The range of religious healing practices in Latin America today seems extraordinarily diverse, especially to those accustomed to thinking of health care only as science-based medicine. One obvious reason for this range is poverty. Poverty excludes many Latin Americans from full access to science-based medicine, thus encouraging other avenues to healing. The fact that the majority of Latin Americans are poor, that there are even more poor now than there were one, two, or three decades ago, directly affects the distribution of systems of healing in Latin America today. This is true whether we are speaking of treatments for infertility or excess fertility; prevention and treatment of childhood illness and mortality; HIV/AIDS treatment and prevention; treatment for common chronic diseases, such as arthritis, hypertension, or diabetes; or treatment of epidemic diseases of the poor, such as tuberculosis and cholera.

But there is another fundamental reason, besides poverty, for the prevalence of non-science-based modes of healing in Latin American societies—modes called by a variety of names in North America, including faith healing, spiritual healing, holistic healing, and alternative medicine. Poor Latin Americans are much more likely than their North American counterparts to see science-based medicine as only one option for effective healing, and they are much more likely to view science-based medicine as inferior for treating some health problems. Any survey of healing and medicine in Latin America must deal not only with the poverty that exerts such a strong influence on healthcare practices, but also with this ideological openness to alternative, non-science-based medicine.

The healing landscape in contemporary Latin America reminds those in North American and European healthcare systems that the developed world is not normative, that the vast majority of the world's people are poor, and that the health needs and healthcare beliefs of the poor and of poor nations cannot be dismissed as anomalies. They are not exceptions to the norm; they are the norm. Furthermore, interest in non-science-based healing represents both survival and recovery of some central elements of premodernity, but not a longing for premodernity itself. Present practices reflecting premodern understandings of health offer important resources for developed and overdeveloped societies.

MEDICAL ETHICS IN LATIN AMERICA TODAY
The important ethical issues raised in developed nations, such as organ transplantation, reproductive surrogacy, and gene therapy, are not generally discussed in Latin America. The extent of poverty makes these technologies unavailable to the majority poor, and an insufficient market makes the technologies unavailable locally to the rich, except in a few private hospitals in the largest metropolitan centers.

Thus there is little popular knowledge about organ transplantation, for instance. Only when a corpse missing internal organs is found floating around the docks of a major city, or when a dead or dying street child is taken from a garbage dump to an emergency room where large surgical scars are uncovered, does the Latin American public ask questions about organ transplants.¹ The political left in some Latin American nations occasionally points to organ transplants as an example of the gulf between the rich and the poor; military officers can often obtain transplants in military hospitals, while the poor die from such curable diseases as measles and tuberculosis because inoculation and treatment programs go unfunded.

On the other hand, from the perspective of Latin American indigenous and African medicines in which physical matter is never only physical matter but is always characterized by spirit, organ transplantation is problematic, for it cannot avoid changing or at least blurring personal identity. The larger the transplant, the more danger to the spirit of the original person. Among the different groups who agree that with an organ comes some aspect of identity, judgments still differ as to the wisdom of transplant surgery within specific situations.

Reproductive surrogacy does not evoke strong concerns in Latin America, especially among indigenous and African peoples. African and indigenous Latin Americans do not necessarily oppose surrogacy, but neither do they generally approve. For while these traditions have not been greatly influenced by scientific concepts of genetic relation, they inherit a focus on kinship and on the importance of familial and tribal descent as central to individual identity. For this reason, they are less likely to approve of surrogacy or, for that matter, adoption outside kinship lines. But given traditional connections between reproduction, social role, and status, they often approve gift surrogacy within families. In fact, both central African and southern Andean tribes have been known to give an excess child to close relatives who were childless. But reactions are very case-specific. Both African and indigenous Latin Americans tend to value the experience of maternity over the scientific, genetic fact of maternity, and give virtually no weight at all to legal contracts; experiential bonds generally outweigh scientific or legal bonds. In a number of Amazonian tribes, practices of couvade—in which fathers avoid tabooed foods and activities, like smoking and hunting, and fulfill mandated tasks to safeguard the spiritual welfare of the newborn child—ensure that fathers have strong non-scientific bonds to newborn children.²

In the area of genetic research, Brazil, for example, has a notable history of seventy years.³ The Human Genome Project has been the only area of genetic research that has stirred heated ethical debate in Latin America, and that only within indigenous communities. Indigenous peoples in Chile, Peru, Ecuador, Bolivia, Guatemala, and Brazil objected to having their genetic material owned and patented by the Project. Nor have they been bargaining for a piece of the pie. Rather they object to the essence of the Project, arguing that it represents a misplaced emphasis on preserving the DNA of endangered indigenous communities for the use of other communities, rather than on preserving the endangered communities themselves. At root, they say, it treats people as things. They object on a number of different grounds: that this is yet another form of colonialism in which indigenous peoples are raw material for the developed world, that it is a denial of their human right to control their own genetic material, and that in many cases representatives of the Project used deceit in offering blood tests and medical treatment without disclosing their intentions for the specimens. At the same time, since the mapping has been completed, research groups from countries with indigenous peoples have demanded and received access to the results.⁴

For the Amazonian indigenous, this "theft" of genetic material is related to the tremendous incidence of botanical theft taking place in Amazonian reserves.⁵ The global pharmaceutical industry is employing botanists not only to study, which is legitimate, but to indiscriminately remove large numbers of plants known or believed to have medicinal properties. Some indigenous medicinals have disappeared or are disappearing because of this theft, which is estimated by one analyst to be worth more than $10 billion a year.⁶

Thus the experience of the people reflecting on ethical issues dictates the content and direction of the reflection. Transplantation, surrogacy, and gene therapy have limited relevance for the vast majority of Latin Americans because these usually touch their lives in peripheral ways. The most debated ethical issues in Latin American medicine in the last decades have occurred undoubtedly around access to health care. One of the most persistent access issues has been in the area of reproduction, originally artificial contraception and most recently abortion and sterilization. The Catholic Church has defined all three of these practices as immoral. All three impinge on central experiences and desires of the majority of the population, and involve a number of functions of the state, from legislation and law enforcement to public health provision.

In Latin America the authority of the Catholic Church delayed the widespread introduction of twentieth-century technologies of contraception, sterilization, and abortion. Both contraception and abortion, of course, had long been practiced by all the cultural groups that make up Latin America. Beginning in the 1960s one Latin American nation after another not only legalized but also began funding contraceptive services for its population. This was done in response to rapid growth rates that were overwhelming states' ability to provide services, thus depleting development gains. Subsequently the average fertility rate in South America dropped from over 6 children per woman in 1950 to 2.⁷ children per woman in 2000 and in Central America from 6.2 to 3.1.7

No Latin American nation except Cuba has legalized abortion, though medical personnel throughout the continent have estimated that somewhere between 8 percent and 35 percent of all pregnancies are aborted, based on the incidence of maternal sepsis and death following illegal abortion.⁸ The legalization of abortion has been debated yet consistently defeated in the legislatures of a handful of Latin American nations and states in the last decade. Debates have been accompanied by strong opposition from the Catholic Church.

Brazil has had legal sterilization for years, and over 40 percent of all Brazilian women using contraception are sterilized.⁹ On the other hand, attempts to legalize sterilization in Peru have failed at least twice in the 1990s under strong church pressure. Of Latin American states that do have legal sterilization, many, like Brazil, require that women have a husband's permission and have already had a minimum of four children.

Despite strong opposition from the Catholic hierarchy to both sterilization and abortion, many pastoral workers throughout Latin America, including many nuns and priests, openly refer poor women to both illegal sterilization and illegal abortion services. One Brazilian nun, Ivonne Gebarra, was ordered by religious superiors not to speak, teach, or write on these issues for two years and sent to Spain to study theology after she was quoted in a popular Brazilian magazine as saying that the poor favelada, or slum-dwelling, women with whom she worked who had abortions were not sinning because they acted out of necessity.¹⁰ Popular response to her punishment by the church made her a heroine in Brazil as well as a heroine of the international women's movement.

AIDS is another area of medicine that is increasingly capturing public attention in Latin America. Though the statistics for 2000 are not in, the United Nations Children's Fund (UNICEF) predicted that the number of AIDS orphans in Latin America would increase between twofold and fourfold between 1997 and 2000; in 1997 while only two in 10,000 children were orphaned by AIDS in Argentina, Ecuador, and Mexico and one in 10,000 in Chile, Columbia, Peru, and Venezuela, the rates in Brazil, Central America, and the Dominican Republic were closer to one in 1000.¹¹ The Catholic Church in Latin America, as in the rest of the world, has opposed the use of condoms to contain the HIV pandemic on the grounds that condoms illicitly separate the unitive act from the procreative act in sexuality.¹² Brazil has one of the longest histories of HIV/AIDS and the largest HIV/AIDS populations. In the Andes HIV rates were relatively low in the 1980s, but jumped in the '90s as narcotics traffickers dumped excess product locally. Shared needles, sex with intravenous drug users and mother-to-child infection are the chief avenues of spread today in the Andean nations. Only Brazil has begun to develop widespread public health campaigns advocating condom use, though other nations are testing such campaigns in urban areas.

Many Catholics throughout Latin America have rejected the Church's ban on using condoms so that women and potential children are protected from an HIV-positive spouse. As more people have recourse to condom use, the condom no longer appears an evil object in itself, and its moral use increasingly appears to depend upon the situation and intent behind its use. Still I know of no national condom distribution or needle exchange programs in Latin America. Moreover, publicly funded treatment programs that existed before the size of the affected population began growing exponentially have now been discontinued due to lack of funds. HIV/AIDS patients in Latin America are one of the patient populations most involved in alternative therapies, many of them religious, from herbal remedies to treat the opportunistic diseases that accompany the disintegration of the immune system to religious rituals to remove the disease altogether.

THE HISTORY OF RELIGION AND HEALING IN LATIN AMERICA
The history of healing in Latin America offers some explanations for why Latin American perspectives on medicine and health vary so much from those in the North. From the very beginning of "Latin" American history poverty has been a constant, beginning with the poverty resulting from the enslavement of the indigenous population and the capture, enslavement, and importation of millions of Africans to Latin America. The forms of poverty born in this enslavement created a great demand for healing practices of all kinds.

The Enlightenment was late in coming to Spain, not beginning until the eighteenth century and never fully penetrating.¹³ Modern medicine, based in Enlightenment science, was correspondingly late to develop in Latin America. By the early nineteenth century, whatever brief scientific flowering had occurred in Spanish and Latin American medicine disintegrated in the stagnation of academic and intellectual reform resulting from the Napoleonic wars.

The absence of "modern" medicine in Latin America did not, however, constitute a void in healing. The indigenous peoples of the New World had well-developed ethnomedical practices which addressed both physical healing as well as divining and dealing with the spiritual realm. These prescientific modes of medicine tended to involve the whole person: the body, the spirit, the relationships of the person, and the environment surrounding the person. Healing was thus a spiritual, a communal-psychological, an environmental, and a physical process all taken together. Healers in these traditions used not only their knowledge of the body, the community, and the local environment as tools in healing, but also magic, personal charisma, and communal religious ritual. Exorcism of evil spirits was often as much a part of healing as herbal medicines. Since the spiritual/divine power restored health, communal well-being, and balance in the universe, healing was understood as an activity of the gods, and healers as agents of the gods. According to Irene Silverblatt:

Pre-Columbian Andean society did include members who were specialists in medical knowledge; these men and women were renowned as herbal specialists, bonesetters, and curers. Others were said to be able to predict the future, often using coca leaves or tobacco as instruments . . . in divination. Both curing and divination rites entailed the worship of native deities.¹⁴

Ironically, the healing arts of many of the indigenous tribes were, for the first century or two of the colonial period, of more use to the conquering Spanish and Portuguese than to the indigenous themselves. Their herbal medicine provided no protection against European diseases. Ten thousand years without foreign contact, which would have instilled immunological protection, left the natives prone to massive epidemics that depopulated whole regions. From the beginnings of contact with Europe, indigenous tribes suffered devastating epidemics such as smallpox, measles, and cholera, all of which had fatality rates many times higher among the natives than among the Europeans.¹⁵ Malnutrition and overwork raised the fatality rates even higher.

Arriving African slaves brought with them a parallel ethnomedical system, though they were hampered for some time by the differences between Latin American plants and the pharmacopoeia they had left in Africa.¹⁶ As African slaves began to serve on ships that returned to Africa, they brought back with them plant stock for religious and healing purposes; by the 1600s many important African plants were firmly established in Brazil.¹⁷

By the time the Africans were imported in large numbers, the indigenous populations along the coast were so depopulated, or even extinct, that African medicine stepped into a curative void. For many African slaves whose societies had been at least as advanced as Spain and Portugal in both agriculture and mining,¹⁸ herbal healing was a way not only to claim superiority for one's heritage, but also to secure a niche for oneself in the plantation economy.

At the same time, slaves were also major consumers of healing, due to the terrible conditions of slavery. The average slave survived a mere seven years in captivity, and life expectancy was only twenty-three years. This was why, in Rio de Janeiro, even after three centuries of sustained slave trade, over 73 percent of its 1832 slave population had been born in Africa rather than Brazil.¹⁹ Colonists, too, early turned to indigenous medicine for medical relief, and later to African medicine, though more ambiguously due to perceived connections between African medicine and African black magic.²⁰ The European medicine that was present in Latin America was not necessarily more effective than indigenous or African medicine, and was often more expensive and less accessible to the masses.

The Enlightenment's insignificant impact on Latin America had another effect on healing in Latin America. Because the Enlightenment so emphasized reason and materiality and, thus, western body/soul dualism, where the Enlightenment was strong it limited the healing of the body to the material means of modern science. Thus religion in modern societies was largely excluded from the practice of healing the body. But in Latin America, the lesser penetration of the Enlightenment served to moderate acceptance of the premise that religion had no place in healing, thus inadvertently supporting the traditional indigenous and African religious healing. In fact, some of the early Christian missionaries, for example, Jesuits in Brazil, learned herbal healing from the indigenous peoples of the coast and became the main conduit for such learning throughout the Portugese empire.²¹

The Catholic Church waged a long campaign in Latin America against those indigenous and African religious practices it condemned as paganism. Though the Church did make some efforts to distinguish indigenous and slave religions, which were condemned as pagan, from indigenous and slave practice of the healing arts, historians such as Silverblatt maintain that inevitably: "idolatry, curing and witchcraft were blurred. As in Europe, the campaign against heresy had obvious political motives. It was the ideological arm of the attempt to force Indians into the reducciones [supervised reservations]—all the better to evangelize, to maintain political control, to facilitate the collection of tribute."²²

This blurring of religion and healing was not difficult. Religion and the healing arts were intertwined within both indigenous and African cultures. The Spanish and Portugese brought to the New World a well-established suspicion of witchcraft among midwives and herbal healers. Further complicating the case was that one major part of both indigenous and African healing arts was the very conjuring of spells both by and against witches that was condemned by the Church. Many indigenous tribal healers today continue to use spells for both protection and affliction. Contemporary accounts by Bastien and Briggs of healers in Bolivia and Venezuela demonstrate both types of spells.²³ According to Felicitas Goodman, Macumba—the Afro-Brazilian religion that combined Yoruba, Congolese, and Angolan traits—has been largely replaced by Umbanda in the last half century.²⁴ Umbanda adopted Macumba practices of female as well as male mediums, spirits of the dead as possessing spirits, and urban centers that reflected social fragmentation. But unlike Macumba, Umbanda's possessing spirits are nonhistorical characters, rather than spirits of exceptionally evil persons, and only white magic, and none of the black magic known in Macumba, is practiced within Umbanda.²⁵ On the other hand, Macumba has not disappeared, and still does practice afflictive spell-making.

Of course, premodern religions, both in the past and the present, are extremely diverse; we make them sound unified and cohesive only by lumping them together in comparison to modernity. Among the African-based religions of the New World, for example, there are numerous significant differences, depending on which area of Africa, and in what numbers, the last waves of local slaves were captured. Also important is the identity, especially the religious role and training, of individual slaves captured and taken to any location, and the extent to which the local slave population engaged in syncretism with Iberian Catholicism. Santeria, Voudou, Candomble, Macumba, Umbanda, and Xango are not merely different names for the same religion, but have different tribal origins and relations to indigenous and European religions. In fact, within Candomble, the principle African religion of the state of Bahia, there are a number of different nations, such as Candomble de Ketu, Candomble de Angola, Candomble de Jeje, Candomble de Ijexa, and Candomble de Caboclo.²⁶ The practices of indigenous tribal healers are similarly diverse, depending upon tribal heritage, the flora of the tribal area, and the degree of incorporation of non-indigenous healing traditions.

THE DIVERSITY OF RELIGIOUS HEALERS IN LATIN AMERICA
Remarkably, not only are very different styles of religious healer in competition with each other in Latin America, but all of them seem to be prospering. The major religious groups that directly address sickness and health as a part of religious practice are (1) evangelicals, sometimes called Pentecostals;²⁷ (2) Spiritists, especially strong in Brazil; (3) the priests and priestesses of Candomble/Xango/Umbanda/Macumba mostly in Brazil, Voudou in Haiti, and Santeria in Cuba; and (4) indigenous healers with various tribal titles who are called curanderos/curanderas by the Spanish- and Portugese-speaking. These groups have little in common theologically, with the African-based religions being "practical, here and now belief system[s], dedicated to the realities of life rather than the uncertainties of death"²⁸ and contrasting with Christian theological focus on life after death and earning a place in paradise. Yet the majority of those who have recourse to healing practices of all four groups belong to the poorest segments of the Latin American population, and reflect the needs of that population for a variety of types of healing. The poor, who suffer from a variety of afflictions that involve the intersections of the physical, the emotional, and the spiritual, demonstrate an understanding of health as a reflection of balance and peace within individuals and among individuals and their relationships and environment, including their relationship with the deity/deities.

Popular Catholicism is also a common avenue for those in search of healing, but it does not offer rituals or ritual healers in ways that are analogous to these other four traditions. Official Roman Catholicism long ago ceded bodily healing to science-based medicine. Catholicism does retain a sacrament for the sick. Formerly called Extreme Unction, or the anointing of the dying to prepare them for death, since Vatican II this sacrament has been termed the Anointing of the Sick. Unable to shake the moniker of "last rites," this sacrament has not been successfully recast as a sacrament of healing. Families frequently either fail to ask for it or even refuse to have their sick anointed until illness is clearly terminal, out of fear that the sacrament will signal to the patient and others that death is inevitable. Partly because its historical use as a sacrament of the dying, and partly because of a global shortage of priests, current practice globally confers the sacrament less often on sick individuals than on groups in regularly scheduled public rituals to which all people in the congregation who are sixty-five and older and all those with chronic diseases are invited in order that they be prayed for. While the wish is for healing, expectations are low, and most pastoral explanations are that the sacrament promotes peaceful acceptance of illness in the sick and functions to reconnect them to the church community in order that it support them in their suffering.

While Catholic clergy have distanced themselves from healer roles, they have constituted themselves as authorities who set the criteria for legitimating or condemning certain medical techniques and decreeing under what conditions they are licit. The religious and moral legitimacy of amputations, abortions, contraception, vaccinations, blood transfusions, anesthesia, sterilizations, euthanasia, fertility drugs, withdrawal of nutrition/hydration/respirators or oxygen—all of these have been debated within the Church, and the positions developed by the Church have contributed the central concepts, categories, and logic used for wider public policy in healthcare ethics in Latin America and elsewhere.

While the Catholic Church does have a rite of exorcism based in ancient beliefs that evil spirits, including spirits of the dead, can be responsible for human ills and misfortunes, the rite requires the permission of a bishop which has been rarely given in the last century. The Church is loath to encourage what it regards in most instances as superstition.

Given this lack of focused attention on healing in historic Catholicism, it is not surprising that popular Catholicism in Latin America, influenced partly by poverty and partly by belief that healing involves more than simply the discrete material body, continues to use individual devotional practices developed in the medieval church. Most common are vows and petitions to Mary, the saints or the suffering Jesus for healings of sickness, hunger, alcoholism, unemployment, broken families, curses and spells, and general poverty. Believing "that the personal misfortune precipitating the request for supernatural assistance is brought about by God as punishment for a misdeed or sin committed by the sufferer,"²⁹ the petitioner attempts to obtain the intervention of "friends" of God—Mary, the saints—who, once motivated, will intercede for the petitioner with God for forgiveness and the withdrawal of the affliction. Petitioners vow to Mary, for example, that if they are healed, the looming disaster is averted, or a loved one recovers, then they will offer a novena or make a pilgrimage to one of the Marian shrines. The vow must only be fulfilled if the healing occurs, if the misfortune is averted or resolved. In Brazil, for example, one of the most popular pilgrimage sites is the shrine of St. Francis in Caninde, where up to half a million pilgrims go every year, inundating the little town of 19,000 residents. Most of those pilgrims are fulfilling vows, and the most common intercession granted is healing for one's self or family member.³⁰

Evangelical Healers
Evangelical healers³¹ are often called faith healers, from the New Testament accounts of Jesus Christ's healings in which he told those whom he had healed that it was their faith that had made them well. Like Jesus, faith healers today, who are usually pastors but may hold other offices in the churches, exorcise evil spirits, cure bodily ills, and mediate the forgiveness of sins. Faith healers either use "the pass"—passing their hands over—or lay hands on the ill person to cure illnesses of the body, spirit, and mind. Andre Droogers writes that evangelicals want to end the fragmentation of body from mind: "It is their belief based on experience that mind, body and spirit become one through healing, prophecy, dreams and visions. Consequently, these practices are introduced into normal religious service and become part of normal religious practice."³² From this perspective, all of evangelicalism is about healing.

Evangelicals now make up over 10 percent of the Latin American population, and in some countries 25–30 percent.³³ R. Andrew Chesnut, a researcher of Brazilian evangelicalism, suggests that dramatic evangelical growth is based on the spread and endurance of poverty. For example, he says that evangelicals in Brazil:

are not escaping rampaging armies or suffering anomie. Rather, they seek immediate solutions to their health problems stemming from poverty. Illness is one of the most common and life-threatening manifestations of poverty in Latin America. In Belém (Brazil), insufficient caloric intake, unsanitary living conditions, and tropical heat create a fertile breeding ground for the gastrointestinal and infectious diseases that plague the poor throughout the world.³⁴

Chesnut's research demonstrated that most Brazilians who had become evangelical had done so in the grip or immediate wake of a serious illness afflicting them or someone in their family. Healing is the central liturgical focus of evangelical churches, so this is not surprising. The majority of evangelical members are women, and women demonstrate a disproportionate share of spiritual charisma within the evangelical churches. These demographic facts are also relevant to the healing practices of the church in that women's greater powerlessness makes them more vulnerable to illness and their familial role makes them more responsible for illnesses of other family members:

The unequal allocation of spiritual gifts between the sexes is a function of power and culture. It is the socially weakest who, in compensation for their temporal impotence, must seek spiritual power. And in twentieth century Brazil, favelada and rural women, particularly negras and mulatas, stand the furthest from the center of power. Not only victims of classism and racism, poor Brazilian women suffer material and psychic stress owing to their subordinate position in a patriarchal society. Without husbands or boyfriends to bring home a meager paycheck, they frequently live in abject poverty.³⁵

Evangelicalism has other aspects that contribute to its success among the poor, including ecstatic language (glossolalia), mutual aid networks, informal job banks, and general extension of personal support, often expressed in familial terms. Job banks help alleviate both the hunger and depression of unemployment, while glossolalia allows the poor the experience of ecstatic freedom from everyday troubles as well as feelings of power through divine possession. Ritual healing based on faith stands clearly at the center of all of these activities.

The work of John Burdick suggests that healing ritual is only one part of the larger healing function of evangelicalism.³⁶ Like Chesnut, Burdick points to the evangelical ban on alcohol, gambling, and adultery as freeing up resources that help alleviate poverty and restore ruptured relations between men and their wives and children. The local evangelical templo [church] offers men an alternative society, complete with self-respect and status, to that of the street. But Burdick also points out that evangelicalism functions as a religion of affliction, that it gathers together those who are suffering and allows them to help one another by listening and advising in groups based not in neighborhoods or occupation or family, but in shared affliction. The makeup of these groups allows participants to bring up all their troubles without embarrassment, and to receive support that is not patronizing.

Spiritism
Sharing some similarities with Pentecostalism in Brazil is Spiritism, an offshoot of nineteenth century Spiritualism usually attributed to the Frenchman Allen Kardec³⁷ who taught that Spiritism was a combination of empirical research on spirits of the dead, philosophical reflection, and right action governed by the law of karma and the Christian Golden Rule.³⁸ Spiritism's devotion to the language and concepts of science—though some would say nineteenth century science—distinguish Spiritism from Evangelicalism, which presents itself in terms of more traditional, conservative Christianity, often over against science. Spiritism is not necessarily Christian, though in deference to its many members who regard both Spiritism and themselves as Christian, its leaders insist that one can be Spiritist and also belong to any other religion. In contemporary Brazil, writes Spiritism researcher David Hess:

the Spiritists with college educations—the doctors, lawyers and engineers in the movement—tended to be more interested in the "scientific side" of Spiritism. As a result, they generally paid more attention to Kardec's first two books . . . In addition, the intellectuals were very interested in the legacy of psychical research that developed in France and Britain at the turn of the century. Psychical research was an earlier form of parapsychology in which researchers attempted to study from a scientific perspective the phenomena associated with mediums, ghosts, telepathy and so on.

In contrast, the nonintellectuals—the vast majority of the Spiritist movement—tended to be more interested in the day-to-day charitable activities at the Spiritist centers, which included providing food and medical services for the poor, running orphanages and mental hospitals, and holding sessions of passes and "disobsession" for the earthbound spirits and the people afflicted by them.³⁹

While much of the literature of Spiritism reflects the interests of the intellectuals, the ritual life of the Spiritist communities reflects the interest of the nonintellectual majority in physical and mental healing through the expulsion of the energies of evil, which express themselves in alcoholism, hunger, depression, disease and despair. Neither Spiritists nor Evangelicals deny that western scientific medicine is effective against ordinary sickness, only that evil spirits are responsible for a great deal of the physical and mental illness, sometimes in conjunction with more concrete causes such as germs and viruses. In fact, Spiritist centers in Mexico are not simply about contacting dead spirits for advice and assistance, but are a vigorous healthcare system in which mediums are healers possessed by long dead physicians often bearing Indian names. Through the Spiritist mediums, these Indian dead diagnose the cause of illness and prescribe both material and spiritual treatments to eliminate it.⁴⁰

Evangelicals are more likely than Spiritists to think that faith healing is effective even against, for example, virus-caused disease. In both groups adherents will, in the face of illness, consult health clinics in addition to presenting themselves for particular healing rituals. They attempt to maintain health between illnesses by regular reception of passes to screen out potential new problems with possessing spirits and to protect them from those chronic threats that follow from past lives.

Indigenous Curanderos/Curanderas
In addition to Pentecostals and Spiritists, there are many indigenous religious healers in Latin America. Within indigenous Latin American religio-cultural traditions healing was also a central function. While Christianity never came close to eradicating indigenous religious practices altogether, it is difficult to find throughout Latin America intact indigenous religious systems. What has persisted despite persecution are remnants: isolated rituals, songs and invocations, myths and stories, many of them pertaining to those elements of indigenous life to which the religion of the conquerors offered nothing relevant. For example, throughout the Andes nominally Christian indigenous peoples still enact pre-Christian agricultural rituals. These rituals petition Pacha Mama, mother earth, and the Apus, spirits of the mountains, for good potato harvests and related good health—rituals to which the Father, Son, and Holy Spirit have often been added and some select Catholic priests invited.

In mining areas of the Andes, popular religion has maintained belief in and rituals to traditional underground deities. As Xavier Albo writes:

The axis around which the religion of the miners in the tunnels turns is the devil. They call him Tiu; his identity and location is both generalized and localized and varied in each mine location. The tunnels are populated by images of Tiu, characterized by his big horns, a prominent male organ, and his arms in an attitude of embracing or grasping. His sole clothing consists of a multitude of paper streamers and confetti, reflecting the ever-present ch'allas (offerings or blessings) with alcohol, coca leaves and cigars which the miners offer him at Carnaval, during the month of August, and every Tuesday and Friday, which are the devil's days. To reciprocate, Tiu protects them against accidents and grants them the coveted vein of ore.⁴¹

Among Andean peoples, clothing woven in very distinctive styles speaks one's identity, and in the southern Andes clothing is anthropomorphized as human, as when weavers give aspects of cloth the names of body parts.⁴² Many items of woven clothing take on a sacred quality and cannot be sold; some cannot be worn by another person. The symbols woven into clothing often have a healing function. For example, the symbols for livestock, crops, and children woven on women's headbands symbolize a desire for fertility—both personal and social-environmental. Also woven into cloth are symbols of the natural environment: sun, moon, mountains, rivers, and animals. These symbols representing creation in harmony—without hunger, famine, flood, fire, drought, or epidemic—not only depict this desired reality, but also magically help to achieve and maintain it. Thus depictions of snails are regarded as magical good luck: the snail carries its home on its back, lives on land as well as in water, and therefore signifies survival.⁴³

While many surviving rituals, such as weaving magic or the ch'allas to Tiu, function to preserve life and health in a way analogous to healing, there are also, in indigenous communities and popular culture, more specific avenues for healing. Curanderos and curanderas inherited an indigenous healing tradition that combines both herbal healing and what to modern "scientific" minds appears as magic. It is difficult to make generalizations about these indigenous healers because their training and practices vary so widely. Many retain not only many ancient diagnostic and herbal healing techniques but also the religious incantations and mythology that supported them. Curanderos/as both in the Andes and in the Amazon utilize a wide variety of local plants to diagnose and treat disease, beginning with the coca leaf and tobacco leaf, both of which have long been believed to have special curative and spiritual properties. Local plants are utilized to treat hunger, diarrhea, altitude sickness, open wounds, migraines, indigestion, hangover, heart disease, diseases of the eyes and skin, and many more ailments. Not only do curanderos/as in many parts of Latin America constitute a major part of professional health providers, but their methods and remedies constitute the major part of the remedies offered to the popular masses in botanicas, bodegas, and farmacias.

In recent years many of the diagnostic techniques and treatments used by traditional curanderos/as have been found equally or more effective than those used in modern, scientific medicine; this tends to be most true for those medical complaints that are most common within indigenous communities. In spring of 1988 while teaching in the Catholic Seminary in Cajamarca, Peru, I stayed in a local convent where my roommate was a Colombian doctor, part of a three-doctor team investigating medical treatments by curanderos/as in Peru. Her team had compared diagnosis and treatment of a number of complaints with those of science-based medicine, and had developed great respect for many of the curandera/o practices. One that particularly impressed her was a three-day water and papaya diet in cases where diagnosis was impeded by too many symptoms. She insisted that she had seen this diet enable curanderos to cure by itself a number of minor complaints, such as impacted bowels, but more importantly to diagnose very complicated conditions of the liver, kidneys, and stomach that she herself could only do with the aid of high-tech laboratories and machines. On the other hand, she was sceptical of the curandero use of cui, a furry Andean rat, in diagnosis through divination. A patient with internal complaints could be required to spend a number of hours, even a day or more, with a cui pressed to their chest under their clothes. Then the cui would be dissected, and the curandero would diagnose the patient's complaint by examining the entrails of the cui. Though many of the curanderos' diagnoses using this technique were accurate, the Colombian team attributed this to the acuity of curanderas' direct observation of the patient, and not to their power of divination through cui entrails.

As might be expected, the primary basis for respect for the curanderas/os from the Colombian doctors was the pharmacological use of local herbs. The doctors emphasized that most herbal treatments did not work the kind of miracle cures that antibiotics made paradigmatic of western medicine. Rather, herbal medicine supports the body's own resistances to disease and works more incrementally. These doctors were especially impressed by the ability of the curanderos/as to treat chronic illness: to adjust dosages to bring pain relief for a variety of bone and joint conditions, to regulate heart and blood flow, to enhance breathing for asthmatic and tuberculosis patients, to alleviate jaundice and gall stones. These scientifically trained doctors readily admitted that taking curanderas' prescriptions to dispense in their offices would not produce the same effects. Part of the curanderas' cure, they were sure, was the charisma and mystique of the curandera herself as expressed in the ritual action and recitation, but also in her ability to listen to the entire complaint and incorporate treatment for the physical and psychic pain, depression, and spiritual isolation aspects of the complaint.

Umbanda/Candomble
A fourth type of popular healer with religious rather than scientific training is found among Latin Americans of African descent and within their extended religious communities, especially in Brazil. As Robert Voeks writes of Brazilian Candomble:

Adherents or clients who fail to make timely offering to their guardian deities, indulge in excesses, or neglect the preferences and prohibitions of the gods chart a spiritual course that is fraught with hazard. The medical effects of risky behavior can range from temporary illness episodes to chronic, even life-threatening health disorders. Although illness can occur for other reasons, it is when health problems become chronic, when families confront one disaster after another, or when Western medical assistance fails that suspicion falls on failure to tratar os santos "treat the orixas [spirits]."⁴⁴

At this point the adherent consults a priest or priestess who acts as intermediary between the adherent's relevant deity and performs a shell toss, the most enduring of the methods of divination brought from West Africa. He or she tosses sixteen African cowry shells; each configuration of the shells is associated with several Yoruba myths, and the diviner must determine which of these are relevant. Based on this determination the diviner gives a prescription, which often includes several steps. The most common initial step is a spiritual cleansing to eliminate negative fluids and energies that have settled in the body. This cleansing will often involve an ebo, material offerings, often including animal sacrifice, a leaf whipping or sacudimento, and an abo or leaf bath. The ebo will involve pouring bowls of food sacred to the deity, and passing animals to be sacrificed, over the client's head and shoulders. In the leaf whipping, one to three plant species, each consecrated to the orixas of the client or of the offending deity, are bundled together and either brushed lightly or briskly whipped, depending on the severity of the problem or the mood of the priest or priestess, over the shoulders of the client.⁴⁵

The leaf bath, the abo, is prescribed for health problems and for finance and personal relationship problems. The abo can take place in the client's home or in the communal space. The leaves of at least three species that belong to the deity of the client, with serious problems requiring seven or more species, are crumbled into a basin of cool water and poured over the body. If the problem is a severe one, preparation is more complicated, with great attention given to the way in which the leaves are harvested (for example, late at night or early in the morning), who prepares them, and the invocations that accompany the manipulation of the leaves in the basin. If it is not the occult powers of the plant, but merely its medicinal qualities that are desired, then these special precautions are not necessary.

According to some sources, some western doctors in Brazil maintain reciprocal relationships with Umbanda or Candomble priests and priestesses; one refers clients to the other if the problem appears to be in the other's area.⁴⁶ However, many priests and priestesses in Umbanda and Candomble are themselves skilled herbalists who prescribe medicinal plant therapy beyond the rituals. Priests and priestesses routinely recognize that viral diseases are not their province and refer these problems to western doctors.

IMPLICATIONS FOR NORTH AMERICA
All of these Latin American religious alternatives to scientific medicine share some characteristics. They are all disproportionately attractive to the poor. All of the them accept and even encourage use of scientific medicine where it is accessible and useful. All of them understand healing in ways profoundly different from scientific medicine; for none of these alternatives does healing involve only the physical body of an individual.

One major difference between popular Latin American and North American attitudes toward healing results from different experiences of and attitudes toward autonomy. North Americans have a greater experience of autonomy, due partly to higher incomes, partly to more education, and partly to cultural patterns that emphasize autonomy and support demands for it. North Americans thus tend to think of themselves as in charge of their lives, even of their health. While even upper middle-class North Americans do have health problems, their general expectation is that if they seek medical help in a timely fashion and follow medical advice, they will have good health. Latin Americans, largely due to high poverty levels, do not have the same level of confidence in good health. Many more of them are aware that personal good health has some element of chance; even the rich are more likely to understand that but for the grace of God or random chance, they could catch cholera from the maid, their kids could contract TB at school, or their spouse could die in an ill-equipped ambulance following a car accident. When death and illness hover over so many, so constantly, illusions of safety, of being exempt from human mortality, are harder to achieve and maintain.

Accumulated experience of vulnerability makes Latin Americans take fewer demands and lower expectations to healers of all kinds. This is not an issue of less faith or hope in any or all particular healing methods. Lowered expectations are based not only on the prevalence of illness or death, but also on an understanding of illness and therefore of healing as both diverse and complex. The evangelical who hopes for but does not expect a permanent cure of her leg pain by her pastor's laying on of hands is not lacking in faith. She is recognizing that some kinds of problems respond better to laying on of hands, some to the curandera's teas, and others to the local clinic. Even when a particular illness is cured by the pastor, that does not mean that every instance of the same illness will be successfully cured by the pastor. One alcoholic is saved, but the next may have a weaker faith, a more or less supportive wife, or live closer to the temptation of "the street." There is mystery, magic, and gift in healing. It is perhaps one important spiritual lesson we can learn from Latin America. In a religious sense, North Americans have lost a great deal of our sense of finitude, of dependence on God, of gratitude for the health and healing we receive, as well as compassion for those who have not received health and healing. We have fashioned a healthcare system aimed at curing, which has virtually no capacity to care for those suffering whom it cannot cure. In this system, those who are not cured are not only deprived of care, but are often regarded as burdens, as if the failure to be cured were the fault of the patient.

Latin American systems of religious healing hold some distinct advantages over scientific medicine in that they directly address caring for the sick as well as curing them. Nevertheless, within Latin American religious healing practices there are distinct differences in the ability to convey care for the sick. Care for the sick can have both a personal and a social dimension.

The Catholic sacrament of anointing the sick, while only weakly addressing curing, does demonstrate the concern of the community for the sick, and may involve a personal caring of the ritual provider for the sick though this relationship is often impersonal due to the size of congregations, which may exceed 30,000, even 40,000 nominal members. Vows and pilgrimages in popular Catholicism, because they are private, involve neither healing personnel nor a social dimension.

Evangelicalism also treats healing within a social context, and again that social context is the community of the templo. The healing ceremony is public, in fact, often advertised outside the templo itself to attract new members. But pastors and other church healers generally make a point to know congregants. Knowing congregants is much easier than in Catholic parishes, as congregations tend to be not only much smaller, but also much more regular in attendance. Evangelical pastors are often well known, even revered within their templos. So important is that status that the Assemblies of God, the largest evangelical church in Latin America, has a policy of rotating elders in lesser congregational offices every few years so as not to create competing followings within the congregation. Faith in the pastor is thought to be key to healing as well as to complete conversion.

The evangelical churches are for the most part closed communities. This is certainly a strength in curing "social diseases," such as alcohol, gambling, adultery, fornication, and drug use: it provides an alternative family, space, and neighborhood. The templo's ban on adultery, fornication, alcohol, and gambling and its strong enforcement of these bans create a space where there are few if any temptations to backslide. The templo is also supportive in terms of supplying welfare services, such as food banks, job referrals, and recommendations. Evangelical job recommendations often carry weight even outside evangelicalism, since they virtually guarantee employers sober, serious-minded workers. Teams of women called visitantes travel through neighborhoods to visit members and recent attendees. They are a major support to the sick, frequently providing cooking, cleaning, and childcare services in addition to company and support; often these women have suffered afflictions similar to their charges' illnesses. The evangelical understanding of the templo as "saved space" surrounded by the sinful world that must be resisted creates a strong supportive community while discouraging contact with unconverted family and friends.

Many Spiritist centers also offer varied social services in addition to rituals that repel hovering earthbound spirits of the dead by means of the pass, mediums offering guidance in health matters from spirits of the dead, and healing rituals that expel malevolent spirits of the dead from afflicted members. Compared to evangelical templos, Spiritist centers are at some disadvantage in creating a community that supports holistic health. Unlike evangelicals, Spiritists are neither exclusivist in that they do not forbid members to belong to other religions, nor separatist, in that they do not require rigid codes of dress and behavior that mark them out from other members of society. Nor is the priority of the poor for healing the exclusive focus of Spiritist centers. The intellectual interests of many of the core leadership are not always compatible with the practical, therapeutic interests of the mass of poor members. While one group would fund a Spiritist library or psychic research, the other would fund a food kitchen or clinic.

Indigenous and African American healers and their communities bring an even broader context to healing practice. Their perspective is not merely social—healing humans within their human context—but takes in all living and non-living things. Indigenous and African American rituals of healing make use of the natural world as a pharmacy, producing teas, baths, medicinal foods, and other infusions. The natural world also supplies equipment for healing ritual, as in the cowry shells used in Candomble divination to discover the roots of an affliction. Natural materials abound as symbols within healing ritual, evoking the power of the forces for which they stand. For example, when Rosinta Garcia, a Kaatan (Bolivia) healer, was called to end a string of family disasters beginning with infertility and culminating in widespread typhoid and the death of a child, she first offered coca to the Lord of the River.⁴⁷ Coca leaves have been chewed by the Andean peoples for thousands of years to anesthetize hunger pains and to support grueling work and travel in the altitude. Rosinta then sprinkled alcohol to the spirits of the mountain, and made wads of cotton, coca, pig fat, daisies, seeds, herbs, and moss, which were burned, then the ashes thrown in the river. All of these were local products representing a different aspect of the life of the Kaatan community, here offered back to the deities that produced them.

But healing rituals are not merely performed for individual human bodies, but often for the wider purpose of restoring good luck to whole families, or to avert disaster from an entire village, often following some violation of the natural world upon which human health and prosperity depend. This holistic sense of health—that it depends on one's relationship with one's family, living and dead, with one's community, living and dead, with one's natural environment, and with the gods and spirits that animate the world—pervades both African and indigenous healing.

This holistic understanding of health as not only involving all the different parts of the human person—body, emotions, and spirit—but also the entire context of that human person, both social and natural, invites reflection from North American religion as well as North American health care.

NOTES
1. See, for example: E. Cantarovich, "Organ Commerce," Transplantation Proceedings 31 (1999): 7, 2958–61; Vivek Chaudhary, "Suspicious Deaths at Hospital Uncover Traffic in Human Organs," [Montreal] Gazette April 19, 1992, B5 (from Buenos Aires Guardian, Argentina); "Foreign Ghouls Profit From Our Laxity," [Montreal] Gazette, November 23, 1993; Gary Abrahamson, "US Protests Spanish Prize for Story on Child Murders, Organ Theft," The Associated Press, March 16, 1996; Elizabeth Aird, "Doctor Refuses to Give Treatment to Patients Who Buy Transplants: The Specialist at St. Paul's Hospital Has Raised an Ethical Issue That Will Be Debated by Colleagues at a Meeting in May,' The Vancouver Sun, April 27, 1996, A18; Christine Gorman, "Body Parts for Sale: FBI Sting Operation," Time (Canadian edition) March 9, 1998, 41; Mario Osavo, "Brazil: Public Opposes Compulsory Organ Donation," Inter Press Service, January 12, 1998; "Mexican Government Dismisses Reports of 'Organ Trafficking,'" EFE News Service, March 7, 2000; and "Organ Transplant Racket is Focus of Arrests in Italy," Deutche Presse-Agentur, July 20, 2000.