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A study on the effects of income and education on preference between allopathic and

traditional treatment-types and how medical pluralism impacts the allopathic doctor-

patient relationships in Oaxaca, Mexico.

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Principal Investigator: Richard Alan Russell

Advisors: Carmen-Garcia Downing, Theodore Downing

Sponsor: University of Arizona, The Honors College

Date Fieldwork: May 20th, 2010 thru July 20th, 2010

Date Presented: February 9th, 2011

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ABSTRACT

This study focuses on the doctor-patient relationship between allopathic doctors and their patients in

the public health sector of Oaxaca, Mexico in context of culturally prominent medical pluralism. Both

allopathic and traditional treatment types that are widely available throughout the city constitute this

medical pluralism. The original purpose of this study was to determine if income and education

influence treatment type preference, but the study expanded to inquire into the doctor-patient

relationship. The techniques used to collect data include a 36-question questionnaire with a comments

section and a structured interview. Ninety-two questionnaire participants supplied usable data and six

healthcare professionals were interviewed.

The data supports the prominence of pluralism in Oaxacan healthcare and reveals no significant

correlation between either income or years of education in relation to preferred treatment type. A

patient’s pluralistic belief and usage of traditional and allopathic medical remedies can be somewhat

problematic for allopathic doctors attempting to most effectively treat a patient’s acute illness due to:

one, the doctors’ lack of information on proper co-prescription—combining allopathic and traditional

medicines—which is further complicated by non-existent scientific literature investigating traditional

remedies and two, the dualism between maintaining a patients faith and hope, while honestly, tactfully

and respectfully sharing the benefits of modern allopathic studies and science. These shortcomings are

exacerbated by time constraints that cause rushed visits, especially in the public healthcare sector, and

together, these hurdles can hinder the allopathic doctor-patient relationship. Based on these

observations, when considering allopathic treatment, re-evaluation of the importance of the doctor-

patient relationship as an educational opportunity for the doctor and patient to share scientific and

traditional-healing information likely will benefit both parties in both short and long -run.

INTRODUCTION

The research population is localized within the city Oaxaca De Juárez and nearby satellite communities.

It’s important to know traditional healing alternatives are widely used throughout Oaxaca and the more

localized research population.1 Likewise, allopathic medical services are also widely utilized. Most

frequently urban citizens receive this allopathic treatment through federally managed and mandated

hospitals. Instituto Mexicano del Seguros Sociales (IMSS) is one of the federal hospitals, and it serves,

free of charge, all citizens of Mexico employed by a business. Instituto de Seguridad y Servicios Sociales

de los Trabajadores del Estado (ISSSTE) is a similar institute, no costs, but for government employees.1,2

Previous research notes common positive and negative perceptions, held by the patients, and

associated with each type of treatment, whether allopathic or traditional8, and this project’s main goal is

to determine if the variable factors of education and income affect or relate to preference between

treatment types. Specifically, preference of these individuals is measured with implementation of

questionnaires requiring participants to compare effectiveness, utility and price/benefit of both types of

medicine on a scale (1-100). The questionnaire develops mostly quantitative grounds to consider

allopathic and traditional treatment-type preference from the perspective of individuals categorized

based upon education and income, and these grounds are further developed, and complemented, with

structured interviews aimed to capture the perspectives (of allopathic doctors) on the current state of

pluralism, specifically concerning their notions of the doctor-patient relationship.

BACKGROUND

The people of Oaxaca remain severely economically challenged compared to the wealthiest of nations

and are calculated to live in one of the poorest states of Mexico.4,18 Although, the poverty is not

absolute and uniform because juxtaposed to the common, affluent individuals do reside in the urban

centers and outskirts. Pueblos are rural satellite communities beyond

these outskirts and constitute a large portion of the population of Oaxaca

(see figure 1). 17 Note that in Valles Centrales, the location of Oaxaca de

Juárez, a greater number of people reside in an urban setting.

A large number of Oaxacan citizens are monolingual, speaking an

indigenous language, and according to the 1993 governmental census, sixty-eight percent retain Indian heritage.4 Indigenous roots of traditional

thought and practice are also common and they powerfully influence

contemporary culture, even in major rural region.

Traditional medicine is common throughout the world with origins in pre-

colonial Indian, European and African heritages.4 Within Oaxaca traditional

medicine is formally defined “the sum total of the knowledge, skills, and

practices based on the theories, beliefs, and experiences indigenous to

different cultures, whether explicable or not, used in the maintenance of

health as well as in the prevention, diagnosis, improvement or treatment

of physical and mental illness.”3 The terms traditional, allopathic and alternative are not equivalent, and

uniquely, the major practitioners of traditional medicine include shamans, parteras (midwifes) and

curanderos (healers).4,6 Allopathy is any type of medicine involving biomedical, westernized or modern

substance intake (i.e. pill or vaccination). Culturally prevalent health concerns in Oaxaca include

gastrointestinal, spinal, oncologic, infectious, spiritual and mental affliction.5,8 Traditional practitioners

often classify these ailments as a state of “disequilibrium” and unlike allopathy, include spiritual and

mental factors in diagnosis. 7,8 Many Oaxacans prefer a combination of healing ideologies to cure these

states of ailment. This dualistic approach is known as medical pluralism.7,9

Even more so, within the spectrum of medical pluralism, all consultations with allopathic doctors

depend on a healthy doctor-patient relationship.11,15 The doctor-patient relationship’s impact extends to

include actual patient health, prescribed regiment compliance and (indirectly) healthcare costs.11,12

Some studies highlight a single thematic component of this relationship, in which the patient expresses

her own values, increasing her involvement in the treatment process, which concomitantly augments

treatment satisfaction.10,11,16 So, often effective doctor-patient relationships include a doctor

interpreting the psychological, the desires and the explicit requests, in context of each particular

patient’s ailment and values, to pragmatically offer healing options.13

Fig. 1

METHODOLOGY

The fieldwork and materials consist of two parts. The first, a questionnaire (see below) completed by

ninety-two participants. The first fifty of these participants were from Hospital General, a facility under

IMSS, located northeast roughly 1.53 miles from the center of the city, Parque Central del Zocalo. The

following forty-two participants were from Parque Llano, a public park .64 mile northeast of this center.

All questionnaire respondents were approached in the same manner. Each participant was read the title

of the project and was briefly explained the premise of the project. If they met the selection criteria (see

below), they were asked to participate. To all participants it was made clear that the questionnaire

responses should only reflect their own thoughts, that any concerns or confusion should be directed to

the PI and that the questionnaire could be read aloud or independently. The gender of all potential

participants that were approached was not considered during selection; however, males did asked their

wives to fill out the questionnaire for them or in place of them periodically. Illiterate (apparent or

stated) persons at IMSS were excluded from questionnaire submission even though they did satisfy all

participation requirements because of the complexity of certain questionnaire questions and time

constraints. This selectivity sped the collection process and also accurately focused the sample

population to represent an urban majority.

Difference in methodology between the two questionnaire locations includes: participant selection

criteria (but not participation requirements) and temporal factors. At IMSS, all individuals were waiting,

not busy. Therefore, selection was based upon ability to communicate and understand Spanish;

consequently, at IMSS persons appearing “elderly” (45+years) were specifically avoided, whereas

participants appearing “younger” (21-45years) were presumed more likely to be able to answer the

questionnaire accurately, with greater comprehension. In contrast, at Parque Llano, the apparent age of

potential participants was not considered, and instead, unoccupied (not engaged in conversation or

playing soccer, for example) persons were selectively approached. Temporal implementation differed in

that each IMSS participant was approached between noon and five post meridiem on weekdays

between June 28th and July 9th, 2010. However, each Parque Llano participant submitted their

questionnaire between July 6th and July 11th, 2010 between five and ten post meridiem; this includes

weekend and weekdays. With these two differences, little unavoidable bias is introduced.

The complete week following collection at Parque Llano involved interviews, and can be considered the

second part of fieldwork. A total of six doctors were interviewed. One homeopath (originally a

allopathic practitioner) and five allopathic, federally employed doctors. The structured interviews (see

below) contained two areas of concern: personal thoughts on traditional/allopathic medicine and

pluralism’s bearing on the doctor-patient relationship. Three (of five) allopathic doctors were

interviewed simultaneously in conversational manner, allowing each doctor to both respond to the

original question and other responses. All interviews were structured, but dynamic; the PI responded to

the provided answers, probing in-depth for clarification or details.

The data collected in each part of fieldwork was recorded differently. The questionnaires were stored

both as hard copies and digitally within an encrypted database; whereas, the interviews were recorded

on a digital recorder, formatted mpeg. Finally a minor note, ample preparation by the PI included:

cultural acclimation; extensive Spanish communication studies spanning a complete month in the

classroom setting of Instituto Cultural de Oaxaca (ICO); professional and personal networking; two days

shadowing allopathic doctors from an Anti-SIDA clinic and a major ISSSTE hospital; and review of

fieldwork materials by multiple ICO, native Oaxacan, instructors.

Questionnaire

Participation Requirements

Structured Interview

RESULTS

Questionnaire Data

Table1

*The percent

includes only 83

participants in

total, 43 from

IMSS and 40 from

Parque Llano. 9 of

the 92 total to

submit

questionnaires did

not provide

complete data.

Graph1

Graph 2

0

20

40

60

80

100

120

0 500 1000 1500 2000

AveragedA Scale-measured Preference Versus Average Reported Daily Income (pesos/day)

Series1

Series2

0

20

40

60

80

100

120

0 5 10 15 20 25 30 35 40

AveragedA Scale-measured Preference Versus Years of Education

Series1

Series2

X, Y-axis

Correlation=

-1.634E-3

X,Y-axis

Correlation=

-1.204E-1

IMSS

Parque Llano

IMSS

Parque Llano

Table 2

Table 3

Table 5

AThe averaged scale-measured calculation derives from the three value-types measure: útil, eficaz and valiosa. All

of these averages are derived from all three value-types, two or just one (dependant on the participant’s choice to respond or not). BPair-wise, meaning the participant also responded to the scale-measured value-type set as described, whether

útil, eficaz, valiosa, or averaged scale-measured preference. CAn effective total is the number of participants, partitioned from the original 92, that provided sufficient data by

responding to the involved questionnaire questions (Qn). For example, all participants not answering Q30 or at least one question of Q18, Q20 and Q23 are excluded from all effective totals in the first two data tables because respectively Q30 measured the participant’s years of education and Q18, Q20 and Q23 all measured the participant’s daily income (pesos).

Interview Data

The interviews each contain details and idiosyncratic tonal regard best summarized into main ideas,

which for the most part are shared by each of the interviewees and focus on:

The cultural definition of traditional/allopathic medicine.

o The major difference resides within the origin of traditional medicine, how its historic

prominence within the culture makes it almost an automatic aid to treat any primary

symptoms. This can lead to poor prevention of serious diseases, and the doctors

clarified that this historical prominence and its effects are best exemplified when

parents or grandparents repeatedly treat their children with traditional treatments. The

influence of immediate family is so strong, one of the doctors I interviewed saw his

father suffer with additional epileptic seizers because his mother encouraged him to

stop taking his prescribed allopathic pills, replaced by a simple tea composed mostly of

lemon and water.

Superior nature of experimentally tested medicine.

o All of the doctors I interviewed believed that when responsible for the life of a patient

and when scientific data or experimentation supports the use of a particular

medicine/practice, that the rigorously tested treatment-type is preferred over a

treatment-type without records, and that traditional medicine lacks this type of rigorous

testing.

Elements of patient faith.

o A patient that truly believes in traditional medicine has faith in these practices. The

example provided by one interview is a man that trips and falls, injuring himself. The

man might visit a doctor and be prescribed powerful pain medicine and a cast; however,

might not feel comfortable that the injury has been resolved until he travels back to the

place he tripped to pour out mezcal on the ground. This ritual is a part of a complete

treatment for the man, and his perceived condition is not fixed until it is complete.

Effective ways of handling conflictive pluralism.

o Tactful honesty with the patient will always be best. If a patient with cancer, left

untreated it will metastasize, asks the allopathic doctor about an herb tea to cure the

cancer, then the doctor must tell the patient what information she has about cancer and

what she knows about the tea. In cases like this, the doctor must decide how strong to

condemn the usage of traditional medicine.

Effects of endemic low education, specifically related to preventative measures actively sought

by the patient.

o Many people prefer to use traditional medicine until symptoms worsen, until necessary

to use allopathic medicine or visit the hospital.

The harmonious nature that can pervade a doctor-patient relationship with pluralistic co-

prescription and understanding of the patient’s culture and beliefs/faith in this culture.

o The only concern mentioned regarding co-prescription is the continued belief, if not

strengthening of trust, in traditional medicine or allopathic medicine when only one

medicine actual effectively treats the ailment because the treatment effects cannot be

attributed with certainty to either medicine. This can lead to inflated faith in less

effective treatment; the ensuing damage can expand to include large groups of people

or entire communities because of misdirected treatment-praise shared with others.

DISCUSSION

Unique benefits of the questionnaire include “historical” and hypothetical question types, a comments

section and integration of checks/averages. The advantage of factual and hypothetical questions is the

distinction between actual behavior versus insight into participant consideration or thought, reflection.

The most striking example, the ratio of participants that prefer traditional or allopathic treatments more

but visit allopathic or traditional practitioners (equally) or more often to participants who consult their

preferred type of doctor more often (Table 5, Q3, Q10, Q11). This question directly compares

participant thoughts to their “historical” actions. The comment option expanded the possible

information to glean from each participant’s response and some of the most insightful comments

include clarification on why some questions were left blank and how the cultural concept of both spirit

and body apply to preference. The similar, repeat-questions of the questionnaire allowed for averaging

and more accuracy of effective data. The integrated checks confirm data; for example, if a person

indicates that a final level of education was primaria, the reported number of years of education should

be no greater than 7 years, which includes an additional year of leeway, based upon public schooling

tiers. These facets increased the investigation-value of the questionnaire data.

The questionnaire spans numerous topics of interest and measures income, preference and level of

education. The application of the analyzed questionnaire data clearly supports the statement: Pluralism

in the city of Oaxaca (Table 5, Q4, Q5) is not composed solely of static preference (Table 5, Q12), and

considering that many patients do not receive their most preferable treatment-type (Table 5, Q10, Q11,

Q3) and that the population feels more scientific information (Table 5, Q36) and/or income (Table 5,

Q24) can affect preference, then, to improve the healthcare, an increase in the doctor-patient science-

based information exchange and decrease cost of treatment would help. The first note regarding this

statement is that further investigation is necessary to better understand what these induced preference

changes might be; particularly, would the preference of an individual with increased income favor

traditional or allopathic treatment-type. Regardless, it can be assumed any person with more knowledge

(correct information) and financial freedom will select the most improved treatment-type, which no

matter what equates to better healthcare, at least from the perspective of the individual. Secondly, this

statement does not conflict with other project data, graphically demonstrating little correlation between

treatment-type preference and education and income level (graph 1 and 2). Based upon interview

extrapolation, during which nearly all doctors (also) agreed that increased education would alter patient

preferences (specifically toward preventative medicine and to a lesser, biased degree, allopathic

treatment), one main subtly explains why the graphs merely appear to be discrepant. The subtly:

interviewed doctors consider the factor of time and possible trends dependent on time, which includes

any “cascading” cultural changes; statistically, too, correlation does not determine causality. An

explicative example regarding the first subtly, the same correlation values could be obtained ten years

from now, even if the linear regression lines (in black) shift upward (or downward) on the y-axis; this

shift equals change due to some force, that regardless of the correlation constant, is hypothesized to

possibly be augmented scientific education or income by the very people that would experience the

change. Everything, this statement, all the data and the project in whole only retain investigational

value, though, if the sample population precisely models the stated research population of Oaxaca

without major deviation.

To obtain a more reliable sample population with minimal bias from the research population (see

Introduction) methodological changes were made as necessary. Primarily, the discovery that ~81% of

the possible participants on the premise of IMSS traveled from pueblos, required the PI include another

questionnaire location with more urban participants, the Parque Llano participants. Another population

detail accounted for, the correlation between socioeconomic disadvantage and site of questionnaire

collection; the first fifty surveys from IMSS represented participants with a lower spectrum of reported

daily income. Thus, collection at Parque Llano offered an alternative pool to randomly (as possible)

select from to add to the (should be primarily urbanite) sample population. Even with these

acknowledgements and improvements, the sample population in future studies will be predefined based

upon contemporary census data from the federal government. This will have immense effects on the

veracity of the results and applicability of the investigation, and it is worthwhile to compare these

investigation results to this census data. Overall, the challenges of this project reduce the accuracy and

precision of data, but do not render the results insignificant.

Specifically, some challenges include: unexpected language barriers, mildly frequent low participant

literacy in Spanish and weak questionnaire methods. The language barrier includes (Spanish to English)

translation by a non-native PI and a high number of participants, whom primarily spoke an indigenous

language (in addition to Spanish). However, the interference of Spanish to English translation are nearly

negligible because assistance from several native Spanish and Oaxacan professionals familiar with the

cultural intricacies of healthcare, guided and proofread both the questionnaire and the structured

interview. Also, participation required a level of Spanish literacy enabling comprehension of read or

spoken questionnaire questions. In particular, participants at IMSS required more explanation and

found it more difficult to understand some questionnaire questions. This is attributed to a greater

presence of rural dwelling participants—therefore greater indigenous language usage, lower levels of

Spanish language education—that traveled, often several hours, seeking hospital care for a family

member. In the future, either a translator or more linguistically inclined PI could serve to rectify these

language hindrances.

The weak questionnaire questions mainly refers to the scale measurement of preference in Q13,Q14,

and Q15; these questions were too complex. The error was discovered after initiation at IMSS, and was

not corrected mainly because the effects hopefully were controlled for during questionnaire

administration with extensive explanation and breakdown, if necessary. In the future Likert scales and

more straightforward means could be utilized, even if limiting the depth/range of answers.

The positive facets, shortcomings, solutions, and conclusions discussed above comprise the noteworthy

points regarding the questionnaire and general investigation results and procedures.

CONCLUSION

In Oaxacan allopathic treatment, respect of patient value or preference for traditional treatment by the

doctor remains a delicate situation centered on the patient’s wellbeing and faith. Because patients’

assign preference—which is not always in accord with “historical” accounts of treatment-type

received—on the basis of personal ideas, knowledge, experience and values, this component of the

doctor-patient relationship is highly variable and unique to each patient. The degree of

cumbersomeness a pluralistic treatment-type preference introduces to the doctor-patient relationship,

from the perspective of an allopath in Oaxaca, appears to exist only when co-prescription is interfering

with the allopathic treatment of a serious ailment. The interference often imputes to the lack of trust of

the allopathic treatment by the patient or actual unpredicted substance interference, and in both cases

more rigorously confirmed data on the traditional treatment-type would be valuable to the allopath.

Most often though, the patient is permitted to complement the treatment with any desired means and

the pluralistic conflict is minimal provided the patient informs the doctor about all other current

treatments. An extended investigation might attempt to determine whether the costs of pluralism

outweigh the benefits of this belief system for patients and/or allopathic doctors based upon population

health and livelihood, or explore the depth of cross-cultural translation of these current results to a

similar culture consisting of traditional and allopathic treatment-types or more specifically the

contemporary American healthcare system woven extensively with alternative, naturalistic and

allopathic healing methods

Unfortunately, due to the flood of patients receiving situational optimization of aid at IMSS, ISSSTE and

the like, a paternalistic model—the doctor elects the patient’s best interest12—automatically dominates,

as there is only time to consider the patient’s physical pains and chart data.16 This means that the

element of the doctor-patient relationship that’s always unique to each patient because of personal

values, yet pertinent for the most effective treatment of both individuals in the short-run and the entire

Oaxacan people in the long-run—through generationally-rippling improvement, (potentially) inducible

through medical-health science education—is sacrificed. If so, the importance of increased doctor-

patient interaction, which includes information exchange during increased consultation time between

both patient and doctor of a scientific, culturally-relevant and value-based nature, will allow patients to

draw from their own augmented, updated stocks of knowledge, creating more satisfaction (plus the

medical health corollaries) while concomitantly adding benefit to the Oaxacan people in whole, through

promulgation of new information increasing both the faith in science and its exactitude and the

understanding of the beauty and nature of tradition and traditional techniques, and equally through,

bettering of lives by fostering a long life of health.

Currently, medical pluralism is undeniable within Oaxaca. The results that 46 of 82 patients are

receiving medical treatment-types they do not prefer most (Table 5, Q11, Q12, Q3) and that 78 percent

of participants believe more scientific information can change their preference (Table 5, Q36), both

conflated with findings from studies on patient satisfaction and values and from this investigation’s

clarified understanding of the culturally specific doctor-patient relationship, support the cruciality of

instructional interaction in every allopathic consultation. Whether faith in traditional treatment-type is

condemned or condoned by the allopathic doctors of Oaxaca, will largely affect the culture in the long-

run and the doctor-patient relationship in the short-run. Currently this faith appears to be handled with

an honest explanation of the allopathic doctor’s extent of knowledge. This should include sharing with

the patient how more modern scientific, allopathic treatment originates and the reliability of results

based upon extensive research that form the basis of allopathic treatment.

These study results warrant further investigation for two reasons. One, there is room for major

methodological improvement on sample population definition and on faulty or incomplete

questionnaire questions. Two, the opportunity exists to greatly improve the understanding of the

effects of medical pluralism and patient treatment-type preference, respecting the doctor-patient

relationship, to ultimately improve the lives and work of both patient and doctor.

SOURCES

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16. Shadowing two doctors, one at IMSSTE and another at a SIDA clinic in Mexico.

17. Governmental Census. "México en Cifras: información nacional, por entidad federativa y municipios."

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<http://cuentame.inegi.org.mx/default.aspx>.