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The interaction between access to health care and alternative medicine in Monteverde, Costa Rica

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Title:
The interaction between access to health care and alternative medicine in Monteverde, Costa Rica
Translated Title:
La interacción entre el acceso al cuidado de la salud y la medicina alternativa en Monteverde, Costa Rica ( )
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Book
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English
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Heuchan, Heidi
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Behavior and health--Costa Rica--Puntarenas--Monteverde Zone
Medical care--Costa Rica--Puntarenas--Monteverde Zone
Alternative medicine
Salud Comunitaria 2001
Servicios de salud--Costa Rica--Puntarenas--Zona de Monteverde
Comportamiento de búsqueda de salud
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Books/Reports/Directories
Books/Reports/Directories

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Summary:
Overview of traditional biomedical health care services and alternative medical practices. Includes recommendations for follow up studies.
Summary:
Descripción general de los servicios de atención de la salud biomédica y las prácticas médicas alternativas. Incluye recomendaciones para el seguimiento de los estudios.
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EN

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usfldc doi - M38-00009
usfldc handle - m38.9
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SFS0000203:00001


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The Interaction Between Access to Health Care and Alternative Medicine in Monteverde, Costa Rica Heidi Heuchan Jason Lind Santiago Ruiz Globalization, Nutrition, and Health Monteverde Institute June 24 to July 21, 2001

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Abstract In Monteverde, issues relating to access to health care and health services in the community are very important. This paper provides a brief overview of the health services available to the community both through the CCSS and through alternative medicine including homeopathy and herbal remedies. Our research team also collected information concerning variation, use, and application of different medical alternatives encountered in the community. Our preliminary results show that many people in the Monteverde zone seek and administer alternative medicine and that this manifestation is based on a response by the people to seek health services that may not be readily provided through the biomedical system. Introduction This report is intended to provide a building block from which to better understand the comprehensive relationship between access to biomedical health care and the use and etiology of the many health alternatives that exist in the Monteverde zone. Originally, five researchers collected information concerning this topic including a pharmacologist from Mxico, and a Nurse from the University of Alaska. Due to course logistics, these two individuals were unable to follow this report through to its conclusion. Still, our core team remains grateful to the assistance of these individuals regarding their ideas and contribution to data collection. In the end, our core team consisted of three anthropologists who compiled and analyzed the majority of the information that appears in this report. Finally, the three anthropologists included a Honduran Ph.D. student of socio cultural anthropology at the University of Florida, the other, a Ph.D. student studying applied medical anthropology at the University of South Florida, and finally, a senior majoring in anthropology at the University of South Florida. Initially, the impetus for this report originated during a community meeting to discuss health issues and possible research topics that were to be explored by each research team. Based on this meeting, it was clear that community members were concerned with issues concerning access to health care ranging from the lack of laboratory services at the Santa Elena clinic to the bureaucracy of the Caja Costarricense de Seguridad Social (CAJA) referral system. These concerns of health access were also understood by our group members in the context of several health care alternatives that exist in the community. Some of these alternatives include homeopathy, sobadores, and the extensive use of medicinal plants that were self administered by the population as herbal remedies. It was at this crux that our group acknowledged the complex synergistic relationship between access to biomedical health care and other “traditional” and non traditional” health alternatives in the community. This report, therefore, is an attempt to foster our understanding of this topic and to promote further study. Research Methods The methodologies used to collect information for this report coincided with the ethnographic and epidemiological methods that were taught as part of the Globalization, Nutrition and Health field school sponsored in part by the Monteverde Institute, the University of South Florida, and the University of Illinois at Chicago. Much of the information gathered for this report stemmed from ethnographic methods including observation, participant observation, formal interviews, and finally structured interviews/questionnaires. Due to the nature of this study, epidemiological methods including anthropometry, nutrition recall, and morbidity

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and mortality were not used. However, we acknowledge that epidemiological methods may play a crucial role in furthering the understanding of this topic in the future. The following methods were used to compile data for this report. Observation and Participant Observation Focused observations were done at local pharmacies, the Santa Elena clinic and in the homes and places of employment of informants. Observations of this nature often included informal conversations with people in order to add context. Several of our team members also visited people in their homes and were thus able to gain insight concerning health beliefs and behaviors. These informal conversations during observation helped lead us to other sources of alternative medicine, while at the same time providing insight into the issues concerning access to health care through the CAJA system. From these observations and informal conversations we were able to conceptualize themes and patterns relative to health seeking attitudes and behavior. These themes and patterns then enabled us to determine salient issues that we would bring to light through more formal interviews that we conducted later on in our fieldwork. Formal Interviews Based on information gathered through observation and informal conversation, our research group conducted several formal interviews concerning issues of access to health care and alternative medicine with informants representing a cross sample of the population. For example, several interviews were conducted with individuals known in the community as having extensive knowledge of alternative medicine including a sobadora, an herbalist, and a midwife. Several other individuals were interviewed about their lay knowledge of self administered herbal remedies. Other interviews were conducted relating to individual experience with the CAJA system. Still other interviews were conducted with biomedical health practitioners in the community and other professionals. Structured Interviews and Questionnaires During our second week of fieldwork we were able to administer 22 structured interviews and questionnaires to a non random group of community members in San Luis. The questionnaires consisted of only eight questions relating to health access and use of both biomedical and alternative medicine. The questions administered were as follows: 1. Where do you seek medical attention? 2. Do you use home remedies? 3. Do you use homeopathic medicine/doctor? 4. For what type of illnesses do you seek medical attention? 5. What type of illnesses do you treat with home remedies? 6. What type of illnesses do you treat with homeopathic remedies or doctor? 7. How do you treat respiratory illnesses? 8. How do you treat diarrheal illnesses?

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These questions were then augmented with ethnographic context. In most cases, informants were asked to explain exactly what kind of home remedies they used for specific diseases and their particular reason for doing so. There are several acknowledged limitations regarding our data collection and methodologies. First, time limitations severely impeded our ability to gather and collect comprehensive data concerning these issues. For this reason, we acknowledge the impossibility of collecting extensive information concerning access to biomedicine and the use of alternative medicine. Second, our sample is non random. Though we did observe and interview individuals from a cross section of the community (Ticos, Quakers and foreigners in both Santa Elena and San Luis), the majority of these informants were referred to us through our contacts at the Monteverde Institute, community leaders, as well as medicinal healers. Finally, the questionnaire/interviews carried out in San Luis were not all administered by our research team; rather, they were carried out by other members of our field school. Thus, we are unable to ensure research reliability within the context of these questionnaires. Findings Discussion of Health Services Offered through the CAJA System in Monteverde, Costa Rica The following discussion is based on information gathered from the 2000 Anlisis de la Situacin de Salud (ASIS) and from several formal and informal interviews gathered from community members and leaders. This part of the report is not intended to be an all inclusive overview of the services offered by the CAJA in the Monteverde zone. Instead, the intent is to provide the reader with a general sense of which health services are offered and which health services according to informants are lacking in the community. It should be mentioned that it is not our intent to make value judgments of existing and non existing health services offered through the CAJA. Rather, this discussion is intended to open dialogue among community members concerning their needs and desires concerning health services in Monteverde. Positive Aspects of the Health Services Offered by the CAJA in Monteverde 1. The clinic offers extensive health education classes and seminars concerning varied health concerns relevant to the community. According to perceived need in the community, the clinic provides health education classes to anyone in the community. Education classes and seminars that were provided through the CAJA by doctors, nurses, and social workers include: Child Development, Nutrition, Accident Prevention in the Home, Family Violence, Sexual Abuse, Family Dynamics, Identification, Prevention and Treatment of Common Ailments, Self Breast Examinations, Family Planning, Birthing Classes, Adolescent Pregnancies, and Alcoholism. 2. The clinic offers comprehensive health service and consultations for all mothers and children of the community.

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Through the clinic, regular pre natal checkups and education are provided to all mothers regardless of their CAJA status or Nationality. Also, children under the age of one (1) are attended to in terms of vaccinations and growth and nutrition status. Families are provided education and are expected to play a major role in child development. 3. The clinic offers a wide range of health services that are available to the community. In the Monteverde Clinic there is one Equipo Bsico de Atencin Integral de Salud (EBAIS) which provide primary health care to designated rural areas. The professional staff of the EBAIS consists of: 1 Doctor, 1 Nurse, 2 Health Promoters, 1 Pharmacist, and 1 Secretary. The professional staff at the Santa Elena clinic consists of: 2 General Physicians, 2 Nurses, 1 Pharmacist, and 2 Secretaries. Apart from full time general consultation and a permanent pharmacy, the clinic offers the following services: Dentistry Services (2 days a week), a Social Worker (1 day a week), Laboratory Services (1 day a week), and Gynecology (once every two weeks). Apart from these services there are referral services to higher levels including specialization. Also the clinic has an ambulance that is able to transport people to Puntarenas or San Jos in case of emergency. 4. Integral Medicine for community participation : One of the philosophies of the Caja system is that of medical integration into the community where the doctor works with the community to discuss problems and possible solution not only pertaining to medicine but also in relation to mental health and the common good of the community. This is an integral part of the CAJA health care system. The Santa Elena clinic is part of the Caja Costarricense de Seguridad Social (CCSS) otherwise known as the “CAJA” for which it offers primary medical services that consist of four primary functions: prevention, promotion, curing, rehabilitation, referral services to higher levels of health care in the country, and health promotion programs offered directly to the local population. A Discussion of Health Services that are lacking in Monteverde The following discussion relates to information gathered from informal and formal interviews from community members and leaders based on their perceptions of the adequacy of the health services offered through the CAJA. 1. The clinic in Monteverde does not offer specialized health services. In order to receive these services people must be referred to a larger clinic or provincial hospital. Informants also told us that the following services were lacking: Obstetrics (women have to travel to Puntarenas or San Jos to have their babies), X Rays (which are only offered in Puntarenas or Chomes), Mammograms, and a full time Laboratory (lab results can take more than a week to arrive). 2. People in rural communities often have a difficult time accessing health services due to geographic location and infrequent medical attention. Residents of San Luis and Rio Negro, for example, only are visited by a doctor once a week. Residents often complain that if they get sick they have to wait until the doctor comes in order to receive medical attention. In

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non emergency circumstances, residents of these communities have to wait for the doctor in order to receive a referral to go to the clinic in Santa Elena. Also, there are several communities that pertain to the Province of Guanacaste whose residents are legally unable to seek medical attention in the Monteverde Clinic located only a few kilometers away. Instead, these residents must go to Las Juntas located some 35 kilometers away in order to receive medical attention. 3. The Monteverde Clinic lacks personnel to meet demands and needs of the Community. According to one of the physicians at the Monteverde Clinic there is a need for more personnel especially a nurse. One of the interesting facts we were told was that if the clinic wanted to add a birthing center at the new clinic they would have to add more staff including a pediatrician and an obstetrician. According to CAJA rules, these positions are based on need and population. For this reason, these services would most likely not come to the region for some time. 4. There are no emergency services in the zone Although there are two ambulances in the community including one serviced by the Red Cross, the clinic does not have the resources to attend medical emergencies which include anything from accidents to heart attacks and strokes. Patients needing emergency services are transported to the nearest hospital which may be located more than two hours away. Discussion of Health Alternatives to Biomedicine in Monteverde The following is a partial list of medical alternatives that are found in the Monteverde zone. Due to time and logistic limitations our intent is to merely lay the framework of the various health alternatives that are available to the people that reside in Monteverde. It is our hope that the knowledge surrounding health alternatives will continue to grow through further investigation. Thus, the following alternatives listed represent the culmination of anthropological interviews and personal encounters with either the individual or with the system as related to us by its beneficiaries. We readily acknowledge the existence of other medical alternatives in the community, which include private physicians, massage therapists, acupuncture, various homeopathic practices, and others yet undiscovered. These examples of other sources of alternative are not mentioned due to the fact that we were unable to formally investigate them. Our present findings and discussion focus on five distinct health alternatives. These are as follows: Sobadora, Partera, Herbalist, Homeopath, and finally, individual treatment most commonly uses is home herbal remedies and over the counter homeopathic medicine. All five alternatives have distinct etiological frameworks ranging from acquisition to diagnosis and finally treatment of particular disease and illness. The sobador/a, for example, is an unaccredited individual who is sought out by people in the community based on his or her knowledge and abilities to treat or cure certain disease or illness. These individuals are rarely paid for their services. In contrast, the homeopathic doctor is formerly recognized as having the authority to diagnosis and treat disease and illness with a prescribed medicine based on formalized theory. Furthermore, herbal remedies used by whole communities consist of a general knowledge base (of herbs and their use) that are applied and understood differently by each individual based on experience and necessity.

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Self Medication: Over the Counter Drugs and Herbal Home Remedies In the Monteverde Zone, we argue that self medication is the most common and readily available source of alternative medicine. By self medication we refer to the way in which people diagnose and treat disease or illness in the home with either over the counter drugs, homeopathic medicine, and or herbal home remedies. Here we will focus on herbal home remedies instead of over the counter biomedicine, which includes aspirin and other symptom relief medication. To note, over the counter drugs are readily available in the community in any number of small tiendas or stores. Most over the counter medications treat common ailments including colds, headaches, fever, and diarrhea. Herbal remedies are also a very common form of self medication that is widely used in the community. Most herbal home remedies in the region are derived from plants that are native to the region and are most commonly used to make teas, which are prepared and ingested according to standard protocols. While most herbal remedies are ingested orally in the form of teas, others are applied directly on the body to treat a rash or skin irritations and sometimes to treat muscle sprains and joint pain. While many people have at least some knowledge of herbal medicine, there seems to be much variation in terms of specific application of certain plants and herbs. For example, Manzanilla is cited by many people as being an excellent herbal remedy. However, the application of Manzanilla varies according to the individual; for example, we were told by several informants that Manzanilla is used for diarrhea, stomachache, colic, empacho, pega, colds, and gastritis. Other informants told us that they combine Manzanilla with other herbs like mint, yerba buena, and or yanten which are then used to treat other types of illnesses. In total, our group collected 54 different herbal remedies through interviews with 13 informants. A list and short discussion of these remedies can be seen in the next section. Sobadora Sobadores are persons in the community who administer healing for digestion problems such as pega, mal de estomago, diarrhea, and fever. The technique used by the sobadora consists of a massage like motion in the middle of the forearm, located around the elbow joint. According to a sobadora we interviewed, she is able to detect digestion problems through applying pressure to certain points; consequently, the patient will feel pain during the pressure, which then indicates illness. Once the area of pain has been identified on the arm, the sobadora will administer specific rubbing motions, which will isolate and hopefully cure the patient of illness. If there is no pain, the sobadora told us that the patient is experiencing something other than digestion problems, and she might refer the patient to the clinic or another specialist. Herbalist Herbalists are individuals who have comprehensive knowledge of herbal medicine and their applications, while the majority of people are familiar with various home remedies to treat common alitions. While the majority of people are familiar with various home remedies to treat common aliments including diarrhea, stomach aches, and colds, herbalists, in contrast, have mastery over a wide range of herbal remedies and therefore are able to treat or cure a wide range of disease and illnesses. Herbalists also are known in their community as having the potential to cure and treat patients and are therefore sought out by other members of the community. Herbalists generally come to learn about herbal remedies throughout their lifetime through

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others who know about herbs as well. Herbalists also gain their knowledge about herbs based on their own need to cure and treat themselves or others. Herbalists generally do not formally distinguish their abilities to treat others with herbs, rather, other people in the community identify the herbalist as someone they can consult to seek treatment. Their skills are understood as a general service to the community, not as a source of income. Homeopathic Doctor Of the various alternatives mentioned thus far, homeopathic doctors seem to hold the greatest amount of expectations and trust by the communities and their members in which we studied. In the Monteverde zone, we gathered that there are 1 or 2 doctors who visit on specific dates throughout the month. They do not appear (according to the data we collected) to have a “home base” within the community. However, their location and arrival dates seem to circulate around the community, in efforts to inform locals. From the data we gathered, homeopathy seems to represent a net under the clinic (or the CAJA system), used to cure/heal illnesses that the clinic fails. For example, after inadequate or failed treatment administered from the clinic, people we interviewed said they would then go to the homeopathic doctor. This is not a generalization or fact about all members, just several of the people who were interviewed by our group. Contrasting the “allopathic” or conventional method used in biomedicine, homeopathy approaches sickness and disease in a more holistic manner. The symptoms are seen as indicators of the body’s immune system fighting to heal itself. Homeopathic remedies attempt to prompt, or catalyze the organisms’ own natural healing process, instead of battling against diseases as allopathic medicine attempts. Private Clinics In the Monteverde Zone there are also private medical clinics that are available to the population. To our knowledge there is one private clinic and one private dental clinic. Our group, however, was not able to collect data concerning these two private clinics, which are both located in Santa Elena. Furthermore, we are unable to speculate on the services offered through these clinics or to guess how many people in the community seek these services. Through interviews with people in the community, we discovered that many people also seek medical consultations through private clinics in both Puntarenas and San Jose. Research Findings Our research team was interested in learning the number of households that use alternative forms of medicine as health resources. After several informal interviews that were conducted in Santa Elena, Monteverde and San Luis it was clear that many people relied on alternative medicine to treat disease and illness. At the same time, we were interested to know what kinds of illnesses were being treated with alternative medicine and which were being treated with biomedicine through the CAJA system. Subsequently, our group conducted an interview survey among 22 households (approximately 1/4th of households) in San Luis during the two days following the nutrition study at the health post in that community. As a consequence, the results are only generalizable to San Luis; further studies should be done in neighboring communities in order to identify contrasts and similarities. The results of the questionnaires/interviews are as follows.

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Figure 1.1 clearly indicates the fact that the majority of households (95%) in San Luis use herbal home remedies to treat disease or illness in their homes. Only one family in the survey indicated that they did not use any type of herbal remedies to treat illness in their home. Many informants openly told us of several different types of home remedies that they regularly use to treat common ailments including diarrhea, colds and fever. A few informants also alluded to the fact that they have stopped using biomedical medicine because they were afraid of the dangerous side affects that often go along with biomedicine.

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Figure 1.2 demonstrates that the population of San Luis has also sought medical treatment in the form of homeopathic remedies. Although the pharmacy in Santa Elena sells several over the counter homeopathic remedies, all respondents in this survey told us that they consult with the homeopathic doctor who comes once a week to a location in Santa Elena. In total 64% of respondents told us that they use or have used homeopathic medicine. Only 36% of households informed us that they had never used or consulted homeopathic medicine. In this next section, we asked informants from San Luis specifically which type of treatment they sought to treat specific illnesses. We were interested to know which illnesses people sought treatment through biomedicine, herbal remedies or homeopathic medicine. We allowed informants to freely list the types of illnesses they treat with biomedicine, home remedies, and homeopathic medicine. As a result, informants were able to choose several illnesses in relation to the route of treatment they choose. The results were then quantified. In figure 1.3 we see the distribution of treatment people in this sample choose to treat a variety of stomach ailments including diarrhea, stomachache, gastritis, and ulcers. As is evident from the graph above, the overwhelming majority of respondents (83%) administer herbal remedies to treat stomach ailments. In contrast, only a small percentage of respondents told us that they consult a biomedical doctor or use biomedical medicine to treat stomach ailments. Only one respondent told us that they use homeopathic medicine to treat the same ailments.

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In Figure 1.4 we see a contrast in the type of treatment chosen in relation to symptoms of cold and fever which include cough and sore throat. In this scenario, the majority of respondents (58%) told us that they consult a medical doctor or use western medicine to treat symptoms of cold and fever. Interestingly, 42% of respondents told us that they use herbal remedies to treat these same symptoms. None of the respondents told us that they use homeopathic medicine to treat such ailments.

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In figure 1.5 we see an interesting distribution of treatments for headache. For example, we see that an equal number of respondents treat headaches with either biomedicine or homeopathic medicine. Only 14% of respondents told us that they treat headaches with herbal remedies. In figure 1.6 we see that for cases of chronic illnesses including different types of cancer, diabetes, osteoporosis, high blood pressure, and others, the majority (63%) of respondents seek biomedicine. Interestingly 25% of respondents said that they treat chronic illnesses with herbal remedies. Several respondents said that it was possible to control diabetes and high blood pressure with herbal remedies. Finally, only 13% of informants told us that they use homeopathic medicine to treat chronic illnesses.

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In figure 1.7 we see that with regards to chronic pain including muscle, joint and back pain, arthritis, and aching bones, 44% or respondents administer herbal remedies to treat like illnesses. Another sizable proportion (33%) seeks homeopathic medicine to treat the same illnesses. Finally, 22% of respondents said that they consult biomedicine to treat such illnesses. In figure 1.8 we see that of the respondents 50% in this sample treat allergies and respiratory problems with herbal remedies. Another 38% of respondents said that they treat allergies and respiratory illnesses with biomedicine. Only 13% of respondents said that they used homeopathic medicine to treat the same illnesses. As we see in the previous diagrams, alternative medicine plays a significant role in the health care system in Monteverde zone. Almost everyone in the area of Monteverde either has some knowledge on herbal medicine or has gone to the homeopathic doctor. List of Herbal Remedies Used in the Monteverde Zone The following information was created by gathering a list of herbal home remedies that we encountered in the region. Our group interviewed 12 informants who resided in different communities in the Monteverde Zone including Santa Elena, Caitas, Cerro Plano, Monteverde and San Luis. In total, we gathered 54 home remedies along with their varied applications. The following list was created from these interviews. Herbs and Uses by Informant from Santa Elena, 65, Sobadora # Herb Purpose 1 Romero Nerves, Stomach Infection, Cancer, Cleanses Uterus 2 Yanten Antibiotic for Coughs, Throat Infection 3 Sbila + miel de abeja Cancer 4 Oregano Cough 5 Hierba buena Upset Stomach / Diarrhea

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6 Guayaba tierno Upset Stomach 7 Ajenjo Nerves, Gall Blater 8 Hombre grande Amebas / Parasites 9 Cucumeca (sarsa) Anemia, Indigestion, Vomiting, Diarrhea 10 Cucaracha Diabetes 11 Diente de leon Diabetes 12 Ruda + romero Cancer, Colds 13 Manzanilla Diarrhea, Colic 14 Esencia coronda Diarrhea, Colic 15 Menta Diarrhea, Colic 16 Mariposa Diabetes 17 Conchita Menstrual Pain 18 Juanilama Stomach Pain 19 Cipres Allergies 20 Altamisa Nerves and Stomach Problems 21 Gengibre Stomach Pain and Infection 22 Sauco Colds, Phlegm in Throat, Cough 23 Ajo Stomach Parasites 24 Semilla Arthritis Herbal Medicine Gathered from 10 Interviews in San Luis # Herb Purpose 1 Menta Diabetes 2 Matapalo Diabetes 3 Manzanilla Cold, Diarrhea, Stomach Pain 4 Lemon Diarrhea 5 Hojos tiernos de guayabo Diarrhea, Cough 6 Manzanilla Stomach, Pain 7 Almidon de yuca Stomach Pain 8 Sabila, Yanten, Hojas de Anona, Limon con Sal Inflammation and Sore Throat 9 Yanten, malva, guayabo Stomachache and Acid Indigestion 10 Limon, almidon Diarrhea 11 Menta, Hierbabuena, metilo Stomach Problems 12 Mosote, Manzanilla, Sabila Gastritis, Stomachache 13 Hombre grande Diarrhea 14 Oregano, hierbabuena Cold and Cough 15 Raz de Naranjo Bronchitis 16 Menta, manzanilla 17 Agua de Limn, yuca, miel Asthma, Nasal Congestion, Stomach Problems 18 Menta Intestinal and Colon Cleansing 19 Menta, Juanilama Stomach Inflammation 20 Manzanilla, hierbabuena, menta Diarrhea 21 Menta Stomach Problems, Fever

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22 Juanilama, Menta Stomach Problems 23 Hojas de Guayabo, Canela, Yanten Diarrhea 24 Manzanilla, menta, Yanten, Sabila Stomach Problems, Migraines. The list of herbal remedies that our group collected during field work should be understood as only a preliminary list. Still, it is interesting to note the number of herbal remedies used to treat specific disease or illness. The diagram below was created by aggregating the list herbal remedies according to their use. It should be noted that many remedies have several applications and were therefore counted several times. The pie chart above shows the percentages of herbal home remedies used to treat different illnesses and diseases in this region. As we can see, most of the home remedies are for stomach problems such as diarrhea, stomachaches, digestion problems and gastritis. An herbal home remedy used to control diarrhea diseases represents more than 43% of total remedies used in the region. This frequency it is only followed by remedies for cough, fever, and cold with only a 15.63%. This phenomenon of high numbers of home remedies for diarrhea might be suggesting the presence of a high incidence of stomach problems in the community. This speculation, however, is in contrast to 2000 ASIS of Monteverde where only 3.57% of clinical consultations were in regards to diarrhea related illnesses. In light of this finding, we suggest that most of this diarrhea disease might not be reported to the clinic, but rather,

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treated in the home with herbal home remedies. A follow up study of diarrhea morbidity and treatment pathways would have to be realized in order to offer concrete findings. Discussion Why do people in the Monteverde Zone Seek Alternative Medicine? Our preliminary findings suggest that many people in the Monteverde Zone seek and administer several types of alternative medicine to treat a variety of medical conditions. In this section we would like to address the principal reasons why people use alternative medicine. Through interviews with people in the community we have identified common themes and reasons people use alternative medicine. For the scope of this paper we only intend to relate what we were told through these interviews. Due to our research limitations it is impossible to speculate whether there are greater socio economic and or political reasons why people use alternative medicine. Instead, we will only present these findings based on qualitative ethnographic research. The following are some of the reasons people seek and administer alternative medicine. 1. Sometimes it is difficult and time consuming to access health services at the clinic As mentioned before, people in rural areas like San Luis often have a difficult time arranging medical consultations because of the infrequent medical services available to their community. Also, referral services may be time consuming and require patients to travel to distant clinics where lines may be long. Informants also told us that traveling to distant clinics takes time and forces people to miss valuable time they could be working at home. 2. Sometimes it is more effective to treat common ailments in the home Informants often told us that it is easier and often more effective to treat common ailments including diarrhea, stomach problems, colds and fevers with herbal home remedies and or over the counter drugs. Many people told us that the medicines that they give you in the clinics only treat symptoms and may not be affective in treating the actual ailment. They often complained that medicine that they give you at the clinic has delayed effect or no effect at all. In contrast, people seem to have success when administering home remedies. 3. Biomedicine has the potential to produce negative side effects. People were well aware of the fact that some medicine like antibiotics can and do produce harmful side effects in people. Many people told us of someone they knew whose medical condition worsened after having undergone biomedical treatment. In contrast, people site the fact that herbal medicine, while sometimes ineffective, has yet to kill anyone. 4. Lack of confidence in biomedical system and capacity of medical staff. Many people site the fact that many of the doctors that come to work in the clinic are just practicing doctor’s fresh out of medical school and are therefore perceived as inexperienced. Also, some people complain of the poor treatment they receive from doctors and nurses in the form of meeting patients needs and desires.

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5. People in the Monteverde Zone have many medical options available to them and also have a long tradition of using alternative medicine Many people talk about the fact that they have always used alternative medicine including homeopathy and herbal medicine. Indeed, these alternative forms of medicine have been around in some cases longer that biomedicine in many of these regions. Conclusion The following diagram represents a conceptual framework of access to health services in Monteverde including common alternatives. The diagram includes different pathways of health seeking behavior based on perceptions of disease and illness severity and accessibility to different health care services. It should be noted that 1 way arrows signify a linear relation between options whereas two way arrows represent a reciprocal relationship allowing people to move back and forth between different options. This model is only intended to demonstrate the health options available to people and the way in which people move back and forth between different alternatives. As mentioned before the specific reason why people choose different pathways is beyond the scope of this paper. The following conclusions are based on the following diagram and our perceptions of the relationship between access to health services and alternative medicine in the Monteverde Zone. 1. This framework of the different levels of health alternatives and services function together as an integrated health care system. In other words, different health alternatives fill in and provide services where other services fail to do so. 2. This integrated health care system has been created by the community, as a response to their health care needs. Health alternatives including homeopathy and herbal remedies are vital to the health care system because they offer people flexibility treatment alternatives that meet varied medical and health needs. 3. Understanding this dynamic relationship between health access and different kinds of medical options available to the community will allow us to better understand the health care system as a whole and enable us to suggest ways in which health services and access in all sectors could be improved.

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Recommendations The following recommendations suggest possible directions in which we believe this ongoing study should take in the future: An applied study and report that would facilitate dialogue and greater understanding between biomedical practitioners and community members. We believe that if both medical practitioners and community members were better informed of health issues concerning access, services, medical alternatives and needs of concerned parties that health care issues could be better addressed. A study to discover and understand the transitions relating to access to health care services in the community. For example, we would like to understand the growing popularity of homeopathic medicine in the community and to see whether different sectors of the community rely on herbal remedies more than others. To increase our knowledge of alternative medicine in the community. For example, we were unable to talk to the homeopathic doctors who visit the community. Likewise, we would like to continue gathering data on herbal remedies and homeopathic remedies that are used in the community. A study to look into the cultural, economic and political aspects of access to health care and the subsequent use of alternative in the community. This study could also include an examination of health decision making models in relation to cultural, economic and political factors. That all future studies are based on more representative samples. One way to do this would be to focus on a single community each year, for instance, looking at these issues in San Luis one year, and then looking at the same issues in Santa Elena the next.


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520
Overview of traditional biomedical health care services and alternative medical practices. Includes recommendations for follow up studies.
Descripcin general de los servicios de atencin de la salud biomdica y las prcticas mdicas alternativas. Incluye recomendaciones para el seguimiento de los estudios.
546
EN
653
Behavior and health--Costa Rica--Puntarenas--Monteverde Zone
Medical care--Costa Rica--Puntarenas--Monteverde Zone
Alternative medicine
Salud Comunitaria 2001
Servicios de salud--Costa Rica--Puntarenas--Zona de Monteverde
Comportamiento de bsqueda de salud
7 655
Books/Reports/Directories
720
Lind, Jason
Ruiz, Santiago
Scanned by Monteverde Institute
1 773
t Community Health
4 856
u http://digital.lib.usf.edu/?m38.9