In some parts of the world, emotions are not experienced as personal feelings but as communitywide phenomena that are contagious and deadly. Such is the case with a culture-bound syndrome, "coraje," as it relates to the Amuzgos Indians of Mexico.
She discussed her experiences at the fifth annual Critical Research Issues in Latino Mental Health conference held in November in Princeton, N.J. The meeting was sponsored by the Robert Wood Johnson Foundation and the National Institute of Mental Health (see story on page 11). Cartwright was joined by her mentor, Peter Guarnaccia, Ph.D., a professor in the department of human ecology at Cook College at Rutgers University. Guarnaccia discussed the broader implications of her research on coraje.
Coraje is most commonly translated into English as anger by social scientists, but Cartwright advised against any direct translation. "The Amuzgos conceptualize anger much differently from how we do," she said.
She explained that a Western conceptualization of anger is that of a negative reaction—a "mental upset" resulting from an unpleasant situation. For the Amuzgos, however, the reaction comes in the form of various ills, including headache, pneumonia, diarrhea, or heart attack. Since domestic and political violence are so prevalent in Ouaxaca, she explained, so are the effects of coraje.
Cartwright noted that a person can acquire coraje through a negative interaction with someone else, by contagion, or both.
"If you just came back to the municipal president, and he angered you," she said, "you can acquire coraje, and it can fall onto your baby and cause illness."
The illness suffered by the victim depends on where the coraje falls on his or her body, Cartwright explained. For instance, if it falls on the head, a person gets a headache; on the stomach, diarrhea; in the lungs, pneumonia.
Since coraje can move around the body, a number of the village women with coraje wear belts over their slips but under their dresses, according to Cartwright. This keeps the coraje contained to the stomach area and prevents the coraje from traveling to a person’s heart, which can be fatal.
Containing coraje can mean that daily frustrations are not expressed. Cartwright recalled a conversation she had with the head of one village family, who said, "Whenever we go to see the municipal president, we get angry. It’s frustrating. When we come home, we have coraje, and we have to be careful because the coraje can make someone who has just been sick, a baby, or an old person ill."
Expressing frustration in such cases might lead to contagion. "This led me to see how in these households, no one yelled at one another," Cartwright said.
A person who falls ill with coraje will likely visit a "curandera," who is designated to cure the ill effects of coraje in a healing ceremony. For instance, when 5-year-old Pacito became ill with coraje, his aunt, a respected curandera, initiated a "limpia de huevo," or egg-cleansing ceremony combining elements of Roman Catholicism and Amuzgan beliefs. She began the ceremony with a prayer to St. Isidro that the cure would work. She then immersed an egg in a curative herb mixture and rubbed it on Pacito’s body, where she made the sign of the cross. The egg is thought to absorb the coraje and is dropped into the river, where it flows downstream.
"After flowing for a while," said Cartwright, "the coraje is believed to travel upward into the air where it circles, waiting to find another victim."
During curing ceremonies, she noted, Amuzgan women often pass shawls over their heads to protect them from coraje that can be blown off the victim and onto them.
This is how Pacito is believed to have become ill with coraje. He often played outside his Aunt Maria’s house, who lay inside, dying of a chronic form of coraje. Pacito is thought to have caught her coraje during one of the curing ceremonies that took place at the house.
Maria was said to have acquired coraje as a result of a tumultuous relationship with her husband, the municipal president, who was "incredibly abusive" toward her, according to Cartwright. She also lived in extreme poverty, and when there was food available, she fed her five children and often went hungry herself.
Maria has not only sought help for her poor health with various curanderas, but also visited a series of medical doctors and spent time at a hospital toward the end of her illness.
While villagers and curanderas believed that Maria died of coraje, Cartwright said the local doctors were at a loss as to the exact reason for her death. Some hypothesized that she died of cancer, while others attributed her demise to severe malnutrition.
Cartwright’s mentor, Guarnaccia, highlighted the relevance of the research presentation for psychiatrists and other mental health professionals in the audience. "For those of us who are interested in somatization," he said, "the ethnopsychology of the Amuzgans has a physical force. . . . We often have a hard time thinking of emotion in this way—that if you get angry at someone else, it can change [that person’s] physiology."
Belief in coraje is not limited to a small village in Oaxaca or the agricultural camps in Sonora, Mexico, where Cartwright conducted her research. Guarnaccia pointed out that just blocks away from the conference site in Princeton stood a Mexican barrio, "filled with people from this background."
Cartwight told conference attendees that villagers from the Oaxaca region are migrating to different parts of the U.S., especially states like Washington, Oregon, and California to work in the grape fields and apple orchards.
"Migrants can make anywhere from $100 to $200 a day in the grape fields of the U.S., compared with just a couple of dollars a day for the same work in Sonora," Cartwright said.
Since indigenous people such as the Amuzgos are seeking better lives in the United States, it is important that U.S. physicians and mental health practitioners understand the components of coraje, according to Cartwright. Guarnaccia, while discussing Cartwright’s paper, pondered the possibilities for intervention in a world where poverty and violence are the norm. "How do we help people like Maria overcome such problems?" And while cautioning against simplification of coraje into the notion of depression, he asked, "Is there a way to use the treatments we have available for depression in cases such as hers?"
Cartwright suggested that physicians and mental health practitioners should "talk to people about what they are feeling and the context of their lives" rather than focus on a diagnosis in the short term.
She also said she is working with Patricia Boiko, M.D., M.P.H., a family practice physician and clinical researcher at the University of Washington in Seattle, to develop a verbally administered depression-screening instrument for a group known as the Triqui, an indigenous people who live in a village 20 miles south of Oaxaca and are affected by coraje. ▪