Social Science & Medicine 126 (2015) 9e16

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Latent and manifest empiricism in Q'eqchi' Maya healing: A case study of HIV/AIDS James B. Waldram*, Andrew R. Hatala University of Saskatchewan, Canada

a r t i c l e i n f o

a b s t r a c t

Article history: Available online 2 December 2014

This paper presents a case study of the traditional treatment of a Q'eqchi' Maya man in southern Belize in 2011 who is suffering from AIDS-related sickness. The purpose is to detail the empirical nature of Q'eqchi' Maya medicine, distinguishing between manifest and latent empiricism, as evidenced in the healers evolving attempts to treat the patient in the absence of knowledge of his biomedical diagnosis. The paper argues for a more complete understanding of the empirical nature of much Indigenous healing, which parallels aspects of scientific medicine, and for better collaboration among traditional healers and biomedical practitioners in strongly Indigenous areas. © 2014 Elsevier Ltd. All rights reserved.

Keywords: Belize Maya Indigenous healing HIV/AIDS Biomedicine Collaboration

The purpose of this paper is to demonstrate, via a case study of a Q'eqchi' Maya patient in the Toledo District of Belize, how a traditional healing system is empirically invoked when a problem is encountered that confounds existing knowledge, in this case in the treatment of a patient already under the care of the biomedical system for HIV/AIDS-related medical problems but whose diagnosis is not initially revealed to the healers who treat him. The case provides an opportunity to see a traditional medical system “at work,” so to speak, as it confronts the challenges of serial- and comorbidity that do not fit neatly into the existing nosology and broader medical epistemology. A concurrent goal of the article is to demonstrate the need for dialogue between traditional and biomedical systems, a search for areas of compatibility, and greater efforts expended toward collaboration in the treatment of specific medical problems. 1. Latent and manifest empiricism “Empiricism” is a general term that refers, broadly, to the accumulation of knowledge through experience and observation (Lett, 1997). Here we refine the notion of empiricism as it exists within traditional medical systems as well as within biomedicine, by distinguishing between “latent” and “manifest” empiricism. We take “latent” empiricism to refer to the existing, collectively-held

* Corresponding author. Department of Psychology, University of Saskatchewan, 9 Campus Drive, Saskatoon, SK S7M0A4, Canada. E-mail address: [email protected] (J.B. Waldram). http://dx.doi.org/10.1016/j.socscimed.2014.12.003 0277-9536/© 2014 Elsevier Ltd. All rights reserved.

medical knowledge pertaining to diagnoses or treatment, and the standard against which clinical efficacy is judged. In biomedical terms, this is characterized by both scientifically-derived “textbook” knowledge learned by clinicians in formal educational settings and the knowledge previously accumulated through experience with specific medical cases. It is knowledge that can be consciously recalled and explicated, as in the traditional use of a specific plant or medicine, or a diagnostic procedure. It is also the “tacit” knowledge at embodied, non-conscious levels that forms the “background” of a practice or activity (Heidegger, 1996; Polanyi, 1966). Latent empiricism is the collection of professional or procedural knowledge that, after sufficient practice, experts possess. It provides the form, model or “paradigm” through which and by which a particular case is observed, “the entire constellation of beliefs, values, techniques, and so on shared by the members of a given community” (Kuhn, 1970, p. 175), in this case, the healing fraternity. Latent empiricism can be couched in the language of “tradition.” But while an appeal to tradition may represent a default to a moreor-less fixed body of knowledge, as is the case with Traditional Chinese Medicine (Quah, 2003)dwhich has parallels with biomedicine's textbook knowledgedfor the most part this represents evolving knowledge handed down, often orally, from healer to apprentice, from generation to generation. Craig (2012) quotes a Tibetan traditional doctor who aptly describes this process: “In our tradition, discoveries have been made based on individual experience and what we might call qualitative methods, rather than methods that can be reproduced in the same way in different

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environments,” as is the goal of science (p. 92). In both biomedicine and traditional medicine, latent empiricism refers to the knowledge, whatever its source and however transmitted, that provides the lens through which the clinician approaches a specific case, knowledge which is accepted as accurate and trustworthy because of its time-testedness even where the origin of the knowledge is unknown to the practitioner (Kirmayer, 2004). In this sense, biomedicine and those systems often characterized as “traditional” are both “traditional” knowledge systems. The accumulation of latent empirical knowledge, like Kuhn's (1970) notion of “paradigm,” is the “prerequisite to perception itself” (p. 113): it informs the clinician what the problem “sounds like,” or “looks like” as they commence their clinical investigation. Manifest empiricism, in turn, refers to the application of this generalized latent knowledge to particular cases, how this knowledge is tested against the case and challenged for its accuracy and effectiveness, with diagnosis and treatment adjusted accordingly in an effort to cure the patient or achieve some other standard of efficacy (Waldram, 2000, 2013). Manifest empiricism as praxis is most visible, then, in the clinical treatment of patients. As latent empiricism is closely involved with processes of perception, manifest empiricism is closely involved with the processes of interpretation. Manifest empiricism is the point at which a specific medical sign or symptom is observed and where the hermeneutical decisions are made in clinical time regarding their significance. From a narrative perspective then, manifest empiricism is about “therapeutic emplotment” (Mattingly, 1994), the process of “reading” clinical signs and determining the most appropriate treatment regimen to follow, which is based on or informed by the accumulated knowledge of prior cases, i.e., latent empiricism. Neither form of empiricism is, strictly speaking, “science.” They highlight the art of clinical decision-making that is therapeutically pragmatic (Barnes, 2005; Quah, 2003; Waldram, in press), a “practical reasoning [which] seeks the best answers possible under the circumstances … enables the reasoner to distinguish, in a given situation, the better choice from the worse … [and] is inescapably particular and interpretable” (Montgomery, 2006, p. 43e44). Arguing that Indigenous or traditional approaches to medicine or healing are “scientific” represents a conflation of ideas of empiricism with ideas of structured, purposeful and controlled inquiry that represents science, and misses the nuances by which traditional knowledge is collected through both processes of gnosis e the collection of knowledge through spiritual means e and those of practical engagement with the material world (Bates, 1995). What we demonstrate in this article is how Q'eqchi' Maya healers approach particular cases through both forms of empiricism, and constructively employ gnostic and material evidence as they do so. Our intent is to offset common notions that “traditional” or Indigenous forms of medicine, because they are not scientificallybased, are little more than the rote application of what we are calling latent empiricism at best, and primitive or magical thinking at worst, and therefore incompatible with biomedicine. The ubiquitous references to “beliefs” rather than “knowledge,” with liberal references to “folk” medicine, that have characterized medical anthropology's engagement with non-western medical systems have created a deep-seated bias in how these systems are best understood (Foster and Anderson, 1978; Good, 1994). Young's (1979) caution that traditional medical practices may exist not because they are effective but simply because there is no better option, or Kirmayer's (2004) notion that traditional practices characterized as “healing” are primarily symbolic and metaphoric, and endure primarily because of dissatisfaction with biomedicine rather than patient confidence in efficacy, need to be balanced by deeper examinations of the empirical and medical basis of much “traditional” healing. Manifest empiricism particularizes and

problematizes the clinical case, and we argue this is inherent in Q'eqchi' Maya clinical treatment. 2. Methodological concerns Collaborative research with members of the Maya Healers' Association (MHA) of Belize (formerly the “Q'eqchi' Healers' Association”) has been ongoing since 2004. The MHA is a group of varying membership, as many as ten active healers, which formed more than a decade ago to promote their healing activities. As part of this, the healers requested that research into their healing practices be undertaken with the goal of demonstrating their effectiveness to the health officials in the Belize government, medical practitioners in their region, and to their own people, many of whom are moving away from the traditional ways (in part due to persistent missionization from United States-based fundamentalist churches). The research has involved extensive interviewing of both healers and patients, and documentation of healing practices through video recording. Included in the interviews has been an exploration of the healers' knowledge of infectious disease and transmission. HIV/AIDS as a particular topic has arisen circumstantially as part of these interviews, which predate the case study to be presented by a few years and shed some light on the reaction of the Q'eqchi' medical system to the emergence of a problem for which it cannot easily account. The case study presented here unfolded in 2011 in the course of this on-going research. The research has received ethical approval from both the University of Saskatchewan Behavioural Research Ethics Board and the National Institute of Culture and History (NICH) of the Government of Belize. 3. HIV/AIDS in Belize HIV, Human Immunodeficiency Virus, causes AIDS, Acquired Immunodeficiency Syndrome, in which the immune system is progressively compromised, rendering the body vulnerable to a variety of infections and cancers, which, in many cases, ultimately cause death. The first case of HIV/AIDS was reported in Belize City in 1986 (Andrewin and Chien, 2008; Cohen, 2006), and Belize today has among the highest prevalence rates of HIV/AIDS infection in Central America. Between 1986 and 2009 there were 5045 cases of HIV and 963 deaths reported (PAHO, 2013). In 2009 the prevalence rate of HIV infection was estimated at 2.3% (PAHO, 2013). In 2010, HIV/AIDS was the fourth highest cause of death overall, at 6.7%, a slight increase from 2006 (PAHO, 2013). Indeed, HIV/AIDS was identified as the leading cause of death among adults in the 30e39 age range, at 25.5% and 17.7% in 2005 and 2006 respectively; between 2006 and 2009, HIV/AIDS was also the leading cause of death among those 40e49 years, at 17.2% (PAHO, 2013). However, more recent data suggest that, while the majority of new cases are in the 20e34 age range, the overall numbers of new cases of HIV infection are declining, although this apparent trend could in fact be due to better data collection and recording (Government of Belize, 2011). The Belize District, the area that includes Belize City, remains the most problematic area of the country, with most new infections occurring there (Government of Belize, 2011). In 2011, 1358 persons in the country were receiving anti-retroviral therapy (Government of Belize, 2010). Toledo District, in the south where this research was undertaken, is the poorest district in the country, with a household poverty rate of 46.4% in 2006e2010 (PAHO, 2013), and the highest unemployment rate of 14.9% (USAID, n.d.). Maya peoples, primarily Q'eqchi' and Mopan, constitute the largest group in Toledo, at 60% of the total population. Toledo District had the second lowest number of new HIV cases reported in 2011, at seven (four men, three women), and the general sentiment among health

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professionals in conversation with the researchers is that the district's Maya communities are less affected by HIV/AIDS despite the poverty, and that sexual transmission is the assumed route of infection in the cases that do occur. HIV/AIDS is certainly in the Maya communities of the south, however, so it is reasonable to assume that at least some of the many Q'eqchi' and Mopan traditional healers in the district have encountered HIV/AIDS-related cases, even if they were unaware of the over-arching AIDS connection. Our research with members of the Maya Healers' Association suggests that, while some have barely heard of HIV/AIDS, those that have view AIDS in particular as a discrete “disease,” as opposed to a syndrome, that is “new” to the Maya people. Their knowledge of its causes and clinical manifestations is minimal at best, as is their understanding of the origin of the human immunodeficiency virus. Links with animals are suspected, and they have learned that sexual transmission is now a key route of infection. According to one of the healers, the problem is not Indigenous to Belize but rather has arrived through sexual contact with foreigners who, in turn, have had sexual contact with monkeys. Two other healers' views on transmission involve sexual contact with dogs. Another healer, when queried about prevention, suggests that the only way to avoid getting HIV is to avoid sex with infected people. In all cases, a breach of the normative moral order is implicated. While there have been public health campaigns, and billboards, stickers and other message media are evident in the villages and towns in southern Belize, as yet there has been no attempt by the Government of Belize to reach out to the healers, teach them about this emerging problem, and work in collaboration with them, on the assumption that they will likely encounter HIV/AIDS cases. The linguistic barrier has compounded the problem of public health dialogue. Despite little apparent experience with HIV/AIDS per se, the healers do treat a large variety of other sicknesses. Some of these, including certain infectious and contagious diseases such as tuberculosis, cancers (undefined), and dementia, are known in biomedicine to be related to HIV/AIDS. By their own admission, the healers expect to be successful when they treat a patient. But individuals do, of course, die in the hands of traditional healers (Lewis, 2000), and to some extent self-vindicating explanations are invoked. But the healers do try to change the course of sicknesses, even ones that they are lead to believe by patients or medical practitioners may be terminal, because, as one healer noted, “It is our job to cure.” So what happens when the healers are called to deal with a complex and serious medical problem that confounds them, in this case a patient with a biomedical diagnosis related to late stage HIV/ AIDS, a diagnosis not disclosed to the healers until the final days of the patient's life? How does the existing traditional treatment system react? Does it simply invoke latent empirical knowledge e tradition e in a rigid fashion? Or does it approach the enigma dynamically, invoking manifest empiricism? How is the ultimate death of the patient contextualized within the existing knowledge base and the healer's imperative to heal, and how does the experience add to that knowledge? In the case study that follows we explore these questions, highlighting the dynamic interplay between latent and manifest empiricism. 4. A case study: the story of Domingo It is early Saturday morning and our research team meets up with Q'eqchi' healers and brothers Emilio and Francisco for our planned two-hour trek into the mountains to treat a patient. But when we arrive at Francisco's home in Punta Gorda, he and Emilio are visibly distraught. Standing with an unrecognized man, they

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explain that the man's son, Domingo, had collapsed into unconsciousness while harvesting beans on their farm near the village of Jalacte and was rushed to the Punta Gorda hospital. At the unadorned, six-bed hospital room, it is obvious to us that Domingo is seriously ill; he hardly moves and seems catatonic. His arms are strapped into the hospital bed and a small bag of clear intravenous fluid drips into his right arm. His bones seem to protrude through his thinly stretched skin and only small bursts of grunting noises whisper from his foam-covered lips. We learn from the patient's father, and from the discussions between Emilio and Francisco, that Domingo is believed to suffer from eet aj yajel, which the healers gloss as “epilepsy,” and in particular a severe type which the healers refer to as rilom tzuul, a genre of spirit “attack” translating as “illness of the Mountain Spirit” (Hatala, 2014). The brothers have actually been treating Domingo intermittently for almost two years, we learn later, during which time both diagnosis and prognosis had evolved (more on this later) and the condition more or less stabilized. Oblivious of the hospital setting, Francisco rolls up his sleeves and speedily begins his work. While Domingo lay motionless on the hospital bed, Francisco readies the herbal medications prepared in advance of the trip to the hospital. The plant he is using is known as puchuch retzul, which he explains later was appropriate because “he couldn't talk, hear or see,” and this plant would remedy that, so he could “tell us how he's feeling.” Francisco pours a small amount of the medicine onto Domingo's head and then into the small cap of a plastic water bottle. He feeds the liquid slowly and carefully to his patient while Domingo's parents stand beside the hospital bed watching intently. Even after two small capfuls of medicine, Domingo's disposition changes little; he continues to lie on the bed moving his legs and arms only slightly. Francisco then begins to pour the medicine onto his hands and wipe it onto Domingo's head and chest; this combination of ingestion and bathing of medicines is common in Maya healing (Nash, 1967; Fabrega and Silver, 1973). As he does so, Francisco cites a special healing prayer for this precise problem. Following the administration of medicinal herbs, Francisco reaches into his healing sack and removes a dark plastic bag filled with the remains of a duck that was killed earlier that morning in anticipation of this treatment. Within Q'eqchi' healing epistemology, a sacrifice or awas, meaning “feeding the spirit of the illness,” or “taking out the spirit of the illness” is called for in particularly difficult cases; the intent is to offer up the sacrifice to the offended spirit in return for the release of the patient from the spirits' malevolent influence (cf. Fabrega and Silver, 1973). Francisco slowly moves the bag over and across Domingo's entire body while starting a new prayer, uttered quietly and with little concern that others in the room might want to hear it. The awas is delicate and treated with cautious respect, and both Domingo's parents and Emilio take a large step back when Francisco begins the procedure. As the bag glides a few centimetres above his skin, Domingo remains motionless, save the movements of his left arm still strapped to the hospital bed and his long, grunting breaths. After several moments of this process, Francisco and Emilio say good-bye to Domingo's parents and swiftly leave the hospital, their treatment seemingly undetected by hospital staff. Francisco carries the plastic bag with duck remains slightly in front of him, as if the contents are dangerous or contaminating, and crosses the street to the edge of the bay. He offers some more words of prayer before quickly throwing the bag down the steep slope to the water below. Francisco then returns to the road where Emilio is waiting with a bottle of rum. Emilio carefully pours rum over Francisco's hands, who then wrings them in a washing motion. Concern with the powerful contents of the bag is palpable, and in their medical tradition alcohol serves both to spiritually and physically cleanse as well as protect against evil spirits.

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Later that same evening Francisco returns to the hospital to check on Domingo. This time, however, he seems more sensitive to the hospital setting, as he moves swiftly to avoid confrontations with a nurse or doctor who may object to the treatment. This kind of subtle avoidance between the “traditional” and biomedical systems is a common occurrence in Belize, especially in the southern region of Toledo where efforts to open conversations around collaboration remain preliminary at best (Killion and Cayetano, 2009; Staiano, 1981; Waldram et al., 2009). Francisco searches the room for a container in which to mix the medicinal plants he has brought in his healing sack. This time he is using tzul che' (lit.: mountain tree; f: Rubiaceae; sp: Gonzalagunia panamensis) “so that his mind can begin to work.” An old water bottle is found under the hospital room sink. After filling the bottle half-way with tap water, Francisco shreds and mixes the leaves, places them in the water, and blends them into a murky green liquid. As before, he pours some of the liquid into Domingo's mouth using the bottle cap. Domingo remains motionless on the bed, grunting occasionally, alternatively opening and closing his eyes. About three capfuls of medicine are given to Domingo, while Francisco smiles and offers tender words of encouragement. Francisco also pours some medicine onto his hands and rubs it on and around Domingo's head and chest. Pleased with this, Francisco puts the lid back on the medicinal water bottle and places it on the bedside table. With the session now over, he utters his farewell and we leave. Over the next three days, Francisco continues clandestinely to treat Domingo in the hospital with a combination of standard Q'eqchi' healing practices: herbal medications, traditional healing prayers, and the awas procedure. Domingo's condition improves slightly and, four days after our first visit, his father requests that the hospital staff allow his son to leave in order to continue treatment at Francisco's nearby home. Some of Domingo's strength has returned as he is able to get up from the hospital bed and move himself into a wheel chair to exit the hospital. His parents seem delighted to see this development and hopes remain high for a full recovery. At this point we are still unaware of Domingo's biomedical diagnosis, what treatment he may have been receiving in the hospital, and if that treatment, or Francisco's, or both are responsible for the apparent improvement. Based on previous experience and common knowledge, Francisco believes that it is unlikely that he would be allowed to treat Domingo in the hospital if the staff there were aware of his activities. Rilom tzuul was not the initial diagnosis in this case. From our later interviews with Francisco we learn that he first diagnosed kaanil, a fright-related sickness, likely related to a visit to a river where the patient fell, losing his spirit. Fright-related sicknesses are extremely common among Maya peoples and in Central America generally (Fabrega and Silver, 1973; Chevalier and Bain, 2003). This sickness developed slowly over a month or so and was not initially treated, leading to complications. Its treatment was guided by a form of latent empiricism, in which the set of symptoms and signs was compared to the existing body of medical knowledge and a likely diagnosis determined. The healer in effect recounts a “best practices” clinical approach as he explains. Upon diagnosis, Francisco had travelled to the place at the river where the patient had fallen, to make an offering of the patient's hair and copal pom, a tree resin considered sacred, in an effort to retrieve the patient's spirit. Water was also retrieved from the river for the patient to bathe in and drink. The treatment logic is clear to the healer. When asked why the water from the river is used to bathe and drink, he replies simply “Because that is the water that he got frightened in so we had to dampen his head,” and he had to drink it “because it is his entire body that got sick.” As Francisco relates, “That's the way we

treat. We're experienced. That's why we know” the complex procedures to follow. The healer initially believed that his treatment would be successful, and continues to think so after the hospital session. “He will get better,” explains Francisco, “but it will take about two to three weeks because his sickness is serious now.” But later, as the sickness continues to evolve, he grows concerned. “We thought that he would get well but it just worsens,” explains Francisco. “His blood is frightened so the sickness turned into eet aj yahel,” and then ultimately into rilom tzuul, the most serious kind of epilepsy that the healers recognize. Domingo is also suffering from cancer, admits Francisco. Francisco had employed a common Maya diagnostic technique often glossed as “pulsing,” or pulse reading (Balick et al., 2008; Fabrega and Silver, 1973; Nash, 1967). It involves “listening to the blood” while likely sicknesses are called out; the healer will feel the pulse react when the correct sickness is identified. The healer also “speaks” to the pulse, offering commentary, even admonishment, to the negative spiritual influences that are causing the problem, asking and if necessary ordering them to leave the patient alone. Continued pulsing during the treatment allows the healer to assess its effectiveness; the blood will respond in prescribed ways to signal improvement, a concrete example of manifest empiricism. The awas procedure was done in recognition of the seriousness of the case, which if left untreated would lead to the patient's death. The meat is offered to the spirits in exchange for the health of the person they are making sick. “The young man is in serious condition,” explains Francisco, “and you have to replace the person [patient] with that meat so he won't die.” At least a month of such treatment is required, with as many awas procedures as necessary. Demonstrating the relationship between latent and manifest empiricism, Francisco explains that using a duck is logical in this system. “That's the way it is. With eet aj yahel and rilom tzuul, that's what we give to the sickness.” The awas was done at a particular time in the evening as well. “That's the way we're taught to do it,” explains Francisco. A unique prayer was used during efforts to massage the patient's back, one that is “specifically for that” condition. Later, treatment continues at Francisco's home, where Domingo reclines in a hammock. Francisco places his hands on Domingo's head and begins uttering his prayers, starting a new round of treatment. His hands shift to the patient's wrists, checking the pulse, while he continues the prayer. After a few minutes, Francisco moves to feel the pulse at Domingo's forehead. With eyes closed, Francisco's hands remain there for a short time while he continues praying. He then moves his hands in a sweeping motion over and across Domingo's head and body and down to his chest, then repeats, performing the jilok or “spiritual massage” or “cleansing” (Sandstrom, 2001). “You start the “jilok” on the head then go down, because the whole body is suffering from this illness,” explains Francisco of this technique. In Domingo's case it “feels that the sickness is severe and will not get cured within a few days. It will take weeks.” Stopping on his chest, Francisco places both hands upon the boy, bows his head, and continues his prayers. Domingo is breathing heavily and remains motionless on the hammock. After repeating the jilok several times, Francisco takes hold of Domingo's wrists and once again continues his prayers while feeling the pulse. “In the prayer, I'm talking to the power of God,” Francisco later notes, “or the power of the Valleys and Mountains” (considered having significant spiritual force and which are often implicated in sickness). “They have high power over the earth and I borrow them to put down the heat of the sickness.” Francisco then bends down and picks up a water bottle full of green medicinal liquid prepared earlier that day. This is ik kehen

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(lit.: pepper herb) and che' puchuch (a tree) “for him to get up and move around,” Francisco explains, “to make him more alert and able to relieve himself as needed. “He was completely paralyzed,” added the interpreter. Domingo follows Francisco's instructions and drinks the medicine. He consumes about one-third of the liquid before Francisco says “Bueno” (Spanish for “good”), takes the bottle and places it on the ground behind Domingo. Domingo smacks his lips together from the bitter taste of the medicine. Later that same evening around midnight we return to Francisco's home to find him seated on a green plastic lawn chair beside Domingo, ready to perform another awas procedure. Francisco's figure assumes a prayerful position, one hand on his patient's forehead, slightly bent over, with his other hand over his knees grasping onto the top of a large white bag typically used for collecting corn or beans in the fields. Francisco remains in prayer for nearly two minutes while Domingo, barely visible, rests in the hammock with legs sprawled out over the edges. Francisco opens the large white bag and reaches inside. Immediately, loud screeching sounds pierce the quiet night, and the bag jerks. Francisco keeps a calm, stern face while he slowly pulls his hand from the bag. In his grasp is a large, white duck flapping its wings hysterically as it is hung upside-down by the legs. Eventually the duck calms and Francisco resumes his prayers. With his right hand holding the head and his left hand holding the feet, Francisco moves the duck, chest down, over and across Domingo's body, starting at the head. He repeats three more times; at some places he touches Domingo with the belly of the duck, at others he remains about an inch above Domingo's exposed skin and clothes. His prayers continue. “I was doing the jilok,” Francisco later describes, but one of greater complexity due to the continuing seriousness of the sickness. The duck was used in this case, “to tell the sickness that it has done enough and to stop disturbing the body and spirit.” After four repetitions sweeping the duck across Domingo's body, Francisco steps away and slowly stretches the neck of the duck until it is dead. Domingo and his parents watch, showing little emotion. Francisco returns to Domingo as the duck's wings agitate, and resumes his prayers and the jilok for several more minutes. Satisfied, Francisco places the duck back into the white bag, secures it, and resumes his prayers. He begins moving the bag rhythmically over and across Domingo's body, as in the first healing encounter in the hospital. After four movement cycles Francisco signals that it is time to dispose of the bag and bird. We climb into the truck and head off to properly offer the duck to the Mountains and Valleys. As the truck rolls along the dirt roads outside Punta Gorda, Francisco and Domingo's father exchange few words. We drive for about ten minutes before arriving at a small, wooden bridge where Francisco signals us to stop. Francisco jumps out and moves over to the bridge, looking to the small stream below. Bending over the edge of the bridge he begins offering prayers, white bag in hand. Francisco continues for nearly five minutes. When satisfied with his prayers, he turns the bag over and dumps the duck into the water below. During the following two days Domingo is closely watched and treated by Francisco at his home. Domingo remains weak and motionless, although generally seems to be on the path to recovery. Francisco has again changed the medication. It now includes a warm mixture of ru'j I rak' Aj Tza (Devil's Tongue) (f: Adiantaceae; Scientific name: Adiantum wilsonii) primarily used to treat epilepsy and seizures, severe headache pain, or madness (Bourbonnais-Spear et al., 2005), plus mai pim (lit: pain or infection plant) and b'aknel pim (lit.: bone plant), for fever and pain. The evidence suggests that Francisco continues to follow a treatment regimen for rilom tzuul, or extreme cases of epilepsy, but now with

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attention to possible dementia and concern for the pain experienced by Domingo, possibly a result of the cancer. After the third day of treatment at Francisco's home, Domingo's parents, now visibly worn and tired by the ordeal, express the desire to return their son home to Jalacte. Upon arriving, Domingo's father helps his son out of the car and up to their family home at the top of a large hill. Although apparently strong during the journey, Domingo collapses into a hammock while Francisco immediately attends to his patient. Healing prayers, medicinal herbs, burning of candles, jilok, and the awas procedure now have a constant rhythm and presence for Domingo and his family. In the week that follows, Domingo remains motionless, save the occasional transfer between hammocks, all the while showing little interest in food. His condition appears to be stable or even in decline; he is weak and visibly underweight. Due to the general lack of change in his patient's condition, Francisco now appears to alter his therapeutic approach, trying more combinations of medicinal plants (including retzul, tzul che', ik kehen and b'aknel pim), a variety of animals for the awas procedure (i.e., chicken, fish, turkey, and duck), and other procedures or mayejak, including intense prayers with candles and deep tissue massage. The once expectant hope of Domingo's parents now wanes. Several days later, in another attempt to re-establish Domingo's health, Francisco and his brother Emilio e a religious and healing specialist e conduct a two-hour healing ceremony for Domingo and his family. This is the first time they have worked together on Domingo, perhaps a somewhat desperate attempt to help him recover by calling on their combined knowledge and experience. It is also the first time that the family is actively involved. On a hill behind Domingo's family home, overlooking the village of Jalacte, Emilio and Francisco begin their preparations for the elaborate ceremonial procedure that will hopefully bring positive results. Cut and prepared by Domingo's family earlier that evening, a large bundle of sticks, approximately one foot long and now wrapped together with twine, is placed into a large, metal cooking pot. Additional healing paraphernalia are laid out: several candles, four eggs, copal pom, and several different kinds of seeds and grains. Domingo's parents emerge from the home with Domingo barely able to walk and visibly weak, clutching onto both parents for support. His parents lead him a few short strides away from their thatched dwelling and seat him on a plastic lawn chair. As Domingo faces the moon in his chair his skeleton-like features are exposed by its pale light. His father places his left hand tenderly on Domingo's shoulder as they watch the two brothers prepare the ceremonial and healing paraphernalia. Emilio pours different seeds and other objects into and around the wooden sticks, while Francisco watches. Satisfied with the preparations, Emilio pulls from his bag a red sash that he ties around his waist and a green scarf that he ties around his head. These are Emilio's credentials, visible insignia of the expert level of healing knowledge he has attained, and the only one of the healers in our project to achieve such status. This change of physical appearance signals the beginning of the treatment. The brothers commence by pouring gasoline into the large metal cooking pot and lighting the sticks on fire. Emilio takes hold of the four eggs that were placed just beside the burning sticks and offers his words of prayer. After several minutes of prayer Emilio approaches Domingo and begins sweeping the eggs over and across his body while he continues offering his prayers, an act designed to draw out the sickness. He pauses occasionally, blowing on the eggs to propel the sickness into them and then holding them on Domingo's head before returning to his sweeping motions. Domingo remains silent and motionless, gazing into the fire, while his father stands close, offering his love and support.

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Emilio, still praying, continues sweeping the eggs over Domingo's body. Occasionally he approaches the fire and waves the eggs briefly through the smoke and flames to purify them before returning to Domingo, placing the eggs on his forehead as before. Emilio then asks Domingo to blow on them several times, then approaches the fire, and while still in prayer and making several gesturing motions to the fire with the eggs still in hand, drops them, one by one, into the flaming cooking pot. The sickness, now contained within the eggs if the procedure has worked, will be incinerated. Once all of the eggs are engulfed by the fire, Emilio takes thirteen differently coloured candles from his pile of healing paraphernalia that are resting several feet away. This large and varied set of candles e red, black, white, green, yellow and blue e suggests that this is a difficult case, as each colour represents a different aspect of the treatment process, and are offered up in hopes of learning what the patient may have done wrong to bring this sickness. Identifying and treating the cause of the sickness is often as important as treating the sickness itself; in a sense, they are inseparable (Waldram, 2000). While holding the whole lot in his left hand, Emilio removes one candle at a time, offers words of prayer for several minutes, and then places it in the fire with the eggs and burning sticks. He continues this for nearly five minutes with each candle while Domingo and his father continue to observe. In the midst of his prayers with the candles, Emilio signals to Francisco, watching from a few feet away. Francisco immediately enters the home and emerges quickly with a baby duck. While Emilio continues offering his prayers with each single candle, Francisco performs an awas, sweeping the duck over and across Domingo's entire body while pausing at his head and then his stomach area, his prayers joining Emilio's. Once satisfied with this process, Francisco, with a small knife, removes the head of the baby duck, and holds it for a moment while offering words of prayer. Slowly the blood drains from the duck's body into a small plastic bowl and is disposed of with the duck remains. Francisco places the duck into a black plastic bag, glances at his brother (who has continued to pray with the candles) and proceeds to a small creek behind the house where the remains of the animal are left. He then returns to the house where Emilio is still at work. With all thirteen candles placed in the flames, Emilio takes a larger, white candle and continues with his prayers for several minutes. Francisco and Emilio then give one candle each to Domingo, his father and mother. Francisco and Emilio both hold large white candles. After Emilio has lit all the candles, the two healers, Domingo and his parents all begin, with the utmost intensity, offering simultaneous prayers. The cacophony continues for several minutes before Emilio signals the family to place their candles into the fire. One by one they follow his instructions, Emilio placing Domingo's for him. Emilio then signals Domingo's parents to pick up their son and move him towards the fire. Domingo's steps are slow as his parents hold him tightly on either side. They move towards the fire and circle it once. Emilio asks Domingo to wave his feet through the fire, which he does with some hesitation, one at a time. Emilio smiles and nods in approval while signalling that their healing work is complete. Sweating from being so close to the fire, his family walks Domingo back inside their home. Francisco follows behind and then returns with a large plastic bag full of plant medicine. Emilio takes the bag and, while facing each cardinal direction, begins offering prayers for the medication to be effective. Following a short clean-up, Emilio and Francisco head back to Emilio's Jalacte home. They leave the wooden sticks to burn on the hill. Despite occasional moments of apparent improvement over the previous few weeks, after this treatment session the emotional tension in the home clearly grows as, unfortunately, Domingo's

condition remains, for the most part, largely unchanged over the next several days. At this point, the family, Domingo, and Francisco begin to seriously doubt their initial hope for a full recovery. Everyone's frustration is evident. At the outset, Domingo's father was confident that Francisco could help and was eager to get Domingo out of the hospital in order to seek traditional assistance. Now, however, after nearly a month of varying treatments from Francisco, Domingo appears very ill and his father is open again to seeking help from the hospital and biomedicine. The day after the evening ceremony, Domingo's father asks the research team to assist him with a refill of Domingo's medication from the hospital. The empty bottle reads “Nevimune.” Nearly one month since our first meeting Domingo, the research team approaches the attending nurse in Punta Gorda regarding the medication, and she describes her version of Domingo's medical history. According to the nurse's records, Domingo was confirmed HIV positive two years prior and is now in advanced stages of AIDS. Apparently, Domingo has been taking Nevimune and other antiretroviral medications for nearly two years, going to a health centre for regular refills. There is a good chance, the nurse cautions, that Domingo has also contracted tuberculosis (TB), since his immune system is so weak and TB is present in many of the southern Belize villages. The nurse is anxious to learn about what the Q'eqchi' healers were doing to treat Domingo as well as what his family and healers' thought of his condition. The research team explains the healer's initial diagnosis of a spiritual sickness called kaanil that progressed to eet aj yahel and had now become rilom tzuul, one of the most serious conditions that Q'eqchi' healers know. The nurse is patient with the story but confident that the healer's treatment would have limited effectiveness. She is especially concerned with how Francisco's herbal remedies might interact with the antiretroviral medications and is surprised to learn that the father had discharged Domingo from the hospital. It is apparent that Domingo's family did not know or fully understand their son's medical history with HIV/AIDS. The following day in Jalacte, Domingo's parents, who only a few weeks prior were visibly hopeful, now seem outright angry. Domingo remains motionless on the bed, wheezing and coughing steadily. He had been vomiting violently through the night as well, we were informed. Francisco and the family talk together for several minutes while Francisco mixes a fresh batch of herbal medications. Domingo drinks the medicine, but immediately vomits. After another several minutes of concerned discussion, Francisco opens the Nevimune bottle, pulls out two pills and motions for Domingo's mother to bring some water. Despite his earlier troubles with vomiting any ingested substance, Domingo is able to hold the pills down. Francisco ultimately recommends that Domingo return to the hospital as there seems to be no more he can do. Domingo's condition, however, now leads the family to feel it is best to keep their son at home in Jalacte. Domingo's father holds his son's hand while sitting hunched over on a wooden stool; his mother's eyes tear up as we say goodbye to the family, perhaps suspecting the worse. Later that same evening, the research team receives a phone message from Domingo's sister that Domingo has died. The funeral is planned in Jalacte a few days later and the family invites the team to attend. Following this depressing and desperate concluding visit, Francisco explains that he suspected something more serious was happening since nothing he did seemed to alleviate Domingo's condition. Francisco does not refer to AIDS but instead refers to a “severe sickness” that is “uncontrollable” and likely predates yet is linked to Domingo's onset of kaanil, the fright sickness. Francisco's original diagnosis of kaanil developing into rilom tzuul still remains the most logical way to conceptualize the seriousness of Domingo's

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state, although Francisco seems unsure why Domingo was unresponsive to the traditional treatments for that well known condition. In a later conversation, we bring up the idea of Domingo being diagnosed with AIDS-related sickness and talk with Francisco about the implications. Since it is obvious that Domingo knew about his AIDS status, Francisco expresses some frustration that this important information was not shared with the healers or the family. He now suspects that Domingo contracted HIV from “being with a woman.” When we ask him how he feels regarding Domingo's death, Francisco appears detached and unemotional, saying that he had “done everything” possible and that there is nothing different that he could have done to ensure a better outcome. The failure of his treatments to work was a sign that something else was going on in addition to kaanil and the rilom tzuul but that time ran out before he could make a determination. Domingo's reluctance to seek medical help in a timely fashion was also a confounding factor that clearly frustrated him. Francisco explains: Even the doctor tried, so Domingo had to die. When he was not suffering he could have looked for help, but he just waited for it to turn severe. Then he tried but he didn't have the strength to withstand the pills or the medicinal plants … For two years back he could have looked for help, but now there's nothing we could have done. He still would have died. In death, Francisco suggests that Domingo's spirit and body are both “happy, since the spirit is now resting.” “He didn't do anything bad,” Francisco clarifies, suggesting that the sickness, in the end, was not Domingo's fault and disengaging the connection referred to earlier between HIV/AIDS contraction and behaviour seen as morally problematic. 5. Discussion Francisco's judgement that the patient and his family failed to take appropriate action in a timely fashion, and that Domingo was already suffering a serious sickness, might seem self-vindicating. But further reflection suggests a much more complex explanation is needed. The condition from which Domingo suffered was seen differently within biomedicine and the Q'eqchi' healing system, yet practitioners in both medical systems shared a critical opinion of the patient's irresponsibility in failing to act appropriately in his own interests. The biomedical practitioners, invoking existing biomedical knowledge of HIV and AIDS-related illness, set a course of treatment that emphasized antiretroviral medications and hospital treatment. The Q'eqchi' healers, invoking existing knowledge of sicknesses caused by Mountain spirits and fright, set a course of treatment that emphasized herbal medicines, jilok, pulsing, sacrifices, and ceremony. Both approaches are typical of all medical systems in that they “frame problems in relation to the solutions they have to offer” (Barnes, 2005: 246) e that is, latent empiricism e and they are therefore logical within the context of their knowledge systems. When the initial diagnosis proves to be inaccurate, as evidenced by the failure to cure the patient or, more specifically, lack of clear evidence that his condition was improving, the healers began to search for alternative diagnoses and treatment approaches. It is in this process that manifest empiricism comes to the forefront, as they shift medications and other treatment techniques and assess their effectiveness. And it is through this process, and the retrospective revelation that the patient was suffering from an AIDS-related condition, that the healers learn empirically the signs and symptoms of a weakening immune system related to this new problem, and reverse their prior understanding of AIDS as related to morality, knowledge that presumably will be synergistically added to their latent empirical medical tradition to be called

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upon and tested the next time that a patient with similar problems is encountered. In this case, the relentless effort to successfully treat the patient was thwarted by the patient's own behaviour. For the healers, while the death of any patient is unexpected, the death of Domingo could be predicted in part because of his reluctance to disclose the nature of his illness to his family or to follow faithfully the course of treatment laid out by doctors, who knew the condition, and healers, who did not. At no point was there a conversation among these health care practitioners regarding the case. Indeed, the healers were forced to treat the patient in a clandestine manner while in the hospital. Given that the patient and his family were embedded within the broader Q'eqchi' cultural system, recourse to a traditional treatment, especially in such dire circumstances, could easily be predicted. The disinclination e mostly on the biomedical side, as the healers have repeatedly invited collaboration and, as we saw, are willing to practice in hospitals e to work with the traditional system created an unnecessary conflict for the patient and his family, who seemed torn between the two systems and unsure of the best course to follow. Of course the outcome for the patient may have been the same regardless of any collaboration, but both systems' failure to meaningfully engage was certainly not optimal for the patient or the family. And given the potential consequences of infection, the healers themselves unknowingly put themselves at risk of contracting the virus through their traditional treatment techniques and lack of understanding of its non-sexual transmission potential. It is not a question of understanding the concepts of infection and contagion e for they do e but rather the lack of knowledge and experience to appreciate the idea of a syndrome e as opposed to a discrete disorder e and identify this particular problem as a potential danger. Collaboration between healers and medical practitioners in the education about and treatment of both “old” and “new” diseases and syndromes, such as HIV/AIDS, is certainly possible (e.g., George et al., 2013; IRIN, 2003; Liverpool et al., 2004; Mills et al., 2006). It is therefore essential that efforts not be directed toward the dismissal or eradication of the traditional systems themselves, but rather toward education and integration of biomedical and traditional knowledge through an appreciation of the latent and manifest empirical dimensions of both. Instead of trying to reconcile the nature and variability of traditional healers' knowledge of conditions such as HIV/AIDS, collaboration should focus on “windows of compatibility” (Dickinson, 2008) where there is convergence in the two systems. Obvious windows of compatibility are evident from the case study presented here: both the healers and the biomedical practitioners are caring individuals focused on the wellbeing of their patients; both systems have high expectations for patient accountability; both work from a body of latent empirical knowledge; and both engage in elaborate processes of manifest empiricism in their efforts to diagnose and treat. There are important differences between the two systems, of course, which cannot be discounted. This may be best understood ontologically, in the manner in which their latent empiricism has been built up culturally and historically over the years, that is, drawing on the insights of scientific rigour and clinical training and practice for biomedicine or the slower process of clinical apprenticeship and cosmological guidance for Q'eqchi' healing. But we feel that a mutual respect of these ontological differences will go a long way toward opening the door for collaboration. Q'eqchi' healing is inextricably intertwined with the spiritual and cosmological, but there is much potential to find compromise, a middle ground where Q'eqchi' healers can become more active in partnership with scientifically-trained biomedical specialists without having to surrender what they see as the central and most crucial element of their healing. Spirituality, while somewhat ineffable, is, as Csordas

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(1997) reminds, still empirical “in the sense that phenomena such as evil spirits, or the sense of divine presence, are experienced as real in their own domain, just as are viruses in the somatic and emotional traumas in the mental domains” (p. 39e40). The potential for collaboration is great, especially because of the relative openness of the Q'eqchi' medical system, one that is considerably less dogmatic and hence quite able to incorporate new knowledge. 6. Conclusion Understanding the manifest empiricism that underscores Q'eqchi' medical practice allows us to see how such systems remain open to new ideas, a “whatever works” ethos (cf. Quah, 2003) that facilitates the incorporation of new ideas, particularly when they are proven to work. Such medical systems, which are patientfocused rather than tradition-bound, are inherently flexible and not at all characterized by the assumed inflexibility suggested by the notion of latent empiricism. The healers do not resist new ideas; instead, they welcome change. In the course of our research with them they have often asked us to help bring them items such as surgical gloves and snakebite kits, which they understand will make their work safer, and analgesics, which they know to be highly effective for pain and fever. Latent empiricism e a euphemism for “tradition” e of course informs their work, but it represents an organic, constantly evolving body of knowledge (as are all oral knowledge systems). It is manifest empiricism that allows them to treat patients successfully, a willingness to challenge the latent empirical knowledge within the context of a specific case, and to question their own diagnoses and treatments in the face of contrary empirical evidence as the case unfolds. Acknowledgements Funding for research with the Maya Healers' Association has been provided by the Social Sciences and Humanities Research Council of Canada (# 435-2012-0634). We wish to acknowledge the assistance of Victor Cal, members of the Healers' Association, and our interpreters employed over the years: Pedro Maquin, Romalo Caal, Federico Caal, and Tomas Caal. Pamela Downe provided valuable insights on HIV/AIDS research. References Andrewin, A., Chien, L., 2008. Stigmatization of patients with HIV/AIDS among doctors and nurses in Belize. AIDS Patient Care STDs 22 (11), 897e906. Balick, M., De Gezelle, J., Arvigo, R., 2008. Feeling the pulse in Maya medicine: an endangered traditional tool for diagnosis, therapy, and tracking patients' progress. Explore 4, 113e119. Barnes, L.L., 2005. American acupuncture and efficacy: meanings and their points of insertion. Med. Anthropol. Q. 19 (3), 239e266. Bates, D., 1995. Scholarly ways of knowing: an introduction. In: Bates, D. (Ed.), Knowledge and the Scholarly Medical Traditions. Cambridge University Press, Cambridge, UK, pp. 1e22. Bourbonnais-Spear, N., Awad, R., Maquin, P., Cal, V., Vinda, P., Poveda, L., Arnason, J., 2005. Plant use by the Q'eqchi' Maya of Belize in ethnopsychiatry and neurological pathology. Econ. Bot. 59 (4), 326e336. Chevalier, J., Bain, J., 2003. The Hot and the Cold: Ills of Humans and Maize in Native Mexico. University of Toronto Press, Toronto, ON. Cohen, J., 2006. Taking it to the streets: an unusual prevention program targets gang members, who are seen as particularly vulnerable to HIV. Science 313 (5786), 483.

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