Susto, a Folk Illness [Reprint 2020 ed.] 9780520342132

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SUSTO, A FOLK ÍLLNGSS

C o m p a r a t i v e Studies o f Health Systems and Medical C a r e General

Editor

C H A R L E S LESLIE

Editorial

Board

FRED DUNN, M.D., University of California, San Francisco RENEE FOX, University o f Pennsylvania ELIOT FREIDSON, N e w Y o r k University YASUO OTSUKA, M.D., Y o k o h a m a C i t y University Medical School MAGDALENA SOKOLOWSKA, Polish A c a d e m y o f Sciences CARL E . TAYLOR, M.D., T h e J o h n s Hopkins University K . N . UDUPA, M.S., F.R.C.S., Banaras Hindu University PAUL U . UNSCHULD, University o f M u n i c h FRANCIS ZIMMERMANN, Ecole des Hautes Etudes en Sciences Sociales, Paris J o h n M . Janzen, The Quest for Therapy in Lower

Zaire

Paul U . Unschuld, Medical Ethics in Imperial China: A Study in Historical Anthropology Margaret M . L o c k , East Asian Medicine in Urban Japan: ical

Varieties of Med-

Experience

Jeanie Schmit Kayser-Jones, Old, Alone, and Neglected: Care of the Aged in Scotland and in the United States A r t h u r Kleinman, Patients and Healers in the Context of Culture: An ploration of the Borderland between Anthropology,

Ex-

Medicine, and

Psychiatry Stephen J . Kunitz, Disease Change and the Role of Medicine:

The

Navajo

Experience C a r o l Laderman, Wives and Midwives:

Childbirth and Nutrition in Rural

Malaysia Victor G . R o d w i n , The Health Planning

Predicament: France,

Québec,

England, and the United States Michael W. D o i s and Adil S. Gamal, Medieval Rijwän's

Leith M u l l i n g s , Therapy, Urban

Islamic Medicine:

Treatise "On the Prevention of Bodily Ills in

Ibn

Egypt"

Ideology, and Social Change: Mental Healing in

Ghana

J e a n de K e r v a s d o u é , J o h n R . K i m b e r l y , and Victor G. R o d w i n , End of an Illusion: dustrialized

The

The Future of Health Policy in Western In-

Nations

A r t h u r J . Rubel, C a r l W. O ' N e l l , and Rolando C o l l a d o - A r d ö n , Susto, a Folk

Illness

SUSTO, A FOLk iLLNess Arthur J. Rubel Carl W. O'Nell Rolando Collado-Ardon With the assistance of John Krejci and Jean Krejci

University of California Press Berkeley

• Los Angeles

•

London

University of California Press Berkeley and Los Angeles, California University of California Press, Ltd. London, England Copyright © 1984 by The Regents of the University of California Library of Congress Cataloging in Publication Data Rubel, Arthur, J. Susto, a folk illness. (Comparative studies of health systems and medical care) Bibliography: p. 169 Includes index. 1. Zapotec Indians—Diseases. 2. Chinantec Indians— Diseases. 3. Zapotec Indians—Medicine. 4. Chinantec Indians—Medicine. 5. Indians of Mexico—Oaxaca (State)— Diseases. 6. Indians of Mexico—Oaxaca (State)— Medicines. 7. Folk medicine—Mexico—Oaxaca (State) I. O'Nell, Carl W., 1925. II. Collado-Ardon, Rolando. III. Title. IV. Series. [ D N L M : 1. Stress, Psychological— Complications. 2. Disease—Etiology. 3. Psychophysiologic disorders. 4. Medicine, Traditional. 5. Ethnopsychology. W M 172 R894s] F1219.3D5R83 1985 616.85'22 84-214 ISBN 0-520-05196-3 Printed in the United States of America 1 2 3 4 5 6 7 8 9

Contents

Acknowledgments / vii 1: Introduction to Susto / 1 2: The Samples / 15 3: Description of Susto / 30 4: Sampling of Groups / 49 Methods of Testing the Hypotheses / 53 Levels of Social Stress / 55 Levels of Psychiatric Impairment / 60 Levels of Organic Disease / 63 5: Results / 71 Indications of Social Stress / 71 Indications of Psychiatric Impairment / 73 Indications of Disease / 80 Classes of Diseases / 87 Results of Laboratory Tests / 98 Gravity and Severity / 100 Fatal Consequences / 106 6: Interrelationships Among Results / 112 Implications of This Study / 120 Appendix / 123 22-Item Screening Score for Measuring Psychiat Impairment (Modified) / 125

Contents/vi

Instructions for Scoring the 22-Item Screening Score Responses / 125 Social Factors Questionnaire / 127 Scoring Instructions for the Social Factors Questionnaire for Males / 133 Score Sheet for Social Factors Questionnaire—Males / 141 Scoring Instructions for the Social Factors Questionnaire for Females / 146 Score Sheet for Social Factors Questionnaire—Females / 152 Clinical History / 157 Instructions for Scoring Gravity and Severity / 160 Score Sheet for Measures of Severity and Gravity / 167 References / 169 Author Index / 183 Subject Index / 185

Acknowledgments

T H I S investigation owes much to many. So many that it is truly difficult to know with whom to begin. The late Dr. Ralph Clayton Patrick, formerly a member of the Department of Epidemiology, University of North Carolina, was the teacher whose ideas lie behind many of the conceptualizations we present. He showed why the distribution of health conditions within specific populations is of critical interest to the social anthropologist, and sagaciously helped us to improve early formulations of the research design. The National Institute of Mental Health supported our search for "Stress Factors in the Etiology of the Susto Syndrome" (RO 1MH16861). Additional funds were provided by the Seminario Medicina del Hombre en su Totalidad of the Secretaria de Salubridad y Asisténcia de México, directed by Dr. Fernando Martinez Cortés. Dr. Martinez Cortés and his colleagues constantly demonstrated their intellectual and practical interest in this research and we are indebted to them for it. The O'Brien Fund of the University of Notre Dame kindly afforded Carl O'Nell the opportunity to begin testing of the "Social Stress Gauge" in Oaxaca in anticipation of data collection, and the Instituto de Investigaciones Antropológicas of Mexico's National Autonomous University provided Arthur Rubel a welcome research appointment during which much of the manuscript was prepared for publication. We are grateful to all of those organizations for their support and interest. Arthur Rubel wishes to acknowledge with gratitude the continuous support and encouragement of Dr. Bernard Gallin, Chairman, Department of Anthropology at Michigan State Univii

Acknowledgments/viii

versity, and Rolando Collado is grateful to Dr. Eleuterio Gonzalez Carbajal and other colleagues of the Departamento de Medicina Social, Preventiva, y Salud Pública of the Universidad Nacional Autónoma de México for their intellectual stimulation and inspiration throughout this investigation. The ideas which we offer here result from interaction between ourselves and many others. This is especially true of the responses of Dr. Carole Browner and Dr. Nancy O'Nell who have read and reread many of our preliminary efforts to set ideas to paper. They have helped us enormously with their thoughtful criticism. Dr. Alfredo Heredia Duarte, Dr. Scott Swisher, and Dr. Raymond Murray provided able and remarkably constructive criticisms of the clinical findings; we thank them for their willingness to do so despite their already overladen schedules. Professor Philip Dennis helped us improve an early draft with his helpful suggestions. Professor Charles Leslie painstakingly read and criticized a preliminary manuscript. His editorial skills and knowledge of the field have served all of us beyond measure. The assistance of Dr. Salomon Bautista in the analysis of the clinical data went well beyond the call of duty and is gratefully acknowledged. In Oaxaca, we are indebted to Dr. Oscar Martinez, who collected all the samples for examination by the clinical laboratory, and performed most of the physical examinations under trying circumstances. We could not have succeeded without his help. Dr. Fernando Galindo and Dr. Miguel Angel Reyes supervised all the clinical laboratory examinations and counseled us in the techniques to use to collect and preserve blood and stool samples under adverse conditions. They and their laboratory staff consistently accommodated the exigencies of our field work with good humor. The support of these clinicians and of the Oficina de Estudios de Humanidad del Valle de Oaxaca, directed by Mr. Cecil Welte, were simply invaluable. The help of Judi Lynn Anderson made possible the presentation of Chinantec terminology and is gratefully acknowledged. The panel of scoring physicians was composed of Drs. Noe Castillo and Roberto A. Reyes D. Statistical support was pro-

Acknowledgments/ix

vided by the Computer Center and the Social Science Research and Training Laboratory, University of Notre Dame, and the Unidad de Bioestadística of the Departamento de Medicina Social, Preventiva y Salud Pública of the Universidad Nacional Autónoma de México. Particularly helpful in the statistical treatment of data were Dr. Vasilikie Demos, Dr. Bobby Farrow, Theresa O'Nell Quintero, and Marlyn T. Ritchie. In Mexico, statistical analyses were accomplished with the aid of Dr. Jesus Reynaga Obregón, Dr. Elizabeth Reynosa Ramirez, and Estadístico Jaime Garcia Romero. Professor Timothy Ready was meticulous in scoring results of the 22-Item Screening Score for Psychiatric Impairment. Keith Bletzer helped with Spanish to English translation of the clinical sections, and H. Sue Henry assisted in the preparation of bibliographic references. Their collaboration was essential to our efforts and is gratefully acknowledged. We are most appreciative of Martha Reyes, Ursula Traub Greenberg, and Myrna Shoemaker who, in their separate countries, carefully and patiently typed innumerable drafts, which ultimately joined to form this report. Linda Salemka typed the manuscript in its final form and remained patient and constructive in the face of last-minute revisions. We thank them all. To Vincente Martinez Gutierrez and Señora Rafaela Aragón we are indebted for their informed introduction to Valley Zapotee life, and to ways of combating health problems. Among the Chinantecs, Miguel Hernandez Hernandez served as interpreter and was invaluable in countless ways. Catarino Lopez shared his medical wisdom, Felipe Hernandez Hernandez offered endless help as Presidente Municipal and very good friend, and Señora Virginia Martinez Hernandez was unfailingly informative and hospitable during the course of our introduction to Chinantec life. Finally, to all the people whose lives and problems are reflected on these pages, this book is dedicated. For all of us, the opportunity to know well the individuals of these societies and the problems they face remains the most stirring of the many things we will remember from this shared experience.

I Introduction to Susto

-EFFORTS

to d i s c o v e r the m e a n i n g o f illness are a tradition

in a n t h r o p o l o g y . In these p a g e s w e s e e k the m e a n i n g o f a f o l k i l l n e s s k n o w n as susto.

T h e study was conducted among

three

different M e x i c a n populations—Mestizo, Zapotec, and Chinant e c — i n the state o f O a x a c a .

T h e following account

describes

h o w one y o u n g w o m a n b e c a m e sick w i t h susto w h e n she traveled w i t h her father.

A s t h e y f o r d e d the r i v e r b e l o w their ranch, the s w i f t current s w e p t the f a t h e r o f f his feet. H e s a v e d h i m s e l f o n l y b y seizing an o v e r h a n g i n g v i n e . T h e d a u g h t e r , s t a n d i n g on the b a n k , w a t c h e d in a l a r m . T h e f a t h e r r e p o r t s o f his d a u g h t e r ' s reaction, as f o l l o w s : " I n f i f t e e n d a y s she w a s v e r y sick w i t h susto, but I d i d n ' t s u f f e r a n y t h i n g . It . . . is v e r y interesting: S o m e p e o p l e b e c o m e ill w i t h s u s t o and others d o n o t e v e n w h e n t h e y s u f f e r the s a m e e x p e r i e n c e . "

A s a n o t h e r i n f o r m a n t p u t it: It's this w a y . . . the w a t e r contains a b e i n g w h i c h is its virtud, its f o r c e o r s t r e n g t h , the s a m e as the earth, the w o o d s , the h i g h m o u n tains, and e v e r y t h i n g . W e s a y that that f o r c e steals the strength o f h u m a n s . It steals o u r s t r e n g t h and w e a k e n s it. T o k e e p this f r o m h a p p e n i n g , o n e m u s t speak to the earth [or w a t e r ] , o n e m u s t take this action . . . so that o u r spirit does n o t r e m a i n there.

W e h o p e b o t h to p r o v i d e n e w , m o r e relativistic understandi n g s o f w h a t it m e a n s " t o b e i l l " i n o t h e r c u l t u r e s , a n d t o a c q u i r e

1

Susto, a Folk Illness/2 s o m e insight a b o u t ourselves. T h e r e surely r e m a i n f e w r e d o u b t s of e t h n o c e n t r i s m as f o r m i d a b l e as explanations of disease causation a n d t h e m a n a g e m e n t of illness.* All societies h a v e b e e n obliged to d e v e l o p p r o c e d u r e s to p r e v e n t a n d treat illnesses. T h e s e p r o c e d u r e s constitute significant d i m e n s i o n s o f a culture a n d are sensitive to social values: ". . . it is t h e prevailing p h i l o s o p h i c concepts of m a n w h i c h influence his m e d i c i n e m o s t p r o f o u n d l y " (Pelligrino 1963:10). W e initiated o u r m u l t i d i s c i p l i n a r y investigation of susto (the w o r d itself m e a n s f r i g h t ) w i t h the a s s u m p t i o n that w e could n o t u n d e r s t a n d illness across cultures o n the basis of premises p r o d u c e d b y o u r o w n ( K l e i n m a n 1980:378). C o n s e q u e n t l y , w e d e fined illness as " s y n d r o m e s f r o m w h i c h m e m b e r s of a particular g r o u p claim t o suffer a n d for w h i c h their culture p r o v i d e s an etiology, a diagnosis, p r e v e n t i v e measures, and r e g i m e n s of heali n g " (Rubel 1964:268). We s o u g h t to build o n earlier studies (particularly the w o r k s o f B a h r et al. 1974; Fabrega and Silver 1973; Frake 1961; K l e i n m a n 1973; G. Lewis 1975; M e t z g e r and Williams 1963) in w h i c h the researchers had r e c o r d e d and s c r u tinized t h e m a n n e r in w h i c h different peoples t h i n k a b o u t illness. W e felt w e could n o t h o p e to c o m p r e h e n d health and illness a n y w h e r e until freed o f o u r o w n e t h n o c e n t r i s m . O n e of t h e m o s t i m p o r t a n t goals of a n t h r o p o l o g i c a l research has been to d e m o n s t r a t e h o w health u n d e r s t a n d i n g s and practices elucidate t h e d o m i n a n t values, beliefs, and n o r m a t i v e expectations of a society and serve as a m i r r o r of the affective qualities of social relationships. Early a n t h r o p o l o g i s t s described health institutions m u c h as t h e y discussed the cultural patterns revealed b y o b s e r v a t i o n s o f the fa* lily, g o v e r n m e n t , and religion. T h i s tradition persists, f o r e x a m p l e , in a recent analysis of the rural C o s t a Rican c o n d i t i o n k n o w n as nervios. Barlett and L o w sort

* D i s e a s e , illness, a n d s i c k n e s s will h a v e d i f f e r e n t r e f e r e n t s . Disease

will

h e n c e f o r t h r e f e r t o p a t h o l o g i c a l p r o c e s s e s , illness t o t h e v i c t i m ' s p e r c e p t i o n a n d d e s c r i p t i o n o f d i s c o m f o r t , a n d sickness t o a c k n o w l e d g m e n t o f his p r o b l e m a n d t h e r e s p o n s e t o it b y t h e social g r o u p .

Introduction to Susto/3 out the manifestations of this problem to establish a relationship between the complaint and other dimensions of the lives of these people. They conclude that "the examples of nervios sufferers seem not only to illuminate a complex culture-specific complaint, but also to reveal the most fundamental expectations of life in rural Costa Rica" (1980:554). Morsy (1978) uses another culture-bound syndrome—uzr—to elucidate the patterns of social power relationships among Egyptian villagers and goes on to show how her results permit us to better understand the bonds between relatively powerless villages and the central government. These and other studies have helped demonstrate the functional interrelationship that obtains between health concerns and other value or belief constructs—for example, the relationship between the visitation of illness in a family and a member's having transgressed social norms (Rubel 1966; Vogt 1969:371374). Marwick's (1965) interpretation of a case of illness as precipitating the fission of subgroups from a parent kinship unit when their social relationships have become insupportable is another case in point. However, Comaroff (1978) has cautioned that the tightness of the researchers' integration of a society's understandings about health with other concepts of its social order represents the analytic efforts of the former more than the thinking of the latter. In other accounts, researchers have suggested that therapeutic rituals exploit the opportunity presented by a patient's difficulties to resolve interpersonal and intergroup problems and restore social unity (Turner 1967:361—362). In a somewhat different vein, Lévi-Strauss considered the trial of a Zuni youth accused of causing a friend's illness as providing the group an opportunity to reaffirm its confidence in the cultural system at large (1963:172-175). Some studies of folk illnesses have simply assumed that they are psychiatric in nature, ignoring the contribution of organic problems to these complaints even when organic signs and symptoms were observable (Kiev 1968). This "psychologizing" of folk illness has exacerbated the difficulties of separating disease

Susto, a Folk Illness/4 processes f r o m the cultural response to t h e m . Because the presentation of emotional difficulties is even m o r e stylized than presentation of an organic p r o b l e m , the task of developing crosscultural evidence a b o u t psychological disease conditions has been m a d e the m o r e difficult (Fabrega 1974:40; G. Lewis 1975:93-94; K l e i n m a n 1973:209). Studies that emphasize traditional healing rituals generally fail to r e p o r t w h e t h e r or n o t the patient recovered or even w h e t h e r s y m p t o m s w e r e alleviated. T h e y sometimes i m p l y that the ritual was efficacious, b u t present n o s u p p o r t i n g evidence. For example, Klein, discussing treatments for susto, assures the reader that they are efficacious: " . . . recognizing the cultural and p s y chological bases for susto cures should not belittle the physiological effectiveness of the m e t h o d s e m p l o y e d ; all three dimensions interact in healing to c o m b a t the s y m p t o m s , w h i c h are alleviated in m o s t cases" (Klein 1976:26, emphasis added). A l t h o u g h this claim is plausible, n o data to s u p p o r t it are presented. Similar u n s u p p o r t e d claims a b o u n d in the literature. This r o m a n t i c idealization of traditional healing, w h i c h reverses the m o r e c o m m o n ethnocentric view, only adds to the difficulty of assessing any kind of healing in unfamiliar cultural settings (Donabedian 1966). K l e i n m a n and Sung reported, in 1979, s o m e of the factors that complicate such an effort. T h e y u n d e r t o o k assessments of patients' s y m p t o m s t w o m o n t h s after initial treatment at a shrine in T a i w a n . A l t h o u g h the patients generally reported themselves to be either cured or significantly i m p r o v e d , the investigators failed to " f i n d conclusive evidence to s h o w that a single case of biological-based disease was effectively treated b y the tang-ki's therapy alone." K l e i n m a n and Sung suggest that, prior to an assessment of healing, it is p r u d e n t to c o m p r e h e n d all the dim e n s i o n s of the p r o b l e m s of w h i c h patients complain. We are not d e n y i n g the efficacy of n o n c o s m o p o l i t a n systems of healing, but w e are r e c o m m e n d i n g that traditional practices be approached w i t h m o r e rigor than has been c o m m o n (see Finkler 1980). T h e extent to w h i c h disease is m o l d e d by culture remains one

Introduction to Susto/5 of the m o r e p r o v o c a t i v e issues in a n t h r o p o l o g y . For instance, the chronic disease c o m m o n l y k n o w n as arthritis or r h e u m a t i s m and technically recognized as degenerative j o i n t disease appears mainly a m o n g older individuals or as a sequel to injuries of a j o i n t . It is f o u n d a m o n g cultural g r o u p s in diverse e n v i r o n m e n t s (Lawrence 1966:755-756). Radiological assessments portray degenerating j o i n t s , and patients indicate pain on m o v e m e n t or pressure applied to a j o i n t , and complain of weakness. Swelling and enlargements, d e f o r m i t y , atrophy, and shortening of the muscles and abnormalities in the affected skin are easily noted by the trained eye ( E d w a r d s 1966:747). W i t h such objective evidence, it is n o t unreasonable to expect victims to express their d i s c o m f o r t similarly. H o w e v e r , reports of this illness vary systematically a m o n g culturally different populations, and even Americans of similar ethnic b a c k g r o u n d have learned to respond differently to it w h e n they are m e m b e r s of different social classes. (Elder and Acheson 1970; K o o s 1954). O t h e r reports have s h o w n that A m e r i c a n s complaining of ear, nose, and throat p r o b l e m s systematically emphasize different s y m p t o m s depending on their ethnic b a c k g r o u n d s (Zola 1966). F u r t h e r m o r e , even patients' complaints of pain vary according to ethnic g r o u p m e m b e r s h i p ( Z b o r o w s k i 1952). It is clear f r o m this evidence that the objective signs of a given disease process m a y be m o l d e d by the culture and experience of the victim. T h e distinction between the invariant objective indications of a sickness—the disease—and the w a y in w h i c h the patient describes the p r o b l e m — t h e illness— (Eisenberg 1977) is especially i m p o r t a n t w h e n the complaint is unfamiliar to the researcher. Efforts to "domesticate" exotic health conditions to m a k e t h e m m o r e understandable are described as using the concepts of biomedicine as if they f o r m e d a Procrustean bed, c o n t r i b u t i n g to "the degradation of a productive scientific m o d e l into a d o g m a " (Engel 1979:257). T h e extent to which culture provides the f o r m in w h i c h disease becomes illness and then sickness is one of the m o r e fascinating inquiries in crosscultural research. In a discussion of c u l t u r e - b o u n d s y n d r o m e s , K e n n e d y c o m m e n t s that " m o s t m o d e r n scholars tend t o w a r d

Susto, a Folk Illness/6 t h e o p i n i o n that these exotic maladies are n o t clinically distinct s y n d r o m e s , b u t are s i m p l y the old familiar psychiatric s y n d r o m e s o f the West called b y different n a m e s and shaped b y d i f f e r e n t c u l t u r e s " (1973:1152). We disagree w i t h these scholars; o u r investigation of susto d e m o n s t r a t e s h o w cultural and disease processes interact to f o r m an entity unfamiliar to c o s m o p o l i t a n medicine. T h e cross-cultural s t u d y of susto is best a p p r o a c h e d by fixing a t t e n t i o n o n the w a y s in w h i c h the patient and his o r her family describe the c o n d i t i o n : T h e victim is (1) restless d u r i n g sleep and (2) o t h e r w i s e listless, debilitated, depressed, and indifferent to f o o d a n d to dress and p e r s o n a l h y g i e n e (Sal y Rosas 1958; Gillin 1945; R u b e l 1964; L o g a n 1979; cf. T o u s i g n a n t 1979:153). A striking discovery is that this condition is not culture-bound. T h a t is, it is n o t restricted to a p o p u l a t i o n speaking a distinctive l a n g u a g e , o r t o a singular cultural b a c k g r o u n d . It is f o u n d in m a n y cultural g r o u p s in N o r t h and S o u t h A m e r i c a . It is r e p o r t e d a m o n g Mexican Americans in the U n i t e d States (Clark 1959:155158; M u l l and M u l l 1981; M a r t i n e z and M a r t i n 1966; R u b e l 1960; Saunders 1954), in Peru (Gillin 1947; Sal y Rosas 1958; C h i a p p e C o s t a 1979; B o l t o n 1981), in A r g e n t i n a (Palma 1973; Palma and T o r r e s Vildoza 1974:164, 171), in C o l o m b i a (Leon 1963; Seijas 1972), a m o n g G u a t e m a l a n g r o u p s (Gillin 1945; A d a m s and R u b e l 1967; L o g a n 1979), and t h r o u g h o u t M e x i c o ( A d a m s and R u b e l 1967; O ' N e l l and Selby 1968; V o g t 1969:370). M o r e o v e r , s i m ilarly characterized c o n d i t i o n s associated w i t h f r i g h t are r e p o r t e d in t h e literature f r o m t h e Philippines, India, T h e People's R e public of C h i n a , and T a i w a n ( H a r t 1969). F o c u s i n g o n the n a m e s given to the condition, w h i c h is also k n o w n locally as pasmo, tierra, espanto, and pefdida de la sombra, m a k e s it easy to be distracted f r o m the c o m m o n a l i t i e s that exist (Seijas 1972, 1973; O ' N e l l 1970; R u b e l 1970) and, indeed, m a y sometimes temporarily obscure real differences. In research a m o n g the S i b u n d o y of C o l o m b i a , Seijas (1972:177) w a s eventually o b l i g e d to c o n c l u d e that w h a t they called susto w a s n o t the c o n d i t i o n described in these pages, b u t an a s s o r t m e n t of pediatric

Introduction to Susto/7 c o n d i t i o n s a n d a catch-all c a t e g o r y o f a d u l t illnesses f o r w h i c h m o r e u s u a l e x p l a n a t i o n s w e r e socially i n a p p r o p r i a t e . W e u s e t h e t e r m susto h e r e o n l y w h e n it refers t o a c o h e r i n g set o f c h a r a c teristics t h a t r e c u r s a c r o s s g r o u p s . W e fix o u r a t t e n t i o n o n a p h e n o m e n o n , a reality, r e p o r t e d b y g r o u p s t h a t d i f f e r in l a n g u a g e a n d c u l t u r e . D o i n g so m a k e s p o s s i b l e c o m p a r i s o n s a n d replic a t i o n o f results. Rejecting any correlation b e t w e e n w h a t our i n f o r m a n t s ref e r r e d t o as s u s t o a n d diseases o r f u n c t i o n a l d i s o r d e r s d e s c r i b e d in t e x t b o o k s o f c o s m o p o l i t a n m e d i c i n e , w e b e g a n w i t h t h e ass u m p t i o n t h a t a n y e q u i v a l e n c e t h a t m i g h t be e s t a b l i s h e d s h o u l d b e b a s e d o n e m p i r i c a l d e s c r i p t i o n s o f t h e f o l k c o n d i t i o n . O n this m a t t e r C o m a r o f f (1978:249) has b e e n h e l p f u l : Anthropologists have been critical of the indiscriminate application of the bio-medical paradigm to the study of actual medical systems, for it presupposes pre-emptive definitions of relevance. T h e perspective of scientific medicine is expressed by means of conceptual categories which may well be inappropriate in other medical systems; as a base-line for comparison, it might obscure their particular relevance. In t h e C o s t a R i c a n r e s e a r c h m e n t i o n e d earlier, B a r l e t t a n d L o w (1980), a p p a r e n t l y s h a r i n g this v i e w p o i n t , p r u d e n t l y r e f r a i n f r o m p r e m a t u r e biomedical identification of nervios. C o m p l a i n t s o f n e r v i o s , t h e y r e p o r t , are r e g u l a r l y a t t e n d e d to b y p h y s i c i a n s even t h o u g h they s h o w no equivalence to the kinds of conditions p h y s i c i a n s are t r a i n e d t o c u r e . T h e s e r e s e a r c h e r s r e c o r d a w i d e a r r a y o f s y m p t o m s a f f e c t i n g p e o p l e o f b o t h sexes a n d all ages, w i t h m u c h h i g h e r p r e v a l e n c e a m o n g t w o g r o u p s — t h o s e 19 years o f a g e a n d o l d e r , a n d w o m e n . W i t h s u c h a v a l u a b l e baseline d e s c r i p t i o n in h a n d , this p r o b l e m b e c o m e s a m e n a b l e t o m o r e finely h o n e d inquiries. S i m o n s ' s (1980) w o r k o n latah, w h i c h afflicts l a r g e n u m b e r s o f p e o p l e in M a l a y s i a a n d I n d o n e s i a a n d has close c o u n t e r p a r t s in t h e P h i l i p p i n e s , T a i w a n , T h a i l a n d , a n d B u r m a , is s i m i l a r l y

Susto, a Folk Illness/8 free o f a priori assumptions about equivalents in cosmopolitan medicine. Simons finds that most victims o f latah are women, tend to be in mid-life when the experience occurs for the first time, and are o f relatively low social status. The person suffering from latah typically responds to a startling stimulus with an exaggerated start, often throwing or dropping an object and uttering words ordinarily inappropriate in conversation. Both those studies indicate the fruitfulness o f a careful search for explanations in the interaction among biological, emotional, and cultural factors rather than a focus on the pathologies described in textbooks o f medicine. Following some o f O'Nell's arguments (1975), Bolton begins his study o f susto, or tierra, among the Qolla o f Peru with the assumption that it is equivalent to the controversial (Blonde and Riddick 1976; Hale et al. 1975; Permutt et al. 1976) disease that we speak o f as hypoglycemia. T h e study then tries to demonstrate that equivalence by searching for a correlation between having been found severely hypoglycemic at any time in one's life and having ever complained o f susto, or tierra. Because hostility is an often reported symptom o f hypoglycemia, and the display o f such feelings is unacceptable among the Qolla, Bolton concludes that the conditions, although not present at the same time, are one and the same. We will shortly address this issue o f whether, in Oaxaca, hypoglycemia is "a perfectly adequate biomedical syndrome" (Bolton 1981:261-262) by which to explain susto. Suffering susto, being asustado, is based on people's understanding that an individual is composed o f a body and an immaterial substance, an essence, that may become detached from the body and either wander freely or become a captive o f supernatural forces. This essence may leave the body during sleep, particularly when the individual is dreaming, but may also become detached as a consequence o f an unsettling or frightening experience. Among Indians, this essence is believed held captive because the patient, wittingly or not, has disturbed the spirit guardians o f the earth, river, ponds, forests, or collectivities o f

Introduction to Susto/9

animals, birds, or fish. Its release depends upon expiation of the affront. This process dramatically illuminates the relationship that binds humans and suprahumans in these societies. A social bond of this kind has been described by Bahr and colleagues (1974) in a study of the Pima of northern Mexico. Here again, illness is attributed to the patient's having failed to s h o w deference to the spirit being of a species of animal, fish, or bird, or to the guardian of a locale. T h e sanction of illness follows transgression of the contractual relationship that binds that species and Pima society, a social contract referred to as the " w a y . " "When way is cited as a causal agent we understand that it is not the individual object which is causing illness but the class of dangerous objects collectively" (p. 65). Further, "the concept of way approximates the concept of a guardian of the species. In this capacity way is implicitly endowed with magical powers. Way is offended the m o m e n t an improper action is committed, but the offense is not realized until years later" (p. 73). T h e southern Mexican groups on which we focus here differ f r o m the Pima in attributing many cases of susto to the startling or frightening effects of an encounter with another human being. Furthermore, by no means all manifestations of such an encounter are delayed; many victims of susto report s y m p toms within hours or days of an untoward experience. Some researchers have seen susto as simply a way of explaining mental illness for people w h o lack the education to understand its true significance. Pages Larraya (1967:18, 23, 71) has identified it as schizophrenia, and Leon (1963:211; cf. Billig et al. 1948) provides a more sweeping identification: Leaving aside infection, poisoning, parasites, nutritional or metabolic processes which can produce problems compatible with the clinical picture and which are capable of producing the condition in its most intractable and dramatic f o r m , the great majority of cases are psychiatric disorders of functional derivation. T h e circumstances in which the condition makes its appearance and its clinical manifestations indicate the possible presence of at least five entities: a

Susto, a Folk Illness/10 massive stress reaction, reactions to stresses caused by patients' adjustment to problems associated with early childhood or infancy, psychoneurosis, depression, or anxiety. The first may be considered the equivalent of those which we know as traumatic neuroses, whose etiology would reflect stress which affects the child in circumstances in which he feels helpless, unable either to fight or flee.

It appears best to avoid drawing any such conclusions prematurely. It is useful to begin by assuming that when someone is said to be sick, whether by him or herself or others, no matter how the complaint is couched, his or her overall well-being is diminished. It follows that those thought to be sick are in some discoverable, objective ways different from those not thought to be sick. These differences, however, are by no means necessarily of a "health" nature as measured by cosmopolitan medicine. Rather, the presentation of a complaint simply indicates that something is amiss; the problem may just as well be located in social relationships or relationships with spirit beings as in the sphere of disease. As White (1972:18) has put it, "we can . . . proceed safely on the assumption that something must be the matter with a patient who consults a physician when in fact nothing is the matter with him." We assume that the difference between those who are and are not suffering susto may be located in one or more of three systems of the self—social, psychological, and organic—and that stress affecting one of these systems may be wholly or partly transmitted to others "so that several become involved in the process of adaptation and defense" (Caudill, quoted by Cassel et al. 1960:940). From this perspective, interaction among physiological, psychological, and sociocultural processes produces variations in relative health. This model has the advantage of assigning no greater weight to problems of, for example, an infectious nature than to a discrepancy between an individual's expectation and actual performance or to problems produced by maladaptive emotional responses.

Introduction to Susto/11 W e f u r t h e r a s s u m e that each i n d i v i d u a l h a s an ideal level o f w e l l - b e i n g , o r h o m e o s t a s i s . W e d o n o t s u g g e s t that a n y o n e e v e r achieves this ideal; rather, it r e p r e s e n t s a s t a n d a r d f o r e v a l u a t i n g a c t u a l h e a l t h status. A s H o w a r d a n d Scott (1965) c o m m e n t , " e q u i l i b r i u m , c o n c e p t u a l l y , is m e r e l y a p o s t u l a t e d state t o w a r d w h i c h t h e o r g a n i s m m a y t e n d , b u t w h i c h is n e v e r f u l l y a t t a i n e d . " W e see s t r e s s f u l f o r c e s g e n e r a t e d w i t h i n t h e s o c i o c u l t u r a l , b i o logical, o r p s y c h o l o g i c a l e n v i r o n m e n t as calling f o r t h e e x p e n d i t u r e o f e n e r g y b y the individual to maintain well-being. Because t h e t h r e e e n v i r o n m e n t s are o p e n t o o n e a n o t h e r , w h a t taxes o n e e n v i r o n m e n t w i l l e x a c t e n e r g y f r o m all t h r e e . O r d i n a r i l y , t h e i n d i v i d u a l ' s e n e r g y is s u f f i c i e n t t o the d e m a n d . S o m e t i m e s , h o w ever, t h e d e m a n d e x c e e d s t h e s u p p l y , a n d t h e o v e r t a x e d i n d i v i d u a l m a y d e v e l o p s u c h s y m p t o m s as h e a d a c h e s , j o i n t pains, d i s t u r b e d social r e l a t i o n s h i p s , e m o t i o n a l crises, a n d o t h e r s . T h e f o r c e s t h a t t a x a p e r s o n ' s e n e r g i e s will h e n c e f o r t h b e called stressors (cf. M a s o n 1975:29), a n d stress will r e f e r to t h e effects t h e y are p r e s u m e d t o h a v e o n t h e i n d i v i d u a l . Stress h e r e is s i m i l a r t o State III in Selye's classic d e s c r i p t i o n o f t h e G e n e r a l A d a p t a t i o n S y n d r o m e (1956) a n d is e q u i v a l e n t t o w h a t Scott a n d H o w a r d h a v e called " t e n s i o n " ( 1 9 7 0 : 2 7 2 - 2 7 3 ) . Several h y p o t h e s e s d e r i v e d in p a r t f r o m p r e v i o u s r e s e a r c h o n social stress p h e n o m e n a guided our efforts:* 1. S u s t o will a p p e a r o n l y in social s i t u a t i o n s t h a t v i c t i m s p e r c e i v e to be stressful. 2. T h e social stresses reflected in s u s t o will b e i n t r a c u l t u r a l a n d i n t r a s o c i e t a l in n a t u r e . Stresses o c c a s i o n e d b y conflict b e t w e e n c u l t u r e s o r b y a n i n d i v i d u a l ' s c u l t u r a l m a r g i n a l i t y o r social m o b i l i t y (in o t h e r w o r d s , t h e f r u s t r a t i o n o r alienation that

* For excellent reviews of social stress research, see Dohrenwend and Dohrenwend 1974; Levine and Scotch 1970; Levi 1971; Lazarus 1967; Mason 1975; Selye 1975. Our approach to social stress has been most influenced by the work of John Cassel and collaborators; Holmes and Masuda; Wyler et al.

Susto, a Folk Illness/12 often results f r o m relations with members of a social stratum distinct f r o m that into which one has been socialized) will be symbolized by problems other than susto. 3. Susto will appear as a consequence of an episode in which an individual is unable to meet the expectations of his or her o w n society for a social role in which he or she has been socialized. Corollary A: Because these societies differentially socialize males and females (see O ' N e l l 1969; Rubel 1964), and because society's expectations of male and female children differ f r o m those held for mature men and w o m e n , it is expected that girls and w o m e n will be afflicted by susto as a consequence of experiences different from those which jeopardize the health of boys and men of the same society. For example, girls are socialized to be demure, dependent, and home-oriented, whereas boys are trained to show aggressiveness, independence, and orientations t o w a r d occupational and public-responsibility roles. We would not expect many girls or w o m e n in these societies to manifest susto as a consequence of inability to meet male-gender responsibilities. Neither should one expect a y o u n g man to suffer ill effects f r o m his inability to carry out successfully a task usually assigned to w o m e n . Corollary B: Since these three societies attach greater i m p o r tance to the successful accomplishment of some tasks than of others, the m o r e importance socializers attach to a particular task, the greater the likelihood that susto will occur in association with failure to p e r f o r m it adequately. It follows that, although females and males both risk illness as a consequence of failure adequately to p e r f o r m sex-specific and age-specific tasks, not all such tasks are equally risky. 4. Although all persons in these societies believe in the concept that vital essences leave the body and that distress accompanies such an occurrence, not everyone will actually fall victim to this kind of problem. It is hypothesized that individual personalities act as contingency variables. That is, if

Introduction to Susto/13 t w o m e m b e r s of a society matched for age and sex fail to meet adequately the society's role expectations, one may respond to his self-perceived inadequacy by becoming asustado, whereas the other may adapt by an expression of generalized anger or by displacement of hostility. Moreover, among those w h o do become asustado, the severity, chronicity, and frequency of episodes will vary systematically with respect to personality and societal variables. Uzzell (1974) looked carefully at some of the earlier w o r k on susto and arrived at a different explanation f r o m this one for its occurrence. H e suggests that the victim of susto assumes a "sick" role primarily in order to impose his or her definition upon situations and thereby control the interactions. "This implies dissatisfaction with existing definitions but it does not necessarily imply 'role stress' or perceived inadequacy to meet the demands of a role" (p. 374). Instead, Uzzell concludes, "asustados take time out, relieve themselves for a time of some of the onerous tasks they are obliged to p e r f o r m . " We will return to Uzzell's persuasive argument after presenting the findings of this study. Since we declined to make any a priori j u d g m e n t s as to the nature of susto (although w e did not initially expect it to be associated with either organic or psychiatric difficulties), we had to devise ways of measuring dimensions of social role, organic disease, and psychiatric impairment, each independently of the others (cf. Mason 1975:24). We created three original measures to do so, one to assess the level of social-role stress, the others to measure severity and gravity of disease. In addition, we adapted to our needs the standardized 22-Item Screening Score for Psychiatric Impairment. T h e procedures for the development ofeach of these tests and their evaluation prior to adoption are fully discussed in later chapters. Although victims of susto reach back in time for one or several traumatic events to explain their conditions, we considered it likely that susto reflected the cumulative effects of fairly longt e r m debilitation resulting f r o m social problems with which the

Susto, a Folk Illness/14 victim was unable to cope (e.g., problems in relationships with spouse or with provision for family), which exacted energy from the emotional and biological dimension as well. The assumption that derives from the open-system model is that a response required by one such dimension may tax resources in one of the others (Cassel et al. 1960; Howard and Scott 1965; Mechanic 1962:4-5; Selye 1975:39, 41). Although we might have carried out this research in a single community, the conclusions would have been limited to that unique cultural setting, requiring replication in other groups. The ethnographies we have cited demonstrate the presence of susto in different Hispanic cultural settings, creating the opportunity to build on earlier studies and to determine whether the social attributes of a person co-vary with susceptibility to the condition regardless of cultural context. To what extent do circumstances leading to becoming asustado override cultural differences? This was our guiding question. Efforts to answer such a question have been relatively uncommon in anthropology, in no small measure because of the tradition of anthropologists' working in a single community rather than comparing several. If, in fact, affliction with susto did regularly co-vary with characteristics of victims in different cultural and social settings, it would appear to be a shared response to similar social stressors within a particular range of sociocultural contexts. In summary, this is an effort to discover the meaning of an "exotic" health complaint by showing how those who complain of susto differ from those who do not. The chapters that follow specify the procedures we used and their results.

2 The Samples

_L H E similarity of previous ethnographic accounts of the susto phenomenon from regions highly diverse in cultures and languages made it reasonable for us to think that a causal explanation transcended cultures. However, to test our hypotheses in only one society would leave us with concern that the results might not apply to other societies, even within the same cultural and language group. Consequently, rather than test them in only one group, we worked in several with different histories, languages, and cultures. This procedure offered the possibility that the results would provide some understanding of human behavior that transcended social group or culture (see Eggan 1954:748). Furthermore, we felt an "hypothesis worth testing once in a field situation deserves replication both in that and other settings" (LeVine 1970:193). It was critical to ensure that institutions such as the form of government and gender-specific role expectations were similar in the various societies because, if they were not, we could not be certain that we were observing a relationship between the same social forces and susto susceptibility. Likewise, we already knew from our own experiences, and from observations reported by others, that an agent, like a Catholic priest or a schoolteacher, can have a marked influence on villagers' thinking about supernatural forces, or what they believe to be the "appropriate" ways to comprehend illness. We therefore selected societies that shared the same experience in regard to change-agents. The critical consideration was that the communities be comparable, not whether such persons were present or absent. 15

Susto, a Folk Illness/16

The features of the three communities we sought most assiduously to control were demography, income, gender-role expectations, form of governance, and the influence of important outside change-agents, such as Catholic priests, schoolteachers, or physicians. In addition, the variables with which we sought to differentiate these communities were maternal language and cultural heritage. One of the communities is Valley Zapotec in heritage, and all residents speak the Valley variant of the Zapotec language. Another is of Chinantec heritage, in which the Dzah-hmi dialect is spoken. The third population (also Valley) is of Ladino, or mestizo, culture, and its population speaks only Spanish. This latter group has been mestizo—or non-Indian—for at least the past two centuries. The communities are clearly distinct from one another both geographically and historically. In this respect, J . W. M. Whiting has advised: A s i m p l e precaution is to a v o i d using t w o cases which are k n o w n to h a v e derived f r o m a c o m m o n origin within the recent past. T h a t is, within such a short time that their cultures have not had a chance to change. A m o r e cautious rule w o u l d require choosing no m o r e than one case f r o m a linguistic area in which the languages were still m u t u a l l y intelligible. (1954:528)

There is little risk that their separateness was contaminated by "Galton's Problem," as we shall try to show. Neither ethnographic nor ethnohistorical information suggests significant direct contact between either of the valley groups and the Dzahhmi Chinantecs. Moreover, there is little direct contact between the two valley communities despite geographic proximity. There can be no doubt that the maternal language—Spanish— of the Mestizos derived from altogether different roots from either of the two indigenous languages. The latter were also derived from different language families—the Zapotec language forms part of the Oaxaquena group and, according to what

Susto, a Folk Illness/18 Swadesh concluded from lexicostatistical testing, the Chinantec language lies outside that group, separated from it by at least 5,000 years. Even more, Swadesh's evidence (1967:96) suggests Chinantec is so different from languages of the embracing Macro-Mayan network as to recommend its being placed entirely outside that Meso-American affiliation. Although Dzah-hmi groups of Chinantec, and Sierra Zapotec-speaking people have enjoyed social and economic contacts for a very long time, Valley Zapotec is a different language from Sierra Zapotec. It is possible that there has been meaningful cultural contact between these highland Chinantec and Zapotec of the valley, but there is nothing to suggest that theirs has been a relationship in which the culture of one has strongly affected that of the other. Providing support for such an impression, Swadesh concluded that ". . . Chinantec appeared to be a long way from Zapotecan as long as it was compared with the Isthmus dialect, but proved to be not nearly so remote from that of Ixtlan [Sierra]" (p. 87). The separateness of the roots from which these groups drew their cultural nurturance is testified to by Driver's work (1974). He concluded that when populations living close to one another speak different languages it can be predicted that they will also have distinctive cultures. That finding receives support from genetic data that testify to the inconsiderable levels of intermarriage that occur between these highland Chinantecs and their Zapotec neighbors (Zavala et al. 1980). Our effort was to conduct a quasi-natural experiment to the extent possible, varying certain critical characteristics (i.e., language and culture), and attempting to hold others (e.g., genderrole expectations and form of governance) constant. All three groups were peasant by nature, and lived by dint of subsistence gardening, supplemented by small-scale production of produce and/or manufactured goods for local markets. In the best sense of the phrase, they represented part-societies (Redfield 1956). In all these localities, the major crop was maize, grown almost entirely for household consumption, and supplemented by other crops grown primarily for the same end.

The Samples/19 T w o of these c o m m u n i t i e s — t h e Mestizo and the Z a p o t e c — w e r e located in the Tlacolula w i n g of the Valley of Oaxaca. D u e to its m o d e r a t e l y high elevation, approximately 5,000 feet above sea level, and the protection offered by adjacent m o u n t a i n ranges, the climate o f the valley tends to be cool and dry. Rainfall is not copious, w i t h a yearly average of approximately 26 inches, the heaviest falls being registered in September. Soils vary even within the same c o m m u n i t y . Except for rare patches of b o t t o m l a n d alongside rivers, n o n e of the soil in this area is of first-class quality, r a n g i n g b e t w e e n lands of second or third class, and those w h o s e utility is restricted to the gathering of f i r e w o o d and the f o r a g i n g of goats and sheep. T h e s e second- and third-class lands are cultivated w i t h the aid of simple w o o d e n p l o w s d r a w n by uncastrated bulls. In contrast, the C h i n a n t e c g r o u p lives on lands extending f r o m the highest range of the Sierra M a d r e del Sur—Sierra de J u a r e z — d o w n to a p p r o x i m a t e l y 2,000 feet above the sea; the h e a d - t o w n , or cabecera, is f o u n d at 6,000 feet above sea level. These lands range f r o m alpine in the u p p e r reaches, w h o s e natural cover is pine forest, d o w n to rain forest, w h i c h represents the n o r t h e r n m o s t extension of the great Central American tropical forest. A l t h o u g h m a n y of these C h i n a n t e c lands are covered by pine forest and boulders, and are too cold to be productive, others are quite fertile and exceedingly well watered. T h e highlands d e p e n d on seasonal rainfall and are cultivated w i t h the aid of w o o d e n p l o w s d r a w n by bulls; in contrast, the tropical lowlands are w e t t h r o u g h o u t the year, are cultivated by the digging stick and, a l t h o u g h v e r y fertile, p r o v i d e b u t one crop of corn a year because the constant cloud cover prevents sufficient sunlight f r o m getting t h r o u g h . T h e three populations range between 800 and 1,800 w i t h the Mestizo g r o u p the smallest, the Chinantec the largest, and the Z a p o t e c s in b e t w e e n . A l t h o u g h numerically there is considerable disparity b e t w e e n the largest c o m m u n i t y of 1,800 residents and the smallest w i t h 800, population density per kilometer is virtually the same. T h e C h i n a n t e c municipio evidenced a density of

Susto, a Folk Illness/20 28.22 persons per square kilometer as c o m p a r e d w i t h 30.0 per square kilometer in the other t w o g r o u p s (IX Censo General de Poblacion, J970, Datos Por Municipios, Cuadro I). All three populations are g o v e r n e d by a political system in w h i c h male m e m b e r s are obliged to fill administrative posts w i t h o u t salary. T h e y represent variations on a t h e m e of the traditional M e s o - A m e r i c a n civil-religious hierarchy. Each has responded in s o m e w h a t different w a y s to the emigration of adult males, and to the directives that emanate f r o m state and federal g o v e r n m e n t s . A m a n suffers s t r o n g social pressure to give his time, energy, and m o n e y to the public well-being by his service in the local g o v e r n m e n t a l structure. T h e positions a m a n fills b e c o m e increasingly d e m a n d i n g of his t i m e and m o n e y as the years progress. T h e higher and m o r e responsible the position, the greater the personal expenditure of cash and g o o d s by an office-holder. For example, a person w h o sponsors the fiesta h o n o r i n g the patron saint in the Mestizo p u e b l o expends a relatively e n o r m o u s a m o u n t of m o n e y and produce, whereas a m o n g the Chinantecs the person occupying the office of Presidente Municipal—highest of the secular posts— is obliged personally to pay the costs of his n u m e r o u s official trips to the state capital, together w i t h the costs incurred by those officials w h o a c c o m p a n y h i m . These duties at the t o p of the p y r a m i d a l structure are onerous and costly, so it is not surprising to find n o m i n e e s for these positions—and their w i v e s — reluctant to accept n o m i n a t i o n . Nonetheless, social pressures to accept are r e m a r k a b l y p o w e r f u l , and failure to meet those e x pectations is labeled socially undesirable. T h e only w a y to avoid the o p p r o b r i u m heaped on those w h o fail to accept office is by leaving the c o m m u n i t y entirely. At the time of the study, this was a feasible alternative only for the Mestizos. O n this matter, C o r b e t t c o m m e n t e d that: . . men time term

. the likelihood of migration decreases motivation among young to serve in municipal office. It seems unproductive to invest and money in civic participation when it will serve no longpay-off. (1974:40)

The Samples/21 N o n e of the three communities is rent by persisting structural opposition. Despite the fact that the Ladinos are currently divided into three barrios and the Chinantecs formerly had four such divisions, there is no evidence that these currently exert strong influence on the self-identification of residents, or on their relations with residents of other barrios. O t h e r indications of status serve to differentiate a m o n g residents of the Chinantec and Ladino pueblos. A m o n g the Chinantec, individuals k n o w n as caracterizados are influential in decisions of importance to the community. Caracterizados are adult males w h o are literate in and have a command of the national language, and w h o are credited with the capacity to think t h r o u g h difficult problems, especially those which have reference to relations between the c o m m u n i t y and forces outside of it (e.g., the federal or state governments, the timber c o m panies, or neighboring communities). Although many of the caracterizados have passed through the hierarchical civil—religious structure, attaining the respected status of ancianos, some of t h e m have not. Theirs is an advisory role to the Presidente Municipal (see Dennis 1973) and his officers, much as the group of ancianos serves in an advisory capacity to the municipal officers. Although some of those known as caracterizados are among the wealthier men of the community, there is no correlation between that status and their relative wealth. N o r can it be reported that this group of influentials is in any way self-perpetuating, passing their status on to sons or nephews. A m o n g the Ladinos, ownership of milk cows and the manufacture of cheese for the city market is profitable enough to contribute to the formation of a segment of the population that is considerably better off than others, and socially influential. Reflective of these wealth differences are a dozen locally owned pickup trucks, and one passenger auto. Since the introduction of electricity in 1969, television sets, refrigerators, and a few electric p u m p s to obtain water for household use have appeared. These innovations are so recent as to have begun with the current generation of middle-aged residents. T h e y derive f r o m increased access to the city with the arrival of the Pan-American highway

S u s t o , a Folk Illness/22

in the 1940s. The influential townspeople are characterized by formal schooling ranging from two to five years, with a mean of three and a half years; however, their schooling is little different from others of less influence. Their newly acquired status seems more closely related to an ability to exploit the few resources available, and to turn them to good advantage by commerce with the city. Furthermore, among these Ladino influential there seems to have developed a consciousness of like interests, and a growing social distance between them and those who have been less entrepreneurial. Although the criteria for identifying "leaders" among the Ladinos resemble those used to identify caracterizados among the Chinantecs, the former seem to have developed a greater sense of like interests and separation from others than is true of the caracterizados. The Ladino influential seem to act in a more cohesive fashion, being linked among themselves by godparental and other bonds. Nonetheless, governing structures in both towns encourage, even require, universal participation by males in public service, with the greatest responsibilities currently assigned to those boasting the greatest literacy in Spanish. The extensive lands cultivated by the Chinantecs and the logistics dictated by seasonal cultivation in distinctive ecological settings have led to the presence of several concentrations of population, of which the largest by far is in the head-town with a year-round population of approximately 600. Smaller numbers of people reside in hamlets constructed alongside the Sierra highway, which was completed in 1956. A few people live all year round in some of these hamlets, but most divide the year between their hamlet residences and their homes in the cabecera, or headtown. In the three sample communities, access to cultivable lands is the minimal feature of a reasonable life. In each, small privately held properties are important and are passed by inheritance from fathers to sons, more rarely to daughters. Access to arable land is the economic base of a family's existence, but it also serves to confirm that a man is a citizen with rights in the community,

The Samples/23 and obligations to its continued w e l l - b e i n g — t h a t he is an hijo del pueblo. A l t h o u g h all sons theoretically have reason to expect a share in heritable private holdings, in truth it m o s t often passes to the y o u n g e s t son in the expectation that he will assume responsibility for his aging parents as they b e c o m e unable to care for themselves. For similar reasons, the parental h o m e is usually assigned to the y o u n g e s t son as a f o r m of social security for the parents w h o expect to be able to remain u n d e r its protective roof. A l t h o u g h this appears the best insurance for enfeebled parents, it is n o t at all a strategy that encourages confidence, and m a n y families suffer severe t r a u m a , persisting for m a n y years, as the parents a t t e m p t to m a k e tactical decisions regarding distribution of private holdings and residences in order to ensure care for themselves in their declining years. Indeed, a m o n g the Zapotecs, there are instances of w i d o w s retaining rights to land they hold in trust so as to guarantee continuing s u p p o r t f r o m w a i t i n g sons. T h e i m p o r t a n c e of heritable private land and h o m e s is such that, apart f r o m its influence on relationships between parents and children, it often has a divisive effect on relations between brothers. A m o n g the Chinantec, competitiveness a m o n g b r o t h ers is o f t e n severely exacerbated by unequal distribution of their father's private properties. In addition, here and a m o n g the Ladinos, private holdings are c o m p l e m e n t e d by other properties, title to w h i c h rests in the c o m m u n i t y . T h e s e publicly held lands among-the C h i n a n t e c are c o m m u n a l in nature, c o m m u n i t y title dating f r o m early colonial or precolonial eras. T h e s e c o m m u n a l lands, the forests they bear, and the p r o d u c e of certain fruit-bearing groves, are controlled by a political and social entity k n o w n as Bienes Comunales. Bienes C o m u n a l e s is an association c o m p o s e d of native-born males w h o s e ancestors are credited w i t h wresting their gardening plots f r o m virgin forest. T h e association elects its o w n officials, and votes on legislation g o v e r n i n g these properties as well as to h o w profits f r o m their exploitation are to be used. For example, the highland t i m b e r is harvested by l u m b e r and p u l p w o o d c o m -

Susto, a Folk Illness/24 panies, w h i c h contract w i t h Bienes C o m u n a l e s as to the n u m b e r of b o a r d feet they will be p e r m i t t e d to cut d u r i n g a contract period, h o w m u c h the companies will pay per b o a r d foot, w h e r e access roads are to be built by the companies, and the scale of wages paid comuneros w h o fell and prepare the timber prior to cartage. A n y m a t t e r that affects the cultivation of c o m m u n a l soil, or the rights to its use, is a m a t t e r for decision by the m e m b e r s h i p of Bienes C o m u n a l e s , n o t the municipio. H o w e v e r , the m e m berships of Bienes C o m u n a l e s and the municipio overlap to a great extent, even t h o u g h there are a f e w individuals w h o w o r k only private lands and d o not have rights in c o m m u n a l holdings. A n o t h e r indication of the interrelationship that obtains b e t w e e n these a u t o n o m o u s entities is p r o v i d e d by the fact that the f e w m e n f r o m other municipios w h o m a r r y into Bienes C o m u n a l e s families gain access to arable lands b y p e r f o r m i n g cargos (duties) in the public service hierarchy. In contrast, publicly held lands a m o n g the Ladinos are n o t a reflection of the fact that they have been w o r k e d since " t i m e i m m e m o r i a l " by this community. Rather they represent an award in 1937 b y the agrarian r e f o r m agency, based on the need for land of these previously landless peasants. These lands w e r e e x propriated f r o m a large hacienda for w h i c h they had labored, and w e r e a w a r d e d in trust to the c o m m u n i t y of w h i c h they w e r e m e m b e r s . T h e s e ejido (public) lands are w o r k e d in small lots by peasants w h o are m e m b e r s of an ejido organization, w h i c h legislates their use. A l t h o u g h all m e m b e r s of the ejido are also m e m b e r s of the c o m m u n i t y , n o t all m e m b e r s of the c o m m u n i t y b e l o n g to the ejido or have rights to its lands. Despite the fact that b o t h Ladinos and Chinantecs m a y have rights to the use of lands title to w h i c h rests in a public entity, the c o m m u n a l lands of the C h i n a n t e c are far m o r e extensive than the ejido holdings of the Ladinos. C u l t i v a t i o n of the land and, in particular, the back-breaking tasks involved in t r a n s f o r m i n g it f r o m a wild to a cultivable state, is primarily a m a n ' s role. In all three c o m m u n i t i e s , culti-

The Samples/25 vation is impossible w i t h o u t p l o w animals. Uncastrated bulls are the animals of choice, and these are very expensive. A man w i t h o u t bulls must, therefore, rent t h e m f r o m a neighbor, or give part of his harvest to the o w n e r f r o m w h o m he rents them. An exception to this is found a m o n g those Chinantecs gardening in the tropical lowlands, w h e r e machete and digging stick are the only tools required. However, in all these groups, the often long distances between fields and h o m e make desirable such draft animals as horses, burros, and mules. T h e y literally take the load f r o m a man's back and are m u c h prized possessions. It is not u n c o m m o n for w o m e n , particularly f r o m the poorer families, to w o r k in the fields. However, w o m e n ' s tasks are of a lighter nature than their menfolk's. Similarly, unmarried men w o r k w i t h their fathers, and under their supervision, the more difficult tasks falling to the m o r e mature of the men. T h e most onerous w o r k is d o n e by hired day-laborers, those whose lack of land, illness, or other misfortune forces them to w o r k for others. A y o u t h reaches social maturity at the time of his marriage, regardless of chronological age. O n marrying, he becomes liable to c o m m u n i t y labor—tequio—clearing paths, building roads, or doing other construction w o r k , as ordered by the local authorities. Marriage also initiates his career in public service, where he will hold office well into his most vital years. A girl does not attain social maturity until she has borne viable children within a stable union. In the Indian groups, a w o m a n ' s relative i m m a t u r i t y will continue in marriage, if she resides in the household of her mother-in-law, until one of her o w n daughters provides a grandchild, product of a stable union. U n i f o r m l y , having children is positively evaluated and encouraged; it represents one of the foundations of a successful union. A union which has not produced offspring is considered problematic and inherently frail. Children validate their parents' union, add to the household's productive labor force, and p r o m ise social security for their parents in declining years. In a union w i t h o u t offspring, it is the w o m a n on w h o m the

Susto, a Folk Illness/26 blame is placed. A mother must also breast-feed each of her children and failure to do so makes her a subject of opprobrium. In these groups, there is a clear differentiation of gender-roles. From infancy on, boys and girls are socialized differently and, among the Chinantecs, midwives charge a family twice as much for the delivery of a boy: a male will earn twice as much as a girl, they point out. That is a realistic expectation since males earn considerably more than their sisters throughout life. They are able to command higher wages as agricultural hands, and possess many more opportunities to move to more lucrative employment in Mexican cities, or in the United States. These differential expectations for males and females are reflected in the extent to which boys and girls are encouraged to pursue formal schooling. When our current generation of middle-aged subjects was of school age, there existed far less opportunity to attend primary school, much less the secondary grades. At best, these towns provided schooling up to the fourth year, and it was decidedly rare for a pupil to leave home in order to pursue secondary education in an urban school. As late as 1970, in the Ladino town, the one best served by public transportation, costs of attending secondary school in the nearby capital were so great that only three adults had gone beyond the primary grades, all of them men (Corbett:40). Chinantec girls are dissuaded from continuing to the secondary level since they will not "need" such training in order to be mothers and housewives. "You are not going to serve as a town official," they are advised. This differing emphasis on formal schooling is reflected in distinctive levels of literacy and, within the Indian groups, command of the national language. Thus, few Zapotec girls at all attended classes prior to 1960. By 1965, however, the local school population more faithfully represented the sex ratios of school-age children. Nonetheless, of ten children attending secondary school in the city, only two were girls. Yet today, these Zapotec women, as well as the Zapotec men, take great pride in being literate. Among the Chinantecs, criteria for awarding respect to men

The Samples/27

and w o m e n m o r e clearly reflect differences in educational expectations. A m a n earns little respect if he does not have a good c o m m a n d of Spanish, and even less if he is illiterate, whereas a w o m a n m a y c o m m a n d respect even t h o u g h she is n o t literate or proficient in Spanish language skills. A m o n g the Mestizos: In the school census taken in 1970-71 . . . only three percent of the adults admitted to being illiterate. . . . These figures are no doubt deflated due to embarrassment involved in admitting illiteracy to the school teachers (who were the census takers). Illiteracy suffers severe negative sanction. Some w h o are listed as literate in the census admitted privately that they could not read or write, but answered affirmatively to avoid shame. (Krejci, 1974:32)

Similarly, the school census of Z a p o t e c pupils taken in 1965 listed 170 adult illiterates, of w h o m 150 w e r e w o m e n . O ' N e l l surmises that those figures grossly underestimated the illiteracy p r o b l e m , t h o u g h n o t necessarily the d i s p r o p o r t i o n b e t w e e n the sexes. Clearly, in the 1950s w h e n o u r sample was attending school, these t o w n s p r o v i d e d little o p p o r t u n i t y to proceed past the f o u r t h grade, and boys received far m o r e e n c o u r a g e m e n t to remain in school than did their sisters. T h r o u g h o u t those years, o u r sample attended p r i m a r y grades, and teachers resided in each of the three locations. T h e s e teachers t o o k active roles in i n t r o d u c i n g social and cultural change, and perceived themselves as m a n d a t e d by the national g o v e r n m e n t to r e c o m m e n d and i m p l e m e n t forcefully radical social, cultural, and e c o n o m i c changes. In a n u m b e r of i m p o r t a n t ways, these resident schoolteachers have exerted strong influence in each of the sample c o m m u n i t i e s . A l t h o u g h the three populations are Catholic in faith and training, n o n e boasts a resident Catholic priest. Religious celebrations and sacramental acts m u s t await the periodic visit of the parish priest, unless families go to churches in other communities. E x c e p t a m o n g the Zapotec, other religions did n o t gain a

Susto, a Folk Illness/28 f o o t h o l d until the late 1940s. A t that time, only about five percent of the Z a p o t e c s identified themselves w i t h evangelical g r o u p s . T h e n , s o m e residents, vociferous in their opposition to the use of h a r d - e a r n e d resources for the celebration of traditional religious feasts—especially sponsorship of the mayordomias (celebration of the s a i n t s ) — f o u n d a sympathetic hearing f r o m outside evangelical missionaries w h o w e r e periodic visitors. Today, m o s t of those Z a p o t e c s w h o are n o t practicing Catholics identify themselves as S e v e n t h - D a y Adventists. In the early years of that m o v e m e n t , m e m b e r s h i p in an evangelical cult separated adherents f r o m other residents, since the f o r m e r did not serve in i m p o r t a n t c o m m u n i t y roles celebrating the saints. This no longer represents a p r o b l e m because, in 1950, the t o w n authorities, s u p p o r t e d by a significant p r o p o r t i o n of the citizenry, simply decreed that m a y o r d o m i a s and other religious services w e r e n o longer obligatory. A l t h o u g h religious service became v o l u n t a r y in 1950, secular service to the c o m m u n i t y remained an obligation, a distinction that has continued. T h e municipal g o v e r n m e n t exercises f o r m a l control w i t h its local police, and derives its p o w e r f r o m the consensus s u p p o r t of the citizens. E v e n m o r e pervasive and of greater influence are the i n f o r m a l means of governance, b o t h h u m a n and supernatural. T h e r e are social n o r m s and, w h e n s o m e o n e has transgressed one of these n o r m s and is stricken by an infirmity or other grave p r o b l e m , the difficulty is c o m m o n l y attributed to the transgression. T h i s is another f o r m of governance. A b o v e all else, the g o o d citizen—man or w o m a n — i s the one w h o lives tranquilly, at peace w i t h his neighbors. T o live at odds w i t h one's fellow beings, to bear rancor, to be argumentative, to be clearly self-serving and selfish, grasping and uncooperative, will call i n t o play n o t only verbalization of the transgression by one's n e i g h b o r s b u t sanctions exercised b y supernatural beings. A t individual and c o m m u n i t y levels, every effort is m a d e to avoid disagreement and, considered m u c h w o r s e , open c o n f r o n t a t i o n over differences of opinion. Consensus is s o u g h t at

The Samples/29

all costs but, failing that level of agreement, differences are played down, and the rhetoric of being "a united pueblo" becomes overriding. A commentary in the municipal archives of the Mestizo town provides a good illustration. Although acquisition of a water system ensuring potable water was of high priority to the community, the plan recommended by government engineers remained unapproved and unimplemented for a full six years because it would have provided residents of two barrios easier access to the hydrants than residents of the third. A substitute plan was finally developed that provided for more equal access to the hydrants for the entire community. The archives note, as follows: "Not to take that potential problem [unequal access] into account could well generate divisiveness between us, causing many problems. What we most ardently desire is always to work together in a unified manner." With respect to the decision to host a full-time physician among the Chinantecs, a matter we know to have been controversial, the following interview segment is relevant. "Following 1958, then, little by little the government began to pay some attention to the needs of the community. So that in 1972 it began to provide a physician. The matter o f healing began to undergo changes; prior to that time healing had been in one's o w n hands. It was the new highway which made the difference." "Were you in favor o f bringing a physician into the community?" "Oh, yes! We were all in agreement." "You were all in agreement? In other communities the elders have opposed the arrival of a physician." "No, no. Here, thanks be to God, a unified front has always been present. Everyone united. Everyone together, a consensus, here it has always been that way."

Similar commentaries about potentially divisive problems and ways of resolving them by avoiding fractiousness are found throughout the field notes.

3 Description of Susto

A S indicated in the previous chapters, social norms are enforced by indirect sanctions at least as constraining, if not more so, as the police power of the municipio and state. The most often apparent of these is sickness, which is considered a social sanction. Sickness is attributed to both the initiative of supernatural forces and to the manipulation of such forces by evil humans, who are thought to be witches. An individual who becomes symptomatic seeks alleviation but, at the same time, searches for possible reasons why he or she has become ill at that particular time. Individuals are understood to vary considerably in their relative susceptibility to sickness: some are strong and, consequently, resistant, others weak and susceptible. The very young and the very old are inherently weak—the former have not yet developed resistance, the latter are in the process of losing it. In addition, women are considered weaker and more susceptible to sickness than men. Within each of these groups it is recognized that some individuals are relatively stronger than others. Thus, it is assumed that, when two individuals of the same sex and approximate age are exposed to the same noxious circumstances, one may succumb and the other may not. Those differing reactions are regularly observed and noted by the people. The differences are explained by the fact that the one who succumbed was simply less resistant than the others: "Her blood is weaker." Traditional specialists—diagnosticians and diviners—are able to predict who is weak and more susceptible and who is strong and more resistant by the way in which a person's blood courses through his body, a determi30

Description of Susto/31 nation m a d e b y pulsing, or "reading the b l o o d , " "listening to the b l o o d , " "consulting the b l o o d . " F u r t h e r m o r e , reading the b l o o d t h r o u g h pulsing at the wrist enables a curer to determine the relative gravity of a patient's condition. In instances in w h i c h a patient is neither very y o u n g n o r of advanced age, and has e n j o y e d relatively g o o d health, s y m p t o m s cause considerable preoccupation. If the patient fails to respond to the t r e a t m e n t called for b y the diagnosis, concern is heightened. T h e r e is then the possibility that he is suffering the consequences of an inadvertent slight or affront to a supernatural being or, and of equal seriousness, he is a victim of s o m e o n e else's malevolence. Fear of exciting s o m e o n e else's rancor is a p o w e r f u l contributing factor to the effort to live at peace—en tranquilidad—with family and neighbors. Such u n d e r s t a n d i n g s are part of a comprehensive explanatory f r a m e w o r k by w h i c h occurrences of illness are explained. In this view, illness—lack of well-being—derives f r o m the loss of vital bodily substances such as blood, semen, heat, or the essence k n o w n as alma (soul). T h e other i m m e d i a t e cause of illness is attributed to the intrusion of a foreign substance or substances. P r o m i n e n t a m o n g these substances are spirits or their representations in the f o r m of aires (winds, breezes) as well as insects, w o r m s , or such objects as twigs, pebbles, and tobacco smoke, w h i c h are forced into a victim's b o d y at the behest of a witch. G o o d health is equated w i t h systemic h a r m o n y , or h o m e o stasis. In a healthy body, balance is characterized by the even distribution of " h o t " and " c o l d " h u m o r s . A n y t h i n g that w o u l d disturb that distribution should be avoided. Potential sources of disturbance include (1) the w a n d e r i n g or displacement of the " s o u l , " w o m b , fontanel, or nerves, (2) a rush of heat, cold, moisture, or p o w e r f u l e m o t i o n s , too s t r o n g or too sudden to allow the b o d y to re-equilibrate on its o w n , (3) failure of either n o r m a l or diseased b o d y fluids to drain completely, since selfcleansing is essential for equilibrium. S y m p t o m s indicate that balance has been disrupted by internal or external stressors. T h e y f u r t h e r indicate w h a t m u s t be done

Susto, a Folk Illness/32 to restore equilibrium. The steps taken to restore balance vary according to the imbalance perceived. They usually require administration of herbs, foods, or other substances to neutralize the imbalance: purgatives to unclog offending organs or orifices, and the use of a live chicken, turkey, or other instrument, which they brush over the patient to "sweep out" an intrusive substance and absorb it. Clearly, these are not the only concepts with which our sample people confront illness, but they do form the ideology to which such new ideas as the effects of bacteria and the efficacy of antibiotics are adapted. Ideas about the prevention and curing of illnesses logically flow from these explanations. Individuals are careful to avoid excessive loss of bodily substances, but when this proves unavoidable they "replenish" them as rapidly as possible. Strong emotions are avoided, and precautions taken to avoid rancorous social relations, which may incite another to direct invasive magic against an offender. Finally, care is constantly taken to prevent qualitative changes in the humoral balance of the body: to avoid becoming too "cold" or too "hot." When homeostasis is lost, the victim is administered herbs and minerals that contain the needed "qualities" in the proper amounts. Likewise, sickness attributed to loss of vital essences is cured by recalling or replenishing them. Foreign materials intrusive to the body are drawn or swept out by magical means, usually by ritual specialists. It is within this general frame of health and illness that we will discuss susto, one of the most prevalent of all those illnesses of which these people complain. Susto is a well-recognized entity with a well-established etiology, diagnosis, and regimen of healing. Although understanding of susto varies among villages and even among residents of the same village, the consistency across otherwise distinctive cultures is most impressive. There are some exceptions, among which are the nouveaux riches among the Ladinos in this study who currently deny the reality of susto as a problem. Some case materials follow to illustrate the reality of susto in these three societies.

Description of Susto/33 When residents o f the Ladino village heard the report that a middle-aged neighbor had committed suicide, "an epidemic o f sustos resulted among relatives and neighbors." O n e o f those who was asustada (asustado for males, asustada for females) was Elena, an elderly aunt o f the suicide, a widow who, even prior to her husband's death, had been quite poor. She now owned insufficient land and had to launder the clothing o f others in order to support herself. Elena had borne nine children, o f whom seven had died in infancy and an eighth at the age o f 20. Her remaining son was mentally retarded with a serious drinking problem, causing Elena considerable anxiety. She acknowledged herself to be held in low esteem by her neighbors who considered her a gossip who "sweeps the dirt from the streets with her long skirts!" O n one visit to the anthropologists, she commented, as she wiped her face and eyes in exhaustion, "I have suffered so much, and have had so many sustos." Another instance from the Ladino village should be mentioned because it clearly outlines the circumstances under which susto (the condition) can be expected to occur. Our ethnologist was pregnant at the time, and her husband was gathering data in another village. Heavy rains threatened to bring down a r o o f under which the family automobile was parked, requiring her to move the car. After she accomplished this, a neighbor suggested she be given a simple preventive cure for susto, both for her own sake and that o f her unborn child. T h e helpful neighbor went home and returned with a bottle o f mezcal (an alcoholic beverage) and proceeded to spray Jean's chest and back with the cold liquor, causing Jean to gasp from the shock. Over the next few days, other neighbors brought gifts o f eggs, tortillas, and cheese, suggesting that, if she did in fact develop susto, she would not be able to or would not want to engage in her normal cooking activities. T w o Zapotec cases follow. T h e first refers to a woman who devoted her time primarily to the care o f her husband and their only child, a boy, and secondarily to the manufacture o f pottery ware for commercial sale. O n one o f her weekly trips to market,

Susto, a Folk Illness/34

the heavily laden burro—carrying all her pottery—repeatedly fell to the ground, eventually smashing the entire load. There is no indication from her account that she felt in any personal danger from the awkward animal, nor is there any indication that she suffered explicit repercussions from her husband, although the financial loss to the family was considerable. One year following the incident, she reported herself suffering from susto, which she attributed to the earlier event. In the year elapsing between the loss of her pottery and the initial complaint of susto, several things had occurred. Most important of all was that she had twice become pregnant and twice suffered spontaneous abortions. She expressed a fear that she might never conceive and deliver another viable child. Her concern over her son increased and became a constant, gnawing fear. She and her husband both explicitly expressed a desire to have more children, but the miscarriages had increased their doubts that they would attain that cherished goal. A neighbor of theirs explained his own susto condition as a result of recently coming upon a dangerous snake ensconced in an arroyo (dry gully). He reported being startled, but he could recall no sense of fear until he attempted to kill the creature, only to discover it had disappeared as suddenly as it had revealed itself. His was a short-lived fright, however, and he forgot about it in his preoccupation with other matters on the walk home. A few weeks later he felt ill enough to consult a physician. The resultant treatment availed him little and, since his discomfort continued unrelieved—in fact he thought it worsened after that treatment—he consulted a local curandera (healer). During his meeting with her, she probed for events in the past that would serve to explain his problem; they agreed that the encounter with the snake was of importance and that he was suffering susto due to that frightening experience. To understand this man's problem in full context, one must be aware that, prior to and following the incident with the snake, he had bought a lot and had begun to build a house on it. However, due to his failure to ensure that he held clear title to

Description of Susto/35 the plot, he was forced into long litigation, risking loss of his investment in both the land and the newly constructed house. We will return to this case shortly. In another case, a wife was subject to constant accusations that she was not as responsive to her husband's needs as a wife should be, and that she was also negligent in the care of their modest home. One evening, after berating her once more for her inadequacies, her husband went out. She resolved to wait up for him and, when darkness enveloped the reed structure of the house, she lit a kerosene lamp to serve a double purpose— to keep her awake, and to light his path home. She grew increasingly sleepy with the passage of time, but he still did not appear. She refilled and relit the lamp, and decided to hang it from a hook in the ceiling. She was determined to stay awake, but she leaned against one of the reed walls, and promptly feel asleep. As she slept, the lamp shifted position on the hook and slipped to the side of the wall where she reclined. She was awakened by the flames, which not only licked at her clothing but were beginning to engulf one wall of the house. At that moment her husband made his appearance and, between the two of them, they beat out the flames. She was not burned badly, but one entire section of the residence had been destroyed. She was terribly frightened by this calamity and became asustada. The husband used the accident to confirm his earlier accusations of her negligence. During our research, a woman described a susto that had occurred to her in 1939. This Chinantec had been traveling at that time from the fields back to her home. She and her companions were beginning to ford a swift-flowing river when she lost her footing and fell in the water—"me empujo el rio." The current started to sweep her away, but her companions were able to reach in and pull her out, senseless and soaking wet. Someone loaned her a blouse until her own clothes had dried out. Immediately after her rescue she had "felt asustada." She suffered only a loss of appetite at the time, and did not lack energy

Susto, a Folk Illness/36

or m o t i v a t i o n to carry o u t her c u s t o m a r y duties until three years later, in 1942, w h e n her matrix (uterus) began to pain her. Field notes record her account: " I m m e d i a t e l y after the accident in the river she felt a loss of appetite; h o w e v e r , she did not then feel a loss of m o t i v a t i o n in carrying o u t her usual role tasks until the susto illness was j o i n e d by the matriz illness, b o t h together p u t ting her o u t . " At the time of the cited interview, 32 years after her susto del rio, she was suffering f r o m three sustos and a h e m o r r h a g i n g condition, w h i c h she attributed to a "loosening" of the w o m b — " s e aflojo la m a t r i z . " T h e second of her three sustos had occurred as a result of encountering a snake, and the third occurred as a consequence of looking on while one man killed another in o n e of the hamlets w h e r e she w o r k e d . T h r e e m o n t h s prior to o u r visit, her condition had taken a decided t u r n for the worse, and for the ensuing t h r e e - m o n t h p e r i o d — d a y and n i g h t — s h e had lain on a sleeping mat at h o m e . She was unable to sit u p for m o r e than ten minutes at a time, as was m a d e evident d u r i n g o u r visit. She complained that w h e n she did sit u p r i g h t , her spinal c o l u m n hurt. While in a standing position, her w o m b ached. W h e n e v e r she climbed the hill, she lost her breath; her breath n o longer "circulated." When she w o r k e d m u c h in the house, or w a l k e d uphill, her spinal c o l u m n h u r t . E v e n w h i l e lying d o w n it h u r t her. N o w she had no appetite and w h e n she did eat s o m e t h i n g , she was unable to keep it d o w n . "She does n o t w a n t to d o anything, n o t h i n g at all in the house. A hired w o m a n does everything; w h e n she eats tortillas, they taste like chicle." Medical examination by Dr. Collado revealed a large, t h o u g h p r o b a b l y benign, uterine t u m o r . Surgical intervention was strongly r e c o m m e n d e d , but rejected as unfeasible by the patient and her father. O n a n o t h e r occasion, the h u s b a n d of an asustada w o m a n s o u g h t consultation f r o m the anthropologist. H e and his w i f e had one child, a boy. T h e y v e r y badly w a n t e d a larger family, but d u r i n g the nine years f o l l o w i n g the birth of their son the w i f e had suffered seven miscarriages. She was presently p r e g nant, and was terribly concerned that she w o u l d again fail to

Description of Susto/37 carry the fetus to t e r m . She was suffering f r o m a serious susto, w h i c h had occurred s o m e years before. T h e h u s b a n d i n f o r m e d us that she was o n e of those individuals w h o , ever since childh o o d , s h o w themselves to be w e a k and easily asustada. (Clinical examination of his w i f e f o u n d that she suffered palpitation and breathing difficulties subsequent to physical labor. H e r blood pressure and pulse w e r e n o r m a l , a l t h o u g h she complained of a buzzing in her ears. She complained of generalized pains and weakness, and a bad taste in her m o u t h , swelling of her feet, and n i g h t m a r e s . Varicosities w e r e detected, and laboratory results indicated the presence o f t w o classes of parasites, and a slight anemia. Despite all of this, the pregnancy concluded h a p pily, resulting in a healthy boy. T h e n there was the case of Rogelio, a C h i n a n t e c w h o vacillated b e t w e e n calling his p r o b l e m muina (repressed anger) and a c k n o w l e d g i n g it as susto. W h e n interviewed and examined in 1971, Rogelio was 57 years old. N i n e years earlier he and one of his t w o sons had been part of a force that had engaged in battle w i t h a n e i g h b o r i n g municipio over a piece of land (see D e n n i s 1976:176-177). D u r i n g the attack, the son had been killed and it had fallen to Rogelio to carry his b o d y back to their h o m e village. H e w a s v e r y sad at that time, finding himself left w i t h only one other son, and a daughter w h o lived in M e x i c o City. H e lost interest in his w o r k and in living, he w e p t frequently, and felt himself to be w e a k e n i n g physically. According to R o gelio, his health had taken a decided t u r n for the w o r s e a year before he came to our attention. O n e day in 1970, he felt a generalized pain and "a b u r n i n g in his h e a r t " [pointing to his right a b d o m i n a l area]. T h i s was precipitated by an effort to lift a sack of corn to his back. As a consequence of these difficulties, he had consulted a physician w h o advised that he suffered "liver p r o b l e m s " for w h i c h he was then treated. H e later suffered a b o u t of diarrhea and w o r s e n e d ; he lost his appetite, his entire b o d y swelled, and he lost la Juerza (power, strength). Additional e t h n o g r a p h i c i n f o r m a t i o n indicates that his rem a i n i n g son w a s so d r u n k and disorderly on one occasion (in

Susto, a Folk Illness/38

N o v e m b e r 1970) that the municipal police placed him under arrest. H e succeeded in escaping only to be recaptured and placed in jail. He refused to pay the fine assessed him by the municipal authorities because, he claimed, someone had stolen some of his personal possessions while he was in custody. Consequently, the authorities removed him f r o m jail and incarcerated his father, Rogelio, in his stead, as the responsible head of the household. Rogelio languished in jail for t w o days and t w o nights, suffering intensely f r o m the cold, and f r o m mortification. When he finally agreed to pay his son's fine, he was released. By then he felt "very weak and, more than anything else, very, very sad" ("muy triste, muy, muy, triste. Otra vez me asusté"). H e had suffered another susto. Later, in 1971, while pasturing his draft animals, a drunk began shooting capriciously in the area where Rogelio was w o r k ing, some of the bullets landing quite close to him. Thinking himself the target, he hid behind some bushes, and again suffered a susto. H e attributes the seriousness of his present condition to the combination of three sustos. His incapacitation continued and a prominent local healer was consulted. We observed his efforts to erase any doubts as to the nature of the problem; he diagnosed it as susto and wasted no time in beginning procedures for curing it. He directed the family to have a n u m b e r of items on hand for him when he returned that night. These included a bottle of mezcal liquor, a small bottle oí catalán—another liquor—a cross made of blessed palm leaves, an embroidered image of a saint, cigarettes, leaves of the tarabundi tree, resin, and one of Rogelio's shirts. We were invited to watch the proceedings. T h a t night, after dark, the curer waited until there were no further sounds f r o m either revelers or the usual passel of dogs. He then stepped outside the house carrying all the articles with the exception of the catalán. T h e sudden barking of dogs persuaded him to go back inside until it was absolutely quiet; he waited another twenty minutes, and then ventured outside once again.

Description of Susto/39 In the garden, the curer took the bottle of mezcal and shook it vigorously, allowing some to fall to the ground as a libation. He prayed to the spirits inhabiting the area who might have been responsible for capturing Rogelio's vital substance. After finishing several stanzas of prayer in which he called Rogelio's name, in an attempt to retrieve Rogelio's vital substance, he threw a cigarette to the ground, as an offering. He turned to face in a different direction, and repeated the procedure in its entirety. When he had faced in four directions, each time praying, throwing a cigarette to the ground, and calling to Rogelio's vital force, he took the patient's shirt, shook it to its full length, and then rolled it up again. We then walked slowly and deliberately back to the house, where he lit resinous coals in the waiting brazier, moved the brazier next to the prone patient, and unrolled the shirt in which were the palm leaf cross and the embroidered image. He drew the shirt through the heavy clouds of smoke to waft them over the face and head of the reclining patient. A tea of nine herbs was prepared and the patient instructed to drink it, as well as some of the catalán. The weakened condition of Rogelio can be estimated by the observation that he was unable to come to a sitting position unassisted; after his wife and son had pulled him to an upright position, his wife scurried around behind, placing her back against his to support him while he sipped the tea. Finally, the tarabundi leaves were wrapped around his feet (it was later discovered that these were for another of his health problems, not directly related to his susto condition). The wife, the son, and the daughter, who had been called from Mexico City because of her father's grave condition, were all advised to watch the patient closely. N o one was to sleep that night if the cure was to be effective! The healer made arrangements with the anthropologist to look in on the patient early the following morning. (On leaving, the anthropologist was convinced that he would never again see Rogelio alive.) However, he certainly was alive the following

Susto, a Folk Illness/40

morning, although not much improved. The curer explained the lack of improvement with the observation that someone in the family must have fallen asleep. We could look in on Rogelio in the early evening, which we did. He remained unimproved. The healer counseled that no one of those watching over the patient was to fall asleep or the cure would come to naught. O n the following morning, the patient showed signs of a slight recovery and asked for coffee. He seemed to be somewhat more energetic, chipper, and better oriented to his surroundings. The following day was marked by a relapse in which he was as lifeless as on the day treatment had begun. However, following that one-day relapse, he began a slow recovery, regaining his animation and strength a bit more each day. By the end of the third day of recovery, he was walking about the house with the aid of a cane, going outside the house to relieve himself, and talking with others. Several months later, on returning to the village, the anthropologist wrote the following observations: Today saw Rogelio, our patient. He is not only walking about and visiting with neighbors, he is all smiles and laughs, recognizing full well that he had been, in his words "ready to deliver up the account." He n o w boasts a good appetite and says that when he was very grave, but on his way to recovery, they fought the good fight ("hicieron la lucha") and obtained four chickens, one o f which he ate entirely by himself, the others he shared. He reports having eaten "like a coyote." Even n o w he is hungry at noontime and again by 3:00 in the afternoon, and he eats tortillas, beans, some meat if he can find it. Also, they have bought some canned condensed milk (a luxury) which he mixes with his coffee.

Several days following that encounter, we found him working in a road construction crew. His job was to wield a heavy steel tamp to crush stone into gravel. Asked how he felt, he smilingly talked about his newfound strength and stamina.

Description of Susto/41 B e t w e e n the t i m e of the curer's ministrations and his seemingly complete recovery, he was examined by the project p h y sician. T h e f o l l o w i n g is f r o m that clinical record: Pale and thin, he showed little interest in what was going on around him. Hypotensive—80/50—with a rhythmic pulse of 85 per minute. Heart sounds were without alterations. He complained of a pain in the right hypochondrium, but no other observed pathology. T h e l a b o r a t o r y reported: ". . . h e m o g l o b i n of 10.1 g r . % w i t h 4.2 million red b l o o d cells per milliliter, hematocrit was 3 5 % , and n o evidence of parasites." Rogelio was one of those asustados w h o subsequently died; w e remain u n i n f o r m e d as to the cause of his death. Several cases of susto have been presented in varying degree of completeness f r o m each of these culturally different p o p u l a tions. In each instance, there was an understanding by the people involved that the victim had lost a vital part of himself or herself, and that that vital part was recoverable if appropriate measures w e r e taken. A l t h o u g h the t e r m m o s t universally used in Spanish for this vital part is alma, w h i c h has reference to the Christian concept of soul, use of this t e r m for all three of the populations n o w seems inappropriate, for reasons that follow. A m o n g the Chinantec, a victim is u n d e r s t o o d to have lost a vital substance (called the bi4 in that language),* w h i c h is held captive by spirit forces o f the locality w h e r e a startling event has occurred. T h e bi 4 is referred to by several Spanish glosses:^«er2:0.05f

Zapotee

33.5

Mestizo

106.5

—

-1.75

Mann-Whitney U Test * Significant at «0.05, one tail, f Not significant.

71

«0.025* «0.04*

Susto, a Folk Illness/72 TABLE 2 SOCIAL STRESS SCORES: ASUSTADOS AND C O N T R O L S

Gender All Males All Females

U

z

42.5 537.0

—

-1.60

Probability Level «0.025* «0.05*

M a n n - W h i t n e y U Test * Significant at SO.05, one tail.

A positive association existed between high scores for stress and complaints of susto in all three communities. The association proved statistically significant for the Zapotec and Mestizo groups, but fell just short of the 0.05 level among the Chinantecs. We then segregated males and females across the sample without respect to cultural affiliation, the results of which are shown in table 2. Again, a positive association occurred in the two tests, in each case statistically significant. Inferentially, regardless of culture, a high level of social stress and complaints of susto were associated among both men and women. Tables 1 and 2 are somewhat redundant, but they require different data alignments so that the ordinal positions of the Social Stress Gauge are somewhat different. One could not assume that, given the results in table 1, those in table 2 would follow. We employed one further test of the basic hypothesis by controlling cultural affiliation, gender, and age simultaneously. Since the results shown in tables 1 and 2 were in the direction predicted, but failed to attain statistical significance for the Chinantec sample, tests of the matched pairs were limited to community consideration rather than opened to a total sample analysis. The figures in table 3 show that, when matched by relative age, sex, and ethnic group, asustados registered significantly higher levels of stress than controls among Zapotecs and Mestizos, but the association fell just short of the acceptable level of significance among Chinantecs.

Results/73 TABLE 3 SOCIAL STRESS: MATCHED

PAIRS

Probability Level

Culture

T

Chinantec

68

>0.05f

Zapotee

10

«0.01*

Mestizo

19

«0.005*

Wilcoxon Matched-Pairs Signed-Ranks Test * Significant at =£0.05, one tail, f Not significant.

Indications of Psychiatric Impairment The results (table 4) show no statistical differences between asustados and controls with respect to psychiatric impairments. The screening score failed to differentiate between asustada women and their controls or between the two male samples. To state this important finding somewhat differently, symptoms tapped by this screening instrument were not significantly different when persons actively complaining of susto were compared with those who were not. Susto is not associated with psychiatric impairment as measured by the 22-Item Screening Score.

TABLE

4

MODIFIED 22-ITEM SCREENING

SCORE:

GENDER

Gender All Males All Females

U

z

Probability Level

63.5

-1.58

s=0.06t

658.0

-0.48

3=0.32f

Mann-Whitney U Test t N o t significant.

Susto, a Folk Illness/74 TABLE 5 MODIFIED 2 2 - I T E M SCREENING SCORE: CULTURE

Culture Chinantec

U

z

Probability Level

155.0

-1.12

Zapotec

62.5

-1.38

3=0.13f 5=0.08f

Mestizo

140.0

-0.68

3=0.24f

Mann-Whitney U Test f Not significant.

Are these results truly ". . . a rough indication of where people lie on a continuum of impairment in life functioning due to very c o m m o n types of psychiatric symptoms" (Langner 1962:269), the purpose for which the index was adapted? O r were they simply chance results obtained by an instrument that may have been inadequate for tapping the cognitive world of these Mexican peasants? The following speaks to that issue. Although individuals' scores did range broadly up and down the scale, their distribution failed to differentiate those with susto from those without. This finding was as true of one community as of the others (table 5). Moreover, failure to find a statistical association between having susto and a high score on the test for psychiatric impairment was characteristic of both men and women (table 4). An interesting and provocative pattern did appear in that, when a break-even point was established at the 11.5 level, women, regardless of culture, consistently scored above that level, rather than below it. In contrast, men scored high and low with equal frequency in the Zapotec and Mestizo groups, whereas Chinantec males scored below that break-even point three times more frequently than they scored above it (table 6). This pattern acquires more significance when compared with results from other cultural groups. Roberts et al. (1973:19) summarized their study of American Blacks, as follows:

Results/75 TABLE 6 MODIFIED 2 2 - I T E M SCREENING S C O R E : G E N D E R DIFFERENCES

Gender

High (above 11.5)

Low (below 11.5)

All Males

12 (43%)

16 (57%)

All Females

48 (65%)

27 (35%)

Totals

60 (58%)

43 (42%)

N = 103 (100%)

T h e f i n d i n g f o r this s a m p l e that f e m a l e s h a v e higher s c o r e s than m a l e s is c o r r o b o r a t e d b y e v e r y s t u d y r e p o r t e d but o n e w h i c h has e x a m i n e d s y m p t o m s c o r e s in relation to s e x . [ A l s o ] . . . s e x u a l status o v e r r i d e s b o t h s o c i o e c o n o m i c status and a g e . ( C f . C r a n d e l l a n d D o h r e n w e n d ; G a i t z and S c o t t )

In none of the three communities did level of education affect psychiatric impairment score. Moreover, even taking into account income differences in the Mestizo group, we could not find an association between economic status and either total score or the manner in which an individual's score was distributed between the physiological and psychological subsets. In view of the fact that measures of organic health were available on the same respondents for whom we had 22-Item test scores, it seemed reasonable to find some association between high score on organic problems and high score on those three of the 22 items said to reflect physiological orientation. However, when these physiological items were selected out, and their scores compared with measures of severity of organic disease, no association was discovered (table 7). An effort to find some correlation between these same physiological items and measures of gravity of disease was unrewarding (table 8). The conclusion to be drawn is that, in these Oaxaca societies, as in social groups in the United States, women are emotionally

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4-» 0

fi

- 3 t/iD C i -i— ?, .se c o o u ¡i „O 2 8 Qh rt vì o y . è. c Jl> « g C Q •BJS „ -D 6

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Si O \0 Q\ ,2 "I" S § 5QU H c " 2 2 c o WO •«.su § x¡ . C ^ rt O c ^ -a *-» aj t/i •fílj S C 'rt < o 0.05t

Zapotee

0.6

1.92

>0.05f

0.2

0.49

>0.20f

Mestizo

-0.2

0.75

>0.20f

0.04

>0.20f

Spearman Rho Test f Not significant.

r

,

-0.01

Asustados Probability t Level

Interrelationships Among Results/119

why both social stress and gravity of disease are associated with susto complaints and not associated with one another. Similar puzzling results are reported by other stress researchers (McGrath 1970:12-13). One must guard against an overly simplistic interpretation of the relationships among mind, body, and social dimensions in any evaluation of relative states of well-being. As indicated elsewhere, we express bemusement, not dismay, at the lack of correlation between a social stress score and measures of gravity of disease (O'Nell, Rubel, and Collado 1978). Unfortunately, this research was not organized to provide historical depth, nor did it lend itself to sequential analysis of the several problems affecting the asustados. It was difficult to discern from these results whether susto victims became seriously diseased first and then experienced a drop in role performance or whether they performed unsatisfactorily first and then suffered health impairments. As noted earlier in the folk explanation, the great variability in time elapsing between the frightening event that precipitated the susto and the onset of signs and symptoms made a sequential analysis even more problematic. Nonetheless, some inferences of a temporal nature were possible. Longitudinal information was available in responses to some of the questions on the Social Stress Gauge. For example, we found that an adult who had not completed the number of years of formal schooling he or she thought essential had been suffering from that discrepancy for a number of years. For those who considered it necessary to own plow animals but failed to possess them, the consequences of that incongruence had been cumulating over the years. Similarly, women who experienced difficulties in bearing children or nurturing them through infancy provided a time depth not otherwise available. These sequential data suggested that an individual's sense of social inadequacy probably preceded the onset of disease. Acknowledging to himself that he is not meeting his own standards of performance in critical tasks apparently makes a person's body even more vulnerable to endemic disease, a sequence that has dangerous con-

Susto, a Folk Illness/120 sequences for overall well-being—socio-economic, organic, and emotional. T o suffer f r o m susto is to suffer a deterioration in overall well-being. T h e associations w e have reported are only that. T h e y do not suggest that one or m o r e sustos cause an increase in n u m b e r of s y m p t o m s , or exacerbation of severity, or that they bring about the asustado's demise. H o w e v e r , there remains n o d o u b t that susto greatly increases the probability of grievous deterioration in health, and eventual death. O u r results c o n f i r m e d an interaction a m o n g the complaint of susto, inadequacy in the p e r f o r m a n c e of social role, and a heavier than o r d i n a r y disease load. Suffering susto adds to the already heavy b u r d e n of disease c o m m o n l y experienced by Oaxacan villagers. Clearly, it did not require an interdisciplinary project like this one to p o i n t o u t that O a x a c a n villagers bore m o r e than their share of disease. It was only by means of such an investigation, h o w e v e r , that s o m e peasants w e r e identified as m o r e diseased than others and that that difference was associated w i t h the susto condition.

Implications of This Study T h e value of taking an interdisciplinary approach to p r o b l e m s of well-being in other cultures is strongly affirmed by these results. We began w i t h a social anthropological question seeking the relationship b e t w e e n social role p e r f o r m a n c e and the susto condition. Subsequent inclusion of a physician in the research g r o u p p r o v i d e d n e w perspectives, added clinical questions, and obliged us to consider interactions between clinical and social p h e n o m e n a w h i c h w e had n o t expected. A s k i n g u n c o m m o n questions p r o d u c e d unexpected i n f o r m a t i o n a b o u t the susto p h e n o m e n o n . T h i s n e w i n f o r m a t i o n carries i m p o r t a n t implications for b o t h social scientists and clinicians. Susto poses a challenge to cosmopolitan medicine: it d e m a n d s of the clinician an u n d e r s t a n d i n g of its cause, its dynamics, and

Interrelationships A m o n g Results/121

the means of prevention. It is dangerous to the health of the individual and, consequently, detrimental to the well-being of society. We have shown that the presence of susto demonstrably adds to an already heavy burden of disease among rural Mexicans. For practitioners the message is clear: if a patient includes susto in the presenting complaint, he or she is more likely to be overwhelmed by the overall clinical problems, less able to cope with obligations, and less capable of earning a living or otherwise contributing to maintenance of the family. Such physical exhaustion and its accompanying lack of ordinary motivation to accomplish daily tasks should cause attending physicians alarm and alert them to a potentially life-threatening situation. The results have important implications for anthropology as well. They show the fruitfulness of a search for cross-cultural generalizations about a clearly defined phenomenon in a culture area in which substantial ethnographic background is already available. Under such benevolent circumstances, controlled comparisons can produce generalizations across a range of similar societies. Our own efforts were encouraged by the already solid ethnographic base provided by earlier studies of the health dimensions of Mexican cultures (Aguirre Beltran 1963; Carrasco 1960; Foster 1951; and others). The results demonstrate the value of analyzing how patients afflicted by a folk condition act out being ill as opposed to simply providing a description of how a group understands and explains it. We assumed that, in any society, difficulties that caused suffering or impairment would be responded to actively, not fatalistically, and that that behavior would be susceptible to description, comparison, and analysis (Kluckhohn 1953:509-510). We assumed that when disease was involved some of the victim's response would be generated by the pathology itself, relatively free of cultural guidance, and that it would prove rewarding to probe for it. The effort bore fruit. Because we used the methodology of cross-cultural, controlled comparison, our results took us beyond how residents

Susto, a Folk Illness/122

of one small and culturally specific municipio in Mexico coped w i t h a p r o b l e m . O u r findings transcend cultural boundaries, applying equally well to three g r o u p s w i t h distinctive languages, cultures, and social histories. We n o w understand better s o m e of the w a y s that social, biological, and emotional systems of rural Mexicans respond to t r y i n g circumstances. A l t h o u g h the hypothesized relationship between a susto c o m plaint and a victim's inadequate level of role p e r f o r m a n c e was d e m o n s t r a t e d , it p r o v e d insufficient to explain susto. Finding that asustados also suffered an u n c o m m o n l y heavy b u r d e n of biological disease obliged us to reappraise the premises w i t h w h i c h w e began. N o w it is inadequate and inappropriate to conceive of susto as a f o r m of u n i q u e social behavior on the one hand, or as a purely biomedical p h e n o m e n o n on the other. Before collection of these data, w e had argued (Rubel 1964:280; O ' N e l l and Selby 1968:97; O ' N e l l 1972:4) that a susto complaint simply legitimized " t i m e o f f ' f r o m the exigencies of everyday roles, and w e f o u n d Uzzell's (1974) application of the sick-role concept persuasive and helpful. H o w e v e r , o u r n e w findings d e m o n s t r a t e that the life burdens of o r d i n a r y Oaxacans o v e r b u r d e n the asustados. D o u b l y taxed b y a perceived inability to p e r f o r m critical role assignments and an excessive load of disease, the asustado finds it impossible to carry out his n o r m a l responsibilities. Rather than electing the sick role to legitimize a respite f r o m their o b ligations, asustados are forced to the sidelines by excessive d e m a n d s on their adaptive resources. It remains a theoretical possibility that other folk illnesses could be credibly explained as either uniquely social or uniquely biological processes. Such a conclusion must, however, remain in d o u b t until empirical research has taken the other, rival p o s sibility into account and seriously p r o b e d its explanatory value. As o u r results d e m o n s t r a t e , the m o s t f r u i t f u l approach to u n derstanding folk illnesses is to seek an interaction between social and biological factors.

Appendix

22-Item Screening Score for Measuring Psychiatric Impairment (Modified) 1. D o you feel tired most of the time?

2. Are there many times when you don't feel like doing anything? 3. H o w do you feel most of the time? Happy, variable, worried?

4. D o you often feel that others are not helpful enough? 5. Are you ever troubled by your heart beating very strongly and quickly? 6. D o you usually enjoy eating?

7. Are there times when you feel so nervous that you can't remain in one place for a long period? 123

Yes No Don't know Yes No Don't know Happy Variable Worried Don't know Yes No Don't know Often Sometimes Never Don't know Yes No Don't know Yes No Don't know

Susto, a Folk Illness/124 8. Do you consider yourself a worrier?

9. When you become annoyed with someone, do you feel your breathing become more rapid? 10. When someone annoys you, do you speak to them about it? 11. Have you lost consciousness because of a strong reaction to something? 12. Have you had problems in going to sleep, or remaining asleep? 13. If a drunk affronts you, do you become angry?

14. Do you often forget things?

15. Have you suffered chills or hot and cold flashes? 16. When troubled by problems, do your hands tremble?

17. When troubled do you seek advice?

Yes No Don't know Often Sometimes Never Don't know Yes No Don't know Yes No Don't know Yes No Don't know Yes No Sometimes Don't know Yes No Don't know Yes No Don't know Often Sometimes Never Don't know Almost always Sometimes Never Don't know

Appendix/125 18. D o y o u r family p r o b l e m s tire you or cause y o u sickness? 19. D o y o u feel alone even while in the c o m p a n y of others f r o m y o u r community? 20. For you, d o things result as you w i s h t h e m to?

21. D o y o u get headaches w h e n y o u m u s t m a k e a decision?

Yes No Don't know Often Snmpfimc! Never Don't know Often Sometimes Never Don't know Often Snmefimec Never

22. For y o u , h o w does life treat you: well, all right, sadly?

Don't know Well All right Sorlly Don't know

Instructions for Scoring the 22-Item Screening Score Responses A. 1. Indicate o n the m i m e o g r a p h e d scoring sheets the place, name, and n u m b e r of the protocol you are currently scoring. 2. T h e scorer should indicate his name, or code n u m b e r , and the date of scoring on the score sheet. 3. All items must be scored. A p p r o p r i a t e scores for each item are: 0, 0.5, 1. T h o s e scores m u s t be placed in the space provided immediately to the right of the item being scored. 4. If the scorer has a p r o b l e m or a question about h o w to score an item, or if he finds it necessary to c o m m e n t in

Susto, a Folk Illness/126

some way about an item, this should be indicated by a checkmark in the space allocated for " C o m m e n t . " 5. Please refrain f r o m s u m m i n g the item scores until decisions can be arrived at with respect to the best way to score items 10 and 13. 6. Please do not mark anything in the "Corrected Score" space. 7. If more than 5 items have been scored as " N o sabe," this should be noted in the space allocated to "General C o m ments"; other general comments are to be noted there as well. B. Scoring is to be as follows: 1. 2. 3. 4. 5. 6. 7. 8. 9.

Yes = 1 Yes = 1 Happy = 0 Yes = 1 Often = 1 Yes = 0 Yes = 1 Yes = 1 Often = 1 10. Yes = 0 11. Yes = 1 12. Yes = 0 13. Yes = 1 14. Yes = 1 15. Often = 1 16. Often = 1 17. Almost always = 1 18. Yes = 1 19. Often = 1 20. Often = 0.5 21. Often = 1 22. Well =: 0 Note: For accuracy when

No = 0 Don't know = 0.5 Don't know = 0.5 No = 0 Don't Variable = 0.5 Worried = 1 Don't know = 0.5 No = 0 Don't Sometimes = 0.5 Never = 0 No = 1 Don't know = 0.5 No = 0 Don't know = 0.5 Don't know = 0.5 No = 0 Don't Sometimes = 0.5 Never = 0 No = 1 Don't know = 0.5 No = 0 Don't know = 0.5 No = 1 Don't know = 0.5 Don't No = 0 Sometimes == 0.5 No = 0 Don't know = 0.5 No = 0 Don't know = 0.5 Don't Sometimes = 0.5 Never = 0 Don't Sometimes = 0 Never = 0 Don't know = 0.5 No = 0 Don't Sometimes = 0.5 Never = 0 Don't Sometimes = 0 Never = 1 Don't Sometimes = 0.5 Never - 0 Don't Sadly = 1 All right = 0 summing scores, always use 0.5 when called for,

know = 0.5 know = 0.5

know = 0.5

know = 0.5

know = 0.5 know = 0.5 know know know know

= = = =

0.5 0.5 0.5 0.5

not .5!

C. It is an assumption of this scoring procedure that an intermediate, or N . S . (Don't know), response is indicative of a partial agreement with the thrust of the question. For the same reason, responses that are not called for in the instrument but which also indicate positions between stress and nonstress are to be scored 0.5.

Appendix/127

Social Factors Questionnaire* Place (town) No. I General Data 1. Complete name 2. Sex

3. Age

4. Living with one's spouse? Yes 5. Children

No

Sex

Age

6. Total number o f sons Total number o f daughters 7. House size

House type

8. Additional observations concerning the house: II Personal Information on the Individual Being Interviewed 1. Does he . or she have physical or mental impairments which lead to failure in his/her social role? Describe here: 2. Is there any indication that this individual fails to maintain suitable relations with others in the community? Describe here: 3. With respect to his/her conduct does he/she behave adequately with neighbors and community members? Describe here: Place (town) No III For Men

Only

1. Is it necessary to have animals in this town? Yes No * F r o m "Social Stress G a u g e , " copyright 1976 by Carl W. O ' N e l l and A r t h u r J . Rubel.

Susto, a Folk Illness/128 2. Is it necessary to have a team of oxen in this town? Yes No 3. H o w many years of "cargo" service should a man of your age have completed? 4. Should an individual consult with another person to resolve a domestic problem? Yes No 5. When a person from here works as a field hand (for others), is it a good thing, is it simply all right, or is it unfortunate? Good All right Unfortunate 6. H o w much corn does a family such as yours need to harvest? 7. Is it important for a person in this town to know how to read and write? Yes No 8. H o w many years of study are suitable for a farmer from here? 9. Is life more difficult for husbands or wives, or is it equally difficult for both? Husbands Wives Equal (for both) 10. Is life more difficult for one before 40 years of age, or after 40? Before After 11. Do your fellow townsmen/neighbors have great or little respect for you? Great Little 12. Do your own children have great or little respect for you? Great Little 13. Does your wife have great or little respect for you? Great Little 14. What is the amount of corn consumed daily by your family?

Appendix/129

15. F r o m the time of H o l y Week (or All Saints), have you d o n e any of these things? a. H a v e y o u sold s o m e t h i n g in the market? b. H a v e y o u tilled y o u r o w n fields? c. H a v e y o u d i s c h a r g e d a " c a r g o " in the community? d. H a v e y o u served o n s o m e c o m m i t t e e — s c h o o l , road, water c o m m i t t e e , etc.? e. H a v e y o u r w o r k e d on s o m e obligatory c o m m u n i t y project? f. H a v e y o u w o r k e d a w a y f r o m the t o w n ? g. H a v e you helped a close relative, neighbor, or compadre in his w o r k ? h. H a v e y o u engaged in another task? 16. D o y o u r older children help you w h e n e v e r possible? Always Sometimes Never 17. O f the offices that follow, w h i c h have y o u filled? a. policeman b. police chief c. d. e. f.

s p o n s o r of patron saint first regidor municipal president c o m m i t t e e president

18. O f y o u r offices and services, w h i c h w e r e the last ones in w h i c h y o u served? 1.

2

19. In w h i c h years did y o u serve them? 1.

2.

20. W h e n y o u began living w i t h y o u r w i f e did you live in the h o u s e of y o u r elders? Yes No If the a n s w e r is yes, for h o w long? Less than 1 year M o r e than 1 year Place (town) No

Susto, a Folk Illness/130 For Women

Only

1. Should an individual consult with another person to resolve a domestic problem? Yes No 2. When a person from here works as a field hand or a house servant (for others), is it a good thing, simply all right, or is it unfortunate? Good All right Unfortunate 4. H o w much corn does a family such as yours need to harvest? 5. H o w many years of study are suitable for a country woman from here? 6. Is life more difficult for wives or husbands, or is it equally difficult for both? Husbands Wives Equal (for both) 7. Is life more difficult for one before 40 years of age, or after 40? Before After 8. Do other people in your town and your neighbors have great or little respect for you? Great Little 9. Do your own children have great or little respect for you? Great Little 10. Does your husband have great or little respect for you? Great Little 11. What is the amount of corn consumed daily by your family? 12. From the time of Holy Week (or All Saints), have you done any of these things? a. Have you sold something in the market? b. Have you prepared food? c. Have you given birth? d. Have you made pottery, bread, or cheese?

Appendix/131

13. 14.

15.

16. 17.

e. Have you helped a close relative, a comadre, or a neighbor in her work? f. Have you taken care of children? g. Have you engaged in another task? O f the things you have done, which is the one of which you are most proud? In the task in which you have most pride, do you do it better than, equal to, or less well than other w o m e n in the town? Better than Equal to Less well than Is your father (or husband) satisfied with the work you do? Yes No D o your older children help you whenever possible? Always Sometimes Never O f all your children, how many were born dead?

18. Have you nursed all your surviving children? Yes No 19. O f all your children, living at the time of birth, can you tell me h o w many have died before attaining 3 years of age? 20. H o w do you perceive your tasks as wife and mother in your family? Very laborious? Ordinary? Easy? 21. When you began to live with your husband, did you live in the house of your elders? Yes No If the answer is yes, for h o w long? More than one year Less than one year

Place (town) No.

Susto, a Folk Illness/132 IV For Both Men and Women 1. To w h o m does this house belong? Husband Wife Another 2. For h o w many years have you gone to school? 3. D o you k n o w h o w to read and write? Some Scarcely D o not k n o w h o w 4. D o you have a burro? A horse? An ox team? A truck? A bicycle? 5. A couple ought to live in the house of the man? The woman? N o difference? 6. O v e r the last t w o years, have you worked as field hand or servant for others? Yes No 7. When one's fellow townspeople or neighbors gossip about one, can a person live contentedly? Yes No 8. For a person to live contentedly, is it necessary for him (or her) to have much or little respect (from others), or is that not important? M u c h Little N o t important 9. O f the following questions concerning life situations, can you tell m e whether each one is serious, of little importance, or not at all significant? a. When a daughter elopes with her boyfriend, is the criticism that her parents endure for her serious? O f little importance? N o t at all significant? Have you experienced this misfortune? b. When a son elopes with his girlfriend, is the criticism his parents endure for him serious? O f little importance? N o t at all significant? Have you experienced this misfortune? c. When a y o u n g w o m a n becomes pregnant before m a r -

Appendix/133 riage, is the criticism her parents endure for her serious? O f little importance? N o t at all significant? H a v e y o u experienced this m i s f o r t u n e ? d. W h e n their son is a d r u n k a r d , is the criticism his parents e n d u r e for h i m serious? importance?

O f little

N o t at all significant?

H a v e y o u experienced this misfortune? 10. Since All Saints (Holy Week) or over the last 6 m o n t h s , have y o u consulted w i t h any other person to solve a h o u s e h o l d p r o b l e m ? Yes No With w h o m have y o u consulted? 11. W h a t quantity of corn did you harvest last year? 12. Is it a g o o d thing w h e n a h u s b a n d tells his w i f e the a m o u n t of corn yielded by his harvest? Yes

No

Scoring Instructions for the Social Factors Questionnaire for Males I Purpose and Rationale of the Questionnaire and Score Sheet T h e j o i n t use of the Social Factors Q u e s t i o n n a i r e and Score Sheet enables outside observers to t r a n s f o r m verbal response data into numerical scores reliably. This will be useful in the c o m p u t a t i o n of measures relating to factors of social stress. T h e basic p u r p o s e is to facilitate the derivation of a single measure of cognitive role stress f r o m sets of items that reveal discrepancies b e t w e e n perceived ideal role expectations and perceived actual discharge of role obligations. Positive scores result w h e n respondents' answers indicate deficiencies in their r e p o r t e d behavior or experiences as c o m p a r e d to stated cognitively ideal standards of behavior.

Susto, a Folk Illness/134

T h e Score Sheet has been designed to allow for the differential w e i g h t i n g of the various c o m p o n e n t s that m a k e up each item. T h e w e i g h t i n g is based on the ethnographic k n o w l e d g e the researchers have of the communities included in the study. Scoring is therefore done w i t h respect to the explicit instructions presented in the t w o following sections and, in cases of ambiguity, w i t h recourse to the scoring rationale indicated above. II General Instructions 1. Each Social Factors Q u e s t i o n n a i r e requires the use of a separate Score Sheet. 2. Write y o u r name, or code n u m b e r if given one, in the u p p e r r i g h t - h a n d corner of the Score Sheet. Also indicate the date on w h i c h the scoring is done under your n a m e or n u m b e r . 3. Transcribep/ace, number, name, sex, and age of person being i n t e r v i e w e d f r o m the Q u e s t i o n n a i r e to the Score Sheet. 4. D o n o t enter a n y t h i n g in the space provided for an ID Code. 5. Items are n u m b e r e d sequentially within sections. N o t e that in all sections except Section A, each item is divided into idea (a) and actual (b) measures. Immediately f o l l o w ing each Score i t e m n u m b e r is a c o m b i n e d n u m b e r enclosed in parentheses. T h e R o m a n n u m e r a l style n u m b e r refers to the various sections of the Questionnaire. T h e Arabic n u m e r a l refers to the Q u e s t i o n n a i r e item in that section. A f e w Score items also refer to subitems in the Q u e s t i o n n a i r e designated w i t h letters, a, b, c, etc. N . B . Score sheets for males are scored w i t h reference to Q u e s tionnaire section III, entitled Solamente Para Senores. 6. Scoring j u d g m e n t s for each Score item are made w i t h reference to the Q u e s t i o n n a i r e items as indicated in (5), above. 7. Score items are scored first of all w i t h respect to their c o m p o n e n t s , as indicated in III, Item Instructions. O n c e all the c o m p o n e n t s have been scored, the scorer derives

Appendix/135 a score for each i t e m in the space provided. C o m p o n e n t scores m a y be checks or n u m b e r s . Item Scores are always n u m b e r s : 1, 2, or 0. T h e G r a n d Total is a n u m b e r derived by adding all the item scores for a given Score Sheet. 8. For items w i t h n o response or a response that cannot be scored w i t h the present i n s t r u m e n t , d o not score. Write in the n u m b e r of the item under R e m a r k s on the first page of the Score Sheet. Ill Item Instructions A. 1. C o m p o n e n t scoring (1.4): If the respondent is not an adult, this item is n o t scored. If the respondent is an adult, does he have a spouse? C h e c k Yes or N o . 2. Component scoring (1.6.7.8): For Chinantecs, if the house type is adobe or tabla, check Yes. If the house type is palito, check N o . For Zapotecs (1.8), adequate = yes; n o t adequate = no. 3. C o m p o n e n t scoring (II. 1): A n y positive answer on this section of the Q u e s t i o n n a i r e is to be scored Yes w i t h a check m a r k . A negative or n o a n s w e r at all is to be scored N o . B. 1. a. Component

scoring (III. 1) (III.2): Check the proper

response. b. Component scoring (IV. 4): If either a horse or b u r r o or b o t h are indicated, check Yes for Has Animals. C h e c k other items as indicated. 2. a. Component scoring (III.6): Write in the a m o u n t of corn harvest as indicated by the respondent. Clearly indicate the measure as well as the n u m b e r (kilo, toneladas, etc.). b. Component scoring (IV. 11): Write in the a m o u n t of the corn harvest as indicated by the respondent, w i t h n u m b e r s and measure, as above. 3. a. Component scoring (III.7): C h e c k Yes or N o . b. Component scoring (IV.3): Check Some, Little, or None. 4. a. Component scoring (III. 8): Write in n u m b e r of years

Susto, a Folk Illness/136

C. 1.

2.

3.

D . 1.

2.

3.

indicated by the respondent, b. Component scoring (IV.2): Write in number of years indicated by the respondent. a. Component scoring (III.3): Write in n u m b e r of years indicated by respondent, b. Component scoring (III. 17): Write in number of years derived by s u m m i n g up completed services to the community. a. Component scoring (III.3): Write in the number of years indicated by the respondent, b. Component scoring (III.15.c.d.e., III. 18, III.19 and the marginal indications with III. 17 are added to those services listed in III. 17 to get a total n u m b e r of years given to service in both the explicit and informal systems): If respondent indicates he has served more years than has been indicated in C . l . b . , above, add this time to the time indicated in C. 1.b. above. a. Component scoring (III): For Zapotecs. Indicate highest office should have held, in space provided. Also indicate highest office actually held, including present one, if applicable, b. Component scoring (III. 18, III. 19) a. Component scoring (III.4): Check Yes or N o , as indicated by respondent, b. Component scoring (IV.10): Check Yes or N o , as indicated by respondent. Indicate also the numbers of persons consulted. a. Component scoring (IV.8): Check level of respect, as indicated by the respondent, b. Component scoring (III. 12, 13): Check each c o m ponent in this item as it relates to the Questionnaire items, M u c h or Little. a. Component scoring (IV.9.a.b.c.d.): Indicate by n u m bers h o w many times each subitem is checked, b. Component scoring (IV.7): Check sensitivity to gos-

Appendix/137 sip, Yes or N o . A N o answer is indicative of sensitivity in this context. E. 1. a. Component scoring (III.5): Check as indicated by the respondent. Bueno = positive; regular = neutral; triste = negative, b. Component scoring (IV.6): Check Yes or N o , as indicated by the respondent. 2. a. Component b. 3. a. b.

4. a.

b.

5. a. Component b.

6. a. b. 7. a.

scoring

(1.2):

Check

sex

of

the

respondent. Component scoring (III.9): Check Males, Females, or Equal, as indicated by the respondent. Component scoring (1.3): Write in the age of the respondent. Component scoring (III. 10): Check Before 40 or A f ter 40, as indicated by respondent. Also indicate if r e s p o n d e n t is 40 years old. Component scoring (IV.5): If respondent indicates propria, check H u s b a n d . If señora, check Wife. If es igual, check N o Difference, Component scoring (IV. 1): If respondent indicates propria, check H u s b a n d . If señora, check Wife. If he indicates otra, check S o m e O t h e r on the Score Sheet. scoring For Chinantecs, write in 0. For

Zapotees, w r i t e in 2. Component scoring (III.20): C h e c k Yes or N o , as indicated by respondent. If yes, check Less T h a n 1 Year or M o r e T h a n 1 Year. Give n u m b e r of years, if indicated. Component scoring: For b o t h Chinantecs and Z a potees, indicate Yes. Component scoring (III. 16): Check as indicated by the respondent: Always, Sometimes, or Never. Component scoring Disgrace is implied for C h i n a n tecs a n d Z a p o t e e s : communities.

Check

Yes

for

these

Susto, a Folk Illness/138 b. Component scoring (IV.9.a.b.c.d.): Check each disgrace indicated by the respondent for N o n e , O n c e , or T w i c e or m o r e . A. 1. Item Scoring: If respondent is not an adult, score 0. If r e s p o n d e n t is an adult and Yes is checked, score 0. All N o checks are scored 2. 2. Item Scoring: Yes = 0; N o = 2. 3. Item Scoring: Yes = 2; N o = 0. B. 1. Item Scoring: If Yes for animals and oxen on both the ideal and actual c o m p o n e n t s , score 0. If Yes for animals and oxen on the ideal c o m p o nents, but N o for animals and oxen on actual c o m ponents, score 2. If Yes for animals and oxen on the ideal c o m p o n e n t s and one Yes and one N o for these on the actual m e a sure, score 1. If Yes on either of the ideals and N o on b o t h actuals, score 1. If N o on b o t h ideal c o m p o n e n t s and N o on the m a t c h i n g actual c o m p o n e n t s , score 1. If Yes and N o on the ideal c o m p o n e n t s and Yes and N o o n the m a t c h i n g actual c o m p o n e n t s , score 1. T h e indication of a truck a n d / o r bicycle will reduce a 2 to a 1 and a 1 to 0, as scored above. 2. Item Scoring: If (a) exceeds (b) by V3 or m o r e , score 2. If (a) exceeds (b) by less than V3 so that (a) and (b) cannot be seen to a p p r o x i m a t e one another even roughly, score 1. If (a) and (b) are a p p r o x i m a t e l y equal or if (b) exceeds (a), score 0. ( N o t e : O n e tonelada equals a p p r o x i m a t e l y 907 kilograms.) 3. Item Scoring: If Yes for (a) and S o m e for (b), score 0. If Yes for (a) and Little for (b), score 1. If Yes for (a) and N o n e for (b), score 2. If N o for (a) and N o n e for (b), score 1. If N o for (a) and S o m e or Little for (b), score 0.

Appendix/139 4. Item Scoring: If (a) and (b) are approximately equal, score 0. If (b) exceeds (a), score 0. If (a) exceeds (b) by one year, score 1. If (a) exceeds (b) by t w o or m o r e years, score 2. C. 1. Item Scoring: If (a) and (b) are equal, score 0. If (b) exceeds (a), score 0. If (a) exceeds (b) by one year, score 1. If (a) exceeds (b) by t w o or more years, score 2. 2. Item Scoring: If (a) and (b) are equal, score 0. If (b) exceeds (a) by one year, score 0. If (a) exceeds (b) by one year, score 1. If (a) exceeds (b) by more than t w o years, score 2. 3. Item Scoring: U s e scale provided by the researcher to score this item. D. 1. Item Scoring: If N o for (a) and N o for (b), score 0. If N o for (a) and Yes for (b), score 2. If Yes for (a) and Yes for (b), score 1, if no more than one person is consulted. If Yes for (a) and Yes for (b), score 2, if t w o or more persons were consulted. If Yes for (a) and N o for (b), score 0. 2. Item Scoring: If (a) is checked Much, and t w o or three answers in (b) are checked Little, score 2. If (a) is checked Much, and one answer in (b) is checked Little, score 1. If (a) is checked Little or N o Importance, and (b) is checked Much, score 0. If both (a) and (b) are checked Little or N o I m p o r tance, score 0. 3. Item Scoring: If three or more for Serious (3.a), and Yes for sensitivity (3.b.), score 2. If three or m o r e for Serious, and N o for sensitivity, score 1. If one or t w o Serious, and Yes for sensitivity, score 1.

Susto, a Folk Illness/140

If none for Serious, and N o for sensitivity, score 0. E. 1. Item Scoring: If (a) is Positive or Neutral, and (b) is Yes, score 1. If (a) is Negative and (b) is Yes, score 2. If (a) is Negative and (b) is N o , score 0. If (a) is Yes and (b) is Yes, score 1. If (a) is Yes and (b) is N o , score 0. (Yes equals positive or neutral.) 2. Item Scoring: [when (a) is male]: if (b) is Males, score 2; if (b) is Equal, score 1; if (b) is Females, score 0. 3. Item Scoring: If (a) and (b) match, score 2. If (a) and (b) do not match, score 0. If (a) is 40 and (b) is After 40, score 1. 4. Item Scoring: If (a) checks Husband or N o Difference, and (b) checks Husband, score 0. If (a) checks Husband, and (b) indicates Wife or Some Other, score 2. If (a) checks Wife and (b) checks Wife or Some Other, score 1. If (a) is checked N o Difference, and (b) is checked Some Other, score 0. 5. Item Scoring (For Chinantecs): If (b) is Yes and M o r e T h a n O n e Year, score 1. If (b) is Yes and Less Than O n e Year, score 0. If (b) is N o , score 0. For Zapotecs, if (b) is Yes and M o r e Than O n e Year, score 0. If (b) is Yes and Less Than O n e Year, score 1. If (b) is N o , score 2. 6. Item Scoring: If (a) is Yes and (b) is Always, score 0. If (a) is Yes and (b) is Sometimes, score 1. If (a) is Yes and (b) is Never, score 2. If (a) is N o and (b) is Always, score 0. If (a) is N o and (b) is Sometimes or Never, score 1. 7. Item Scoring: Disgraced t w o or more times, score 2. Disgraced once, score 1. N o disgrace, score 0.

Appendix/141

Please total all item scores. The grand total constitutes the Social Factors Score for the individual. Enter this cumulative score as a Grand Total in the space provided.

Score Sheet for Social Factors Questionnaire—Males Place: Number: Name: Sex:

Age:

A . Situational

Factors

Scorer's Name: Scoring Date: Remarks: ID Code: Item

1. (1.4) Satisfactory conjugal relationship: 2. (1.6.7.8) Adequate living conditions, given size and composition of family: 3. (II. 1) Physical or mental impediments to adequate social participation: B . Resources

Scores

Yes

No

Yes

No

Yes

No

(Males)

Ideal Measures 1. a. (III. 1) Animals necessary: (II.2) Team of oxen necessary Actual Measures 1. b. (IV. 4) Has animals: Has team of oxen: Has truck: Has bicycle: Ideal Measures 2. a. (III.6) Necessary amount of yearly corn harvest

Yes

No

Yes

No

Yes Yes Yes Yes

No No No No Item Score:

Susto, a Folk Illness/142 Actual Measures 2. b. (IV. 11) A m o u n t of yearly corn harvest Item Score: Ideal 3. a. (III.7) Important to read and write:

Yes

No

Actual 3. b. (IV.3) Reads and writes: Some Little None Item Score: Ideal 4. a. (III.8) N u m b e r of years in school Actual 4. b. (IV. 2) N u m b e r of years in school Item Score: C . Community

Service

(Males)

Ideal 1. a. (III.3) N u m b e r of years Actual 1. b. (III. 17) N u m b e r of years Item Score: Ideal 2. a. (III. 3) N u m b e r of years Actual 2. b. (III.17, III.15.c.d., III.18, III. 19) N u m b e r of years Item Score:

Appendix/143

Ideal 3.

(III.3.) Highest office should have held

Actual 3. b. (III. 18, III. 19.) Highest office actually held Item Score: D . Dependency

of Others

(Males)

Ideal 1. a. (III.4) Ought to consult with another: Actual 1. b. (IV. 10) Had consulted with another:

Yes

No

Yes No . How many? Item Score:

Ideal 2.

a. (IV.8) Respect from others is desirable: Much Little .

N o importance .

Actual 2. b. (III.11.12.13) Respect from townspeople/ Much neighbors O w n children Much O w n wife Much Response ratio: Score:

Little . Little . Little . Item Score:

Ideal 3. a. (IV.9) Sensitivity to criticism of others: Serious Light. 3. b. (IV.7) Sensitivity to gossip:

Nothing Yes

No Item Score:

Susto, a Folk Illness/144 E . Personal

Control

of

Affairs

Ideal 1. a. (III. 5) Working for another: Positive Neutral _ Actual 1. b. (IV. 6) In last two years has worked for another:

Yes

Ideal 2. a. (1.2) Sex of respondent: Male Female Actual 2. b. (III.9) Life is more difficult for: Males Females

Equal

Negative .

No Item Score:

Item Score: Ideal 3. a. (1.3) Age of respondent Actual 3. b. Before 40 After 40 . Is respondent 40 or over?

Equal Item Score:

Ideal 4. a. (IV.5) A pair should live in the house of: The Husband The Wife

N o Difference

Actual 4. b. (IV. 1) Does the pair live in the house of: The Husband The Wife .

Some Other Item Score:

Ideal 5. a. Ethnographic data: H o w

Appendix/145

long should a young couple reside with parents before they establish their own house? Actual 5. b

(III.20) Did the young couple (respondent) live with the parental pair: If yes, Less than 1 year More than 1 year

Yes

No

Item Score: Ideal 6.

a

Actual 6. b

Ethnographic data: Should older children help their parents when possible? (III. 16) D o your children help you as much as possible?

Ideal 7. a Ethnographic data: Parental responsibility for the behavior of unmarried children is always marked Yes for Chinantecs and Zapotees Actual 7. b (IV.9.a.b.c.d.) Times disgrace is experienced by parent as result of child's behavior:

Yes

No

Always Sometimes Never Item Score:

Yes

No

None Once Twice or more Item Score: GRAND TOTAL:

Susto, a Folk Illness/146

Scoring Instructions for the Social Factors Questionnaire for Females I Purposes and Rationale of the Questionnaire and Score Sheet T h e p u r p o s e and rationale of the Q u e s t i o n n a i r e and Score Sheet for Females is the same as that described in Section I of the Scoring Instructions for the Social Factors Questionnaire for Males. II General

Instructions

T h e s e instructions are the same as those provided in Section II of the Scoring Instructions for the Social Factors Questionnaire for Males. Ill Item Instructions A. 1. Component

scoring (1.4): If the respondent is not an

adult (over 18), this item is not scored. If the r e s p o n dent is an adult, does she have a spouse? C h e c k Yes or N o . 2. Component scoring (1.6.7.8): For Chinantecs, if house type is a d o b e or tabla, check Yes. If the house type is palito, check N o . For Zapotecs (1.8), adequate = yes; n o t adequate = no. 3. Component scoring (II. 1): A n y positive answer on this section of the Q u e s t i o n n a i r e is to be scored Yes w i t h a check m a r k . A negative or no answer at all is to be scored N o . B. 1. a. Component scoring (1.4): If w o m a n has a spouse, check in space provided. (1.3): Indicate age of respondent. b. Component scoring (1.5.6): F r o m i n f o r m a t i o n recorded for these items, indicate the total n u m b e r of children a w o m a n has. 2. Component scoring (III. 17): Write in the n u m b e r of children w h o died at birth. (III. 19): Write in the n u m b e r of children w h o died before three years of age. 3. a. Component scoring: For Chinantecs and Zapotecs, check Yes.

Appendix/147

4. 5.

6.

7.

8. 9. C. 1.

2.

3.

b. Component scoring (III. 18): Respondent nursed all of her infants. Indicate Yes or N o . Component scoring (III. 12): Indicate total number of tasks reported. a. Component scoring (III. 13): Write in special task respondent says that she is proud of. b. Component scoring (III. 14): Indicate level of competency. a. Component scoring (IV. 12): Should the husband inf o r m his wife of the quantity of the corn harvest. Check Yes or N o . b. Component scoring (III.4): Check Yes or N o whether she indicates a knowledge of the amount of corn harvest. a. Component scoring: For Chinantecs and Zapotecs, indicate Yes for responsibility, b. Component scoring (IV.9.a.b.c.d): Write in the n u m ber of times the respondent indicates she has been disgraced after Yes. If she reports none, check N o . Component scoring (III.20): Check Onerous, Moderate or Easy, as indicated by the respondent. Component scoring (III. 15): Check Yes or N o , as indicated by the respondent. a. Component scoring (III.4): Write in the amount of the corn harvest indicated by the respondent. Indicate measures used, e.g., kilos, etc. b. Component scoring (IV. 11): Write in the amount of corn reported actually to have been harvested using n u m b e r s and measures indicated by the respondent. a. Component scoring (III.3): Check Yes or N o . b. Component scoring (IV.3): Check Some, Little, or None. a. Component scoring (III. 5): Write in number of years indicated by the respondent, b. Component scoring (IV.2): Write in the n u m b e r of years indicated by the respondent.

Susto, a Folk Illness/148 1. a. Component scoring (III.l): Check Yes or No, as indicated by the respondent. b. Component scoring (IV. 10): C h e c k Yes or N o ; if yes, 2.

3.

1.

2.

3.

4.

5.

6.

1.

how many? a. Component scoring (IV.8): Check level of respect indicated. b. Component scoring (III.8.9.10): Indicate Much or Little respect from each category of person. a. Component scoring (IV. 9): Check level of sensitivity. b. Component scoring (IV.7): Check Yes or No. a. Component scoring (III.2): Indicate response as Positive, Neutral, or Negative. b. Component scoring (IV.6): Check Yes or No. a. Component scoring (1.2): Check Female. b. Component scoring (III.6): Check Males, Females, or Equal. a. Component scoring (1.3): Indicate age of respondent. b. Component scoring (III.7): Indicate Before 40, After 40, or Equal. a. Component scoring (IV. 5): Check Husband, Wife, or N o Difference. b. Component scoring (IV.l): Check Husband, Wife, or Other. Component scoring (III.21): Check Yes or No. If yes, check Less Than or More Than one year. If time is indicated by respondent, write it in. b. Component scoring (III. 16): Indicate Always, Sometimes, or Never. Item scoring: If respondent is not an adult, score 0. If adult and checked Yes, score 0. All N o checks are scored 2.

2 Item scoring: Yes = 0; n o = 2. 3 Item scoring: Yes = 2; n o = 0. 1 Item scoring: If a woman has between three and eight children, is between the ages of 20 and 40, and has a spouse, score 0. If less than three, score 1; more than eight, score 2.

Appendix/149 If a w o m a n of any age has eight or m o r e children but n o spouse, score 2. If a w o m a n of over 25 has n o child and n o spouse, score 1. 2. Item scoring: If N o n e in b o t h categories, score 0. If one in either category, score 1. If t w o or m o r e in one or b o t h categories, score 2. 3. Item scoring: For Chinantecs and Zapotecs, score 0 if (b) is checked Yes. Score 2 if (b) is checked N o . 4. Item scoring: If answer is five to seven tasks, score 0. If three to f o u r tasks, score 1. If t w o or fewer tasks, score 2. 5. Item scoring: If (b) is answered Better T h a n or Equal To, score 0. If (b) is answered Less T h a n , score 2. 6. Item scoring: If (a) is Yes and (b) is Yes, score 0. If (a) is N o and (b) is N o , score 0. If (a) is Yes and (b) is N o , score 2. If (a) is N o and (b) is Yes, score 0. 7. Item scoring: (for Chinantecs and Zapotecs): If o n e disgrace, score 1. If m o r e than one disgrace, score 2. If n o disgrace, score 0. 8. Item scoring: If O n e r o u s , score 2. If M o d e r a t e , score 1. If Easy, score 0. 9. Item scoring: Yes = 0 No = 2 Don't know = 1 C . 1. Item scoring: If (a) exceeds (b) b y 1/3 or m o r e , score 2. If (a) exceeds (b) b y less than 1/3 so that (a) and (b) cannot be seen to a p p r o x i m a t e one another even roughly, score 1. If (a) and (b) are a p p r o x i m a t e l y equal or if (b) exceeds (a), score 0. ( N o t e : O n e tonelada equals a p p r o x i m a t e l y 907 kilograms.)

Susto, a Folk Illness/150 2. Item scoring: If Yes for (a) and S o m e for (b), score 0. If Yes for (a) and Little for (b), score 1. If Yes for (a) and N o n e for (b), score 2. If N o for (a) and N o n e for (b), score 1. If N o for (a) and S o m e or Little for (b), score 0. 3. Item scoring: If (a) and (b) are approximately equal, score 0. If (b) exceeds (a), score 0. If (a) exceeds (b) by one year, score 1. If (a) exceeds (b) by t w o or m o r e years, score 2. D . 1. Item scoring: If N o for (a) and N o for (b), score 0. If N o for (a) and Yes for (b), score 2. If Yes for (a) and Yes for (b), score 1 if no m o r e than one is consulted. If Yes for (a) and Yes for (b), score 2 if t w o or m o r e persons are consulted. 2. Item scoring: If (a) is checked M u c h , and t w o or three answers in (b) checked Little, score 2. If (a) is checked M u c h , and one answer in (b) is checked Little, score 1. If (a) is checked M u c h , and all three answers in (b) are checked M u c h , score 0. If (a) and (b) are b o t h checked Little or N o I m portance, score 0. 3. Item scoring: If three or m o r e indications of Serious in (a), and Yes (equals N o on Questionnaire) for sensitivity, score 2. If three or m o r e for Serious and N o for sensitivity, score 2. If three or m o r e for Serious and N o for sensitivity, score 1. If one or t w o Serious, and Yes for sensitivity, score 1. If n o n e for Serious, and Yes for sensitivity, score 0. If n o n e for Serious, and N o for sensitivity, score 0. E. 1. Item scoring: If (a) is Positive or Neutral, and (b) is Yes, score 1.

Appendix/151 If If If If

(a) (a) (a) (a)

is is is is

N e g a t i v e and (b) is Yes, score 2. N e g a t i v e and (b) is N o , score 0. Yes and (b) is Yes, score 1. Yes and (b) is N o , score 0.

2. Item scoring: If (b) is Females, score 2. If (b) is equal, score 1. If (b) is males, score 0. 3. Item scoring: If (a) is less than 40 years and (b) is Before, score 2. If (a) is 40 or m o r e years and (b) is After, score 2. If (b) is Equal, score 1. If (a) is Less T h a n 40 years and (b) is After, score 0. If (a) is 40 or m o r e and (b) is Before, score 0. 4. Item scoring: If (a) is H u s b a n d and (b) is Wife or O t h e r , score 2. If (a) is Wife and (b) is H u s b a n d or Wife, score 1. If (a) is N o Difference, score 0. If (a) is H u s b a n d and (b) is H u s b a n d , score 0. 5. Item scoring (for Chinantecs): If N o , score 0. If Yes, and Less T h a n one year, score 0. If Yes, and M o r e T h a n one year, score 1. (For Zapotecs): If N o , score 2. If Yes and Less T h a n one year, score 1. If Yes and M o r e T h a n one year, score 0. 6. Item scoring (for Chinantecs and Zapotecs): Always - 0 Sometime = 1 Never = 2 Total u p all Item Scores. Enter this total as the G r a n d Total score. It constitutes the Social Factors Score for the individual.

Susto, a Folk Illness/152

Score Sheet for Social Factors Questionnaire— Females Place: Number: Name: Sex:

Age:

Scorer's Name: Scoring Date: _ Remarks: ID Code: Item

A . Situational

Factors

Scores

1. (1.4) Satisfactory conjugal relationship: 2. (1.6.7.8) Adequate living conditions, given size and composition of family: 3. (II. 1) Physical or mental impediments to adequate social participation: B . Family

Obligations

Yes

No

Yes

No

Yes

No

(Females)

Ideal Measures 1. a. (1.4) Living with spouse (1.3) Age Actual Measures 1. b. (1.5.6) Number of children Item Score: 2. a. (III. 17) Number who died at birth b. (III. 19) Number who died before 3 years of age Item Score: Ideal Measures 3. a. (For Chinantecs and Zapotecs) Is it considered important to nurse own children

Yes

No

Appendix/153

Actual Measures 3. b. (III. 18) Nursed all viable children:

Yes

No Item Score:

4. (III. 12) H o w many tasks done Item Score: Ideal Measures 5. a. (III. 13) Special task Actual Measures 5. b. (III. 14) Level of competency Item Score: Ideal Measures 6. a. (IV. 12) Husband informs wife of quantity of harvest? b. (III.4) Does she know the amount of the corn harvest?

Yes

No

Yes

No Item Score:

Ideal Measures 7. a. Mothers have some responsibility for behavior of unmarried children in both Chinantec and Zapotec villages. Actual Measures 7. b. (IV.9.a.b.c.) Disgrace at children's behavior: Yes (how many?) No Item Score: 8. (III.20) Tasks as wife and mother are perceived as:

Onerous Moderate Easy Item Score:

Susto, a Folk Illness/154

9. (III. 15) Is significant male satisfied with w o m a n ' s work?

Yes

No Item Score:

C. Resources (Females) Ideal Measure 1. a. (III.4) Yearly corn harvest needed Actual Measure 1. b. (IV. 11) Yearly corn harvest obtained Item Score: Ideal Measure 2. a. (III.3) Importance of reading and writing: Actual Measure 2. b. (IV.3) D o you read and write? Some Little

Yes

No

None Item Score:

Ideal Measure 3. a. (III.5) N u m b e r of years should be in school Actual Measure 3. b. (IV.2) H o w many years have you studied in school? D . Dependency (Females) Ideal Measure 1. a. (III. 1) O u g h t to consult with another: Actual Measure 1. b. (IV. 10) Did consult with another:

Item Score:

Yes

No

Yes No H o w many? Item Score:

Appendix/155 Ideal Measure 2. a. (IV.8) Respect f r o m others Much Little

N o t Important

Actual Measure 2. b. (III.8.9.10) Respect f r o m T o w n p e o p l e and neighbors: One's o w n children: One's husband:

Much Much Much

Little Little Little Item Score:

Ideal Measure 3. a. (IV.9) Sensitivity to criticism of others: Serious Light Unimportant Actual Measure 3. b. (IV.7) Sensitivity to gossip: E. Personal Control of Affairs (Females) Ideal Measure 1. a. (III.2) Working for another: Positive Neutral Actual Measure 1. b. (IV.6) In last t w o years, have you w o r k e d for another? 2. a. (1.2) Sex of respondent: Male Female b. (III.6) Life is m o r e difficult for: Males Females

Yes

No Item Score:

Negative

Yes

No Item Score:

Equal Item Score:

Susto, a Folk Illness/156 3. a. (1.3) A g e of respondent b. (III.7) Life is harder: B e f o r e 40 A f t e r 40

Equal Item Score:

Ideal M e a s u r e 4. a. (IV.5) A pair should live in the h o u s e of: Husband Wife Actual M e a s u r e

N o Difference

4. b. (IV. 1) T h e pair lives in the h o u s e of: Husband Wife

Other Item Score:

5. (III.21) D i d the y o u n g c o u ple (respondent) live w i t h t h e p a r e n t a l pair a f t e r marriage? If yes; less than 1 year

Yes

No

M o r e than 1 year H o w long Item Score: Ideal M e a s u r e 6. a. E t h n o g r a p h i c data: C h i l dren living at h o m e are e x p e c t e d always to help their parents (For C h i n a n tecs and Zapotees.) b. (III. 16) D o y o u r children help you?

Always Sometimes Never Item Score GRAND TOTAL:

Appendix/157

CLINICAL HISTORY Number . Locality Name Occupation Number of children living Complaint History

Date Sex Age — Lives with spouse Duration of complaint

Pressure / Pulse X ' Breathing I am going to read you a list of symptoms and would like you to tell me whether they trouble you all the time, sometimes, or never; are you troubled by headaches? Always Sometimes Never 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19.

Headaches? Noise in ears? Dizziness? Nausea on standing up? Difficulty in seeing? Does noise bother you? D o you feel cold? Migraine (headache and nausea)? Lack of appetite? Bad taste in mouth? Burning sensations in stomach? Stomach ache? Diarrhea? Blood in bowel movement? Constipation? Weakness; lacking strength to do your work? Are you tired after eating breakfast? D o you cough? D o you spit blood?

Observations

Susto, a Folk Illness/158 20. Is it difficult for you to breathe? 21. Palpitations? 22. Do your feet swell? 23. Are your eyes swollen in the morning? 24. Do you lose consciousness? 25. Do you have pains in the chest? 26. Fever? 27. Do you have a burning sensation when you urinate? 28. Blood in urine? 29. Do you have aching throughout your body? 30. An ache in one part of your body? Which? 31. Do you have pimples? 32. Does your skin itch? 33. Do you suffer attacks? 34. Sleep badly? 35. Become very angry? 36. Have a desire to cry? 37. Do your hands sweat? 38. Are you unhappy when you work (in your fields; in housework)? 39. Suffer nightmares? 40. Sigh a lot? 41. H o w many times have nodules been removed? 42. Do you have any now? 43. Between the N e w Year and today, have you lost weight (a lot, a little, or none)?

PHYSICAL EXAMINATION Difference between Pressure / Pulse X ' Breathing x ' Temperature Presentation: Healthy

Appendix/159 All right Sick Weight Stature Eyes Ears Nose Mouth Head (nodules) Neck (thyroids, veins) Skin Thorax (respiration) Heart (bruits, arrythmia) Abdomen: Masses Pain Liver Spleen Extremities: Varicoses Arthritis Cyanosis Reflexes: Muscular atrophy Dermatosis Onicomicosis Summary of pathology found (physical) Patient's attitude during interview and examination 44. Which important sickness have you suffered previously? 45. Which important sicknesses has your family suffered? 46. H o w many older siblings do you/did you have? younger than you? 47. Of all your brothers and sisters, how many are alive now? 48. What did the others die of? 49. In all, how many children have you had? 50. O f those children no longer living, of what did they die? Diagnostic impression

Indications: Laboratory examinations. Routine: additional: Laboratory Examinations by Name:

/.

Susto, a Folk Illness/160 fittile»* TELEFONO 42.23

MELCHOR OCAMFO IOS DR. F E R N A N D O G A L I N D O

O AX AC A. OAX. D R . M I G U E L A N G E L R E T E S G.

ENRIQUEZ.

Nombre: J S ^ ^ H Fecha: I 9 - I I - 7I Sol: EST. I K1!.'.:.:VA G X'.Z . CITOLOGIA HEMATICA HEMOGLOBINA 14 91' % (N: H: 15.5 M. 14.8 grms. % ' .140.occ ERITROCITOS p. mm.1 (N: H: 4.5-6, M. 4.2-5.4 mili.) 6 . 6 0 0 LEUCOCITOS „ „ (N: 5,000-10,000) HEMATOCRITO 4? (N: H: 40-54, M: 35-48%) % SS V O L G L MED mieras 1 (N: 82-92) 2 7 micro-microgramos (N: 27-32) Hb. GL. MED 31. CONC. MED. Hh. GL (N: 32-37) 10 ERITROSEDIMENTACION mm. TEC. W1NTROBE CORREGIDA (N: H. 0-8, M: 0-10) PLAQUETAS p. mm.» (N: 250,000-500,000)

%

FORMULA LEUCOCITARIA N: Adultos LINFOCITOS ? MONOCITOS 0 EOSINOFILOS 35 BASOFILOS 0 NEUTROF1LOS5 7

20-30 2-6 1-4 0-1 60-70

% „ „ „ „

FORMULA DE SCHILLING N: Adultos

528 P 23IQ o 3762

* CIFRAS PROMEDIO: M-Hnmtx*. M - Ma.ircl

1000-3000 100-600 50-400 0-100 3000-7000

Normal

p. mm.' „ „ „ ,

M1ELOCITOS 0 METAMIELOC1TOS 0 STAB 4 SEGMENTADOS 53 0.07 I. SCHILLING

' A t e n t a m

0 o-l 3-5 51-67 0.02-0.1

t e . O

Instructions for Scoring Gravity and Severity I Definitions Severity: T h e extent to w h i c h the disease(s) i m p e d e the person f r o m carrying o u t c u s t o m a r y activities. Gravity: T h e extent to w h i c h the disease(s) bring the person closer to death. II Scoring Overall Scoring: B o t h gravity and severity will be scored by points. For each, the m a x i m u m points that can be scored are 40. A person w h o scores 40 points o n severity will be c o n sidered totally incapacitated and unable to p e r f o r m any of

Appendix/161

;

nieo¿>

MELCHOR OCAMFO 111 DR. F E R N A N D O O A LIN DO E N R I Q U E Z .

TELEFONO «-JJ

OAXACA. OAX. DR. M I G U E L A N G E L R E T E S G.

EXAMEN COPROPARASITOSCOPICO (Unica Muestra)

S E HICIERON- EXAMENES EN FRESCO Y DE CONCENTRACION DE FAUST EN LA-MUESTRA R E C I B I D A ,

HABIENDO ENCONTRADO:

QUISTES DE E . H I S T 0 L I T I C A . 1)01

HUEVECTLLOS" DE ASCARIS LUMBRICOIDES.

BRAS, ADULTOS Ï HUEVECILLOS DE OXIUROS.

his o r her c u s t o m a r y obligations; a score of 20 indicates the p e r s o n able to carry o u t only one-half of the usual activities. In gravity, 40 points indicate that the patient's death is i m minent; a score of 20 indicates a point h a l f w a y between apparent g o o d health and the person's demise. Scoring by Sections: Scores will be provided each of the f o u r sections, A t h r o u g h D , respectively. These sectins are: H i s tory, S y m p t o m s and Family History, Physical Examination, and L a b o r a t o r y E x a m i n a t i o n s . Each one of the sections is c o m p o s e d of f r o m three to seven subsections, each of w h i c h m a y be scored independently of the others. T h e m a x i m u m score that can be earned in each section is 10 points. Ill P r o c e d u r e First read the patient's protocol in its entirety in order to be able to f o r m a general impression of the state of health, as m u c h in relation to severity as to gravity.

Susto, a Folk Illness/162 Scoring

Section

A,

History

1. What is the nature of the patient's complaint, its duration, or history? With respect to severity, a score of 10 points would be indicative of complete prostration, whereas a total of 5 points would mean that the person is reduced to only half of customary activities. In terms of gravity, a score of 10 advises that the patient is moribund, and 5 points indicates that he is midway between apparent good health and death. 2. Tendency. 3. Strength required to meet the demands of work tasks. If the protocol contains this response, use it to complement—in either positive or negative terms—the scoring of severity. Use it, to a lesser extent, to complement the evaluation of gravity. 4. Review the scores resulting from subsections of Section A; make sure that they are correct and reasonable in context of only 10 points allowable for each of the subsections; then enter total sum of points for Section A, on the right side of the page. Scoring

Section

B, Symptoms

and Family

History

1. Sum the number of symptoms reported: Count the symptoms that are recorded as Always, Sometimes, or Never and indicate these results on the lines allocated for this purpose. 2. O f those symptoms reported as "always" present, indicate which are of a "subjective" nature and which are "objective" in the proper spaces. "Objective" symptoms are those which are responses to questions 13, 14, 18, 19, 22, 23, 24, 28, 31, 33, 37, 41, 42, 43. "Subjective" symptoms include repsonses to questions 1 through 8, and 9, 10, 11, 12, 15, 16, 17, 20, 21, 25, 26, 27, 29, 30, 32, 34, 35, 36, 38, 39, 40. 3. Note those "objective" and "subjective" symptoms which

Appendix/163 are present only " s o m e t i m e s " or "never." Check y o u r results. 4. Score by a w a r d i n g 1 point to each s y m p t o m that is rep o r t e d as " a l w a y s " present, and 0.5 p o i n t to those only " s o m e t i m e s " present. T h e resulting total of the "objective" s y m p t o m s is to be inserted in the subtotals of b o t h Severity and Gravity. Contrariwise, the resulting total of the "subjective" s y m p t o m s is to be inserted only in the subtotal c o l u m n of Severity. It follows that the total score of Severity will include all s y m p t o m s reported, whereas the total Gravity score will consist uniquely of "objective" symptoms. 5. Disease fatalities in siblings. (Questions 46 and 47, of the Clinical History.) a. C o u n t the n u m b e r of siblings living, including the patient. b. T h i s material will not enter into the scoring of Severity. It will be taken into account in scoring Gravity if the patient's p r o b l e m appears to reflect diseases characteristic of his or her family. If the latter is true, a w a r d 1 point if the p r o p o r t i o n of siblings still living is 7 5 % of those ever living; 2 points if the p r o p o r t i o n of those living is only b e t w e e n 5 0 % and 7 4 % ; 3 points if it is a p r o p o r t i o n bet w e e n 2 5 % and 4 9 % of those ever living; and 4 points if it is as l o w as 2 5 % . 6. Disease fatalities in children. a. Establish the p r o p o r t i o n that children still living represents of children ever alive (information f o u n d on the f o u r t h line of Clinical History, and in question 49 of the History). b. Assign 0 points to Severity if all children remain alive. If the p r o p o r t i o n is b e t w e e n 7 5 % and 100%, score 1 point f o r Severity. B e t w e e n 5 0 % and 7 4 % , score 2 points; bet w e e n 2 5 % and 4 9 % , score 3 points, and, w h e n the p r o p o r t i o n of children living is less than 2 5 % , assign a score of 4 points t o Severity. T h i s consideration will not affect the Gravity scoring.

Susto, a Folk Illness/164 7. Review your evaluations of Section B and place your total point scores in the appropriate space on the right. Scoring

Section

C, Physical

Examination

1. Presentation and attitude of the patient. The patient's presentation of self will weigh on both Severity and Gravity scores. Healthy appearance scores 0; moderately healthy appearance receives a score of 0.5, and sickly appearance, 1 point. However, the patient's attitude should be kept in mind, to be used later in formulation of the disease diagnoses. 2. Systolic blood pressure, second measurement. If it is abnormal but seems not to be related to the other symptoms or to the history, it will be scored as an "objective" symptom. Points will be assigned Severity on the basis of the discomfort it causes, but to Gravity only as a reflection of the extent to which it endangers life. 3. Systolic blood pressure, difference between second and first readings. Assigned to Severity to reflect the discomfort related to a change in levels; to Gravity solely to indicate the extent to which the change imperils life. 4. Diastolic blood pressure, second measurement. Assign points to Severity according to the symptoms and incapacity for which it appears responsible; to Gravity to reflect its threat to the patient's life. 5. Diastolic blood pressure, difference between second and first readings. Assign points to Severity to indicate symptoms and incapacitating effects; Gravity points will reflect your judgment as to the extent to which it endangers the patient's life. 6. Pulse, second reading. Your point score should reflect the extent to which you consider the pulse rate to be abnormal (as an objective symptom), and what it appears to signify in interaction with other symptoms. Points assigned Gravity will reflect your clinical judgment as to the extent to which abnormality of pulse rate signifies a threat to the patient's life.

Appendix/165 7. Pulse, differences in rates on second and first reading. Points assigned Severity will reflect the extent to w h i c h this change is associated w i t h other s y m p t o m s or has an incapacitating effect. Points should be assigned Gravity to indicate h o w this change reflects on the state of the cardiovascular and emotional systems, respectively. 8. Respiration. T o be treated similarly to pulse rate. 9. T e m p e r a t u r e . A temperature, taken by m o u t h , of 38°C will receive 1 point; 39°C will receive 2 points; 40°C will be a w a r d e d 3 points. T h e s e points will be recorded in the Severity c o l u m n only, except w h e n t e m p e r a t u r e is higher than 40°C, w h e n it m a y be included in the Gravity colu m n , depending on its relationship to the patient's general state of health. 10. A b n o r m a l findings. Severity, according to the incapacitation it causes. Gravity, to reflect the extent to w h i c h a patient's life is endangered. 11. R e v i e w y o u r findings and calculate the extent to w h i c h this physical examination suggests the patient to be incapacitated b y the p r o b l e m s discovered. Your evaluation of the implication of discrepancies f o u n d between second and first measures (e.g., systolic blood pressure, diastolic b l o o d pressure, pulse, and respiration) for disease p r o cesses or emotional dynamics, m a y tell y o u m u c h m o r e a b o u t the patient's state of health than any of the specific abnormalities diagnosed. T h e m a x i m u m you can assign this section is 10 points. In a similar way, estimate the extent to w h i c h this physcial examination suggests the patient's life to be threatened by the p r o b l e m s it reveals. Scoring Section D, Laboratory Examinations Each of the six issues that m a k e up this section should be evaluated in t e r m s of the overall clinical impression thus far achieved. Should y o u n o t conceive of a relationship between, for example, an a b n o r m a l i t y reported by the laboratory and the clinical impression, assign scores to b o t h Severity and Gravity a n y w a y , a l t h o u g h in this case you will p r o b a b l y

Susto, a Folk Illness/166 assign l o w e r points than if y o u had noted such a relationship. (Even t h o u g h there is n o relationship between a finding of Amoeba histolytica and Ancylostoma duodenale, presence of b o t h in a patient should be scored double that a w a r d e d other p a r asites. T h e p o i n t score will be increased still m o r e w h e n these appear to be associated w i t h y o u r gestalt clinical impression.) Make Note of the Retrospective Diagnoses T h e r e are tentative diagnoses and they include b o t h organic and p s y c h o e m o t i o n a l p r o b l e m s . Include each of the diagnoses at w h i c h y o u have arrived, separating t h e m into, respectively, organic and p s y c h o e m o t i o n a l classifications. Be sure to include those observations w h i c h y o u feel will contribute to obtaining a relatively complete clinical understanding of each patient. Arrive at a Total Score 1. Seventy. In accord w i t h the diagnoses d e v e l o p m e n t and the clinical impression arrived at, score for estimated incapacitation, based on m a x i m u m score of 40 points. 2. Gravity. In similar f o r m , based on a m a x i m u m possible score of 40 points, estimate the extent to w h i c h the patient has suffered d i m i n i s h m e n t of health so as to be threatened by death. C a r r y the section scores to the s u m m a r y c o l u m n and w r i t e the totals in the spaces provided. C o m p a r i s o n between scores arrived at by adding the s u b totals c o r r e s p o n d i n g to each section, and those achieved by a s u m o f the total s y m p t o m s and diagnoses. If there are differences b e t w e e n these t w o subtotals, review again the scoring w i t h i n the respective sections and select the clinical criteria that seem most appropriate. If such a correction proves necessary, m a k e a n o t e of h o w the a d j u s t m e n t was m a d e and w h y . Place the definitive total point scores in the spaces indicated. Include y o u r n a m e at the b o t t o m of the second page to facilitate c o m p a r i s o n s of criteria and j u d g m e n t s at a later date.

Appendix/167

Measures of Severity and Gravity Location Age Sex Identification N u m b e r of Individual Subtotal of Total of Severity Gravity Severity Gravity A. History 1. Complaint, its history and duration 2. Tendency 3. Effort required to accomplish customary tasks B. Symptoms and Family History 1. S y m p t o m s Always Sometimes Never Objective Subjective Total 2. Fatal disease in siblings 3. Fatal disease in children C. Physical Examination 1. Patient's attitude 2. Pressure (systolic) a. Second measure b. Discrepancy between second and first 3. Pressure (diastolic) a. Second measure b. Discrepancy between second and first

Susto, a Folk Illness/168 4. Pulse a. Second measure b. Discrepancy between second and first 5. Breathing a. Second measure b. Discrepancy between second and first 6. Temperature 7. A b n o r m a l findings D. Laboratory Examinations Blood: 1. H e m o g l o b i n 2. Hematocrit 3. Sedimentation 4. Leukocytes 5. Increase in n u m b e r of leukocytes 6. Parasites in stool Summary A. History B. S y m p t o m s and Family History C. Physical Examination D. Laboratory Examination Retrospective Diagnosis Organic

Psychoemotional

Name:

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Author Index

Adams, R. N., and A. J. Rubel, 6 Aguirre Beiträn, G., 121

Elder, R., and R. M. Acheson, 5 Engel, G., 5

Bahr, D. et al., 2, 9, 43, 44 Barlett, P., and S. Low, 3, 6 Billig, O. et al., 9, 60 Blonde, L., and F. Riddick, 8 Bolton, R., 6, 8 Brodman, A. J. et al., 60 Brown, G. W., 57

Fabrega, H. Jr., 4, 115 Fabrega, H. Jr., and G. McBee, 60 Fabrega, H. Jr., and D. Silver, 2 Finkler, K., 4 Foster, G., 109, 121 Frake, C., 2

Carrasco, P., 121 Cassel, J. et al., 14 Caudill, W., 10, 56 Chance, N., 61 Chiappe Costa, M., 6 Clark, M., 6 Comaroff, J., 3, 6 Corbett, J., 20, 26 Crandell, D. L., and B. P. Dohrenwend, 60, 75, 79 Dennis, P., 21, 37 Donabedian, A., 4 Dow, J., 41 Driver, H. E., 18 Edwards, M. H., 5 Eggan, F., 15 Eisenberg, L., 5

Gaitz, C. M., and J. Scott, Gillin, J., 6, 60 Gove, W. R., and J. F. Tudor, 78 Hale, F. et al., 8 Hart, D. V., 6 Holmes, T. H., and M. Masuda, 8n. Howard, A., and R. A. Scott, 11, 14 Kennedy, J. G., 6, 42 Kiev, A., 3 Klein, J., 4 Kleinman, A., 2, 4 Kleinman, A., and L. H. Sung, 4 Kluckhohn, C., 121 183

Author Index/184

Koos, E. L., 5 Krejci, John, 27 Krejci, J., and J. Krejci, 51 Langner, T. S., 60, 74, 80 Lawrence, J. S., 5 León, C., 6, 9, 60 Lévi-Strauss, C., 3 Le Vine, R. A., 15 Lewis, G., 2, 4 Logan, M. H., 6 McGrath, J. E., 55, 119 Macmillan, A. M., 60 Manis, J. G. et al., 60 Marcus, J., and K. V. Flannery, 43 Martinez, C., and H. W. Martin, 6 Marwick, M., 3 Mason, J. W., 11, 13 Mechanic, D., 14 Meile, R. L., and W. E. Gregg, 61, 62 Metzger, D., and G. Williams, 2 Morsy, S., 3 Mull, J. D., and D. S. Mull, 6 Muller, D. J., 60 Nash, J., 78 Nash, M., 78 O'Nell, C. W., 6, 8, 12, 45, 53, 71, 78, 122 O'Nell, C. W., and A. J. Rubel, 53 O'Nell, C. W., A. J. Rubel, and R. Collado-Ardón, 119

O'Nell, C. W., and H. A. Selby, 6, 53, 78, 122 Pages Larraya, F., 9, 60 Palma, N. H., 6 Palma, N. H., and G. Torres Vildoza, 6 Panum, P. E., 44 Pelligrino, E. D., 2 Permutt, M. A. et al., 8 Redfield, R., 18 Roberts, R. E. et al., 61, 62, 74, 78, 79 Rubel, A. J., 2, 3, 6, 12, 53, 57, 109, 122 Sal y Rosas, F., 6 Saunders, L., 6 Schader, R. I. et al., 60 Seijas, H., 6, 78 Seiler, L. H., 78 Selye, H., 11, 14, 55 Simons, R., 6 Snow, J., 44 Swadesh, M., 18 Tousignant, M., 6 Turner, V., 3 Uzzell, D., 13, 122 Vogt, E. Z., 3, 6 Waxier, N., 84 White, K., 10 Whiting, J. W. M., 16 Zavala, C. et al., 18 Zborowski, M., 5 Zola, I. K., 5

Subject Index

Health and social relationships, 3 Health O p i n i o n Survey, 60 Hypoglycemia, 8 Hypotheses tested, 11-13, 15, 49, 50, 114

Ancianos, 21 Barrios, 21 Caracterizados, 21 Chinantec, 16, 19, 20, 21, 22, 23, 24, 25, 26, 29, 61, 63 C o m m u n a l holdings, 22-24 Cornell Medical Index, 60 Cross-cultural controlled comparison, 14, 15, 16, 49-50, 51-52, 121

Illness as cultural f o r m , 4, 5,

6 Latah, 7 - 8

Educational levels, 22, 26, 27, 49 Esparanto, 6

Mestizo, 16, 19, 20, 21, 23, 24, 26, 27, 29, 32, 51, 61, 63

Folk illness: in Argentina, 6; Colombia, 6; Costa Rica, 2, 3; Egypt, 3; Guatemala, 6; Peru, 6; Philippines, Malaysia, Indonesia, 7 - 8 ; People's Republic of China, 6; Taiwan, 6, 7; U . S . A . , 6; efficacy in curing, 4; "psychologizing" of, 3 - 4 , as reflection of social relations, 2, 3, 14

Nervios, 3, 7 Pas mo, 6 Pérdida de la sombra, 6 Political office (cargos), 20, 21, 22, 24, 28, 49-51, 52, 53 Sampling of individuals, 4 9 51, 52, 53 Severity measure, 13, 100 passim Social stratification, 21-22, 32, 49, 51, 61 Social Stress Gauge, 13, 59,

"Galton's P r o b l e m , " 16 Gender role expectations, 24-25, 26, 27 Gravity measure, 15, 100 passim, 116, 118

112

Stress defined, 11, 57 185

Subject Index/186 S t r e s s o r s defined, 11, 113, 118 S u s t o : as c u l t u r e - b o u n d s y n d r o m e , 6; described, 6; fatalities f r o m , 71, 106, 1 1 5 - 1 1 6 ; healing of, 3 8 - 4 1 , 42; h y p o g l y c e m i a , 8; loss o f vital substance, 1, 43; and o r g a n i c disease, 13, 53, 54; p r e v e n t i o n of, 3 0 - 3 1 ; as psychiatric disorder o f functional d e p r i v a t i o n , 9; and psychiatric i m p a i r m e n t , 54, 8 3 - 8 6 ; as schizophrenia, 9; and social stress, 13, 5 5 - 5 6 , 113; and

social stress theory, 1 1 - 1 4 ; caused b y spirits, 1, 8, 9, 10, 43, 112; and witchcraft, 4 5 - 4 6 ; w o r l d distribution o f soul l o s s , 6 Tierra,

6, 8

T w e n t y - t w o Item S c r e e n i n g Score, 13, 60, 73, 74, 7 9 -

80

Uzr,

3

Z a p o t e c , 16, 19, 23, 25, 26, 27, 28, 61, 6 3

Designer; Compositor; Printer: Binder: Text: Display:

U . C . Press Staff Publisher's Typography Thomson-Shore, Inc. John H. Dekker & Sons 10/13 Bembo Bembo