals kinship with Einstein's belief that "imagination is more important than
knowledge."
"They laugh at death and sometimes show little respect for human life."
It is difficult to defend callousness in Mexico, just as it is difficult to defend 23,000 annual handgun murders and routine schoolyard slaughter in the United States. However, behind-and-beyond 'the lack of respect for human life,' is a familiarity with
death that enables Mexicans to confront death squarely. In "The Labyrinth of Solitude," Octavio Paz says that "death in the
United States is accidental; in Mexico, death is incidental." Familiarity with death is, perhaps, healthier than being so afraid of
"the inevitable" that we must approach death with fear and denial. Jessica Mitford's "The American Way of Death" portrays the
ghoulishness of the American funeral business. Alternatively, "el día de los muertos" inspires Mexicans to picnic on the graves of their ancestors, to exhume - and lovingly clean - the bones of their departed loved ones, inviting departed souls to join a communion so democratic that it includes "the living and the dead."
It is true that Mexican "humor is blacker than most." However, many observers also note that Mexicans laugh more --- and more heartily --- than we self-conscious (and often self-obsessed) gringos.
Admittedly, there is an "exasperating fatalism" about many Mexicans. Yet, this fatalism induces a kind of contemplative calm
and peaceful acceptance inaccessible to gringos hurtling ever faster toward the receding horizon of Progress. We nortenos are a people obsessed with willfulness and control. In turn, these obsessions provoke needless anxiety.... anxiety that pre-empts the joy of contemplation and the fruitfulness of creative inactivity.
The following story, while legendary, illustrates several core values.
An American businessman was at the pier of a Mexican fishing village when a small boat with just one fisherman docked.
Inside the small boat were several large yellow fin tuna. The American complimented the Mexican on the quality of his fish and asked how long it took to catch them.
The Mexican replied, "Only a little while."
The American then asked why he didn't stay out longer and catch more fish.
The Mexican said he had enough to support his family's immediate needs.
The American then asked, "But what do you do with the rest of your time?"
The Mexican fisherman said, "I sleep late, fish a little, play with my children, take siesta with my wife, Maria, stroll into the
village each evening where I sip wine and play guitar with my amigos, I have a full and busy life, senor."
The American scoffed, "I am a Harvard MBA and could help you. You should spend more time fishing and with the proceeds buy a bigger boat. With the proceeds from the bigger boat you could buy several boats, eventually you would have a fleet of fishing boats. Instead of selling your catch to a middleman you would sell directly to the processor, eventually opening your own cannery. You would control the product, processing and distribution. You would need to leave this small coastal fishing village and move to Mexico City, then LA and eventually NYC where you will run your expanding enterprise."
The fisherman asked, "But senor, how long will this all take?"
To which the American replied, "15-20 years."
"But what then, senor?"
The American laughed and said, "That's the best part. When the time is right you would announce an IPO and sell your
company stock to the public and become very rich, you would make millions."
"Millions, senor? Then what?"
The American said, "Then you would retire. Move to a small coastal fishing village where you would sleep late, fish a little, play with your kids, take a siesta with your wife, and stroll to the village in the evenings where you could sip wine and play your guitar with your amigos."
***
How should we interpret the "busy-ness" of do-good reformers like the Harvard MBA supplying an up-to-date business plan to a remote Mexican fisherman? Despite "the good" intended by cross-cultural reformers, there is a level on which efforts to "develop and modernize" oblige "underdeveloped peoples" to abandon tranquil receptivity in favor of the "progressive" clamor for "MORE!"
As a result of accelerated consumption, the planet is literally heating up while the toxic by-products of hyper-productivity find their way into the soil, air and water.
Cross-cultural understanding is never easy, especially for North Americans whose belief in progress and modernization is
tantamount to religious conviction, a conviction we propagate with missionary zeal. Despite the lip service paid to
multiculturalism, do we, at bottom, believe that the cultural characteristics outlined by Patrick Oster at the beginning of this
essay are as honorable as our own? To what extent has Progress become a prideful effort to re-make the world in our own image?
Nearly a hundred years ago, G. K. Chesterton offered this counsel: "To be merely modern is to confine oneself to an ultimate
narrowness."
If we wish to understand Latinos -- which is to say, if we wish "to stand under" and look up at the honorability of their culture -- it is necessary to examine the underpinnings of culture itself.
Inevitably, these underpinnings are rooted in Creation Stories.
Take, for example, the scientific cosmology on which our own view of Progress depends. Most educated Americans assume
that "The Big Bang" started it all. We harbor a bedrock belief that "true scientific insight" obliges rational beings to accept the
centrality of The Big Bang and the random interplay of a few elemental forces.
Interestingly, one of the fellows who shared the 1978 Nobel Prize for Physics now believes that there was no basketball-size
lump of hyper-condensed matter which suddenly "banged" existence into being.
Instead, he concludes that the Big Bang occurred "out of nothing."
A retired Yale physicist sees no inconsistency with the belief that an intelligent being outside "our universe" created "reality." He even suggests that our universe is "the hardware" on which a superior intelligence is testing the "beta version" of a "program." Perhaps the program has been designed to determine whether love and freedom are stronger than self-interest, indifference and hatred. He even posits that those unusual events which impress some observers as "divine intervention" are episodes in which "the outside intelligence" tweaks the program to make necessary modification.
It is not my purpose to endorse either of these cosmological views, but to indicate how little we know -- how little we can know -- at the root level of things.
As a British astronomer put it: "Not only is the universe stranger than we suspect: it's stranger than we can suspect."
The entire superstructure of culture springs from this root level.
We are living in a time/space continuum, and each of us -- each of our cultures -- makes its own peace with these remarkably fluid - and inexplicably mysterious - parameters. (Given our scientific view, it is not surprising that atomic clocks measure the passage of time differently at the top - and bottom - of skyscrapers.)
Typically, Hispanics are as blasé about the passage of time as gringos are intent on micro-measuring its passage. As a result, Latinos are notoriously lax about punctuality. It's almost as if Latinos don't believe in the reality of time: they certainly do not believe in its primacy.
Instead, Hispanics place primary faith in living people, people with whom relationship can be established only in "the now. And "the now" -- being "a point in time" -- is dimensionless. Lacking dimension, time cannot be measured. Although Hispanic
disregard for time's apparent mandates seems reckless to us, Latinos are completely at home with Einstein's view that "time is an illusion.... albeit a persistent one."
The great Spanish poet José Ramón Jimenez cut to the quick when he noted that "more time is not more eternity."
Pursuing lines laid by Jimenez and Einstein, Octavio Paz observed: "Unquestionably the conception of time as a fixed present and as a pure actuality is more ancient than that of chronometric time, which is not an immediate apprehension of the flow of
reality, but is instead a rationalization of its passing." ("The Labyrinth of Solitude," Grove Press, 1961)
By "ignoring" time --- by making time secondary to "the eternal now," by recognizing that time is a rationalization that has no
life outside "the eternal now" --- Latins live lives of great immediacy.
What is, is.
"Live it, or, live with it."
On the other hand, the clock, that inevitable interloper in gringo relationships -- whether we are relating to people or things -- has little hold on the mind and imagination of Hispanics. "Freed" of the clock, Latinos -- in a literal sense -- are "outside time."
My efforts to "level the (cross-cultural) playing field," may undervalue the fact that every culture displays traits that are
simultaneously advantageous and disadvantageous.
One of the advantages of strict adherence to clock-time, for example, is that human activity -- particularly group activity -- can be scheduled. By way of timely coordination, humankind's corporate and collective activities have been given a tremendous
boost.
Nevertheless, as Carl Jung pointed out, all personal and collective manifestations tend to go "too far." Once critical thresholds are crossed, cultural manifestations -- that were originally beneficial -- tend to transmute into their opposite. In describing this
paradoxical process, Jung notes that "the shift of one thing into its opposite" usually occurs suddenly, and often when least
expected.
Too much of anything, like too much medicine, tends toward self-destruction. Rapidly consolidating transnational corporations -- like the huge "collectives" of communist socialism -- bring about the conditions of their own senescence.
Nevertheless, the attractiveness of these hyper-active "corporate organisms" is irresistible.
Like moths to flame, migrant workers flood the United States. However, migrants also report that living in the United States is like living in a "jaula dorada" (a "gilded cage"). Migrants perceive little substantive freedom in the U.S. while acknowledging the
immense material advantages bestowed by the nation's industrial engine.
When Hispanics talk of freedom, their concerns are personal, interpersonal and transpersonal. For Hispanics, freedom does not derive primarily from material advantage, although adequate health care, decent housing and ample food are deemed
indispensable.
The relentless accumulation of "things" means little to Hispanics, unless they were born to the middle or upper class where North American values are normalized. Revealingly, "los de abajo" ("those at the bottom") regard the gringo urge to store "stuff" in air-conditioned rental sheds as bizarre and incomprehensible.
For Hispanics, "things" that are not primary. Persons and Families are.
The primacy of the Person has an interesting symbolic counterpart in religious iconography. Although it is no longer as
commonplace as it was forty years ago, Latinos still tend to place crucifixes in locations where Americans would place clocks.
Independent of any specific theological content, the displacement of the crucifix by the clock represents the usurpation of
"Personhood" by "The Machine." Notably, this displacement imbues The Machine with a power over peoples' lives considerably more dictatorial than the ethical suasion embodied in The Ten Commandments and the Sermon on the Mount.
Given the centrality of the human Person (and, by extension, the human Family), we find that decisions made by Latinos tend to be driven by the requirements of interpersonal relationship. In other words, Hispanics typically ask how a given behavior will
influence others. More specifically, how will one's actions impact upon the extended family?
The central importance of "others" -- particularly other members of one's family -- is revealed by the fact that Mexican culture is motivated by "shame" more than it is by "guilt."
Anthropologists recognize a fundamental distinction between "shame and guilt cultures." They note that wherever family -- and
extended family -- are primary, shame and honor are far more important motivators than an interiorized sense of personal guilt.
On the other hand, in cultures like our own -- where the extended family has been atomized, and the nuclear family eroded by divorce, and where unprecedented numbers of adults live in single-person households -- there is little reason to protect "family
honor" from the incursions of shame since the family has become a transient shell for individuals whose concerns increasingly
center on personal advantage. (The ongoing erosion of "the common good" as a social and political category reveals a significant "downside" to the individualization that characterizes "guilt culture.")
Japanese society, on the other hand, is a classic illustration of "shame culture." In Japan, it has long been necessary for certain family member to commit suicide if shame is brought on the family. Furthermore, Japanese culture urges this ritual suicide on individuals who may have no role in the provocation of shame.
Wherever "shame and honor" are deployed as fundamental poles of cultural value, people frequently die by suicide or murder.
Whether death results from ritual disembowelment (as in Japan), or from the murderous rage arising from insults slung at one's mother, shame cultures are powder-kegs of interpersonal violence. (Notably, U.S. gang violence is also motivated by codes of "honor." These codes are enacted to protect the "respectability" of the gang, a sort of surrogate family which also functions as an extended family. When gang honor is sullied, the expiation of shame is most readily achieved by blood sacrifice.)
As bleak as these scenarios seem, they are, at least, "personal" scenarios. Killing a particular person whose behavior is
offensive is qualitatively different from the random slaughter motivated by modern political ideologies. In the 20th century, we
have witnessed the rapid ascendancy of indiscriminate ideological murder. Stalin, Pol Pot and Hitler immediately come to mind.
Typically, ideological murder is perpetrated by capitalist states, communist states or surrogate "client states." People are killed according to their presumed ideological affiliation, even when this affiliation is a merely accidental association. In modern,
state-sponsored slaughter, people are no longer "particular individuals" but interchangeable ciphers who -- more often than not --
simply get in the way of uncontainable ideological eruptions. (The American Revolutionary War sanctioned a prototypal version
of modern political violence, by declaring it unnecessary for combatants to distinguish themselves from non-combatants.
American history dismisses British soldiers as fools for wearing "red-coats" rather than having "enough common sense" to
camouflage themselves --- to make themselves fit in with the local environment, both physical and social. Two hundred years
later, American soldiers slaughtered 500 women and children at May Lai, Viet Nam, in part because the boundary between
combatants and civilians had disappeared.)
In a perverse way, murder provoked by shame pays inverted homage to Martin Luther King Jr's dictum that "if a man has not
discovered something he will die for, he isn't fit to live."
Strict codes of honor enable Mexicans -- especially "los de abajo" ("those below") -- to decide what they will die for (and, as a
shadow phenomenon, what they will kill for.)
On the other hand, as corporate culture transforms us all into atomized "consumer units" divorced from any committed sense of interpersonal, familial or group responsibility, death becomes a sort of freakish bogeyman --- a meaningless "accident" to be
avoided at any cost, even the cost of sacrificing one's honor.
In examining the underpinnings of American and Mexican culture, I have perhaps overstated the case. However, the cultural
trajectories of societies bent on self-interest may eventually embody even greater decadence than I envision.
In 1961, Octavio Paz concluded "The Labyrinth of Solitude" -- his landmark study of Mexican history and character -- by saying: "Modern man likes to pretend that his thinking is wide-awake. But this wide-awake thinking has led us into the mazes of a nightmare in which the torture chambers are endlessly repeated in the mirrors of reason. When we emerge, perhaps we will
realize that we have been dreaming with our eyes open, and that the dreams of reason are intolerable. And then, perhaps, we
will begin to dream once more with our eyes closed."
Alongside Paz's criticism of "the modern mentality," Frederick Franck's provides this analysis of our specifically scientific
outlook: "The consciousness of the scientist, in his mechanized universe, logically reaches the point where --- if he practices his
science existentially and not merely intellectually -- the meaning of his own existence becomes an absurdity and he stands on the rim of the abyss of nihil face to face with his own nothingness. People are not aware of this dilemma. That it does not
cause great concern is in itself a symptom of the sub-marine earthquake of which our most desperate world-problems are
merely symptomatic... It is becoming ever clearer that the terrors of war, hunger and despoliation are neither economic, nor
technological problems for which there are economic or technological solutions. They are primarily spiritual problems..."
("Fingers Pointing at the Sacred")
I willl close with a two stories, and a recommendation.
First, an amusing story that circulated Latin America in late 1998. It was forwarded to me by a Honduran friend who heard it from a Nicaraguan couple.
"Ovejas y Algo Más" ("Sheep and Something More")
Un pastor cuidaba sus ovejas en un rincón de los Andes cuando de pronto, ve en el horizonte un Toyota Tercel verde, que se
aproxima. Al llegar al lado del pastor, el Toyota se detiene. Desciende un hombre que, sin presentarse, pregunta al pastor "si le digo cuántas ovejas tiene Ud. aquí, me daría una?" (A shepherd was taking care of his sheep in a remote corner of the Andes
when suddenly, in the distance, he spots a green Toyota Tercel drawing near. When the car finally catches up with the shepherd, it stops. A man get out, and, without introducing himself, he says to the shepherd: "If I can tell you how many sheep
you have here, will you give me one?"
El pastor, humildemente, dice que sí. (Meekly, the shepherd answers "Yes.")
Rápidamente el hombre saca su notebook de ultimísima generación, con sistema de conexión satelital, se conecta inmediatamente, activa el GPS y el servicio de Yahoo de fotos satelitales, un contador de pixels y al instante responde: 335
ovejas! (Quickly, the man takes out his up-to-the-minute portable computer, establishes a satellite uplink, activates his Global
Positioning System and Yahoo's satellite photo service complete with pixel counter, and immediately says: "335 sheep.")
El pastor, sin decir nada, le da un oveja y luego le dice: "si yo le adivino su profesión y lugar de trabajo, me devolvería mi oveja?" (The shepherd, without saying anything, hands the fellow a sheep. He then says: "If I guess your profession and where you work, will you return my sheep?")
"Claro que sí", responde el hombre del Toyota. ("Of course," says the Toyota driver.)
"Usted, señor, es un consultor de una organización internacional", afirma contundentemente el pastor. (Without dropping a beat, the shepherd declares, "You, sir, are a consultant employed by an international organization.")
Estupefacto, el hombre devuelve la oveja al pastor, no sin antes preguntarle cómo lo había adivinado. (Stupefied, the Toyota
driver returns the sheep to the peasant, but not before asking how he'd guessed.)
"Muy fácil - responde el pastor - Ud. llegó aquí sin ser llamado, se mete en mi negocio sin pedir permiso, me dice algo que ya yo sabía y, encima de que tiene muchísima más plata que yo, pretende que yo le pague por eso". ("It was very easy," answers the shepherd. "You arrive here without being called, you stick your nose in my business without asking permission, you tell me something I already know, and, then -- on top of the fact that you have a lot more money than I do -- you think I should pay you for your 'service.'")
*******
Aymará Women
Aymará Indian women from Peruvian highland villages near Juli gather once a week to talk and work. They have formed an
artisans' association that enables them to increase their earnings by directly marketing their own products. Two women sit side by side embroidering a large wall hanging. Others spin thread and work on smaller projects. The same cooperative spirit that
fills the air as they work prevails at lunch. Each woman takes out a cloth filled with something she brought for the noon meal
and places her contribution on a large colorful cloth known as an aguayo. Then the women seat themselves on the ground in a
circle around the cloth and share the food: chunno (freeze dried potatoes), puffed corn, and patties made from quinoa, a
high-protein grain. The women discuss events in their villages as they eat. Not long ago a food aid program offering milk
powder, flour, and oil began in their region. Some women have stopped coming to the cooperative gatherings so they can attend
the day-long meetings that are required to receive the food aid. The women gathered around the aguayo spread with traditional
foods lament the absence of these women and quickly agree they do not want these new foods. "We're happy with the food we
and our ancestors have always eaten," comments one. "We do not want aid," concludes another. "All we want are markets in
which to sell our embroidery so we can keep growing our own food." Linda Shelly, La Esperanza, Honduras. Excerpted from:
"Extending the Table... A World Community Cookbook" by Joetta Handrich Schlabach.
*******
(Students are encouraged to read "Ladakh: The Razing of a Village," a case study in globalization. This account provides
keen insight into the unintended consequences of "development" work with traditional peoples. HIGHLY RECOMMENDED.
*******
NOTE: Hispanic Health employs the word "gringo" to refer to citizens of the United States since "American" refers to any citizen of the western hemisphere, while "North American" lumps Mexicans and "gringos" together. In Spanish, the adjective/noun "estadounidense" refers specifically to citizens of the United States. No English word except "gringo" eliminates ambiguity.
á é í ó ú ñ 