Bull Pan Am Health Organ 1X2), 1979.
DIFFICULTIES OF PRESENTING COMPLAINTS TO PHYSICIANS:
SUSTO ILLNESS AS AN EXAMPLE’p2
Arthur J. Rubel’ and Carl W. O’Nel14
Susto is afolk term in the Mexico-U. S. border area for an illness
characterized by loss of appetite and weight, listlessness, and
lack of motivation. It is generally attributed to a startling expe-
rience that results in the departure of the soul from the body.
This epidemiologic study demonstrated that the sufferers were
in fact significantly less healthy than those complaining of
illness that did not implicate susto. They also suffered more
social stress, but did not score higher in psychiatric impairment.
One of the most important health prob- Astudy (1957-1959) of persons of Mexican
lems found in the area along the border descent living in Hidalgo County, Texas,
between the United States and Mexico is the pointed up that when English-speaking
communication between patients and physi- physicians began practicing in the area in
cians from different cultural backgrounds. 1910, Mexican-American patients would
While some researchers have studied the attach labels to their set of symptoms that
communication difficulties between Span- proved unfamiliar to the new physicians.
ish-speaking patients and English-speaking One such label was susto, and the symptoms
physicians in the area, such difficulties re- attributed to it included loss of appetite and
present only one dimension of the problem. weight, listlessness, and lack of motivation
Because physicians and nonphysicians share to carry on ordinary, socially expected tasks.
so few technical understandings about dis- The physicians responded to the use of these
ease-regardless of their respective mater- folk labels by attempting to educate their
nal languages-adequate communication is patients to present complaints in ways more
severely hindered. It has been suggested that familiar to the doctor and to think of the
patients’ generally lower level of formal symptoms as representing disease categories
education is the primary cause of this to which the physician had been trained to
problem. It may be more reasonable, how- respond. As a result, many Mexican-Amer-
ever, to consider the high degree of physi- icans came to consider symptoms to which
cians’ education as an obstacle to the effec- they affix a folk label, such as susto, to re-
tive communication of useful information present illnesses with which physicians are
to their patients. unfamiliar and in which they claim no
healing competence. Consequently, only the
IFrom Modern Medicine and Medical Anthro$ology foolhardy would present complaints of these
in the US-Mexico Border Area. PAHO Scientific Pub-
lication 359, Washington, 1978. illnesses to physicians.
SThis study was supported in part by a National It is therefore not surprising that today in
Institute of Mental Health grant (1 RO 1 MH18561) Hidalgo County, Texas, a very high preva-
and by the Seminar on Medicine of the Whole Man
(Seminario de la Medicina de1 Hombre en su Totali- lence of what local physicians refer to as
dad). “Valley T. B.” is reported. Valley T. B. is
SDepartment of Anthropology, Michigan State Uni- nothing more than an advanced state of
versity, East Lansing, Michigan.
4Department of Sociology and Anthropology, Uni- common tuberculosis-a disease whose signs
versity of Notre Dame, Notre Dame, Indiana. and symptoms are very similar to susto.
134
Rubel and O’Nell l EPIDEMIOLOGY OF SUSTO 135
Collective Case Studies: Swto in Three Hypotheses
Mexican Communities
Given the unequal distribution of the
illness in these populations, another expla-
As part of an effort to improve under- nation was tested: could manifestation of
standing in Latin America between patients the condition vary as characteristics of
accustomed to presenting complaints that social behavior vary? The central hypothe-
reflect one nosological system and physi- sis was that those who become ill with susto
cians trained to respond to those symptoms perceive themselves to be inadequately per-
according to the terms of another system, it forming sex- and age-specific social roles.
was proposed to determine how adults com- Furthermore, considering the sharp distinc-
plaining of susto illness differ from others tions drawn in rural Mexico between male
who also feel ill but whose complaint does and female roles and the fact that some tasks
not implicate susto. are considered far more important than
To this end, an epidemiologic study of others,two corollaries of this central hypoth-
susto was carried out among rural people in esis followed:
Oaxaca State, Mexico. In order to assure
that the results would apply to more than 1. Because these societies’ expectations of males
and females differ, and because their expecta-
one culture group, three culturally and
tions of male and female children likewise differ
linguistically different populations were from those held for adult men and women, in the
selected: one which is Mestizo and Spanish- same society girls and women will be afflicted by
speaking, one which is Indian and Zapotec- susto as a consequence of experiences different
speaking, and another which is Indian and from those which affect the health of boys and
men ;
Chinantec-speaking. In each group, susto is
2. Inasmuch as these societies attach more im-
an endemic condition. portance to some tasks than to others, the greater
In each of these three populations, the the importance attached to any particular task,
villagers attribute loss of appetite and the greater the chances are that susto will occur
weight, listlessness, and lack of motivation if that task is unsuccessfully performed.
to a startling experience that results in Having established two groups, one con-
departure of a prime essence of the self, the sisting of those afflicted with susto (asusta-
soul (alma), from the body. At this point the dos) and one acting as experimental controls
interpretations vary somewhat: in the two who complained of illness but not susto, two
Indian communities, the essence is believed null hypotheses were proposed:
to be held captive by supernatural beings
1. An instrument designed to measure levels
and must first be ransomed from its captor
of psychiatric impairment will find that ususta-
to then be led back to the abandoned body; u!os suffer more impairment than controls.
in the Mestizo community, the soul has only 2. Tests designed to measure levels of organic
wandered from the body and therefore need disease will find mustados suffer more from
not be ransomed. All three populations, organic disease than controls.
nonetheless, do concur on the main expla-
nation: the symptoms are the product of a Test Methods
startling experience. Some other explana-
tion is required, however, when it is deter- In order to measure self-perceived social
mined-as has been done among residents of performance, the extent to which individ-
Hidalgo County, Texas-that not all those uals meet their expectations for successful
who subscribe to the startling-experience compliance with important social goals, a
explanation and then suffer one actually “social stress gauge” was devised. The ex-
develop susto illness. pectations measured were not idealized com-
136 PAHO BULLETIN l vol. 13, no. 2. 1979
munity norms but each person’s under- corded on cassette tape by a resident of the
standing of what he or she should accom- respective communities.
plish to ensure a state of well-being. Since These three measures- the social stress
these communities socialize males and fe- gauge, the organic disease scoring system,
males differently, two tests were developed and the psychiatric screening score-were
-one for men and the other for women-to used to ascertain whether those who were
measure the role stresses peculiar to each presenting complaints of susto did in fact
sex. Role tasks were selected that anthro- suffer from a state of well-being significant-
pological research had indicated would be ly lower than those whose complaint of ill- -
critically important to adults of each sex. ness did not implicate susto and, if so, in
Data to measure the level of organic what respect.
health of those with susto as well as the con-
trols were gathered by means of a medical Results
history, a physical examination, and labo-
ratory analyses of blood and stool speci- The results supported the central hypo-
mens. Subsequently, to quantitatively mea- thesis: the asustadosevidenced significantly
sure these data a system was used in which a more social stress than did the controls. In
panel of two Mexican physicians ascribed a all three communities, scores measured by
numerical score to specific symptoms fol- the social stress gauge were generally higher
lowing objective guidelines. Each physi- for usustados than for the controls: in both
cian, scoring the data independently and the Zapotec- and Spanish-speaking popula-
unaware of which patients were suffering tions the results reached levels of statitisti-
from susto, evaluated the symptoms in terms cal significance (0.05 probability); in the
of their “severity”- the extent to which a Chinantec-speaking population the results
symptom represented a threat to the were as hypothesized, although not statis-
individual’s social functioning-and grav- tically significant. When social stress for all
ity- the extent to which a symptom threat- males in all three communities was com-
ened the individual’s life; for example, a pared, those identified as asustados scored
patient with clinical manifestations of significantly higher than did their controls,
onchocerciasis would, with respect to ‘that and a similar result was obtained when the
disease, most likely be scored high on sever- women were compared.
ity and low on gravity. The physicians’ The “Wilcoxon Matched Pairs Signed
judgments were found to be highly reliable Ranks” test, in which each of the mustados
when correlational techniques were used was matched with his or her control to rank
for comparison. the differences in scores between them,
In addition, the “Twenty-two Item proved to be an even stronger test of the
Screening Score for Psychiatric Impair- hypothesis, revealing differences in the pre-
ment” (I-3) was adapted to determine dicted direction in all three communities.
whether asustadosindicate more psychiatric The differences were statistically signifi-
impairment than controls do. The screen- cant in the Zapotec- and Spanish-speaking
ing score, originally designed for a survey of communities, reaching levels respectively of
psychiatric symptoms in New York City and 0.005 and 0.0005, whereas they went in the
later used effectively in two areas of Mexico, predicted direction among the Chinantec-
was translated into Spanish, modified to be speakingpopulation, although not quite at-
suitable for the rural inhabitants of Oaxaca, taining a level of 0.05 significance.
and then translated again into Chinantec The social stress gauge for male subjects
and Zapotec. Each of these versions was re- comorised 18 items of which 12 served to
Rubeland O’Nell l EPIDEMIOLOGY OF SUSTO 137
successfully discriminate men complaining the modified “Twenty-two Item Screening
of susto from their controls. In the com- Score.” Psychiatric symptoms, whether
parable test for female subjects, of 24 items measured as a whole or by the manner in
15 succeeded in discriminating women com- which they distributed on the instrument,
plaining of susto from their controls. A few failed to differentiate the groups; nor did a
inquiries on each of these tests failed to dis- single cluster of items distinguish m&ados
criminate asustados from controls, a result from controls. Notwithstanding, the screen-
that raised questions as to the validity of ing score did consistently discriminate be-
some commonly held opinions regarding tween the responses of men and women;
sex-specific tasks in Mexican communities furthermore, within both the male and fe-
such as the three under study. male groups sharp differences were reported
The null hypothesis that predicted that among the respondents.
the group complaining of susto would score This study thus demonstrated that those
significantly higher in levels of organic dis- with susto were significantly less healthy
ease was unexpectedly confirmed: that than those complaining of illness that did
group was found to be more organically dis- not implicate susto. The former were more
eased in terms of both severity and gravity organically diseased and proved to be signif-
than the control group. This finding is even icantly less adequately meeting their own
more important when one considers that standards of social role performance than
individuals in both groups-ax&ados and selected other persons from the same com-
their matched controls-perceived them- munities. A high score for social stress and
selves sick enough to present complaints to high scores on the “severity” and “gravity”
physicians. scales for organic disease did not, however,
The second null hypothesis, that the onus- co-vary; that is, the data did not predict that ,
tados would score higher in psychiatric im- one who was organically diseased would also
pairment, received no support according to score high on the social stress gauge.
SUMMARY
Results of this epidemiologic study of an tion on the signs and symptoms patients present
endemic folk illness are of considerable impor- rather than on the labels they use to identify ill-
tance to physicians and other health specialists ness. Within a community, individuals success-
throughout Latin America and the area along fully communicate the nature of health problems
the border between the United States and Mex- by affixing labels such as susto,cblera, and bilis
ico. They would indicate a strong probability to a set of cohering symptoms, whereas persons of
that a patient who presents a complaint of susto is another segment of that society use the terms
suffering both “severe” and “grave” organic “tuberculosis,” “diabetes,” and “hypertension”
problems that require careful workup as well as to describe the same or other sets of symptoms. As
considerable stress related to selfperceived fail- physicians and other health staff become more
ure to adequately perform social roles. sensitive to the language and manner in which
On the basis of these data educational efforts patients present their complaints, they will expe-
are recommended to train medical students and rience greater opportunities to provide better
health professionals to concentrate their atten- health care to the respective communities.
138 PAHO BULLETIN l vol. 13, no. 2, 1979
REFERENCES
(I) Langner, T.S. A twenty-two item screen- (3) Fabrega, H., Jr., A. J. Rubel, and C. A.
ing score of psychiatric symptoms indicating im- Wallace. Working class Mexican psychiatric
pairment. J Health Hum Behav 3(4):269-276, outpatients. Arch Gen Psychiatry 16:‘704-712,
1962. 1967.
(2) Murphy, J ., and A. Leighton (eds.). A$-
proaches in Cross-Culture Psychiatry. Ithaca,
New York, Cornell University Press, 1965. p. 360.
TEACHING AIDS ON TROPICAL DISEASES (MEDDIA)
In cooperation with WHO, the Royal Tropical Institute in Amster-
dam, the Netherlands, and the Liverpool School of Tropical Medicine in
the United Kingdom are compiling definitive sets of color transparencies
on 10 groups of important tropical diseases: schistosomiasis, malaria,
leishmaniasis, leprosy, trypanosomiasis, geohelminth infections, fila-
riasis, amebiasis, other helminth infections, and other protozoa1 infec-
tions. These sets are intended mainly for health workers of different
levels who are engaged in the study and control of these diseases.
The sets will be available as microfiches and as unmounted slides, and
will cover epidemiology, pathology, etiology, diagnosis, treatment, and
control. Each set will be accompanied by a short explanatory text,
available in English, French, and Spanish. The first of the series (schisto-
somiasis) is now available; others will follow during 1979 and 1980.
Subscription prices including airmail postage are US$65 for all the
microfiche sets (840 color images in all for the 10 diseases, each with a
,separate text, and one hand-viewer), and US$lSO for unmounted slides.
Individual sets are US$9 for microfiche and US$15 for unmounted slides.
Payment should be made in advance in U.S. dollars to the Royal Tropical
Institute, ABN NV. rek. nr. 540264903. UNESCO coupons are also
accepted. Orders should be sent to the Royal Tropical Institute, Depart-
ment of Tropical Hygiene, Section Medical Education and Training,
Mauritskade 63, 1092 AD Amsterdam, Netherlands.
Source: WHO Chronicle X3(2):66, 1979.