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Medicine Man Tattoo

Alfredo Alonso sat on the edge of the rumpled bed tucked in one corner of his Northern Manhattan apartment. He was facing the altar and wearing ceremonial garb: white cotton fabric swaddling his head, colorful beads around his neck. His silky white pants were cropped at the knee, revealing watermelon-size calves, riddled with lumps and purple welts.

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The priest--a wiry man with bulging, tattoo-covered biceps--dabbed cocoa butter onto Alonso's thumbnails, the crown of his head, his inner arm. Then he sprinkled Alonso with perfumed water, called Agua Florida, to shoo away unwanted visitors from the spirit realm. All the while, Alonso prayed. "Health and prosperity, open all my pathways," he pleaded, scrunching his eyes shut. "Cure my legs. Cure all my health problems."

The priest knelt in front of the altar--a squat pedestal holding a wooden tureen full of sacred herbs and stones. Before it lay dozens of offerings: corn meal bundled in banana leaves; 12 white roses; speckled pears heaped on a white plate. He drizzled wine and honey over three empty dishes before fetching a bone-white pigeon. Grabbing the bird by its talons, the priest swept it slowly over Alonso's body, then held it up to Alonso's face. Its beak, a sliver of translucent yellow, pressed against Alonso's lips. "Cure my legs," Alonso whispered tenderly to it. He said this again and again, even as the priest pulled the bird away, slashed its throat and dribbled its blood over the honey-filled dishes.

Alonso suffers from a host of diseases, but the one that worries him most is the lymphedema, sometimes called elephantitis. It attacks the lymphatic system that is designed to filter toxins out of the body. Lymph fluid, which normally circulates like blood, pools beneath the skin of his legs, making them grow bigger and bigger. Most days Alonso can barely walk because of the pain and swelling. Doctors say there's little they can do to ease his symptoms. So he relies increasingly on Santeria, an African-based religion and healing system. Believers curry favor with deities, called orishas, through chanting, music, dance and offerings. The pigeon sacrifice, performed by a priest of Candomble, the Brazilian equivalent of Santeria, was one of a series of rituals intended to heal him.

Alonso hasn't told his doctors that he practices the religion; he worries they'll think he's ignorant or superstitious. He's simply blended the two healing systems as he's seen fit, often disregarding doctors' advice when it conflicted with that of his priests. Like Alonso, a growing number of people are finding themselves caught between two systems of healing. More than half of the 1.5 million immigrants to the United States each year come from Latin America and the Caribbean, where spiritually-based healing traditions flourish. These include Santeria, which arrived in Alonso's homeland, Cuba, on 16th century slaves ships, as well as its Hatian cousin Voodoo; Puerto Rican Espiritismo; and Curanderismo, practiced primarily in Mexico. Statistics on these traditions are scant. But Santeria expert Migene Gonzales Whippler estimates that five million people in the United States practice it. And the number practicing all of these traditions is likely to keep growing. Yet, most health care providers know little about the herbs and rituals associated with them, and this can work to their patients' detriment. Some herbal remedies can interact dangerously with prescription medications. And believers who don't feel they can talk to their clinicians about their spiritual practices are likely to disregard doctors' advice when it conflicts with that of their healers.

There are signs of change on the horizon, though. The growing emphasis on "cultural competence" has led a number of universities to begin researching Latin American and Caribbean healing traditions and integrating information into their medical school curricula, even bringing Santerian and Voodoo priests to talk to students. A handful of doctors is also collaborating with healers from such traditions in treating patients.

Such programs are advancing under a veil of skepticism, though. "We're talking about changes that are more sensitive than those that came with the sexual revolution," said David Hufford, a Pennsylvania State University medical anthropologist. "It's hard for people to get over the notion that these practices are rare, perverse, the product of ignorance. But I think the time is coming when they'll have a different standing in the medical world and the world in general."

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Babalawo vs. Doctor

Alonso's dark hair is peppered with gray, and his plump cheeks are dusted with stubble. He has narrow eyes that sink into his face when he's tired or hurting. But they come alive when he's explaining his religion. Perhaps it reminds him of his life before lymphedema, when he taught world history at a high school in downtown Manhattan. He had to give up his job because of the disease. Now, at 41, he lives in a cramped one-bedroom apartment with his mother. Usually, he sports a T-shirt and cotton drawstring shorts and sits in a plastic-covered, pink armchair in one corner of the living room.

Born in Cuba, Alonso moved to the United States before his fourth birthday and was initiated into the Santeria religion at age ten. He has long relied on the herbs and rituals associated with it for his fragile health. He's had asthma since childhood and has developed a variety of other health problems over the years, many of them because of his weight; he weighs 475 pounds.

Alonso got more deeply involved with Santeria after a crippling 1995 accident. He was visiting an upstate New York church when a rotten porch board buckled under him. His leg jammed between two ends of the split board, and an inch-long splinter lodged in it. Almost immediately, his calf swelled up, and the skin covering it grew scorching hot. He went to his family doctor, Carlos Toledo, who diagnosed him with a bacterial infection and sent him to Mt. Sinai Hospital. He spent his first night on a gurney shoved in one corner of the emergency room, where he lay awake, a nauseating ammonia smell swirling in his nostrils.

The hospital staff ran a battery of tests but had difficulty diagnosing him. Like many Cubans in the United States, Alonso's father practiced Espiritismo alongside Santeria. When Alonso was sick, his father often took him to seances, during which spirits offered insight and advice through human mediums. The spirits were quick to name his illness--be it diabetes or chicken pox--and prescribe herbs, spiritual cleansing or a doctor's visit. Alonso, who was accustomed to healers' decisive approach to diagnosis, was puzzled by the dithering of Mt. Sinai doctors. But when, after three weeks, they finally labeled his illness, he felt worse. Apparently, the bacterial infection had invaded his lymphatic system, triggering lymphedema. He was already hobbling and now might never walk normally again.

Alonso's hospital room overlooked Central Park. Every day, he watched women with baby carriages ambling down paths and children tumbling in the grass, and it crushed him. The doctors and nurses tended his body but didn't help him cope with his grief. "I was just a number and a name," he grumbled.

For support, Alonso relied on his family and, increasingly, on his babalawo, or Santerian high priest. During his first week in the hospital, his priest sacrificed a chicken to the orisha Babalu Aye, protector of the ill and crippled, guardian of the gates between life and death. Afterward, the priest stuffed some blood and feathers in a burlap pouch, along with corn and dried beans, Babalu Aye's favorite foods. Then he drizzled rum over the concoction and tied it closed with a royal blue ribbon.

He brought the pouch to the hospital, where Alonso and his parents waited. Chanting, he moved it over Alonso's leg to draw out the illness. Before leaving, he put a string of consecrated beads, called an eleke, around Alonso's neck for spiritual protection. His encounters with doctors often left Alonso feeling gloomy. But when his babalawo visited, his pain abated, and he saw glimmers of hope. Alonso's not alone. Dr. Arthur Kleinman, a Harvard medical anthropologist, has found that many people get more relief from healers--who treat the emotional and spiritual as well as the physical--than they do from doctors.

Toward the end of his hospital stay, Alonso was awaiting the results of a scan to find out if he had blood clots in his legs, that could break loose, causing a stroke or heart attack. His babalawo brought in four pieces of coconut shell. When he tossed them, they all landed fleshy side up--a good sign. "You might not be healed completely," he said. "But you're clot free."

The priest told Alonso to leave the hospital when he got the scan results. Shortly afterward, the scan came back negative, and Alonso asked to be discharged. "The doctor refused," he recalled defiantly. "So I discharged myself."

Concerned that if he left Alonso would be crippled for life, his doctor brought in two other physicians to convince him to stay. "I couldn't sit and explain that my babalawo said I needed to leave," said Alonso. "They're not going to buy it. They're going to think it's superstitious."

When the doctors realized there was no changing Alonso's mind, they encouraged him to at least come back for follow-up appointments and antibiotic prescriptions. He never did. He did, though, stop by to see Dr. Toledo shortly after leaving the hospital and told him he was planning to take a trip to Cuba. Dr. Toledo got him to agree to stay off his feet and take 1,000 milligrams of Cipro three times daily. It's hard to say how much good this treatment did.

Lymphedema progresses gradually through three stages. In the first stage, it causes only mild swelling. If it isn't treated properly, however, it invariably progresses to stage three, called elephantitis. The limbs become severely swollen and sometimes develop oozing lesions. Moving also becomes difficult and a rare, untreatable lymphatic cancer sometimes develops. Alonso is in stage three, according to Dr. Toledo.

Did he progress to this stage because he left the hospital before his treatment was complete? Or was it because doctors had trouble diagnosing him? It's impossible to know. But clinicians probably would have had more luck getting Alonso onto an effective treatment had they better understood his cultural expectations and spiritual practices.

Some clinicians have begun teaming up with healers to avoid tragedies like Alonso's. Dr. Daniel Korin, former medical director at Lincoln Hospital in the Bronx, has found collaborating with Santerian priests and Espiritistas often helps him get his patients to comply with his prescriptions. Once, he sent a seven-year-old epileptic boy to an espiritista after his mother refused to give him medication because she believed the seizures were caused by evil spirits. It worked. "The espiritista told her, 'This is no evil spirit. Give that child medication or he's going to die,'" Dr. Korin recalled.

Psychologist Sam Tsemberis referred a patient to a healer when he was directing Project HELP, a mobile psychiatric crisis unit for the mentally ill living on New York City streets. His team found a rumpled 68-year-old Latino man huddled in an alcove. He babbled endlessly about the spirits that possessed him, and his right calf oozed a putrid, yellowish puss. Worried that if left untreated the leg would need to be amputated, they took him to the hospital, only to find him back in the same spot a few months later. He had quit taking his psychiatric medication, and his condition was worse. Desperate, Tsemberis asked a Latino colleague at Gouverneur Hospital, where Project HELP was based, if he knew a healer who could perform an exorcism. He was stunned when the man pulled out an appointment book for an espiritista. After the ceremony, the homeless man quit muttering about spirits and started cooperating with doctors. His leg finally healed and, after a decade of homelessness, he moved into an assisted-living facility.

Patients who practice Santeria, Voodoo and Espiritismo often end up getting labeled delusional. "We miss the boat in terms of who the sufferer is and why they are suffering," Tsemberis said.

Prozac and Herbs, Much to Learn

After leaving the hospital, Alonso became a babalawo himself as a way of putting his life back together. His weight had surged from 350 pounds to 475. After losing his job, he saw his income slashed from $32,000 to around $6,000. Not surprisingly, he tumbled into a depression. So, he consulted the orishas, who told him high priesthood was the road to healing. Alonso flew to Cuba for the initiation ceremony, which lasted seven days. His head was shaved, animals sacrificed, his old clothes shredded--all gestures of cleansing and rebirth. Immediately afterward, the gloom lifted. He was also able to walk for the first time since he had left the hospital. His babalawo suggested that he stop taking all his medications, except the one for diabetes. Gradually, many of his symptoms began to reappear, and he started taking all of them again, with the blessing of his religious elders.

Every morning Alonso takes Glucotrol for diabetes, Naprosen for pain, Hydroclothiazide to control the leg swelling, Cozar for high blood pressure, Lipitor for cholesterol, Claritin for allergies, Prozac for depression, and the list goes on. Throughout the day, he puffs on his inhalers and sips medicinal teas. Some are made from common herbs. Others are virtually unknown to those outside Santeria. Among them is ero, a shriveled pod with a piney scent, which Alonso takes for blood pressure. Doctors don't know he's taking it. Even if they did, they probably wouldn't know how it interacts with his prescription blood-pressure medication.

At least once a week, Alonso talks to his babalawo. He has also started consulting a priest of Candomble, Santeria's Brazilian sister religion. In addition, he sees a bevy of medical specialists, but none of them knows about his religion, except Dr. Toledo. And even he doesn't have much tolerance. "He comes like a ghost, every three, four years," Dr. Toledo said. "He doesn't stay on a treatment. He's extremely difficult."

Dr. Toledo is most annoyed by Alonso's failure to stay on weight-loss programs, as many of his ailments are weight related. Alonso has also refused to undergo gastric bypass surgery, or stomach stapling, as some doctors have suggested, because his babalawo has warned against it. The procedure causes people to shed pounds quickly, but it can also have serious complications. Instead, Alonso consulted the spirits of his ancestors, called egun in Santeria, who suggested that he become a vegetarian. He followed their advice, swapping Big Macs for veggie burgers.

While most medical professionals have never heard words like egun and orisha, a number of programs are developing to help clinicians understand the traditions. The University of California, Los Angeles recently completed a two-year National Institutes of Health study on healing traditions popular among Southern California Latinos. It documented more than 5,000 herbal remedies, most from Santeria, Espiritismo and Curanderismo. The Boston Healing Landscape Project at Boston University Medical School is studying African-based religions and holding a series of "herbal tours," which take medical professionals to botanicas, where Santeria priests discuss how they use plants medicinally.

Linda Barnes, the project's director, is also building an online clearinghouse for information on African-based religions and developing curricula on these traditions for every level of medical education. The goal: training medical students to spot patients who are using traditional remedies and to talk to patients in a way that fosters trust and open communication.

Barnes spent more than two years trying to build trust with healers in the community. And she's found many doctors and medical students are wary of exploring Santeria and Voodoo. But they're willing to listen if she approaches it the right way. "Doctors care about potential toxic interactions," she said. "They care about the doctor-patient relationship. It's a matter of couching it all in terms that doctors identify with."

Another group, the Milwaukee Area Health Education Council, conducts trainings on Latino culture for some 500 medical students from four Wisconsin medical schools each year. About a third of each session focuses on Santeria and Espiritismo. Medical schools across the country--from Pennsylvania State to Columbia University--are also integrating training on such traditions into their curricula.

But some worry that conducting trainings on Santeria could damage their careers. "The truth is, your job is on the line. Your reputation is on the line," said a New York University professor and cultural competency trainer who asked not to be identified.

Healing in the Religion

It was a bone-chilling winter day. Rain pounded the streets, turning the snow into muddy slush. On days like this, Alonso normally stayed inside. But today he had a doctor's appointment. Unable to walk the three blocks to the clinic, Alonso lumbered out, cane in hand, to wait for a car service. It picked him up and deposited him on an ice-encrusted curb in front of the clinic, where he almost toppled over.

Once inside, Alonso discovered his appointment had been cancelled. "We tried to call," said the receptionist coldly. After much wrangling, a receptionist arranged for Alonso to visit another doctor. "It's only a few blocks away," she said smiling, clearly unaware how far that was to him. She added that his file would move to the new office, and he'd have to be seen there from now on. Alonso had been coming to this office off-and-on since childhood and didn't want to change. So, he decided to go home.

Outside, the rain was driving down harder. Alonso always requests a cab without a divider between the front and back seats because, while it's difficult for him to get into any car, he can't get into the ones with dividers at all. But this time when the car arrived it had a divider, so he sent it away and waited for another. Twenty minutes ticked past. Cars zoomed by splashing Alonso with water from the overflowing gutters, and his back and his legs started cramping up. Finally, the divider-less car came. Alonso got in, and immediately started wheezing.

Back inside his apartment, Alonso settled into his plastic-covered pink armchair and puffed on his inhaler. Then he sat head in hand, looking defeated. "I guess my healing's going to be done in the religion," he said. "You are assured, not that you'll be healed on the spot, but at least there's someone there to help you."

Mariah Blake is a staff writer for the Columbia Journalism Review.

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