White Coat Underground

As my readers know, I take a very hard line on alternative medicine, not because I just don’t like it, but because it harms, both actively with dangerous treatments, and passively by keeping people from effective science-based treatments. So what am I to think about a hospital in California that is now allowing Hmong shamans to perform healing rituals on patients?

There is a long history of religious and quasi-religious beliefs interfering with good health care. This interference comes in many forms.

“Mainstream” Religions

Religion obviously has a strong influence on people’s health
decisions. Certain religions have, for example, specific ideas about end of life
care, mandating medically futile care in the name of preserving “life”.
This often means flogging the mostly-dead with painful, useless,
expensive care until they finally expire “naturally”. Most medical professionals who spend significant time in an
ICU know how much suffering is inflicted by this type of belief.

Other
religions prohibit certain medical procedures such as abortion or blood
transfusion based not on medical facts but on moral or scriptural
precepts.

Intrusion of mainstream religions into medical
decision making is not necessarily a bad thing, but it certainly can
be, given it’s reliance on the arbitrary mystical veneer it
uses to coat real, bloody medical facts.

Religious Cults

Less mainstream religions often have very strong (and harmful) views
on health. Christian “scientists” eschew real medicine completely; Scientologists famously rob and abuse the mentally ill; and lesser known cults such as Nemenhah condone and abet the murder of children.

Beliefs
such as these need to be marginalized. There is no room for them in a
civilized society, and while a free society should of course not
prohibit them, we should make it clear that they lack any legitimacy in
the field of health care. Tacitly approving their actions through
silence is not “cultural sensitivity” but lunacy.

Medical cults

I have argued many, many
times that much of alternative medicine functions more as a cult than
as the practical application of scientific knowledge. Chiropractic,
homeopathy, and many other so-called alternative medicine practices
have revered founders, charismatic leaders, rely on faith rather than
evidence, and followers will not abandon their beliefs, no matter how
much evidence is presented. Vaccination as a cause of autism has been
soundly defeated as a hypothesis, but like any cult, the folks who
fetishize this idea simply find excuses to ignore the science—most of
these arguments boil down to, “but I believe it works.”

There is no difference between, for example, reiki and intercessory prayer. To believe that either act directly manipulates the real
world in any tangible, effective way is a misapplication of faith, and neither has a
place in medicine.

Shamans

What of shamans? Shamans occupy different places in different
societies, but often serve an explicitly religious purpose. Since in
pre-scientific societies health was tied closely to religious belief,
shamans often function as healers. The Hmong, who until recently lived
in rural Southeast Asia, traditionally hold complex religious-medical
beliefs regarding souls, possession, and other mystical explanations
for illness. They may also carry some cultural baggage regarding
American authority figures, given their history of being used by
Americans during the Viet Nam War and then largely abandoned.

Doctors in Merced, California noted the trend of Hmong patients refusing health care and decided to try something. They
gave Hmong shamans clergy-level privileges at the hospital and
accommodated as much as possible their rituals. As far as I know they
haven’t formally studied the results, but the general feeling seems to
be that this is allowing Hmong patients to feel comfortable accepting
modern medicine.

There is of course the danger that some will conflate acceptance of ritual with medical effectiveness of ritual but if they are able to keep clear the difference, they may be on to something. Shamans are being given classes in real medicine and appear to be interested.

This is what real integrative medicine is. So-called integrated medicine that takes fake medical treatments and blends them with real ones are dangerous. Allowing shamans to create a bridge between cultures to help people get the care they need is smart and compassionate.

Religion is a comfort
to many of my patients, and I don’t interfere with their beliefs. Not
only would it be wrong, but it also doesn’t work—a patient’s
beliefs always trump yours. Sometimes, religious beliefs create insurmountable barriers to proper care, but if we are able to understand our patients beliefs and work within them to provide science-based medicine, we not only serve our patients but co-opt them before the murderous woo-peddlers get to them. That seems like a good thing.

Comments

#1 megan
September 21, 2009

There has to be a happy medium in that science shows that the human mind has vast ability to control our systems and biofeed back research proves it. Regardless if there is a god, allowing patients the ‘additional’ support of a ritual or religious pray/mediation is not wrong. This reactionary neo-proscience’Taliban’ rejection of how ANY pre-industrial methods of healing can be reintegrated into medicine therapies using research is JUST AS HARMFUL. It’s almost sounding like a pharmaceutical and HMO conglomerate lobby is funding some of the supposed scientist bloggers here. There is no compromise of recognition of possible underlying benefits with some of the bit of mostly quackery out there. Doctors are using leeches now and can see how they CAN be of use in therapy and that they DO have anti-coagulant properties in their saliva that can be emulated. By your anti-quack dogma if it ain’t Western Euorpean science recently paid research it’s fake falseand harmful and that leech discover squelched.
#2 PalMD
September 21, 2009

@megan

That was a parody,right?
#3 Kim
September 21, 2009

“The Spirit Catches You and You Fall Down” by Anne Fadiman is a heartbreaking and sensitively told story about one young Hmong girl and her family in the Central Valley, and the tragedy that came about from the cultural and linguistic gaps between the family, medical, and social services personnel. I highly recommend it to anyone who is interested in these issues in this community.

Americans tend to think of cultures unlike mainstream American culture to be like a made-up scifi culture with a gimmick (oh look, another fierce warrior culture seemingly based in late 80s TV showings of “Shogun”!) or at the very worst Mexico. Compared to any of that, Hmong culture is in some ways almost unfathomably alien. Back in Wisconsin, I had the privilege of hearing a Hmong pastor talk about how Christianity came to the Hmong, and despite being a fairly familiar story of 19th century missionary conversion, the tale as it is told is metaphysical in a way that is almost hard to follow for an American listener. It is really quite fascinating. After you’ve heard something like this, the idea of addressing concerns about Western medicine through the language of the native belief system suddenly makes a vast amount of sense.
#4 Rogue Epidemiologist
September 22, 2009

I read Fadiman’s book before I studied public health. It’s a good read, and great for highlighting the necessity of cultural competency in health care delivery.

However the book isn’t recent enough to discuss what’s going on with American-born Hmong. Even though the Hmong are the poorest, least-educated, and most prone to poor outcomes (like teen pregnancy and incarceration) when compared to all other Asian groups, a good proportion of Hmong-Americans have made their way to college and into medical and professional schools (I studied alongside many of them at Berkeley).

These new doctors (ages 35 and under) will be able to go back to their communities and treat their elders with both an understanding of medicine and an understanding of the culture (and language, in many cases). While I like and strongly support the shaman idea, I want to see what this highly-educated birth cohort can do to improve the health outcomes in the Hmong community in America.

And for those of you who aren’t terribly familiar with the Hmong people, consider this: they were scorned and marginalized in their home countries for being illiterate and “backwards.” I, for one, have heard my (Thai) relatives speak condescendingly of Hmong folks here, and back in the home village. To say Hmong immigrants experienced some culture shock upon arrival in America is a gross understatement.
#5 Vince Whirlwind
September 22, 2009

“a patient’s beliefs always trump yours”

I know what you mean, but, why? Are they *all* immune to science education?
I’m recalling a recent sceptics-organised public lecture about “Science Communication” in which the basic message was that what you describe is an example of “failed” science communication, and that scientists should try to do better.
(I thought at the time that the speaker was a hopeless optimist, but it was an interesting thesis.)
Personally, I’ve always found the hospital space devoted to chapels an offensive waste of money, and now that muslim prayer-rooms are springing up all over the joint I’m totally livid – what happened to keeping your idiotic superstitions at home!?!?!?!?
#6 Kim
September 22, 2009

Good point re the younger Hmong professionals. My Hmong friends in school were girls, and for the most part their educations stopped at marriage in junior year or so; I tend to forget the boys had a chance to continue on. And now that my cohort are the parents of teen (and older) daughters, hopefully some of that generation of girls has been able to postpone marriage for education as well.
#7 CynicView
September 22, 2009

That’s a very interesting post. It’s smart what they’re doing.

@Vince: As irrational as religion may be, it is; during traumatic events such as hospitalisation, one of the few sources of comfort for religious patients (and their families). In fact, I speculate, that having an outlet such as a prayer room for believers is beneficial for the hospital processing system as a whole.

If the patient, or family of, is already religious and having such a room provides comfort – then why not?

Sure, you may argue that; in times of great stress, irrational thinking and behaviour might encourage one to take up religion solely based on the circumstance – but if they’re converting in a hospital chapel they’re likely to convert anywhere else anyway. And I don’t think that reason has much to play into such a decision at all.

So screw people not “keeping their idiotic superstitions” from the hospital, if it doesn’t cause them to blow up, I’m happy with it.
#8 BB
September 22, 2009

Cultural competency is different from allowing shamans to practice “medicine” in the hospital. Cultural competency is more like having a chaplain of your faith in the hospital. If a culture-specific ritual (prayer, ceremony, whatever) helps you feel better, that’s fine. It’s replacing the necessary treatment with the ritual that can be the problem.

This week my med school will feature lectures on ayurvedic medicine and healing. Guess what boys and girls? Since you don’t need a license to practice ayurvdic medicine in the US, you don’t need to go $250K into debt to become- an ayurvedic practictioner! Whether or not you actually cure anyone is beside the point.

The day spa I go to for manicures offer ayurvedic “treatments” too, recommended and sold by the person who checks me out.
#9 titmouse
September 22, 2009

“Personally, I’ve always found the hospital space devoted to chapels an offensive waste of money…”

You don’t favor the use of opiates in the hospital?
#10 Tsu Dho Nimh
September 22, 2009

Despite what the NYT article says, the hospitals in Arizona and New Mexico, not just the IHS hospitals, have had a close working relationship with various Indian healers, singers, etc. for a long time.

The only time I can recall hearing of a problem was when the Navajo patient’s roommate was allergic to the corn pollen that was used in the ceremony.
#11 Denice Walter
September 22, 2009

Whew! What a relief! Skimming the words “Shamans”,”hospital”, and “California” in the title/first paragraph,scared up images of, oh, I don’t know, Ornish or someone hiring sham “Native Americans” to exorcise heart patients’”bad” cholesterol in San Rafael, or a New Age-y fertility clinic in Malibu.This is actually reasonable!(I *am* biased: my classmates had a much older brother who became a yoga instructor,nutritionist,and faux-subcontinental-Indian “healer” in the “70′s. Yes, he’s still at it.)
#12 Rogue Epidemiologist
September 22, 2009

@BB

Cultural competency is different from allowing shamans to practice “medicine” in the hospital. Cultural competency is more like having a chaplain of your faith in the hospital. If a culture-specific ritual (prayer, ceremony, whatever) helps you feel better, that’s fine. It’s replacing the necessary treatment with the ritual that can be the problem.

And that’s exactly the gist of the article: the shamans come in to perform spiritual ceremonies, but they are not administering herbals, supplements or therapeutics. I agree: as long as the shamans don’t interfere with Tx protocols, and they offer the patients support, then by all means allow them to volunteer in the hospital!

@Kim
Actually, my current cohort already includes a lot of educated Hmong women. I had a lot of female Hmong classmates in undergrad and grad school. Considering that refugees of violent conflict are usually the least successful at assimilating, the Hmong are really quite upwardly mobile.

@Vince
You do realize that a lot of hospitals are owned and operated by religious organizations, right? Your comment is condescending and callous.
#13 Calli Arcale
September 22, 2009

I actually like the idea of giving the Hmong shamans clergy privileges. That’s precisely how they should be treated — not as medical professionals, but as people who can provide a particular sort of comfort in the appropriate cultural context to be understood and appreciated by the patient. I am relieved that this is how it is being approached, and hope that the results are positive — that it leads to better acceptance of proper medical care by the Hmong immigrants. We’ve had good luck with that up here in the Twin Cities, which actually has a larger and more-established Hmong community. By and large, they are interested in integrating. It’s just that it really is a MASSIVE cultural shock for them, especially the ones coming over right now, who have spent the last 30 years (an in many cases, their entire lives) in a refugee camp in Laos. I think one of the biggest benefits of inviting in the shamans is that they can act as intermediaries, translating not only the words but the *intent*, which is difficult when although their language can be used to describe life in America, they lack the cultural context to understand what’s really being said. By educating the shamans, they get intermediaries with a foot in both worlds, who can bridge that gap.

Anecdotal experience: my father had many Hmong patients, and was very well liked and trusted by them. In many respects, they are less wooey than many fourth-generation-Americans. They know third-world medicine is inferior, because they’ve had to put up with it for many years, and are extremely grateful to have access to real medicine for a change.
#14 Joseph Putnoki
September 23, 2009

there is a bit of ignorance displayed in the obviously well meaning article, not too bad how ever the writer did a Richard Dawkins who is a smart and good scientist and made excellent documentaries except the last one I saw where he put alternative medicine in the cross-hairs. And he stuffed up this time. A rushed and superficial biased arrogant tirade. Obviously did not do his homework.
neither did the writer above. Allopathic medicine has it’s charlatans too, its criminal failures as well as stupid ones. The patients loose out because of hostility of the two camps instead cooperation. The scientific evidence is buried for complementary medical validity on the proverbial rubbish tip of discarded ideas, innovations and inconvenient evidence of efficacy. Covered over copious layers of propaganda and lies by big phrama and ignorant or corrupt doctors, medical writers or FDA advisers and adjudicators. Couple of examples to consider: doctored research, falsified findings, scandals like the latest advisory panel establishing lowered cholesterol levels to be 4, the panel of 9 only one was not affiliated with with big pharma and ‘forgot to declare their competing interest, and even the FDA’s lawyer empanelled to represent the interest of the regulator actually sided with the corrupt majority! Another issue is acupuncture persecuted before and lately accepted by mainstream practitioners who demonstrated it is working in competent hands regardless the theory.
And now homoeopathy: dismissed arrogantly and ignorantly as ineffective yet demonstrated it not only works with humans but with animals and animals can not be accused to have a concept of the placebo effect! Fortunately this inconvenient fact can not be buried thanks to the Internet. Religion is irrational lets face it, a cultural phase of human ascent eventually on the way out as the core need of spirituality continues. Religion does and did a lot of good and lot of harm do not overlook that!
During my studies one of the lecturer said: ” when experiments written up for peer review can not be repeated despite following closely the instructions one more thing we must do before dismissing the topic, is that we must go to the original source and watch how it is done, we may have missed something.-
Be well! joseph.
#15 PalMD
September 23, 2009

agrammatical comments from random troll disturb: make no sense to shill of pharma and cronies.
#16 antipodean
September 23, 2009

When I grow up I want to be like Rogue Epidemiologist: Insightful and satirical.

At the moment I keep skipping the first characteristic.