Apremio personal en materia de alimentos

Introduction and Medical Pluralism

The goal of this chapter is to delineate the breadth of health practices among the Lancaster Amish. Together with the information from the last two chapters, this section will address how key Amish cultural constructions show up in understandings of health and the body.

After introducing the concept of plural medical systems, I will discuss these constructions in relation to incidence of medical use, practitioner choices, and health economies.

Since the 1970s, medical pluralism and the “plurality of care-seeking strategies” have been perennial themes in medical anthropology (Castro and Farmer 2007). In the same period, Arthur Kleinman’s labeling of medical and health practices as cultural systems (1978:85) opened up these pluralities as uniquely suitable for anthropological study. While plural systems have often been conceived as a cosmopolitan versus indigenous dynamic (Leslie 1980), medical anthropologists have frequently investigated the introduction of biomedicine into indigenous systems and attended to the resulting hybrids and pluralities that arise as the medical knowledges and power structures collide. More recently, medical pluralism has come to encompass

additional constructions of plurality including the more recent focus on implementations of medical and health technologies in practice. The study of health modalities, and biomedicine in particular, has to recognize a wide array of concerns including local “priorities about individual and community well-being” (Lock 2007:2). In choosing between medical settings and

technologies, members of a cultural group are faced with decisions, and sometimes dilemmas, as to what approach (or combination of approaches) may be most suitable, most socially acceptable, and most effective in addressing the body.

The Amish have not been suddenly introduced to biomedicine; the concern here is not how new technologies disrupt an indigenous health system. Instead, just as Amish settlements have engaged in other sorts of technological negotiations, use of various medical modalities have been gradually accepted or rejected with the slowed patience of Gelassenheit—that call to

adherents to sacrifice self-interest, to give up personal motivations, to yield autonomy to the

Gmay. Klienman notes that health decisions are typically made in what he calls the “popular arena”— the family, social network, and community contexts of sickness and care (1978:86). This description holds true, but only partially so for the Lancaster Amish. Decisions are certainly made in all of these arenas but normative health practices and the suitability of health

technologies are intensely impacted by Amish collective identities emerging in the practice of mutual separation.

Unlike the prevailing medical context in which biomedicine dominates other medical practices, the Amish pluralistic system reflects mutual separation—their pluralism is a faith- driven, intentional removal from overriding, state-related hierarchies94. Using non-state-favored medical technologies in Amish healthcare results less from a challenge to hegemonic forces and more from intentional separation from the non-Amish cultural currents affecting their

community of practice in other arenas. To put it in terms an Amish person might use, they refrain from indulging in practices that encourage or reward the empires of man: secularism, scientific authority, higher education, and economic excess. Instead, they seek to honor the empire of God.

94 _{This can be seen in compliment and contrast to Baer’s (2004) emphasis on ethnic and class minorities using pluralism to} challenge the dominance of biomedicine and elite hegemony.

Seeking this goal, the Gmay must dictate acceptable relationships and acceptable boundaries that legitimize certain health practices and health practitioners.

Bourdieu characterizes the kinds of social relationships that exist among alternative sources of knowledge and practice such as characterizing health practitioners as competitive fields and as constituting sites of struggle for different forms of power. One thing at stake is the amassed and accrual of symbolic capital that is then used to reproduce the field itself. “Culture,” for Bourdieu, does focus on meaning, but that meaning is fashioned, replicated, and utilized by subjects operating within assemblages of objective fields in everyday life (2006:85). Such fields can be characterized by the struggle for symbolic capital. However, in the case of the Amish, a depiction of Amish medical pluralism as amenable to Bourdieu’s concept of a field of practice begs an important question: in a community that strives toward the rejection of personal power and prestige, does it make sense to imagine that symbolic capital is at stake?

The field of medical modalities that constitute Amish plural medicine emerges in the struggle to achieve uffgevva. This “giving up,” in the spirit of Gelassenheit, aims to create placidity in the community and avoid situations of social inequity; this results in the goal of similarity, the lamination of the individual as first and foremost a personification of the collective, even with regard to bodily dispositions. In other words, the sought-after capital is a state of denying capital any importance, a quiet parity where one is submerged in lamination of the collective whole. The symbolic capital gained by the community through faithful and consistent separation is a tool used by the Amish within their field of plural medicine to gain dominance in economies of the body and thus to reproduce themselves over time.

How, then, is plural medicine a field where Lancaster Amish collective identities are in practice? Fields offer people spaces of a sort within which they can navigate some part of reality.

Fields are spaces of “play and competition in which social agents and institutions which all posses the determinate quantity of specific capital … confront one another in strategies aimed at preserving or transforming this balance of forces” (Bourdieu & Wacquant 1996:76). The field of education accommodates practices of learning, fields of the arts accommodate practices of aesthetics, and fields of medicine are one way to practice moral economies of the body. A first step in sketching plural medicine among early 21st century Amish settlements as a field of cultural practice is to identify the nature of bodily understanding. This certainly relates back to anthropological notions of habitus and embodiment, but more immediately relevant here are ways that bodies are understood as spiritual homes.

The given shape, condition, or characteristics of Amish bodies are a spiritual gift from God to the community that should be navigated for its advantages or challenges. Stasis of the body is determined not by man, but by God alone. It is considered an earthly task to care for the body as a vessel, but all Amish settlements have been strictly adverse to alteration, amendment, or embellishment of those vessels. Using the term vessel, however, should not imply that the body is understood as simply a container for spirit as it is in some Christian sects, that the two are fundamentally separate, or that the spirit is a priori the body. The two exist as the

entanglement of flesh (from the world of man) and breath (from the world of God), and the Amish see them as inseparable—what one does to the body impacts spirit and vice versa. To this end, economies of the body are imbued with concerns of the spirit, and any experience with medicine and its practitioners will include the effort to keep these balances in check. This balancing dynamic sits at the heart of Amish economies of the body; the resources of physical and spiritual are both wrapped up in bodiliness and managed for the productivity of the community.

The plural medical system formed and being formed by a Lancaster Amish district responds to this dynamic relationship. Their theology as played out in physical practices dictates a balance of body with spirit, and they recognize this merging as a marker of mutual separation. The force of this cultural construction will become evident in some of the examples below. Amish districts respond to and incorporate medical modalities provided by others as part of a field of medicine to the degree that those pieces respond to and incorporate their expectations about the mind-body relationship95. They accomplish this by employing an array of medical approaches specific to contexts of affliction.

Amish Pluralistic System

Simon Shenk looks out from his front porch on a cold January morning just as his English neighbor, Roscoe, trundles up his own driveway to get the paper. Simon, standing behind the team that had just been hitched by his oldest son, closes a heavy black coat of layered polyester against the cold, his greying beard flapping a bit in the morning wind. Roscoe shuffles around his blue F-150 in a red flannel bathrobe over sweatpants and fleece-lined moccasin slippers. Simon and Roscoe live just a few meters away from one another. One man with no grid-based electrical power, a daily commute by buggy to a small furniture shop two miles away, and a steadfast spiritual community holding up his family. The other with wireless devices scattered all over his house, a thirty-year career in the public sector, and two kids currently enrolled in state

universities. But no matter the cultural worlds they inhabit, they both hold something

considerable in common. Both of these men have human bodies. And both of these men have cancer.

It’s not difficult to speculate on the illness career of Roscoe. His diagnosis came after not feeling well for weeks and struggling with fatigue. Managed by an oncologist at Hershey

medical center, Roscoe takes up a familiar illness career—attempting to maintain control of his life, normalizing everyday activities, and operating in a relatively isolated bubble of not wanting to worry or bother the wider community with his family’s needs (Muzzin, et al. 1994:1201). “We’ll get this all figured out, we will,” Roscoe says. “Doctor Saunders up there at Hershey, he’s going to set me right. The treatments are hard on [wife] Betsy, taking care of everything and all, but we manage. With the kids at school and the doctor bills, well, it’s a lot, but the state

[Pennsylvania] does right by us.”

Simon’s illness career is less familiar. Beginning with his own bout of exhaustion and weight loss, Simon and his Gmay began a series of interventions along almost all strands of Amish pluralism—from chiropractors and chemo to boarding a bus headed for Mexico, he’s seen it all. Simon’s story will continue below, but for now Amish medical pluralism needs to be sketched out. In the Lancaster area, these plural approaches run along in five strands and each attends to certain sets of concerns. These five health modalities tend not to dominate or

subordinate others (ie. a “traditional” or indigenous healing systems are sometimes found to be subordinated by biomedicine or the reverse) and certainly overlap in many instances. While it does seem to be true that they are used with varying frequency, each seems appropriate and applicable in its own class of bodily states. In other words, the interplay of these strands can be illustrated any number of ways: they can be made hierarchical by frequency of use, ranked by financial cost to the community, or listed in order of their potential conflicts with the spirit of

Gelassenheit. But the predominant emphasis I found concerned their match to specific health needs. In the illustration above, they are simply diagramed as equal parts of a whole system. Continuing, each area in this field of practice will be outlined to further explain Amish health approaches and their uses as each gets specified to contexts of health and dis-ease.

Before I continue, however, the topic of powwowing or brauche should be briefly addressed. This category is noticeably missing in the construction above, largely due to the fact that brauche is no longer used as a specific category among the Old Order Amish in the

Lancaster area. Powwowing, a folk-healing method originating in the Pennsylvania Dutch (non- Plain) communities is defined as “an unofficial traditional magico-religious practice—

originating with and chiefly practiced by the Pennsylvania Dutch and emphasizing healing of Figure 1: This model illustrates a non-hierarchical

arrangement of approaches; note that the term "alternative care" is avoided here as not to relegate one

humans and animals, but with other goals as well—that uses words, charms, amulets, and

physical manifestations to achieve its objectives” (Kriebel 2007:16)96. Brauche, in the traditional sense, is no longer found among the Lancaster Amish for two reasons. Powwowing focuses on removal of hexes, protection via amulets, healing, casting out demons, finding lost items, and the like. In addition to magical objects (like the amulets), it relies on touch and incantation of

spells—some of which come from established spell books and others lifted directly from the Bible. During the 20th century, many of these practices came to be seen as “devil’s work,” and Amish groups, particularly the more progressive, moved away from them. Brauche rendered the line between “black magic and white magic” too blurry (Kriebel 2007:204-207). The other reason that powwowing is not found outright, is that elements of brauche enjoyed by the Amish have simply been absorbed into the category I refer to as Home Care. Some may reject this analysis by claiming that brauche still exists as a secret practice among the Lancaster Amish. To the contrary, the use of some powwowing elements is certainly still around, but they have become too involved with other forms of Amish healthcare intervention to be well aligned with the Pennsylvania Dutch practice of powwowing. The few Amish naturopaths who might be known in the area as powwowers—braucher or brauchfraa—incorporate chiropractic approaches, reflexology, herbalism, and other home alongside traditional brauche uses of biblical incantations and laying on of hands.

Choice of Practitioner

The group’s enacted autonomy of being Amish puts them in positions to dictate which medical modalities can play in their pluralistic field as well as how these modalities (and the

96 _{Kriebel’s book (2007) provides the most detailed and thorough examination of powwowing available. See also Miller (1981)} where elements of the braucher (powwower) are conflated with chiropractic categories among the Amish.

actors associated with them) are incorporated. In the examples to follow and throughout the case study around the Clinic for Special Children, there are factors that weigh into the decision- making matrix for choosing a modality or type of practitioner. Some of these are similar to reasons consistently found to affect the choice of a certain model for addressing health or illness. But even those common elements have aspects intensified or deepened by Amish communities of practice. Cost of care is an essential feature in decision-making within this group that carries no medical assistance other than the aid provided by the church body as a whole. Amish families are acutely sensitive to continuity of care issues, particularly in light of most practitioners

coming from outside of the realm of Amish practice. Appropriateness of care must fall in line with community rules of order, standards of Amish Aid, and the general spirit of Gelassenheit. Health practitioners’ successful in retaining a practice among the Amish rely on intensive word- of-mouth referrals in a cultural world that not only places a great value on the experiences of others but where individuals interpret good outcomes for an individual as good outcomes for the whole, laminated social body. Medicine of any type will generally garner more favor among Amish if it can be conceived of as a craft practice with tactile work and material aesthetics. This is one of the more tacit formulations, and perhaps thereby one of the more interesting elements playing into a conception of Amish embodiment. Likewise, Amish consumers will always move toward practices with a higher perception of natural origins. The term “natural” here being the difficult one to define or interpret, even among the Amish, but its characterization often connects to the last category97. Time and time again, what I call the foundational knowledge dualism

97 _{While tempting to put the term natural in irony quotes throughout, I will refrain as I continue below. Just as in the English} world, natural is both a buzzword, thrown about to sell products or services, as well as a real concern for some (but not all) Amish families. Likewise, the use of natural products may enjoy a double standard even within one household. One Amish mother spent an hour taking me through all of the amber-colored glass jars from her naturopath and explaining how she uses each one because they are so much more “natural and closer to God” than pharmaceutical “medicines from doctors and stores.” Just after, she served kool-aid at lunch and made sandwiches using a sleeve of white bread from Costco containing additives such as

arises as a point of conflict in many decisions about the body—actions that reflect and exalt the knowledge of God are preferred to those that reflect and exalt the knowledge of man.

The likelihood of Amish peoples’ choosing a particular strand of their plural system is shaped by the “kind of theories that the therapist will invoke: global, holistic, spiritual, rather than local, partial and physical” (Douglas 2002: 24). These “global, holistic, and spiritual” ideas are aligned with Amish concepts of “natural” and the knowledge of God. The “local, partial, and physical” are aligned with systems of the state, empirical science, and the knowledge of man. Consider the seven themes outlined here as the strands that weave through the pluralistic system, tugging at Amish decision-making and influencing the ways Amish bodies become actors in vast networks of health and wellness98.

Paying attention to how actors talk about health decisions offers insight into the nature of cultural knowledge as it applies to illness, how this knowledge is applied by community

members in evaluating illnesses, and the processes whereby treatment decisions are made (Garro 1998, Crandon 1986). A great deal of my analysis draws from these kinds of conversations and focuses on the themes and cases discerned from listening to people talk about health.

Complementary to this qualitative data, I implemented small quantitative study in conjunction with the Young Center for Anabaptist and Pietist Studies99. Our sample (N=112) included Amish adults (44 males, 64 females). One of the more interesting measures asked respondents what kind

calcium propanoate and azodicarbonamide. She mixed the kool-aid, despite the red#40, with agave syrup instead of sugar because it “has no refining, more natural than the white sugar so your body will take it up better.”

98 _{See appendix two for a redrawing from field notes that sketches out these areas visually.}