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Sm. Sci. Med. Vol. 27, No. 1, pp. 69-73, 1988 0277-9536/88 53.00 +0.

Printed in Great Britain. All rights reserved Copyright 0 1988 Pcrgamon Press plc
Assistant Professor, College of Nursing, University of Florida, Box J-187 JHMHC.
Gainesville, FL 32610, U.S.A.
Abstract-Although Costa Rica has one of the most effective national health systems in Latin America,
popular medicine still persists. The sobada is a traditional healing technique which involves rubbing. Used
principally to treat pego, a folk-diagnosed gastrointestinal condition which mainly affects children and old
people, it was used by 70% of a random sample of families from the poorer barrios of San Jo&. In recent
years Costa Ricas health system has been under great strain because of increased costs and numbers of
users. The prevalence and possible resurgence of the sobada may be an adaptation of poor people to
national health services which have grown suddenly very large and impersonal and to the recent
introduction of oral rehydration in hospital settings.
Key words-ethnomedicine, sobadu, oral rehydration, folk illness, gastrointestinal illness
Costa Rica, with a population of slightly over 2
million people, is unique among Latin American
countries for its long-sustained democracy, upper
class social conscience, and a relatively large middle
class. Throughout the colonial period the Spanish
settlers labored to produce their own food [l]. Al-
though a few wealthy families were granted special
privileges by the Spanish crown, they never occupied
the dominant position which the aristocracy of Gua-
temala, Nicaragua and El Salvador assumed, and
land they held never amounted to more than a small
portion of the cultivated area of the colony. In 1848
people were permitted to buy land that they were
using, and this greatly increased the number of
landholders [ 11.
Although a small class of large landholders re-
sulted from the cultivation of coffee and bananas as
cash crops, and the introduction of cattle raising for
export [2], an egalitarian philosophy was maintained
within the government. A series of enlightened social
welfare programs were enacted in the years following
the second World War that affected social security,
health, housing, and the protection of children. At
the present time, Costa Rica has one of the most
effective health systems in Latin America, encom-
passing both curative and preventive medicine. Mesa-
Lago [3] describes the current system in detail and
notes that these advances have made Costa Rica
second in Latin America for such indicators as
population coverage, infant mortality, and life ex-
pectancy. An infant mortality rate in 1980 of 19.1 per
1000 population and a life expectancy at birth of 73.4
years [4] reflect the general health status of the
population. Life expectancy at birth in the United
States in 1978 was 73 years and infant mortality for
Whites 12/1000, for Blacks 23.1/1000, and for Blacks
and other minorities 21.1/1000 [S]. In 1979 other
countries in Central America such as El Salvador and
Guatemala had infant mortality rates of 53/1000 and
70.1/1000 respectively [6]. Mata and colleagues [7,8]
state that in Costa Rica no cases of poliomyelitis or
diptheria have been recorded in recent years, and
cases of measles and whooping cough have been few.
This speaks well for the national health immunization
system, yet the diarrhea1 disease death rate was 11 per
A recent study of nutrition and growth among
poor urban children in San JosC found that they had
good access to primary health care. Over 90% of a
random sample of 107 children aged 3 years and
under, drawn from the poorest areas were found to
have had their BCG, DPT, polio and measles (rubella
and rubeola) immunizations completed [9]. In com-
parison, records show that in Florida, although
93.7% of all school entrants had been immunized, the
rates for children aged l-3 or 14 are probably closer
to 60% [IO].
In spite of Costa Ricas excellent health system,
however, popular medicine continues to thrive. One
aspect of this system is a healing complex using
rubbing as its central treatment. I prefer to translate
the technique of the sobada as rubbing rather than
massage since masuje is generally used in Costa Rica
to refer to techniques used in massage parlors and
health clubs. The verb sobar is always used to refer
to therapeutic rubbing. Although the sobadu is com-
mon among lower class people, it is not prevalent
among the upper classes, and it has been neglected by
professional medicine. Pardo [ 1 l] mentioned the sob-
ada briefly in her work on self-medication in Costa
Rica, but as a rule, my upper class friends and
acquaintances knew little or nothing about it. Of
course, European humoral traditions from antiquity
used therapeutic massage, cupping, blistering, hot
applications and various other physical manipu-
Of special interest to the introduction of oral
rehydration therapy, the sobada is the primary treat-
ment for a folk illness called pega, gastric upset. Pega,
means literally to stick or become stuck. It is an
illness in which food becomes stuck in the stomach,
causing discomfort. It resembles empacho among
Mexican-Americans and in Honduras [12-141. Some
of my older informants said that when a pegu had
gone on for many days it became empucho. Younger
informants, however, knew it only as pegu. The
Honduras study [14, p. 2551 described empacho as a
painful condition of the gut characterized by ex-
plosive evacuations and flatulence and brought on by
eating improperly. In Honduras, empucho is treated
by sobadores, and Rubel [12] also describes massage
for empucho among Mexican-Americans.
In Costa Rica, pegu is also treated by sobadores,
who employ the rubbing techniques described below.
These practitioners have varying levels of expertise,
ranging from those who treat only family members to
those who are known throughout the country. In the
discussion that follows, these healers and their prac-
tices will be described as well as the potential impli-
cations this complex may have for the imple-
mentation of oral rehydration therapy.
Symptoms of pega
I asked mothers of the 44 small children who were
selected from a larger random sample of poor chil-
dren in San Jose to describe the symptoms of pegu,
and I interviewed 9 sobadores. These informants were
uniform in describing the loss of appetite, thirst,
vomiting, upset stomach and sunken eyes of pegu. If
no diarrhea occurred the condition was called a pegu
secu or dry pegu. Fever may also be present. When
a child was taken to the hospital with these symptoms
the diagnosis was usually gustro (gastroenteritis).
A pega can be caused by almost any food, de-
pending upon the circumstances. The conditions sur-
rounding ingestion of the food were important. For
example. eating too much, or eating something the
person disliked, which frequently happened when one
was visiting another home. It is obligatory to offer
guests food, and an insult not to eat what is offered.
According to informants pega primarily affects small
children, but adults, particularly older people, may
also suffer from it. Some biomedical researchers
believe empucho in Honduras may have a different
etiology from most diarrheas, e.g. a rotoviral agent or
food allergies [ 141, and this may apply to pegu as well.
The sobador first asks whether the person has had
diarrhea, vomiting and loss of appetite. He or she
then feels the inner aspect of the elbow for a small
lump or ball, behind the ears for lumps, and then
thumps on the stomach, listening for the sounds. If
the stomach and abdomen sound full the patient is
ventudo or blown up with air and it is a sign, along
with the lumps that pegu is present. The sobadores
were very specific about symptoms, and indicated
that they sent patients to the hospital and did not
initiate a sobuda if they did not have pegu. The
mothers concurred, many of them having been sent
to the hospital or health center by sobadores to whom
they took their sick children.
The usual order of the sobadu is to rub the inner
aspect of the elbow and down the inner side of the
forearm toward the hand and then between the
thumb and forefinger. Next, the sobudor rubs the area
behind the ears and the back of the neck. In some
cases they also rub the back. Finally the sobudor rubs
the area directly behind the knee.
Most informants said that in the past the stomach
was rubbed as well, but now that practice was
considered dangerous. Pardo [l l] for example. men-
tioned rubbing the stomach for pegu. All but two of
the sobadores denied rubbing the stomach during the
Vegetable shortening (muntecu) is usually used in
the rubbing process. The rubbing is very firm and
may be uncomfortable for the patient. Occasionally,
the patient may vomit, and this is considered a good
sign since it removes food stuck in the stomach.
After this rubbing the patient is usually given either
milk of magnesia, manzanillu (chamomile) tea mixed
with lemon juice and baking soda, or duke (cane
syrup) with salt. The patient is told not to eat
anything for a day. These medicines are mild lax-
atives and antiacids, but strong purgatives were de-
scribed in the Honduras study [14]. Most sobadores
also insist that the patient fast for a day before
beginning the treatment, although water is allowed.
Sometimes, if the pegu has gone on a long time before
the sobador was consulted, or otherwise proves to be
a difficult case, the procedure may have to be re-
peated 2 or 3 times before the patient recovers.
Most sobadores who treat pegu are women. Some
people, mostly men, use the sobuda to treat pulled
muscles and sprains, and in this case, the practice
overlaps with other forms of massage. A sobuda is
also the treatment for uire and quebrunto, which are
common illnesses in hispanic populations [12, 131.
Aire occurs when a cold draft enters the body. The
victim develops aches and pains and may have a
slight fever. A sobadu with vegetable shortening or
some other oil may relieve the affliction. Quebranto
usually occurs when babies under 6 or 7 months of
age are handled roughly. The hips and legs are
believed to be damaged. The symptoms include irri-
tability, crying, and when the baby is placed on its
stomach and the legs measured against each other
one may be shorter. A sobuda of the hips and legs
with vegetable shortening is followed by binding the
hips and legs. My informants thought this illness is no
longer as common as it once was. Perhaps some of
the cases once diagnosed as quebrunto involved con-
genitally dislocated hips which are now diagnosed in
the hospital soon after birth or in the well-baby clinic.
Some preliminary considerations on the sobada
Nine healers were interviewed and observed. Four
of them were men and five were women. They ranged
in age from late 20s to 70 years of age. Except for 2
men who treated clients from all over the country,
none of the sob&ores interviewed worked as healers
full time. Most of the women were housewives,
although one worked as a cook for an upper class
family. The younger male healer worked as a clerk in
a store. The older man who was not employed full
time as a sob&or was retired.
Almost all of the healers had learned their tech-
niques from some older family member, suggesting a
strong tendency for certain families to follow this
tradition. Those healers who had larger clienteles
used other types of healing methods, including the
use of herbs, spirit healing, and sorcery, as well as the
sobada. Neighborhood healers used only the sobada.
Dofia Inez began to do the sobada because her
mother was a healer. She was one of the two healers
I interviewed who insisted that a person needed to
have a gift for healing to carry out the treatment with
success. She considered herself to be clairvoyant, and
was in some demand to help people who suffered
from sorcery. She told of a woman patient who had
been ill in bed for months. The doctors did not know
what she had, but Doiia Inez discovered that the
trouble stemmed from a charm buried in her yard by
her lovers wife.
Neighborhood sobadores do not customarily
charge anything. However, when the treatment is
successful, people give them fruits and vegetables or
other gifts. One practitioner told me that she knew
about her rate of cure by the gifts which people
brought when the sob& was successful. The two
older men who were full time healers with large
clienteles from all over Costa Rica did charge for
their services.
Ana Maria
Ana Maria was one of the younger healers. She
began by working with an experienced woman, and
initially performed the sobado on her own children.
She had been in practice for about 1.5 years, and said
that she had treated at least 40 children successfully,
although some were brought back to her several times
because their symptoms returned. She did not charge
for her services, but people frequently brought small
gifts. When asked about an interesting case, she told
of a 6-month-old child who vomited while she was
rubbing. According to her, this was unusual since
vomiting may occur with the illness, but not usually
during the rubbing. It was a certain confirmation of
the pegu diagnosis.
Doiia Inez lived in a neighborhood which she
considered violent, and she was always very con-
cerned about my visits. She usually sent one of her
older children to accompany me to the bus stop, but
she did not show concern for her own safety, saying
that she was respected as a healer. Since she dealt
with sorcery she may have been feared as well. Her
patients came from the immediate neighborhood, and
around the city. During one of my visits a woman
from Escazu, a small town just outside San Jose,
brought her child for a consultation because of pega.
Separated from her alcoholic husband years ago,
Dofia Inez lived with her children. Although she was
very poor, I thought that she had a great deal of
strength, wisdom and hope. She was intelligent and
had an elementary education. She never charged for
her work, but in gratitude clients gave her gifts of
money and food. She refused to have a conversation
about her clairvoyance tape recorded, saying that
most of her neighbors were not aware of it, and that
she did not want people to think she could place
spells on them. Her treatment for pegu was essen-
tually the same as that of the other healers.
Unfortunately, no controlled studies have looked
at the outcomes of treatments by these healers.
Although the healers I interviewed admitted to some
failures, they attributed the failures to poor diag-
Another case Ana Maria told about was an older
woman who had to have the rubbing treatment 3
times. This was very unusual, and when the woman
came for the third time, Ana Maria told her that even
though she herself was convinced that the woman
had pegu, if the treatment did not help after the third
try she should go back to the doctor. The third time,
however, the woman recovered.
Don Pace
One of the older male healers, Don Pace, began to
be interested in curing with herbs and in the sobadu
in about 1939-1940 when his children were small. His
mother was well known as an herbalist and sobodora.
His brother also practices curing full time and
charges a fee. Don Pace said that he never charged
for his services. He treats himself for diabetes, at the
same time taking medicines that the doctor pre-
scribed. His remedies were teas made with herbs, tree
bark and other vegetable matter. His patients were
mainly his family, friends and neighbors.
Since physicians and nurses do not diagnose pega,
and discount its reality when others refer to it, they
are not aware of the extent to which it pervades life
among the poor. While gathering data on child
nutrition, I became aware that pega was a widespread
phenomenon. In 70% of the families of 44 children
that 1 followed, either the child or another person in
the family had a pegu treated by a sobador one or more
times during the preceding year. The figures ranged
from 20% of the children in the central barrios of San
Jose to 100% in the more marginal outer areas. These
families were representative of the poor in San Jose
since they were chosen from a larger random sample.
Many people told stories about how they and
friends nearly lost children or other family members
because they had been taken to the hospital and given
suer0 (glucose water) orally, when what they really
had was a pega which doctors did not recognize or
treat. I was told of many children who did not
improve after several days in the hospital, and were
then taken to a sobador who successfully treated the
illness. However, when the child had the symptoms of
pega most parents went to the sobudor first. Although
people who consulted the sobadores did seem to
believe in them, they also complained about long bus
rides to consult doctors, long waits for appointments,
and the failure of physicians to look at them or listen
to what they said, indicating that these were addi-
tional reasons for preferring to use the sobador.
The apparent popularity and possible resurgence in
the use of the sobuda for treatment of pegu appears
to be a contradiction in view of the success of the
existing National Health System. In Costa Rica,
preventive medicine seems to have been embraced
wholeheartedly through the community health pro-
gram, while the system of Social Security Hospitals
and Clinics is a formidable resource for curative
medicine. As other studies have shown, however,
[15, 161, various kinds of curing coexist with profes-
sional biomedicine in urban centers throughout the
world. In this sense, San Jose is no exception.
The mother of a small child with gastrointestinal
symptoms weighs the alternatives-the hospital, or
the sobador. At the hospital she can expect at best a
lukewarm reception and at worst a scolding for
whatever it is that she supposedly has not done. My
informants claimed that the sobudu has become more
widely practiced in recent years to treat children with
pegu. If this is indeed the case then the resurgence of
the sobudu may correspond with the introduction of
oral rehydration. Costa Rica has long been a pioneer
in the development of a practical regimen of oral
rehydration [17, 181. The Nutrition Rehabilitation
Center in Tres Rios and the National Childrens
Hospital now use oral rehydration for all except the
most severely dehydrated children. People in devel-
oping countries have long put up with many short-
comings in the patient/practitioner interaction in
hospital settings because they have tremendous awe
and respect for modern technology. Oral rehydration,
however, is very similar to many of the traditional
practices. Giving a child an oral solution is not so
different from the traditional use of herbal teas. Thus
the family awaiting modern technology at the hospi-
tal may find that their expectations are unfulfilled.
The use of suero in a baby bottle or with a spoon was
a frequent complaint. The oral rehydration at the
hospital was administered in an impersonal way. One
has only to experience the warm, concerned atmos-
phere in which the sobudor works and the total
concentration on the patient during treatment, to
realize why many mothers may opt to utilize these
practitioners rather than the hospitals and clinics of
the National Health System. This is especially SO
when the treatment does not seem to differ
significantly from traditional practices.
Popular medicine is widely used in urban Costa
Rica in spite of a modern and effective national
health system. The sobudu complex is an integral part
of therapy among the poor, and, according to infor-
mants its use is increasing. It should be taken more
seriously by practitioners of scientific medicine.
Rather than being condemned or ignored as is now
the case, the sobudu complex should be evaluated
with attention to the relationship between ex-
pectations and outcome [19]. People maintain their
medical traditions because they affect undesirable
conditions in expected ways, and because they are
effective for dealing with disruptive events that can-
not be allowed to persist (20, p. 51.
Aggravated by the unrest in Central America.
spiraling costs of imports, and the strain of providing
health care to greater numbers of poor people [3],
including many refugees from other Central Ameri-
can countries. the increased cost of medical care and
medicines suggests some thought be given to the
incorporation of sobadores into the National Health
Care System. They might be trained in the use of oral
rehydration techniques, eliminating the laxatives and
antiacids now used. At the time these healers were
interviewed they were not asked specifically about
their reactions to oral rehydration techniques since
that was not the focus of the study. Several factors,
however, suggest that they may represent a significant
resource in the fight against diarrhea1 disease. First,
all those interviewed were very intelligent people, and
I believe they are representative of the people one can
find practicing as sobadores. Second, according to
informants, the sobadu has already changed over time
in response to pressures from the biomedical system,
e.g. elimination of the rubbing of the abdomen and
the gradual switch from traditional remedies like
nrunzunillu and dulce de cuiiu to patent medicines like
milk of magnesia. The third factor is that oral
rehydration itself fits very nicely into the format of
traditional medicine.
In summary, the sobada as practiced by these
healers is not a static process, but rather has changed
in accordance with demands and new medical knowl-
edge which has gradually filtered down from the
biomedical system. This indicates, that these prac-
titioners of popular medicine, like those observed in
other settings [15, 161 would be receptive to new
techniques if they are practical. The sobadores inter-
viewed did not see themselves as being in competition
with scientific medicine, rather, they saw themselves
as being a part of the whole system. This, along with
the factors already mentioned, appears to suggest
that they have the potential to become key commu-
nity resource people in a program to implement
widespread use of oral rehydration therapy.
Acknowledgemenr-The research reported here was sup-
ported by NSF grant no. BNS8104679.
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