Cultural Patterns of Health Care Beliefs and Practices among Muslim Women in Uzbekistan

The purpose of this ethnographic study is to describe and analyse the meanings and uses of healthpromotion practices and beliefs, healing practices and folk medicine for Uzbek Muslim women.Contemporary healing practices can be seen as combining shamanic and Islamic concepts aboutdisease and healing, Sufi Research focus. The research questions ask how participants make decisions to seek remedies throughhealing practices, and how and whether they experience these choices and actions as empowering.The research also asks about what sorts of conditions women seeks to address through traditionalhealing practices; those in this study discussed seeking out such healing for colds, bronchitis, heartdisease, arthritis, as well as emotional and economic distress.Significance. With the increasing migration of Uzbeks to Canada, strength-based health care provisionapproach based on person-centred care, empowerment, health promotion and prevention and collaborative partnership is crucial in achieving quality of care.


I. Introduction
Uzbekistan, located in Central Asia at the crossroads of the ancient Silk Road between China, the Middle East, and Europe, was for centuries a centre of world civilisation in medicine, education, and trade.In 1991 Uzbekistan gained Independence with the breakup of the Soviet Union and transitioned from a centrally-planned to a market-oriented economy.Communities faced drastic changes due to reduction of employment, decline in income, and the deterioration of social protection and benefits that had been provided for free in Soviet times (Kandiyoti, 2002(Kandiyoti, , 2003(Kandiyoti, , 2004;;Tursunova, 2012aTursunova, , 2012b)).Traditional medical practices, to which the late Soviet state had given some encouragement in the 1980s, expanded in independent Uzbekistan (Hohmann, 2010).This article asks how, when, and why Uzbek women seek out folk healers.
The purpose of this article is to describe and analyze an Indigenous Uzbekistani epistemology about disease and healing that continues to exist in a very normal, accepted way, alongside modern "Western" medicine.This epistemology regards disease as involving interconnected physical, spiritual, and psychological dimensions.Healing involves the interconnectedness of humanity: healers whose ancestral calling authorizes their practice interact with patients in ways that draw on spirituality, faith, and ever-evolving traditions of herbal remedies and rituals.In Uzbekistan, healers and their clients participate in health promotion and healing practices that empower communities to address health and holistic well-being.Finally, we plan to provide recommendations for health providers who want to formulate strength-based care (SBC) and culturally competent care for immigrants coming from Central Asia to North America.
Folk medicine as it is currently practiced in Central Asia draws on the foundations built by eleventh century Muslim scholar Ibn Sīnā, and also incorporates Asian shamanic traditions.Ibn Sina, known in the West as Avicenna, composed numerous volumes on medicine and anatomy, herbal remedies, ailments and diseases, and pharmacology (Chishti, 1990).In Uzbekistan today, healers known tabibs (naturopaths/herbal healers) draw on Ibn Sina's concepts and recommendations; many also use verses of Qur'an to heal patients (Rasanayagam, 2011).In the centuries following Ibn Sina, other Central Asian physicians continued to expand the body of medical knowledge, drawing in particular on Persian-language treatises composed in South Asia, under Mughal patronage (DeWeese, 2013).Some of this knowledge passed from one generation to another, orally and through treatises and booklets that continue to be sold in Central Asian bazaars.Otins (women religious teachers and leaders) often include advice on health promotion deriving from Qur'anic and Islamic knowledge in their religious ceremonies.Contemporary folk healing practices draw on Sufism, a mystical approach to Islam that includes worship of saints, visiting shrines and mazars (cemeteries); Sufi rituals are a locus of physical, spiritual, and psychological healing (Fathi, 1997;2007).Some folk healers draw more extensively on Central Asian shamanic practices.Kinnaji (healers who bring release of pain) engage in practices focusing on touch and on psychological interventions.In the shamanic tradition of healing, healers receive their calling from their ancestors, learn of their calling through dreams, and practice many shamanic healing techniques, which will be described below (Penkala-Gawęcka, 2013).
Uzbekistan's health system consists of free public clinics and private clinics, medical centers and hospitals.Most medical personnel are trained in Soviet-Western modes of biomedicine, but traditional Chinese medicine is also recognized by the medical establishment, and there is a Tashkent Academy of Traditional Medicine.Physicians may gain official training and recognition as tabibs, and tabibs may take formal courses to improve their diagnostic skills (Hohmann, 2010).By contrast, kinnaji, otins, and other folk healers do not go through institutional training but take up their healing role as a calling.
Patients who have chronic illness usually see doctors in clinics; many also choose and/or are instructed by doctors to pursue traditional healing methods based on Islamic rituals, shamanism, and the use of herbs.Doctors who are trained in Soviet-Western modes of biomedicine focus on physical well-being but may feel untrained to address emotional, psychological, spiritual well-being.Perhaps because of this, many refer patients to a tabib, kinnaji, or otin.Those who face physical illness may seek out traditional healers in addition to seeking help from the modern medical establishment; they may turn to a tabib first and a doctor second, or they may turn to the tabib, kinnaji, or otin when they believe that modern medicine has failed to address their condition.
Muslims, including Central Asians, generally believe that illness and healing happen by the will of Allah.Folk healers in Uzbekistan draw on a cosmology which holds that Allah wishes good to people and facilitates their possibility to heal.Muslims in Central Asia and elsewhere frequently repeat Hadith such as this one: "The One who sent down the disease sent down the remedy" (Muwatta 50: 5.5.12).This foundational epistemology is not exclusive, though; those who experience illness engage with many forms of treatment, combining Islamic epistemologies with modern bio-medical understandings of germ theory, as well as concepts like bio-energy (Rasanayagam, 2006).More broadly, many Central Asians see no contradiction between the idea that disease and cure come from Allah, and the idea that spirits cause illnesses, so that people who are uniquely gifted at engaging with spirits can heal certain conditions.Healers, then, are people who have been called, whose ancestors have transferred to them the special blessing or baraka of healing.Some scholars (Eliade, 1964;Snesarev, 1969;Basilov, 1989) regard certain folk healers as continuing a pre-Islamic shamanic tradition, while others (Hohmann, 2010;Rasanayagam, 2006Rasanayagam, , 2011) ) would argue against a "stages of development" understanding, instead pointing out that a dichotomy between what is Islamic and what is shamanic is not one that troubles healers themselves.Their patients can and do discuss whether certain practices are right or wrong, effective or ineffective, appropriate or inappropriate according to what Islam, the bio-medical traditions, and folk traditions teach them.(Schrode, 2008) Many patients regard the healer who has an ancestral, shamanic calling to be the best at diagnosing chronic illnesses or mental or emotional imbalances.
Folk modes of treating and healing draw on various traditions, knowledge of which is passed on from a practitioner to an initiate.Some of these cures (herbs and ointments) come from tract versions of Avicenna's Canon of Medicine.Others are shared among Siberian, Tibetan, Mongol and other shamanic cultures (the investing of the healer with ancestral authority, the use of trance, drum, whip).Some come from shared Islamic traditions, sometimes called Prophetic medicine, such as reciting Quran, blowing over water that the patient drinks, massaging with honey, and cupping (Doumato 2000).A kinnaji, for example, may treat diseases using words, by reciting the Qur'an; through touch -diagnosing through pulse or other forms of touch, and directing breath, massage, or physical objects to touch the skin; through herbal and natural medications, teas, ointments, yogurt, purgatives; and through ritual actions, such as symbolically casting problems into water.
The Soviet ethnographer Snesarov, who carried out research in Central and Inner Asia, used the term "shaman" to denote specialists who practiced rather similar approaches to healing.Snesarov (1969) pointed out that a shaman believes that he or she is called to this role, usually through a dream, a strong mystical experience, or through designation by another shaman who recognizes his or her gift.Often, the shaman has experienced serious illness or lasting disability.Shamans who tell their own stories explain that through moments of illness and dreams, they encounter spirit agents and analyse the meaning of their experience.The Shaman may use trance techniques to enter a spirit world and see the deep causes of illness in others.Many ethnographers have documented the accounts that Central Asian healers give regarding their own calling: the tabib, kinnaji, otin, and others all tell similar stories of recognizing their calling through experience of illness, the dream appearance of an ancestor who charges them with this calling, and their recognition and perhaps training by another shaman, who may present them with a handdrum or whip.The one who is called must accept his or her calling, or relapse into illness; and they often seek blessing and validation for their calling by consulting with other healers and by visiting a saint's tomb (Bikzhanova et al 1974;Basilov 1989;Allione 1997;Rasanayagam 2011).Healers thus are connected to ancestors and spirits, and interact with them to relieve a person's suffering with prayers and propitiations.Spirit agency refers to a form of healing, as an "imaginal encounter with spirit agents, which enables people validate their own concepts of Muslim selfhood" (Rasanayagam, 2006, p. 377).Those who seek out healing from these traditional healers rely on their special abilities to exercise spirit agency.

II. Theoretical and Conceptual Considerations
This research is based on my (Zulfiya Tursunova) fieldwork in a rural area of Tashkent region, Uzbekistan, in a village we will call Ok Yul.Some Ok Yul respondents practiced traditional forms of healing, while many sought out traditional healing.I interviewed kinnaji, tabibs, and otins, and their patients, Ok Yul's women and men, to learn about their healing methods and traditional medicines.In seeking out encounters of healing, and stories about healing, we are trying to understand both the content of those interactions--the practices that constitute traditional healing--and the understandings and significance that patients and healers give to these encounters and their results.
Through critical ethnographic methods, we seek to understand Ok Yul epistemologies by drawing on introspection, autobiography, and memory work and discussion of dreams (Denzin & Lincoln, 2011).During the fieldwork 98 persons (87 women and 11 men) were interviewed for a larger project about livelihoods, and among those, many spoke about illnesses.In general, I collected data by listening to respondents own narratives and stories, talking with them about how they made meaning out of experience, and made choices affecting themselves and their families (Smith, 1999).Respondents were asked about their healing methods, and I participated in and observed traditional women's rituals.As a native Uzbek, I was able to participate in and observe healing rituals and my cultural knowledge helped me to connect to the knowledge system and enhance it.As a native speaker of Uzbek, I was able to understand healing words and utterances and build rapport with otins, tabibs, kinnajis and patients.We gave pseudonyms to the place names and personal names of participants to preserve their anonymity.
Several theoretical and conceptual considerations guided this research.Following the approaches of Shawn Wilson, outlined in Research is Ceremony (2008), I adopt the term "Indigenous epistemology," meaning, in the case of Ok Yul, the ways that Uzbeks think that draw on the interpersonal, intrapersonal, environmental and spiritual relationships among persons and things.This approach seems especially pertinent to a discussion of the shared epistemologies of healers and those who seek healing, all of whom accept a set of ideas that link disease and healing to spiritual agency.Second, in research, I consciously seek out women's voices and their situated knowledges, while continually reflecting on my own research position.Wilson's Indigenous research paradigm, developed as a way of exploring the worldviews of First Nations and other Aboriginal peoples, informs my ways of researching and analysing Central Asian epistemologies, including worldview, spiritualties, and place in the cosmos.Indigenous epistemology is an integral part of our systems of knowledge in their context, or in relationship.The ontology of disease and healing, in Central Asia, emphasizes relationships between the healer and the patient, between human and God, between the healer and the ancestors, between the healer and various spirits sometimes referred to as jinn and pari.
In Uzbekistan, Indigenous epistemologies are not static; they transform to address global issues and deal with local distress and trauma.Hence, people may transform epistemologies to mobilize power, to reclaim voice, and to engage with any and all strategies for healing that have the potential to be efficacious.Further, I draw on Wilson's insight that an Indigenous axiology is grounded in the notion of "relational accountability."This is important to me as a researcher, in that I strive to be accountable to those whose voices this research represents, but also in directing my attention to the ways that healers and their patients form relationships that are built on the healer's accountability to the ancestors and to the community.
In Uzbekistan, people who are ill go to clinics and hospital for treatment by doctors who are trained in western bio-medicine.People believe that medical doctors can cure them physically, without necessarily helping patients to achieve emotional and spiritual balance.Many people value traditional healers because they have a holistic approach to the person as well as to the universe.Otins and other traditional healers encourage a path of surrender to the Creator; this allows the patient to attain a state of peace that we might refer to as 'ecology of the sprit' (Irani & Funk, 2001).We regard healers as bearers of the "ecology of spirit," who lead followers on a path toward wholeness.Healers cure illnesses in a holistic way through their access to divine power, while building a relationship with the patient that allows them to treat the patient's emotional and spiritual challenges as well as their physical problems.

Accounts of healing
To explain this relationally-based epistemology of disease and healing, this article begins with my own account of seeking out a traditional healer.The article then presents two women's narratives about becoming healers; the purpose is to outline their understandings of disease, healing, and relationships to their human patients and spiritual agents.The article then turns to women's and men's stories of healing, drawing from their narratives their own multi-faceted ways of thinking about disease and cure, grounded in Indigenous epistemologies that draw on spiritual agency, Islam, and bio-medicine.
The participants of the study defined kasallik as including both short-term afflictions and long-term illnesses; being sick meant having physical ailments but also emotional and spiritual imbalance.They regarded these as treatable through modern medications, natural remedies, and/or healing practices, all of which might restore spiritual balance and physical well-being.

Visiting a kinnaji
While in Ok Yul, I took advantage of the opportunity to pursue my own to healing, seeking out someone whom I could trust to address my own physical and emotional well-being.On the recommendation of a relative, I visited Zulfiya opa seven times.Others spoke of Zulfiya opa as a kinnaji, someone with the shaman's ability to interact with spirits and release pain; Zulfiya opa spoke of herself as a tabib without a diploma.In my visits with Zulfiya opa, some of them individual sessions and sometimes in a group, I saw her engaging with a wide variety of healing approaches which I describe below.
Zulfiya opa asked me to bring yogurt, sugar, tea, white thread, water, and flour.She read verses from the Qur'an seven times to bless these items.She put a little bit of flour into a piece of paper.She folded white thread seven times and put it into the flour rolled into the piece of paper.She explained that flour symbolises happiness; thread symbolizes the road, path, or journey; and water, cleanliness and purity.She asked me to request Allah to help me to fulfill my wishes as I stood by a river, facing the water, and to throw this little package of flour, thread, and paper into the water.
In the course of my healing to achieve holistic balance Zulfiya opa called upon her spirit helpers, while symbolically cutting my back, shoulders, and feet with a knife, saying: I am cutting all knots, junctures.I am cutting, cutting, cutting.I am cutting all bewitching.Take them to the running water.You are the only one [addressing Allah].You are the Almighty one.
[She continues to invoke spirits in this cleansing, saying]: Open the road.Open the junctures.Wash and remove everything.Remove the burden from her shoulders.Take the entire burden from her shoulders.Wash inside all that bewitches.I cut everything.Prepare for cleaning.She will drink yogurt and all the bewitching will be gone.Zulfiya opa's approach, elaborated below, drew on a strong symbolism: my difficulties were knots that she cut by drawing her knife across parts of my body; they were also the result of bewitchment--in other words, spirits with malevolent intent, rather than spirits with good intent--and that Allah, through Zulfiya's spiritual agents, would release me from these problems.
Besides the emphasis on healing and restoring relations, a healer calls down punishment for people who cause and inflict harm on others.She utters curses, saying that those who are punished will have pimples, spots on their faces, sickness, or even death as forms of restitution.Zulfiya opa explained, regarding another patient: "He brings punishment on himself.I do not do anything.Some persons come and say that they have stomatitis (oral inflammation), but they do not know that this is because they cursed someone.Allah knows who is right and who is wrong.He should give a verdict himself." The healer uses expert knowledge and legitimate authority, and appeals to the ultimate authority of Allah to design and enforce punishment.Both healers and their patients share understandings of proper moral behaviour that are based in Islamic notions of a halal life.In this cosmology, some cases of disease are punishments from Allah for violating moral behavior, or engaging in impure acts.Thus healing practices that come from Islam and shamanism reinforce a social order and moral behavior in Muslim communities.
Zulfiya's healing methods are varied.She reads the Qur'an over her patients, children, men, and women who are sick; she recites Qur'an for them when they are present at a ritual, but also when they are absent from one of the ceremonies that she leads.She may place photographs of patients on her table to symbolize those who are absent.Zulfiya opa places items from the patient's clothing on her small table (for example, T-shirt, underwear), along with food (for example, tea, sugar, candies, water in jars or bottles), the traditional herb isiriq (rue), and yogurt.Zulfiya also uses bio-medicinal knowledge which she discovered when she worked as an accountant.Her body became hot, and she would lie down on the cool floor or stand against the cool walls to cool down in order to balance what she understands as her biological energy.These episodes led her to discover the path of healing she uses.
Cleansing is one way she deals with patients who have physical and psychological distress.One male patient attributed his ongoing stomach problems to being cursed.He went from one hospital to another and none of the doctors could cure him.Zulfiya opa tests the health of a patient by putting her feet on the patient's feet; he felt the heat of her feet going from one foot to the other, and this led her to diagnose his health as weakened.Zulfiya opa read suras from the Qur'an over water and yogurt and other items on the table.On her recommendation, the patient drank two jars of yogurt mixed with water (six liters) in one day and vomited.This vomiting expelled all witches, and he attested that he had been cleansed.Zulfiya opa's epistemology and her practice come from her self-acknowledged identities as Muslim and shaman; her approach transcends the visible and the unseen, connecting the real world of existence with different spirit helpers.During the healing process, she invokes her Muslim saints such as otakhonlar and onakhonlar sent by Allah to help her identify the distressed and suffering, clean and purify the ill body and space, and develop the healing action that she should take.Zulfiya opa also refers to 41 jon parilar, including water and bird parilar.I also met other healers who refer to ancestral spirits sent by Allah as otakhonlar and onakhonlar.
I argue that when healers distinguish themselves from bakshis (shamans) or folbins (soothsayers) and call upon otahonlar and onakhonlar instead of jinns (a Qur'anic term for spirits), they define their own Muslim selfhood as legitimate within the context of Islam as it re-emerged in post-communist space.Ideas of Muslim selfhood, of what is and is not correct practices, are under continual discussion; healers and their patients offer their own understandings of spiritual agency in relationship to scripturalist Islam (Rasanayagam, 2006).I suggest that some healers relate to both paris and ancestral spirits such otakhonlar and onakhonlar to contest the notion of Muslim selfhood and authorize their integrative framework of what constitutes a good Muslim, by pointing out that their spirit agency is positive and good, contrasting their own practice against witchcraft and sorcery.
Zulfiya's approach to healing, like that of many traditional healers in Uzbekistan, assumes that Allah knows the disease and the cure; that spirits communicate with and direct her as a healer; and that she should take actions that address her patient's physical and spiritual health.Her practices include recitations of Qur'an, directions to the patient to restore righteous relationships, efforts at physical cleansing, ritual actions to draw the patient's intentions and wishes into harmony with the spiritual agents, interacting with spirit agents to remove emotional and physical obstacles that prevent the patient's wholeness, and using various kinds of touch to diagnose and treat patients.

III. Becoming a Healer
Spirit agency, that ability to become the connection between the patient and the spirits, is central to this Indigenous epistemology of disease and cure.Becoming a traditional healer demands that the healer has this capacity, which Uzbeks regard as rare and unusual, the specific gift given to a few, rather than an ability that belongs to everyone.One becomes a healer through a process of recognizing this gift in oneself.Prolonged sickness and long lasting imbalance can be interpreted as showing an individual his or her need to recognize a calling to become a healer, and to regain health through initiation ceremonies that recognize and authorize the healing ability.
Nazira, a teacher in a public school, described how her mother-in-law's extended illness led toward the discovery of her healing gifts: My mother-in-law used to worked in kindergarten for twenty years.After the death of her sister she became bed-ridden (at age 69).She complained that her sister is calling her constantly.Low blood pressure, weakness, and poor heartbeat.The doctors could not diagnose her problem.She continued complaining that [her sister] called her from the other world.Later one of the doctors said that we should use traditional healing methods.We started looking for otin, and we found a woman in Kibray who had a strong bio-energy.She recited (Qur'an) over her, and used a knife to "cut" the evil spirits.The otin said that my mother-in-law should become a "kinnaji" (healer), otherwise she will not be healed.Only spiritual assistance to others, relatives and children can help her to find her path to recovery.We found a domla (male religious teacher) who with his female followers organized an initiation ceremony.My mother-in-law was healed, and she started healing others and feeling better.
Stories of becoming ill and/or having dreams that instruct a person to become a kinnaji, healer are widespread, and thus widely accepted as legitimate and real in Central Asia.The moments of sickness, dreams, and healing constitute the process of becoming a healer through interpretation of the dream encounters with spirit agents and experience at the individual psychological level.These initiation ceremonies are vital in making a step towards recovery and stepping into path of healing.
Nazira herself acquired healing methods from her grandmother and mother-in-law, who became a healer through the initiation ceremony.Nazira heals her two daughters when they have headache by giving massage to head and shoulders asking Allah to cure them.She yawns strongly, hiccoughs, and make strange sounds.She feels some heaviness and then she suras from Qur'an to heal herself and then feels better.Nazira regard this healing practice as important and efficacious because her daughters are cured from illness.
Zulfiya opa recounted how her initiatory illness led her become a healer.She entered her calling through the following moments: sickness; identification by a healer who pointed out Zulfiya's abilities, but also Zulfiya's kinship connection to a deceased healer; and then blessing given by a practicing healer: I became a healer when I was 40 years old.When I was 40 I got sick each day for fifteen days. . .My fatherin-law, who has since passed away, brought a healer.After the healer performed a ceremony, I was cured.I was cured by her reading the Qur'an over me.One day I started looking for a healer.We did not have a healer in our mahalla (urban neighborhood). . . .I found one old woman.I found that woman, and she was reciting.She told me that I should accept the call to becoming a healer.Why should I accept this call for no reason?I thought.I was 35 at that time.She said, not now but at the age of 39.I told her that that I will not become a healer for no reason.Why should I take [this role] if there is no one from my mother's side, father's side, and parents-in-law's side [who was a healer]?
The healer asked: "Who is this woman standing behind you in a white scarf and a white dress?She has an oval face.She is looking at you and smiling."Zulfiya opa replied: "She is my mother's grandmother's mother-in-law.This relative gave her name to me, Zulfiya." Zulfiya opa remembered that her maternal great-grandmother practiced the traditional knowledge of healing, in part by reciting Quran aloud from memory to purify people and the environment they live in.She healed people who were sick or in distress and even persons who possessed shaitonlar, devil spirits.She also massaged muscles that were pulled.She read Quran aloud and all their knots were untied.Sick people who had seizures were cured after her healing practice.
While Zulfiya knew about her ancestor's practice of healing, Zulfiya opa also became aware of her own gift of healing through experiences.She remembered that in her childhood she cured her five brothers who fell down and had injuries, by massaging them.
At the age of 39 Zulfiya opa became ill again and started having uncontrollable hiccoughs, even in public spaces, but the hiccoughs stopped abruptly when an otin blessed her.Zulfiya opa had taken her daughter to consult with a ninety-year-old otin, because that daughter's children fell down often.While the otin was performing a healing ritual for her daughter, Zulfiya opa was constantly hiccoughing, to which the otin remarked repeatedly that Zulfiya had an affliction.After finishing her healing of Zulfiya opa's daughter, she asked Zulfiya opa to sit next to her.
The otin asked Zulfiya opa to toss coins.The otin put tea and sugar in front of Zulfiya opa, who brought them.The otin summoned the spirits and put two whips and a knife on the table to whip and cut the pain.At the end of the initiation ritual, the otin gave potaha (a blessing) to Zulfiya opa, enabling her to cease hiccoughing immediately.Now Zulfiya opa hiccoughs only in cases when someone is cursed and has the evil eye.
Zulfiya's stories about her initiation, and Nazira's story about her mother, are testimonies that healers make to their patients, families, and community.These narratives draw on and reiterate an Indigenous epistemology wherein all manner of diseases and maladies, from daily bouts of illness, to frequent falls, low blood or hiccoughs, may find remedy in western bio-medicine, but may require the spirit agency of someone who has been given a healing gift, blessed and initiated, and who is capable of summoning and interacting with spirits and enable healing.
According to her own words, Zulfiya opa's knowledge and the spiritual power of her healing derives from Allah and following in the path of Allah, by living in a right religious manner: performing namaz (prayer) five times a day, paying zakat (tithe for charity), and doing volunteer work.Like many healers in Central Asia, Zulfiya opa identifies herself as a slave of Allah and distances herself from bakhsi or folbin (fortune tellers) who can be found anywhere.Healers like Zulfiya regard bakhsi or folbin as working with jinn (evil spirits) to harm people, and some people regard these practices as illegitimate according to the Islamic belief.Working with devil spirits (shaitonlar) contravenes work in the service to Allah, and telling fortunes to people as bakshi or folbin do contradicts the idea that Allah is the only one who knows the future.Zulfiya opa practices her halol life and stresses that she does not ask patients to pay a particular amount for the service, but receives what patients can afford to pay in cash or in kind.
While Uzbek Muslims follow traditional scripturalist practices, traditional healers carry out authorising processes that engage with religion's norms, such as Qur'an recitation, and with locally accepted practices.Healers establish their legitimacy through their successful healing practices, and the testimony of women and men who visit healers expands their circle of patients.Zulfiya opa sometimes sees persons individually but she also convenes groups that allow people to hear others' dilemmas and her successful therapeutic action.These healing circles and people's conversation explain how Zulfiya opa's reputation is spread, and why people in the community believe that her words and practices are successful.

IV. Patients who Seek Traditional Healers
This section focuses on the narratives of three residents of Ok Yul and their interactions with healers who exercise spirit agency.Nazira told about healing through Qur'anic recitation.Marip told of seeking out a tabib for healing from a variety of serious ailments, including heart problems.Napisa opa related her experiences in seeking healing for arthritis.Each of them also saw doctors in clinics, but in these cases, they were convinced that traditional forms of healing were efficacious.This section explores some of the ways that Ok Yul people explain their understandings of disease, their decisions to seek out particular healers, and what they regard as successful outcomes.
When children are ill or seem to be having problems or not thriving, Ok Yul mothers may purchase pharmaceuticals, and they also administer naturalist medicines to their children, and they may also take their children to healers to remove evil eye.Nazira, who had married in 1991 when the Soviet Union collapsed and people in Uzbekistan experienced poor social services, unemployment, poor quality goods, and inadequate medical care, told of what she did when her ten-month-old daughter got sick from eating contaminated porridge: She became poisoned by eating porridge with butter.It turned out that the butter was of poor quality, not what was printed on the label.I kept her at home for a week and treated her with a solution of manganese and with enema.It seemed that condition got better, but on the third day she was feeling extremely bad.The emergency doctor put her into the reanimation (critical care) unit.They cleansed her stomach by injecting some fluid, but the medicine (that she required) was not available in the hospital.We had to buy it.After these procedures my daughter's conditions improved.One nurse who treated my daughter, also offered her services such as reciting over my daughter.She told me that my daughter is "too close to the eyes" [meaning that it is easy to curse her].I agreed, because I remembered that in my childhood, my grandma read over me.The nurse, who is an official representative of medicine, made this proposal for me.Certainly, I agreed.She began reading suras from Qur'an, asked Allah to cure her and made sounds that kinnaji make.I sat beside her, and I begged Allah to help cure my daughter.I paid as much as I could at that time.The next day my daughter's stool was much better and the condition of my little one improved.Her help in treating my daughter was more important than the doctors' remedies.She did not charge a fixed amount for her services.She had more and more clients who asked her to read over their children.
Nazira conveyed her surprise at finding a medical practitioner using traditional methods in a clinical setting.However, Nazira recognized this approach to healing drawing on her own prior experience, and she knew that paying a fee or giving something to a healer, in the amount that one can afford, is an important aspect of the ceremony.Her story reflects her holistic view of disease and cure.She attributed her daughter's illness to a physical cause, food-poisoning, but this also held spiritual dimensions: the package was misleadingly labeled, claiming to be a worthy product when it was not, and she assented to the nurse's comment that her daughter was too open to being harmed by "the evil eye".Nazira provided bio-medical treatments (manganese and enema), and the hospital provided a stomach-flushing treatment, but Nazira set these symptoms and treatments within a larger framework based on spirit agency.She attributed her daughter's healing to the nurse's traditional approach, reciting the Qur'an, praying, and breathing over the baby.The nurse in Nazira's story combined western bio-medical practice with the practices of the otin and the kinnaji.
Similarly, the tabib in Marip aka's story combined herbalist remedies with recitations from the Qur'an.Marip aka had pain in his right side of chest and was hospitalised.He met a male tabib in the hospital who stayed in the same room with him, and witnessed his nightmares.Marip aka told me that he then went with his two daughters and a granddaughter to a tabib.One of his daughters, Yulduz, experiences pain in her legs and hands when the weather changes.The tabib held the wrist of his male patient, Marip, to check his pulse; he and diagnosed Marip as having "salt in his heart" and two ulcers in the stomach.Then, the tabib turned to Marip aka's daughter, Yulduz, but he would not touch her directly, probably because he followed an understanding that prevented him from touching a female who was not in his family.The tabib put a handkerchief on her wrist and then checked her pulse.The tabib told Yulduz that her left-side heart valve was not working well; therefore, she is weak.In addition he diagnosed her as having problems with her female organs, and a poorly functioning gallbladder.The tabib explained that Yulduz gets upset and nervous often and therefore, she has heart problems, and as a result, she is weak.The tabib also read suras over Yulduz's three-year-old daughter, who had a fever for a long time.The tabib said that children are cursed easily because they are small.The tabib diagnosed Marip aka's second daughter, Zamira, who had never had children and hence, has never lost lots of blood.Checking her pulse through a handkerchief, he told Zamira that she had a flu and that her blood poured into her heart, giving her a heart attack that Zamira did not recognize.He also suggested that Zamira has pain in the back of her head and back, and female problems.He suggested blood-letting, removing 300-500 grams of blood because she has slags.Their understanding is that when blood is let, the slags come out, while the liver produces new (slag-free) blood.He suggested boiling meat and eating the bone marrow inside the bone, explaining that bone marrow generates blood cells in the body.Blood vessels run through the center of the bone so that the bone receives food, oxygen and minerals.
Marip aka and his family members seemed to regard this consultation with a tabib as producing successful results.He offered diagnoses through his sensitive and gender-appropriate reading of the pulse, but he also observed their personal characteristics; he addressed what he perceived as a source of Yulduz's stress by reading Qur'an over her little daughter.He offered remedies that were grounded in shared understandings of the body, offering elaborations that enabled his patients to view his proposed treatments as physically reasonable and spiritually appropriate.
Tabibs draw on practices that can be traced back through Galenic medicine, such as blood-letting; and they prescribe cupping therapy to treat polyarthritis.Cupping therapy, also used in traditional medicine in China and in Islamic medicine, involves a glass cup or jar used to create suction.Tabibs and patients explain its effects as warming the skin's surface to promote energy and the flow of blood; in Ok Yul, this treatment may be used to reduce swelling and pain and dispel cold and dampness.The procedure requires three steps: placing a burning, alcohol-soaked cotton ball or burning paper into the cup, moving it around the inner walls of the cup, and putting the mouth of the cup against the required spot.In a few minutes the skin becomes congested with a violet coloured blood stasis formation, and the person should remove a cup (Li & Jiang, 1999).People in Uzbekistan use this procedure and do cupping at home.Napisa opa, a woman in her 70s who has polyarthritis, told me about how a tabib treated her for pain in her knee joints and shoulders.The tabib advised relieving the pain and arthritis through cupping, as a cure.The tabib also instructed her to use cabbage leaves to soften the tissue around her joints.First Napisa opa used the cabbage leaves to sooth the pain.She poured hot water on cabbage leaves, making them pliable and warm.She wrapped her painful joint with the leaves for eight hours.Others used the Plantago major (common plantain) plant for the same purpose.Following the tabib's recommendation, after four days of wrapping joints with leaves, cupping began.Napisa opa's husband and children took turns to apply the jars: My husband […] peeled a potato in a size of a one-centimeter circle and put it on my knee joints.He inserted three matches into the middle of the potato.The he lighted three matches and put cupping glass over it, for 20-25 minutes.During this period, the cupping glass sucks skin and the muscles of leg.This procedure is repeated 4 times a day.On the fifth time there is a first-or second-degree burn.There is a blister full of water and after the cupping glass is removed, Vaseline is applied.The same procedure was used for my shoulders.As a result, the liquid came out for a long time.It seemed that extra liquid was leaving and the relief came.
In this case, Napisa did not discuss anything about the tabib's spirit agency; she relied on the tabib as a traditional natural healer.Evidently cupping was not sufficient, though, and she also applied other natural remedies for knee pain.Another traditional remedy for salt deposits in joints, bones, or in knee joints, is honey."Salt deposit" here is a folk term for uric acid, which is a symptom of gout.(Patient Education Institute, 2011) Oinisa, Napisa's daughter, treated Napisa's knees by covering them in honey, and then striking them with the palm of her hand for an hour.Oinisa repeated this procedure once in a day for 5-6 times a week.Napisa related the way she understood this treatment: if there is salt in the body, then the honey tastes salty.Some kinnaji tell women who do not pray regularly that performing namaz (Islam's five daily ritual prayers) will cure polyarthritis.They teach that namaz provides physical activity but also spiritual and intellectual growth.Patients who seek out the kinnaji's treatment for such knee pain may receive spiritual healing in the form of recitation from the Qur'an, combined with a physical, biomedical treatment involving paraffin.
Patients seek out traditional healers, tabibs, otins, kinnaji and others, in order to find a cure.Although the healer may rely on his or her calling and initiation and his or her spirit agency as that which enables healing, the patients seem most interested in finding a trustworthy healer, gaining the healer's careful, personal attention, and in finding treatments that will relieve their physical pain or emotional imbalance.

V. Commonly Used Folk Remedies and Medications
During this research I spoke with tabibs to ask about some of the treatments that they advise for various physical conditions, and I also talked extensively with residents of Ok Yul about natural remedies that they often use, whether those are recommended by a tabib, or simply part of local knowledge.This section outlines some of these treatments, drawing on narratives that help to explain the healer's or patient's understandings of this treatment's efficacy.
A tabib recommends a hawthorn decoction for heart problems.Drawing on Avicenna, he said hawthorn would treat irregular heartbeat, high blood pressure, and hardening of the arteries; it also blood pressure and consequently, headaches.His patients consume several small cups per day of a liquid of hawthorn in hot water, to which he suggests adding navat (chrystallised sugar) to balance the decoction's effect of drawing out saliva.This remedy, he said, would bring on sweat but provide relief.
The same tabib advised using aconite (monk's hood plant) against intestinal worms (med.helminth).His understanding of this treatment is that it "removes cold" and hence, allows the patient to regain energy.He established a course of treatment for three days, wherein aconite is diluted in water, and the patient should then drink more water, although we do not know whether this recommendation is a way of dealing with monkshood's poisons, or a response to its diuretic properties.He recommended a decoction of immortelle (helichrysum flower) and water to cleanse the gall bladder and improve blood production.The tabib uses herbs and flowers that are widely known and recommended among herbalist healers; his use of immortelle seems to echo Chinese medicine's recommendation of this herb for restoring qi and cleansing the blood.Tabibs recommend a decoction of mumiyo (mountain balsam or shilajit, a naturally occurring black, resinous mineral deposit found in certain mountain regions, including Central Asia's Pamir and Altai) in hot water, consumed daily, to thicken blood and strengthen cells in bones.Patients or healers who want to obtain mumiyo and other herbal and natural medicines find them sold at bazaars, often in a section of the market devoted to traditional medicines.
Natural oils are another widely recommended remedy.The tabib with whom I spoke said that badger oil (fat from the Eurasian badger, meles meles), massaged externally in the area of the kidney, will resolve kidney stones.Massaged on other parts of the body, he said, it would increase blood flow, though he also saw it as a relief for hemorrhoids, where one might think increased blood flow would not be desired.He recommended badger oil as a respiratory treatment in two forms: both massaged externally and drunk as a decoction.Almond oil was another remedy for which the tabib had many recommendations.Almond oil massaged on the scalp in circular motions relives itch, dryness, and scalp inflammation, while minerals in the almond nourish hair and make it strong and shiny, as well as reducing hair loss.Almonds are a common tree-nut crop in Uzbekistan, are eaten raw, often with raisins as a desert following the meal.Uzbeks believe that eating raw almond improves digestion.A tabib's recommendations may be trusted in part because they so frequently concur with common knowledge.
In Ok Yul, before they seek out expert medical aid from either the western medical establishment or the traditional healers, women treat themselves and their family members for ordinary ailments using common knowledge of herbal medicine.For example, when children catch a cold, have a fever and a headache, mothers often give them warm milk with butter and honey.Sometimes a mother will massage a feverish child with hot mutton fat and wrap the child in traditional quilt for a night.After sweating for the night and changing damp clothes for dry ones, the child feels better in the morning, when the fever has passed.When children have bronchitis, women put honey in a green turnip overnight and in the morning they give the child juice from turnip with honey.To treat nasal congestion, women will mix carrot or aloe vera juice with a natural oil, using the combination as drops to put into the nose.
Isiriq (peganum harmala, or wild rue) is an herbal medicine that is also widely used in purification rituals among Uzbeks.In Uzbekistan, medicinal uses of isiriq include turning it into a decoction with salt for rinsing the throat, for inhalation, for bathing the feet, and for cleansing the vagina.Bathing in water with isiriq is considered a treatment for joint pain and arthritis.Isiriq is burned as a fumigant: in public places like bazaars women burn isiriq to smudge (to create smoke) as the smoke drives out bad smells and bad spirits.When someone in the household is ill, women often smudge rooms with isiriq to kill bacteria and purify air.isiriq to send up its scented smoke is frequently part of rituals at life cycle occasions, and otins and kinnaji often begin ritual actions with this smudging, to purify a place where prayer or other religious ritual will take place.
In Ok Yul, those who are ill or their family members often begin their quest for a cure by using the herbal knowledge that has been passed on to them by family and community, often based on information that has come from a tabib.Those who feel some confidence in their knowledge of herbal remedies, or confidence in a certain tabib, will turn to western medicine a last resort.In Ok Yul, respondents said that people usually do not combine western medicine prescribed by doctors with traditional medicine; they will pursue a course of treatment first with one approach (western or traditional) and if the results are unsuccessful, they will turn to the other.

VI. Conclusion
Findings from this study suggest that culturally based care remains an important element in treating physical, psychological, and spiritual disease in Uzbekistan.Widely shared traditional healing practices draw on Islamic practices and beliefs, Avicennian medical teachings, and shamanic traditions.An Uzbek Indigenous epistemology of disease and healing, as described above, allows that diseases and mental or emotional imbalances may have tangible, physical causes, and also may be related to malevolent spirits.A shared understanding that Allah who sent disease also sends the cure seems to shape attitudes of openness toward many approaches to treatment, from western bio-medicine to Qur'an recitation, and from herbal treatments to spiritual interventions.
In contrast to the medical establishment's health providers, otins, tabibs, and other folk healers address their patients ailments and imbalances in holistic ways, recommending physical remedies, but also influencing the patient's behavior through their spirit agency and access to divine power and knowledge.To be regarded as an effective healer, the otin or kinnaji is expected to be able to bless the patient in order to protect him or her from the evil eye or malevolent spirits, as well as to be capable of offering wise counsel and instruction.Unlike the otin or kinnaji, the tabib may draw on professional herbalist training, but also legitimizes practice and exercises accountability to ancestors and the community through Qur'an recitation and enacting the halal life.
Uzbeks in Ok Yul, probably like many other Central Asians, actively seek out multiple paths to treatment and healing.They share stories and recommendations about healers, building the reputation and clientele of those healers whose work they see as successful.Ok Yul women and men exercise their own agency in weighing the merits of various forms of treatment, consulting with tabibs for some forms of illness, and with shamanic healers in other cases.They also seek out medical attention from Uzbekistan's medical establishment, if and when they believe this course will be most efficacious.

Nursing implications
With the increasing number of people from diverse cultural background in North America, the nursing profession is turning toward strength-based care (SBC).SBC emphasizes a holistic approach to care, that begins with a new understanding of the patient and his or her situation.Especially in cases of chronic illness or disability, SBC inquires about what is working for the patient, what coping strategies are used, and what capabilities the patient and his or her family and network have.SBC also takes into account that the patient's culture and past experiences form his or her understanding of disease and illness.The SBC method emphasizes working with patients and their families to make decisions collaboratively, using language that is based on hope, and that takes into consideration the patient's own values, thoughts, and subjectivity.Ultimately, SBC urges health care practitioners to work out plans for care designed around the particular patient, that strive not just for coping or management, but for empowerment (Gottlieb & Gottlieb, 2013).The minority immigrant population from Central Asia is increasing in Canada, and like other immigrants, Central Asian men and women may experience barriers to addressing their own health care needs (WHRA, 2010).Future research can be carried out to examine the ways of coping and strategies that individuals from Central Asia undertake to care for relatives and friends dealing with chronic and serious illness upon settlement and adaptation in the new Canadian culture of health care.
Health care providers and nurses may not be aware fully about the health promotion practices, meanings and beliefs, healing methods and folk medicine used by some individuals in Uzbekistan.Therefore, as Leininger (1999) suggests, nurses should do their best to understand pathways of culture care and practicing culturally based care acts.Knowing something about folk medical practices in Central Asia may help nurses to be more aware of these patients' values, understandings of illness, and attitudes about treatment, which in turn may allow nurses to work with patients in culturally sensitive ways that enhance patient health and empowerment.