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Use of Curanderismo in a Public Health Care System
Ricardo Padilla, MD;
Veronica Gomez, CMA;
Stacy L. Biggerstaff, MS;
Philip S. Mehler, MD
Arch Intern Med. 2001;161:1336-1340.
ABSTRACT
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Background Curanderismo ("the healing") is a centuries-old
synthesis of Mexican Indian culture and beliefs.
Objective To evaluate the rate of use of curanderismo
among Hispanic subjects seeking medical care at the Denver Health Medical
Center, Denver, Colo.
Methods We conducted a survey of 405 Hispanic subjects attending outpatient
primary and urgent care clinics at Denver Health Medical Center, the public
hospital system for Denver. The main outcome measure was independent predictors
of use of curanderos.
Results Of the 405 subjects, 118 (29.1%) (95% confidence interval, 20.9-37.3)
had been to a curandero at some time in their lives.
Of all the subjects, 91.3% knew what a curandero
was. Univariate analyses demonstrated an association between those who had
been to a curandero and level of income, level of
education, and whether the subject was bilingual. The results of fitting a
stepwise logistic regression model revealed an independent association with
subjects who had been to a curandero and level of
household income (>$20 000 vs <$10 000), with an odds ratio of
2.19 (95% confidence interval, 1.20-4.01) (P = .01),
and level of education (post–high school vs elementary school), with
an odds ratio of 3.16 (95% confidence interval, 1.45-6.86) (P = .004).
Conclusions Many Hispanic patients who receive their health care at a public hospital
system use the services of curanderos. This potentially
has important implications for their health care.
INTRODUCTION
ALTERNATIVE MEDICINE and its therapies have become increasingly popular
during the past decade. Information concerning these therapeutic forms of
healing in the United States can be found in medical textbooks, brochures
for healing groups, and a burgeoning variety of different medical information
sources.1 In 1990, a national survey conducted
by Eisenberg et al2 found that 33.8% of 1539
adults, which would extrapolate to approximately 60 million Americans, had
tried at least 1 of 16 alternative procedures or therapies, including such
practices as acupuncture, chiropractic, spiritual healing, herbal medicine,
or folk remedies, within the past year. An additional one third of this subset
of Americans were thought to have visited a nonphysician provider who practices
alternative techniques on 1 or more occasions.2
A national follow-up survey of 2055 adults, conducted again by Eisenberg et
al,3 in 1997 revealed that 42.1% of the subjects,
which would extrapolate to 83 million Americans, had used at least 1 of the
same 16 forms of alternative therapy in the previous year.
A form of alternative therapy that tends to be used by Hispanic subjects
is the ancient practice of curanderismo. Curanderismo is a diverse folk healing system of Latin America. It
began with the Aztecan, Mayan, and Incan tribes and their religious beliefs
of harmony with nature, spirit, and self. The Mexican Indians had many gods;
they believed that their gods punished sins with illness. Therefore, disease
or illness was supernatural in nature. As a balance, some mortals, who were
spiritually chosen, were given the power to heal the wounded spirit and cure
the supernatural illness. This is the role of the curanderos and curanderas.
A study4 based on interviews with 16 curanderos in California revealed that a typical curandero is in his mid-50s, is married, and has had 5.5
years of schooling, including some special training. Their fees are usually
in the form of donations, and they have an income derived from sources other
than curing.4 Curanderos typically live in the neighborhood where they practice. The setting
for their practice is often their home. They generally use prayer, massage,
herbs, and reassurance to treat their patients. In addition, curanderos frequently share their patients' social class, background,
language, and religion.5
Curanderos and their patients concurrently
use the services of the old and traditional medical systems. Curanderos are not expected to treat the major medical problems of
their clients. As a result, if asked to treat a case that is clearly beyond
their abilities, a reliable curandero will refer
the patient for traditional medical care.
Hispanics constitute about 11.4% of the US population, or roughly 31.1
million people, and are the single fastest-growing minority group in the United
States.6 Hispanics in Denver, Colo, make up
23.3% of the population. Previous studies7-12
have estimated that 2% to 70% (mean, 24%) of Hispanics have visited a curandero. It is estimated that there are 150 to 200 curanderos in the Denver metropolitan area. There are no
available figures on the number of curanderos in
the entire United States. Since there is a large Hispanic population along
with numerous curanderos in Denver, we assessed the
use of curanderismo in Hispanic subjects attending
outpatient medical clinics for routine and urgent health care.
SUBJECTS AND METHODS
An administered survey was conducted by a single research assistant
(V.G.) from October 5 through December 18, 1998, at 13 different outpatient
satellite clinics affiliated with Denver Health Medical Center, the public
safety net hospital for Denver. Approximately 39% of the total patient population
served by Denver Health Medical Center and its affiliated clinics are Hispanic.
Candidate subjects were identified based on their Hispanic surname during
registration for their clinic appointments. They were then approached about
their desire to participate in the survey while in the clinic's waiting room.
The survey was available in English and Spanish. The only exclusion criteria
were non-Hispanic subjects and subjects younger than 18 years. Subjects were
paid $5 for a completed survey, and they were limited to 1 survey per person.
The survey consisted of a 2-page, 22-question document that gathered
the following information: age, sex, ethnicity, level of education, primary
language, whether bilingual, number of years in the United States, country
of origin, marital status, employment status, history of use of a curandero, type of problem treated by a curandero, treatment outcome, frequency of use of curanderos, and overall satisfaction with curanderos.
No interventions were performed. Subjects were considered to be bilingual
if they spoke English and Spanish at home or with their physician.
Descriptive data analysis was performed using standard techniques, means
± SDs, and percentages. The percentage and corresponding 95% confidence
interval (CI) was calculated for the use of curanderismo. Univariate analyses were performed for subjects who had been to a curandero and for those who had not. For univariate comparisons,
a 2-sample t test was used when the variable was
continuous. If the variable was categorical, a  2 analysis
was performed. Multiple logistic regression was performed to evaluate the
effects of independent variables (age, sex, level of education, amount of
time spent living in the United States, primary language, bilinguality, country
of origin, marital status, and household income) on use rates. Odds ratios
and the corresponding CIs were calculated from the logistic regression variable
estimates.
RESULTS
A total of 405 subjects were included in the survey. The demographic
features of this group are defined in Table
1. Of 399 subjects, 352 (88.2%) were Denver Health Medical Center
patients or associated with patients and 47 (11.8%) were clinic employees.
Three hundred sixty-nine (91.1%) of the subjects claimed to know what a curandero was.
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Table 1. Overall Demographic Characteristics
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Of the 405 subjects, 118 (29.1%) (95% CI, 20.9-37.3) had been to a curandero at some time in their lives. Of those who had
been to a curandero, 48 (40.7%) had been to one within
the past year and 75 (63.6%) had been to one within the past 5 years. The
overall 1- and 5-year use rates of curanderos in
our study were 11.8% and 18.5%, respectively. When those who had been to a curandero were asked if their physician knew that they
visited curanderos, 96 (81.4%) responded no, yet
86 (72.9%) believed that they benefited from seeing a curandero. Univariate analysis demonstrated an association between those who
had been to a curandero and level of income, level
of education, and whether the subject was bilingual (Table 2).
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Table 2. Demographic Characteristics by Use of Curanderos
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Results of fitting a multiple logistic regression model for use of curanderismo are presented in Table 3. Variables that are independently associated with use of curanderismo are level of education, level of household
income, current age, and being bilingual.
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Table 3. Multivariate Analysis of Characteristics Predicting Use of Curanderos*
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Performance of a stepwise logistic regression model revealed an independent
association between subjects who had been to a curandero and level of education (post–high school vs elementary school:
odds ratio, 3.16; 95% CI, 1.45-6.86) and level of income (>$20 000 vs
<$10 000: odds ratio, 2.19; 95% CI, 1.20-4.01).
Table 4 lists frequencies
of problems evaluated by curanderos for our study
group. Headache was most common, followed by empacho
(pseudointestinal obstruction), nervios (nerves),
and susto (fright). The following problems were listed
1 time by study subjects as being treated by curanderos: impotence, assistance with allergies, drug problems, arthritis, constipation,
and palpitations.
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Table 4. Problems Treated by Curanderos
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COMMENT
The results of this study serve to reinforce that many Hispanics use
the services of curanderos. This is important to
know because Hispanics are the second largest and the fastest-growing minority
group in the United States.6 Most of the previous
studies7-12
are limited by a small sample size and wide variations in the degree of use
of curanderos. The Hispanic Health and Nutrition
Examination Survey is the largest study on this subject to date and included
a survey from 1982 to 1984 of 3623 Hispanic subjects from the southwestern
United States.13 In that study, the use rate
of curanderos within the 12 months before the study
period was 4.2%. The second largest of these past studies14
included 434 foreign-born subjects who were presenting for medical care at
rural east Washington State migrant health clinics. Skaer et al,14
in 1996, found in this study that 21.4% of their subjects had been to a curandero within the past 5 years. Our study was conducted
in an urban area with a similar number of subjects, although our study population
was different from the foreign-born study population in the Skaer et al study
in that 39% of our subjects were born in the United States, yet our overall
5-year use rate was similar, at 18.5%. This is consistent with the finding
in our study that the amount of time spent living in the United States, which
could be used as a surrogate marker for the degree of acculturation of the
foreign-born subjects, did not have a significant impact on decreasing use
in our study. The population in our study is similar to the population used
in the Hispanic Health and Nutrition Examination Survey study, yet it is unclear
why there is such a disparity in the degree of use of curanderos at 1 year in both studies.
Since Denver has a large Hispanic population and numerous practicing curanderos, it is apparent that these services are frequently
being used. This has important implications for the Hispanic population because,
despite the progress that has been made to improve access to health care,
differences remain between Hispanic and non-Hispanic whites in health outcomes.15-17 For example, type
2 diabetes mellitus is more prevalent in this population,18
and Hispanics have an increased prevalence of diabetic retinopathy19 and diabetic end-stage renal disease.20
Significant cultural and attitudinal issues associated with the use of curandero services could hinder efforts to improve care
to Hispanic patient groups who are often beset with many long-term health
problems.
Data from the Hispanic Health and Nutrition Examination Survey suggested
that interviews conducted only in Spanish, along with dissatisfaction with
modern medical care, predicted curandero use.13 Skaer et al14 also
found that Spanish as the language of preference, having resided in the United
States from 1 to 5 years, and having received medical care in Mexico within
the prior 5 years also predicted use of curanderos.
Nall and Spielberg9 found that not being married,
not knowing most of the people in one's neighborhood, and being 39 years old
or younger all predicted the use of curanderos. Our
study revealed that being bilingual in English and Spanish was associated
with a higher use rate of curanderos. We also found
that at least some post–high school training and a somewhat higher household
income predicted use of curanderos. Interestingly,
as previously noted, level of assimilation, as defined by the amount of time
spent living in the United States, was not a significant predictor of use
in our study or in the Hispanic Health and Nutrition Examination Survey study.
Reasons for this are not exactly clear, although it may be that certain cultural
beliefs are not readily relinquished.
It is evident from this study that curanderos
attempt to give therapy for a diverse range of problems. Many of these problems
have a strong emotional component to them. As stated earlier, one of the basic
tenets of curanderismo is that illness is the result
of the punishment for a sin. There is no dichotomy between emotional and somatic
illness. It is natural to process emotional problems through their somatic
aspects.21 It is with these types of problems
that curanderos can be of the greatest utility for
patients. Their use of ritual prayer, massage, and reassurance does not place
subjects at significant risk of medical complications and can provide substantial
relief for what often turn out to be long-term complaints with a lot of psychosocial
overlay. The use of herbal preparations could, however, occasionally be problematic
if not used appropriately and with caution. Furthermore, some of the problems
treated by curanderos may have significant medical
causes. The fact that headache was the most common problem treated by curanderos in our study group is concerning as there may
potentially be some serious pathological features that may go unchecked for
a long period if not evaluated by a trained medical professional. The same
applies for the evaluation of abdominal pain, back pain, kidney problems,
and diabetes, all of which were identified as problems that our study subjects
had treated by curanderos. Therefore, it is of utmost
importance that a curandero knows when to refer a
patient for more traditional medical care. This also reinforces the importance
of physicians knowing when their patients might be using the services of curanderos. Keeping the lines of communication open with
patients about their use of the services of alternative therapy practitioners
is essential.
Our finding that most subjects who had been to a curandero had not informed their physician that they use these services
has also been found in previous studies. Eisenberg et al2-3
found this to be true in 60.2% and 61.5% of the subjects who used alternative
therapies in 1990 and 1997, respectively. This is a concerning statistic that
is due, in large part, to physicians and allied health professionals not being
trained or accustomed to inquiring about the use of alternative therapies
when taking histories from patients. In response to this problem, Carrillo
et al22 have developed a cross-cultural, patient-based
curriculum that teaches a framework for analysis of an individual patient's
social context and cultural health beliefs and behaviors.
In summary, although dealing directly with a patient's cultural view
of his or her illness may complicate therapy by introducing new variables,
one obvious benefit of doing this is establishing a better therapeutic alliance
with the patient. A better therapeutic alliance leads to more optimal patient
compliance, which improves the effectiveness of medical treatment. Our study
demonstrates that many Hispanic patients are using curanderos, and many of these patients are not telling their physician about
these visits.
The successful delivery of health services to Hispanics must involve
an open discussion of health perceptions and practices. It is clear that race
and ethnicity are powerful determinants of health outcomes, especially when
cross-cultural interventions are involved. There is a need for a greater understanding
of these cultural health beliefs to help reduce variations in care that may
be contributing to inequities in the health care of the US population. There
is also a need to determine whether curanderismo
can assist with the successful implementation of culturally sensitive health
interventions in chronic disease management and with the receipt of preventive
services.
AUTHOR INFORMATION
Accepted for publication October 2, 2000.
This study was supported by the small grants program at the Division
of General Internal Medicine, Department of Medicine, University of Colorado
Health Sciences Center, Denver.
Corresponding author and reprints: Ricardo Padilla, MD, Westside
Family Health Center, Denver Health Medical Center, 1100 Federal Blvd, Mail
Code 3000, Denver, CO 80204 (e-mail: rpadill{at}dhha.org).
From the Division of General Internal Medicine, Denver Health Medical
Center (Drs Padilla and Mehler and Ms Gomez) and the Colorado Prevention Center
(Ms Biggerstaff), Denver, Colo.
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