Project Findings

Original Study Objectives

Following from “Building the Bridge. A Discussion of the Evidence”, this section represents the final part of the EC-funded project “MEDICINE. Indigenous concepts of health and healing in Andean populations. The relevance of traditional MEDICINE in a changing world”. It meets the overall project goal, as defined by Research Objective 6 of the proposal to the European Commission Horizon 2020 funders:
“RO6: ‘Bridge’ to contemporary global ethnic scenarios and policy making ‘tool’. Drawing upon the stages developed in ROs 3 and 4, a conceptual ‘bridge’ will be developed from the study population to generate a trans-cultural model for use with contemporary peoples from migrant or marginalised backgrounds that informs best practice for the integration of their traditional beliefs into modern health and social care provision.”

This has since been modified into being a ‘practitioner’s tool’, but one with clear with policy relevance and guidance for policy making. Lessons learned from the study of a population with an historical experience of destructive impacts to collective cultural identity via persecution, socio-cultural trauma and population displacement would aim to draw out key dynamics related to their survival and adaptive processes into contemporary global population displacement scenarios via the aforementioned ‘bridging process’. This process built upon 1) Project Phase 1 – the study of archaeological, ethnohistorical, ethnographic and bibliographic sources to draw out key ancestral (pre-European) Indigenous Andean beliefs related to health, illness and healing and 2) Project Phase 2 – the development of a survey instrument to take into three contemporary Indigenous Andean (Ecuadorian) communities to test the validity of the concepts previously identified, to review evidence for the survival of key cultural patterns and ancestral beliefs and practices related to Indigenous pre-European Andean epistemologies and ontologies.

The earlier chapters in the report presented the evidence in this sequence, building a clear narrative serving this overarching goal, concluding with “Building the Bridge. A Discussion of the Evidence” wherein it is stated:
“The preceding section has interwoven the historical narrative of the study populations within their broader regional and historical contexts, with the way that Andean Indigenous mythos offers a more nuanced insight into the lived experience, as it impacts psychologically upon people. The relevance to human experience more generally, beyond any constraints of time, culture or space are clear. This forms the bridge of common human experience that links us to the final section of the study, where the aim is to connect with modern displaced peoples – refugees, asylum seekers and migrants – and to see what the lessons in common tell us, and the way from this we might be able to construct a practitioner’s and policy ‘tool’”.

The process of developing the ‘bridge’ between the two apparently widely different populations has sought to identify the common denominators and core processes involved, where they are comparable and where divergent, as demonstrated graphically in the figures below.

It is noted in MEP-TP that many traditional societies have a series of commonly accepted elements that persist and form an essential part of the culture, which have been situated here into what I am calling ‘Framework 1’ and have set these to be considered in terms of the personal, family, originating community (Community 1) and recipient community (Community 2) dimensions and which will all influence the ways in which people are affected and will therefore demand appropriate consideration under these categories by health care professionals.

Framework 1 (see Section 3. Ch. 6. Full Report: From Bridge to Policy and Practice Guidance) synthesises key points identified by the ASPHG that need to be addressed by practitioners, which I have developed further with Framework 2 (see below), which includes additional ethnic/culturally specific dimensions which need to be addressed in a similar way, across the dimensions of individual, collective, community of origin and recipient community. Both work well as ‘guidance frameworks’ to assist practitioners in the way they classify refugees at initial stages of presentation, within the interactive dimensions relevant to individual, family and community contexts. As with the ‘Trauma Grid’ (Papadopoulos 2007), information is tabulated within these dimensions that allows a more comprehensive and sensitive assessment of the presenting individual/s and their circumstances and needs.

Lessons Transferable from the Study Populations

Key factors which have emerged earlier as present or absent in the two contrasting study populations of Salasaka and Zuleta in their respective ability to engage successfully (or not) with the impact of the alien colonisation of their land were:

• Resilience;
• Agency;
• Opportunity (with circumstances);
• Creative engagement with adversity;
• Assistance.

And two polarised survival scenarios emerged from this:

  1. Assimilation
  2. Enclave formation

In the absence of any mediating circumstances to promote either of the above, where agency and choice is reduced to a minimum, there might be a reduction to ‘basic survival’ outside of any sustaining social context promoting identity and hope in a constructive future, as with ‘mere continued existence’, itself a worst case scenario and one clearly to be avoided.

However, assimilation carries with it the clear risk of loss of ethnic/cultural identity/distinctiveness, (i.e. not a ‘meaningful’ survival of the people concerned), whilst enclave formation (one in general discouraged by refugee resettlement policies of receiving countries) promotes ‘meaningful survival’ and the continuation of ethnic and cultural distinctiveness detached from the society and culture of the recipient country, exhibiting introspective isolationist tendencies, as exemplified in the Salasaka’s ‘cultural denial’, something also ‘not ideal’ as far as the dominant culture of the recipient country is concerned.

A synthesis of these two polarised and mutually exclusive survival scenarios therefore needs to be sought in order to achieve a ‘meaningful reconciliation’ of survival outcomes, promoting both ethnic/cultural integrity with a realistic integration of the refugee group within the society of the dominant culture of the recipient country. It should be remembered that the meeting of people from different ethnic/ cultural groups can be a very positive experience and exposure to different ways, beliefs and customs brings with it opportunity for the cultural enrichment of both sides. How this itself might be achieved is the task of policy makers to determine, in dialogue with both their own society and culture, and that of the incoming refugees being resettled.

Additional points to bear in mind

Additional factors to emerge in the development of realistic guidance frameworks include the importance of developing an awareness, based upon prior training, of ‘critical attention to cultural detail’ (both Frameworks 1 and 2 perhaps) that may not be initially clear at the earliest stages of reception of the individual or family into the receiving country. Examples include:
1. Behavioural characteristics. The importance of making accurate and informed assessments of critical behavioural characteristics to identify correctly conditions which might indicate a pathological psychiatric condition such as Dissociative Identity Disorder (DID) or Possession Trance Disorder (PTD) from non-pathological culturally mediated spiritual experiences of people from traditional belief systems, bearing in mind that “spirit possession is a common idiom of distress in the majority of societies in the world” (Hecker et al. 2015).
2. Unusual cultural practices. These might have a fundamental significance to the individual/family. A good example of this is the placing of a red cord upon the wrist of a new born infant to guard against the ‘evil eye’, widely practiced in Andean societies. Accounts were given that upon arrival at clinical or hospital facilities, the red cord is often cut off automatically being deemed as being unhygienic, thereby exposing the child to dangerous influences in the understanding of the family.
3. Active engagement with narratives. As highlighted earlier, to engage actively with storytelling/narrative in displaced societies in a way that incorporates the dynamic into the fabric of welfare services provided to refugees, both early in their presentation as well as later, following placement and integration in the recipient country.

The provision of ‘intercultural mediation’ to allow a meaningful dialogue between receiving health and social care professionals and the presenting refugee/asylum seeker is already commonplace in the provisions for the reception of refugees. It is clear, however, that the consistency of standards and standards of competency are very variable and probably better knowledge and awareness training would improve the quality of the service .

Training modules in Diversity and Sensitivity to Diversity developed by the ASPHG and the approaches devised by Renos Papadopoulos, also address these to some extent.

Policy Guidance

Predictably, the policy research and guidance literature dealing with refugee integration from major organisations such as the UNHCR, UNDESA, the OECD and the EC is very considerable and it has not been possible to include it here. Recommendations which follow are therefore drawn solely from the study findings, and do not include such additional material.

Briefly stated:

• policy makers must decide how best to manage the contradictory survival strategies highlighted earlier in a way that promotes ‘meaningful survival’ via balanced socio-cultural integration strategies, and not impose practices and pressures that are essentially assimilative, which is to say, erode and ultimately eradicate individual ethnicities and cultural distinctiveness.

• policies should promote plurality through preservation of ethnic diversity. There is a real danger that, in the professed commitment towards equality of opportunity and integration within the receiving countries’ socio-cultural structures and employment markets, pressures will be put upon refugees and asylum seekers to demonstrate their willingness to prioritise those of the receiving countries’ culture to the diminution of their own.

• A balance should to be sought that both respects diversity and ethnic/cultural distinctiveness, yet allows for a wholesome integration of the refugee/asylum seekers within that of the receiving country. Whilst not desirable that incoming displaced people being resettled form large blocks which exercise a form of ‘cultural denial’, a balanced approach between these two polarised scenarios should be sought via full engagement and dialogue with the relevant organisations representing people seeking asylum.


ASPHG. Ainhoa Ruiz Azarola and Olga Leralta, Andalusian School of Public Health, 2015. Module 1: Sensitivity and Awareness of Cultural and Other Forms of Diversity. Unit 1: Diversity and Unit 2. Intercultural Competence and Sensitivity of Diversity Guidelines (M1-U1 and M1-U2)).

Hecker, T. L. Braitmayer and M. van Duijl. 2015. “Global mental health and trauma exposure: the current evidence for the relationship between traumatic experiences and spirit possession”, European Journal of Psychotraumatology, 6:1, 29126, DOI:10.3402/ejpt.v6.29126 To link to this article:

Papadopoulos, R. K. 2007. “Refugees, Trauma and Adversity Activated Development." European Journal of Psychotherapy and Counselling, September 2007; 9(3): 301–312

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