Competing health care systems in an inner city area.

Preliminary findings of a research project1 at the University of Miami School of Medicine indicate that five local ethnic populations (Bahamian, Cuban, Haitian, Puerto Rican, and southern United States Black) are combining the use of orthodox and traditional systems in different ways and to different extents according to the individual ethnic group. This communication reviews hypotheses which attempt to explain this variable use of folk and orthodox health care systems in order to point up the need for intensive research into the underlying factors involved in making choices between or among therapies and healers in competitive situations. Several commonly accepted reasons have been put forth to explain preferential use of folk health care systems or the use of them in tandem with the orthodox health system. Frequently cited are language and transportation difficulties, the "social d i ~ t a n c e " ~ factor and lack of health cultural "fit" between specific beliefs and practices. In addition, these groups attribute certain symptoms and conditions to social/interpersonal conflict and supernatural activity; "everybody knows" that medical doctors generally are incapable of curing these illnesses. Although preliminary data suggest that the five Miami ethnic groups have unique patterns for utilizing orthodox and traditional health care systems, one characteristic cuts across the five individual patterns: the use of different therapies or healers serially or concurrently. Evident in our study are four types of competition within and among systems. In each of these, the remedies and/or healers are utilized one after another or at the same time: (1) competition among healers and therapies within the orthodox system; (2) competition among healers and therapies within a folk system; (3) competition between healers and therapies in two different folk systems; and (4) competition between healers and therapies in a folk system and in the orthodox system. Given the wide variety of healers and therapists in competition with each other in Miami, we cannot be content to note only the above mentioned factors of a practical or obvious nature which influence choice. Those factors which motivate an individual to accept or reject the orthodox health system, such as poor transportation or a poor health cultural "fit," provide us with only partial answers to the problem of selection. Elements which are specific to each group's health behavior add to, but do not complete the picture. We must search for deeper, more compelling motives which underlie the selection of a particular therapy or healer. Schwartz, describing her health research in the Admiralty Islands, recapitulates earlier statements that in the process of cultural change, "universals are replaced by others but there is a period in which the new is added to the old in competitive alternativity until a new universal emerges" (1969:205). She also described Erasmus' notion that "where medical treatment is quickly effective, dramatic and evident, it will prevail over others" (1969:208). Acknowledging the validity of these but suggesting that they are not the complete answer, she proposes another explanation for the underlying motivation toward a particular therapy or healer. Schwartz hypothesizes that alternative modes of curing are arranged in hierarchies of resort, with different alternatives being used as the illness progresses without cure, and according to the particular phase in the individual's or group's acculturative process (Schwartz 1969: 205). An additional theoretical explanation for the motivational factors underlying the choice of alternatives in life crisis situations (such as illness) is suggested by BryceLaporte (1970). Two of his hypotheses relating to plural societies which manifest asymmetrical relations are relevant to the Miami context: (1) the subordinate minority will tend to observe the norms of the official superordinate culture as well as the subordinate culture; and (2) their choice of alternatives will relate to the degree of assimilation or perceived appropriateness of the institution, e.g., health institution. The Miami study data indicate that the five local ethnic populations are bicultural in their choice and utilization of therapies/therapists, as Bryce-Laporte suggests will be the case when subordinate groups are only partially assimilated within a dominant culture. Simmons (1 9 5 9 , speaking of Mestizo communities in Peru and Chile, proposes an additional explanation of health-seeking patterns. He notes that "modem cures have supplemented rather than replaced their popular (i.e., folk) counterparts . . . . " and suggests that the reason is to be found in beliefs concerning etiology