Anthropology Archive

Popular Folk And Professional Health Care Sectors

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All cultures have ethnomedical systems: institutionalized practices for addressing health maladies. Westerners often consider biomedicine the only reliable health resource, but people around the world—and many in the United States—use other healing systems as well. Modern societies typically have medical pluralism, where within a single society competing ethnomedical traditions coexist and form distinct health subcultures with unique beliefs, practices, and organizations.

Kleinman (1980) illustrated this medical pluralism in showing that complex societies have three overlapping sectors or health care systems:

• The popular (lay) sector involving culturally based personal and familial beliefs and practices
• The folk sector involving cultural ethnomedical traditions and specialists
• The professional sector involving legally sanctioned professionals

The use of these sectors varies by immediate circumstances and as a hierarchy of resort or priorities. Generally, health concerns are initially addressed in the popular sector with self-assessment and self-help procedures in consultation with significant others. This may be followed by consultation with folk specialists or, if necessary and available, with biomedical or other professional services. Biomedical resources may be the first choice but are generally accessed through decision making at the family (popular) level. These sectors have implications for biomedicine because they are often used in conjunction with or as an alternative to biomedicine.

Popular (Lay) Sector. The popular sector, also referred to as family care in nursing, is the basis for most personal health care decisions. These cultural understandings derived from family socialization provide principal interpretations of health and generally preempt biomedical care, constituting a first line of resources. Family members and other interpersonal relations and social networks generally assist in assessing maladies and making decisions regarding treatment, including seeking biomedical care. The popular sector primarily involves what people, without recourse to specialists, believe and do about health care, including ignoring symptoms, and decide whether biomedical care is necessary or whether recourse may be made to the folk sector. Popular-sector health practices involve minor first-aid preventive measures such as lifestyle activities, hygiene, and vitamins and over-the-counter medicines. Informed sources on TV, the Internet, and numerous publications also advise popular health behavior. Knowledge of popular health beliefs and behavioral patterns gives health care providers the basis for appropriate interpretations of help-seeking behavior, symptom presentation and complaints, communication about the body, and sick-role behavior and coping strategies. If health care providers are not aware of the cultural frameworks used by patients to conceptualize and communicate about their ailments, then noncompliance, patients' failure to comply with medical recommendations, is more likely. Case studies of African American health beliefs and Mexican American cultural factors affecting pregnancy and prenatal care illustrate the importance of the popular sector.

Folk Sector. The folk sector involves a variety of traditional cultural healing practices that are generally not part of an official or professional medical system. These include religious and spiritual healers, natural and physical healers (such as herbalists, midwives, and masseuses), and psychological healers (diviners, fortune-tellers). These ethnomedical systems have been called superstitions, charlatanry, quackery, and worse, and biomedicine has generally discounted their efficacy. But there is evidence that eth-nomedical systems provide amelioration of suffering through curative social, psychological, and physiological processes. The appeal of this sector as both a complement and alternative to biomedicine is examined with specific examples from the U.S. subcultures such as Mexican curanderismo, African American religious healing, and Native American healing practices.

Other ethnomedical systems in the United States, often referred to as alternative medicine, are also of considerable economic importance, reflected in expenditures that exceed the out-of-pocket expenses for biomedical care (Eisenberg et al., 1993; Eisenberg, Davis, Ettner, Appel, Wilkey, Van Rompay, and Kessler, 1998). The extent of this alternative care indicates that health care providers need to understand this medical pluralism and how its utilization affects patient care. Other ethnomedical systems have implications for biomedicine because they may be employed as a complementary rather than an alternative approach. This simultaneous use of several health care sectors is illustrated in treatments for HIV/AIDS.

Professional Sector. The professional sector of medical care is generally dominated by biomedicine, although other professional healers are found both in the United States and cross-culturally, such as naturopathic physicians. The professional sector provides the official and legally sanctioned medical care services. In the United States, it includes biomedical practitioners, osteopathic physicians, pharmacists, chiropractors, auxiliary practitioners such as nurses and physical therapists, and competing and often marginalized professionals such as naturopaths, homeopaths, and acupuncturists. What constitutes the professional sector differs cross-culturally, reflecting the effects of culture and politics on health systems and practitioners.

The cultures of biomedicine are illustrated in cross-cultural variations in practice preferences and in differences between physicians and nurses. These cultural aspects of biomedicine affect clinical relations and can undermine patient compliance, requiring cross-cultural adaptation to be effective and competent in patient care.

The popular, folk, and professional sectors ideally represent the major differences in the principal health practices found in modern societies. There are differences cross-culturally in the practitioners found in each sector. The professional sector of one culture may function as a folk sector in another, such as Chinese medicine or acupuncture in China versus the United States. The distinction between sectors is not absolute: popular practices may overlap folk practices (such as herbal medicine use), and folk healers may adopt biomedical practices (such as stethoscopes). The relationships among practitioners and sectors may change as folk healers professionalize and collaborate with the biomedical sector or when professional healers adopt folk practices, such as acupuncture in biomedicine.

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