Ethnographic Study among Seattle Cambodians: Wind Illness

Methods

Participants

Three bilingual Cambodian interpreters and twenty-six Cambodian speaking informants participated in the study. Twenty-one were women and eight were men. The interpreters have worked at least three years with non-English speaking Cambodians. Three informants had a high school education in the USA. Most had little to no education in Cambodia. All of the informants lived in Cambodia until at least 17 years of age. Most were raised in rural and urban provincial towns. Two came from the capital city. Their ages ranged between 31 to 71 years. The informants were identified through the Refugee and Children’s clinics, and the Community House Calls Program, which provides services to the Seattle Cambodian community.

Data collection

Two focus groups of bilingual Cambodian interpreters were conducted in English. The initial focus group provided primary terms and definitions used in translation for fever and dizziness. The final one assured the quality of translation, reviewed and validated the findings.

Two focus groups and seventeen semi-structured interviews were held with non- English speaking Cambodians. The interviews were done in English with paraphrased and summary interpretation by an interpreter who was trained in interview techniques. The focus groups and the interviews lasted approximately one and a half hours. Handwritten notes were taken and an audiotape was made with informed consent from the informants. Transcripts of the tapes were made. They were edited by the interviewer and the interpreter to verify linguistic and cultural information.

The informants were asked to describe fever and dizziness, their causes, common symptoms associated with fever and dizziness, symptom management, and their worries and fears. The informants associated both fever and dizziness to a syndrome called “wind illness,” or known in Cambodian as khyol (pronounced khyol). It was decided that in order to understand fever and dizziness” in the Cambodian cultural context, the study needed to explore the association between fever, dizziness, and wind illness.

Analysis

Analysis for themes, linguistic and cultural contents was done by the principal investigator, the interviewer, and the interpreter. After the preliminary analysis, the findings were reviewed and validated in focus groups of non-English speaking Cambodians and bilingual interpreters. The methods are summarized below.

Initial Interpreter focus group

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Semi-structured interviews

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First focus group with non-English speaking informants

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Semi-structured interviews

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Second focus group with non-English speaking informants

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Final interpreter focus group

Translation and Language Equivalents

Wind Illness (khyol, kerd khyol, khyol chab,krun khyol)

Khyol literally means wind. The informants interchangeably used kerd khyol (having the wind), khyol chab (catching the wind), krun khyol (wind illness) to describe wind illness. A focus group suggested that at one time the term “having wind illness” might have been synonymous with the terms “illness, sickness, or fever.” The informants defined wind illness as: 1) not a physical wind, or air but rather a state of illness when the body was out of balance from overwork, lack of food and sleep, and exposure to diverse weather from hot to cold to rain; 2) an illness state when the body responded to known conditions such as a common cold, diabetes, or hypertension; 3) an illness resulting when the four basic human elements (wind, water, earth, and fire) were out of balance. (This was explained by two men in their 70s, however, it was not known among younger informants.)

Clinical Features

The following are characteristics of wind illness found in this study: mild to moderate (normal khyol); moderate to severe (blocked khyol); severe (ripe khyol); and life threatening (mute khyol).

• Mild to moderate (normal khyol)
  Khyol associated symptoms or illnesses included: complaints of feeling hot and cold, dizziness, headache, body ache, tiredness, weakness, having low energy, abdominal cramps, diarrhea, vomiting, trouble sleeping or eating, bad blood circulation, tightness in chest, restlessness, common cold, diabetes, or high blood pressure. Children could have a warm body but not necessarily have an elevated body temperature. They don’t feel like eating, sleeping, or playing.The informants disagreed when describing a relationship between krun (fever) and khyol. Some of the informants thought that khyol (wind illness) had no relationship to krun. They said the body was not warm. There was no krun when a person had khyol. This could be illustrated by a story from a 48 year-old- mother who said, “krun khyol is different from a common cold. With a cold you have a temperature and it comes with runny nose, and cough. But with krun khyol you start feeling uncomfortable, restless, can’t sleep, can’t eat well, feel nauseated.” Other informants said that khyol and krun were used interchangeably. In other words, people said they had khyol when they had krun such as when they felt “hot and cold,” or had “a little bit of fever.”Khyol could develop as a result of, or be associated with, other illnesses such as common cold, diarrhea and vomiting. For example, when a person has a cold, they could also develop khyol . A 64 year-old-woman said, “when a kid plays outside too much, he is tired and then he has cold. Then the mother coins and the kid gets better. He is sick from cold and when you coin and it helps that means he has Khyol . The khyol comes from having cold.”
• Moderate to severe (blocked khyol- slak,or steah khyol)
  Incorrectly treated normal khyol could turn into blocked khyol, or more serious illness. After coining, a person should not take a cold bath or drink cold water. The cold element from the water could get in and block the flow of the khyol, or cause sudden shock to the body. It could result in worsening the existing symptoms. Also the bath water could get into the lungs and cause pneumonia.
• Severe (ripe khyol – khyol toum)
  Incorrectly treated or untreated regular khyol could further develop into severe khyol. The term “toum” literally meant ripe, or close to rotten. People who had severe khyol were described as weak, and could not get up or eat. The development of severe khyol from regular khyol was illustrated by a story told by a 30-year-old woman: “Grandma had krun khyol. She could neither eat nor sleep and was restless. She felt warm. She had a little bit of fever but no runny nose, so she asked me to do coining. She had red marks after coining. It meant that she had severe khyol. The more red, the more khyol…If you have severe khyol and you don’t coin it, it could become khyol kho.“
• Life threatening (mute khyol – khyol kho)
  Khyol kho literally meant mute wind illness. It was the kind of khyol that people worried about the most. A person with mutel khyol became unconscious and could not talk. There were two ways khyol kho developed: incorrectly treated, or untreated regular khyol which further developed into severe khyol and then mute khyol or a person suddenly collapsed and became unconscious without any warning signs. Khyol kho happened in middle age or in older men and women. It could kill people if help was not available in time. Khyol kho was believed to cause seizure, unconsciousness, and death in children. However, parents believed that it was not so common among Cambodian children in the USA, because of the availability of doctors and medicine. The informants thought that in the USA, Khyol kho was called stroke or heart attack.

Cambodian Concept of Wind Illness

Health Practices

Multiple health practices were used by study informants and were consistent with complex cultural meanings of fever, dizziness, and wind illness. They included traditional, self, medical, and dual treatments.

Traditional Treatments

The traditional treatments did not aim to treat only specific symptoms such as fever or dizziness but rather symptom complexes of the illnesses. The treatments were used to “balance” khyol, so therefore treat fever and dizziness. Coining was the most commonly used treatment. Others were pinching and cupping, and home supportive treatments.

1. Coining
   
   Coining (rubbing the wind- kos khyol) is rubbing or scratching with a coin on the skin of the back, neck, upper chest, and arms. Coining practitioners used a US quarter, or coining tool made from a quarter-sized coin attached to a handle. Before or during rubbing, they applied Tiger Balm, herbal liquid medicine (preng khyol), skin lotion, or water on the skin. The technique helped to smooth the skin and also was believed to improve the coining outcome. Rubbing was done in symmetrical patterns but its techniques varied slightly. The practitioners needed experience and strong arms to “rub the wind off” and leave lesions resembling superficial skin bruises. The lesions, in turn, were used to diagnose and measure the degree of khyol. Post-coining lesions indicated amount and severity of khyol. The redder the lesions, the more khyol the person had. Light red, red, and dark red referred to mild, moderate, and severe khyol respectively.
   
   The more coining was used, the more it became necessary for future illnesses. It worked by improving the blood circulation and restoring balance. It was used to treat and also diagnose khyol. If the patient’s symptoms improved from coining, they were believed to definitely be due to khyol. If the symptoms did not improve, another condition was suspected. Not only did coining treat symptom complexes of fever and wind illness, but it also relieved associated symptoms and illnesses of, for example, common cold, pneumonia, diabetes, or high blood pressure. The informants agreed that coining did not treat the above illnesses. It only relieved their symptoms.
   
   Coining was widely practiced by most informants. Among 26 informants, only two persons abandoned the practice saying that it was too painful and they preferred to take medicine. However, it was perceived by some as becoming a less-preferred treatment in the USA because of the availability of other medications.
   
   Coining could be used with other home treatments. After coining, the patients usually had warm drinks, such as rice soup or hot water. They also wore warm clothes or wrapped themselves with a blanket and avoided cold baths. Some waited up to 48 hours before taking a bath.
   Tylenol could be taken with coining; however, with caution. Many said this dual treatment is an effective one. Most informants preferred to wait for a few minutes or up to hours after coining for fear of adverse interaction between coining and Tylenol.
   
   Coining had it own disadvantages and limitations. A 71-year-old man described the pain this way, “it hurts but you are patient, you don’t scream, you hold the pain. When you do that, the body gets warm and sweats and you feel better.” Parents usually did not want to coin children younger than one year old. They were too little and their skin was soft. Some parents were concerned that doctors would misunderstand them when they saw coining marks on children. All of the informants avoided coining on the face and some avoided it on the neck. Other than that, they believed that there were only benefits and no risks from coining. One mother said, “coining is not dangerous, it’s only useful. The redness and the dark marks are misunderstood by some people. If they don’t know that, they may think that you abuse children. Other than that,
   there is no danger.”
   
2. Cupping and pinching
   
   Cupping (sucking the wind- choob khyol) and pinching (pinching the wind- chab khyol) worked the same way coining did: by improving circulation and restoring balance.
   
   Cupping is sucking the skin on forehead, back, and upper chest with a set of cups. It involved burning a small candle and covering it with the sucking cups, glass jars, or old medicine bottles. The heat created a vacuum inside the cups. Then the cups were placed on skin to create red circular lesions. Cupping did not require the application of Tiger Balm, skin lotion or water.
   Pinching required the first and second fingers to pull upward hard on the skin which in turn caused bruises. It was often done on the skin of the neck, back, chest and between the eyebrows.
   
   Some people preferred cupping over coining because it was not as painful. However, cupping required experience and equipment. If the practitioners were not experienced, the cups could be over-heated and cause skin burn. Pinching was a very convenient and popular treatment done on the skin between eyebrows for headache and dizziness.
   
3. Other home supportive treatments
   
   In Cambodia, juice from bitter melon leaves, tea from mixed roots and rice water were used to reduce a temperature. In the USA, when children had a temperature the mothers gave warm rice soup, or orange juice along with Tylenol.
   
   Most Cambodians would not give a cold bath to their children when they had a hot body or elevated body temperature. They often used a wet cloth to wash or cool the forehead.

Self-medication

Tylenol was the most common self-medication used to reduce temperature, treat dizziness or headache. It was often available at home or could be obtained over the counter or at the clinic. When fever was perceived not to be serious, the informants used Tylenol once or twice and waited for a couple hours. They were likely to seek medical attention if Tylenol self-medication and other home treatments failed. In fever, often Tylenol was used with a sponge bath to the forehead to treat a hot body temperature. A 36-year-old mother said, “the head is important, so put a wet cloth on the forehead. Not too much water, just a little bit. I learn from a doctor. I believe in doctor… If not high fever, I will give them Tylenol at home.”

Another mother expressed her concern in using Tylenol. She was afraid of using too much medicine, “if give Tylenol too much, it can make them too cold. When the fever is high I am afraid to give Tylenol because the medicine can reduce body temperature too much. The body will be cold and chill. It’s cold outside but still hot inside. I may give too much medicine so I am afraid to give.”

The informants had a general knowledge of Tylenol. They knew that Tylenol was for fever, dizziness, headache, and body ache. Although the informants said they used Tylenol according to the directions, many of them were not able to read. They relied on their children for interpretation which was not always accurate. Most children had very limited Cambodian language skills. Taking or giving the right dose of home medication was still a concern for many households.

Medical Treatments

Some informants seek medical treatments when the above treatments failed. Others used medical treatments simultaneously with the traditional treatments mentioned above. A few prefer medical treatments as their first choice of treatment. The informants and interpreters described experiences and beliefs about medical treatments as follows:

1. Use of fever and pain medication
   
   Tylenol was a medication that the informants received and were familiar with by name. Others such as Advil or ibuprofen were less known by names. When a doctor prescribed Tylenol, it could be interpreted that the illness was not severe. A 32-year-old woman said, “If the doctor saw that fever is not bad they just gave Tylenol and sent the patient home. I did not mind if the doctor only gave Tylenol. But if my child is not better I will take him back. They are doctors so they know. I just followed the doctor’s advice.”The informants acknowledged that they’d learned how to use Tylenol from the doctor. For example, they learned that if after giving Tylenol every six hours for a couple days, the child is not better, they should call or bring the child back to the clinic.
   
2. Treatments for specific problems
   
   The informants knew that when fever or dizziness came from specific illnesses, they needed to take care of the problems. Taking only Tylenol would not help. For example, when dizziness was associated with anemia, or high blood pressure, they seek medical help. A 71-year-old man said, “if you have fever from toothache you have to pull the tooth out. If you have ear and eye problems the doctor will give medicine for ears and eyes. When the eye and ear pain goes away, the fever will go away.”
   
3. Beliefs about western medicine
   
   “Expected to be treated, not just to be told that they are OK.” was the consensus among interpreters of Cambodian patient expectations when they came to see doctors. They expected some medicine. “When they come with fever, they usually get Tylenol, or Ibuprofen. It does not matter what it is, give them something so they don’t walk away with empty hands… at least somebody does something.” Another interpreter gave an example of some of the patients he translated for, “They were sick for a week and waited for three hours and the doctor told them to go home, get rest, and drink a lot of water. They don’t want water, they want medicine!”
   
   “Give something else but not Tylenol.” Some patients might expect to get different kinds of medicine if they had already tried Tylenol and did not get better. The interpreters suggested, “something like Advil or ibuprofen. They think the new medicine is very good, and they feel good.” Some people believed Ibuprofen worked quickly and was stronger than Tylenol. Sometimes the interpreters were caught in the middle of patient-doctor negotiations. One interpreter laughed while recalling his experience, “usually doctors don’t know (what patients want) so they just say … take this medicine, it will help you with ache and pain. Whether patients were satisfied or not they did not say anything to the doctor. After the doctor left they complained to the interpreter. They complained that they only got Tylenol, fever and pain medicine. They expected something like an antibiotic.”
   “Avoiding blame for not seeking care.” A 48-year-old mother took her children to the doctor knowing they would get the same medication. “After giving Tylenol and it did not help, I went to a doctor. I knew that they were going to give Tylenol, but I still took them. I tried what I supposed to do. In case something happened, I would not get blamed.”
   
4. Dual treatments
   
   Many informants in this study combined traditional with medical treatments. A 41- year-old woman with pneumonia took antibiotics and used coining. She said, “if you just follow American ways you don’t get better. You coin and take medicine. Coining helps get rid of the body ache and the sickness.” The most common dual treatment for fever, dizziness, and wind illness was coining and taking Tylenol or Advil. There were two approaches to this particular dual treatment: taking medicine simultaneously with coining or right after it; or waiting a few hours after coining to take medicine in order to prevent an adverse interaction between coining and medicine.

Discussion

Fever (krun) and dizziness (vilmuk) were both clearly associated with the folk concept of wind illness or khyol. Our informants had a clear concept of types of wind illness and the illness syndromes each person reported were remarkably similar, as were the traditional treatments recommended. The life circumstances, or external factors which they thought produced wind illness were also very similar among informants.

There have been few explorations of wind illness in the Western medical literature. Mueke described wind illness as a common complaint in North Thai women. (1) In her sample of 415 everparous women, 43% reported having had wind illness. There are several differences between information from our mixed gender Cambodian informants and her Thai women. First, our informants related the causes of wind illness to more global life circumstances that produced imbalance such as overwork, overplay, stress, climatic change. Her informants stressed exposure to bad odors and food, neither of which were mentioned in our interviews, and kharma was also mentioned as a cause of wind illness. Wind illness was recognized as more common in women, but not limited to women, by our informants.

Our informants, like those of Mueke, use traditional methods of healing for wind illness and realize that most Western trained doctors do not recognize wind illness as a medical entity. In contrast to the Thai practices of using herbal treatments for wind illness, Cambodians commonly use techniques of coining or cupping and these were usually done by a family member or friend.

Buchwald documented widespread use of traditional health practices in several Southeast Asian groups in Seattle. (2) In their sample coining, cupping and massage were the most common practices in Cambodians. They noted the frequent use of coining for wind illness. Handleman, in a survey of 76 older Cambodian patients having chronic symptoms (headache, chest pain, SOB, dysuria syncope, chronic cough, wheezing, palpitations, muscle and joint pain, dizziness, dyspepsia, anorexia and abdominal pain) found that coining was reported to be used by 76% of the patients for these symptoms. (3) In this study, 41% of the patients attributed their symptoms to “wind illness”. Yeatman reported the frequent use of coin rubbing or Cao Gio among Vietnamese living in the U.S. to relieve common symptoms of illness, especially for cold, cough, flu, and headache, but did not relate it to wind illness. (4)

Our informants did not refer to the wind of wind illness as coming from drafts or exposure to climatic conditions, but rather as an internal condition generated within the body from a lack of balance or harmony in a person’s life. Coining was used to regulate the degree of wind. The skin response to coining, and the degree of relief from coining, helped to confirm that they symptoms were actually due to wind illness. This is in contrast to the reports of other authors that provide explanations of wind illness that draw on the Chinese model of environmental wind as a common cause of illness. (5)

Some authors have related wind illness to depression (6) but in Handleman’s study comparing older Cambodian adults with psychiatric illness to those who were not psychiatric patients, the same percentage of subjects in each group attributed their chief complaints of physical symptoms to wind illness. A higher percent of psychiatric patients compared to non-patients attributed their symptoms to a condition called pruiy chitt kitt chraen, which is loosely translated as depression. Our informants did not link wind illness to depression or sadness. However, they did relate it to mental stress (eg. over-work, worry).

Wind illness as described by our informants seems to be an explanatory model that functions to acknowledge and handle minor illness complaints and stress within the family setting. It is a concept that persists and strongly influences health behavior in spite of many years of living in the U.S. and exposure to biomedical health care. Folk treatment of this condition co-exists with medical treatment. Health care practitioners need to recognize this distinct folk illness syndrome and not confuse it with depression or somatization. If symptoms of wind illness persist, it may suggest that the patient or their family perceive important imbalances in their life circumstances. Identifying the patient’s belief that their symptoms are wind illness can lead to a discussion of the parts of their life that they view as out of balance and causing the wind illness.

Assimilation into the mainstream culture seemed to have an impact on how the informants described illness. They have tried to equate their term, wind illness, with biomedical terms they thought were similar. Many suggested that the terms “stroke” and “heart attack” might be severe wind illness (khyol kho). However, they were fully aware that biomedicine does not have an equivalent term for wind illness. As a result, when describing wind illness to health care providers, they said stroke or heart attack rather than saying wind illness. This could lead to provider-patient miscommunication.

References

1. Muecke MA. An explication of ‘Wind Illness’ in Northern Thailand. Culture Med Psychiatry. 1979; 3:267.
2. Buchwald D, Panwala S, Hooton T. Use of traditional health practices by Southeast Asian refugees in a primary care clinic. West J Med 1992;156:507.
3. Handleman L, Yeo G. Using explanatory models to understand chronic symptoms of Cambodian refugees. Fam Med 1996;28:271.
4. Yeatman GW. Cao Gio (Coin Rubbing). Vietnamese attitudes toward health care. JAMA 1980;244:2748.
5. Lee RV, D’Alamo F, White LM, Cardinal J. Southeast Asian folklore about pregnancy and parturition. Obs Gyn 1988;71:643.
6. Eisenbruch M. ‘Wind Illness’ or somatic depression? A case study in psychiatric anthropology. Brit J Psychiat 1983;143:323.