Clown Doctors: Shaman Healers of Western Medicine

Clown Doctors: Shaman Healers of Western Medicine
Author(s): Linda Miller Van Blerkom
Reviewed work(s):
Source: Medical Anthropology Quarterly, New Series, Vol. 9, No. 4 (Dec., 1995), pp. 462-475
Published by: Blackwell Publishing on behalf of the American Anthropological Association
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LINDAMILLERVANBLERKOM
Departmentof Anthropology
Drew University
Clown Doctors: Shaman Healers of Western
Medicine
TheBig AppleCircusClownCare Unit, whichentertainschildrenin New
YorkCity hospitals, is compared with non-Westernhealers, especially
shamans. There is not only superficial resemblance-weird costumes,
music,sleight of hand,puppet/spirithelpers,and ventriloquism-butalso
similarity in the meanings and functions of their performances.Both
clown and shaman violate natural and cultural rules in their performances. Both helppatient andfamily deal with illness. Both use suggestion
and manipulationof medical symbols in attemptingto alleviate their
patients' distress. Just as traditional ethnomedicalsystems have been
integratedwith Westernmedicine in other societies, clown doctors can
providecomplementarytherapythatmay enhancethe efficacyof medical
treatmentin developed nations,particularlyfor children. [clowns, shamans,pediatriccare, medical systems, complementarymedicine]
n Monday,Wednesday,and Fridaymornings,Dr. WinonaDo-More preparesfor her roundsin the pediatriccardiologyunit of a large New York
City hospital.She checks her hospitalbadge, white coat (with red hearton
the sleeve), glasses, makeup (including red nose), oxygen tubing (worn twisted
aroundherhead),andbag of medicalinstruments(kazoo,bells, whistles, andother
noisemakers).Satisfiedthat all is ready, she leaves the changingroom for another
day of funny-boneremovals,squeakectomies,andbed-pandemonium.Dr. Winona
Do-More is not a medicaldoctor;she is a clown doctorwith the Big Apple Circus
Clown CareUnit.'
The Clown CareUnit (CCU) is a group of professionalclowns who work in
the pediatric wards of New York City hospitals. Created in 1986 by Michael
Christensen("Dr.Stubs"),cofounderandcreativedirectorof the Big Apple Circus,
the CCU beganwith two clowns in one hospital andhas since grownto 35 clowns
serving seven medicalcentersthroughoutNew York City plus a summerprogram
at Paul Newman's Hole-in-the-WallGang Camp for children with cancer and
chronicblooddiseases. Clowns typicallyworkin groupsof two or three,threedays
a week, and spend these days cheeringpatients,their families, and hospital staff.
Medical AnthropologyQuarterly9(4):462-475. Copyright? 1995, AmericanAnthropologicalAssociation.
462
CLOWNDOCTORS
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Theiractivitiesincludeentertainingboredchildrenandmothersin crowdedoutpatient clinic waiting rooms, distractinganxious families in inner-city emergency
rooms,comfortingparentsof childrenin intensivecareunits,and distractingsmall
AIDS or cancer patients during painful and frighteningprocedures.They spread
joy and mayhem wherever children might be found in what is otherwise an
environmentnot designed with childrenin mind.
In many ways, CCU clowns resemble shamans and traditionalhealers of
non-Westernsocieties. The inclusion of clowns in pediatric hospitals reflects
growing interestin and respect for alternative,or, more correctly,complementary
styles of healing. Western medicine is oriented toward allopathic treatmentof
clinical symptoms, while traditionalnon-Westernhealing more frequently addressesa patient'ssocial condition and constructionof the illness experience.One
cannot deny the efficacy of physicians compared to shamans, but integrating
doctors with complementarypractitionerssuch as clown doctors may render
Westernmedicine even more effective.
Clowns and Shamans
A review of the literatureshows that comparingclowns and shamansis not
new. Clowning and otherpopularentertainment(magic tricks,sword swallowing,
juggling, acrobatics,etc.) originatedwith shamanisticperformances(Kirby 1974).
Some trace the derivation of all performingarts to shamanism(Flaherty 1988;
LaBarre1979). Turner(1985:235-236) includes clowns and fools with shamans,
tricksters,healers,and othercharactersin a list of liminalfigures found in rites of
passagedealingwith social crisis and affliction.Both clowns and shamansmediate
between order and chaos, sacred and profane,real and supernatural,culture and
anticulture,or nature(Charles1945:32-33; Willeford1969:100-150). This mediation of culture and nature is central to the healing arts and sciences (Moerman
1979:59).In the languageof semiotics, clown performancesaremetaculturaltexts,
acts of communicationaboutculture,thatinvertculturalrules, therebyprovoking
emotional responses (Bouissac 1985:151-175). Whether the antics of clowns
producemirthor agitationin the observer,suchfolly has long been associatedwith
psychologicalhealing (Willeford 1969:29).
Clown figures with healing functionsoccur in other societies, particularlyin
Native Americancultures.Institutionalizedclowning is best developed among the
Pueblos.CharlesranksPueblo clowns with the Commediadell'Arte as among the
"four major groups of clown societies ... known to exist or to have existed"
(1945:30). Not all Pueblo clown societies function as healers, but some do. For
example,the Zuni Ne' wekwe is a highly regardedmedicinesociety, some of whose
membersare clowns who improvise farces and burlesquesduringcuring ceremonies (Bunzell 1932:498). The Laguna Koshareand Santa ClaraKossa are sometimes called on for curing,althoughmost Kosharesdo not heal (Parsonsand Beals
1934:495). Other clown societies for which curing is a primaryfunction occur
among the Yaqui and Mayo Indians of Sonora (Parsons and Beals 1934:506).
Iroquois False Faces use clown-like theatrics to exorcise disease (Towson
1976:13).
Plains Indianclowning takes the formof "contrary"behavior,such as talking
or performingactions backwardand in other ways violating naturaland social
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MEDICAL
ANTHROPOLOGY
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conventions (Steward 1931:198). Moder Plains Indiansconsidercircus clowns
similar to contraries(Towson 1976:13). Some of these contrariesfunction as
healers, but only if they are of the comic type or "buffoon";"serious"contraries,
such as the Oglala Heyoka, never cure (Ray 1945:91). Healing buffoons include
the Plains Ojibway Windigokan and Plains Cree Wetigokan,who use contrary
behaviorandraggedcostumes, as well as dancing,singing, whistling,and shaking
rattlesin theircuring(Ray 1945:84-87; Steward1931:203).The CanadianDakota
(Wahpeton)considerclowns to be the most powerfulshamans(Ray 1945:86).
Clowns, Shamans, and Complementary Medicine
MedicalanthropologistshavefrequentlycontrastedWesternandnon-Western
medical systems. Foster (1976) classified non-Westernmedical systems into personalistic and naturalistic,depending upon whetherillness-causationbeliefs involved supernaturalentities or naturalprocesses. He placed Western,presumably
scientific, medicine in a different category altogether. Kleinman (1973:206)
pointed out that medicine deals with two kinds of reality, "scientific"and "ordinary,"that is, with biophysical and humandimensions.Westernphysicians concentrate on the biophysical dimension and treat the symptoms of disease. In
contrast,indigenoushealersaddressthehumandimension,theillness, by providing
and manipulatingthe personal,social, and culturalmeaningsof the illness experience (Kleinmanand Sung 1979:7-8). This distinctionbetween "disease,"a biological reality,and "illness,"an experienceand social role (Eisenberg1977), has
becomecommonusagein medicalanthropology,especiallyin studiesof non-Westernandalternativemedicalsystems (Leslie 1980:195).Moerman(1979) also wrote
of this dichotomybetween biomedicine's allopathictreatmentof physical symptoms and the shaman'sconcern with the whole patientand the mental predicates
of disease. He called the former "specific therapy"and referredto the shaman's
more holistic approachas "generaltherapy"and "symbolichealing,"wherebythe
healermanipulatessymbols within a culturalsystem of meaningso as to promote
psychosomatictransformation.Symbols centralto a society's medical system are
particularlyimportant(Finkler 1980:271, 300; Kleinman1973).
These comparisonsof Westernand non-Westernmedical systems echo distinctionsmade between the biomedicalestablishmentandholistic medicine. Proponentsof holism accuse physicians of bioreductionismandof focusing more on
the disease entity than on the individual's illness experience (McKee 1988).
Accordingto some, it is this illness experience, and the feeling that biomedicine
does not pay adequateattentionto the whole person, that induces people to seek
alternativetherapies(Furnhamand Forey 1994:467-468; Leslie 1980:193). And
many people are turning to alternativemedicine. A recent survey showed that
Americansmakemore visits annuallyto alternativeprovidersthanto primary-care
physicians,andthey spend more on these unconventionaltherapiesthanon hospitalizations (Eisenberget al. 1993). A community survey in London also found
substantialuse of alternativetherapies(Murrayand Shepherd1993). Both studies
found thatmost of these people also soughttreatmentfromphysicians(in fact, the
London study showed more frequentvisits to general practitionersby users of
alternativemedicine). For this reason complementaryor additivemedicine better
describesthis practicethandoes alternative.
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Westernmedical practitionersincreasinglyrecognize the need to escape the
limitationsof a bioreductionistview of healthanddisease. This can be seen in the
integrationalmodelof medicine-espoused by thementalhealthmovement,family
practice,psychosomaticmedicine, and publichealth-that views a personas more
thana collection of cells and symptoms(Aakster1986:269).Biomedicineincreasingly acceptsa healthcarerole for some kindsof complementarypractitioners.The
U.S. National Institutesof Health now include an Office of AlternativeMedicine
to screen and evaluatealternativetherapies.A recentBritishMedical Association
reportconcedes that some unorthodoxtherapies,such as acupunctureand homeopathy,areuseful, andurgesphysiciansto becomebetterinformedso they can refer
patientsto otherpractitioners(Gould 1993:44).In Denmark,centersfor integrated
medicinehave been established,where conventionaland alternativepractitioners
cooperate(Launs 1989). Physicians in some non-Westernsocieties, for example
China and India, work alongside practitionersof traditionalmedical systems
(Jingfeng 1987; Last 1990:359-360), and the World Health Organizationhas
establisheda new department,the TraditionalMedicineProgram,thaturges member states to integrateindigenoushealers into the generalhealth system (Jingfeng
1987:659).
Complementaryor additive medicine is attractivein theory, but questions
remainaboutthe efficacy of non-Westernandunorthodoxmedical systems. While
some complementarytherapiessuch as chiropracticandhomeopathyhave yielded
evidence of efficacy in clinical trials (Gibson et al. 1980; Kirkaldy-Willisand
Cassidy 1985), attemptsto gauge thatof shamansand most forms of complementary medicine are plagued with problemssuch as lack of propercontrols, subjectivity of patientself-reporting,and incongruencebetween emic illness categories
and etic, or biomedical, disease definitions. This article does not address this
question, but suggests instead that the question is wrongly focused. Ratherthan
asking whetherclowns, shamans,or unorthodoxhealers have efficacy by themselves, patternsof usage suggest one shouldask whetherthey enhancethe efficacy
of biomedicinewhen used as a complementaryor additivesystem.
Methods
This articleis based on participant-observation
of the CCU and its activities.
Five groups of clown doctors were observed for one workdayeach, in five New
York City hospitals. A writtenrecord was kept of time, context, actors, clowns'
reactions. The clowns' behavior was the main
actions, and patient/parent/nurse
observationalfocus. Their activities were recordedin as much detail as possible,
especiallyduringinteractionwith patients,parents,andnurses.The behaviorof the
"audience"was also noted, and any obvious effects of clown visits on mood or
behavior.
This was supplementedby manyhoursof interviewswith CCU clowns. Other
sources of data were two hospital staff evaluationmeetings and a monthly CCU
staff meeting. The formerprovided informationconcerningmedical personnel's
attitudestoward and relationships with the clowns. The latter combined CCU
business (hospital assignments, scheduling, relationswith hospital directorsand
staff), rehearsal,and "emotionalhygiene"-a ritualactivity duringwhich clowns
sharedtheir affective reactions to distressing hospital experiences and received
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MEDICALANTHROPOLOGY
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emotionalsupportfrom the group, a healing ritualin itself. Brief interviews with
parentsand hospital staff were supplementedby their writtenevaluationsof the
CCU,which allowedme to gain some ideaof attitudestowardandsubjectiveeffects
of the clowns.
A Day in the Life of Dr. Do-More
A CCU clown's typical day begins in a hospital changing room, where he or
she dons makeupand costume, assuminga clown doctorcharacterin the process.
The clowns work in groups of two or three, with one clown (generallythe most
experienced)designatedthe supervisor.At New York Hospital, this is Dr. DoMore, who was trainedin mime and physicalcomedy andhas been with the CCU
for six years.HerassociatesareDr. Bobo, a graduateof the Moscow CircusSchool
with many years of work on the stage in Russia as well as a universitydegree in
directing,andDr. Fidget,experiencedin mime,physicalmovement,magic, music,
and children's theater.Both Dr. Bobo and Dr. Fidget have been CCU clowns for
four years. They all wearoutlandishcostumes toppedoff by a doctor's white coat
with "Big Apple Circus"on the back. They carrydoctor's bags filled with magic
tricks, puppets, musical instruments, bubble solution, juggling balls, and other
props.
At 10:00 a.m. they leave the changingarea,exchanginggags with anyonethey
meet in the halls, elevators, or waiting rooms on their way to the pediatric
cardiology outpatientclinic. After enteringthe clinic playing music and blowing
bubbles,they look to see which rooms containwaiting patients.They stay out of
rooms with doctors'examinationsor treatmentsin progress,but one doctorleaves
when the clowns arrive,explainingto the patient,"Wehave a specialistto see you
now."In come the clowns, with Dr. Fidgetblowing soapbubbles,Dr. Bobo playing
a balalaika,and Dr. Do-More popping red foam-rubberclown noses out of the
respiratortubingwrappedaroundherhead.In otherrooms,babiesget soft lullabies
and bubbles, and teenagersget slapsticksketcheswith ribaldhumor.
Puppetsare popular.Dr. Fidget has a pesky blue jay who gobbles up all the
bubbles,then begins nippingthe otherclowns' ears,noses, necks,andpockets.She
hides a lifelike furrypuppetunderher coat, in her hat, in a child's bed, and even
undera nurse's sweater,while the nurseplays along: "Doctor,is there an animal
in here?You know we don't allow animalsin the hospital!"
A little girl in the waiting room is frightenedof clowns and hides behindher
mother.The clowns act terrifiedof her and attemptto hide behindeach other, the
chairs,and even anothermother.Soon the little girl is giggling and chasing them.
Aftera half hourin cardiology,the clowns go upstairsto pediatrichematology
and oncology. They perform magic tricks and gags for parents in the waiting room,
then stop at the nurses' stationto find out whetherany patientsareoff-limits. "We
could definitelyuse a clown in here,"one nursesays, pointingto a nearbytreatment
roomwherea frightenedchild is connectedto anintravenousunit.WhileDr. Fidget
distracts her with bubbles, magic tricks, and a funny dance, Dr. Do-More squirts
otherchildrenand parentswith a tiny squirtgun, and Dr. Bobo dances and plays
the harmonica.They pull clown noses, tiny toy animals,andeven an entirelitterof
sponge-rubberbaby rabbitsfrom children's ears and noses. One child becomes
CLOWNDOCTORS
467
overly excited, punching and grabbing at the clowns and their props, so Dr.
Do-More signals thatit's time to move on.
At 11:10, in pediatricintensive care, afterchecking with the nurses' station
about any restrictionsand washing theirhands and toys, the clowns console and
distractthe tearfulparentsof a young girl in a coma. The girl's breathingquickens
noticeably as the clowns sing to her and strokeher, and her eyelids briefly flutter
(the clowns relate that two childrencame out of coma while they were visiting).
For other childrenand parentsin the intensive care unit, the clowns sing, dance,
play instruments,put on a puppetshow, andhandout autographedpictures.
Next stop is the Children'sClinicalResearchCenter,where nurses greet the
clowns warmlyand participatein a few gags. The blue jay puppetis nippingtheir
behinds, picking pockets, and stealing scarves. Dr. Bobo sneezes marbles out of
his nose. Several childrenin this section arein isolation with chicken pox, but this
doesn't deter the clowns, who make faces andpuppetantics outside the windows.
At noon they breakfor lunch in the hospitalcafeteria.They're out of character
now, as physicianshave requestedno clowning in the lunch room. Anywhereelse
in the hospital, however, doctorsare fair game.
Afterlunchthey returnto pediatriccardiology,to amusethe afternoonpatients
and their parents by making funny paper hats the children may keep and by
performingsqueakremovals, or "squeakectomies."After half an hour they move
to a general pediatricsward,where they stop to sing to a long-termpatient.They
proceed down the hall with a brief visit to every room. Dr. Do-More distractsa
burnedchild from her pain with bubblesand magic tricks while Dr. Bobo tries to
fool some older childrenin the solarium.They figure out all his tricks,but this is
intentional,for the clowns are rehearsedto make themselves appearsilly and the
childrenfeel in charge.Dr. Fidget has lost her furryanimalpuppet(which is under
her coat, bushy tail sticking out of the back of her collar) and is frantically,and
unsuccessfully,looking for it. A physicianarrivesto see a patient.Dr. Bobo pulls
a scarf out of the doctor's tie.
Around2:15 the clowns leave the ward,exchangingbadjokes with nurseson
the way out. In the crowdedhallway of the outpatientburnclinic they discover an
old friend,a girl who had spentsix monthsin the bur unitrecoveringfrom a plane
crash.She pokes all theirsqueakyplaces andasksif they have any new tricks.While
she and Dr. Do-More toss scarves aroundpeople's heads, Dr. Bobo goes up and
down the hall with a metal cup, kerplunkingquartersinto it fromout of doorknobs,
fathers' noses, and other unusual places. He plays a racy Russian song on his
balalaika,and Drs. Do-More and Fidget do a hula. After several more tricks and
gags, they go to the inpatientburnunit.
The intensive burnunit is a serious place. Here each clown puts on a fresh
sterilegown andcap before enteringeach room,andthese patientscan't touch any
of the toys and props.This is also the unit the clowns find most difficult emotionally. The injuriesthey see here are often serious and disfiguring.
The workdayends at 3:00 p.m., when the clowns head back to the changing
room, remove their makeup and costumes, and assume their "normal"identities.
The work appearsto take a great deal out of them, and they head home on the
subway, tiredand emotionallydrained.
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Resemblance to Shamans
Like traditionalhealersin many societies, clowns wearunusualcostumes.The
clothes of a clown violate culturalconventions-jarring colors;plaids, stripes,and
polka dots all together;a brassiereworn as a hat.Clown makeupfurthereffects the
transformationfrom culturalpersonto anticulturalother,and is similarto the face
paint and masks of non-Westernritualhealers. Like the shamanrole, the clown
figure transcendscultureand is nearlyuniversal(Willeford1969).
Both types of actorsareviewed with some ambivalence.Much of the respect
given the indigenous healer results from fear of sorcery (Kleinman and Sung
1979:9). In addition,the ethnographicliteratureaboundswith descriptionsof the
strangeappearance,personality,and actions of the shaman(for many examples,
see Eliade 1964). Thus, fear of this individualis easy to explain. Similarly,small
childrenare frequentlyafraidof clowns, whose bizarreappearancesuggests the
dangersof the unknownanduncanny,andwhose performancesdramatizecommon
childhoodfears.
The use of puppetsby CCU clowns is reminiscentof shamanhelper spirits.
Indeed,some shamansuse puppetsto representthese spiritsin theirrituals(Kirby
1974:10). Most clowns have two or threewell-developedpuppetcharacters,each
with its own strangevoice. Both clowns and shamansuse ventriloquism.
Music, rhythmicdrumming,singing, and chantingare found in both nonWesterncuringandCCU clown performances.Shamansuse drummingandchanting to enter altered states of consciousness. Several clowns reportedbeing in
"anotherspace"or "adifferentconsciousness"while performing;all assumeclown
characterswhen they put on theirmakeupandcostumes.Kirby(1974:14) suggests
thatpopularentertainmentsthatsummona differentrealityfromthe ordinary(e.g.,
magic tricks,escape acts, absurdskits) originatedin shamantrances.Furthermore,
both clowns and shamans use rituals, that is, repetitive, stylized, exaggerated
actionsin a predeterminedorder,with anevocativestyle anda collective dimension.
When done by clowns, we call them performances.
Sleightof handis importantin bothtypes of performance.Many shamanscan
seeminglycutoff andreattacha bodypart,effect Houdini-likeescapesfrombinding
ropes, or produce the appearanceor sound of spirits (Kirby 1974). Extremely
commonis the suckingshaman,whose apparentremovalof the cause of illness, in
the form of a bloody worm or tiny dartpoint, is echoed in the clowns' pulling of
red noses, scarves, and other items out of children'sears, noses, and so on. They
frequentlydo this in the context of removing a squeakor extractinga pain (after
askinga childwhereit hurts,theclown will removesomethingfromthatbodypart).
Legerdemainis an importantpartof many healing rituals,as it enhancesbelief in
the healer'sefficacy. The power of suggestion is importantfor all styles of curing.
Consideringthe nearuniversalityof object removal,it must be a powerfulhealing
metaphor.
This relianceon magic tricksillustrateshow in theirrespectivesocieties, both
clowns and shamans are viewed as acting in some other, abnormal context.
realms.In trance,they
Shamansarebelieved to travelandfunctionin supernatural
communicatewith spirit helpers, retrieve lost souls, and find solutions to the
problemof illness. Clowns also operateoutside of and,in this case, contraryto the
usual cultural rules and norms. Like Native American contraries, circus
CLOWNDOCTORS
469
clowns invert the culturalorderby breakingcultural(and natural)rules in their
performances(Bouissac 1985:164 ff.; Kerman 1992:15). They violate conventionalrules of dress andbehavior;theirpropsfall up insteadof down. CCU clowns
bend many hospital rules, or appearto; the "animalin the room"sketch illustrates
this. One is supposedto be quiet and reservedin the hospital setting. The clowns
are noisy and boisterous.
Shamans and other healers manipulatesymbols of their societies' medical
systems in ways thatmay enlist the power of suggestionor placebo effect (Finkler
1980:300-301; Kleinman 1973). For example, patients of a Mexican spiritualist
believe thatillness resultsfrom imbalancein the body's "hot"and "cold"humors,
and that "cleaning"has beneficialeffects. In this system, healers who treatillness
withherbs,foods, or therapiesthathave the appropriate"heat"or "coldness,"and/or
prescribe"cleaning,"are able to effect cures (Finkler1980). While the physiological basis remains to be delineated, it is clear that dualist philosophies of the
mind-bodyrelationshipareinadequateto explainthisphenomenon,andit probably
involves the mediation of language and other cultural symbols (Byerly 1976;
Moerman 1979). Suggestion is not the power of mind over body; ratherit is the
functioningof the entirephysical system, which includesthe brain/mind.Cultural
symbolism,linguisticor otherwise,sets this processin motion(Levi-Strauss1967).
The power of placebos lies in the power of symbols.
Clown doctorsalso use medicalsymbolism.CCU performancesplay with the
physiciancharacterandpoke fun at hospitalprocedures.Clown dress suggeststhat
of a doctor (white coat, reflectingmirroron a hat, stethoscope aroundthe neck),
but with absurdadditions(the coat is paintedin wild colors, the mirrorbounces
abouton a foot-long spring,andthe stethoscopeis used to blow bubbles).Medical
paraphernaliais used in unusualways, such as makingmusic with oxygen tubing
and hypodermicsyringes. Clowns address each other as "Doctor"but act quite
unlikereal ones. For example,"Dr.Meatloaf,"as his alterego "Igor,"shuffles into
a pediatricemergency room in Harlem wearing black buck teeth, grunting,and
acting like a hunchbackedimbecile, while his associate, "Dr.Gizmo," introduces
him as the hospital's chief of pediatricmedicine. At this point, Igor emergesfrom
the restroomtrailinga 15-footpiece of toilet paperandbegins climbingoverchairs
(including those with people sitting in them) and trying to sit on women's laps.
This sketch is reminiscentof Pueblo clown performancesthatburlesquepowerful
people, illness, and scatologicalfunctions (Steward1931:189-191).
The clowns say they parody doctors and play with hospital equipmentto
lighten up the atmosphereand make children less afraid of doctors and their
instruments,butone can also recognizeanothershamanisticfunction:psychosocial
support(FosterandAnderson1978:128;Kleinmanand Sung 1979:24).By involving the social group,illness andcuringaregiven public recognitionandthe patient
receives group support (Murphy 1964:80). Shamanisticrituals reinforce social
roles andcan be therapeuticforfamilies strugglingto cope with illness anddisorder.
Social workersdealing with families in crisis have adoptedsimilarpractices(Laird
1984).
The social environmentof a hospitalized child consists largely of family
membersand hospital staff. CCU clowns entertainall these individuals,reducing
family tension createdby the illness and making the hospital atmospherehappier.
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Parents'writtenevaluationsof the clowns include commentssuch as "Theymake
us both very happy,""It works for both child and parent,"and "Clownsboost the
morale of the parentsas well as the kids." When asked to rate on a scale of 1
(disliked a lot) to 5 (liked a lot) how they (not the child) felt aboutthe clowns, all
except two of forty parentschose 5; the other two chose 4. One clown told me of
a routinehe uses in which a hospitalizedchild turnsa squirtgun on her siblings.
He believes this reduces patientresentmenttowardshealthy siblings. As another
example, the CCU makes a point of interactingwith parentsof ailing babies who
are not old enough to respondto clowns, for when parents'spirits are lifted, less
stress is communicatedto theirinfants.
Another clown organizationthat engages in social healing is the clown
ministry,a new movement in AmericanProtestantism(Kerman1992; Litherland
1982).These practitionersareprofessionallytrainedin bothministryandclowning,
which they use for both liturgy and pastoralministry.According to Kerman,the
clown ministryhas two purposes:renewal of liturgy and social healing. For the
latterpurpose,it focuses on nursinghomes and hospitals, attemptingto "lift up"
their audience.Like the CCU, it has an explicit ethic of letting the clowns be the
subjectsof jokes and not makingfun of otherpeople.
Lifting the spiritsof hospitalstaff improvesthe institutionalatmosphereand
the moraleof professionalswho are overworked,or who must deal with terminal
patientsor the effects of child abuse.They believe this improvesthe qualityof their
caregiving. Evaluations of the CCU by hospital staff unanimously praise the
clowns' work. Doctors and nurses who administertraumaticproceduressuch as
surgery,blood drawing,or radiationtherapyreportthathaving clowns distractthe
childrenmakestheirjobs easier.The medicaldirectorof one pediatricinpatientunit
reportedthatclowns improvethe careof childrenbecausestaff membersfeel better
abouttheirwork and can respondmorepositively to theirpatients.Caregiversfeel
more relaxedwhen the clowns arethere.The mood is moreupbeat,they say: "The
whole unitis brighter,""Theatmospherealways changesfor the better,""Itmakes
our job easier," and there are "morepositive interactionsbetween parents,staff,
and patients."One overworkednurse in an understaffedunit wrote that clowns
relieve her stress and even help her answerpatients'calls for assistance.
Another way clowns act upon hospitalizedchildren's social relationsis by
empoweringpatients. "Powerto the children"is an expressed philosophy of the
CCU. Pediatricpatientsareperhapsthe most powerlessof all hospitalizedpeople.
Poked andprodded,examinedand orderedabout,subjectedto painfulprocedures
they don't understand,childrenfrequentlyreact with fear, noncompliance,tantrums,andwithdrawal.Noncompliancecan be anexpressionof a patient'srejection
of the power structureof a situationand an attemptto regain some control. The
effects of treatmentareimprovedif the power differentialcan be equalized(Elsass
1992:335-336).
This goal of patient empowermentcan be seen in the structureof clown
routines. Built into the CCU's standardperformancesare situations that make
clown doctors(andfrequentlya realdoctoror nurseas well) appearsilly andinept,
while the childrenare smartandcapable.A clown mightpretendto be afraidof the
child and attemptto hide in obvious places. Ora magic trickkeeps backfiringuntil
the child shows the clown how to do it right.An animalpuppetis hiddenfrom the
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471
doctor, but the child always knows, and controls, where it is. These interactive
performancesarecarefullyrehearsed,as witnessed at a monthlyclown meeting,in
which CCU directorMichaelChristensenhadtwo clowns practiceone routineover
and over again until he was satisfied that the patient's reactionwould be one of
empowermentratherthanfrustration.
Shaman performancesmay lead to patient psychological reactions such as
transference and catharsis, which may relieve anxiety (Foster and Anderson
1978:128; Murphy 1964:78, 81). Catharsisis frequentlyassociatedwith shamanistic curing(Kirby 1974:9), andit can be producedby clowns as well. Parsonsand
Beals (1934:499-500) describethe emotionalreleaseaffordedby Native American
clown performancesthat satirizeanxiety-producingaspects of humanexperience
(includingillness). Indigenousclowns universallyaddress,throughhumor,issues
of greatest emotional interest to their observers (Charles 1945:32; Steward
1931:198).
Humor itself is cathartic(Holland 1982:88-103). Laughternot only makes
one feel better,but it can also be a powerful distraction.One CCU clown tells of
his experiencewith an 11-year-oldboy who had been doused with gasoline andset
on fire by an older boy:
He wasconsciousbutin terriblepainwithmajorbumsovermorethanhalfhis
body.I wentrightintoemergencywithhim.Whenthe surgeonsbegancutting
awaydeadflesh,I begantellingfunnystoriesandpromisingcircusticketsand
to keephis mindoff theagony.
makingscarvesappearanddisappear-anything
andfinallyI actuallygot him
Prettysoonhe wasrollinghis eyes in amazement
He was staringdeathin the
laughingbehindhis medicalmask.It wasincredible.
face-and he washavingfun![Darrach1990:82]
Discussion
CCU clowns don't claim to cure anything.They assert that what they do is
make the hospital environmentmore child-friendly.In the absence of biomedical
treatment,it's unlikely that they would effect any cures, except possibly for
psychosomaticand anxiety-derivedillnesses. However, they do have a beneficial
role to play in Westernmedicinetoday, in collaborationwith those of physicians,
nurses,and othermainstreamhealthcareproviders.Forthe clown, like the shaman,
addressesthat aspect of healing that is not as well developed in modem Western
medicine, the treatmentof the whole person, the social milieu, and the mental
predicatesof illness. The clown helps the patientand family provide meaningto
the illness experienceandresolve personaland social problemsthatresultfrom it.
This in turnincreasespatientsatisfaction,compliance,and perhapsoutcome.The
medical establishmentincreasinglyrecognizes the need for providingthis level of
care, butphysicians are not always in a position to give it. The inclusionof clowns
amongpediatrichospitalpersonnelis a practicalstrategyforresolvingthisproblem.
Collaborativeefforts between physicians and traditionalor unorthodoxhealers
have been advocated(for example,see Bastien 1987) or even implemented(Jingfeng 1987; Launs 1989; Leslie 1980), butthis approachis rarein the UnitedStates,
where folk medicine is less accepted.The clown, on the otherhand, is a symbolic
type familiarto and appreciatedby most Americanchildren,so the potentialfor its
use is greaterthan thatof otherunorthodoxpractitioners.
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MEDICALANTHROPOLOGY
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Anotherreasonwhy clown doctorscanassistin thetreatmentof youngpatients
is thatchildren,while somewhatenculturatedinto their society's medical system
and beliefs about illness causation and treatment,are not as fully "vaccinated"
againstbelief in magic andalternaterealitiesas theirparents.Thatis, froma child's
point of view, magicaleffects just mightbe possible. This enhancestheirsuggestibility with regardto the clowns' tricks. Some childrenmay believe the CCU are
doctors, but doctors with special powers. Furthermore,clowns, and circus in
general,represent"humanityfreedfromtheconstraintsof culture,"andthis appeals
to childrenmore thanto adults(Bouissac 1985:8).
Clown therapy is also importantfor terminal patients, such as children
sufferingfrom canceror AIDS. Thereare few family crises more serious than the
death of a child. The individual, too, faces a profound need to cope with the
expectationof mortality.Painandsufferingmustbe dealtwith.KleinmanandSung
(1979:16) observed Taiwanese patients with terminal diseases who had been
dischargedfrom hospitals as untreatablebut who were receiving treatmentfrom
shamans.These patientsand theirfamilies reportedfeeling psychologically better
and had a more satisfying social life as a result.
Conclusions
Clowns are like shamansin several ways. Both use weird costumes, props,
andbehaviors.Commonto bothkindsof performancearesleightof hand,ventriloquism, music, andfeats of skill thatseem to breaknaturaland culturallaws. Both
shamansand clown doctors employ social healing, suggestion, and manipulation
of cultural symbols drawn from the society's medical system. Both pay more
attention to the patient's illness experience and social milieu than physicians
frequentlydo.
Integratingclown doctors into the medical care of hospitalized children is
particularlyappropriatefor the obvious reason that clowns and children are a
naturalcombination.Childrenare more receptiveto the clowns' uncannyantics.
Childrenare less enculturatedinto the orthodoxmedical belief system thatvalues
pharmaceuticaland surgicalinterventionover "magic."Incapacitatedchildrenare
vulnerableto the communicationof theirparents'and caregivers'anxiety, so any
relief the clowns provide these individualsshould improvethe child's social and
medicalenvironment.Use of clowns in conjunctionwith otherhealthcarepersonnel can promotepatientsatisfactionand compliance,especially in children,which
may contributeto more positive clinical outcomes.
NOTES
Acknowledgements.This researchwould not have been possible without the aid and
cooperationof Michael Christensenand the rest of the Big Apple CircusClown Care Unit.
I would also like to thankthe child life and pediatricpersonnelof AlbertEinstein College
of Medicine;Babies andChildren'sHospital,ColumbiaUniversityMedicalCenter,Harlem
HospitalCenter;Mount Sinai Medical Center;and New York Hospitalfor allowing me to
do this study in theirinstitutions.
Correspondencemay be addressedto the authorat AnthropologyDepartment,Drew
University,Madison,NJ 07940; lvanbler@drew.edu.
CLOWNDOCTORS
473
1. Big Apple Circus Clown Care Unit ? and Clown Care Unit? are registered
trademarks.
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