Culture-bound syndromes in migratory contexts: the case of Bolivian immigrants

ABSTRACT Objective: to describe the culture-bound syndromes maintained by Bolivian immigrants in the new migratory context and analyze the care processes of these health problems. Method: qualitative research with an ethnographic methodological approach. Sample: 27 Bolivian immigrants. In-depth interviews and participatory observation were the strategies used for data collection. Data were classified and categorized into logical schemes manually and using the ATLAS-ti program v.5. Results: susto, “wayras”, amartelo, pasmo de sol, pasmo de luna and pasmo de sereno are some of the folk illnesses that affect the Bolivian immigrants and that they have to treat in the new migratory context. Conclusions: in the new environment, the group under study preserves culture-bound syndromes that are common in their country of origin. The care strategies used for these health problems are adapted to the resources of the new context and based on interactions with the domestic environment, biomedicine and traditional medicine. It was observed the need for the health professionals to realize that the efficacy of certain therapies occurs within the scope of cultural beliefs and not in that of the scientific evidence.


Introduction
Biomedicine builds abiological, ahistorical and acultural diagnoses based on the language of the "empirical". This "language of the concrete" gives them a scientific and objective basis, which confers their universal character. However, when these diseases are built as "culture-specific syndromes" (1) (Culture-Bound Syndromes), their complex etiology, description and treatment prevent them from having a "universal character", which at first, makes them specifically limited to certain geographic areas and cultural spheres.
A culture-specific syndrome arises "when the members of a cultural group or community, by mutual agreement, identify a particular pattern of signs and symptoms, to which they attribute a certain causality, meaning and therapeutics, so that they become entities strongly influenced by the cultural context from which they arise". In such cases, it is common the use of procedures of symbolic efficiency for the recovery of the patient (1) .
Research in the field of folk medicine has made it possible to group a wide variety of cultural diseases: hwa-byungin in Korea (2) , hikikomori in Japan (3) , empacho in Chile (4) , evil eye in the Mediterranean countries, etc.
Mental Health and Transcultural Psychiatry is the field that has dedicated increasing attention to these health conditions and has devoted its best efforts in their classification and categorization (6)(7) .
For some authors, culture bound/specific syndromes cannot be dissociated from their cultural context (8) because their etiology brings together and symbolizes fields of meaning and ground rules of behavior in society. The patient needs to believe in this reality and become a member of a society that also believes in it. Therefore, illness is crystallized into a worldview and the recognition of its reality depends on the degree to which a particular cultural universe is shared. However, what happens when this worldview is not shared?
The social dimension of the disease, or the process of socialization of health problems (9) have, in the case of immigrants, a special complexity since the entrance into a new context represents a great change (10) . This disconnects the immigrant from the cultural environment where the semantic networks and the socially shared definitions of what the disease is or is not emerge. In this environment, where acculturation seems to be an unequivocal destination, how do immigrants deals with these diseases? How does the immigrant community deal with culturebound illness in contexts where biomedicine exercises its hegemony?
The ability to emigrate is one of the distinctive features of our species and is the basis of our evolutionary success, but the intense stress levels in the migration process may compromise the capacity of immigrants to adapt and their health (11)(12) . Regarding the culturebound syndromes, they have been widely studied in the countries of origin, but there are few studies addressing them in the new migratory context (13)(14) The studied group, Bolivian immigrants, are characterized by a great cultural diversity, since Bolivia is one of the countries with greatest ethnic diversity (36 peoples form the ethnic map of Bolivia) (15) . This great diversity creates, depending on the cultural group in which we will focus our observations, a large repertoire of diseases with a cultural origin. This study aims to find out whether the folk illnesses of the Bolivian immigrants coming from the Quechua, Aymara and Guarany/ Guarayo groups, as well as those who do not selfidentify with any ethnic group, are maintained in the new migratory context in Spain. The objective of this study is to describe the health-disease-care processes related to these culture-bound syndromes.

Method
Qualitative research project with a "particularist" or "focused" ethnographic methodological approach, carried out in the region of Murcia, in the Southeast of Spain.
Participants were Bolivian immigrants living in the Region of Murcia. The inclusion criteria to participate in the study were: length of residence in Spain of at least two years, minimum age of 18 years, consent to participate in the study.
This research is based on some theoretical assumptions of Anthropology, such as the "self-care" (16) , in which the individual interprets its illnesses and makes an articulated use of different care strategies. The study of these concepts requires two essential strategies for data collection: in-depth interviews and participatory observation.
During the interviews, in order to limit the topics of interest, a series of broad questions was designed and a first script was defined, which was later remodeled as the theoretical sample profile changed. The interviews ranged in duration from 30 to 60 minutes. The participants' comments transcribed in this study are part of the interviews, the letter E refers to "Interviewer" and the letter I refers to "Informer".
In total, 27 interviews were conducted, 16 with women and 11 with men, and they were carried out by the main researcher of the project who has previous experience in the area of qualitative research. The age range of the interviewees varied from 21 to 55 years www.eerp.usp.br/rlae  Table 1.
Participatory observation was carried out in markets, call shops, cyber cafes, grocery stores and public places, such as parks and gardens in different localities. The main researcher maintained close contact with a Bolivian family for a month, which allowed her to gain a deeper understanding of the domestic life and the self-care patterns of the group. This close contact also allowed expanding the relationship with more Bolivian immigrants, making it possible to collect data in other scenarios: other domestic environments (this time, discontinuously), bars, restaurants, discos, etc. It was also possible to watch various events and celebrations of the families (birthdays, baptisms and various celebrations) or community (celebration of the day of the pacha-mama). Therefore, "snowball" sampling was the most used method during the research, although at the end of the study, when part of the data had already been analyzed, priority was given to a theoretical sampling whose selection of informers occurred in a more selective way.

Susto or fright
According to the concept of human being typical of the cultural and linguistic groups Quechua e Aymara, from the Andes, a person is composed of a body and a series of psychic elements that are known "ajayu", "essence", "courage" ou "spirit" (17) .
This category of psychic elements involves a hierarchy. The loss of the main psychic element, "ajayu", involves the death of the individual. On the other hand, if other psychic elements ("essence", "courage" or "spirit") that play a secondary role in the vital force of the individual are lost, the individual would suffer from a condition with a very confusing symptomatology (18) , which can be treated using appropriated ritual practices (19) . The different ways of healing the "fright" in the Bolivian plateau include the intake of medicinal plants (20) and "to call of the lost soul", which is made through rituals of offerings (made by yampiris or yatiris) or through the "white table", performed by the kallawayas, who play other roles in the traditional Andean medicine (19) .
The treatment for the fright in Spain acquires a domestic nature, since the impossibility of contacting any yatiri or kallawaya causes any member of the family group to take on the role of the healer in treating the The fright, or the physical and psychological symptoms triggered by this syndrome, can also be diagnosed and treated by biomedicine (14,17) . In  The "wayra" are a group of diseases carried by the wind, which in the case of the informer, triggered "refusal", boredom and neurological symptoms. In view of this health problem, the informer reports that she went to see a doctor, but she realized that he could not solve her problem. Thus, she decided to see a "Spanish yampiri", who did not heal like the jampiris in her country although he also "prayed". Although the Spanish healer does not invoke or Beni and Santa Cruz. Bolivian immigrants from these regions describe a health problem called "pasmo" that, according to some explanatory models of the disease, it would be considered as an exogenous condition, in which the disease is due to the action of an element (real or symbolic) unrelated to the patient. Newborns are especially vulnerable to "pasmo de luna" and to "pasmo de sereno" because of the weakness of their "fontanelle" (weak bones in the skull).
At the root of this syndrome we find the opposition of two contrary concepts, strength/weakness. Moonlight and dew (night or early morning dew) are perceived as dangerous and especially harmful to newborns, whose skull bones have not yet joined, and are considered too fragile to withstand some natural atmospheric elements.
To prevent the infant from having "broken head", it is necessary to grease its head with "aceite de pata" (neatfoot oil) or with "aceite de cusi" (babassu oil), which is prepared and shipped by the family members who remained in Bolivia. Neatfoot oil is made from cow fat, and babassu oil is made from a type of fruit, calucha or babassu, which is collected from babassu palms or Attalea speciosa and used to treat the cradle cap (infantile seborrheic dermatitis) on the scalp of newborns. These are two traditional remedies used in the Eastern part of Bolivia (Amazonian region) to treat infants and newborns (Figure 1).  The transnational family provides, through these shipments, traditional remedies with a cultural meaning that go beyond their specific function. The sending of food and medicines have a great symbolic value that strengthens the ties of the transnational family because they are related to the sphere of care (21) . Another culture-bound syndrome or culture-specific syndrome is the "amartelo", and this health problem is caused by the distance of a loved one.

Amartelo or sorrow disease
Even from a distance, mothers also take care of their children and to avoid the "amartelo", they tie a thread to the children's wrists or "q´aytu" (thread, in the Quechua language), which they had previously rubbed on their own body, the body of the person who departed.
To prevent their children from missing them, mothers also create symbolic bonds of affection through phone calls and by sending them gifts (21) .
According to some authors, the discourses reporting the sorrow and the struggle for the loved ones, scenery, language, customs, etc., are a constant in the relation mental health-immigration (11,22) , which in this study were associated to the "wayra" and the amartelo.

Therapeutic procedures for the culture-bound syndromes
The informers describe the therapeutic procedures and Virgin Mary). These elements seem to be sufficient for the therapy to be recognized as effective and so that in the destination countries, these immigrants continue to seek ritual healing (24) , even though it does not have the same characteristics as in their original contexts. This shows us the flexibility of our schemes in conceptualizing, explaining and treating a health condition (25) .
In the care sphere, the different ways to

Limitations
The speeches, representations and circumstances of the health sphere have been relegated to the fringe of the analytical axes and, therefore, this work requires further results that reflect the relationship between health professionals and immigrants in the contexts where the culture-bound syndromes occurr.
Culture-bound syndromes also evolve, and globalization makes them less linked to culture and increasingly influenced by cross-border factors, although this aspect has not been evaluated in this study.

Conclusions
In -In the scope of official care services (biomedicine is used to treat the biological aspect of the health problem).
-In the scope of traditional medicine (traditional healers or witch-doctors from Spain are requested). www.eerp.usp.br/rlae