The Bounds of Belief in Belize: Health, Belief, and Biomedicine in Rural Communities

by douglas c reeser A paper presented at the 111th Annual Meeting of the American Anthropological Association, San Francisco, November 14, 2012

I was first in southern Belize in 2007, when I conducted my MA/MPH research in the southern Toledo District on gardening and diet among two Q’eqchi’ Maya communities. Subsequent visits for work and pleasure helped to maintain relationships there until I returned in 2011 for fieldwork for my dissertation. Belize is a unique place in which to work – it is a mix of the Caribbean and Latin America both culturally and environmentally, and is a very small country (only about 325,000 people in total). Yet even in the south of the country it is also very diverse, with Mopan & Q’eqchi’ Maya, Garifuna, Kriol, East Indian, Chinese, Mennonite, Mestizo and a noticeable US/UK/European expat population all calling the Toledo District their home. The combination of a large diversity of people within a small population makes for a unique research environment that allows for the investigation of questions that are relevant at the global level in an environment that becomes intimate very quickly. Upon my return to Belize for my fieldwork, I was originally planning to look at how people managed their health in three distinct ethnic villages in the Toledo District. There remain Mopan, Q’eqchi’, Garifuna, and East Indian villages that are primarily composed of the given ethnic group, and I anticipated getting useful comparative data from whichever three communities welcomed my work. Health and health services were topics that I had been looking at since I began preparing for my MA/MPH research in 2006. Health statistics from organizations like PAHO and the WHO have singled out the Toledo District as a place of concern in the realm of health, citing evidence of chronic undernutrition and vitamin deficiencies, and high rates of growth stunting. A shortage of health services and providers has also been consistently reported. However, this information has always been based on quantitative data from the Belize Ministry of Health, and not supported with qualitative research in any way, providing a perfect opportunity for the insights offered through anthropological research. Given the nature of many economic and social indicators, the Toledo District is a place where services are needed. Nearly half of all households in the district live under the poverty line, which represents 58% of total poor in Belize. District-wide, 40% of children suffer from stunted growth. There is a high fertility rate of 5.6 children/woman, a high prevalence of Vitamin A deficiency among young children, and a high prevalence of anemia among pregnant women. Belize has a national health insurance program that includes a co-pay for most regions in the country, except in Toledo, where services are free. Health services at no cost certainly expand access to those services, but after spending some time there, I learned that these State services have a very poor reputation. Because of this reputation, many people avoid the State health services except in emergencies. After a short time in Belize at the start of my fieldwork, I decided on one fairly significant change to my research: I decided to focus solely on the town of Punta Gorda. PG, as it is called 1

locally, is the hub of the district in many ways despite its less than central location toward the south of the district. It houses the regional market, most government offices, banks, and stores not found elsewhere in the district, and it is home to a variety of health services, including the only hospital and largest polyclinic in the district. The ethnic diversity of PG reflects the diversity of the rest of the district, and I also discovered that a number of traditional healers of different ethnicities live in and practice in town. It also turned out that nearly everyone I spoke with uses some traditional home remedies passed down through their family, indicating that traditional health knowledge is still common. Working in PG made sense in many ways. PG offered the opportunity to explore a place that is in the middle of the traditional and the global/modern/Western. Many families in PG have family members living outside of Belize, TV is more common, and people are generally more exposed to global factors that may influence health care decisions. With the State hospital and polyclinic, and a number of private clinics in town, people can more easily access and use biomedical services – whether state provided or through private practitioners. This easier access most likely also has an influence on people’s health practices. Having decided to work in PG, I went ahead with my research. I conducted interviews and observations with local public and private doctors and nurses, pharmacists, and traditional healers. I also interviewed over 60 women heads of household from five major ethnic groups: Q’eqchi’ and Mopan Maya, Garifuna, East Indian, and Kriol. With official approval from the Belize Ministry of Health, I also conducted observations in the polyclinic and hospital, and was able to talk with staff in each location. Through my research and experience living in PG, a picture of the health system in its totality began to take shape. The health system in PG can be conceptualized as composed of layers consisting of biomedical services, the pharmacy, self-care and traditional home remedies, and traditional healers. The layers themselves are distinct and fairly bounded, but their use is blended by most people. Some prefer one aspect of the system over another, but almost universally, people use and rely on each of these layers to some extent. What layer a particular person or household turns to in a health event depends on a variety of factors, including the type and severity of the health event, economics, and personal preferences and beliefs. Most everyone in PG has had some interaction with the State health system, or the National Health Insurance (NHI) system. The NHI is a referral system, and patients are required to go to a local polyclinic for any case that is not an emergency. Polyclinics only provide basic services and basic medicines like vitamins, Tylenol and cough syrup. If needed, patients are then referred to one of two second tier polyclinics in the Toledo District, one of them being in PG. More serious cases are then referred to the hospital in PG, which then refers to a larger regional hospital about 3.5 hours away by bus. Many more serious cases then require a final transfer to the national hospital in Belize City, another 3 hours by bus. The most serious emergencies are transferred north to the regional or national hospital by ambulance (when it is running) or in rare cases by plane. In the PG and the Toledo District more widely, NHI only provides basic care, and all patients that require any specialist or emergency services need to be transferred. Unless it’s a dire emergency, people are asked to transport themselves, which raises issues like the cost of transport, accommodations, food, and loss of work, to name a few. Often these costs are prohibitive, especially for the half of the population living below the poverty line. Most people generally do 2

their best to avoid going to the polyclinic or hospital. They report long waits, poor service, negligence, watered down medicines, and risk of death as some of the more popular reasons. For those that can afford it, there is a second option for biomedical care in PG. There are four private doctors in town, all of whom either currently or have worked in the NHI system. So they are the same doctors, but they reportedly give better service in their private clinics. The two pharmacists in town are also a popular choice for health care, and also act as a primary entrance into the biomedical health care system as they often refer cases that are the least bit difficult to diagnose. Most households report some (varying) level of knowledge of traditional and home remedies that they often turn to as the first option in treating a health problem. There are a number of practicing traditional healers in town as well, although not everyone readily admits to consulting with them. One of the primary means that this layered system and how people interact with it is shaped is by beliefs. Health beliefs are often cited as driving how people respond to an illness, but this research shows that the role of belief is much wider than that, and is influential at almost every level and within every aspect of the health system. For example, belief can be seen at the level of the MOH in how they make policy, budget, and day-to-day decisions about the health system. In meetings with the MOH, they were interested in my research only in so far as it could help them get more people to use the NHI system “correctly.” MOH officials believe they have a good system in place, and health statistics would improve if people would learn to use the system – and not let their own beliefs lead them to use other types of services. The MOH believes that they are doing good – at least publicly. In defense of the MOH, the provision of free health services for the poorest district in the country is a good thing. However, the system has its problems. For instance, the new polyclinic, which was built for villagers who live outside of PG, is severely understaffed and often without a doctor, and the location is actually inconvenient for a large part of its catchment area. In response, people continue to go to the PG polyclinic from the villages because of convenience – even though they’re not supposed to. Further, the NHI referral system works, but only to a certain degree. The ambulance is frequently down, the available services are limited, there are shortages in medications, shortages in doctors, no specialists, and the system is poorly equipped to deal with the cultural variety of people who use their services. These types of problems the MOH is less interested in hearing about, and from what staff and doctors have told me, not likely to address. So, from the MOH point of view, it is local (indigenous, mostly Maya) beliefs that are preventing improvements in the health statistics in the district. And through extension, many employees (doctors, nurses, and staff) in PG and the Toledo District share this belief which directly affects how some patients are treated. More simply, beliefs affect health service provision within the NHI. Belief has been an important topic for some of the most seminal scholars in anthropology and other social sciences. The basis of the study of belief is in the study of religion. Durkheim, often recognized as one of the most influential theorists on religion and belief, explained how beliefs, identity, significant cultural symbols, and bonds within a group are all connected and mutually influencing. Together, these things form the glue that holds a group or society together. EvansPritchard argued that we cannot know the origins of a particular culture’s beliefs, and instead have to understand beliefs in terms of their relationships with other aspects of social life. How do beliefs make sense in the wider picture of a culture? Victor Turner went further by saying that the study of religion and belief will always fail, and that it can only be (partially) understood if the investigator holds shared or similar beliefs. 3

And belief continues to be a tough nut to crack. It is something that is at once subjective, perhaps the most personal part of ourselves, and yet it is also greatly influenced by the collective and those around us. All of this complexity is evident in the case of health beliefs in southern Belize. Beliefs about health and health care are present in every aspect of the health care system including among the MOH, the entire variety of health care providers and related staff, and the patients who use those services. And so the examination of health beliefs becomes complicated very quickly. Evans-Pritchard argued that belief in magic among the Azande offered them an explanation for social events that were otherwise unexplainable. For example, if a grain hut on stilts collapsed and killed someone sitting underneath, there were two levels of thought. On one hand, the Azande accepted the explanation that termites may have chewed the supports that led to the collapse. On the other hand, a belief in magic explained why that particular person was under that grain hut at that particular time and met his untimely demise. Similarly, in southern Belize, health beliefs, and thus people’s decision making, are influenced by explainable and unexplainable events. What makes someone ill, what to do about it, and what happens at any particular point of service are all based on belief. Across all households in this study, biomedicine has its place and is good at “explaining” many illness events; however, there are some things that it cannot explain, and some things that it fails in treating. In these instances people often turn to traditional healers. When, why, and how people do this, however, is part of the subjective realm, and appears to vary from household to household. And so there are innumerable ways in which people’s blends of beliefs are constituted. What a person believes will largely dictate what he or she does during an illness episode. Further, the person(s) providing the chosen services will also carry a set of beliefs about health and the person they are treating that will influence the services their patients receive. In order to improve services as they are provided, and how they are used, we need to understand what influences people’s beliefs. Keeping with Durkheim, I would argue it’s a person’s many relationships that influence their beliefs, and thus their actions. Providers and patients come together for a common cause – to treat an illness event – but their beliefs are often shaped by different groups or communities. People do not enter into a health event on a common baseline. All of this raises some important questions for southern Belize and beyond. When we understand that beliefs about health affect every aspect of the health environment, from personal health decision making to the actual services that are available, how do we begin to create a more effective health system? Whose beliefs matter? When people don’t trust or “believe in” the MOH services – or traditional healers – will the simple improvement or professionalization of services change health outcomes? Are we back to changing people’s beliefs (the MOH is certainly still there)? In other countries in the region, NGOs have attempted to provide health services appropriate to their target communities that, from the outside, appear to be having some success. However, there are no NGOs providing health services in the Toledo District, Belize. This is partly due to MOH and government policy that reports concerns about the integration of NGOs with the NHI system. Medical Missionaries are allowed to work in the district – there are at least two groups that I know of, but perhaps more. They come in for two-week periods and offer services that are infused with messages about Jesus and religion. They bring medicines that aren’t available after they leave, change people’s medicines with little knowledge of the situation, and have no link to the NHI 4

system. I was told that they often leave people in worse shape, and are primarily concerned with converting people. Clearly, these groups are influencing beliefs in a number of ways. For a number of reasons, the traditional healers remain an important piece to this picture. Besides among the Kriol community, I was able to identify traditional healers from each of the ethnic groups in the study. The vitality and availability of the traditions, however, varies across groups. There is only one East Indian traditional healer left, and his knowledge is primarily focused on treating venomous bites. Most Q’eqchi’ Maya healers are 50+ years old with nobody in training; however, they are among the most sought after for their treatment of health issues unsolved by other methods. I came across two Mopan healers in PG, both women. One was a renowned traditional massage therapist, and the other a young herbalist. Among the Garifuna, there are a handful of healers ranging in age and gender, which bodes well for the vitality of the tradition. Traditional healers often treat a patient more holistically than biomedicine, including a spiritual aspect to their treatment. This spiritual aspect is something that frightens many people – people know working in the spiritual realm has both good and evil aspects, and they are concerned about potentially nefarious intentions. Still, traditional healers remain widely used, and form an integral part of the health system in PG. The MOH is working on an official policy on traditional healing, but made no progress on the project in the year and a half that I was in Belize. Finally, home remedies are widely used, and a first look at my data show many commonalities across ethnic groups. Home remedies are usually passed down from parents and grandparents or other family members, akin to herbal remedies common elsewhere in the world. Here in Belize, the home remedies include a fairly localized plant knowledge, much of which is not widely studied. Also interesting is the finding that many households across ethnic groups refer to a book on Maya traditional medicines in Belize as a source for their home remedy knowledge. Home remedies appear to hold a good deal of popularity in PG, both out of necessity, and out of a belief that using plants is a healthier form of health care. In this brief description of the health system in PG, it becomes clear that a variety of beliefs influence how people negotiate the different layers of the health system. It is also evident that beliefs shape how those layers are themselves constituted. The examination of belief as it relates to health must include a wider cross-section of health beliefs than has previously been done. The beliefs of actors from all levels of the system must be understood on their own terms and in the larger context of the entirety of the system.

*Please email author for paper references. Suggested Citation: reeser, douglas c. 2012 The Bounds of Belief in Belize: Health, Belief, and Biomedicine in Rural Communities. Paper presented at the Annual Meeting of the American Anthropological Association, San Francisco, November 14. 5

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