Navajo Indian Medicine: Implications for Healing John L. Coulehan, MD, MPH Pittsburgh, Pennsylvania

Traditional medicine men coexist with physicians and hospi­ tals on the 25,000 square mile Navajo Indian Reservation. Most seriously ill Navajos utilize both systems of health care. This natural experiment of coexistence emphasizes several general characteristics of all healing. Traditional ceremonies are successful because they are integrated into Navajo belief systems and meet needs of sick people not dealt with by the available Western medicine. Physicians and other healers simply remove obstacles to the body’s restoration of homeo­ stasis or, as the Navajo say, to harmony. Reductionism limits the spectrum of obstacles considered relevant (eg, causes of illness), but an alternate model might include emotional, so­ cial, or spiritual phenomena equally as significant to healing as are biochemical phenomena. In that context, nonmedical heal­ ers, as well as physicians, can potentially influence factors relevant to getting well.

Navajo medicine is an example of an American made it marginal for grazing and no mineral de­ Indian system of health and healing that remains posits had yet been discovered. Consequently, ex­ viable, despite the coexistence of contemporary cept for military engagements, the Navajo had scientific medicine. The presence of both ap­ relatively little contact with white or “Anglo” proaches to illness on the Navajo Indian Reserva­ society until well into this century. The Navajo tion presents, to some extent, a natural experi­ culture and language remained viable and, in par­ ment in which it is possible to delineate the contri­ ticular, Navajo medicine men, or Singers, contin­ butions of each. ued to practice successfully. At present, this tra­ The Navajo form the largest tribe of American ditional medicine appears to be expanding after a Indians, numbering about 150,000 people. They decline noted in the 1940s and 1950s. live on a 25,000 square mile reservation in To the Navajo the natural or correct state of all Arizona, New Mexico, and Utah, and in the adja­ things, including man, is harmony.1 Far from being cent country. The land is part of the Colorado dominant over nature, man is seen as interdepen­ Plateau, a high steppe-like territory, crossed by dent with other living beings and physical forces. deep canyons and mountain ranges. Prior to the Likewise, an individual person is dependent on his twentieth century, the white man had little use for family, his clan, and the people as a whole. All Navajo country because the low average rainfall Navajo thinking is grounded in relationships. More emphasis is given to the “connectedness” of one thing to another than to the things in them­ From the Department of Community Medicine, Division of Family Medicine, University of Pittsburgh, Pittsburgh, selves. To maintain correct or natural relation­ Pennsylvania. Requests for reprints should be addressed to ships is to be in harmony. Everything that is, is Dr. John L. Coulehan, Department of Community Medicine, Division of Family Medicine, M-200 Scaife Hall, University related to everything else. The universe is a com­ of Pittsburgh, Pittsburgh, PA 15261. plex matrix of interdependence. There is a proper 0094-3509/80/010055-07$01.75 5 1980 Appleton-Century-Crofts

THE JOURNAL OF FAMILY PRACTICE, VOL. 10, NO. 1: 55-61, 1980 55 NA VAJO INDIAN MEDICINE

group, and the supernatural, which serves to raise set of relationships for each being, a properway' ot the patient’s expectancy of cure, helps him to existing in harmony with the universe. The Navajo harmonize his inner conflicts, reintegrates him Way is manifest in the myths, history, llten*ture3’ with the group and spirit world . . . and, in the art customs, and society of the Navajo people - process, combats his anxiety and strengthens his As in most tribal cultures, there is no separation sense of self-worth. between religion and medicine among the Navajo_ What is the Navajo attitude toward scientific In fact, healing ceremonies are an integral part o medicine? With the appearance of physicians and the community experience, and there is no distinc^ hospitals, people were saved from infectious dis­ Navajo term for “religion” in the Western sense.- ease, the infant mortality rate declined, and the The Navajo interpret all human suffering as dis­ Navajo rapidly accepted the white man’s “ shot” harmony. An individual suffers because in some and his surgery. Navajo thought developed, at way he or she has fallen out of harmony. As one least implicitly, the distinction between the lesion observer put it, “disease is simply, yet precisely, itself, whether cancer or tuberculosis, and the dis­ disharmony.” 4 The person who does not feel well harmony of which it is a manifestation.1 In most has gotten out of phase with the matrix of correct relationships. Consequently, what Western man cases of physical disease, the people realize a interprets as specific disease, an entity in itself, physician is more able to resolve these symptoms and affecting an organ system, is for the Navajo than a Singer. Penicillin may save an infant from only a symptom of underlying disharmony. death or surgery rid a woman of an infected The Navajo people believe that phenomena gallbladder. On the other hand, if lightning or such as storms, lightning, witchcraft, spirits, and witchcraft was the initial etiology, obviously it animal contamination cause most disease or dis­ must be dealt with as well. Thus, only a tradi­ harmony.4 Once the cause of sickness is ascer­ tional Sing can cure the whole person. tained, often by a “hand-trembler” who goes into This author practiced medicine for two years on a trance to make the diagnosis, the sick person the Navajo Reservation and spent a large part of must hire a medicine man, or Singer, to perform an that time as medical officer in an isolated commu­ appropriate ceremony. Such a Sing will last two to nity, Lower Greasewood, Arizona, where the nine days and consist of rituals, prayers, and clinic was nearly 70 miles from the nearest Public chants which must be performed in precisely the Health Service Hospital. The clinic served about right manner to be effective. Major Sings are mys­ 4,500 people whose camps were scattered over tery plays that recount Navajo myths about cre­ more than 400 square miles of semi-desert. This ation, emergence, and salvation of their people. provided an opportunity to share many patients One myth, for example, is that of Changing with Singers, and to observe the outcomes in sev­ Woman whose two sons, Child Born of Water and eral cases. Following are three cases based on Monster Slayer, killed the giants who were ter­ examples of Anglo and traditional medicine treat­ rorizing mankind; parts of this myth are included ing the same patient. in several ceremonies.5 Sings are group ceremonials, which involve the patient, the Singer, his assistants, the immediate and extended family of the patient, and many friends. Family members contribute both money and other resources, such as sheep. When the time comes, all drop their ordinary duties and gather together for the event. The patient becomes the Case 1 center of interest. The support of the whole com­ Tommie Chee, a 38-year-old married man with munity is lavished freely. The community recog­ four children developed progressive low back pain nizes that by restoring harmoi.y to one person the and fatigue over several months, followed by in­ ceremony improves the harmony of the people as somnia, unkempt appearance, and absence from a whole.8 It relates person to environment, past to his family for two or three days at a time. He quit present, and natural to supernatural. The Sings in­ his job at a boarding school dormitory, claiming volve “ an interplay between patient, healer, that he was too weak and sick to continue. Several

THE JOURNAL OF FAMILY PRACTICE, VOL. 10, NO. 1, 1980 NAVAJO INDIAN MEDICINE days later, he was found walking aimlessly in the harmony and had no further requirement for desert, near his family’s camp. At the hospital, strong pain relievers. Her strength increased and Tommie was diagnosed as suffering from she was able to carry out her duties in the camp. endogenous depression, and was prescribed ami- She died quietly at home about six months later. tryptyline 100 mg at bedtime; he was referred for counseling to the Mental Health Clinic in Gallup, a town 65 miles from his home. He neither took the medication, nor kept subsequent appointments. His condition worsened over two months, includ­ ing weight loss of 20 lbs. A Navajo hand-shaker was hired by Tommie’s family. She said that Tommie had been possessed by the ghost of his mother’s brother, who died Case 3 violently in the Korean War. Tommie had married Hosteen Begay was a 50-year-old married man, into an improper clan, and tended to “think too with seven children. He had a large number of much,” both of which lowered his resistance and sheep, both his mother’s and sister’s herds. While allowed the ghost to gain possession. A major riding on the range, he developed acute severe Night Way (Yei-Bei-Chai) ceremony was indi­ right upper quadrant abdominal pain, with nausea, cated, and held. After the nine-day Sing, Tommie vomiting, and fever. He recalled recurrent was cured of possession. He went back to work, episodes of mild to moderate abdominal pain over gained weight, and all symptoms resolved. the preceding year. At Fort Defiance Hospital, Hosteen was treated with intravenous fluids, antibiotics, and analgesics. On oral cholecysto- gram, numerous radiolucent stones were demon­ strated. The diagnosis was cholelithiasis and acute cholecystitis. Surgery was recommended after the infection cleared. Hosteen went to a hand-trembler who told him Case 2 that he was bewitched by an enemy, who caused Athabasca Mailcarrier was a 67-year-old widow stones to be placed in his body. An Evil Way who lived in a camp with two of her daughters and ceremony was held for seven days, during which their families. She developed progressive lower the Singer “sucked out” the stones. Sub­ abdominal pain, bilateral leg edema, poor appetite, sequently, Hosteen had no further symptoms dur­ weight loss, weakness, and exertional dyspnea ing a two-year period, although no repeat x-ray rather rapidly over about a three-month period. films were obtained. She was admitted to Fort Defiance Hospital where diagnostic evaluation revealed carcinoma of the cervix, Stage IV, with extensive local invasion and left ureteral obstruction. She required large doses of morphine or Dilaudid for pain during three weeks of hospitalization, and became con­ fused and combative. Radiation therapy was rec­ ommended, but the family rejected this option and Discussion took her from the hospital against medical advice. These three cases all demonstrate two systems A Navajo diagnostician revealed that Atha­ of care bearing upon the same problem. Only in basca had too much exposure to thunder and Case 3 is Anglo medicine successful in relieving a lightning; she was “ straining against the world.” It major part of the syndrome, and so the selection is was a fundamental disharmony in the fabric of be­ somewhat atypical. Commonly, with tuberculosis, ing. The family sponsored a Holy Way Sing, last­ pneumonia, cellulitis, and other Navajo illnesses, ing nine days, and performed by Hosteen Klah, a the hospital and physicians play a larger role. famous Singer. Athabasca was “cured” of dis­ However, the central question here concerns the

THE JOURNAL OF FAMILY PRACTICE, VOL. 10, NO. 1, 1980 57 NAVAJO INDIAN MEDICINE

mony Navajo people have equanimity in the face role of Navajo medicine. What does it do. of a harsh environment and difficult life. Aches did it do in these three cases? and pains, sore throats, or diarrhea are not prob­ In each one it might be said to be a form of lems for healing proper, although people may use psychotherapy. Clearly, it was effective in Tom­ various herbs and folk remedies at home. People mie Chee’s depression, but what about the patient may also go to the Anglo clinic for some pills or a with metastatic carcinoma? The cancer did not go “ shot” in much the same way. It is only when the away, but the patient got demonstrably better, person and family decide something serious is in­ even if her tumor mass remained the same. Since volved that true Navajo medicine is undertaken. gallstones may produce intermittent symptoms, What lessons can be learned from Navajo how can one say Hosteen Begay was healed? Who medicine, and its relationship to the Western would believe the stones were actually sucked out health care system? There are three related con­ through the skin? Again, from the patient’s point cepts which are implicit in the Navajo experi­ of view, he was better and had no illness, despite ment” and which are, at least partially, responsi­ the cholesterol stones that probably remained in ble for the success of Navajo healing. The first is his gall bladder. The Navajo healers were not that all patients have certain beliefs about health quacks however one labels what they did. At least and illness, and these beliefs do not come from in these cases, they did as much or more for the medical textbooks. More specifically, patients patient than Anglo physicians could have done. have concerns about the origin and meaning of Certain characteristics of Navajo healing are illustrated, directly or indirectly, by these cases. their symptoms that may be more important to First, Navajo medicine does not always seek to them, and ultimately to healing, than the purely prolong life. All living beings have a natural life­ descriptive aspects of pain or vomiting. Illness is span, and the cycle of birth, growth, maturation, not value-free or meaning-free, although medical and decline is essential to the world’s harmony. education has not placed much emphasis on this Thus, an aged person becoming sick and dying fact. The physical world, as studied in natural sci­ does not necessarily mean disharmony, but rather ence, is, for us, an abstraction. Where we really may be fulfillment of the natural cycle. Thus, the live is in what Eric Cassel calls “semantic ceremony for Athabasca Mailcarrier put her back space.”8 We live in a world of symbols and in­ into harmony, allowed her to die well, surrounded terpretations, and the physician must collect data by her personal world, and was, therefore, suc­ about patient beliefs just as he or she collects other cessful, despite the fact that she did indeed die of relevant data. cancer. These beliefs may be centered in coherent sys­ Secondly, all diseases are considered within the tems, such as those of Jehovah’s Witnesses or province of Navajo medicine, not just those West­ Christian Scientists, or they may be fragmented. ern physicians look upon as emotional or The coherent systems are likely to be highly inte­ psychological in nature. As noted before, mind- grated into the person’s value system, and will not body dualism has no place in Navajo thought. be changed by what may be considered a rational From a Western perspective, a Singer may be explanation.9 The systems are, in fact, quite ra­ more successful in curing hysterical paralysis than tional in themselves, as long as one accepts their the paresis of a stroke, and such cures lend much basic premises. If, for example, one accepts that a credence to a Singer’s power. However, both clear understanding of the gospel message will strokes and hysteria are Anglo labels, not Navajo lead to health, and that any illness reflects a failure understandings, and Sings may benefit either, in such understanding, then all the beliefs of a perhaps in different ways. Hosteen Begay had Christian Scientist proceed logically from these clearly a “ physical” illness, which apparently re­ assumptions. A physician will not be able to heal solved after a Sing. that person unless he takes these beliefs into ac­ Thirdly, all these cases represent serious ill­ count. The refusal of Jehovah’s Witnesses to ac­ ness. Self-limited acute illnesses and body discom­ cept blood products is another example of this forts for which contemporary Americans seek principle. medical help are felt by the Navajo to be “part of More frequently, perhaps, patient beliefs about life” and not specifically reasons to hold a cere­ disease are fragmented, and not tightly integrated

58 THE JOURNAL OF FAMILY PRACTICE, VOL. 10, NO. 1, 1980 NAVAJO INDIAN MEDICINE into value systems. Today’s urban society is con­ simply modification or restriction of usual activi­ stantly exposed to health information on television ties. However, our activities, mental or physical, and radio, in magazines and newspapers, from actually define what we are, so that in serious ill­ which a person may gather a variety of beliefs, ness we perceive our identity itself as threatened. some of which may contradict others. A common Eric Cassell, in The Healer’s A rt, enumerates contemporary theme is that people know very lit­ some of the perceived losses in illness: the loss of tle about their bodies, that dire disease may de­ connectedness, the loss of sensing indestructibility velop covertly, that there is little one can do about or omnipotence, the limitation of ability to reason, discomfort on one’s own, and that the physician and loss of control over our bodies.11 The patient holds the key to all these mysteries. These themes feels the whole matrix of his life disrupted and constitute part of the “medicalization” of this threatened, and himself out of control. In effect, society, and result in “cultural iatrogenesis,” to like the Navajo, he sees illness as disharmony. use Ivan Illych’s term.10 If sickness leads to experiences of loss, then Societal beliefs specify a valid range of what the getting well must in some way involve restoring physician is expected to ask and do. Personal these losses. The person has to get connected beliefs about getting sick and its implications, again, to get back into control. Navajo healing whether systematic or fragmented, may be differ­ ceremonies deal with these needs directly. Var­ ent. They may be related to guilt, anger, loss, mis­ ious areas of experiences are covered, from the understanding, or anxiety. But the cultural set historocultural (myths and symbols) to the social screens these feelings out, and problems may have (family and support groups) to the psychological to be expressed in somantic language to be consid­ (catharsis or abreaction) to the physical (herbs, ered legitimate. When this occurs among the sweat baths). The object is to restore harmony. In Navajo, there is a cultural remedy—a healing Western hospitals and clinics, physicians do a ceremony. When it occurs in our medicalized good job when biochemical or anatomic factors society, often no remedy is available. People are are paramount in illness. However, in chronic dis­ labeled with irrelevant diagnoses, such as de­ eases, people may not readily “bounce back.” A generative joint disease to explain chronic back prolonged, intermittent course of rheumatoid ar­ pain, or hiatal hernia to explain chronic epigastric thritis may not permit a “healthy identity” to be discomfort. The meaning of the illness to the indi­ restored. The constant threat of a second myo­ vidual is not addressed because medicine does not cardial infarction may haunt a medically well recognize that symptoms are a language spoken by executive. The need for daily insulin may con­ the whole person, and cannot be understood as tribute to a diabetic’s lack of self-esteem. The simply signs of some textbook disease. biomedical system is poorly adapted to help with Since beliefs about illness in general, and the these problems since the factors it deals with, the meaning of an individual illness, are not part of the synovial pannus, the atherosclerotic plaque, or the expected content of physician-patient interaction, elevated blood glucose are indeed still present. the physician who is interested must develop his And since these lesions are often considered ir­ or her skills of inquiry to learn about them. Inter­ reversible, it can only teach the person to be de­ personal skills can be taught and should be part of pendent, to lack control. In a sense, this is teach­ medical education. The natural experiment among ing the person to remain sick. Navajo ceremonies, the Navajo demonstrates that the biomedical sys­ on the other hand, teach people to be well again. tem which, because of language and cultural Just as with patient beliefs, sensitivity to patient differences has a minimum of interpersonal con­ needs requires highly developed interpersonal tent, must be supplemented by another type of skills. The goal in treating persons should be to care, centered in cultural beliefs and social sup­ help maximize their own independence and con­ port systems. All patients, not only the Navajo, trol over their lives. Szasz and Hollender de­ need both dimensions of care. scribed the styles of physician-patient relation­ The second lesson is that the world, as experi­ ships, from that in which the sick person is totally enced by the sick, is different from the world of dependent, such as a comatose state, to that of the well. The major personal experience of illness mutual cooperation or a therapeutic alliance.12 is one of loss. At the most superficial level, there is Only through developing the latter will the burden

THE JOURNAL OF FAMILY PRACTICE, VOL. 10, NO. 1, 1980 59 NAVAJO INDIAN MEDICINE

understood best by dividing them into simpler and of “health” be tilted away from a misnamed health simpler subsystems. One can proceed from the care system and back toward the patient, whose person as a whole, with social and cultural dimen­ health it is. . . , . sions, to a physical body, to an organ system, to a The third lesson from the Navajo is about the tissue, and thence to a biochemical reaction, or nature of healing itself. Western medicine uses a even a DNA base sequence. (This is obviously a variety of phrases to describe what the physician powerful tool in studying phenomena and has led does; phrases such as, “cure disease,” “treat ill­ to all the understanding and accomplishments of ness,” “care for the patient,” and “heal the Western medicine.) An alternate premise, how­ sick.” “ Healing” implies a relationship between ever, is that complex levels of organization hold patient and healer, one in which forces are more information than exists in the sum of their mobilized to enhance the well-being of the person simpler components. The whole is greater than the who suffers. In that context, “curing” is one as­ sum of its parts. Psychological processes, for pect of healing in which those forces alter a dis­ example, may contain information not evident in crete pathologic process. There are many prac­ studying the neurons. Engel suggested such a titioners of healing who do not cure in the latter sense, or do so only in a peripheral fashion. Chris­ premise, based on general systems theory,13 when tian Scientists, chiropractors, and acupuncturists he proposed a “biopsychosocial model” for are examples of such practitioners. medicine.14 When a physician and a patient interact, who With respect to understanding illness and heal­ does the healing? Although a physician may clean ing, reductionism restricts the observations con­ a laceration to lessen the chance of infection or sidered important and relevant. Biochemical and suture it to provide for a quicker, more cosmeti­ histological data are accepted, but social observa­ cally pleasing scar, the body does the healing. The tions are placed on a much lower level, religious physician removes obstacles. In pneumococcal ones are eliminated entirely. The physician pro­ pneumonia, bacteria invade the lungs. Host de­ motes the patient’s own healing processes, but can fense mechanisms have partially failed in that only utilize tools considered relevant by reduc­ infection has taken place, but they are actively tionistic medicine, such as drugs, vaccines, and attempting to localize and destroy the agents. The surgery. Although Western physicians may learn physician, by giving antibiotics, kills or disables to take a social history from a diabetic, they would many of the bacteria, thus aiding the person’s own not be likely to consider that guilt or plain disap­ defenses. When the balance is tipped toward heal­ pointment might be as important as the blood glu­ ing, the body’s mechanisms restore the lungs to cose in precipitating the current illness. Such normal. Again, the physician has simply removed physicians would never consider that guilt might obstacles and thereby assisted the patient’s own have caused the blood glucose to rise and that this healing processes. The situation may not be so guilt might possibly be easier to deal with directly clear in chronic diseases, but whenever a physi­ than treating its effects. ological imbalance occurs, such as in diabetic The alternate premise that the whole is greater ketoacidosis or in myocardial infarction, the than the sum of its parts suggests that the obsta­ physician can, in one way or another, simply pro­ cles to getting well are often multiple and usually vide better conditions for restoring balance. The occur at various levels of organization. Thus, in a person gets better. given case of pneumonia, they may be both mi­ Unfortunately, this view of the body’s homeo­ crobiological and emotional, and social disorgan­ static mechanisms being the prime force in healing ization, or the loss of a loved one, may be causes is not emphasized in Western medicine. Physi­ of myocardial infarction. If this alternate premise cians are taught that they do the healing, and this is accepted, then it is clear that obstacles to heal­ belief becomes an obstacle to their understanding ing may occur at emotional, social, or even spiri­ of what other types of healers do, and why often tual levels. Removal of such obstacles, just as re­ they are successful. moval of bacteria, may aid the healing process. Reductionism is a central premise of Western This, then, is the common denominator of what medicine. From a reductionistic viewpoint, com­ healers attempt to do. Among the Navajo it is plex phenomena, like people or diseases, can be quite clear. The natural world-harmony is dis-

THE JOURNAL OF FAMILY PRACTICE, VOL. 10, NO. 1, 1980 NAVAJO INDIAN MEDICINE

turbed by some factor, perhaps a witch’s curse or References possession by a spirit. The Singer simply re-enacts 1. Coulehan JL: Navajo Indian medicine: A dimension a great myth, in a sense demonstrates or teaches in healing. Pharos 39:93, 1976 2. Kluckhohm C, Leighton D: The Navajo, revised. New the underlying harmony, thus allowing the per­ York, Anchor Books, 1962, pp 179, 238-239, 309, 311-312 son’s own healing to occur. Most nonmedical 3. Downs JF: The Navajo: Case Studies in Cultural An­ thropology. New York, Holt, Rinehart and Winston, 1972 healers, either explicitly or implicitly, base their 4. Porvaznik J: Traditional Navajo medicine. GP work on the realization that, if certain obstacles 36:179, 1967 5. Waters F: Masked Gods, Navajo and Pueblo Cere­ are removed, the person himself or herself will do monialism. New York, Ballantine Books, 1950 the healing. The actual content of each system de­ 6. Kaplan B, Johnson D: The social meaning of Navajo psychopathology and psychotherapy. In Kiev A (ed): termines which sort of obstacles are considered Magic, Faith and Healing. New York, The Free Press, 1964, important. In chiropractic terms they may be spi­ pp 203-229 7. Frank JD: Persuasion and Healing. Baltimore, Johns nal subluxations; in Christian Science they may be Hopkins University Press, 1973 misunderstandings of the gospel message; in nu­ 8. Cassell EJ: The Use and Function of Language in Medicine, audiotape. Ithaca, New York, Cornell University tritional counseling they may be vitamin deficits of Medical College, 1978 one sort or another. 9. Hufford D: Christian Religious Healing. J Opera­ tional Psychiatry 8(2):22, 1977 Reductionism limits the factors considered im­ 10. Illych I: Medical Nemesis. New York, Random portant in illness and, therefore, prevents under­ House, 1976, pp 127-132 11. Cassell EJ: The Healer's Art. Philadelphia, JB Lip- standing of what nonmedical healers can do. Since pincott, 1976, pp 25-46 factors not considered important by reductionist 12. Szasz T, Hollender M: A contribution to the philos­ ophy of medicine. Arch Intern Med 97:585, 1956 medicine may lead to illness, the high technology 13. Bertalanffy LV: General Systems Theory. New York, medical care system fails to address many sources George Braziller, 1968, pp 205-221 14. Engel G: The need for a new medical model: A chal­ of ill health in this society. This partially explains lenge for biomedicine. Science 196:129, 1977 why we are “doing better and feeling worse” in 15. Wildavsky A: Doing better and feeling worse: The political pathology of health policy. Daedelus 106(1): 105, the United States today.15

THE JOURNAL OF FAMILY PRACTICE, VOL. 10, NO. 1, 1980 61