traditional practices, “folk remedies,” and the western biomedical model: bridging the divide

Pediatric emergency physicians are well-trained in addressing and treating illnesswithin the Western biomedical model.However, more often than commonlyrealized, the practitioner will encounterfamilies whose beliefs and assumptionsabout the etiology and appropriatetreatment for various illnesses differmarkedly from their own. Failure torecognize the ways that folk beliefs andtherapies can impact a child’s illness mayresult in genuine physical harm.Conversely, the uninformed practitionermay mistake harmless folk remedies forabuse and presume that a child is indanger. This article presents a frameworkfor understanding the role of folkmedicine in the emergency care ofchildren. This framework is followed bycase studies that emphasize theimportance of developing a workingknowledge of the folk practices commonin the populations served by theemergency medicine provider.Clin Ped Emerg Med 5:102-108.© 2004 Elsevier Inc. All rights reserved.

Traditional Practices, “FolkRemedies,” and the WesternBiomedical Model: Bridging

the Divide

By Denice Cora-Bramble, MD, MBA,Frances Tielman, MA, and Joseph Wright, MD, MPH

WASHINGTON, DC

“I have always felt that the action most worth watching is not at thecenter of things but where edges meet. I like shorelines, weatherfronts, international borders. There are interesting frictions and in-congruities in these places, and often, if you stand at the point oftangency, you can see both sides better than if you were in the middleof either one. This is especially true…when the apposition iscultural.”1

THE RAPIDLY SHIFTING AND DRAMATIC demographicchanges in 21st century America has profound implicationson the health care delivery system. As multiculturalism hasbecome more the norm than the exception, physicians often

find themselves practicing medicine across both perceived andreal cultural boundaries. What historically has been described asminority populations have been more appropriately named bysome as “emerging majorities.” In California, for example, Latinochildren comprise the largest group of children according to 2002US Census data.2 Based on the same data set, it is estimated thatout of 288.4 million people in the United States, 13% were de-scribed as Hispanic, 12.7% black or African American, 4% wereAsians, and 1.2% American Indian, Alaska Natives, Native Hawai-ians, or other Pacific Islanders.

This article will discuss the impact of multiculturalism inhealth care settings, with specific emphasis on emergency med-

From the Goldberg Center forCommunity Pediatric Health and theDivision of Emergency Medicine,Children’s National Medical Center,Washington, DC.

Address reprint requests to DeniceCora-Bramble, MD, MBA, ExecutiveDirector, Goldberg Center forCommunity Pediatric Health, 111Michigan Avenue, N.W., Washington, DC20010. E-mail: [email protected].

1522-8401/$—see front matter© 2004 Elsevier Inc. All rights

reserved.doi:10.1016/j.cpem.2004.01.006

102 TRAD I T IONAL MED I C INE AND FOLK REMED I E S / CORA -BRAMBLE , T I E LMAN , AND WR IGHT

icine practice. We will review the literature pertain-ing to traditional practices associated with asthma,abdominal pain, and shaken baby syndrome, andpresent several case studies, closing with a practicalsummary for health care providers.

The Role of Culture in Health Care

Culture plays a critical role in health care deliv-ery, as people bring into the health care settingdistinct modes of communication, religious beliefs,family structures, and health beliefs and practices.Culture has been described as an “inherited lensthrough which the individuals perceive and under-stand the world that they inhabit, and learn how tolive within it.”3 Physicians may lack the knowledgeof health beliefs, attitudes, and practices of diversepopulations. Consequently, medical histories, symp-toms, and therapeutic interventions may be miscom-municated or misinterpreted because of linguistic andcultural barriers. The encounter between patientand physician in its basic form can be seen as aninterface involving different explanatory models.Failure to bridge the divide can result in improperdiagnosis, unnecessary testing, misunderstandingof consent, options, and prognosis, and problemswith adherence, satisfaction, and follow-up.

Folk illness or culture-bound syndrome can bedefined as “illness treated within the context of aparticular culture but not thought to fit modernmedical definitions and diagnostic categories.”4

While folk illnesses are recognized as authenticsyndromes or diagnostic categories by specific eth-nic or cultural groups, they are often in substantialconflict with Western biomedical models held bymost physicians. A physician’s challenge lies in try-ing to learn and understand their patients’ beliefmodels to more effectively diagnose and treat theirdiseases.

Practical clinical application of the research incultural competency can enable physicians to dis-tinguish between benign and harmful traditional orfolk practices and between cultural healing prac-tices and child abuse. A thorough cultural historyand a basic knowledge of different cultural healingpractices can be pivotal for health care providers asthey diagnose and treat potential complications ofselected traditional practices.

Examples of Cultural Beliefs and Practices

There are numerous examples described in theliterature of conflict between standard Westernmedical practices and beliefs and those of diverse

populations. Emergency medicine personnel arelikely to encounter scenarios where cultural beliefsand practices affect diagnosis, treatment, and ad-herence (Table 1). For example, studies5,6 havedocumented a common belief among a subset ofLatino mothers of asthma patients that US doctorsover-prescribe medications and that children aresick only when acute symptoms are present. Con-cerned about the negative side effects and the ex-tended use of medications, these families often optto use traditional or folk medicine instead of med-ications prescribed by physicians. In one study,5

Dominican mothers of children with asthma con-tinued to engage in traditional practices withoutdiscussing them with their pediatricians.

While the mothers were more likely to use phy-sician-prescribed pharmacotherapy during theirchildren’s acute asthma exacerbation episode, theyused home remedies to try to prevent asthma-re-lated symptoms. An example of a non-harmfulhome remedy used by some Latinos to treat asthmais zumos,5 a mixture of diverse ingredients such ascod liver oil, honey, garlic, oregano, lemon, aloevera juice, oregano, and other natural substances.While zumos’ ingredients are not considered toxic,they do not result in bronchodilation and may re-sult in a delay in seeking medical care. The conflictbetween the accepted biomedical models and theculturally-bound belief creates significant chal-lenges for both physicians and patients.

Families of Mexican descent might present to theemergency department (ED) with a traditional ill-ness known to them as empacho.4,7-10 This folkillness includes symptoms such as abdominal pain,vomiting, diarrhea, and loss of appetite.4,10 Accord-ing to some Latino families, empacho is caused by“sticky foods” that lodge in the intestines, creatingwhat parents believe to be an obstruction.4,9-10

Symptoms thought to represent this folk illness canbe present in diseases such as gastroenteritis, gas-trointestinal obstruction, or milk allergy.10 How-ever, ED personnel need to be aware that parents’description of such symptoms coupled with a his-tory of “sticky food” intake may have prompted theparents to use traditional herb and mineral treat-ments prior to arriving at the ED. Typical tradi-tional treatments for empacho include azarcon andgreta, commercially available lead oxides, whichhave resulted in lead poisoning in children.9,11

Mexican or Mexican-American infants seen inthe ED who present with signs and symptoms con-sistent with a diagnosis of head trauma or who arefound to have a sunken fontanelle during physicalexam may have been treated for a culturally-boundsyndrome, caida de mollera. Signs and symptoms

TRAD I T IONAL MED I C INE AND FOLK REMED I E S / CORA -BRAMBLE , T I E LMAN , AND WR IGHT 103

of this culturally-bound syndrome, according to se-lect Latino culture, include vomiting, diarrhea,poor feeding, irritability, fever, and sunken fonta-nelle.12 Based on a Western biomedical model, chil-dren with these symptoms merit a work-up fordehydration, gastroenteritis, sepsis and/or meningi-

tis. Parents often associate the caida de mollerasigns and symptoms with a traumatic event for theinfant such as a fall, which they believe “forces thefontanelle downward.”12 The traditional treatmentand practices associated with caida de mollerarange from benign to potentially traumatic, and

TABLE 1. Examples of Folk Illnesses and Remedies With Biomedical Implications

Folk Illness Ethnicity/Nationality Symptoms

OverlappingBiomedicalConditions Folk Remedies

Potential AdverseEffects

Empacho, pega Latino Vomiting, abdominalpain, headache,anorexia, diarrhea,fever, fussiness

Gastroenteritis, viralsyndromes,appendicitis,intussusception,milk allergy

Lead carbonatepowders (azarcon,greta, albayalde)

Lead poisoning

Wormwood tea(estafiate)

Seizures

Elemental mercury(azogue)

Mercury toxicity

Caida de molleraKand-pota

LatinoPakistan

Fussiness, fever,irritability, fallenfontanelle

Meningitis, sepsis,viral syndromes,dehydration

Shaking infant upside-down, with headpartially immersedin boiling water

Subdural hematoma,burns

Susto Latino Insomnia, irritability,exaggerated startlereflex, fever

Psychiatric diagnoses,organophosphatepoisoning

— —

Mal ojoQuebrante

LatinoBrazil

Fussiness, fever,diarrhea, vomiting

Meningitis, sepsis,viral syndromes,dehydration

— —

Umphezulu African Diarrhea, abdominaldistention

Gastroenteritis,dehydration

Kugata vaccination:razor blade cutsaround umbilicus,rubbed with ashes

Cellulitis, omphalitis

Phugrya rat Indian Respiratory distress,anorexia,constipation

Pneumonia,respiratoryinfection

Burning biba seed incircle on abdomen

Circular abdominalburns, skininfection

Dud hagaNazarEshwaha

BangladeshPakistanSri Lanka

Diarrhea, abdominalpain

Gastroenteritis,dehydration

Discontinuation ofbreast feeding,reduced fluidintake

Dehydration,malnutrition

Female chastity,hygiene, groupnorms

African — — Female “circumcision” Urinary retention/infection,dyspareunia,obstetriccomplications

Diarrhea Hmong Diarrhea Gastroenteritis Opium seed enemas,capsules

Opiate toxicity

Hot/cold imbalance Hmong Various Various Coining, cupping,pinching

Mistaken child abuseinvestigation

Adapted with permission from Flores G, Rabke-Verani J, Pine W, Sabharwal A: The importance of cultural and linguistic issuesin the emergency care of children. Pediatr Emerg Care 18:271–284, 2002.


include holding the baby upside down, dipping thetip of the head in water, or shaking the baby. Therehave been several reported cases12-15 of intracra-nial and retinal hemorrhages indistinguishablefrom those seen in shaken baby syndrome.15 EDphysicians are challenged to discern whether theunexplained origin of the “fall,” or trauma to thehead before the ED visit would have caused thesesymptoms, or whether they can be attributed toshaken baby syndrome caused, intentionally orperhaps unintentionally, by a potentially harmfultraditional practice.

The following pediatric cases from the Emer-gency Medicine and Trauma Center of Children’sNational Medical Center highlight the clinical pre-sentation of specific folk remedies and traditionalpractices.

Case 1: Hypernatremic Metabolic AlkalosisSecondary to Use of Baking Soda

as a Home Remedy

The patient is a 3-month-old African Americanmale who was asymptomatic until one day beforeadmission, when he developed watery, non-bloodydiarrhea, decreased activity, and labored breathing.There was no history of fever, cough, or rash. Be-cause the mother believed that the patient had an“upset stomach,” she gave him two tablespoons ofbaking soda, most of it mixed in 8 ounces of water.Approximately 20 minutes later, he vomited whitefluid and subsequently slept several hours. Theevening before admission, the patient was noted tobe lethargic, limp, and unresponsive, and he had ageneralized seizure. He was taken to a communityhospital. A fever of 102.9°F was documented in theED, and the baby had another seizure. Because ofsignificant respiratory depression, the baby was in-tubated and was given an intravenous bolus of 0.9%normal saline. He was subsequently transferred tothe pediatric intensive care unit.

The patient’s past medical history was unre-markable. The physical examination was significantfor pallor, dry mucous membranes, mottled skin,sunken anterior fontanelle, prolonged capillary fill-ing time, decreased peripheral pulses, tachycardia,and pupils that were sluggishly responsive to light.

Laboratory tests on admission demonstrated thepresence of a hypernatremic metabolic alkalosis.An arterial blood gas on 100% oxygen revealed: pH7.83, pCO2 23 mm Hg, pO2 231 mm Hg, bicarbon-ate 39 mEq/l, and base excess 22 mEq/l. The serumelectrolytes were: Na 165 mEq/l, K 3.2 mEq/l, Cl 95

mEq/l, CO2 47 mEq/l, and blood urea nitrogen 25mEq/l.

Hospital Course

The patient was admitted with diagnoses includ-ing hypernatremic dehydration, alkalosis, seizures,respiratory depression, and lethargy/rule-out sep-sis. The patient was hydrated over a 48-hour periodbut subsequently developed acute renal tubular ne-crosis. He developed edema, which responded wellto furosemide. The patient improved clinically overseveral days and was discharged from the hospital.

Differential Diagnosis

The differential diagnosis for metabolic alkalosisincludes gastroenteritis, pyloric stenosis, ingestionof a base such as bicarbonate, citrate, or acetate, orurinary losses (as seen with diuretic use, Cushing’ssyndrome or Bartter’s syndrome).16 Additionally,the differential diagnosis for hypernatremia in-cludes dehydration, gastroenteritis, free waterrestriction, diabetes insipidus and mellitus, improp-erly prepared formula, hyperaldosteronism, and so-dium bicarbonate poisoning.16 The presentation ofboth metabolic alkalosis and hypernatremia is con-sistent with sodium bicarbonate ingestion coupledwith decreased oral intake.16

Case Discussion

Baking soda has been used as a home remedy forthe treatment of gastrointestinal symptoms,17 up-per respiratory infections,18 and diaper dermati-tis.19 The amounts used by parents and thefrequency of use in infants and children is notknown. Nichols et al16 reported that 4% of theirpediatric clinic population had added baking sodato their infants’ formula. Baking soda contains ap-proximately 35 mEq of both sodium and bicarbon-ate per teaspoon, a potentially toxic amount for adehydrated infant. Hypernatremic metabolic alka-losis secondary to exogenous oral sodium bicarbon-ate has been previously described in the medicalliterature.16-21 Moreover, there is at least one re-ported case of metabolic alkalosis that developed asa result of topical application of sodium bicarbon-ate.19 Emergency physicians should attempt toelicit a history of exogenous sodium bicarbonateintake in patients who present with hypernatremicmetabolic alkalosis. Persistence in eliciting the his-tory is warranted given that some parents may bereluctant to discuss the use of alternative therapiesand practices with unfamiliar medical personnel.


Case 2: Coining

An 18-month-old Laotian child presents to theED with a 2-day history of vomiting and diarrheawithout fever. The history of present illness is oth-erwise unremarkable. The patient was referred tothe ED by the family physician for an assessment ofhis hydration status. The physical examination waspositive for patterned skin discolorations streakingdiagonally across the child’s abdomen from themidline to either flank (Fig 1). The mother hadsimilar marks on her face.

ED Course

Because of suspected physical abuse, the initialplan involved a referral to Child Protective Ser-vices. As the mother was informed of an impendingvisit from a child protection social worker, she be-came visibly concerned.

Differential Diagnosis

The differential diagnosis of the described skinlesions include bruises secondary to coagulopa-thies, vasculitis, child abuse, and traditional prac-tices such as cupping and coining. The patternednature of the discolorations coupled with the factthat the mother had similar lesions, is consistentwith cupping or coining.

Case Discussion

Within the Western medical tradition, illnessesare attributed to biological and chemical deficien-cies and imbalances. The cures for most conditionslie in restoring these imbalances and meeting thesedeficiencies. Southeast Asian cultures recognize anetiology of imbalance, not of chemicals, but of “hot”and “cold,” as well as spiritual correlates. Their folkmedicine or traditional medicine is a complex arrayof beliefs and practices that incorporates ritualhealing, herbalism, and the use of dermabrasivetechniques such as coining or pinching. Indigenoushealth care practitioners may pinch, coin, or rub anill person’s skin to treat a range of ailments. Theprocess that produced the markings on the child(Fig 1) is a technique known as coining, adminis-tered by shamans or healers called txiv neeb (pro-nounced tsi neng among the Hmong people).Coining is performed by rubbing a coin repeatedlyover the patient’s skin.15,22 This practice usuallyleaves striations or ecchymoses.22 Pinching is doneby pinching the skin between the thumb and indexfinger to the point of producing a contusion at thebase of the nose, between the eyes, or on the chest,neck, or back, as was seen on the child’s mother(Fig 2).

Figure 2. Contusion secondary to pinching.

Figure 1. Ecchymoses secondary to coining.


Clinical Applications in the ED

The use of traditional practices is presented inthis article in the broader socio-cultural context ofthe clinical encounter. Other factors such as theavailability of interpretive services for limited En-glish proficiency patients are likely to influencephysicians’ ability to obtain a thorough history, toestablish an accurate diagnosis, and to develop aculturally responsive therapeutic plan. Folk ill-nesses, home remedies, and other traditional prac-tices pose a significant challenge for ED physiciansbecause of the likely unfamiliarity with these cul-ture-specific practices. While many traditionalpractices pose no harm to pediatric patients, thereare some that can produce significant morbidityand result in fatality.

Beyond the questions in a traditional medicalhistory, ED physicians will need to elicit clinicallyrelevant information regarding folk illnesses, tradi-tional practices, and home remedies. The term“cultural dialogue” refers to a patient-centered andmedically relevant inquiry that will aid the practi-tioner in both establishing a diagnosis and in col-laboratively developing a therapeutic plan. Unliketraditional history taking, cultural dialogue empha-sizes the reciprocal nature of the discussion. It is ofparamount importance that the dialogue be con-ducted as a respectful colleague, rather than assomeone who is idly curious or narrowly critical. Acultural dialogue can help in establishing a collab-orative physician-patient communication frame-work that acknowledges and even affirms the use ofbenign traditional practices and healers.

When able, physicians should attempt to consultwith their patients’ traditional healers. Against abackdrop of professional respect, physicians mayexplore ways in which traditional healers can playcomplementary roles in treating selected patients.

For example, when working with Hmong familiesthere are cultural norms a health care professionalshould keep in mind1:

● When communicating with the family of the pa-tient, address the elder male of the family (via aninterpreter if necessary). Deference is given infamily interactions to elders and men in Hmongculture. Health care interactions may be moreeffective if attempts to communicate are chan-neled through the elder male or female of thefamily.

● Deference is shown to authority figures in Hmongculture. The style of dress, presentation, and be-

havior all establish credibility as an authorityfigure.

● Never beckon a Hmong person to you by crookingyour finger. This gesture is considered suitableonly for animals.

● Western cultural norms suggest that maintainingdirect eye contact conveys a sense of integrity,sincerity, and good will. Hmong families may con-sider maintaining friendly eye contact a disre-spectful intrusion into personal space.

● Show respect for spiritual beliefs and religiouspractices. The Hmong, for example, conceptual-ize health and illness as manifestations of spiri-tual causes.

● Families who are apprehensive about their pro-vider’s reaction(s) to their indigenous health carepractices tend not to discuss them openly withhealth care providers.

Summary

Some racial or ethnic groups, such as AsianAmericans, view health from a variety of differentperspectives, sometimes simultaneously. Theseperspectives may involve an interaction of spiritualfactors, internal balance inequities, and biologicalfactors. These families may, therefore, combine di-agnostic and treatment elements from different per-spectives with the goal of getting maximum healthbenefits. Western medicine is beginning to appreci-ate this broad view of mind-body interactions andpredisposing factors to illness.

In some communities, organizations such astemples, churches, benevolent associations, andcultural associations may serve as focal points forsocial and other activities. Developing contact withand working through these community-based orga-nizations can be a useful way for providers to de-velop an understanding of the health and socialservice needs of patients from these communities.This understanding includes an appreciation of bar-riers that may be faced in accessing health care,and ways to enhance culturally competent healthcare for diverse patients. However, such an ap-proach necessitates a measured commitment to theestablishment of trusting relationships that canbest be accomplished over time.

References

1. Fadiman A: The Spirit Catches You and You FallDown. New York, NY, Farrar, Strauss and Giroux, 1999.

2. US Census Bureau: US Census 2002. Available at:http://eire.census.gov/popest/data/national/asropopbriefing.php. Accessed January 22, 2004.


3. Helman C: Culture, Health and Illness (ed 3).Boston, MA, Butterworth and Heinemann, 1994.

4. Trotter R: Folk medicine in the Southwest; mythsand medical facts. Postgrad Med 78:167-179, 1985.

5. Bearison DJ, Minian N, Granowetter L: Medicalmanagement of asthma and folk medicine in a Hispaniccommunity. J Pediatr Psych 27:385-392, 2002.

6. Pachter LM, Cloutier MM, Bernstein BA: Ethno-medical (folk) remedies for childhood asthma in a main-land Puerto Rican community. Arch Pediatr Adolesc Med149:982-988, 1995.

7. Risser Al, Mazur LJ: Use of folk remedies in aHispanic population. Arch Pediatr Adolesc Med 149:978-981, 1995.

8. Gomez-Beloz A, Chavez N: The botanica as a cul-turally appropriate health care option for Latinos. J AlterComplement Med 7:537-546, 2001.

9. Baer RD, Ackerman A: Toxic Mexican folk reme-dies for the treatment of empacho: The case of Azarcon,Greta, and Albayalde. J Ethnopharm 24:31-39, 1988.

10. Pachter LM, Bernstein B, Osorio A: Clinical impli-cations of a folk illness: Empacho in mainland PuertoRicans. Med Anthro 13:285-299, 1992.

11. MMWR: Lead poisoning associated with use oftraditional ethnic remedies—California, 1991-1992.MMWR Morb Mortal Wkly Rep 42:521-524, 1993.

12. Hansen KK: Folk remedies and child abuse: Areview with emphasis on caida de mollera and its rela-tionship to shaken baby syndrome. Child Abuse Negl22:117-127, 1997.

13. Block RW: Child abuse: Controversies and im-posters. Curr Probl Pediatr 29:253-272, 1999.

14. Baer RD, Bustillo M: Caida de mollera among chil-dren of Mexican migrant workers: Implications for thestudy of folk illnesses. Med Anthro Qtly 12:241-249, 1998.

15. Steward GM, Rosenberg NM: Conditions mistakenfor child abuse: Part II. Pediatr Emerg Care 12:217-221,1996.

16. Holloway Nichols M, Wason S, Gonzalez del Rey J,et al: Baking soda: A potentially fatal home remedy. Pe-diatr Emerg Care 11:109-110, 1995.

17. Puczynski MS, Cunningham DG, Mortimer JC:Sodium intoxication caused by use of baking soda as ahome remedy. Can Med Assoc J 28:821-822, 1983.

18. Brown AL, Whaley S, Arnold WC: Acute bicarbon-ate intoxication from a folk remedy. Am J Dis Child135:965, 1981.

19. Gonzalez J, Hogg RJ: Metabolic alkalosis second-ary to baking soda treatment of a diaper rash. Pediatrics67:820-822, 1981.

20. Schindler AM, Hiner LB: Hypernatremic meta-bolic alkalosis in a two-month-old infant. Hosp Pract23:31-32, 1988.

21. Fuchs S, Listernick R: Hypernatremia and meta-bolic alkalosis as a consequence of the therapeutic mis-use of baking soda. Pediatr Emerg Care 3:242-243, 1987.

22. Look KM, Look RM: Skin scraping, cupping andmoxibustion that may mimic physical abuse. J ForensicSci 103-105, 1997.


traditional practices, “folk remedies,” and the western biomedical model: bridging the divide

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