DOCTORS, CURANDEROS, AND BRUJAS: HEALTH CARE DELIVERY AND MEXICAN IMMIGRANTS IN SAN DIEGO

To what extent does the complex set of beliefs and practices relating to diseases, cures, health maintenance, and health care practitioners found in traditional Mexican culture influence the behavior of Mexicans seeking health care in the United States? In this paper I examine data gathered on Mexican immigrants in San Diego County, California, that support the growing consensus that socioeconomic factors affect this population's behavioral patterns regarding health care services much more than do cultural beliefs. Many of the members of this population find that access to conventional U.S. health services is limited by their socioeconomic condition and, for some, an undocumented immigration status. However, the evidence suggests that many Mexican immigrants believe in folk illnesses, perceive U.S. health care practitioners as lacking an understanding of folk illnesses, and feel that this lack of understanding does affect practitioner behavior when they seek health care. In short, the overwhelming significance of socioeconomic factors should not blind us to the importance of cultural beliefs and perceptions about health care, although the latter prob-ably diminish in importance the longer that Mexicans and their descendants reside in the United States. Recent research on Mexican immigrants stresses this researchers argue that many factors, working or in inhibit the utilization of health care services by Mexican Americans. Among these researchers cite the high cost of health care in rela-tion to the low income levels of Mexican Americans; the undocumented immigration status of a significant segment of the population; the relatively low levels of medical insurance

of economic and social factors as reasons for underutilization of health services by Mexican Americans, these researchers also emphasize the importance of beliefs about folk illness and folk curers for the understanding of behavior related to the seeking of health care for at least a portion of the overall Mexican American population.

Martinez and Martin (1966) interviewed 75 Mexican American women (24 born in Mexico) in Dallas, Texas.
They concluded that belief in folk illnesses was widespread among urban Mexican Americans. However, belief in folk illnesses and curative practices did not preclude the consultation of physicians and the use of medical services for health problems not defined by folk concepts. Martinez and Martin (1966:164) argue that "many Mexican Americans participate in two insular systems of health beliefs and health care." Mexican American rarely seek care for folk illnesses from conventional health practitioners; when they do, according to information recorded by Martinez and Martin, they perceive the treatment received as too slow and ineffective.
Nail and Speilberg's (1967) research among 53 Mexican American (14 born in Mexico) tuberculosis patients in Hidalgo County, Texas, also revealed that cultural beliefs about folk illnesses and practices did not inhibit the acceptance of modern medical treatment for tuberculosis. Twelve of the patients had sought care from a folk curer (curandero), and 19 had sought folk cures from a relative or friend in addition to seeking care from a physician. Nail and Speilberg's findings are significant but refer specifically to treatment for tuberculosis, an illness defined in the domain of modern, conventional health care. Thus they do not contradict the study of Martinez and Martin, particularly with regard to the finding that Mexican Americans may not seek care for folk illnesses from conventional health care practitioners or that they often perceive conventional care as ineffective for treating such maladies.
Moustafa and Weiss (1968) also found that although Mexican Americans often use home remedies before consulting a doctor, they often seek care from physicians afterward. Other researchers (notably Teller 1978; Farge 1977; Weaver 1973) also argue that belief in folk curers has little effect on the utilization of conventional care. Teller (1978:274) found that in the Texas borderlands area the use of folk healers was not prevalent and that when used they served to complement conventional medical care. Teller stresses the poverty of the Mexican-origin population in the area, racism, and the structure of the health care delivery system as the important factors affecting patterns of utilizing health care services.
More recently, Gilbert (1980) found that information about folk illnesses varies according to socioeconomic class among the Mexican American men and women who had recently become first-time parents, who she studied in Santa Barbara, California. The 14 middle-class couples3 were much less knowledgeable about the specific folk illnesses mollera caida (fallen fontanelle), empacho, susto, and mal de ojo than were the 31 working-class parents. However, even the working-class parents lacked basic information on two of the four diseases. As Gilbert (1980:6) notes, "this is not indicative of tenacious adherence to folk medical beliefs among these new parents." Gilbert presents an interesting finding concerning where the parents she interviewed would seek care if their children demonstrated the symptoms of a folk illness. None of the middle-class parents, only one of whom was born in Mexico, would seek out a traditional folk healer (curandero or senora-a woman who knows remedies). Among the working-class parents, 17 of whom were born in Mexico, 8%, 9%, and 5% mentioned a folk healer as an appropriate resource for treating mollera caida, susto, and mal de ojo, respectively. In addition to variation along class lines, the respondents in Gilbert's sample vary by country of birth, with immigrants reflecting more of a willingness to seek care from a traditional folk healer. Gilbert (1980:7) concludes that socioeconomic factors are strongly related to the underutilization of available health services by the working-class group, but that their "more extensive recognition of folk medical concepts. . . and their preference for treatment within the [extended] family may indicate some reluctance to seek help from doctors and clinics for these diseases." Data on behavior patterns of Mexican immigrants when seeking health care in San Diego County suggest that the cost of health care, the lack of medical insurance, and undocumented immigration status create significant barriers to the delivery of health care to the Mexican-origin population (Cornelius, Chavez, and lones 1983). For most Mexicans in San Diego, belief in folk illnesses or preferences for folk curers did not surface as major reasons for not seeking health care from U.S.-based health practitioners. However, the evidence also tends to support the position that belief in folk illnesses and belief in a lack of understanding of such problems by U.S. health practitioners influences behavior patterns related to health service use, particularly the use of Mexican-based health practitioners and the possible use of a curandero under some circumstances. A small but significant segment of the Mexican immigrant population held such attitudes; however, though such beliefs did appear as responses to health-related questions and cannot be overlooked entirely, survey evidence suggests that Mexicans in San Diego County do not consider folk illnesses to be major health problems.

Mexican Immigrants in San Diego
Between March 1981 and February 1982 the Center for U.S.-Mexican Studies at the University of California, San Diego conducted a survey of 2103 individuals born in Mexico but at the time living or working in San Diego County (Cornelius, Chavez, and Jones 1983). Great care had to be taken to ensure the confidentiality of the respondents, many of whom were undocumented immigrants. Researchers established initial interview contacts throughout the county. Subsequent interviews were identified through a network sampling or "snowball" sampling technique, which relies on the individual's network of social relations (Cornelius 1981). The interview schedule consisted of a series of closed questions followed by several open-ended queries that allowed for the gathering of extensive qualitative information despite the survey format.
The sample population consisted of 51.1% males and 48.9% females. About half (49.4%) of the informants did not have proper documentation from the Immigration and Naturalization Service. The age of the informants varied by immigration status. Those without documents tended to be young; 61.4% of them were under 30 years of age, compared to only 24.7% of the legal immigrants.
Mexican immigrants play a major role in the agricultural, service, and light industry sectors of the local economy. Most undocumented workers in the sample (59.2%) earned a gross income of $7500 or less, while only 34.8% of the legal workers lived at that income level. Women generally earned less than men. The median income of the female interviewees was $6500 per year, while for men it was $7800.

Health Care Utilization Patterns
The majority of the Mexican immigrants in the San Diego sample have utilized local health care services on one or more occasions. When questioned about the most recent occasion when they needed medical attention (Table 1), over three-quarters of the interviewees responded that they had sought care from a health care provider located in San Diego County. Most (10.5%) of the remainder did not seek medical attention anywhere or sought care on the Mexican side of the border. The percentage of respondents who had never sought medical care was much higher among the undocumented (17.7%) than among legal residents (4.7%).
During their most recent illness, the immigrants in our sample sought health care from hospitals and clinics more often than from any other source, as Table 2 shows. Sixty percent of the respondents who sought any medical attention at all chose hospital or clinic-based care. However, well over one-third of the respondents sought care from private physicians.
Only seven persons admitted to having sought care from a curandero (practitioner of traditional Mexican "folk medicine") for their last health problem. In other categories of health care the study revealed a prevalent use of pharmacies, particularly in Mexico, where drugs that require a prescription in the United States are sold over the counter (cf., Logan, in press). The category "other" in Table 2 also includes dentists, an optometrist, a chiropractor, and a local woman (inveccionista) who administers injections of drugs purchased from a pharmacy in Mexico.
A sizable group of immigrants in the San Diego sample appear to fall outside the county's local health care delivery system. Nearly one out of five immigrants in the sample (19.8%) had not sought health care in the United States on any occasion. Some of these individuals have not sought medical care anywhere, and others prefer Mexican-based care.  A number of related reasons surfaced as to why certain individuals had not sought health care in the United States. Many of these migrants said that they were young and healthy and therefore had no occasion to seek medical attention. This explanation corresponds with the concept of migration as a process that selects the young and hardy in a given population. However, responses to specific questions concerning the use of health care facilities indicate certain obstacles, both real and perceived, which help explain under-or nonutilization of health services by the Mexican immigrant population.
The high cost of health care is one such obstacle. Over half (52.5%) of the individuals interviewed believed that they did not have enough funds to cover the cost of care from a hospital or clinic in the United States. The problem of the high cost of health care is compounded by the low levels of medical insurance coverage among both the documented and undocumented segments of this population (Table 3). Both legal and undocumented respondents displayed a pattern of medical insurance coverage distinctly below that of the general U.S. population in 1980, among whom 70% were insured under private health insurance plans (President's Commission 1983:95).
When questioned further, another 28.6% of the respondents expressed fear of seeking care from a U.S. hospital or clinic. These respondents cited most often their undocumented immigration status to explain their fear. Thirtynine percent feared that using medical facilities and filling out the required forms (e.g., an application for Medi-Cal) might lead to their deportation. Patients who do not return for important follow-up visits or do not follow a doctor's advice about seeing a specialist, even when an appointment has been made, often do so because of fear related to their immigration status. Sometimes these patients behave in this way because they do not understand the purpose of followup visits or appointments with specialists, both of which they often view as increasing the cost of health care.
A large percentage of the informants (21.3%) were afraid to use U.S.-based care because of their inability to speak English. Another, 7.8% of the interviewees also feared seek- The information on utilization patterns indicates that Mexican immigrants do not use folk curers or other nonconventional health care practitioners in proportionately large numbers. A major obstacle to health care for this population is the high cost of U.S.-based medical care combined with a low level of medical insurance coverage. In addition, undocumented immigrants feared to use health services because they believed such action would lead to their deportation. Other fears, both real and perceived, also inhibited the use of health services, including a small percentage of respondents who lacked faith in U.S. doctors and believed U.S. doctors did not understand their particular health problems. Other than this last subgroup of interviewees, responses to the survey questions did not reveal that belief in folk illnesses or belief in the relative superiority of folk healers created an obstacle to the utilization of health services by Mexican immigrants.

Seeking Care in Mexico
Rather than completely neglecting their health problems, many of the immigrants who have not sought care in the United States resort to health care providers in Mexico. The data suggest that Mexican immigrants commonly return to Mexico for health care. Almost one-third of the sample (30.8%) had done so on at least one occasion since their arrival in San Diego County. The most commonly used health care providers on the Mexican side are those located in the border city of Tijuana, although some immigrants go all the way back to their hometowns in Mexico to seek care. Eighty percent of those who seek care in Mexico do so on a regular basis, having sought care more than once. Over half (52.4%) of those seeking care in Mexico have done so many times and will continue this practice.
Questions on the last health-seeking trip to Mexico were designed to gather information on the type of health care provider from whom interviewees sought care. Most of these border crossers (75.8%) go to Mexico seeking the personal attention provided by a private doctor. Almost 1 out of 10 interviewees (9.7 %) who went to Mexico seeking health care sought out pharmacies. Traditional practitioners also serve this population of border crossers. Seventeen respondents sought a sobador and six sought a curandero, representing 2.9% and 1%, respectively, of those who sought care in Mexico.
As to why Mexican residents in the United States would seek care in Mexico, the pattern is clear (Table 4). Interviewees sought care from practitioners with whom they had a relationship; from these practitioners they would receive the kind of treatment and understanding of their health problems that they expected at a cost they could afford. The much lower cost of health care on the Mexican side of the border is a major factor in the decision concerning where to seek care. However, the alternative of seeking care in Mexico is one primarily open to legal residents who can move freely across the border. Interestingly, almost 15% of the informants who sought care in Mexico turned to Mexican practitioners because of previous bad experiences with the U.S. health care delivery system, or, perhaps related to those experiences, they did not trust U.S. doctors. These fears relate to a general feeling among interviewees that U.S. doctors and hospital/clinic staff do not sufficiently explain health problems and treatments. As an interviewee put it, "They [U.S. doctors] never explain what your health problems are." Lack of confidence in U.S. practitioners often stems from an experience that resulted in ill-feelings, cultural misunderstanding, or unmet expectations.
Two important points need to be emphasized concerning the data on interviewees who seek health care in Mexico.

The folk illnesses that have been mentioned in this paper do not have equivalent terms in English. They do have descriptive definitions that have been prominently discussed in the anthropological literature (Kay 1977; Kiev 1968; Rubel 1960; Madsen 1964; Clark 1959). These ailments have their own culturally defined causes, which can be found in both the natural and magical domains.
In response to the survey questions, respondents occasionally mentioned folk illnesses. Although interviewees may have sought care for folk illnesses in Mexico or locally from a "traditional" source (e.g., a curandero, relative, or neighbor), they did not exclude conventional care. However, their attempts to have folk illnesses cured by U.S. doctors often led to frustration and cultural misunderstanding. Consequently, some Mexican immigrants in the sample believed U.S. doctors and other health practitioners were unaware of their health problems, particularly the illnesses common in folk culture. The following field note by one of the interviewers in the San Diego research team exemplifies the problems of communication and mutual misunder-standings of behavior and motivations that develop around the seeking of care for folk illnesses:

While the interview was in progress, the respondent's wife became worried about their one-month-old baby's health. They showed me the top of the baby's head and said that the "mollera esta caida" [fallen fontanelle] and that is why the baby was sick.
They have been to a clinic to have the baby checked. This was a great source of distress and anger because they have been there several times and, according to the interviewee, "all they do at the clinic is take blood from the baby. They took out so much blood that the baby cannot get better." They were also told at the clinic not to breast-feed the baby for a while and give it a milk-free substitute. But the father [respondent] says that a mother's milk is best and does not understand why they told them to stop breast-feeding. He said, "they [the doctors] never explain what they do and I do not want to ask because I don't want them to think I do not trust them or have faith in them." He would like to take the baby to a private doctor, but "doctors don't believe in mollera caida." Instead, they are taking the baby to a relative who has previous experience with such health problems.

Different perceptions of health problems, combined with a lack of communication between patient and health care
providers who are often unaware of the Mexican patients' Table 5). However, the number of interviewees that had sought care from a curandero at some point in their lives is undoubtedly much greater than the number who "volunteer" such information. Significantly, a large group (23% of the sample) stated that they would be willing to seek care from a curandero if circumstances warranted it.

beliefs, sometimes lead interviewees to use nonconventional health practitioners (D. Mull and J. Mull 1981). As stated, seven interviewees in the sample admitted to having used a nonconventional health care practitioner-a curandero, or folk doctor-during their last illness. A somewhat larger group (27 individuals, or 1.3% of our sample) volunteered that they had used curanderos in the past (see
Most informants (79.4%) had heard of curanderos. However, their attitudes toward such health practitioners varied. When asked about the services curanderos provide, almost half (44.4%) of the interviewees replied in positive terms, reflecting that they perceived curanderos as healers and health practitioners. However, many informants (34.4%) viewed curanderos in negative terms. "I don't believe in curanderos" was a common reply. Another 20.6% of the informants did not know about the services curanderos provided, had never been to a curandero, or were unfamiliar with curanderos.
Among interviewees who were willing to seek care from a curandero, 14.9% stated that they would do so primarily for  Mull 1981). Another 17.6 % of these interviewees would seek care from a curandero for any pain or general health problem. For 6.2% of the respondents, curanderos served as the health providers of last resort, should conventional treatment fail. Many interviewees (14.8%) stated they would seek care from a curandero for problems they believe U.S. doctors have not heard of and therefore would not treat, such as "mal de ojo" (the negative influence exercised over an individual's well-being by being stared upon by a particularly strong personality; infants are particularly susceptible) and "mollera caida" (fallen fontanelle). While the possibilities that a folk illness might actually lead to care being sought from a curandero are not great, neither are they completely remote. For example, 7% of the mothers in our sample believed one or more of their children had suffered at some point from mal de ojo.
Willingness to seek care from a curandero varies with age (Table 6). Older (over age 30) respondents were much more willing to seek care from a curandero than were younger interviewees. Younger respondents often commented that they and other people in rural areas would use curanderos and other folk practitioners because doctors were not available, but that they would not use them here in the United States where doctors are available.
The amount of time Mexican immigrants have been in the United States has little effect on the proportion of respondents who would seek care from a curandero. For respondents who have been in the United States 10 years or less (N = 1246), 21.8% would seek care from a curandero if necessary, whereas 20.9% of those respondents in the United States longer than 10 years (N = 593) would do so. The illnesses or conditions that make a curandero a legitimate and appropriate alternative to conventional health care under certain circumstances persist among some Mexican immigrants, even after lengthy residence in the United States.
Attitudes toward curanderos vary according to whether informants migrated from a rural or urban area. Most of the informants (67.9%) had migrated from an urban area, although they originally might have been from one of the smallest rural communities (rancho or hacienda) or from a small town dependent on agricultural production (pueblo). Rural migrants (27.6%, N = 631) were much more willing to seek care from a curandero than were migrants from urban areas (20.9%, N = 1332; chi square significance = .05). However, the percentages of respondents who volunteered they had actually been to a curandero were similar: 1.4% of both rural and urban migrants. As migrants increasingly experience urban life before migrating to the United States, they appear to view curanderos in less positive terms. Perhaps rural migrants have had more opportunity to rely on the care of folk healers and thus have learned to place more faith in their abilities.
Although a relatively large number of respondents were willing to give curanderos the benefit of the doubt as to their abilities to cure, only a handful of respondents expressed interest in using espiritualistas (spiritual healers) and brujas (witches) as health care providers, and then only as a last resort. The attitudes reported in Table 7 suggest the reasons respondents avoid such practitioners.
By contrast, interviewees looked favorably upon sobadores-practitioners who manipulate or massage affected areas of the body. Interviewees considered sobadores effective in dealing with such problems as sore or pulled muscles, strains, sprains, back injuries, bone dislocations, and fractures. As reported in Table 5, two-thirds of our interviewees have used a sobador or would be willing to consult one if the need arose. Over 45% of the sample also would be willing to try, or have already tried, an American chiropractor for treatment of the same kinds of musculoskeletal problems. In fact, an examination of the type of health care practitioners from whom care was sought for work-related accidents reveals that chiropractors were seen in 9.4% of the cases and sobadores in 5.3%.
In addition to nonconventional health practitioners, Mexican immigrants often come from areas in which the use of herbs or medicinal plants to cure health problems is still quite effectively practiced. Not surprisingly, 70.1% of the interviewees had used herbs or medicinal plants for health problems (Trotter 1981a, 1981b). Interviewees appear to associate these health problems with lifestyle, or everyday life; thus they do not consider appropriate seeking care for them from a doctor, hospital, or clinic, or they might put off seeking care for such problems. While informants listed a wide range of health problems as treatable by medicinal plants, most problems can be categorized as gastrointestinal problems. Such problems include stomach pains, indigestion (53.8%), empacho (2.8%), colic (3.9%), sick stomach associated with menstruation (0.7%), bills (bile in the stomach as a result of anger or intense emotion, 1.6%), and diarrhea (0.7%); medicinal plants are used to remove air from the body (2.6%), and as a laxative (1%). Other types of problems treatable by herbs include cough, colds, fever, influenzas, sore throat (10.8%), headaches (3.3%), nervios (intense nervousness, 3.8%), arthritis, rheumatism (1.4%), anemia ( 1.1%), and bladder problems (1%). Importantly, illnesses that can be treated at home with medicinal plants include folk illnesses such as bills, empacho, and nervios.
Folk illnesses surfaced when interviewees discussed problems treatable by a curandero and at home using medicinal plants. In contrast, not one folk illness was cited by informants when discussing the health problems that led them to seek care from a private physician, hospital, or clinic during their last health-seeking experience. Consequently, folk illnesses, which appear to affect a small but significant segment of this population, are not illnesses that would generally lead Mexican immigrants to seek care frt in a conventional U.S. health practitioner.

Conclusion
A belief in folk illnesses and folk practitioners did not significantly deter Mexican immigrants in San Diego from seeking conventional medical care. The primary sources of resistance to the utilization of U.S. health services are economic, and, for the undocumented, fear of being detected. Other factors, such as language and negative experiences, also deterred some interviewees from seeking health care. But the high cost of care, given the resources available to the interviewees, limited the actual accessibility of health care to this population. However, the evidence does not allow the conclusion that a belief in folk illnesses and the efficacy of curanderos and sobadores has no influence on the decision-making process concerning the seeking of health care. While no single folk illness or traditional health practitioner surfaced in significant numbers in response to any specific question, the cumulative effect of the incidences of folk illnesses that arose in various aspects of the immigrants' health care experiences indicates that such beliefs persist among this population and influence, to some yet undetermined degree, behavior related to the seeking of health care.
Although perhaps only a minority of the Mexican immigrant population have folk beliefs that result in avoidance of conventional care, many more may suffer health problems that they perceive as folk illnesses. However, in many cases, they will not describe their health problem in terms of a folk illness to a conventional health practitioner who they believe is not familiar or effective with such problems. Mexican immigrants who seek care for folk illnesses from U.S. doctors who are unfamiliar with such illnesses will often become frustrated and turn elsewhere for treatment, for example, to a practitioner in Mexico, a curandero, a home cure, or to a relative or friend who "understands" such problems. The evidence presented here suggests that U.S. health practitioners need to be aware of and to understand folk illnesses in order to ensure that effective health care is administered to all members of the Mexican-origin population.