Chapter 19 Sioui Maldonado-Bouchard1, Lise Bouchard2, and Mario Incayawar3 1 Research Associate, Runajambi Institute for the Study of Quichua Culture and Health, Otavalo, Ecuador 2 Director of Research, Runajambi Institute for the Study of Quichua Culture and Health, Otavalo, Ecuador 3 Director, Runajambi Institute for the Study of Quichua Culture and Health, Otavalo, Ecuador Mrs. Lema’s daughter, Miss Farinango (fictitious names), was feeling helpless. Concerned by her mother’s health the past several months, Miss Farinango had decided, as a last resort, to seek the help of a doctor in Quito, the capital of Ecuador. This had been an effort in money, time, and energy, traveling to the city from their village; long hours walking to the nearest road with her ill mother, and then several bus rides to the capital. Once in Quito, they had consulted a doctor, but he had dismissed the illness, labeling the symptoms as the result of Quichua superstition and nothing more. Mrs. Lema and Miss Farinango had returned to their home in the mountains feeling that the entire trip had been in vain. Mrs. Lema continued to feel ill, and nothing seemed to help. It had begun suddenly, shortly after a family quarrel over land. She began losing her appetite, and soon felt weak for hours at a time. It was usually worse during the evenings. She would complain that her mouth felt dry, and she felt light headed. Often she would wrap herself in blankets, complaining of cold. At first, Mrs. Lema thought that this would pass, but with time her symptoms only became more severe, until she began feeling as though she did not have a reason to live. She was certain one of her neighbors, who had been part of the quarrel over land, had put a curse on her. She felt powerless and betrayed, and could not understand how they could have taken such terrible action. Worried that she was suffering from llaqui, Mrs. Lema and her daughter went to see several yachactaitas (Quichua traditional healers). Mrs. Lema would feel better after the yachactaitas’ treatments, but the symptoms would eventually come back. She ultimately returned to see a doctor, who said her loss of appetite could be due to a problem with her gall bladder. Using up an important part of their life savings, Mrs. Lema underwent surgery for removal of her gall bladder. Yet her symptoms persisted after the surgery. In despair Mrs. Lema and Miss Farinango contacted Dr. Incayawar, after hearing about one of his articles on Andean syndromes, published in a local newspaper. A transcultural psychiatrist and pain specialist from the Runajambi Institute diagnosed Mrs. Lema as suffering from llaqui, a Quichua pain and psychiatric syndrome. The clinical encounter with a Quichua patient suffering from llaqui is challenging for a biomedically trained doctor or health professional. The syndrome appears relatively simple yet at the same time impenetrable; the doctor is faced with the same feelings someone experiences when dealing with the unknown and strange. The symptoms presented by the Quichua patient suffering from llaqui are the ones we commonly encounter in general medical practice in any society. Patients will primarily present a wide array of somatic symptoms to their doctors, including headaches, fatigue, nausea, vomiting, minor fever, migratory pain, and stomach pain. This is followed by some psychological symptoms such as worries, easy weeping, sadness, and the like. However, the doctor never gets a profile of symptoms that would allow a proper diagnosis. After close examination of a series of llaqui patients, it may look as though any symptom could be present in any patient. For this reason, researchers suggest that the identification of this culture-bound syndrome should not be based on symptoms configuration but rather on the local causes attributed to it [1]. The sources of this challenging medical encounter lie in at least in two factors: (1) lack of knowledge regarding the nature of llaqui, despite it being a highly prevalent condition among the Quichuas of the Andes, and (2) physicians’ ethnic or racial bias. Typically, the mishu1 doctor (as the mestizos or Latinos are called in Quichua) will focus on the most familiar somatic symptoms and will figure out a diagnosis such as “lack of vitamins,” malnutrition, pain, and parasitic disease, among others. Consequently, the treatment is polypharmacy based on vitamins, aspirin, or combination of analgesics, and occasionally medicines against helminths. As a result of this quick, simplistic approach, doubts remain concerning the accuracy of the diagnosis performed and appropriateness of the treatment plan adopted. Some patients will return again and again complaining of the same symptoms that led the doctor to dismiss a patient or to declare that nothing is wrong and “all is in your head” in the first place. On occasion, especially when patients claim having llaqui, which is a local culture-bound syndrome, physicians conclude that it is not a real illness; that it is rather an ailment resulting from superstition, and therefore lacking in any clinical importance. This misunderstanding reinforces the deeply held belief among the Quichuas that the mishu doctor knows little about llaqui, or is not qualified to treat it. Understandably, some patients will not return, realizing that the doctor does not give credit to their complaints and the treatment offered does not work. The poor-quality medical care frequently does not translate to relief for patients, but rather results in their deterioration or, even worse, in their death. For this reason, almost all Quichua patients are fearful of seeking care from biomedically trained doctors and some are so mistrustful that they believe that the doctors’ mission is to kill Quichua patients. The doctors’ lack of knowledge about llaqui clearly contributes to their disgraceful image within the Quichua society in the Andes. Physicians’ ethnic or racial bias Despite the fact that the mishu doctors live surrounded by millions of Quichua people in the Andes, they globally disregard the Quichuas and therefore create a social space where two solitudes co-exist. For a population of five and a half million Quichuas in Ecuador, there are only five Quichua physicians [2]. Physicians in the Andes are almost exclusively unilingual Spanish speakers. Therefore they do not speak the Quichua language; they rarely interact with the Quichua people outside the clinical field; and they do not receive any course on cultural competence during medical training, so they are not skilled to provide services that are culturally sensitive. Appallingly, a report from the World Health Organization reported that the indigenous people are racially discriminated against, and treated as second-class citizens and as inferiors [3]. These massive cultural and linguistic barriers, lack of training in cultural dimensions of illness, plus racism and ethnic discrimination, makes the Quichua patients feel they are not welcomed in a mishu medical setting. In addition, the history of brutal colonialism of the last five centuries in the Americas makes the Quichua patients suspicious and fearful that they will not be helped or treated respectfully but rather humiliated, attacked, or even killed by mishu health professionals [4]. Racial profiling and ostracism in medical care The indigenous peoples of the Americas, including the Quichuas of the Andes, are viewed in the Western imagery as savages, dangerous, violent, and stoic. In this biased colonialist view, Quichuas are dirty, backward people, illiterate, a barrier to progress, a nuisance in the medical encounter and good public health. It is not surprising to find that in many countries in the Americas, not only the military but also health policy makers will whisper that the “best Indian is a dead Indian.” With such deeply entrenched and generalized prejudices in the mainstream mishu society, it comes as no surprise that expressions of racism, bigotry, ostracism, bias, and discrimination against the Americas’ first inhabitants are used in the medical arena. The most dramatic manifestation occurred recently when an entire population was blamed for the outbreak of epidemics that threatened the public health of an entire nation. For nearly a decade, in the 90s, a particularly deadly epidemic of cholera surged in the Andes, including Ecuador. Thousands died, and entire communities were in panic. Public health officials and health services in the country were overwhelmed. Shamefully, health professionals, health officials, and the lay mishu population blamed the Quichuas for this crisis. Soon, on the streets, in public places, and in hospitals, mishu (Latinos) were attributing the cholera epidemic in Ecuador to the Quichuas’ bad customs, hygiene, habits, values, and culture. They literally blamed the victims of this deadly disease for the epidemic and deflected the responsibility of the outbreaks from the public health institutions and health officials to the Quichua victims. For example, educated mishus and health professionals deplored the “detestable” Quichua tradition of washing the body of the dead before burial, because they thought the bacterium Vibrio cholera contaminated waters and spread the disease. This phenomenon of blaming an entire group for an epidemic affected not only Ecuador but other countries in the region such as Venezuela [5]. Many mishu
Baffling clinical encounters: Navigating a pain and psychiatric Quichua syndrome
A puzzling encounter
The two solitudes
The western view
Lack of knowledge about the nature of llaqui
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