Folk remedies among ethnic subgroups

Note: This is a revised and updated version of the CSA report presented at the 1997 AMA Annual Meeting; it represents the medical/scientific literature on this subject as of June 1999.

Full text

Folk medicine is a form of complementary and alternative medicine that relies heavily (although not exclusively) on oral tradition. Strongly influenced by cultural norms and values, folk medicine generally comprises the "unofficial" or "lay" health beliefs and practices found in all societies.¹ This is in contrast to "conventional" biomedicine as defined as medical interventions that are taught at U.S. medical schools and sanctioned by practices of licensure, certification, and accreditation. In the United States, folk medicine is commonly associated with individuals from particular ethnic groups. However, a significant number of folk remedies are also widely distributed throughout American society. Examples of folk medicine include acupuncture, naturopathy, and herbal medicine. Also included in folk medicine are religious beliefs and practices (eg, intercessory prayer, meditation, faith healing) believed to affect health.^1-2 

Despite advances in scientific biomedicine, interest in and use of folk medicine is remarkably persistent among ethnic populations in the United States.^1,3 Within ethnic groups, an individual's cultural beliefs and practices often provide an underlying structure for decision making during illness that is not always concordant with the biomedical model.^4-6 The greater the discrepancy between folk and conventional biomedicine, the greater the potential impact cultural beliefs and practices have on the use of health services.⁵ Despite this potential impact, there is little consensus within the medical community on the prevalence of use, effectiveness, or safety of folk medicine.^1,7-10 This report examines folk medicine in the United States and suggests guidelines for addressing clinical issues surrounding folk beliefs and behaviors in a culturally sensitive way. 

Methods

A review of the literature was conducted as part of a broad strategy to identify relevant publications relating to the definition and use of folk medicine in the United States. Primary journal articles were identified through systematic searches of the MEDLINE database for English-language articles on folk medicine, alternative medicine,  and complementary medicine. Articles were selected based on their ability to provide information on: (1) the nature and use of folk medicine; (2) clinical evaluations of folk remedies; and (3) relationships between folk medicine and conventional therapy. Following reading of over 150 review articles, further relevant primary articles and books were selected from the reference listings. A draft report underwent peer review by experts in the field and by the American Medical Association (AMA) Council on Scientific Affairs. This report was transmitted to the AMA House of Delegates, and its recommendations were adopted as policy in June 1997.

Defining folk medicine

The term "folk medicine" is often used interchangeably in the literature with "complementary and alternative medicine." There are, however, subtle differences in the meanings of these terms. Complementary and alternative medicine (CAM)  is a broad designation for all health practices that fall outside of conventional biomedicine but may be used to augment biomedical therapy. These include, but are not limited to, folk medicine (eg, herbal medicine, prayer, etc.), Ayurveda and yoga, massage therapy, aromatherapy, and diet therapy.¹¹ Folk medicine, on the other hand, is a subset of CAM. This term generally refers to a lay person's use of household and traditional remedies. Conventional biomedicine  is a term applied to medical treatments based on the medical model of health care. 

Cultural ideas of health and illness

In any society, attitudes toward illness and treatment are culturally laden.^1,4-5,12-16 The manner in which individuals present their symptoms, how they communicate about their health problems, and the decisions they make about health care are all influenced by cultural beliefs and values concerning sickness. However, the relationship between culture and health-related beliefs and behavior is complex.¹⁷ Individuals usually make decisions about health care based on their own health-related beliefs and attitudes. These in turn are influenced by the interaction of a number of factors, including cultural beliefs about illness and treatment, personal experiences with illness, contacts with health professionals, and information and advice from friends and relatives. The Health Belief Model^18-19 can be used to summarize these various influences.

According to the Health Belief Model, the probability that an individual will perform a health action depends on the perceived benefit of the action as well as the perceived threat of illness.¹⁸ An individual's belief system is key to the model, providing some degree of psychological preparation to act in the event of threat.²⁰ In theory, some of the factors influencing individual belief systems are accessible to a wide cross-section of the population. In many societies, for example, education systems and the news media have been used to effectively communicate conventional medical concepts. Other factors, however, are more idiosyncratic and difficult to predict. Although shaped by cultural norms, personal beliefs and expectations about illness are highly variable, with considerable variation in health-related attitudes across ethnic, class, and family boundaries.²¹ 

Explanatory models for sickness emerge from the synergy of cultural beliefs, individual and idiosyncratic beliefs, and biomedical concepts.⁵ These models for sickness are seldom exclusively "folk" on one hand, or wholly "biomedical" on the other. Instead, individual models are usually arrayed on a spectrum of illness beliefs and, at the individual level, represent highly eclectic combinations of elements from folk tradition, conventional biomedicine, religion, and so forth. Treatment options are generally determined by individual ideas about health and illness. On one extreme are treatments that can be easily classified as household or traditional remedies. On the other end of the spectrum are treatments based exclusively within conventional biomedicine. 

Understanding folk medicine

When cultural and religious ideas predominate in the formation of ideas about health and illness the use of folk medicine is encouraged. Differences in cultures, in turn, produce considerable variation in the reasons for and nature of illness. Some Pacific Islanders, for example, view illness as a manifestation of family conflict. Individuals are believed to mediate socially unacceptable family tensions through illness rather than through direct confrontation.²³ Many American Indians, on the other hand, believe that supernatural forces cause illness, often in retribution for breaking a religious taboo.²⁴ Some African Americans also view disease in religious or supernatural terms, such as a symptom of a hex.^22,25 Finally, many Southeast Asians view illness as a natural part of predestined suffering.¹³ 

Despite the variation in cultural ideas about health and illness, folk medical beliefs and practices do represent a fairly integrated cognitive system for logically understanding illness and making decisions about treatment.^1,22 According to Hufford,^1,3  different folk medical traditions also share many common features. First, folk medicine generally views the underlying causes of illness as a result of some kind of imbalance or lack of harmony, ranging from sin to improper balance in personal relationships. Second, there is a common reference to personal responsibility in folk medicine that provides a moral element that helps to underline the interconnectedness of personal health with the community or physical environment. This moral tone highlights a major psychosocial function of folk healing systems: the integration of the experience of sickness within a meaningful view of the world. Third, folk medical practices are usually complex, involving a multicausal or "holistic" view of disease etiology. Finally, there is an emphasis on various kinds of "energy" that mediates the concepts of harmony, balance, and integration. Examples of energy are implicated in natural (eg, improper cooking of foods) as well as supernatural (eg, witchcraft) ideas of disease and are portrayed as either positive energies or negative, life-destroying energies. 

These common features of folk medicine are interrelated and serve a complex variety of goals. Like conventional biomedicine, the preeminent goal of folk medicine is the amelioration of the effects of disease.¹ However, most folk medical systems also serve goals not typically associated with the medical model, which can affect the perception and treatment of disease. For example, folk medical beliefs will allow an individual to look beyond the underlying pathological process in an effort to assign responsibility for illness, extending the list of diagnostic possibilities to which an individual may subscribe. Responsibility may lie with the patient (eg, their salvation) or with the environment (eg, a hex or some other form of witchcraft). Assignment of responsibility, in turn, dictates the focus of folk therapy. 

Folk medicine in the United States

Use of complementary and alternative medicine in the United States has increased substantially in recent years.²⁶ There is also substantial professional interest in CAM practices, with over 50% of conventional physicians in the United States using or referring patients for some CAM treatments.^27-29 Among those using CAM treatments, the majority also sought treatment for the same condition from a medical doctor.^26,30-32 

Folk medicine has played a central role in the development of CAM in the United States and has experienced growth patterns similar to CAM in general.^5,26 Specific examples of folk medicine include, but are not limited to: (1) the utilization of herbs by immigrants from Asian, African, Caribbean, and Central and South American cultures^22,33; (2) the use of acupuncture, coining (the rubbing of a coin on the arm or back), or cupping (the placing of a heated cup on the skin) by immigrants from Southeast Asia³⁴; (3) the classification of illnesses, medicines, and foods based on the hot-cold theory of disease by Latin-American and Asian-American individuals^35-38; (4) spiritual healing or visits to a curandero (Mexican folk healer) by Mexican Americans^39-42; (5) the use of religious and folk healers by Arab immigrants⁴³; and (6) the use of traditional healers among Native Americans.^44-46 

Much of the recent growth in the use of folk medicine in the United States stems from the introduction of therapies from foreign or Native American cultures. For example, the reopening of China to the West in the early 1970s increased immigration to the United States and the subsequent importation of traditional Chinese medical practices.⁴⁷ Furthermore, the use of folk medicine has persisted among some American-born descendants of immigrants.⁴⁸ In addition, external factors such as socioeconomic status and acculturation have been shown to influence the use of folk remedies. Generally speaking, poorer patients are more likely to engage in folk remedies compared to more affluent patients.^17,42,49-51 As individuals become more "fluent" in the mainstream culture, or become more acculturated, they have higher rates of compliance with conventional biomedicine.^6,30,34 

There is also evidence that folk medicine has become increasingly popular in the general population. For example, most Americans believe that the "common cold" is in some way caused by exposure to weather conditions.¹ Beliefs about cold and colds are widespread, even among individuals who use scientific biomedicine as their exclusive source of health care. Folk medical treatments are also commonly used to treat perimenopausal and menopausal complaints,⁵² nausea and vomiting during pregnancy,^53-55 human immunodeficiency virus infection and acquired immunodeficiency syndrome,^56-59 cancer,⁶⁰ acute and chronic liver disease,⁶¹ and substance abuse.^62-63 Specific folk therapies common in the general population include acupuncture⁶⁴ and herbal remedies.⁶⁵ In addition, almost half of all family practice patients believe that prayers are effective in healing.⁶⁶ 

Effectiveness of folk medicine

Several studies claim to have found that folk medicine has some effectiveness in treating a number of health conditions. Clinical trials on herbs are the most numerous, with several suggesting efficacy in the treatment of disease. Specific examples include, but are not limited to: (1) the use of St. John s wort (Hypericum perforatum) for treatment of mild to moderate depression⁶⁷; (2) the use of feverfew (Tanacetum partheniu)  to treat migraines^68-69; (3) the use of garlic (Allium sativum) to reduce total serum cholesterol in patients suffering from hypercholesterolemia^70-71; and (4) the use of ginkgo (Ginkgo biloba) in the treatment of dementia and claudication.⁷² In addition, studies have found herbal remedies to reduce pain from arthritis^73-74 and to be effective in treating irritable bowel syndrome,⁷⁵ benign prostatic hyperplasia,⁷⁶ and nausea.⁷⁷ 

Evidence in support of the therapeutic benefit of common herbal remedies remains inconclusive as a majority of studies suffer from problems in design, small sample sizes, and other factors.³³  Cost is the primary barrier to developing sound methodological studies on the effectiveness of herbal medicines. Such studies are simply not profitable and, without a mandate, there is little motivation to conduct randomized, placebo-controlled, double-blinded clinical trials of medicinal herbs. Assessment of folk herbal remedies is also complicated by additional limitations to existing data. Often, data about the safety and efficacy of medicinal herbs is limited to in vitro or animal studies. There is also limited information on drug interactions, the effects of medicinal herbs in special populations (eg, children, and pregnant women), or toxic reactions. Finally, there is almost no information on the effects of long-term use folk herbal medicine.

In addition to herbal remedies, other folk therapies have also been reputed to show some health-related benefits. For instance, meta-analyses of studies examining religious commitment have consistently found a strong positive association between commitment and measures of physical and mental health.^86-88 Intercessory prayer has also been associated with improved health outcomes.⁸⁹ Finally, after an extensive review of clinical evidence, the National Institutes of Health has concluded that acupuncture is an appropriate therapy for adult postoperative and chemotherapy-induced nausea and vomiting and postoperative dental pain.⁹⁰ This same report also recommended the use of acupuncture in the treatment of addiction, headache, menstrual cramps, arthritis, lower back pain, and asthma. 

Research on the therapeutic benefit of nonherbal folk therapies is also plagued by problems in study design, small sample sizes, and other factors.⁹⁰ Taken as a whole, the use of herbal and other folk medicine has not proven effective from a biomedical standpoint. At best, they may have only a placebo effect that may give the semblance of effectiveness.^91-92 At worst, some folk remedies may be clinically harmful. For example, research has linked the use of folk medicine to cases of acute and chronic toxicity,^93-100 postmenopausal uterine bleeding,^101-102 Salmonella arizona,^103-104 and pneumonia.¹⁰⁵ In some cases, folk medicine itself may not be dangerous, but it may impede the use of proven conventional therapies. For example, Asser and Swan¹⁰⁶ found the exclusive use of faith healing to be associated with a number of preventive child fatalities. Lyles and Hillard¹⁰⁷ illustrate a case of a patient who refused surgery for an imminently life-threatening situation because she believed her illness was caused by witchcraft. Finally, Benmeir et al¹⁰⁸ also report a case in which a woman tried to treat melanoma with homeopathy. She did not undergo surgical intervention until her tumor weighed almost 2 kg. 

The hazards of incorrect self-diagnosis and a lack of consistency or standardization in treatment seriously complicate assumptions about the effectiveness of folk therapies. By expanding the list of diagnostic possibilities to which an individual may subscribe, folk medicine increases the risk of misdiagnosis. Incorrect diagnosis, in turn, can delay necessary professional care. Furthermore, the use of home remedies has the potential to mask or suppress symptoms, impairing a physician's ability to accurately diagnose and treat illness.¹⁰⁹ Standardization is also problematic.^77,110 For example, the amount of active ingredient in foxglove (used to strengthen the contractions of a weak heart) varies substantially from plant to plant, a serious matter when a therapeutic dose is close to a fatal dose.¹¹ Illnesses and even death have also occurred from errors in the identification of herbs by suppliers.¹¹¹

The use of folk medicine among individuals in ethnic subgroups and the general population persists despite the lack of scientific evidence supporting its efficacy. Clearly, reasons for this continued use must lie somewhere outside the conventional medical model.⁵ Thus, a comprehensive evaluation of folk medicine must examine the individual medical beliefs central to the synergy of ideas behind an individual s explanatory model for sickness. 

Clinical implications

Given the central role of cultural beliefs in the individual construction of ideas about health and illness, it stands to reason that an understanding of these beliefs in a clinical setting would enhance health care. This reasoning is behind arguments in favor of "culturally sensitive" care. Without endangering the health of the patient, a culturally sensitive health care system attempts to respect the beliefs, attitudes, and cultural lifestyles of its patients and works to improve the quality of interaction between the patient and clinician. Mutual respect forms the basis for the successful integration of the physiological aspects of disease with an individual s culturally constructed meaning of illness within the clinical setting. Culturally sensitive health care is also flexible enough to acknowledge intergroup and intragroup variations in beliefs and behaviors, thus avoiding the pitfalls and problems associated with labeling and stereotyping. 

Clinical and nonclinical health outcomes have, in fact, been improved in situations where the clinician considered the patient's cultural beliefs about health and illness.^112-113 Sensitive, open communication between patients and clinicians is key to the development of a collaborative relationship within which treatment decisions can be made.¹¹⁴ Pachter⁵ identifies a number of steps that a clinician can take to facilitate this relationship. Specifically, the clinician needs to: (1) Become aware of commonly held folk medical beliefs in a community. Initially, patients may be reluctant to discuss folk medical beliefs with their clinician, but if the topic is approached in a nonjudgmental manner opportunity for dialog can be created. (2) Assess the likelihood that a particular patient or family will use folk medicine. The clinician needs to be aware of folk medical beliefs in different groups and then determine the extent to which these beliefs are acted on by individual patients. (3) Negotiate between the conventional medical and folk models for sickness. Once the clinician identifies folk medical beliefs common to the community and assesses individual likelihood of use, he or she must address the use of folk medicine.

The last point is important to the delivery of appropriate health care. Given the extensive use of folk medicine and the relative paucity of information on the safety of folk remedies, it is quite possible that patients are putting themselves at risk by using such remedies. A licensed clinician is in a unique position to help patients avoid inappropriate use of folk remedies. Specifically, the clinician needs to evaluate the safety and efficacy of folk remedies. Possibilities with regard to safety and efficacy of folk therapies include:

• The therapy is safe and effective   
• The therapy is safe but ineffective   
• The therapy is effective but unsafe   
• The therapy is neither effective nor safe

The clinician also needs to assess whether the use of folk medicine conflicts with conventional biomedicine and devise an appropriate treatment plan. Most folk remedies are not harmful and do not interfere with biomedical treatment. Under these circumstances, the clinician should not insist that the patient abandon his or her folk beliefs. Instead, the clinician should try to educate the patient as to the importance of the biomedical therapy. Patients should also be encouraged to inform their clinician should their use of folk medical practices change. On the other hand, if a folk remedy has the potential for serious negative outcomes, it needs to be discouraged. Reasons for making such a recommendation need to be clearly explained to the patient in a sensitive way. If possible, dangerous practices should be replaced with biomedical treatments that fit within the individual's belief system.

Conclusion

Folk medical practices arise out of the synergy of individual beliefs, cultural beliefs, and biomedical concepts about illness and treatment. Despite the lack of consensus on the safety or efficacy of folk medicine, the use of folk remedies persists among individuals in ethnic subgroups in the United States and is increasingly being used in the general population. Research examining the effectiveness of folk medicine suggests that most folk remedies are more-or-less harmless. However, a number of serious side effects have been noted. In an effort to provide culturally sensitive and effective health care, clinicians need to acknowledge that many patients have beliefs that exist outside of modern scientific biomedicine. Where appropriate, health care providers must also work to integrate lay beliefs with conventional biomedicine in an effort to improve health care. 

Recommendations

The following statements, recommended by the Council on Scientific Affairs, were adopted by the AMA House of Delegates as AMA policy at the 1997 AMA Annual Meeting.

The AMA:

1. Does not recommend the sole use of unvalidated folk remedies to treat disease without scientific evidence regarding their safety or efficacy;   
2. Encourages research to determine the safety and efficacy of folk remedies;   
3. Urges that physicians be aware that the use of folk remedies may delay patients from seeking medical attention or receiving conventional therapies with proven benefit for disease treatment and prevention;   
4. Urges that practicing physicians routinely ask patients whether they are using folk medicine or family remedies for their symptoms. Physicians can educate patients about the level of scientific information available about the therapy they are using, as well as conventional therapies that are known to be safe and efficacious; and   
5. Urges that physicians be aware of folk remedies in use and the level of scientific information available about such remedies, and should include this information when discussing conventional treatments and therapies with their patients.

Also see the AMA Health disparities Web site.

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