Lime for Chest Congestion, Bitter Orange for Diabetes: Foods as Medicines in the Dominican Community in New York City
Lime for Chest Congestion, Bitter Orange for Diabetes: Foods as Medicines in the Dominican Community in New York City. Several plants serve a dual purpose as foods and medicines in the Dominican immigrant community in New York City. Data show that foods used for self–medication by this community are plants that are well known and readily available in an urban environment, such as lime, bitter orange, garlic, cinnamon, onion and shallot, coconut, watercress, ginger, soursop, and radish. These plants are significant for Dominicans in New York City for treatment of non–communicable diseases, colloquially called “lifestyle diseases” (such as diabetes, obesity, high cholesterol, hypertension, and asthma/chest congestion), self–limiting diseases (including common cold, flu, cough, acute bronchitis), and female reproductive health (such as vaginal infections and infertility). Our findings emphasize the contemporary role of traditional medicine as an alternative and parallel healthcare system that dynamically adapts to current urban epidemiological trends. The double use of foods as medicines has important implications for urban outreach projects, such as Green Carts and community gardens, that play a role in disease prevention of vulnerable populations, especially those living in areas identified as food deserts.
Key WordsTraditional medicineurban ethnobotanymigrantsnon–communicable diseasesself–limiting diseasesfemale reproductive healthfood desertsGreen Cartscommunity gardensbotánicasmedical educationcultural competency trainingDominican Republic
El Limón para Pecho Apretado, la Naranja Agria para Diabetes: Plantas Alimenticias como medicinas en la Comunidad Dominicana en Nueva York. Varias plantas tienen un doble propósito como alimentos y medicinas en la Comunidad inmigrante Dominicana en la ciudad de Nueva York. Los datos demuestran que estas plantas Alimenticias utilizadas para automedicarse por esta Comunidad son plantas que son bien conocidas y fácilmente disponibles en el entorno urbano, como Limón, Naranja Agria, ajo, canela, cebolla y cebollín, coco, berro, jengibre, guanábana y rábano. Estas plantas son importantes para la Comunidad Dominicana en Nueva York para el tratamiento de las enfermedades no transmisibles, coloquialmente llamadas “enfermedades de estilo de vida” (como Diabetes, sobrepeso, colesterol alto, hipertensión y asma/Pecho Apretado), enfermedades auto–limitadas (incluyendo resfriado, gripe, tos, bronquitis aguda) y la salud reproductiva de la mujer (como infecciones vaginales e infertilidad). Estos resultados enfatizan el papel contemporáneo de la medicina tradicional como un sistema alternativo y paralelo de salud que se adapta dinámicamente a las tendencias actuales de la epidemiología urbana. El doble uso de las plantas Alimenticias como medicinas tiene implicaciones importantes para proyectos de extensión urbana, tales como los Carritos Verdes (“Green Carts”) y los jardines comunitarios, que desempeñan un papel en la prevención de las enfermedades en poblaciones vulnerables, especialmente las comunidades que viven en áreas identificadas como desiertos alimentarios (“food deserts”).
“Let food be thy medicine and medicine be thy food”
—A phrase of unconfirmed origin that expresses the medical philosophy of Hippocratic medicine.
Ethnobotanical studies around the world have documented the link between plants used as foods and medicines in various cultures (Cavender 2006; Ceuterick et al. 2011; Cruz-García and Price 2011; Etkin and Ross 1982, 1991; Pieroni 2000; Pieroni et al. 2002, 2007; Pieroni and Price 2006, and papers in that volume; Rivera et al. 2005; Volpato and Godínez 2004). Anthropologist Dr. Nina Etkin dedicated much of her career to understanding how plants are concomitantly used as foods and medicines. She observed that scholars who investigate medicinal plants often forget to mention whether these plants also have dietary roles, and vice versa. Dr. Etkin also advocated biological screening of the extra–nutritive aspects of foods (Etkin and Ross 1991). In our ethnobotanical research with the Dominican community in New York City (NYC), we found a positive effect of migration on knowledge of food plants used as medicines (Vandebroek and Balick 2012). We defined these plants as food medicines. Their primary uses are culinary and their secondary uses are therapeutic, in contrast to plants that are exclusively used as medicines. Following this definition, some species, such as lemongrass (limoncillo, Cymbopogon citratus [DC.] Stapf), were excluded as food medicines in our study because, although their culinary use is popular in several cultures, they are not popular Dominican food plants. For some species, such as Mexican mint (orégano poleo, Plectranthus amboinicus [Lour.] Spreng.), basil (albahaca, Ocimum basilicum L.), or spearmint (hierba buena, Mentha spicata L.), this distinction may not be all that clear cut, and it is possible that some Dominican immigrants have recently begun using these species as condiments in addition to their well–known therapeutic uses. However, since their use in Dominican cuisine is not widespread and their medicinal uses clearly predate more recent food applications, these species were not classified as food medicines in Vandebroek and Balick (2012), nor in this study.
In the present paper, we provide a more in–depth characterization of these food medicines in the transnational Dominican community and attempt to answer the following questions: (1) Which plants are the most popular food medicines for Dominicans living in NYC as compared to the Dominican Republic?; (2) How are they used?; (3) Which health conditions do they treat?; (4) Where are they obtained?; and (5) How does migration influence their use?
Institutional Review Board (IRB) approval for this study was granted by the City University of New York (IRB# 04–06–0599; PI Michael J. Balick). Interviewers received Human Subjects Certification prior to interviewing. We interviewed 165 Dominicans in NYC who were born in the Dominican Republic (105 women and 60 men), and 128 Dominicans currently living in the Dominican Republic (79 women and 49 men). These individuals were lay persons who use medicinal plants for self–care but who do not identify themselves as plant specialists or traditional healers, or are not identified as such by others. Participants were recruited through subjective sampling. This non–random sampling technique includes convenience sampling (people who are available at certain locations and willing to be interviewed), and snowball sampling (prospective participants are recommended by others) (Tongco 2007). Inclusion criteria were: age 18 or older, born in the Dominican Republic, and self–reported knowledge of some medicinal plants. Further details about the study design can be found in Vandebroek and Balick (2012).
The questionnaire comprised 84 questions in NYC and 53 in the Dominican Republic. Verbal informed consent was obtained from each participant prior to interviewing. The interview took place between a participant and an interviewer at the place where the participant was recruited, at the participant’s home, or in rare cases at The New York Botanical Garden’s Institute of Economic Botany. To guarantee anonymity, an ID number was assigned to each interview and no personal identifying details were recorded. Questions were asked in Spanish by the interviewer who recorded the answers on the questionnaire. The interview was also tape recorded if the participant granted consent. From a list of 29 conditions, for each condition the interviewer asked: “Do you know medicinal plants, leaves, or home remedies to treat this condition?” (In Spanish: “¿Conoce Ud. plantas medicinales, hojas o remedios caseros para tratar esa enfermedad?”). If this was the case, the Spanish local name(s) of the plant, plant part used, preparation, and mode of administration were recorded. A final question gauged whether participants knew of plants other than the ones they had mentioned previously to guarantee comprehensiveness of data collection.
New York City participants were asked the following two questions related to plant procurement: “When you lived in the Dominican Republic, where did you obtain or buy medicinal plants?” (In Spanish: “¿Cuando Ud. vivía en la República Dominicana, ¿dónde conseguía o compraba plantas medicinales?”). Further along during the interview, in the section that belonged to the current living situation of the participant, we asked: “Since you have been living in NYC, where do you obtain or buy medicinal plants?” (In Spanish: “¿Desde que Ud. está viviendo en la Ciudad de Nueva York, ¿dónde consigue o compra plantas medicinales?”). After completion of the questionnaire, participants received a remuneration or gift.
Ranking of food plants mentioned as medicines in New York City and the Dominican Republic*.
Species Latin name, plant family, common names in English and Spanish
Citrus aurantiifolia (Christm.) Swingle (Rutaceae)
English: lime; Spanish: limón, l. verde, l. agrio
Allium cepa L. (Amaryllidaceae)
English: onion; Spanish: cebolla, c. blanca, c. roja
Allium cepa var. aggregatum G. Don (Amaryllidaceae)
English: shallot; Spanish: cebollín
Citrus aurantium L. (Rutaceae)
English: bitter orange; Spanish: naranja agria
Cinnamomum spp.* (Lauraceae)
English: cinnamon; Spanish: canela
Allium sativum L. (Amaryllidaceae)
English: garlic; Spanish: ajo
Cocos nucifera L. (Arecaceae)
English: coconut; Spanish: coco, c. indio
Nasturtium officinale W.T. Aiton (Brassicaceae)
English: watercress; Spanish: berro
Zingiber officinale Roscoe (Zingiberaceae)
English: ginger; Spanish: jengibre, j. dulce, j. Caribe, j. blanco, j. picante
Raphanus sativus L. (Brassicaceae)
English: radish; Spanish: rábano
Annona muricata L. (Annonaceae)
English: soursop, graviola; Spanish: guanábana
Lippia micromera Schauer (Verbenaceae)
English: Spanish thyme; Spanish: orégano, o. chiquito, o. de cocinar, o. de comer, o. fino, o. pequeño
Psidium guajava L. (Myrtaceae)
English: guava; Spanish: guayaba
Statistical tests were computed with Sigmastat v2.01 (Jandel Scientific Software) and consisted of two–tailed Chi–squared (χ2) and Z–tests for comparison of proportions, with Yates correction for continuity (which renders the tests more conservative; i.e., it increases the P–value and reduces the chance of a false positive conclusion). The data described and discussed here did not undergo Bonferroni correction. However, in the tables, P–values that remain significant after Bonferroni correction (based on the number of individual statistical comparisons) are underlined for purposes of comparison without correction. Our aim was not to examine the null–hypothesis that there did not exist an overall relationship between the type of plant, health condition, and country; rather, it was to examine the specific relationship between individual health conditions or symptoms, and a plant’s (or plant type’s) frequency of mention in NYC and the Dominican Republic. It may be debatable if the “same hypothesis” is being analyzed repeatedly if one focuses on different plants and health conditions. Failing to use Bonferroni correction in the case of multiple comparisons of the same hypothesis inflates Type I error rates (the null hypothesis is rejected while it is true), whereas overzealous use of Bonferroni increases Type II error rates (the null hypothesis is accepted while it is false). It may be considered problematic that Bonferroni adjustments imply that a given comparison will be interpreted differently according to how many other tests were performed since re–grouping of data would reduce the number of tests and result in a smaller correction factor. Our approach was to forego Bonferroni correction and to look for logical patterns that emerged from the results of the analysis instead of blindly applying this correction.
Comparison of Popular Food Medicines between New York City and the Dominican Republic
Eight of the ten most frequently reported food plants used as medicines overlap between NYC and the Dominican Republic (Table 1). Of these plants, onion and shallot, watercress, and radish were reported more often in NYC than in the Dominican Republic. In contrast, lime, bitter orange, cinnamon, Spanish thyme, and guava were reported more frequently in the Dominican Republic. Finally, garlic, coconut, ginger, and soursop were reported equally between NYC and the Dominican Republic.
Plant parts used in Dominican traditional medicine and their modes of administration*.
New York City
fruit / juice (69)
fruit / applied (38)
fruit / tea (35)
leaves / tea (6)
fruit / juice (62)
fruit / applied (61)
fruit / tea (11)
leaves / tea (10)
Onion and shallot
bulb / juice (92)
bulb / tea (8)
bulb / botella** (6)
bulb / syrup (5)
bulb / eaten (3)
bulb / juice (38)
bulb / tea (11)
bulb / botella** (8)
bulb / eaten (5)
bulb / syrup (4)
leaves / tea (47)
fruit / applied (45)
fruit / juice (36)
leaves / applied (15)
seeds / swallowed (4)
fruit / juice (37)
leaves / tea (35)
fruit / applied (28)
leaves / ritual (11)
leaves / vapor bath (5)
leaves / applied (4)
fruit / tea (4)
seeds / swallowed (3)
bark / tea (29)
bark / tea (14)
clove / eaten (71)
clove / tea (23)
clove / applied (15)
clove / eaten (37)
clove / tea (6)
clove / applied (6)
water / drunk (43)
oil / drunk (17)
fruit shell / tea (10)
milk / drunk (8)
oil / applied (4)
milk / applied (3)
root / botella* (3)
water / drunk (30)
milk / drunk (12)
oil / drunk (8)
fruit shell / tea (4)
root / botella** (4)
oil / applied (3)
plant / juice (41)
plant / syrup (13)
plant / tea (9)
plant /eaten (5)
plant / juice (8)
plant / syrup (4)
plant / tea (3)
root / tea (55)
root / applied (11)
root / tea (25)
root / applied (6)
root / juice (4)
root / juice (24)
root / syrup (10)
root / tea (5)
root / eaten (3)
root / juice (5)
root / syrup (3)
leaves / tea (49)
leaves / applied (4)
leaves / tea (22)
leaves / tea (43)
leaves / tea (15)
leaves / tea (9)
fruit / juice (6)
fruit / eaten (4)
fruit / tea (3)
bark / tea (3)
leaves / tea (19)
shoots / tea (11)
fruit / tea (9)
fruit / juice (7)
fruit / eaten (4)
Contribution of Food Medicines to Alleviate Specific Health Conditions
Appendix 1—Electronic Supplementary Material (ESM)—provides an overview of conditions for which food plants listed in Table 1 were used, either in NYC or in the Dominican Republic. Some species were used significantly more frequently for certain conditions in NYC than in the Dominican Republic, such as lime for asthma and chest congestion, bitter orange for sinusitis and diabetes, and garlic for hypertension. In the Dominican Republic, as compared to NYC, lime was used more frequently for bruises, bitter orange for shingles and wounds, cinnamon for cough, and garlic for parasitic infections.
In Appendix 2 (ESM), illnesses are compared transnationally in relation to their treatments with food versus nonfood medicines. For more than half of all conditions in NYC (17 of 29 conditions, or 59 %), food plants represented more than 50 % of all plant remedies mentioned for treatment. Significantly more food medicines were reported in NYC than in the Dominican Republic for backache, bronchitis, common cold, cough, diabetes, flu, infertility, and vaginal infections.
Obtaining Plant Medicines
In NYC, most people (72 %) purchased plants from botánicas. Golden shower tree (caña fistula, Cassia fistula L.), rue (ruda, Ruta spp.), and rosemary (romero, Rosmarinus officinalis L.) were just a few examples of plants purchased in botánicas. Almost one–fourth (23 %) of the interviewees purchased their plants from NYC markets (called marquetas in Spanish) and greengrocers, some of Asian origin. Chinese and Korean greengrocers and markets were mentioned as places to obtain plants such as horsetail (cola de caballo, Equisetum spp.), cucumber (pepino, Cucumis sativus L.), bitter orange, aloe, celery (apio, Apium graveolens L.), and fresh spearmint. Bodegas were the third most cited source of plants in NYC (15 %) (colmados are their counterparts in the Dominican Republic). Bodegas and colmados are small Latino and Caribbean neighborhood stores that carry products for daily use, including limited fresh produce and sometimes medicinal plants, such as aloe.
New Food Medicines and New Medicinal Uses in New York City
Some food medicines were unique to NYC, even though they were reported infrequently. These species were not recorded during our interviews in the Dominican Republic. Among these are plants such as broccoli (brocoli, Brassica oleracea L. [Italica group]) for treatment of high cholesterol and fungal skin infections; the leaves of caimito (Chrysophyllum cainito L.), dandelion (diente de león, Taraxacum sp.), and pear (pera, Pyrus communis L.) for kidney problems; spinach (espinaca, Spinacia oleracea L.) for fungal skin infections; kiwi (Actinidia deliciosa (A.Chev.) C.F.Liang & A.R.Ferguson) for high cholesterol and hypertension; lemon (limón amarillo, Citrus limon (L.) Osbeck) for asthma, vaginal infections, and high cholesterol; marjoram (mejorana, Origanum majorana L.) to dispel evil spirits; melon (melón, Cucumis melo L.) to refresh the blood; passion fruit (parcha, Passiflora edulis Sims) for hypertension; and peach (Prunus persica (L.) Batsch) for impotence. Peach and kiwi were reported by Dominicans directly by their English common names. Most of these species (except Chrysophyllum cainito) are easily available in NYC supermarkets. These NYC citations may constitute new species that expand the Dominican traditional pharmacopoeia.
In addition, some food species also acquired new uses in NYC that were not mentioned in the Dominican Republic. Examples of these are the use of cucumber for slimming and hypertension; oats (avena, Avena sativa L.) for slimming and diabetes; celery (apio, Apium graveolens L.) for bronchitis and hypertension; pineapple (piña, Ananas comosus (L.) Merr.) for cholesterol, slimming, diabetes, arthritis, and intestinal problems; eggplant (berenjena, Solanum melongena L.) for slimming; and annatto (bija, Bixa orellana L.) for diabetes, labor pain, and vaginal infections.
Food medicines of the transnational Dominican community are versatile therapeutics made from differed plant parts and administered in multiple ways. They are important medicines for treating non–communicable diseases such as asthma, sinusitis, diabetes, and hypertension, especially in the urban environment.
Generally Known Food Plants
Most of the popular food plants identified in this study are not restricted to the Dominican community, but are used in many cultures. The multicultural environment of NYC offers migrants novel plants or new knowledge of their uses that will likely create shifts in the popularity of some plant medicines and bring about changes in their traditional practices (Viladrich 2006) and pharmacopoeias (Medeiros et al. 2012). Several studies in the United States have highlighted Latino migrant traditions of consulting with healers (Balick et al. 2000), visiting botánica shops for spiritual and physical health (Gomez-Beloz and Chavez 2001; Hodges and Bennett 2006; Reeser and Cintrón–Moscoso 2012), adherence to Santería practices (Brandon 1991), and the role of cultural beliefs in healthcare seeking behavior (Risser and Mazur 1995; Sullivan et al. 2010). However, relatively few studies have focused on the botanical characterization of herbal remedies used for self–medication, and no study in the United States has looked into patients’ own assessment of the outcome of those plant–based treatments (Diallo et al. 2006). Foods also represent important medicines for South American immigrants in London. Respectively, 70 %, 62 %, and 57 % of all medicinal species used by Colombians, Peruvians, and Bolivians living in London had a primary function as foods or condiments (Ceuterick et al. 2008; 2011). Given their popularity already observed in several immigrant communities, more studies need to focus specifically on the importance of foods as medicines, as well as on the health threats these communities face as their dietary habits rapidly change after migration (Pieroni et al. 2007). In addition, these types of studies can generate health benefits for the public at large, through extension to non–immigrants suffering from the same diseases, and help alleviate the global epidemic of non–communicable diseases (World Health Organization 2013).
Current Disease Trends
Our results indicate that food medicines are used to treat many of the most frequently diagnosed conditions (see Hsiao et al. 2010) in ambulatory care visits to physician’s offices in the United States. Our results also show that Dominican migrants seek home remedies for self–medication of these prevalent conditions as part of their healthcare strategies. Even more, they are doing so by finding remedies that are relatively easily accessible in an urban environment, either in markets, supermarkets, or botánicas. What remains to be explored is to what extent patients use these food medicines as an alternative to biomedicine, or concomitantly, and how this impacts their health. Food plants are Generally Regarded As Safe (GRAS) by the U.S. Food and Drug Administration. However, this does not exclude the possibility of plant–drug interactions. For example, grapefruit juice can lead to increased serum concentrations of several medicines, including statins and cyclosporine, and the high content of vitamin K in broccoli and other green vegetables can be counter–effective in anti–coagulant therapy (Bailey et al. 2013).
A discussion on the potential safety of food medicines inevitably raises questions about their efficacy. Several authorities, such as the Natural Standard Research Collaboration (www.naturalstandard.com) and the American Botanical Council (http://cms.herbalgram.org/commissione/HerbIndex/approvedherbs.html), have published evidence–based systematic reviews for 9 of the 12 plants listed in Table 1 (the three exceptions being Lippia micromera, Raphanus sativus, and Psidium guajava). In clinical trials, ginger reduces the severity and duration of nausea and vomiting during pregnancy (Dante et al. 2013). Garlic attained the same rating for elevated blood cholesterol levels. However, some studies of garlic, ginger, and other Dominican food medicines provided equivocal or negative results. Importantly, most medicinal use claims made for food plants by the Dominican community in this survey have not been studied. More randomized human trials need to be conducted on the diverse medicinal uses of these plants. Food chemistry, the study of the bioactive components of foods, may help explain differences in therapeutic action between closely related species, such as those between onion and garlic, which both belong to the genus Allium. Whereas onions are rich in flavonoids (antioxidants), the chemistry of garlic is based on allicin and its derivatives. On the other hand, onions do not produce allicin whereas flavonoids are virtually absent from peeled garlic cloves. Therefore, if considered for their medicinal value, these closely related species target different diseases (Griffiths et al. 2002).
Why Are Foods Reconsidered as Medicines after Migration?
Food plants are very accessible and available in the urban environment, and therefore people can easily experiment with them. The Dominican–Spanish words curioso/curiosa (someone who is curious) and inventar (to invent) refer to people who like to experiment with medicinal plants. Ceuterick et al. (2008; 2011) also explain the predominance of foods as medicines among South American immigrants in London in terms of their wide availability, among others in supermarkets. Another reason for the increased popularity of food plants after migration may lie in the complexity of multicultural interactions that characterize the immigrant experience in NYC. On the one hand, food traditions become symbolic representations of Dominican identity in NYC that reinforce “Dominicanness”; on the other hand, culturally diverse food knowledge and practices are easily shared across diverse ethnic communities through jobs, intermarriage, and food shopping (Marte 2011). Knowledge about food plants used as medicines may be transmitted through similar cultural exchanges. From our own experience, it is not uncommon in NYC to stand in line at Latino greengrocers and overhear women exchanging food plant recipes for specific health conditions in Spanish. Knowledge about such generally known plants as foods does not appear to be proprietary and hence not subject to secrecy, as is often the case with less familiar plants known mainly by specialist healers. Knowledge about these plants, therefore, may be quite easily exchanged. The food–medicine hype of the last decade is also widely spread by the Internet, overwhelming the general public with articles about which foods to eat for health purposes; for example, to reduce inflammation.
Food Deserts, Green Carts, Community Gardens, and Medical Education
We suggest that the observed increase in the use of food medicines by Dominicans in NYC reflects the different socio–cultural, ecological, and epidemiological environment in their new home country. Even though this study focused on the Dominican community in NYC, the discussion on food and health should not be restricted to one cultural group, especially given the global importance of these food plants in many human diets and considering the global trends in non–communicable diseases.
Non–communicable diseases represent a worldwide epidemic burden, accounting for more than 36 million deaths (out of 57 million global deaths) each year (World Health Organization 2013). Four categories—cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes—are responsible for most of these deaths. Our results are promising in that they show how a Caribbean community, through its cultural use of food plants, has developed a strategy to respond to this health crisis. Sharing these results with the broader community–at–large provides an opportunity to develop an action plan to attack global non–communicable diseases through diet combined with other lifestyle changes, such as exercise.
The authors are indebted to the Dominican communities in New York City and the Dominican Republic for their time and dedication to this study, for their hospitality, and for generously sharing with us their rich plant knowledge and cultural traditions. Alianza Dominicana, a Dominican non–profit community development organization that works to revitalize economically distressed neighborhoods, and its Deputy Director Miriam Mejía, are kindly thanked for facilitating interviews with study participants. We are thankful to the many interns, research assistants, and volunteers at the Institute of Economic Botany who helped out in the Latino Ethnomedicine Program of The New York Botanical Garden, especially to Elvio Almonte, Gabriela Alvarez, Thomas Diaz, Levenia Duran, Ashley Duval, Thomas Flynn, Ellen Herra, Daniel Kulakowski, Greta Meyers, Saneddy Quezada, Claudia Remes, Kate Sokol, and Margaret Terrero. Thanks also go to Dr. Alain Touwaide and Emanuela Appetiti for their insight into the phrase “Let food be thy medicine,” attributed to Hippocrates. The Latino Ethnomedicine Program was supported by grants from the National Institutes of Health/National Center for Complementary and Alternative Medicine (NIH/NCCAM; PI Dr. Michael J. Balick; Grant #5 R21 AT 001889–02), The Jacob and Valeria Langeloth Foundation, The United Hospital Fund, The Aetna Foundation, and The Cigna Foundation. Photos were taken by Ina Vandebroek.