Cultural Interpretation of Somatic Symptoms: The Mexican American Explanatory Model of Type II Diabetes

BY DEBBIE DADA

INTRODUCTION

Type II diabetes is a leading health concern that is often viewed as a “disease of modernization” because of its prevalence in developed countries, most notably, the United States of America.¹ This illness is particularly prevalent among Mexican immigrants living in America: over one in every ten Mexican-Americans is diagnosed with type II diabetes. As of June 10, 2014, 13.9% of Mexican-Americans were diagnosed with type II diabetes, a rate 1.5 times higher than the national average.² Chronic diabetes can have debilitating effects on one’s life, and puts individuals at a greater risk for many other illnesses.² Given the scope of the disease, it is important to understand how the experience of diabetes differs between ethnic groups and how group experiences of diabetes are mediated through social and cultural forces. This article will aim to address the research question: how do the beliefs and cultural markers of Mexican immigrants in America inform their explanatory model of Type II Diabetes? 

This article employs secondary resources to investigate the Mexican American cultural interpretation of the experience of diabetes.  This study aims to determine the different systems of knowledge and cultural traits relevant to the production of their explanatory model through an idealist approach. This model is then compared with the mainstream North American model for the etiology of diabetes through discussions of syncretism, which is the amalgamation of distinct aspects of different cultures to make something new. This is done in order to evaluate the effects that their cultural beliefs have on their view of the disease. This analysis will use social-cultural anthropology and medical anthropology lenses, the latter subfield being: “the cross-cultural, pan-historical study of health and sickness.” ⁵

The emic mental domain as theorized by Marvin Harris, is an approach to anthropological inquiry where the observer attempts to “get inside the heads” of the population and learn the rules and categories of a culture.³ This is most effective in understanding the cultural values of Mexican-Americans so it will be employed. The idealist theoretical perspective is most appropriate in the exploration of interpretivism within the Mexican-American culture, and is defined as: “focusing primarily on the activities and categories of the human mind (for example, beliefs, symbols and rationality), and seek explanations for the human condition in terms of them.” ⁴

PREMISES AND LIMITATIONS

Since this study aims to study the views of Mexican-Americans, it is important to note that the beliefs and cultural markers discussed are largely particular to this specific subculture. Therefore, it would be erroneous to generalize the conclusions made in this investigation to all other Hispanic populations living in America. I also recognize that within the treated populations there will be differing beliefs between individuals and so although this serves to bring about a greater understanding of the Mexican-American culture as a whole it cannot be assumed that every individual in this subculture holds these beliefs. It is important to note that the studies analyzed were drawn from 1984-2008; because the studies consulted were conducted over the span of many years and focus on only certain aspects of the explanatory model. This provides a limitation, as it is difficult to provide an analysis of the change in the attitudes and beliefs of the Mexican-American population through a diachronic perspective.

It is key in the treatment of Mexican-Americans to recognize that Mexico itself is a large country, filled with diverse histories and beliefs. This is especially important considering the syncretism of indigenous and European (as a result of colonialism) belief systems surrounding illness and health. This is very relevant in analyzing the interplay of the different religious healing rituals associated with each ancestry.

Finally, as the pieces of ethnographic material used include a lot more quantitative data than qualitative data (from methods like participant or non-participant observation), the extent to which the observer can affect the results is rather limited. It is important to recognize that in the presentation of the ethnographic material there may arise issues of accurate representation (due to selectivity bias, assumptions, etc.). I have tried to limit this as much as possible by drawing on a wide variety of sources from reputable journals.

BACKGROUND

Mexican-Americans constitute a subculture within the United States because they have distinct beliefs and practices. For this reason, it is beneficial to understand the mainstream American explanatory model of diabetes in order to properly compare the model produced by Mexican-Americans. Diabetes is a disease wherein the pancreas does not produce enough insulin or the body resists insulin causing blood glucose levels to rise higher than normal. This puts patients at greater risk of having a stroke, high blood pressure, central nervous system diseases and depression.² It is best managed through exercising regularly, eating healthy and avoiding stress. This model, purely biomedical, relies on a secular and scientific belief system accepted by mainstream America. 

COLLECTED EVIDENCE

KEY IDEAS

FOLK ILLNESSES 

Folk illnesses, also known as culture-bound syndromes, are defined as “illnesses created by personal, social and cultural reaction to malfunctioning biologic processes and are understood only within defined context of meaning and social relationships.” ⁶ These are relevant to their explanatory model of diabetes so it is important to have an understanding of what they are and the role they play in their culture. These exist in a variety of forms within many cultures and have been the subject of anthropological inquiry for decades. Susto is one the most commonly referenced within Latin America and Mexico and is believed to be a significant fright or an illness derived from such a fright.^{1, 6,7} During such an event, the spirit is believed to leave the body for a moment and this can cause other illnesses to form or bring forth certain symptoms directly, such as: “listlessness, lack of appetite, depression and withdrawal, diarrhea, nightmares, and headaches.” ⁶ 

Intense emotions like susto can be experienced over a longer period of time or in a specific event. Some of the other significant intense emotion believed to be associated with folk illnesses include stress or anxiety known as nervios, extreme anger known as corteja, as well as intense sadness known as tristeza.¹ Some other folk illnesses are mal de ojo, which is evil eye and empacho, which is a type of stomachache caused by eating low quality foods or eating at the wrong time of the day. Each folk illness has distinct consequences in the lives of those who experience them. It is important to note that these illnesses can exist only within the belief systems produced by the culture and for this reason are largely specific to certain cultural groups.

HOT AND COLD THEORY 

The hot and cold theory, although not often implicated in the Mexican-American explanatory model of diabetes, is key in gaining a holistic understanding how Mexican-Americans view and comprehend illness in general. This theory “classifies treatments, foods, bodily states, and illnesses as predominantly either hot or cold… The goal is to maintain a bodily equilibrium of hot and cold forces.” ⁸ The hot and cold discussed has no reference to actual temperature and is instead arrived at as a result of metaphysical features, for example tropical fruits are cold and wheat products are hot.⁶ An imbalance of the hot and cold forces is believed to cause sicknesses. Their belief in this theory speaks to their reliance on culturally significant symbols in understanding how to view the world, this relates directly to the interpretive approach to understanding culture as postulated by Clifford Geertz. This postulates that “culture is lived experience integrated into a coherent, public system of symbols that renders the world intelligible.” ⁵

The concepts of hot and cold can be viewed as symbols according to the definition used by Victor Turner as “a blaze or landmark, something that connects the unknown with the known”. ⁹ These symbols help people make sense of unknown illnesses by associating them with a culturally understood idea of hot and cold which can relate to other familiar and comprehendible bodily states or foods. In this way the Mexican-American culture creates meaning for these symbols.

EXPLANATORY MODEL

By evaluating the belief systems native to Mexican cultures and the effect of the acculturation of many mainstream American ideals, we are able to see that the Mexican American explanatory model of diabetes is specific to their culture and has been arrived at as a direct result of the interplay of the aforementioned two. This example of cultures in contact renders the Mexican-American explanatory model of diabetes unique to the Mexican-American life experience.

In this section, I will be detailing the explanatory model of type II diabetes as put forth by a combination of six different studies. First, I will provide ethnographic context for studies discussed, then form an explanatory model including etiology, experience and treatment. These studies in particular were chosen because of the wide range in ages, locales, and economic statuses represented. 

The first five studies took place with 3,722 first and second-generation Mexican-American immigrants who had diabetes, had a family history of diabetes or knew somebody with diabetes ranging from teenagers to seniors.  They made on average between $420 and $1600 each month and the majority had less than eight or over twelve years of schooling. These studies took place in Illinois, Texas, Washington, Ohio and Southwestern United States in 2008, 2004, 2003, 2000 and 1984.  The sixth study ¹⁰ was done in 2012 in Guadalajara, Mexico with 36 participants, the majority of whom were married elderly women with six years of schooling earning between 2000 and 4000 pesos monthly. It was chosen even though it was not done with Mexican immigrants because the beliefs of Mexicans still living in Mexico is very relevant to comparative discussion of syncretism between explanatory models of Mexican-American immigrants and mainstream America. 

ETIOLOGY & EXPERIENCE

Most participants were aware of the biomedical explanation for the onset of diabetes with some noting having taken classes after their diagnosis and others being taught by their physicians.^{6, 12} For this reason, we cannot simply conclude that their alternative explanations for the onset of diabetes are due to a lack of knowledge and are simply attempts to have some sort of a concrete idea about what is causing their symptoms. Instead, we can see that their explanatory model is directly dependent on the different cultural markers and beliefs specific to the Mexican American culture. A key similarity between explanatory model of the mainstream culture and that of the discussed subculture is the appreciation, at least to an extent, of the biomedical explanation of the onset of diabetes.

The majority of participants across all studies implicated susto in some way as a cause of diabetes in general, and often as a cause of their own diabetes. Their model incorporates susto because the prevailing belief system concerning health in Mexico is not secular, unlike the mainstream American health system, but rather is a combination of Catholicism and types of divination. This is exemplified by the fact that most participants in the study in Mexico itself noted experiencing susto or nervios at some point in their personal lives as well as the fact that the hot and cold theory is an established element of the Mexican as well as Mexican-American health experience.^{6, 10} Susto is seen as such a culturally significant concept because of its ability to make sense of experiences and symptoms experienced both in the natural and the supernatural, seeing as susto along with other folk illnesses often implicate forces like witchcraft in their origin.¹⁴ Furthermore, it is important to note that the Mexicans saw susto as a folk illness in and of itself, outside of its function in bringing on diabetes. This contrasts with the beliefs in some of the studies with Mexican American participants, where the meaning of susto simply is the frightful event or set of conditions that bring about chronic stress that cause diabetes.⁶ The presence of the symptoms of susto (other than the onset of diabetes) varied greatly between studies. This unique understanding of susto shows some level of conformity to the mainstream model as this strips susto of much of its connotations dealing with the supernatural. This functions to make their explanatory model more compatible with that of the physicians that they might encounter.

Across three studies, participants keenly described their experience that caused diabetes as a very traumatic event; for example, a woman a woman explained, “my rage (cortaje) is like a mark, one that stays with you.” ^{1, 11, 12} Another, described their susto experience twice almost identically nearly a year apart, showing just how traumatizing it was in their life. ⁶ It is also interesting to note that one of the key differences between believing susto causes diabetes and that it is caused by biomedical reasons is that it reduces the agency of the individual.  There is nothing one can do to prevent susto, which leaves people powerless, whereas the biomedical model asserts that the agency of the individual (in controlling their diet, exercise habits, etc.) results in the meaningful, though negative, change of his/her life.  One of the Mexican-American participants explained her “vulnerability to diabetes in terms of her distressing life experiences associated with migration: she was alone, economically dependent and in need of social support.” ¹ That being said, when asked to rank the most significant causes of diabetes in most studies the biomedical and traditional origins were generally viewed as parallel.¹² Of the studies that explicitly asked participants to rank causes, susto or a larger context of intense emotions (as will be discussed later) was ranked first once, second to diet once and last once.^{6, 11, 13} The other most frequently high ranked causes were heredity, weight and a lack of self-care. This is direct evidence of the syncretism of the prevailing American belief system in regards to health, biomedical, and the prevailing Mexican system, traditional. 

This leads us to the varying presentation of susto or coraje in different people’s diabetes narratives as one specific frightening or marking event or a set of circumstances in which these emotional states are prevalent. An example of the latter can be seen with a man named Jorge who attributed his diabetes to his unfortunate living situation and lack of economic stability.  He believes: if it is difficult for you to “to pay rent, electricity and water. Food. If one doesn’t have any food to eat that’s bad. You are left traumatized. That is one powerful reason that causes you to have diabetes.” ¹ Many also believed that further experiences of susto or coraje after being diagnosed could exacerbate diabetes symptoms. A participant in reference to experiences with her son-in-law explained “he makes me so mad. That’s when my sugar was up a lot. When I get mad, it’s dangerous.” ¹² Furthermore, women were more likely to report acute stressors within the domestic world whereas men were more likely to report stressors “outside of the home.” ¹This is relevant to the discussion of the organization of space and place with regards to gender relations within the Mexican American culture where women are to have more power within the private sphere and males are to have more in the public. This makes women more vulnerable to stressors within the family and private sphere than men are. ¹⁰

It is reasonable to conclude that in their lives diabetes through susto or other intense emotional states can serve as a way to express “social suffering and emotional distress.” ¹ In this way, diabetes can be viewed as an idiom of distress, which can be defined as “somatic language for expressing distressing experiences in a culturally meaningful way.” ¹⁴ This means that they use their explanatory model of diabetes as a means by which to communicate personal circumstances that are only appropriate to be discussed in the private sphere, in the public sphere. In this way, they are able to communicate distress without transgressing social norms. In the Mexican-American culture this includes a stigma around mental health issues as well as the open discussion of realities like abuse.¹⁴ Therefore if someone is to experience one of these they use their explanation of the etiology of their diabetes as a justification for discussing taboo topics in the public sphere. This is also consistent with the finding that participants who thought that they had experienced susto at some point in their lives “had more symptoms and were physically sicker than” others who had not. ⁶ This can also be seen as specific to the Mexican-American experience of immigrating from Mexico to America because of all the uncertainty and stress (nervios) associated with acculturation, the formation of “transcultural identities and migration.”¹¹

Diabetes specifically is well suited to be an adequate idiom of distress within their culture because of its prevalence within the Mexican-American community as well as the fact that traumatic experiences (in which susto, corteja or other intense emotions originate) pervade their day-today lives just like the chronic illness does.

TREATMENT 

Within the three studies that spoke to the Mexican-American response to diabetes, all revealed an integration of the biomedical and traditional system.^{6, 11, 13} This meant that participants used the medicine and advice prescribed by their doctors (similar to mainstream America) in conjunction with home remedies or consulting healers known as curanderos. These healers are respected members of the Mexican-American community that have ritualistic cures for “illnesses known for generations” and so they often provide a deeply personal alternative to the often impersonal experiences participants have with physicians. The only group asked to rank the effectiveness of the different treatments put diet, regulation, natural remedies and pills as the most important, in that order.¹¹

In interviews, many described their reliance on curanderos for treating certain illnesses like susto, minor pains and mal de ojo while using physician alone for major pains.¹³ Participants were more likely to rely on home remedies and curanderos if they “recently immigrated, visited the physician often, or lacked health insurance.” ¹¹ The curanderos treatment of diabetes was very ritualistic, usually involving a combination of herbal remedies and consisting of one of two therapies: “1) internal consumption teas prepared with indigenous herbs and prayers; and 2) ritual which often included stylized manipulation of raw eggs, palm leaves, and a variety of incantations.” ¹ Mexican-Americans are more likely than “African-Americans, Asian-Americans and non-Hispanic whites” to use home remedies to “augment the treatment of diabetes.” ¹¹

The participants did not only seek out curanderos and physicians in the event of a diagnosis of diabetes, but many also turned to Catholicism. One woman recounted in reference to Catholicism: “A prayer that you offer to God, in which 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, that will not help, because God does not need us to offer him anything.” ⁶ Here, the Catholic ritual of prayer is believed to be another viable form of treatment. This draws light on the fact that there are different religious belief systems present among Mexican-Americans and one must consider all when compiling a complete explanatory model. It must be noted as well that the evident Catholicism is likely a result of the European colonialist roots in Mexico and has stayed central to the Mexican-American belief system.

Regardless of whether they turned to Catholicism, home remedies or curanderos, many Mexican-Americans decided to exercise agency by taking the ongoing treatment of diabetes, at least partially, into their own hands. This can be seen as a result of the socially acceptable way of managing one’s healthcare in Mexico where “self-diagnosis and prescription without supervision are common practice.” ¹¹ In this way we see another effect of acculturation where they moved from being largely responsible for their own healthcare to following doctors’ orders while also keeping elements of their care within their control.

CONCLUSION

After evaluating the Mexican-American explanatory model of diabetes, it is clear that its many elements and intricacies occur as a result of the distinctive experience that Mexican-Americans have in life as determined by their culture. With discussion of the specific belief systems, gender relations, symbols and systems of knowledge accepted by the Mexican culture in contact with the American culture, we can see that they result in an interesting interchange that create the Mexican-American culture. This culture, informed by ideas of acculturation, syncretism, and conformity brings forth a unique interpretation of the somatic symptoms of diabetes that form the Mexican-American explanatory model. 

Debbie Dada is a freshman in Pierson college. Debbie hails from Toronto and hopes to major in Global Affairs with pre-med requirements. She can be contacted at debbie.dada@yale.edu.

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