In a world of biodiversity, ecological awareness, and expanding markets for medicinal herbs, it is no wonder that there have been more and louder voices calling for an integration of ethnomedical preservation with environmental conservation.(1,2,3,4) Successes in this area could have lasting value for humanity as a whole.(5,6,7,8) Voices calling for preservation of indigenous knowledge now include discussion of ownership, noting that the peoples who originally research and develop medicinal plants are rarely included once profits begin to accrue.(9,10,11)
From Chiapas to Panama, indigenous peoples struggle to preserve their linguistic, cultural, and ethnomedical traditions.(12,13,14,15) Guatemala, with 22 Mayan languages and more than 50 percent of its population indigenous, is home to a series of efforts to document and preserve plant knowledge.(16,17,18,19) Studies from Belize, Honduras, El Salvador and Costa Rica have likewise contributed to medical ethnobotany.(20,21,22,23) Still, and I admit that my viewpoint is biased, Nicaragua, and particularly Nicaragua's Atlantic Coast, may be the most promising area for the study and preservation of traditional medicine.(24)
Nicaragua's Atlantic Coast stretches nearly 300 miles from Costa Rica to Honduras, and is divided geographically into the North and South Atlantic Autonomous Regions. "The Coast" comprises more than half of Nicaragua's territory but is home to less than 10 percent of the nation's people, about 400,000 in all. Six distinct ethnic groups deriving from Africa, Europe and the Americas live in the region. Mestizo (Ladino), Creole (Afro-English), and native Miskitu are the most prominent. Sumu are the most traditional Native Americans, Rama the least populous. Garífuna (Afro-Indian, also known as Black Carib) are perhaps the most interesting, anthropologically, as they derive from African and Red Carib Americans, with bits of French, English, and Spanish in their culture and language.
Subsistence is for the most part based on fishing and slash-and-burn agriculture. Shrimp, crab, fish and turtle complement starchy staples -- corn, rice, plantain, cassava and dasheen. Water permeates all, with several meters of annual rainfall swelling streams into rivers, pouring into lagoons and mixing through mangrove littoral to the omnipresent sea.
The people of the Coast -- the coste¤os -- have developed their ethnomedical traditions over centuries, perhaps millenia. Boom-and-bust economies and a series of armed conflicts have left their mark on politics and culture, yet ethnomedicine has survived relatively intact. The coste¤os have shown that they are more likely to adopt a new health behavior than they are to lose an old one.(25) During the 1980s, the expansion of health care services allowed coste¤os better access to modern medicine, but this trend did little to diminish the respect for or use of traditional practice. In fact, as modern medicine became more available and less costly, it may have lost some of its symbolic power. And, as minority ethnic groups rediscovered their cultural heritage, traditional practices gained in favor. As a result, there is today a thriving tradition of ethnomedical practice among the various peoples of Nicaragua's Atlantic Coast.
THE HERBS
Serendipity often acts as master of ceremonies. In the summer of 1988 a duffel bag was stolen en route from Managua to Bluefields. The bag contained 500 copies of a public health survey that I had brought from Wisconsin to Nicaragua in the hopes of gathering data useful both to the regional health ministry (MINSA-RAAS(26)) and to my efforts to gain a doctorate in anthropology. On hearing of the loss, the regional director for MINSA-RAAS asked me to help analyze medicinal plant data, data that MINSA-RAAS had collected during interviews with traditional healers from 1986 to 1988. I spent the next four months analyzing the data already collected, interviewing healers on my own, and helping the head of MINSA-RAAS's. Division of Education and Popular Communication write a report, a report which was finally published as a booklet in 1992.(27) The report was finished just as Hurricane Joan (Juana) swept in from the east, reducing 90 percent of the structures in Bluefields to rubble. I helped nail a few walls and roofs together, then returned to Wisconsin.
My second major venture to Nicaragua's Atlantic Coast began in October of 1989. Armed with 800 copies of a new-and-improved public health survey, I arrived in Bluefields with a growing interest in medicinal plants. Over the next 10 months I kept busy looking into both traditional and modern aspects of the pluralistic(28) coste¤o health system. The 1986-88 MINSA-RAAS research had revealed a list of 109 identifiable botanical herbs and 1,504 individual plant/illness associations. My 1990 survey resulted in a list of 2,135 plant/illness associations and 162 identifiable plants, only 77 of which had been named in the MINSA-RAAS project. Combined with two smaller previous investigations,(29,30) there is now documentation of the use of well over 200 medicinal plants on Nicaragua's Atlantic Coast.
My third major venture to eastern Nicaragua consisted of gathering plant specimens for positive identification and deposition in herbaria in Managua and Madison. This journey took me through villages I was already familiar with in the south-central Coast, but also to Puerto Cabezas in the north and Waspam, a Miskitu village on the Honduran border. More than 300 specimens were collected, pressed and dried, either over a small gas camping stove or a light bulb in a cheap hostel. Letters of support from MINSA and from the University of Wisconsin-Madison allowed me to transport the specimens not left in Managua out of Nicaragua and into the United States. Botanists at UW-Madison and the Missouri Botanical Gardens were gracious enough to assist with identification and mounting.
Although many of the plants identified are used medicinally in other areas of Latin America and the Caribbean, there appear to be several unique to this region. As might be expected, certain plants are used for specific illnesses by nearly everyone, while others are used exclusively by one ethnic group for one disease. Table 1 lists all medicinal plants mentioned to me by at least 10 informants. Table 2 portrays these plants in more detail, with common names in several languages, parts of plants used, and specific medicinal uses.
The diversity of medicinal properties attributed to eastern Nicaragua's flora makes it difficult to predict which plant or plants would be most interesting to study, either from an ethnomedical or a pharmacological point of view. Of the common plants, soursop (Annona muricata) and sorosi (Momordica charantia) were attributed the widest range of medicinal properties. Soursop was said to be useful in the treatment of 16 different ailments by 114 informants, while sorosi, mentioned by 65 people, was attributed 9 different medicinal uses.
Guava (Psidium guajava), lime (Citrus aurantiifolia) and malva (Malachra alceifolia) were ascribed more limited medicinal properties. About half of the 147 people mentioning lime as a medicinal used it for diarrhea, while an additional 42 said it was useful for bellyache. Fully 29 of the 35 informants mentioning malva said it was useful against headache. Forty-four of 57 people mentioning guava described its use in treating diarrhea.
Christmas blossom (Senna alata) was mentioned as a medicinal plant by 120 informants. Almost half of these described its use as a purgative. Another 26 said it was used for the kidneys, while 27 mentioned its utility against various skin diseases. Following similar information gathered in 1986, MINSA-RAAS chose Christmas blossom as its first plant of clinical study. A double-blind clinical trial of the efficacy of a leaf extract against skin fungal infection was begun in 1987-88, but the destruction of the Bluefields health center and the MINSA-RAAS building by Hurricane Joan in October 1988 stopped the experiment in midstream.
Evidence of clinical efficacy and/or pharmacological activity consistent with indigenous use can be found in the scientific literature. Back in Wisconsin, David Kiefer and I used NAPRALERT,(31) the world's largest data base on medicinal plants, in order to track down relevant findings and references.(32) Of the 162 plants identified in my research, 67 showed similar uses throughout the world, Some 34 had been studied in the laboratory and/or clinic, usually with results supporting their usage in eastern Nicaragua.
Soursop, for instance, is used for childbirth in the Dominican Republic 33 and Curaçao(34) as well as in eastern Nicaragua, and has been shown clinically to have a uterine stimulant effect.(35) Sorosi, used for pain and for diabetes in my survey (and in many other regions of the world), displays analgesic and hypoglycemic activity in the lab.(36,37) Guava is used throughout the world to combat diarrhea, and has been found to decrease intestinal smooth muscle activity, thereby alleviating abdominal symptoms.(38) Christmas blossom, as a final example, is used as a cathartic or purgative in places as far removed as Tanzania(39) and Mexico,(40) and has been shown to have a laxative effect in randomized blinded clinical trials.(41)
There are many more examples, but the point that traditional use of plant medicines may be supported by scientific investigation should not come as a surprise to readers of HerbalGram. What might be of interest, however, is the complex and interactive nature of the cultures and individual healers using those plant medicines.
THE HEALERS
Traditional healers on the Atlantic Coast of Nicaragua are known as curanderos, bush doctors, and sukyas, terms respectively from the Spanish, Creole English, and Miskitu languages. The terms are usually interchangeable, and more often than not are used by people outside of their language group. For example, one Miskitu healer I know calls himself a curandero, while the premier Garìfuna healer is known as sukya, a Miskito term. In addition, healers are sometimes called science men or obeah-men, the latter a term deriving from the somewhat prevalent belief in Caribbean-derived obeah.
Most, but not all, healers take care to differentiate themselves from modern medicine. One traditional healer I know calls herself a pediatrician (pediatra). She assumes the manners and some of the terminology of Western medicine, but treats her patients, mostly children, with herbal remedies. She says that she used to practice obstetrica, but got tired of the unpredictable hours that accompanied attending childbirth.
The most widely known Miskitu sukya shared with me the following words concerning his initiation to healing:
"For awhile I was sitting down like this. I get up. Can't sleep now...I see plenty lightning. I feel funny in my body. For awhile I see that house, it just like catch afire...Then I hear that thunder. And it hit me. I was standing in that door. And it hit me from that door. I went right in that room. It shoot me right in that room. I dead. Done. I don't know which part I went. Until eight days time...So I get up, and I heard a voice, says:
`Now you will try to help your people...All these things I bring for you. But I cannot give you everything. So I give you half that you can help your people. Without price. Try to help your people and your people will try to help you.'"
In this quote, the medicine man describes how as a youth he was hit by lightning, thrown into a coma-like sleep, contacted by a spirit-man, saved from the coma, and allowed to return to normal village life. He was thus initiated into the role of healer in his small lagoon-side community on the Atlantic Coast of Nicaragua. For almost 60 years since he has worked as a healer, and has built a widespread reputation as a skilled and honest man. He usually asks his patients to sleep a night in his home while he waits for advice from the spirit-man in his dreams. The dream spirit-man wears pretty, silver-like clothes, sports a golden cross around his neck, and comes with specific orders about the treatment of patients. This healer's pharmacopoeia includes dozens of plant-based treatments applied in the form of vapor baths, "anointing," and various teas and potions. Other options include patent medicines, referrals to other healers, or advice to visit the doctor or nurse at the nearest health center.
Another well-known healer, a Garífuna called by the Miskitu word sukya, told me about his medicine stone:
"Sometime the thunder light and bust the earth. And you go and find it...You use the thunderbolt. A rock. When the thunder light he left that rock. And you use that rock. You cook the rock and take the water...You drink it...It cure all kind of sickness. A baby born and it no healthy. Bathe him with that. And he get fat."
In this quote the healer describes his palm-sized "thunderbolt stone." Thunder stones are known throughout Central America's Caribbean Coast, and are thought by archaeologists to be ancient Mayan hand axes. This healer found his stone when he was young, and emphasizes that it takes special properties to recognize and use a thunder stone. To protect its powers, he keeps it hidden from sight and away from menstruating women. Unlike the first man introduced, this healer usually charges for his services. For a small charge, he will make up potions to increase his patients' luck or to ward off enemies, bad spirits or accidents. And, unlike the first, he was trained by a great healer, his grandfather, rather than being called by the spirits. However, he is visited in his dreams by Garífuna ancestor spirits, who help him make decisions about his curing practice.
A third and final quote from a Creole healer: "I like to tend babies...Baby make up his face, get a severe pain...The wine, the sorosi (Momordica charantia) kill the fever and it give appetite and at the same time it bring up the blood...As long as the blood is up, it can fight any sickness, but if the baby blood poor, it can't fight no sickness...Some children strain for what you call the breeze...the strength of a person strain...Sometimes I use the cobweb with the baby navel string, the same navel string what drop. Boil the cobweb with it." This quote from a Creole midwife names four healing agents -- wine (homemade), the medicinal plant sorosi, cobwebs, and umbilical cord. This quote also demonstrates the power of "strong blood" to prevent or cure illness. This healer has delivered more than 50 babies in her 16 years as a lay midwife. Although she prefers to work with women during childbirth and with young children, her knowledge of herbal medicine has occasionally been applied to older children and adults. Sometimes people pay her, but it is not a requirement for treatment. She has a strong belief in bush medicine, and thinks that in most cases it is superior to doctor medicine. She does not receive any help from spirits or her dreams. THE ILLNESSES In general, there are three lines of defense against disease. Herbal-based home remedies are the first level in the "hierarchy of resort."42 For more acute illnesses with perceived physical causes, an initial trip to the health center or hospital may be in order. If home remedies fail, a patient might instead elect to go to a curandero, especially if witchcraft, sorcery, or malevolent spirits are suspected. Healers might begin with simple herbal treatments for suspected natural causes, then proceed to magical or spiritual interventions if necessary. People living in rural areas tend to resort to traditional healers more readily than their counterparts in Bluefields. Doctor medicine is usually seen as complementary to herbal medicine. Patients often choose to use both. Theories of disease causation are plentiful on the Coast. Belief in temperature as an inherent "humoral" quality of an object, food, drink, illness, or medicine is widespread, especially among the Mestizo population. Taking a cold drink or bath after working up a hot sweat is thought to be dangerous to the health. Excess of one extreme may also be hazardous, such as drinking rum (symbolically hot) when upset or sweating (also hot). Hot illness such as kidney disease or diarrhea must be treated by cold medicine. Hot and cold sponge baths are common treatment modalities, and are used to counteract opposing temperature illnesses, and to drive out the diseases. The hot/cold syndrome, known also as "humoral medicine" is prevalent throughout Latin America, and has been described by various authors.(43,44,45,46) The idea of illness as a physical agent inhabiting the body is also widespread. Speaking of what she can cure, one Creole healer said, "And maybe a simple measle. You make bath also. And bathe it and it come out. It doesn't keep in. It does throw it out." Objects that symbolize disease are sometimes regurgitated or defecated. A Creole healer who specializes in using blessed wine as a medicine reported a patient who first "passed yellow corn (and then the healer) gave him another shot of wine, when he hock up a little fish." The fish was still alive, and was blamed on a jealous adversary, who sent a devil as an animal, into the body of the patient. "The devil was into her...God stronger than the devil...They drunk the wine and they done throw it up or pass it out. It have to come out...Sometime it be a fish, sometime it be some kind of animal...A little turtle, toads, spring chicken they call them, in the swamp...the wine throw it out." Although certain diseases are known to be contagious, there are various explanations for this phenomena. Microbial germ theory is recognized by some of the lay population as well as by most of the biomedically trained health workers. Dirt and contamination are thought by many to be involved in disease causation. Aerial transmission is also postulated. One healer noted, "Sickness go through the air. It comes like a heat...like a smoke it comes all around, and whenever that sickness drop, it extend. It extends in that town and it kills everybody there...They have a sickness we call the gastro. That gastro come down just through the air." Certain syndromes recognized in other areas are also found in RAAS.(47) Mal de ojo (evil eye) is recognized throughout Latin America.(48,49,50) This syndrome is characterized by the ability of a strong, drunk, or agitated person to infect or damage an infant merely with his or her gaze. This syndrome is usually characterized by fever. In RAAS the phenomenon is recognized, but is usually referred to as calor de vista (heat of the sight). (Mal de ojo refers to actual eye disease on the Coast.) The fever resulting from calor de vista can be treated by chewing ruda (Ruta graveolens) and tobacco, and spitting the residue over the patient.(27) Aire is another widely recognized disease category in Latin America.(51,52) Aire is characterized by pains, usually in the neck or the back, often caused by cold or bad air entering the body. Various types of aires are recognized, depending on the state of the patient and the location of the pain. Herbal treatments documented by MINSA-RAAS include a tea made from hoja de aire (Kalanchoe pinnatum) and altamiz (Ambrosia psilostachya), and a poultice made from breadfruit (Artocarpus altilis). My own research revealed a multitude of treatments for aire, including extracts of albahaca (Ocimun campechianum), Christmas blossom (Senna alata), cilantro (Eryngium foetidum), ginger (Zingiber officinale), and mango (Mangifera indica). For certain syndromes localized to RAAS, traditional medicine is the preferred treatment. "Grisi siknis" and "bulpis" are known only to the coste¤o people. "Grisi siknis" described by Philip Dennis(53) as a Miskitu culture-bound syndrome, is a spirit-induced episode of abnormal behavior. I found variants of grisi siknis (crazy sickness) in Garífuna and Sumu as well as Miskitu populations.(54) In biomedical parlance, the syndrome is manifested by a sudden onset of loud, aggressive behavior, associated with visions and/or auditory hallucinations. In popular description, the illness is caused by spirits of the woods, the water and the wind, and can only be cured by traditional methods. "Bulpis" is a skin disease thought to be caused by ingestion of a poison. Whitening of the skin is the primary sign. Reportedly, the perpetrator uses the urine of a toad and various botanical extracts to create a potion, which is surreptitiously placed in the victim's food or drink. Knowledge of the exact preparation is said to be known only to a few. Special remedies are known to curanderos and bush doctors. Bulpis is recognized by Mestizo, Creole, Miskitu, and Garífuna populations. A physician who grew up in the area believes that there may be a plant or animal-derived substance that can cause an allergic skin reaction when administered internally. Other, more biomedically inclined persons, say that bulpis is merely the result of a particular skin infection, usually attributed to the spirochete bacterium Treponema carateum.(55) Abdominal pains take several different forms in RAAS. "Colic," "spasm," and "bad belly" are abdominal syndromes known to Creoles, the first two characterized by pain, the latter by nausea and diarrhea. Empacho and maleficio are syndromes that may manifest as stomach pain and are known primarily to the Mestizo. Maleficio is sometimes thought to be a personalistic, or malefactor-caused disease, associated with jealousy or "personalistic" magic. Yumu is a syndrome characterized by abdominal pain and known primarily to the Miskitu. Sorosi (Momordica charantia) and kina/sweet stick (Cinchona spp.) were mentioned to me as treatments for yumu. Yumu is known throughout Honduran and Nicaraguan Miskitu populations, and is thought to be caused by the spirit of an animal that has entered the body of a sick person.(56) SPIRITS, SORCERY OR PSYCHOLOGY? Mental illness is often thought to be caused by spirits or sorcery. Susto, a syndrome characterized by fright,(57) is known throughout Nicaragua. One informant said that lulabakbak (Piper jacquemontianum) can be used to treat susto. Sorcery-induced mental syndromes usually are said to come from outside the village. Jealousy and spite are the primary motives. According to a Garífuna curandero known to be especially good with mental illness, enemies "set the devil with you...and he stay with you...and get you running all around...and curandero he work on you and he take away that devil...and you get cured. They say it be science. They also use poison. Is different from science." Diagnosis involves giving a medicinal plant to the patient and observing the results. "If he start to move heavy, you got the devil in you." Treatment includes the use of eight medicinal plants and a special diet. "A crazy person don't want to eat a chicken...Chicken gonna scratch you and then you gonna jump more." Certain fish are prescribed. "They dry and they calm fish so they keep steady. So you become calm when you eat of that." The Garífuna especially believe in spirits as a cause of sickness. Spirit-induced illnesses are said to come from the ghosts of ancestors. Spirits of a patient's dead parents are often implicated. A healing ritual known as walagayo can be called for an especially severe illness. The walagayo is an elaborate three-day event that occurs only rarely. The last walagayo was in the spring of 1990. It was an elaborate three-day ritual characterized by drumming, dancing, consumption of Garífuna food and beverage, and animal sacrifice. Accounts differ, but it seems that walagayo have been held every two or three years, on the average, for most of the 20th century. The sukya of the Garífuna must receive instructions from ancestor spirits in his dreams. The spirits will announce that a walagayo should be held, and the family or friends of the patient must pay for the event. Large quantities of food and drink are required. Three special drums are beaten for 24 hours to begin the ritual. A rattle known as a sisira is used by the sukya. "I's the man shake the sisira...That is the thing who control the walagayo. You make it make it. Is a shake shake. But you make it yourself." If the walagayo is successful the patient is cured, and gets up to dance with a chicken before the event is over. The walagayo is similar to Garífuna healing rituals observed in Honduras and described by various authors.(58,59,60,61) Interactions between traditional and modern medicine can be complementary or adversarial, results beneficial or disastrous. In general, biomedical and traditional explanations of illness are not thought incompatible by the population, but instead are integrated into a coherent framework. Explanations that would be deemed mutually exclusive by Western scientific standards are held as mutually supportive components of an integrated belief system. A REVOLUTION IN HEALTH Improvements in Nicaragua's health care system following the triumph of the 1979 revolution have been widely applauded in the literature.(62,63,64,65,66,67) Infant mortality was reduced from over 100 per thousand to under 80 per thousand in less than five years. Immunization programs involving tens of thousands of volunteers (brigadistas) eliminated polio and drastically reduced measles, tetanus, tuberculosis and whooping cough. Malaria was significantly reduced by a unique program of mass drug administration. Several-fold increases were made in medical and nursing education. Training emphasis was shifted toward primary and community health care. In many ways, Nicaragua created the beginnings of a model system. However, early gains slowed, obstacles emerged, and eventually, the revolution in health was largely dismantled. Although this process was accelerated by Violetta Chamorro's election victory in 1990, it was well under way during the last few years of the 1980s. The U.S.-sponsored Contra war left many direct and indirect scars on the Nicaraguan health care system. Health care workers and medical facilities were consistently targeted by Contra violence.(68,69,70,71) Indirectly, the war and the economic embargo placed severe restrictions on the Nicaraguan economy, resulting in reduced health expenditures, and, eventually, a deterioration of Nicaragua's health care system.(72,73,74,75) Austerity measures first instituted by the Chamorro government in 1991 have nearly completed the dismantling of public health in Nicaragua. ETHNOMEDICAL REVITALIZATION During the 1980s a national program emerged that aimed to integrate traditional and modern medicine. Although an early attempt at investigating the use of medicinal plants was begun in Bluefields in 1981, it was not until 1985 that the "Rescue of Popular Medicine" was created. First in Esteli, then throughout the country, systematic and continued efforts at investigating the use of medicinal plants were initiated.(76,77) Some 845 secondary school students carried out more than three thousand surveys in 26 districts in 1985 alone.(78) Three hundred forty-five different plants were found to be used frequently as medicines. The most important of these were detailed in books published by the Ministry of Health, along with descriptions of their use against various illnesses.(79,80) On the Atlantic Coast a survey of traditional medicine was accomplished in 1986-87, and a regional conference was held in which traditional healers exchanged ideas with biomedical personnel. The healers were presented with certificates, more than one of which were proudly displayed to me during my work. Results of these investigations have been used to improve health care throughout Nicaragua. In 1992 the National Center for Popular and Traditional Medicine published the Manual of Medicinal Plants for the Promotion of Preventive Medicine and Community Health.(81) Plants with low toxicity and probable clinical efficacy are promoted. Through the use of seminars and printed materials, medical personnel are gaining greater understanding of patients' belief systems, as well as of botanical medicine. These efforts may help decrease the overuse of expensive and potentially toxic pharmaceuticals. Hopefully, the beginnings of an integrated health system will emerge.(82)
HISTORICAL INTERACTIONS On Nicaragua's Atlantic Coast, indigenous (Miskitu, Sumu and Rama) ethnomedicines have interacted and blended with those of the Euro-African invaders and immigrants (Spanish, English, Creole, Mestizo and Garífuna) for almost 500 years. Some experts say that the Miskitu culture itself is largely a post-contact phenomenon.(83,84) Health-related beliefs and practices developed interactively, and have repeatedly borrowed from, lent to, and influenced each other. Blacks and Creoles arriving both as slaves and free over the past centuries brought with them strong roots in African tradition. The Garífuna retained their own ethnomedical beliefs and customs when they first arrived in Central America in 1797, and later when one group moved to Nicaragua from Honduras around the turn of the present century.(85,86,87) Military doctors, ships' surgeons, and other medical representatives of Euro-American colonialism sometimes accompanied the traders, raiders, and colonizers that plied the Mosquito Coast. These influences combined to form a complex and dynamic regional network of beliefs concerning health and illness. The 1979 revolution brought a unification and expansion of the nation's health care system. Professional and volunteer health care workers were sent in large numbers to the countryside.(88) Hundreds of new health posts and a few larger health centers were established. In RAAS this meant the construction of additional health centers in rural locations, and a tripling in the number of physicians. A new hospital was built in Bluefields in 1982. Volunteer health care workers (brigadistas) were trained and equipped with basic medicines. By 1983 some 250 brigadistas operated in 135 communities.(89) Especially important to an understanding of health and medicine in RAAS, in Nicaragua, and throughout the developing world is a recognition of ethnic differences between the biomedical practitioners and the population at large. The Atlantic Coast of Nicaragua has remained isolated from the Pacific Coast for most of its history.(90,91) British colonization followed by North American exploitation of lumber and mineral resources left a cultural and linguistic legacy.(92,93) Creole, Miskitu, Sumu, Garífuna, and Rama are more likely to speak English than Spanish. Protestant churches, especially the Moravian, are dominant. Many people identify more strongly with English or North American culture than with the dominant Mestizo culture of western Nicaragua. In addition to linguistic barriers there are ethnic and cultural obstacles. Although hot-cold humoral etiology may be familiar to Mestizo physicians, spiritual or personalistic theories may arouse derision or contempt. Calor de la vista and aire may have been encountered during community service in medical school, but bulpis or a thunderstone may be totally unfamiliar. Lack of mutual understanding, combined with language barriers, can seriously undermine the doctor/patient relationship. Traditional healers, on the other hand, are more in tune with the belief systems of the population at large. They come from the region, speak the language of the people, and understand intimately the norms and values of their patients. They have more time to interact with patients and are not associated with the government bureaucracy. Etiological categories and treatment modalities are mutually understood, providing for greater compliance and patient satisfaction. Traditional healers are physically closer to their patients, and are more likely to live in the region's villages rather than in the city of Bluefields. Although more accessible, traditional healers often lack the prestige associated with medical doctors and have less understanding of the biological basis of disease and healing. Modern Euro-American civilization is well known to the people of RAAS through radio and television, and by word of mouth. Modern technology and the advances of science are associated with the biomedical practitioners, enhancing their reputation and creating for them a role in many ways similar to the role of the traditional healer of the past. The socially accepted power to deal with the unknowns of disease has shifted toward the medical doctor, but there remains a strong undercurrent of belief in magic and faith in the power of the sukya, curandero, or bush doctor. Beliefs and practices surrounding the subjects of health and illness are not fixed in time, nor do they come from a single source. Although the roots of the hot-cold syndrome and of germ theory can each be traced to historical Europe, the branches observed today have been molded by countless additional forces. A person experiencing pain in her stomach may drink a homemade concoction of a "cold" plant to counteract her "hot" illness, may go to the Miskitu sukya to banish the animal spirit causing me yumu, may go to me creme bush doctor to drink blessed wine to remove a foreign object sent by an enemy, may go to a curandero to receive herbal treatment for empacho, maleficio, or aire, or may go to the nearest health center to receive antibiotics for a bacterial enteritis. Her explanations for the illness may be multiple, and may or may not correlate with her ethnicity. Her choices within the pluralistic health system depend on her up-bringing and her experience within the multi-eth nic cultural domain of Nicaragua's Atlantic Coast. Thus, traditional and modern medicine can be seen to play complementary roles in the pluralistic system of health care in Nicaragua's Southern Atlantic Autonomous Region. Differing options allow patients flexibility and choice. Contrasting belief systems vie for acceptance in the dynamic processes of sharing, borrowing, and acculturation. Official medicine -- under the auspices of the Nicaragua Ministry of Health -- has only just begun to open its arms to traditional medicine. In return, a few traditional healers have recognized the value of modern medicine. Individual patients integrate concepts and practices from each, as they try to negotiate the complex pathways of health and illness they face. REFERENCES (1.) Akerele, O., V. Heywood & H. Synge, eds, 1991. The Conservation of Medicinal Plants. 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