Poss, Jezewski - 2002 - The Role and Meaning of Susto in Mexican Americans' Explanatory Model of...

7/27/2019 Poss, Jezewski - 2002 - The Role and Meaning of Susto in Mexican Americans' Explanatory Model of Type 2 Diabe

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J A N E P O S SSchool of NursingUniversity of Texas at El PasoM A R Y A N N J E Z E W S K ISchool of NursingUniversity at Buffalo, The State University of New York

The Role and Meaning of Susto in MexicanAmericans' Explanatory Model of Type 2Diabetes

This article examines the role and meaning of susto (fright) in MexicanAmericans' explanatory model (EM ) of type 2 diabetes. This analysis isbased on a study of the health beliefs about type 2 diabetes mellitus am ongMexican Americans living in El Paso County, Texas, on the U.S.-Mexicoborder. Susto was described as an event that could change the bodilystate, causing a susceptible person to be more vulnerable to the onset oftype 2 diabetes after some unspecified time. The study results illustrate theintegration of mu ltiple etiologies into M exican Americans' EM s of diabe-tes and illustrate how the environment affects the way in which these ex-planations are man ifested. Acculturation of biomedical system beliefsinto the traditional M exican health belief system has resulted in a synthe-sis of both systems and a blending of the participants' explanation of type2 diabetes, [explanatory models, type 2 diabetes, Mexican Americans,health be liefs, susto] T his article examines the role and meaning of susto (fright) in MexicanAmericans' explanatory model of type 2 diabetes. This analysis stems froman investigation of the health beliefs about type 2 diabetes mellitus amongMexican Americans living in four colonias in El Paso County, Texas, on theU .S.-M exic o border.1 The pu rpose of the study w as to de velo p a culturally specificexplanatory model (EM) of diabetes in order to better understand how this popula-tion vie w s diabetes and to improve educational programs and treatment provided to i t

Medical Anthropology Quarterly 16(3):36O-377. Copyright 2002 , Am erican Anthropological Association.

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SUSTO IN AN EXPLANATORY M OD EL OF DIABETES 361

BackgroundType 2 Diabetes

Type 2 diabetes mellitus is an endocrine disorder characterized by elevatedglucose levels in the blood. The m ajority of individuals w ho develop type 2 diabe-tes are obese, and many have a strong family history of the disease. The patho-physiology of type 2 diabetes includes inadequate insulin production, elevated pro-duction of glucose by the liver, and insulin resistance at the peripheral tissues, allof which result in high serum glucose levels. Com plications of type 2 diabetes in-clude macrovascular disease (cardiovascular) and microvascular disease (reti-nopathy, nephropathy, and neuropathy) (SkyleY and Hirsch 2001).Hispanics are disproportionately affected by type 2 diabetes mellitus. AmongMexican Am ericans in the United States, approximately one out of every ten per-sons over age 19 has diabetes (H arris et al. 1998). A recent study of a random sam-ple of 882 adults residing in El Paso County revealed that 16.5 percent of the His-panics in the sample had been diagnosed with type 2 diabetes (El Paso DiabetesAssociation 2000).EMs are ideas and beliefs about an illness that help persons make sense of theillness within a cultural context (K leinman 1980). There are few studies in the lit-erature examining Hispanics' EMs of diabetes. Considering the high prevalenceand severity of diabetes am ong H ispanics, it is surprising how little we know abouttheir knowledge, beliefs, and practices with regard to this illness. Weller et al.(1999) studied Latinos from four diverse communities in the United States, Mex-ico, and Guatemala and found that participants' cultural beliefs about diabeteswere concordant overall with the biomedical model. The Mexican participants inthis study, however, identified susto, anger, and strong emotions as causes of dia-betes and were likely to use folk rem edies to treat it.An ethnographic study of diabetic Mexican Americans in south Texas re-

vealed that the participants attempted to connect diabetes in a direct and specificway to their personal history, citing individual behaviors or events as causes oftheir illness (Hunt et al. 1998). A study by Eid and Kraemer (1998) suggested thatMexican American patients attributed the etiology of diabetes to susto or worriesand were likely to blend the treatment plan of conventional medicine with their na-tive remedies. Brown and Hanis (1999) studied Mexican Americans in a Texas-Mexico border community and found that one-third of the sample used homeremedies to augm ent their prescribed diabetes therapy.Other researchers have examined the impact of differences between patientand provider EMs, but this research has almost exclusively been conducted withwell-educated, female Caucasians who have type 1 diabetes (Paterson et al. 1998).A study of variations between patient and practitioner EMs of diabetes revealed asignificant difference between the two groups, even though both were primarilymade up of well-educated Caucasian Protestants (Cohen et al. 1994). Using bothquantitative and qualitative methodologies, Larme and Pugh (1998) studied pri-mary care providers, both Hispanic and non-Hispanic whites, working with pri-

marily Mexican American clients. This research showed that, when providers donot understand their patients' conceptions of diabetes, communication betweenprovider and patient is impaired. Hernandez (1995) critiqued the traditional


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"adherence paradigm" used by diabetes educators and suggested that relationshipsbetween clients and educators should be based on a deeper understanding of theclients' experience of living with diabetes.Explanatory Models

The study of EMs focuses on individuals' explanations of the etiology of theillness and on their descriptions of symptoms, severity, and treatment, includinguse of folk remedies. Kleinman (1980) distinguishes between the constructs of ill-ness and disease. D iseas e is conceptu alized as the practitioner's construction of pa-tient comp laints, using the terminology and conceptual framework of the biomedi-cal health system. The construct of illness includes the cultural, social, andpersonal elem ents of s ickn ess in addition to the causes, sym ptom s, and perceptionof treatment options (Kleinman et al. 19 78).Analysis of patients' EMs is central to the work of both social science re-searchers and health care providers. Kleinman's (1980, 1986, 1988) concept ofEMs has stimulated a large body of research on individual and microcultural con-structions of health and illness (McElroy and Jezewski 2000). For the researcher,Kleinman's EM of illness becomes a useful framework for collecting data. Analy-sis o f the se data, in turn, can provide theoretical m odels that explain the m eaning ofan illne ss from the perspective of a group o f pe ople w ith that illnes s. There are nu-merous studies in the anthropology and health s cien ces literature that have appliedthe EM paradigm to patient's perceptions of various con ditions, including hyper-tension (Blum hagen 198 2), autism (Gray 199 5), obesity (A llan 1998), and tuber-culo sis (Poss 1998), to name a few.Susto

Susto, which can be translated both as "fright" or "scare" and the "sicknessthat results from a fright," has been described frequently in the anthropology andsocial scien ce literature. Sus to is generally classified as a culture-bound syndrome(C BS) and is reported to be present in a variety of Latin A merican cultures (Simonsand Hughes 1985). CBSs are thought to be illnesses created by personal, social,and cultural reactions to malfunctioning biologic or psychological processes andare understood only within defined contexts of meaning and social relationships(Kleinman 1980). CBSs are generally characterized as acute behavioral disordersconfined to a particular culture or culture group (Landy 1983). Som e widely estab-lished CBSs, l ike nervios (nerves), are viewed as culturally interpreted illnessesbecau se of the variations in their m eanin gs across different cultures (Low 1985).There is controversy among anthropologists as to whether susto is a CBS. Forexample, Simons views susto as a noteworthy event but not a CBS. "In much thesame way that exposure to material objects culturally believed to be polluting, ta-boo or otherwise dangerous may be considered responsible for a variety of ill-nesses, fright or startle are also available as attributional resources" (Simons andHughes 1985:330). Simons's colleague Hughes, however, takes a contrary viewthat susto is a CB S (Simo ns and Hughes 1985).Su sto, as described in the literature, is due to a startling event that may causepart of the self, the soul (alma or espiritu), to separate from the body (Rubel and


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SUSTO IN AN EXPLANATORY MO DEL OF DIABETES 363

O 'N ell 1978 ). Upsetting soc ial situations may also result in susto (Rubel 1960).The person suffering from susto is termed asustado/a and may experience symp-toms of listlessness, lack of appetite, depression and withdrawal, diarrhea, night-mares, and heada ches (Klein 1978; Rubel and O 'Ne ll 1978).Typically, the response to folk illness includes self-diagnosis and treatment,seeking treatment from extended family members, herbal remedies, and treatmentby folk healers who are considered uniquely qualified to care for those afflictedwith folk illnesses. Treatment of susto may include various types of ritualisticsweeping (barriadas) of the body using eggs, lemons, or herbs; family and closefriends may be involved in treatment (Rubel 1960; Trotter 1985). There may bejuxtapositions of indigenous healing rituals nd symbolism from the CatholicChurch. In some settings, for example, priests are involved in the treatment of

susto, and during barriadas, the sweeping motions may be made in the sign of thecross. At the end of the treatment, the asustado/a often drinks water containing spe-cial herbs.Baer and Penzell (1 99 3) investigated a group of M exican migrant farmwork-ers following an incident of pesticide poisoning. The researchers found that thoseindividuals wh o believ ed they had dev eloped susto as a result of the pesticide ex-posure had more symptoms and were physically sicker than persons who did notbelieve they had developed susto. Other researchers have found that asustados/as

are physically sicker than others in their com munity and have higher rates of m or-tality (Rubel et al. 1984).Folk and W estern M edical Systems

A number of researchers have found that M exican Am ericans m ove ea sily be-tween folk and Western medical systems. In their study of Mexican farmworkers,Slesinger and Richards (1981) reported that participants relied heavily on modernclinical med icine and ackn ow ledged many W estern disease categories such as can-cer and arthritis. Farmworkers stated that they had faith in Anglo physicians totreat some illnesses but relied on curanderos to treat others. There was good evi-dence in this study that farmworkers saw little incompatibility between the twosystems.Similarly, in a study of elderly Mexican Americans in Arizona, Applewhite(1995) found that the participants moved freely between traditional healing andmodern medicine, depending on the characteristics and seriousness of the illnessthey experienced. In a study of explanatory models of tuberculosis, Poss (1998)asked Mexican migrant farmworkers who they would choose as a health careprovider if diagnosed either with tuberculosis or susto. The respondents clearlypreferred physicians to treat tuberculosis, but for treatment of susto, they reportedthat they w ould con sult a curandero.Biomedical researchers have begun to examine a possible link between psy-chological stress and type 2 diabetes. A recent cross-sectional study of Dutch indi-viduals revealed that those experiencing a higher number of major stressful lifeevents were more likely to develop type 2 diabetes than those with fewer suchevents (M oo y et al. 200 0). Scheder (19 88 ) also examined the link between stressfullife events among Mexican American migrant farmworkers in Wisconsin, and she


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found that those workers with a greater number of stressful life events were motelikely to have diabetes.Hot and Cold Th eories of Disease Etiology

The anthropology literature related to hot and cold theories of illne ss is of in-terest because some authors report that these explanations of illness etiology areprevalent in the folk medicine traditions of Central and South America (Foster1994; Logan 1975). Accounts in the literature vary with respect to the prevalenceof hot/cold theories of illness among people of Hispanic ancestry. For example,Foster (1976) suggests that a hot and cold theory of disease is prevalent amongM exica n A m ericans. In contrast, Kay (1 97 7) found that youn g M exican A mericanw om en in the barrios in a southwestern city seem ed not to be aware of this systemof classification.M e t h o dParticipants

The investigators u sed K leinma n's E M of illn ess as a framework to elicit in-depth explanations from M exican Am ericans of their type 2 diabetes. After obtain-ing the approval of the Institutional Review Board at the University of Texas at ElPaso, the Principal Investigator (PI), Poss, who is bilingual (English/Spanish),conducted in-depth interviews in Spanish with 22 Mexican Americans diagnosedwith type 2 diabetes mellitus residing in four colonias in El Paso using an open-ended question format. Interviews were condu cted betw een N ovem ber 1999 andAugust 2000.

Participants chose n for inclus ion in the survey m et the follow ing criteria:1. D iagn osed with type 2 diabetes mellitus at least one year earlier2. M exican Am erican (born either in M ex ico or to Mexican-born parents)3. Residing in one of four colonias in El Paso County4. A ged 21 or older

Each of the colonias in this study is served by a Kellogg Health EducationCenter (KHEC) jointly administrated by the University of Texas at El Paso andTexas Tech University Health Sciences Center. Each of the KHECs employs apromotora (a trusted member of the community who represents the same culturaland linguistic background as the persons with whom she works) as a paraprofes-sional to provide outreach services in the community. Recruitment of participantsfor the initial interviews was done with the assistance of these promotoras becausethey kn ew the memb ers of the comm unity and could ea sily identify individuals di-agnosed with diabetes.The promotoras approached potential participants and asked them if theywere w illing to participate in an interview . Participants were assured that their abil-ity to receive any and all future health services at the KHECs would in no way becom pro m ised whether or not they participated in the study. On ce participants wereidentified and agreed to participate, the PI made arrangements to interview them inthe setting of their preference, either in their ho m es or at the K H EC s. After the


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interview wa s com pleted , each participant was paid $25 as compen sation for his orher time. Participants w ere not told prior to the interview that they would be paid,because the promotoras believed that those who volunteered to take part in thestudy w ithout exp ectation o f com pensation wou ld m ake better subjects.Interview Schedule and Informed Consent

The statement of informed consent and the interview questions were writtenin English at a fifth-grade reading level and were translated into Spanish by a quali-fied translator w ho is familiar with the Sp anish u sed in the El Paso area. The Span-ish version was back-translated into English by a second qualified translator andthe results compared with the original Englisti version. Modifications were madeto the instruments with the assistance of the translators to ensure clarity in both ver-sions. Th ese procedures for establishing equ ivalency of dual-language instrumentsare advocated by Brislin et al. (197 3) and M ann and Marin ( 19 91 ).The statement of informed consent was read to participants, because manyhad completed only minimal formal education. Participants were provided with acomplete description of the study and its purpose. All participants were given acopy of the consent form.The interview schedule consisted of 28 open-ended questions that were for-mulated to elicit the participants' beliefs and feelings about diabetes. Th e first itemwas framed broadly: "Please tell me about your experiences living with diabetes."Subsequent questions were increasingly specific, requesting information aboutsuch topics as diabetes etio logy , sym ptom s, treatment, severity, comp lications, andsocial significance. After the initial broad, open-ended item, the subjects wereasked the following general questions designed to elicit their opinions related tothe cause o f diabetes:

What do you think caus es diabetes in most p eople?What do you think cau sed diabetes in your case?

InterviewsInterviews lasted from one-and-a-half to two hours each, and all interviewswere conducted in Spanish and were audiotaped. The tapes were first transcribedverbatim in Spanish by a bilingual research assistant (RA). The PI reviewed alltapes transcribed by the RA to ensure accuracy and consistency. The RA then

translated the transcripts from Spanish into English, and these were reviewed bythe PI for accuracy.Focus Groups

Following analysis of the interview data (discussed below) and the construc-tion of a preliminary model, the PI conducted focus groups (FGs) in the KelloggHealth Education Centers in three of the four colonias where the original inter-views had taken place. The purpose of the FGs was to present the preliminaryanalysis of the data to the participants and elicit their comments and feedback. Inaddition, the researcher used th ese se ssions to clarify con cep ts and belie fs that werenot well develop ed after the initial data analysis. Participants in the FG s included those


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who had taken part in the original interviews as well as three other colonia resi-dents who had been diagnosed with type 2 diabetes. The size of the FGs rangedfrom four to six participants.Because most subjects used the term susto to describe one possible cause oftheir diab etes, the FG ses sions were used to clarify the participants* understandingof the role and meaning of susto in the etiology of type 2 diabetes. The followingquestions were used to start the discussion:1. What does susto mean to you? Please give me some examples.2. How does susto work in the body to cause diabetes?3. H ow long d oes susto generally last? What are the long-term effects?4. How long after an episode of susto does diabetes generally develop?

Data AnalysisKleinman's (1980) concept of EM was used as a framework to develop amodel of type 2 diabetes based on the descriptions of the participants. Data analy-sis was performed using Glaser and Strauss's (1967) grounded theory method todevelop categories using open coding, as described by Glaser (1978) and Straussand Corbin (1998). All interview data were coded separately by both investigators,and the coded data were then discussed by the investigators until consensus wasreached on the ca tegories and their properties that reflected the EM s o f the partici-pants.Categories included the causes, severity, prevention, symptoms, treatment(both Western biom edical and herbal), and social significan ce of diabetes. The pre-liminary model developed from the interviews was revised and amplified on thebasis o f the data from the FGs .

ResultsDemographic Information

Participants in the interviews included 18 females and four males (two addi-tional m ales and on e fem ale participated in the FG s). A ll participants had been di-agnosed with type 2 diabetes. The ages of the respondents ranged from 29 to 77,with an average age of 53. The average num ber of years the participants had livedwith diab etes was 14, with a range of one to 45 years. All but four of the study par-ticipants had attended some type of diabetes education classes, although severalhad attended only two or three se ssion s.All participants listed Spanish as their primary language. Two participantsconsidered them selves to be fully bilingual, on e considered her En glish to be good,and the remaining 20 subjects spoke primarily Spanish. The place of birth for 18participants was Mexico, while the other four were born in the El Paso area toMexican-born parents. The average educational attainment of the sample was sixyears of sch ool ing , w ith a range of zero to 14 years. One participant had studied fora year at the local community college. The average income of the participants was$865 per month, with a range of $390 to $4,000 per month. Seven participantswere u nw illing or unable to supply data on incom e. Table 1 provides a summary ofthe participants' demographic information.


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Table 1Demographic data.

SubjectNumber12345678910111213141516171819202122

Age56453258684564675577715042555846404229713859

MonthlyIncome

N/AN/A$4,000N /A$390$920$750$450$540$380$425N/A$650N/AN/A$800$700$650$669$650$1,000N /A

Years ofSchooling10512666685133095414

119094

Yearssince DMDiagnosis3244

111823475344551223129181211518

Birth PlaceEl Paso, TXMexicoMexicoMexicoEl Paso , TX

MexicoMexicoMexicoMexicoMexicoMexicoMexicoMexicoMexicoMexicoMexicoFabens, TXFabens, TXMexicoMexicoMexicoMexico

AttendedDMClassesYesYesYesY esN oY esY esY esY esY esY esY esY esY esN oY esN oN oY esY esY esY es

PrimaryLanguageSpanishSpanishSpanishSpanishSpanishSpanishSpanishSpanishSpanishSpanishSpanishSpanishSpanishSpanishSpanishSpanishSpanishSpanishSpanishSpanishSpanishSpanish

Self-ratedEnglishAbilityGoodVery LittleVery LittleNoneVery LittleNoneNoneVery LittleNoneNoneNoneNoneNoneNoneNoneNoneFluentFluentNoneNoneNoneNone

Explanatory ModelBefore discussing how susto fits into the explanatory model of type 2 diabetesfor this group of Mexican Americans, we present the participants' overall EM oftype 2 diabetes constructed from the data. The participants' EM incorporates as-pects of both the conventional biomedical system and the traditional Mexican

health belief system. Because all but four of the participants had attended diabeteseducation classes, most knew about the biom edical causes and treatment of type 2diabetes.Generally, there was a basic understanding of the pathophysiology of diabe-tes. Most participants articulated a relationship between the pancreas, insulin, andsugar in the body and knew that insulin production in the body may be decreased indiabetes. Some participants exhibited the classic symptoms of type 2 diabetes (in-creased urination, excessive thirst, blurred vision, weight loss) at diagnosis, butmany participants had no sym ptoms despite very high levels of blood sugar.The study participants believed that diet regulation was important in the treat-ment of type 2 diabetes. Participants discussed the difficulties encountered in


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following prescribed diabetic diets and their fondness for the traditional Mexicandiet, which tends to be high in fat and carbohydrates. The interview s revealed sub-stantial confusion regarding diet. For example, some participants felt that fat wasacceptable as long as they substituted vegetab le oil for lard. Others had m isconcep-tions about the desirable amount of protein in the diet. One patient on dialysis forrenal failure secondary to diabetes believed that eating large quantities of proteinwas indicated. Another participant adjusted her diet by "nibbling" all day long.Overall regu lation of diet w as seen as an important elem ent in the treatment of dia-betes, but knowledge of and adherence to dietary regimes varied greatly amongparticipants.

Each participant was taking a prescribed medication for diabetes, either anoral m edication or injected insulin. A ll but one participant discussed the use o f tra-ditional folk remedies as an aspect of self-treatment for diabetes (Jezewski andPo ss 20 00 ). M ost had used a traditional M exican remedy in addition to the medica-tions prescribed by their conventiona l health care provider. The u se of herbal reme-dies in conjunction with conventiona l med ications prescribed by a physician wascommon. One participant reported that she used both herbal and conventionalmed ications because she had confidence in the effectiveness of both.Participants were questioned about hot and cold theories of illness of the sortreported in the literature. None of the participants had ever heard of such concep-tions , and they had no understanding of the attempt to balance hot and cold humorsin the treatment of illness. Ev en after repeated question ing and probing by the in-terviewer, the subjects in both the interviews and the focus group sessions ex-pressed no kn ow ledg e of this traditional belief.A number of participants reported that they did not tell their physician aboutthe use of herbal teas. Several were fearful that the doctor would "scold" them ifthey revealed this information. One participant reported that "the majority of doc-tors do not believe in herbs," while another observed that "American doctors donot want us to take Mexican medicines." Although several participants were nowusing only Western medicines, they wished that physicians in the United Statesknew more about herbal treatments.Two participants observed that the more "Mexican" a person is, the morelikely he or she is to use ho m e rem edies, and the more "Am ericanized" the personis, the more likely he or she will use Western medicines. When these participantswere asked about herbalists in the El Paso area, they stated that there were none,but one reported that "M exico is full of them." An other participant recalled that hergrandmother, m other, and other relatives in M ex ico knew a great deal about herbsbut that she herself had little kn ow ledge.Susto

The integration of the biomedical and folk systems is best illustrated in theparticipants' discussions of the cause of type 2 diabetes. All but one subject feltthat susto or a powerful emotion (either happy or sad) caused diabetes. Nearly allof the participants could pinpoint a specific episode of fright (which they termedsusto) or a profound emotional experience as the contributing factor in the devel-opm ent o f their ow n d iabetes. After they were diagnosed with type 2 diabetes, par-ticipants a lso attributed fluctuations in their blood sugar to worry, fright, or stress.


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During the interviews, susto was described as a fright or a scare that occursunexpectedly. Susto was not conceptualized as the everyday occurrence of beingmomentarily startled b y a particular situation; rather, it was felt to be a severe frightcaused by a sudden, unexpected, and very unsettling event. One participant re-ferred to the su sto eve nt as a trauma. Susto wa s not view ed as an illness per se but,rather, was seen a specific event that caused the body to become more susceptibleto disease , in this cas e, type 2 d iabetes.W hen subjects were asked during the interview s to discu ss the cause of diab e-tes either in general terms or in their specific situation, nearly all used the termsusto initially to describe the cau se, and many related the spec ific incident they be-lieved cause d the onset o f their diabetes. These, incidents included au tomob ile acci-dents, witnessing a death by gunfire or drow ning, b eing threatened with a gun, andthe sudden death of a close family mem ber. With further questioning and probing,subjects men tioned other cau ses gen erally c onsidered to be part of the b iomed icalexplanation o f diabe tes, such as poor diet, obesity, heredity, and lack of ex ercise .During the FG s, subjects were asked to rank the cause s of diabetes from m ostto least important, and in each FG , they w ere able to com e to an agreement on thisranking that was satisfactory to each participant. In all FG s, participants listed he-redity as one of the two most important causes of diabetes. Other causes, in de-scending order of imp ortance, includ ed lack of proper self-care, being ove rw eight,poor diet, lack of ex erc ise, stress and worry, and susto. Thus, wh ile susto se em ed tobe the factor precipitating the onset of diabetes for most of these subjects, theyranked other, more b iom edically based factors as the more important causes of theillness.

Symptoms. A cco rding to the participants in the study, susto is not preventablebecause it is an unexpected event that cannot be avoided. Although not viewed asan illness per se, when susto occurred, it was often accompanied by a variety ofsymptoms, including dizziness, goose bumps, bursts of adrenaline, trembling,nervousness, and feeling faint. For the most part, these sym ptom s rarely lasted morethan a few hours or days. When asked how susto worked in the body, one manstated, "Well, som etim es wh en I have a strong em otion, a fright, and I feel go osebumps, like adrenaline, like something strange happening in my body."One female participant stated, "You feel like you are going to faint. Afteraw hile that fee ling go es a way, and yo u start to gain control again, but the first f eel-ing is that you are going to faint." Another woman described it this way: "I thinkthat susto is an emotion a person experiences when her metabolism changes sud-denly beca use she had a sudden scare. Sh e reacts in a certain way so that more ad-renaline is pum ped into her bod y and her blood starts to m ove faster."A lthoug h participants in the study m entioned susto as the proximate cause o ftheir diabetes, they did not discuss specific symptoms of susto spontaneously but,rather, had to be asked about these m anifestations. No t every one in the study ex pe -rienced sym ptom s o f susto and, of those w ho d id, not all had the same sym ptom s.The sp ecific sym ptom s of the diabetes w ere more important in their EM s than thesymptoms of susto itself. It is likely that subjects did not mention symptoms ofsusto beca use this event wa s per ceived to be a factor that precipitated a biom edicaldiseas e and not an illness per se.


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The Susto Event. When asked to tell the investigator more about susto as acause, most participants in the study could relate in detail the specific fright theyperceived as eventually cau sing their diabetes. One man related his episode of sustoas follows:In 1966, in August, wewere going to Mexico, and I had been up all night at the fti-neral of a family friend, visiting with the family, and I had to leave early the nextday, and when we left, I asked my oldest daughter to drive.... When we ap-proached Sam alayuca, about 30miles from Juarez, there was a truck parked on theroad that blocked the visibility, and my daughter did not see that there was an on-coming pickup truck, and she went around the truck. I saw all this happening, be-cause I was not asleep yet, and I was sure we were going to crash with the pickuptruck, and I was terribly frightened. But, thank G od, nothing happened, the pickupand our car passed each other very, very closely, but we did not hit each other. Itold my daughter to stop, and then the man driving the pickup came walking to-ward our car, very, very angry, and I saw that he had a pistol and he was shouting,"If you want to kill yourself, that's fine, go do it, go to that mountain and throwyourself off a cliff, but do not endanger anyone else." I thought that he was goingto kill us, but the lady who was with him finally convinced him to get back in thetruck, and so I got in our car and continued driving myself. From that day on, Istarted to drink lots of water, I was always very thirsty, and I used to tell mydaughter and my wife, "Please give m e more water, more water," and we boughtgallons and gallons for the road, and I urinated all the time. When we got backhome, the doctor saw me, and he told m e, "Your sugar is quite high ," and he said,"Buy these medicines and start taking them, have your blood tested, too, and Iwant to see you in a month, with the lab test results." I went to see him one monthlater, and he told m e, "Your sugar count went down, but not very m uch, buy themedicines again and continue taking them , and also follow this diet."When one woman was asked to clarify the event that precipitated her diabe-tes, she related a fright she had during an auto accident, in which the car she was

riding in was hit from the rear by a bus, causing her car to hit the car in front of it.The d river of the seco nd veh icle got out of h is car and w aved a gun, accusing herhusband of ca using the accident. S he was seve n months pregnant at the time, and,at the doctor visit the week after the accident, she was told she had diabetes. Shestated, "I give you this example to help you realize that in only one week after avery frightening event, seeing this man who was angry at us and carrying a gun,w ell I had develop ed diabetes. It wa s a terrible thing for me and more so because Iwas pregnant." Another w om an related a horrible incident: "I got diabetes becausea child drow ned in front of m e and from that time is when I started with diabetes. Ibe liev e that is why I got diab etes bec ause of that fright."When asked what happens in the body of the person who has experienced afright, one woman replied, "Well, perhaps a person starts to feel very depressedand kind o f weak and sick, and then, little by little, diabetes starts to de ve lop in thebody. That is what I think. And then the person starts to feel uneasy and nervous,and he eats more and more of the wrong type of foods. The only symptom I hadwas that I felt kind o f sick and had no strength."

Study participants were very clear about the inc idents that precipitated the de-velopment of diabetes in their respective cases. Several subjects who were inter-view ed and later participated in the focus groups related the sam e story of the causeof their diabetes, almost word for word, during both sessions, even though the focus


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SUSTO IN AN EXPLANATORY MOD EL OF DIABETES 371

groups occurred nearly a year after the initial interviews. Clearly, the episodeswere traumatic and significant events.Several participants belie ved that they p ossibly already had diabetes wh en thetrauma occurred and that the frightening episode caused it to be made manifest.On e subject related,

I think, in my case, that when I feel a fright or a terrible scare, when I feel it, I feelthe scare in the pit of my stomach, like an electrical shock. I actually feel it, andthat is why I think that the feeling is quite strong. Then, the strong emotion that thebody feels, this makes the functioning of the body to go completely out of order,and, it is easier for the diabetes to take hold. Or perhaps we already have diabetes,or almost have it, and only because we had a scare, the diabetes takes hold andprogresses more rapidly.Time between the Susto Event and the Disease. The time between the sustoexperience and the onset of diabetes varied tremendously among participants in thestudy, ranging from day s to years. There wa s no standard or expec ted length of timebetween the episode of susto and the development of diabetes. According toKleinman (1980), lay EMs are characterized by vagueness and impreciseness, andthe scientific notion of direct causality is often lacking. EMs are flexible enough toaccount for a wide range of experiences and often are not refuted by contradictory

evidence.One man attributed his diabetes to two episodes of susto that occurred about20 years before his diag no sis. A nother m an reported that his diabetes started abouttwo years after he witne ssed his child nearly b eing struck by an onco m ing car. Onewoman stated, "A lot of times susto and diabetes do not happen at the same mo-ment, but the diabetes dev elops later on , like, for exam ple, a week after the scare. Ido not mean by this that it will take a w hole we ek, som etimes it is sooner, or some -times longer than a we ek, but the outcom e is that I got diabetes. It wa s caused bythat strong em otion."

Treatment for Susto. W hen specifically asked if there were any treatments forsusto, several peop le stated they w ere familiar w ith specific treatments, while othershad only heard about treatments. Participants in one of the focus groups discusseda barriada in w hich the healer m ov es an eg g o ver the asustado/a and then puts it ina glass and breaks it. By exam ining the eg g, the healer can tell w hat is wrong withthe asustado/a. Th is sw eep ing is accomp anied by prayers. Other objects were a lsomentioned that could be used during the sweeping, including cloth that had beenblessed by a religious person , a special type of stone, and a holy candle. One wom andescribed the use of prayer, holy water sprinkled over the body, and a cross madeof palm leaf swep t ove r the per son's body to cure susto. A male subject said that afew drops of a special herb in a glass o f bo iled w ater can cure susto.Although the people in the study could discuss the concept of sweeping totreat susto and also relate some of the steps in the process, the ritual was not wellunderstood. None of the participants in the study were treated for susto when theevent occurred. Some of the women said that they perform sweepings for theirchildren wh en the latter cannot sleep or wh en they are nervous, and one of the mensaid that his wife occa siona lly performs sw eep ings for others.


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Still others in the study did not believe in sweeping and, instead, used prayei.One woman who believed that susto was a contributing factor in the developmentof diabetes did not be liev e in folk treatments for susto but, rather, relied on prayer:"A prayer that you offer to G od , in wh ich you talk to God with all your heart what-ever you want to tell Him, that is what will help. But using a stone or an egg, thatwill not help, because G od d oes not need us to offer him anything."Perhaps because susto was perceived as an event and not an illness, the meth-od s for treating susto did not see m to be an important part of the participants' ex-planatory model of type 2 diabetes.

Individual Susceptibility. The effect of susto on the body and the ability ofsusto to cause diabetes depend on the individual's experience and constitution.Accord ing to McElroy and Tow nsend (19 96), C BS s, like physical illnesses, followepidemiological principles of distribution, and not all persons are at risk of beingaffected by them. According to the participants in the study, not everyone wasequ ally at risk for acquiring diabetes after a susto event.

One subject stated that the development of diabetes depended on a person'stemperam ent. Other participants related that peop le who are young and strong arenot necessarily affected by susto, that is, they do not deve lop diabetes because of afrightening event. One man equated strength with body size. He described how,years p rev iously , he was "fat and strong" and therefore ev en experien cing the mostfrightening episode would not have resulted in his developing diabetes. Yearslater, when he was in a weakened state, he developed diabetes after an episode ofsusto. Another respondent reported that som e are more susceptible to diabetes thanothers, "I do not know why this is, but we are all di ff ere n t. .. the metabolic systemof each person is different."Other participants felt that some persons were more susceptible to or had atendency toward deve lopin g diabetes. One m an stated, "As I was telling you, a per-son may be healthy, and not have diabetes, and then he experien ces a terrible scare.This person m ay continue along without develop ing diabetes. But the person whohas a tendency to diabetes, if he gets a terrible scare, now he develops full-blowndiabetes."Another women stated that two persons may experience the same kind offright and that this experience might cause diabetes in one but not the other. Shestated that it depended on the body of each person and on how that body is at themoment something happens. She noted, "Sometimes the body may endure manyterrible things and at other times, it won't. For example, two people eat the samefood and one gets sick and the other doe sn't. W hy is this? Because the one that gotsick had a predisposition at that tim e to get sick, and the other had more resistanceto disea se at that prec ise tim e."Discussion

The analysis of EMs of illness allows the observer to understand how indi-viduals v iew an illnes s, including its etio log y, sym ptom s, treatment, and social sig-nificance. EM s can provide an explanation of h ow cultural and biom edical aspectsof illne ss are integrated into an ind ividu al's conceptio n of illn ess. In this article, wehavereportedtheresultsof a study of EMs about diabetes among M exican Am ericans


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living on the U .S .- M ex ic o border in El Paso Coun ty, Texas. In particular, w e havelooke d at these subjec ts' conc eption of the role of susto in the etiology of diabetes.Nearly all participants in this study believed that a terrible fright or scare (whichthey termed susto) resulted in the onset of their diabetes.Susto wa s v iew ed by the participants as a cause of diabetes and not as a condi-tion or illness with specific, long-lasting symptoms. Susto was described as anevent that could change the bodily state, causing a susceptible person to be morevulnerable to the onset of type 2 diabetes after some unspecified time. Participantsin the study could not explain w hy or how susto caused diabetes. In their vie w , theepisode of su sto w as a factor in the develop m ent of diabetes, but susto was not seenas an illness or CBS per se that required specific treatment. When asked specifi-cally about treatment for susto, the participaftts' descriptions were vague and re-

sembled secondhand accounts. Although most of the participants believed thatsusto was a factor contributing to the onset of diabetes, none had sought treatmentafter their susto even t.Like the subjects in the studies by S lesinger and Richards (19 81 ), Ap plewh ite(1995), and Poss (1998), participants in this study moved easily between the folkand Western medical systems both in explaining the etiology of diabetes and incaring for their illness. While they believed that susto was an important cause ofdiabetes and while it was the first thing most mentioned when asked generallyabout the etiolo gy of their illness, they a lso listed biom edically based causes suchas obe sity, poor diet, heredity, and lack of exerc ise.When asked during the interviews what caused their diabetes, most partici-pants discussed susto as the primary cause. However, in the FGs, when asked torank order a variety of cau ses o f diab etes, th ose sam e participants ranked heredityas the most important cause. This discrepancy likely reflects contextual factors re-lated to the study. D uring the interv iew portion of data colle ctio n, in response to anopen-ended question, participants were able to describe the cause of their diabetesin a narrative format, and thus they discussed the emic view of causality. When

presented with a more structured (Westernized) method of discussion (rank order-ing), they reverted to a more biomedical explanation of diabetes, thus incorporat-ing the etic view they learned both in diabetes education classes and from theirhealth care providers.This study illustrates the integration of multiple etiologies into an individual'sEM and how the environment affects the way in which these explanations aremanifested. Acculturation of biomedical system beliefs into the traditional Mexi-can health belief system has resulted in a synthesis o f the two system s and a blend-ing of the participants' exp lanations o f type 2 d iabetes. From the perspective of theMexican Americans in this study, diabetes requires biomedical treatment and, per-haps to a lesser extent, herbal therapies.

When persons move across cultural borders, their traditional illness modelsand explanations may undergo modifications. When terms such as susto are usedby individuals living on the border, they may have lost much of the meaning thatthey had in the country o f origin. S o w hile susto is described in the social scienc eliterature as a CBS among traditional cultures of Central and South America,among this group of M exican A mericans living on the U .S.- M ex ico border it hascom e to m ean o nly a frightening e vent that later produces diabetes in som e suscep -tible individuals. And while the treatment of susto among traditional groups may


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374 ME DICAL ANTHROPOLOGY QUARTERLY

include remedies to restore balance between hot and cold humors, participants fnthis study knew nothing about hot and cold theories of disease nor did they seekhumoral treatment for susto.This study has implications for health care providers working along the bor-der with Mexico. While the results cannot necessarily be generalized to otherM exican Am ericans living on the border, the EM s of the subjects in this study mayhave im plications for understanding other similar groups in the region. Because ofthe high prevalence of diabetes among M exican Am ericans in the border region, itis imperative that health care providers have a clear understanding of how indi-vidu als v iew their disease . C aregivers need to dev elop an approach to treating per-sons with d iabetes that do es not push aside the cultural, soc ial, and moral meaningof this illness and that respects the particular illness exp erience o f each patient. Un-derstanding the role of susto in the etiolo gy of type 2 diabetes is a first step in com -prehending the com plexities o f Mexican A m ericans' EM s of diabetes.

The perception of the participants in this study that a stressful or traumaticevent was the reason they deve loped diabetes is consistent w ith the work of Mooy(20 00 ) in a Dutch population and Scheder (19 88 ) in a M exican Am erican migrantworker population. It is important for health care providers to be alert to the poss i-bility that patients exp eriencing multiple crises may indeed be at increased risk forthe development of diabetes and other illnesses. In addition, if patients perceivethat stressful events may ultimately result in illness, then providers may wish tomak e referrals for support serv ices and coun seling for individu als in crisis.This study also has implications for anthropologists, especially those work-ing, consulting, or conducting studies in health care delivery arenas. This studyaptly demonstrates the integration of biomedicine and folk beliefs into an individ-ual' s EM and illustrates how a CBS evolves and is integrated with the biomedicalview. Explanations of the C BS know n as susto change to adapt to information pro-vided by the biomedical view, just as biomedical information is adapted and inte-grated into a folk EM in a way that makes sense in the context of the individual'sbelief system.

Anthropologists and health care providers alike cannot assume that any onegroup or individual subscr ibes to folk or biom edical information in their traditionalforms. M ost individuals, especially those wh o m ove b etween cultural milieus, cre-ate EM s that integrate aspects of both cultures, resulting in a new perspective.In trying to understand the etiology of illness, it is also essential to examinethe macrolevel soc ial, political, and econom ic factors affecting at-risk populations.Farmer et al. (1997) suggested that, in order to understand why tuberculosis is soprevalent among impoverished populations, it is imperative to consider the largersocia l context in which ind ividuals liv e and work. Factors such as extreme poverty,overcrowded living and working conditions, inadequate nutrition, racism, and anunresponsive health care system all contribute to the tuberculosis epidemic amongunderserved populations in the United States. Likewise, as Scheder (1988) pro-poses in regard to diabetes, the oppressive living conditions of migrant workersand other groups may contribute to the development of diabetes through physi-olog ical r esponses to cum ulative stressful life experien ces.


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SUSTOMAN EXPLANATORY MO DEL OF DIABETES 375

N O T E SAcknowledgments. This study was supported by a grant from the Paso del NorteHealth Foundation through the Center for Border Health Research. Its contents are solelythe responsibility of the authors and do not necessarily represent the official views of the

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Accepted or publication Decem ber 8, 2001.

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