By Eleanor Hummel

Introduction

Complementary and alternative medicine (CAM) have been practiced for generations, particularly within the American South. It has developed into a rich tradition, incorporating home remedies, religion, and race. One of the driving forces behind the prevalence of CAM is a lack of trust in the traditional doctor-patient relationship. People are more likely to seek care where they feel the most comfortable, and for many people in North Carolina, that place is the Church or their family rather than a hospital (Astin). Using the Stories to Save Lives Archive and supplementary research, this paper will explore the ways in which trust continues to influence people to pursue CAM and how mistreatment has increased medical mistrust amongst marginalized communities. In order for medical professionals to provide the most effective care to all demographics, they must adjust their level of authority and focus on creating a sense of shared decision-making in their practice.

The Doctor-Patient Relationship

To understand the use of CAM, it is important to first understand the doctor-patient relationship. To many social scientists, the way this relationship has historically functioned is paternalistic. It perpetuates the belief that a patient’s physical symptoms are the only factors that affect their well-being. By relying strictly on diagnostic tools and technology to uncover a patient diagnosis, a vital part of the process is left out: building rapport (Porter). A physician’s willingness to give up authority, listen to the patient narrative, and develop shared decision-making models can drastically influence a patient’s perception of their recommendation and final diagnosis. (Katz) In shared decision-making, patients have the right to contribute to their treatment plan and are more likely to feel like their provider cares about them. If patients trust their provider, they will feel that everything is being done to help them, even if their condition is uncurable.

This sense of trust and shared authority is especially important when looking at CAM use, as it is largely driven by personal factors and a lack of trust in traditional biomedicine. When a recent study surveyed Americans on why they used alternative forms of medicine, it found that most people use it because it aligns better with their moral and philosophical beliefs (Astin). Particularly in environments such as rural North Carolina, casual conversation, the patient narrative, and humanized care are key factors to encouraging use of the traditional medical system.

Across the United States, medical establishments rely on patients having an ingrained respect for medical professionals. Many assume that when people fall ill their first instinct is to contact their primary care doctor. Yet, for rural North Carolinians, this is not always the case. Families do not have the same history of relying on medical professionals because of the distance between care facilities and their homes, affordability, and the existence of alternatives like religion and home remedies.

“There were eleven kids, and we never went to the doctor, ever. If we got a cold or anything was—upset stomach or whatever, it may have been a virus, whatever, she would have us go out and pull or cut branches off of trees.” (Holt)

For Nancy, she was always taught to be weary of the medical establishment. Moreover, there was simply never a culture of going to the doctor in her home of Alamance County, North Carolina (Holt). This skepticism and hesitation surrounding biomedicine increased the use of religious and home remedies. Thus, the understood authority of the medical establishment and trust in doctors was not taught to her, creating a rift in the doctor patient relationship and encouraging the use of CAM later in life.

A History of Harm

It is not simply a culture of disuse and skepticism surrounding the traditional medical establishment that perpetuates CAM use in the South. Because of traumatic events, trust has slowly been eroded in these rural and marginalized communities. Throughout the nineteenth and twentieth century, North Carolina had a series of racist medical practices, including widespread sterilization of young Black women and racially motivated lunacy trials where Black people were wrongly convicted. In fact, the North Carolina Eugenics Board endorsed targeting Black communities in forced sterilizations until the late 1970s. (Price) This is in addition to the racist medical practices that existed during slavery and CDC-sanctioned studies like the Tuskegee Syphilis Study, which infected Black men with syphilis without their consent. The policies of North Carolinian doctors and medical professionals have inflicted trauma on Black patients and other marginalized communities, damaging trust. Today, medical bias continues to exist, and Black and otherwise marginalized populations continually receive worse care. For instance, in Black Man in a White Coat, psychiatrist, Dr. Damon Tweedy, describes the disparities he noticed in care, the dangers of race-based medicine, and the way he was taught “being Black was bad for your health” (Tweedy). North Carolina’s history and on-going use of racist medical practices is intrinsically linked with the current mistrust in the system.

Distrust Fuels CAM Use

This distrust has led many in the Black community and other marginalized groups to pursue CAM and religion as alternatives to the traditional medical establishment. This shift is evident in Stephanie’s description of her mother and father’s views of care. In fact, her mother was subjected to multiple unnecessary and racially driven operations (Atkinson). During elementary school, her mother and other Black students were targeted and subjected to unnecessary dental work.

“When she was in school, that they sent a paper home to her parents and that what they said was, is that they wanted to pull these teeth as a preventative—because they could potentially get cavities at one point. And there was actually nothing even wrong with the teeth, and because her parents didn’t know any better, they signed the form and they removed a lot of teeth that really didn’t need to be removed.” (Atkinson)

Operations such as this made her parents wary of the traditional medical establishment and more likely to pursue CAM. It also ingrained distrust and trauma surrounding the medical establishment into the family.

“So my mom, I think my mom and my dad, just based off what I can recall,they did a lot of home remedies. So there were a lot of things when we were growing up, “Oh, just drink some honey,” and, “Just mix this.” And even still, probably five years ago, my grandma had this concoction that was some type of alcohol with a banana peel, and that was supposed to be for arthritis and leg pain and she was swearing by it, like, “This works.” She was dropping off bottles to everybody, like, “Try this if you’re having pain.” (Atkinson)

To Stephanie’s family, their cures and past experience seemed more reliable than a physician who had consistently been dishonest with them (Atkinson). For them, home remedies and CAM use were necessities.

This damaged trust and history of systemic racial trauma in the medical field is not limited to Stephanie’s family. Crystal, another Black woman, discusses mistrust in the medical establishment because of racial trauma and financial insecurity. Because she lives in a food desert far from grocery stores and does not have insurance, doctors assume that she does not care about her health and treat her worse than other patients (DeShazor). Additionally, she faced racism during childbirth and when seeing a cardiologist. Providers continually assumed she was lesser because of her race (DeShazor). Because of this, she has little trust in the system and prefers to rely on her religion and home remedies. For instance, she uses water to treat high blood pressure. Her story is indicative of financial and racial discrimination motivating people to choose alternative forms of care. She also notices this pattern amongst her patients and notes how transportation, affordability, and discrimination prevent people from receiving adequate medical treatment.

Crystal and Stephanie’s stories are a reality for many Black people in the North Carolina. The past and present medical trauma has driven many marginalized communities to use CAM. For marginalized populations, reliable alternatives simply do not always exist. In a recent article, it was found that discrimination in the healthcare field has fueled in equity and poor health outcomes for generations. According to the data, these discriminatory and racially motivated practices directly correlate with a high usage of home remedies amongst Black populations (Shippee). This usage has grown as populations have aged. In one study, 100% of the Black participants used at least one type of home remedy. Many participants used similar treatments, including honey, vinegar, baking soda, and lemon (Quandt). This shows the extent of CAM use in these populations, and how it is linked to patient trust and poor doctor-patient relationships.

Concluding Remarks

It is important to consider that trust and barriers to trust like systemic racism are not a perfect explanatory model for CAM use. As seen in this piece, other factors, such as living in a food desert, not having insurance, and transportation, limit people’s ability to access care. There are both physical and emotional hurdles outside of reliability that prevent patients from going to their physician. Yet, trust, especially amongst rural and marginalized communities, remains an underlying issue. It exaggerates other barriers to care and reduces doctor’s cultural authority, especially amongst marginalized populations.

However, doctors and other health professionals can modify their approach to medical care in rural and diverse communities to foster trust. As described by Katz, there must be shared models of authority in which the doctor and the patient are active in the treatment process. Health professionals must also be trained to engage with this model and build rapport with patients from different backgrounds. This could look like cultural competency trainings, or it could be changes to medical school curriculums to encourage dialogue in addition to diagnostics. Doctors should also make an effort to understand a patients’ explanatory models. As described by Atkinson, explanatory models are, “the notions that patients, families, and practitioners have about a specific illness episode” (Atkinson). They help the provider see the humanity behind a person’s illness and take their entire situation into account when creating a treatment plan. By understanding the patient, healthcare professionals are building trust. These efforts to understand patient perspectives show the patient that they are valued by the physician. This mutual interest and shared care will encourage more people to seek a balance of both traditional medicine and CAM when seeking their care. More importantly, it will create a medical environment that is safer and more accepting to all patients, leading to a healthier North Carolina.

References

Astin, John A. “Why Patients Use Alternative Medicine.” JAMA, vol. 279, no. 19, 1998, p.1548., doi:10.1001/jama.279.19.1548.

Katz, Jay. “Sharing Authority: The Willingness to Trust”. The Silent World of Doctor and Patient, by Jay Katz. Free Press, 1984, pp. 85–103.

Kleinman, Arthur. “Conflicting Explanatory Models in the Care of the Chronically Ill.” The Illness Narratives: Suffering, Healing, and the Human Condition, 1988, pp. 121-136, https://sakai.unc.edu/access/content/group/132851ab-32c2-42c8-8a66-0192416dfd3e/Unit%201%20Readings/Kleinman%2C%20Conflicting%20Explanatory%20Models%20in%20the%20Care%20of%20the%20Chronically%20Ill%2C%201988.pdf

Quandt, Sara A et al. “Home Remedy Use Among African American and White Older Adults.”Journal of the National Medical Association vol. 107,2 (2015): 121-9. doi:10.1016/S0027-9684(15)30036-5

Porter, Roy. “Medicine and the People.” The Greatest Benefit to Mankind: a Medical History of Humanity, by Roy Porter, Fontana Press, 1998, pp. 668–686.

Price, Gregory, et al. American Review Of Political Economy, 2021, www.arpejournal.com/archived-issues/volume-15-number-one/did-north-carolina-economically-breed-out-blacks-during-its-historical-eugenic-sterilization-campaign/.

Shippee, Tetyana; Henning-Smith, Carrie; Shippee, Nathan; Kemmick Pintor, Jessie; Call, Kathleen T.; McAlpine, Donna; and Johnson, Pamela Jo (2013) “Discrimination in Medical Settings and Attitudes toward Complementary and Alternative Medicine: The Role of Distrust in Conventional Providers,” Journal of Health Disparities Research and Practice: Vol. 6 : Iss. 1 , Article 3. Available at: https://digitalscholarship.unlv.edu/jhdrp/vol6/iss1/3

Stories to Save Lives. “Stephanie Atkinson – Stories to Save Lives.” Southern Oral History Program, University of North Carolina at Chapel Hill, 25 June 2018, dc.lib.unc.edu/cdm/compoundobject/collection/sohp/id/28268/rec/316. Accessed 2 May 2021.

Stories to Save Lives. “Crystal DeShazor – Stories to Save Lives.” Southern Oral History Program, University of North Carolina at Chapel Hill, 22 October 2018, dc.lib.unc.edu/cdm/compoundobject/collection/sohp/id/28268/rec/316. Accessed 2 May 2021.

Stories to Save Lives. “Nancy Holt – Stories to Save Lives.” Southern Oral History Program, University of North Carolina at Chapel Hill, 13 June 2018, dc.lib.unc.edu/cdm/compoundobject/collection/sohp/id/28268/rec/316. Accessed 2 May 2021.

Tweedy, Damon. Black Man in a White Coat: a Doctor’s Reflections on Race and Medicine. Picador, 2016.