Traditional versus Modern Health Care Use
Traditional versus Modern Therapies
Understanding when and why people choose the health treatment they do is critical in understanding the nature of and driver to change in beliefs, customs and practices. With the recent advent of better access to modern healthcare, how is this influencing people’s choices in use of traditional healing/healers and modern medicine?
Using Traditional Healing
Participants were asked: “When do you go to a yachak or a traditional healer?” A range of responses were given in reply to this, from never going and not trusting traditional healers to having an implicit faith in them, and a mix of the two on a kind of ‘sliding scale’ :
“I’ve never been to a shaman; if I feel bad I go to the doctor”
“I have never been to a curandero/a and I’ll never believe in them”
“Yes, I have gone hoping to get better from an illness, but they never cured me, and that's why I do not believe in shamans”
People go for the diagnosis of an illness, and also for the more perceived traditional Andean illnesses, like malaire or susto:
“[You go] when you don’t know the cause of an illness, to get a diagnosis, usually with a cuy"
“I go to the yachak to know my state of health, if I am healthy or with some illness”
“I went once when my daughter had malaire”
Yachaks are often consulted for divinatory purposes such as finding lost and stolen items:
“I went once to find out who had stolen my bicycle”
“I went once when I had lost my necklace of beads, only on this occasion. I don’t really have much faith in them”
Also out of mere curiosity:
“I went to a yachak out of curiosity and I go to the doctor when I’m ill”
People also go to them for what we might perceive to be emotional and psychosocial problems:
“I went when [my husband] left me to [go to] work and I thought I was going to be left alone with the children and he was with another woman, also other people told me that I should get a cleansing with a healer”
“I have been to a yachak to cleanse me with a cuy because I used to get uncontrollably drunk”
Or when the influence of negative forces was perceived being as a problem:
“When I feel with a negative energy, with an imbalance, [have] bad dreams, and certain strange objects appear in the house”
Overall nearly 37% of respondents from all communities consulted a traditional healer as a matter of course when they were ill, with 44% saying that they never went, although this varied by Greater Community with 45% from Greater Salasaka affirming they went as opposed to just 27.5% of people from Greater Zuleta. A common trajectory reported was consulting traditional healers at the perceived start of an illness when the symptoms weren’t very advanced, and then going to a modern doctor if the traditional healer hadn’t been able to effect a cure:
“[you go] First to a traditional healer, if they don’t cure you, then to a doctor;” this was also reported when people consulted a yachak if the doctor hadn’t been able to help them.
“I go to the curandero when I am ill and when the doctor can’t cure me”
A lady who was also a practicing yackak and partera (midwife) noted:
“When I have no appetite and when I get bad dreams I go to a yachak”
Mostly people reported the common reason of feeling ‘decaido/a’ (run down, unwell) as being why they went to a yachak or a curandero/a, to get a diagnosis and treatment with a herbal cleansing.
Going to the doctor or the modern health clinic
People were next asked: “When do you go to a doctor or a modern clinic?” As with 5.1, a range of responses was given from always going to a doctor, to a general distrust of them and preference for traditional healers or remedies:
“I almost always go to the doctor for whatever disease”
“ I go to the doctor when I have more serious illnesses or when I have bad pains; also you go to the doctor when you want to cure children [of illness]”
“I’ve never been to a doctor because I have always treated myself with medicinal plants. Once I went to a doctor when I had a headache and a hemorrhage, but they didn’t want to attend me and neither did they heal me even though in spite of having taken out pints of blood. I cured myself with medicinal plants”
“Doctors don’t help”
Nearly 40% of respondents from all communities always went to a modern doctor, with only 18% saying that they never went, but again this varied by Greater Community, with people from Salasaka less likely to go (33%) than people from Greater Zuleta (45%). The most common response was that people went to the doctor for some pain or perceived symptom of an illness:
“Generally when I suffer from some pain”
“When I am physically hurt or in pain; I also go to the doctor when my bones hurt”
“When I have some flu symptoms, when I'm weak and I feel dizzy, I go to the doctor”
Although people also said they sometimes went to get a check-up
People (all communities) will commonly go to a doctor when they think they know what the illness is, that it is ‘modern’ and therefore needs a doctor:
“… for cancer or gastritis”
“… for things like a fracture or appendicitis”
when the illness has advanced and/or when the yachak hasn’t been able to cure them of it:
“…When the illness is more advanced and the yachak can’t treat it”
“When the shaman can’t cure you” or when the problem is perceived as being purely physical and not ‘spiritual’.
The cost of health care
There is a perception that the cost of medicine, particularly modern health care, affects people’s decision whether to go to a doctor or to a traditional healer and therefore that traditional medicine is serving a remedial function of healthcare provision that is more affordable. Respondents were therefore asked: “Does the cost of treatment influence your decision to go to either a doctor/modern clinic or a traditional healer?”
Fifty five per cent of all respondents said that yes, the cost of treatment affected peoples’ decision:
“Yes, money always affects you, wherever you want to go”
“Above everything else is money; money always affects you”
“Money is always first, in whatever case”
However, although consultations with modern doctors will attract a fee and drugs issued on prescription will have to be paid for, in Ecuador, primary care is freely available at the Sub Centro de Salud, where medicine may also be dispensed for free, and certain hospital treatment may also be free of charge, so cost is not such a driver of choice as it once was:
“Money always comes first. Well, the issue of money is much more when you want to follow a treatment in a private clinic. So, when you do not have much money (or nothing) we go to the hospital, where most things are free”
“The issue of money depends. When you want to go to the doctor of a private clinic you must first have enough money. But treatment at the hospital is free”
Perceptions of reliability
If cost is not functioning as a driver of choice, then perceptions of reliability are likely to be more influential. People were therefore asked: “Which do you believe is more reliable to treat illness?”
Overall more people seem to be placing their faith in modern medicine. Nearly 48% of all respondents thought that modern medicine was more reliable than traditional medicine, although this varied by Greater Community, with nearly 36% of people from Greater Salasaka trusting modern medicine to 60% of those from Greater Zuleta. The difference is largely accounted for by more people (24%) trusting traditional medicine in Salasaka. Over 25% from both communities trusted both equally.
“Above everything I trust the doctor, then the yachak”
“I believe in the doctor, not the yachak"
“I have more confidence in doctors”
“For me, the doctor is more reliable”
This was particularly the case for the sub-set of Salasaka ex patriot Galápagos respondents.
A smaller number of participants, mainly from Salasaka and Zuleta, continued to trust traditional medicine and healers more than modern doctors:
“The yachak is more trustworthy”
“Because I am a practitioner of ancestral medicine I believe more in the apus (mountain spirits) because they have given me the wisdom and the medicinal plants”
The general trustworthiness of yachaks appeared to be a growing problem, with the point being made that although in the past they served their communities selflessly, now many of them had become materialistic and were seen to be in the profession for profit (all communities).
Other respondents (all communities) thought that you could trust both yachak and doctor, depending upon the illness (although this mainly answered the following question 5.5):
“For me both are reliable, depending on the disease; both have the same degree of ability to heal based on their own knowledge”
“According to the disease or severity, both the doctor and the healer are effective in the treatment of a disease”
“I have faith in both of them, the doctor and the yachak”
“Depending upon the illness, I have believed that those who clean with cuys as well as the doctor are both reliable”
A handful of respondents who had never experienced illness serious enough to consult either yachak or doctor determined that illness itself was probably a modern thing and therefore you would need to consult a modern doctor to be treated for it.
Relative effectiveness
Many respondents had interpreted 5.4 similarly to 5.5, stating that they believed that it was the nature of the illness that determined who of the two were more reliable. The final question asked this more formally: “Are doctors/clinics more efficacious for some illnesses and traditional healers for others?” There was a clear agreement that traditional healers were effective for traditional maladies (some of which broadly conform to modern medicine’s understanding of the spectrum of emotional and psychosocial ‘affective’ disorders), and doctors to illnesses that are perceived as being ‘modern’ (cancer, gastritis, prostate problems, etc), or for serious physical trauma (e.g., fractures), representing 57% of total respondents; 17% of people disagreed with this statement and 22% gave no satisfactory response.
“Both have the capacity to heal you or to treat illnesses well, obviously according to the type or class of illness”
“Yes, I believe in this. In reality, the doctors do not know to deep the evil that overwhelms the life of a person, for example, malaire and susto can only be treated by the Yachak”
“The mal de ojo (evil eye) or malaire can only be treated by the yachak, but more difficult cases, for example, a prostate infection can only be done by a doctor”
“Doctors cannot cure or treat cases of sorcery or witchcraft, these cases only yachak can treat. Doctors are experts in surgery issues”
“A modern doctor cannot detect or treat witchcraft for example, and you can die, so you need to go to a curandero” .
“The yachak cannot cure to the level of a doctor. Maybe a yachak can cure diseases like malaire and susto, but nothing more”
“It depends on the person and their faith. I respect yachaks a lot because my grandfather was a healer. I also respect many of the doctors. Therefore, depending on the diseases, the two can have the same degree of confidence”
“Both doctor and yachak can heal the same kind of illness [although] I commented that there are currently no good yachaks. For example, in her time, my mother was one of the best healers, so we did not need to go to a medical center if we had any ailments. On the other hand, doctors scare people with large machines and injections”
Some realism was expressed about the amenability of all illnesses to successful treatment either by yachak or doctor, however:
“Yes I believe that the Yachak can cure and / or heal what the doctors can’t treat. And there are cases that neither can, neither the Yachak nor the doctor. For example, there are diseases that cannot be detected by doctors and that healers can’t see or advise you about either”
And:
“Doctors treat deafness and blindnesss; however, yachaks treat malaire and mal de ojo. I think that neither one nor the other can see or treat a major illness”
More traditionally and religiously devout respondents placed more faith in their understanding of ‘God’, who was the real source of healing for them:
“The only one who can cure all evils is the Jawamunda Jatun Taita [God of Heaven]”
And there were occasional respondents who had been converted completely to faith in modern medicine:
“Clinics are more efficacious because they carry out analysis of the body”
“I have heard that only the yachak can cure certain diseases, for which one must have a lot of faith. Despite this, I do not believe [in them], for me, everything is a doctor. The doctor can cure all diseases”
Across communities, many respondents simply dipped in and out of the dual system as it suited them:
“Sometimes [you go to] one, sometimes the other; you try both”
“First [you] try a traditional healer, then a doctor; it depends on the state of the soul’s health or type of illness”
Discussion
Responses demonstrate that people in general have a few basic set of experiences of and attitudes towards traditional medicine and modern medicine and the large majority of responses fall into a few basic set of categories. Many people are starting to see modern medicine as being more trustworthy than traditional medicine and perceptions that you can’t trust curanderos/yachaks are increasingly influencing choices to seek health care at the primary level from modern clinics and doctors. In other cases, people see traditional medicine – a curandero or yachak – as being the first port of call when they are feeling run down (decaido and unwell) and if traditional therapy doesn’t work, then they will go to the local Sub-Centro de Salud for further investigation.
People continue to choose traditional medicine for the classic core of traditional illnesses as experienced by sufferers: “malaire”, “espanto/susto”, “mal de ojo” etc. The yachak is also sought for the classic divinatory purposes, to find objects which are missing, or to ensure good luck in love. There is fluidity between traditional and modern medicine too and a certain ease with using both sets of services: if people first go to a yachak or a doctor for diagnosis or treatment and that is perceived not to work, they will then go to the other, exercising choice. The commonest experience here is for people to use traditional medicine in the form of the local yachak or curandero at the start of a perceived illness, or for diagnosis, but to a modern clinic or doctor if the illness is experienced as being more advanced or severe. In this case the traditional ancestral option is serving some form of primary care function.
Modern clinics and doctors are also seen as being who you consult for what are perceived to be ‘modern illnesses’ like cancer; also in the case of trauma, like fractures, modern clinics are sought out.
Although the majority of people say that cost influences their choice in whether to go to the yachak or the doctor, it is the case in Ecuador that primary health care is free at the point of entry, and every town or community has access to a Sub- Centro de Salud where consultation and much of the treatment is free. Certain medicines may be provided free of charge, vaccination programmes etc, although if prescriptions are given then the patient will have to pay for these. A visit to a doctor will cost for consultation, although for several people this is not seen as being a problem if the doctor is seen as being more trustworthy. Trust is an important issue here, as it seems to be the case that traditional healers are not seen to be in service to their communities in the way they once used to be. Until recently, to be a yachak (shaman) was seen to be a ‘calling’ (by the ancestral spirits) and traditional healers would not be demanding high fees for their work, in the way that many now do. They have lost the confidence of the communities they once served it seems.
Many people exhibit outright distrust of traditional medicine now and say they never go to a curandero or yachak and do not trust them; fewer people with more traditional belief sets say the same about modern medicine. But overall the survey shows a clear drift in the direction of choosing modern medicine and the continuity of use of ancestral medicine as a cultural choice that many people still use, although generally trusting the doctor and modern therapy more.
Conclusion
Essentially two sets of health beliefs and practices exist in parallel with each other in the Andean regions of Ecuador. Operating at the primary care level and responding to continued beliefs in traditional illnesses (malaire, susto, mal de ojo etc), the curandero or yachak offers traditional diagnoses and healing to community folk in the age-old way.
European concepts of disease and treatments, that eventually evolved into what we understand to constitute ‘modern medicine’ first arrived with the conquest by Spain, and for a long time remained the purview of the conquering and then the Creole elites, remaining this way down through centuries until, with the rapid advances of modern medicine and, importantly, with, for example, WHO/PAHO campaigns to improve global health, social equity programmes began to extend affordable health care to socially disadvantaged people, including to indigenous Andeans who had, until recently, remained largely excluded. This, together with education and modernisation that included access to TV, has served to raise peoples’ consciousness of what constitutes disease, different medical conditions, medical technology and available treatments. For many older indigenous people, modern clinics and hospitals are still intimidating alien places, where the universal use of ‘white’ simply means ‘death’. But increasingly the younger generations see a visit to the local Sub-Centro de Salud as being the first or second port of call when you’re feeling off colour and need to get treatment.
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