Lessons From the Field

STEALING THE SOUL, SOUMWAHU EN NANIAK, ANDSUSTO: UNDERSTANDING CULTURALLY-SPECIFIC

ILLNESSES, THEIR ORIGINS AND TREATMENTRoberta Lee, MD, and Michael J. Balick, PhD

lessons from the field

Roberta Lee is medical director and codirector of theIntegrative Medical Fellowship at The Continuum Centerfor Health and Healing at Beth Israel Medical Center inNew York City. Michael J. Balick is vice president forresearch and training and director of the Institute ofEconomic Botany at The New York Botanical Garden inBronx, NY.

The bus drove along the winding, narrow road in aremote region of northeastern Brazil, stirring abrown cloud behind it, a mix of diesel fumes andearthen pavement that had not seen a drop of rainfor many months. We were in an area known as

Lima Campos, in the state of Maranhão, surrounded by a seaof tall palms, locally called babassu. In a tropical forest in thispart of the world, babassu palms grow among the taller, moreverdant vegetation, spilling seeds into the ground, where theycan remain for decades without germinating. After the naturalforest cover is destroyed by clearing for pasture, the seeds ofbabassu spring to life, completely dominating the landscapeand prohibiting the emergence of most types of trees from thesoil. Over a few decades, the palms grow to 50 to 75 feet ormore, spreading their seedlings in an ever-expanding range. Infact, the formation of a babassu woodland is so completelyoverpowering that it has given rise to a new ecological term—the oligarchic forest—meaning a habitat dominated by only afew species.

This plant is locally known as the “tree of life” becauselocal people put it to so many uses. Its leaves provide shade forgrazing animals and are cut to thatch houses. The base of theleaves can be shredded into a cottony mass and its sapsqueezed onto open bleeding cuts. Immediately its stypticproperties close wounds and stanch blood flow. The stems ofthis palm are tough and can be made into timbers for bridges.But by far, the fruit is the most valuable part of the babassu.Produced by the thousands on each tree, the fruit is about thesize of a lemon and has the appearance of a small coconut. Thefruit is collected as it falls from the tree and is processed by

hand. The quebradeiras, a term referring to the women whobreak open the fruit, sit on the ground supporting an upturnedaxe head with their legs. They hold the fruit on the blade withtheir hands and tap it with a small wooden bat. When properlysplit, the fruit cracks in half and the oil-rich kernel can beextracted. These kernels are processed into an oil similar tothat from the coconut. The oil can be extracted on the farm orthe kernels sold to middlemen who transport them to process-ing factories in the larger cities of the northeast. The shells ofthe babassu are carbonized, mostly in small pits close to wherethey are cracked, and turned into the charcoal used for cookingin most rural households in this impoverished region. Thecharcoal is rather remarkable in that it has a higher energy con-tent with a lower yield of pollutants than mineral coal. Butthese are only a few of the uses of the tree of life. Because ofthese many properties, our research group, based at The NewYork Botanical Garden, had been studying and domesticatingthis species in collaboration with the Brazilian governmentsince the late 1970s.

Our purpose in coming to Lima Campos today was to visitthe babassu forest, to show a distinguished group of interna-tional palm scientists our research site, and to develop a net-work of collaborators who might help to study this plant inother locations. A few hours into our bus ride, we passed a que-bradeira, a solitary woman sitting along the road, cracking alarge pile of babassu fruits, and tossing the oleaginous kernelsinto her basket.

“Stop!” one of the scientists in the group shouted. “Lookat what she is doing.” The bus lurched to a quick halt, and adozen men from many countries, garbed in their national cos-tumes, furiously piled out of the vehicle and gathered aroundthe rather surprised young woman. Each man quickly openedhis knapsack and pulled out his silver movie camera with itslong lens and trigger handle—it was the early 1980s, before theadvent of the video camera. Raimunda, as the woman wascalled, found herself completely surrounded on all sides by agroup of strange men, speaking a language she did not under-stand, aiming their cameras at her. As each person intentlylooked through the viewfinder, the movie cameras whirred in

This series of essays explores lessons and observations from fieldwork that might be of interest to the integrative medical community. In this context, the authors discuss “new” or less celebrated botanical medicines and unique healing practices that may contribute to the further development of contemporary integrative medical practices. Perhaps this column can facilitate an appreciation for our own roots and those of other cultures, before such ancient wisdom disappears forever.

106 ALTERNATIVE THERAPIES, may/june 2003, VOL. 9, NO. 3

Lessons From the Field

harmony. A loud chorus of “bzzzzzzzzzzz” permeated thisintensely hot, dry, and otherwise peaceful roadside. After a fewminutes of filming, Raimunda began to shake uncontrollably,scream, and go into hysterics. One of her neighbors came overto investigate the commotion and see if she could help herfriend. Our guide sent everyone back to the bus and tried tospeak to Raimunda, who was by this time beside herself. “Theyhave stolen my soul, these devils with their machines, theyhave sprayed something on me and taken my soul in theirmachines!” she moaned.

The local scientists whowere our guides summoned avehicle to take her to the hospi-tal in Coroatá an hour away.There she was administered oxy-gen and given a sedative. Sheremained in the emergencyroom until she became tranquiland had retaken “possession” ofher soul. Our tour continued.The scientists made their obser-vations of the palm project andreturned to the local hotel.

That night at dinner, werevie wed the day ’s obser va-tions, and the incident with thequebradeira was raised. Whilesome of the group discussed theneed for more sensit ivity tolocal people, others argued thatthis young woman’s reaction was “ridiculous, primitive, andhad no scientific foundation.”

But was it really? Could a group of people speaking astrange language quickly descend on someone peacefullyshelling fruits in her front yard, surround her, take aim withstrange whirring machines, and spray something that couldsteal her soul? Perhaps, if this illness was a part of the local tra-ditional medical system, and if it had affected others in the vil-lage as well.

In another part of the world, Belize, Central America, peoplestruggle with conditions equally as complex and disabling. Infantsand children who suffer an emotional trauma, perhaps from wit-nessing a fight between adults at home, or a suicide, or a murderin the household, can manifest an illness known as susto or fright.The child—or adult—suffering from this condition will be unhap-py, have chronic indigestion, may have diarrhea or constipation,does not sleep well, and can break out in a cold sweat for no appar-ent reason. If an infant has susto, he or she will be cranky, sleeppoorly, vomit frequently, and have a rash that will not heal.Traditional treatment of susto in this part of the world is specific tothe healer involved, but usually involves the administration ofherbal teas and baths, along with prayers said by the healer.

Among the Maya people of Belize, malevolent sprits cancause mal vientos or bad winds. Such bad winds are thought to

be sent by practitioners of “evil magic,” and a shaman must becalled in to intercede on behalf of the affected patient. These evilspirits are thought to be associated with persons who died insudden and violent incidents—drowning, murder, or suicide—and who wander between the physical and spiritual dimensionsof life, wanting to make contact with the physical world. Theirconfused state adds to their predisposition to do harm to the liv-ing. Symptoms of a person suffering from mal vientos ofteninclude but are not limited to poor sleep, nightmares, irregularheartbeat, itching skin, poor appetite, indigestion, and melan-

choly. Patients sometimes reporthearing voices. Treatment againvaries from healer to healer, butincludes prayer, herbal teas andbaths, burning of copal incense,and obtaining a protective amuletfrom the healer.Many other types of spiritual diseaseare found in Belize; the illnesses andtheir treatments are discussed inRainforest Remedies: One HundredHealing Herbs of Belize.1

We have spent many years study-ing the ethnomedical beliefs andpractices of Micronesia, particu-larly the island of Pohnpei. Here,a condition known as lusalusgives patients a high fever(karakar) during which they arethought to “lose their mind” and

become incoherent. In severe cases of lusalus, people cannotspeak because their teeth stick together, and their eyes roll upinto the head. Healers on Pohnpei have a hard time treatinglusalus. According to William Raynor, scientist, conservation-ist, and long-time resident of Pohnpei, this condition often isconsidered a symptom of another disease—soumwahu en eni, asickness caused by the spirit of a dead person known to thepatient or relative taking possession of the sick person.(Personal communication with William Raynor March 2003.)

Another sickness that is unique to Pohnpei is soumwahuen naniak, translated as “mangrove sickness.” This illnesscauses a person to become weak, lose weight, suffer fromlightheadedness, depression, headaches, joint pains, red eyes,toothache, and itchiness, particularly at night, according toRaynor. Soumwahu en naniak makes people susceptible toother illnesses because their immune systems stop respond-ing, and they also can develop high blood pressure and heartdisease. Nightmares are characteristic of this disease; oftenthe dreams are set in the lagoon or mangrove forest, with fish-ing or marine themes.

Father William McGarry, SJ, based in Pohnpei for manydecades, discussed the concept of riala, which he defined asa person being cursed, as a cause of illness on the island.2

He noted,

ALTERNATIVE THERAPIES, may/june 2003, VOL. 9, NO. 3 107

In Belize, Silvieno Camberos S., a physician from Mexico, works withKekohi Maya herbalist and bushmaster Jose Tot.

I have run into many cases of people explaining to me whysomeone became sick. They simply became ill becausethey showed a lack of respect for the head of the family orfor some other person, and that person’s Eni [ghost orspirit] became disturbed with this and caused sickness.The very respect shown for the Nahnmwarki and theNahniken [highest of the traditional leaders on Pohnpei] …is largely based on this fear.”

The Surgeon General’s Report for 1999 discussed the influ-ence of culture and society on mental health.3 In many diseasestates, culture affects the way in which the disease will bedescribed to a clinician. Consequently, it is not surprising that inmental illness, ethnic variation will affect how a patient express-es distress. This often is referred to as somatization—a termdescribing symptoms caused by stress and experienced as bodilysensations. It is a condition that requires a thorough medicalexamination to evaluate the symptoms to exclude pathology asthe source for the illness. The Surgeon General’s report notesthat an Asian patient who expresses somatization is more likelyto report dizziness but when questioned further may acknowl-edge having emotional symptoms.4 Lynn Payer, an expert incross-cultural medicine, noted that in France somatization maylikely exhibit symptoms in the area of the liver.5 According toPayer, contemporary medical paradigms have distinct culturalbiases that not only color patients’ clinical symptoms but alsophysicians’ therapeutic choices in treating patients.

Most traditional cultures around the world have diseasesor illnesses that are specific to their culture or region. Patientswith these conditions seek traditional treatments, but whensymptoms become severe, they also go to emergency rooms orto physicians in clinics. Such culture-bound diseases havereceived a great deal of attention, particularly in the field ofpsychiatry. The DSM-IV-TR, published by the AmericanPsychiatric Association, contains an appendix on this topic,“Outline for Cultural Formulation and Glossary of Culture-Bound Syndromes.”6 The first section of the appendix suggeststhat the clinician develop a “narrative summary” for a series ofcategories as follows: “Cultural identity of the individual;Cultural explanations of the individual’s illness, Cultural fac-tors related to psychosocial environment and levels of func-tioning, Cultural elements of the relationship between theindividual and the clinician, and Overall cultural assessmentfor diagnosis and care.”

This document suggests, “The term culture-bound syn-drome denotes recurrent, locality-specific patterns of aberrantbehavior and troubling experience that may or may not belinked to a particular DSM-IV diagnostic category.”6 It furthersuggests6(p898) that

Many of these patterns are indigenously considered to be‘illnesses’ or at least afflictions and most have local names.Although presentations conforming to the major DSM-IVcategories can be found throughout the world, the particu-lar symptoms, course and social response are very often

influenced by local cultural factors. In contrast, culture-bound syndromes are generally limited to specific societiesor culture areas and are localized, folk, diagnostic cate-gories that frame coherent meanings for certain repetitive,patterned and troubling sets of experiences and observa-tions. There is seldom a one-to-one equivalence of any cul-ture-bound syndrome with a DSM diagnostic entity.

The manual lists 25 culture-bound syndromes, includinghwa-byung from Korea, koro from South and East Asia, locurafrom Latin America, mal de ojo from Mediterranean cultures,shenkui from China, and taijin kyofusho from Japan. Hwa-byung,describes a Korean “anger syndrome” and includes symptomssuch as panic, dysphoric affect, and indigestion. Locura refersto a severe form of chronic psychosis in which patients willexhibit incoherence, agitation, and sometimes auditory orvisual hal lucinations. Mal de ojo , or “evi l eye.” is aMediterranean condition to which children are most vulnera-ble. Its symptoms include crying without apparent cause,insomnia, diarrhea, and sometimes vomiting. The explana-tions for these terms are fascinating and can shed light on con-stellations of symptoms that may make little physiologicalsense to a clinician, especially if the culture of the patient dif-fers from that of the practitioner.

The benefits to understanding the significance of cross-cul-tural medicine in the therapeutic relationship is fairly obviousfor medical professionals. We are practitioners seeking to buildrelationships of trust and translators of the culture of medicalscience. What harm can be done by keeping this broader per-spective in mind? However, there is great harm in ignoring it.Anne Fadiman recounts the failure of medicine to engage thetrust of a Hmong family in her book, The Spirit Catches You andYou Fall Down.7 In this book, a child with a fairly complicatedseizure disorder comes for treatment to a medical facility inMerced County, Calif. She has a rocky medical course, in partdue to the clashing cultural paradigms of American medicineand traditional Hmong beliefs over the cause of the child’sseizures. In the Hmong world, seizures are not just neural aber-rations, they are derangements of the child’s spiritual world.Hmong treatment of the seizure addresses this imbalance andrequires rituals that are far removed from medical proceduresor pharmaceuticals but that enlist community support and tra-ditional healers. All of this is seen as extraneous to the medicalcommunity, even obstructive. In the end, neither culture under-stands the language of the other. The medical community per-ceives the family members’ behavior as noncompliant andhostile as they shun medical treatment to address their neces-sary cultural needs. Conversely, the family members misunder-stand the medical community’s intentions and concernsbecause they do not have a person who can help them under-stand. Ultimately, the child experiences many medical compli-cations and loses her life, largely the direct result of this tragicmiscommunication.

The United States is a nation of immigrants. Each culturebrings to our county its hopes, dreams, and knowledge from

Lessons From the Field108 ALTERNATIVE THERAPIES, may/june 2003, VOL. 9, NO. 3

the past. This knowledge includes beliefs that revolve aroundillness and healing, which history has shown us can persist forseveral generations. Why is chicken soup so commonly pre-scribed for the treatment of the common cold? Perhapsbecause our own great-grandmothers—one set from Russia,the other from China—found that it was such an effective rem-edy. We both remember that wonderful and healing chickensoup of our childhoods—one rich with dill and parsnips andthe other filled with ginger, garlic, and astragalus.

As integrative medicine seeks to establish a larger role forthe consciousness of and belief in contemporary healing, it iswise to remember that, wherever we come from, our ancestorsrecognized disease conditions and folk therapies unique to ourown cultures.

As Peter Mere Latham (1789-1875) noted in his CollectedWorks, “Faith and knowledge lean largely upon each other inthe practice of medicine.”8

AcknowledgmentsWe are grateful to the people of Maranhão, Brazil; Pohnpei,

Micronesia; and Belize, Central America for their kindness in teachingus about ethnomedical systems. We thank William Raynor, Ally Raynor,Claudio Urbano Bittencourt Pinheiro, and José Mário Frazão for theircollaboration in the fieldwork; and our great-grandmothers, grand-mothers, and mothers for their “chicken soup for the bowl.” We arethankful to the Overbrook Foundation, the Gildea Foundation, CERC—

the Consortium for Environmental Research and Conservation atColumbia University, The MetLife Foundation, Edward P. Bass and thePhilecology Trust, and the Prospect Hill Foundation for support of thework of the New York Botanical Garden Institute of Economic Botanydiscussed in this report.

This paper results from a multidisciplinary field project studyingthe relationship between plants and people in Micronesia. This effortfocuses on botany, ethnomedicine, traditional land management andresource systems, conservation, and education. Collaborating groupsin addition to those previously mentioned include the College ofMicronesia—FSM, the Continuum Center for Health and Healing atBeth Israel Medical Center, the National Tropical Botanical Garden,the Nature Conservancy, the Pohnpei Council of Traditional Leaders,the Pohnpei State Government, and the University of ArizonaProgram in Integrative Medicine.

References1. Arvigo R, Balick M. Rainforest Remedies: One Hundred Healing Herbs of Belize. Twin

Lakes, Wisc: Lotus Press; 1998.2. McGarry W. West from Katau. Pohnpei Department of Education; undated.3. Surgeon General’s Report. Available at http://www.mentalhealth.org/cre/toc.asp.

Accessed March 28, 2003.4. Lin KM, Cheung F. Mental health issues for Asian Americans. Psychiatr Serv.

1999;50:774-780.5. Payer L. Medicine and Culture: Varieties of Treatment in the United States,

England, West Germany, and France. New York, NY: Henry Holt; 1988: 57.6. American Psychiatric Association. DSM-IV-TR: Diagnostic and Statistical Manual of

Mental Disorders, 4th ed. Washington, DC: American Psychiatric Association; 2002:898.7. Fadiman F. The Spirit Catches You and You Fall Down. New York, NY: Farrar Straus

and Giroux; 1998.8. Latham PM. Collected Works. In Familar Quotations by John Bartlett, 14 ed, (ed Beck

E). Little Brown & C0. 1968.