URBAN PATIENTS' UTILISATION OF TRADITIONAL MEDICINE: UPHOLDING CULTURE AND TRADITION

• URBAN PATIENTS' UTILISATION OF TRADITIONAL MEDICINE:
  UPHOLDING CULTURE AND TRADITION
  Debie LeBeau, Lecturer in Sociology
  University of Namibia
  Sociology Department
  Windhoek, Namibia
  email: lebeau@iwwn.com.na
  
  ACKNOWLEDGEMENT
  
  The following individuals helped with information used in the compilation of this paper: Siballi E.I. Kgobetsi, Saara Witbooi, Paulina Hangara, Thomas Sibiya, Naomi Pacheko and Dr. Jeremiah Mwene (Dr. Jerry). I would like to give a special word of my thanks to my esteemed colleague, Siballi Kgobetsi, who helped to facilitate my attendance at this workshop.
  
  INTRODUCTION
  
  Before I started researching traditional medicine in Katutura (Windhoek's "high density" area), I read several books, journal articles and papers written about the use of traditional medicine. Most of the accounts that I read were based on research done may years ago in the most remote rural areas the researchers could find. The presumed justification for the remoteness of the research was to study the "unspoiled" authentic and most true forms of African traditional medicine...traditional medicine (supposedly) practiced as it has been for centuries. Many of these accounts describe how traditional medicine is based on the religio-magico beliefs of the participants and that only by belonging to the same ethnic group, with the same religio-magico beliefs could traditional medicine work; therefore, traditional healer and patient had to belong to the same ethnic group for the medicine to work. The assumption was that traditional medicine had no basis in efficacy, but was solely based on the beliefs of the people using it. These same researchers also said that patients are forced to use traditional medicine due to the absence of western medicine in such remote rural areas. Through the course of the years, researchers continued to go to remote rural areas, continued to study "uncontaminated" traditional medicine and continued to perpetuate each others' myths. These self-perpetuated myths soon became "assumptions" about the use of traditional medicine, assumptions which remained unquestioned through the course of many studies relating to the utilisation of traditional medicine. These assumptions (myths) are:
  
  1.)Traditional medicine is culturally based and therefore patient and healer must come from the same ethnic group for the medicine to work;
  
  2.)Traditional medicine is based on religio-magico beliefs and has very little efficacy outside of this belief system; and
  
  3.)When given a choice, patients choose to use western medicine due to its alleged superior healing powers.
  
  Today, some researchers have begun to question these assumptions and have demonstrated that the basis for these assumptions are simply not true (ELCI) 1998 and LeBeau 1996). A discussion of all three myths about the utilisation of traditional medicine is not possible in the time allotted; therefore, I will focus on the third assumption: that patients will only use traditional medicine when no other alternative exists.
  
  
  BACKGROUND
  
  After an extensive search of the literature on Southern Africa, I discovered only a few serious attempts at researching utilisation of traditional medicine in Africa's urban areas, areas where the assumption that patients use traditional medicine mainly due to the absence of western medicine could be tested due to the presence of multiple health care options.
  
  Although more users of traditional medicine do live in the rural areas, incidence rates for the utilisation of traditional medicine, especially spirit mediums, has increased in the urban areas of several southern African countries (LeBeau 1995:3). This increase is due in part to the urban dwellers' failure to uphold traditional values and perform the necessary rituals to the ancestors. Witchcraft is seen as rampant in Zambia's urban areas due to rival forces and increased competition in the urban environment (Dillon-Malone 1988:1159 - 1160). Cavender indicates that utilisation patters for traditional medicine are different in Zimbabwe's urban areas, showing an increase of variation in use between modern and traditional health care (1991:364). Staugard found that people in urban Botswana tend to utilise different types of traditional healers with about equal frequency (1986:62). Gelfand states that witchcraft accusations, social discontetion, ill health and other socio-medical factors at the village level in Zimbabwe can cause some people, who would not otherwise do so, to move to towns (1964:157 - 159).
  
  A study of traditional healers in urban Botswana determined that many people in the urban areas still use traditional medicine (Staugard 1986). Staugard states that about two-thirds of the rural and one-third of the urban population had been to a traditional healer during the 12 month time period preceding the research (1986:61 - 62). It is their categorisation of disease that leads patients to chose between alternatives in health care (Staugard 1986:63). People categorise diseases as "European" or "Tswana". European diseases are those like smallpox and tuberculosis while Tswana diseases are indigenous (Edouard 1986:438). Staugard states that witchcraft is still prevalent and traditional medicine still plays an important role in the social lives of the people. Healers in Tswana society are not only medicine men, they are religious leaders, marriage counsellors, and social workers (Staugard 1986:52).
  
  INFLUENCE OF CULTURE ON HEALTH AND ILLNESS
  
  As we can see from Staugard's discussion of health seeking determinates in Botswana, culture is very important in shaping our beliefs about the way we think the world works. It is based on these beliefs that we act in one way or another. As with other cultural attributes, all groups of people have concepts about health and illness that are part of their culture. A group's concept of health does not exist in a vacuum, but is based on the world view of the people and is connected to other parts of their culture (LeBeau 1997:2). Every culture has an ideology of how to stay healthy, how to prevent diseases and how to treat people who are sick. Although western health care personnel think that their method of health care is scientific, it is also based on the world view of modern Euro-western concepts of what is scientific. This world view of medicine came to be termed "biological/scientific". In this view, society tries to explain the world around it through scientific investigation. Another world view of health and illness which is based on spiritual beliefs and ritual healing might be termed "social/spiritual". In this world view, society tries to explain the world around it in terms of good and evil spirits, spiritual intervention and supernatural causes of misfortune. In both cases, the concepts relating to health and illness are interrelated to other beliefs about how the universe is organized. A health care system is part of the people's world view and cannot be divorced from their culture. A health care system includes all of the cultural beliefs and practices which have a direct or indirect effect on the health of people within that particular culture (McElroy and Townsend 1989:72). Since health care systems are part of people's world view, they will utilize the system which thy believe will give them the best likelihood of success.
  
  TRADITIONAL HEALERS IN URBAN NAMIBIA
  
  I decided to research health care utilization in an urban setting because of the availability of several health care systems including the popular, western and traditional health care systems. Since all three health care systems are available in Katutura, the utilization of one system represents a conscious choice by the patient and is not due to the lack of another system. The use of one system over another can be attributed to social factors rather than access and distance of modern health care facilities as was assumed by rural researchers of traditional medicine.
  
  The popular health care sector is defined as the home or community in which the people live. Health seeking behaviour in this arena takes place through informal consultations with neighbours and friends who share the same beliefs about health and illness (Allais 1995:7). The western health care system is the State recognised health care system which is biomedical in focus while the traditional medical system is the non-western healing system with such specialists as faith healers, spirit mediums, herbalists, bone setters and traditional birth attendants.
  
  In the urban areas there are also practitioners of traditional medicine from Namibia's different ethnic groups. Due to Namibia's heterogeneity, some groups have higher utilisation patterns of traditional medicine than others and patients from any ethnic group can utilise traditional healers from other ethnic groups; thereby giving the patient even more alternatives for health care. For example, it is well known in Namibia that the Hereto healers are powerful and one utilises their services for particularly powerful types of witchcraft. In addition, there are many Sangomas from South Africa who enjoy notoriety for their ability to deal with imbalances in social relationships.
  
  Thus, people in Katutura have three different health care systems which they can access, as well as traditional healers from a range of ethnic groups. This variation in health care options makes health seeking behaviour in Katutura quite complex.
  
  PATTERNS OF URBAN UTILISATION
  
  Once someone has determined that they are not well, that they have a disease or illness, they begin a process of seeking solutions that will restore their health or well-being; a process referred to here as health seeking behaviour. A person may seek the advice or assistance of friends, relatives and neighbours, go to a pharmacy for medication (self-medication), go to a hospital or clinic or go to a traditional healer. In Katutura, patients have easy access to all of the various forms of health care mentioned above. Therefore, the choices they make concerning health seeking behaviour are due to their perceptions of the nature of their disease or illness.
  
  Different patterns of utilisation depend on perceived cause, reason and origin (aetiology) of disease and illness. Some disorders are considered clearly African illnesses while some are considered clearly western diseases. In the case where the aetiology of the disorder is positively identified by the patient, a single use pattern of health care utilisation will be employed. Some disorders have an African (social/spiritual) aetiology but a biological manifestation (disease) in which case both medical systems will be used simultaneously, while some disorders are of indeterminate aetiology until treatment begins, in which case a multi-faceted use pattern will take place.
  
  It is important to understand the concept of "cause" in this paradigm. Cause is separate from the actual manifestation of the disease or illness. For example, a person could fall and injure his or her arm which requires hospitalisation and even surgery. This injury to the arm is biological; however, the question remains, "Why did the person fall like that, at just that time and in just that manner to injure the arm?" This question is the basis for the question of cause. If the person has a western world view he or she may believe that the fall was due to an "accident" or "being clumsy", but if the person has a non-western world view he or she may believe that the cause of the fall was due to means such as witchcraft or bad luck.
  
  In the case of the former, the only action required is to be "more careful" whereas in the case of the latter the person may need to go to a traditional healer and be checked, cleaned and protected against witchcraft at the same time as he or she is being treated for the biological injury to the arm. As you can see from this example, where a person seeks health care depends not only on the affliction, but also on the perceived cause of the ailment.
  
  Based on aetiology of a disorder three distinct patterns for health care utilisation can be identified: single health care system utilisation whereby either the traditional or western health system is used but not both, simultaneous utilisation of more than one health care system or sequential (multi-faceted) utilisation of different health care systems.
  
  FAILURE OF WESTERN MEDICINE
  
  Although a person's perceptions of the cause of the illness influences his or her health seeking behaviour, another important factor in health seeking behaviour is the patient's previous experience with efforts at seeking health. Typically when a person first determines that he or she is not well, that person may, for a while, try different suggestions and different self-treatment methods. If these efforts are unsuccessful, the person will re-evaluate his or her illness condition and determine what other treatments are available and necessary for re-establishing well-being. The patient may then go to a clinic or hospital to seek western medical help and advice concerning the health problem. If, for example, a patient with a skin disorder goes to a western medical doctor, but is unhappy with the results of the treatment he or she is likely to turn to other methods of healing in order to achieve the desired results. Many patients who present themselves to traditional healers have already sought the help of western medicine but with unsatisfactory results.
  
  Thus, failure of a medical system will cause the patient to shift to another treatment system. In this case, the western medical system is far more likely to be perceived as having failed than the traditional medical system. If western medicine fails then traditional medicine is sought in the belief that:
  
  1.)it is an African illness (social/spiritual aetiology) and therefore western medicine is the wrong treatment or,
  
  2.) western medicine does not work due to poor western health care provision and resistance of western medical personnel to addressing traditional beliefs about health and illness.
  
  Traditional medicine is far less likely to be perceived as failing; however, if traditional treatment does fail it is due to the fact that:
  
  1.) it is a biological/western disease (very unlikely) or
  
  2.) the wrong healer or treatment was sought rather than some innate problem with the health care system. Listed below in Table 1 are some of the most often identified reasons why western medicine has failed in Africa.
  
  TABLE 1.
  
  HOW THE WESTERN MEDICAL SYSTEM HAS FAILED IN AFRICA
  
  * Facilities are inaccessible for much of the population. In some urban areas the average waiting time at a hospital or clinic can be as much as 8 hrs.
  * The staff are poorly trained and unmotivated. Many staff members believing they hold superior knowledge, treat patients inconsiderately.
  * Patients are frequently not told the nature and cause of their illness.
  * There are inadequate technical services leading to poor quality care.
  * The treatment costs too much, even for state run hospitals and clinics.
  * Governments spend a large proportion of the Per Capita gross national product on western health care.
  * Treatment is divorced from the patient's culture, family and community. Patients are removed from the family and community, stripped of their identity and forced into a sterile hospital setting.
  * The treatment only addresses a patient's biological manifestation of the illness and does not attempt to heal spiritual aspects of illness.
  
  (adapted from Lashari 1984:175 - 177, Ojanuga 1981:407 - 410 and Yangni-Angate 1981:240 - 244)
  
  REASONS FOR URBAN UTILISATION
  
  There are several reasons why patients continue to utilise traditional medicine in Katutura, even though they have easy access to all of the various health care systems. As previously discussed, the choices they make in health seeking behaviour are due to their perceptions of the nature of their disease or illness, their cultural understanding of the cause of the illness, the efficacy of the various treatments and their previous experience with the various health care alternatives (LeBeau 1995:3). However, there are many other reasons why people living in the urban areas continue to use traditional medicine even when presented with other health care choices. Table 2 below lists some of these reasons. As we can see from this table, traditional medicine is part of the patient's culture, and as such its use is based on the cultural value the patient places on it. As we have previously discussed, a health care system is part of the people's culture. One cannot remove health care from its cultural context. Since traditional healers treat the patient's spiritual, as well as biological manifestation of a problem, this treatment is more holistic in approach and based on an attempt to heal the whole person. In addition, traditional healers treat the patient within the family and community, thus they do not remove the patient from his or her social support network.
  
  TABLE 2.
  
  ADVANTAGES OF TRADITIONAL MEDICINE
  * People have faith in traditional healers and they are well respected in their communities.
  * They are part of the people's culture. They treat the spiritual as well as biological cause of an illness.
  * They address social/spiritual illnesses (such as theft and bad luck) which western medicine does not treat.
  * They provide the answer to the question of cause.
  * They are proficient at healing a range of biological diseases such as diarrhoea, vomiting, skin disorders and mental illness.
  * They allow the family, and possibly the entire community to be part of the healing process.
  * They are accessible to everyone, even in the most remote villages and areas.
  * They do not require expensive or sophisticated technical equipment.
  
  (adapted from Lashari 1984:175 - 177, Ojanuga 1981:407 - 410 and Yangni-Angate 1981:240 - 244).
  
  As well as these advantages of using traditional healers, there are also problems specific to living in an urban environment which lead to the need for traditional healing. For example, in urban areas many people come into contact with other people who they normally would not be in contact with, thus causing "cultural contamination". Contamination can also come from simple contact or from the breaking of taboos (mostly sexual) such as mixed marriages and partnerships. In both cases of contamination, traditional cleansing is necessary. Urban dwellers are also more likely to fail to uphold traditions, ceremonies and respect for the ancestors or elders and are therefore more likely to break taboos because they are living "the modern life". The breaking of taboos can cause removal of ancestor protection, contamination, misfortune or witchcraft which are also reasons to seek the attention of a traditional healer.
  
  The most frequently given reason for the increased use of traditional healers in the urban areas is the high prevalence of witchcraft accusations due to a breakdown in social relations or increased competition and jealousy. Social relations are very important but unpredictable and problematic in urban areas; therefore, witchcraft accusations are used to stabilise relationships when there is a conflict in a social relationship but it is desired to continue the relationship. Witchcraft accusation can also be used to justify the ending of a relationship. When things go wrong it can be attributed to witchcraft or jealousy of others. Witchcraft accusation can also be used to sway influence over others by using threats of witchcraft in an attempt to influence the behaviour of others.
  
  In addition to problems in social relationships, witchcraft accusations can also be caused by increased competition in the urban areas for scarce resources such as jobs, money and sexual partners. Competition and jealousy also come from the distrust of people from other cultural groups, jealousy of others who succeed or fear of jealousy by others. As Dillon-Malone puts it, "witchcraft is rampant in the urban areas" (1981:1159 - 1172).
  
  PROBLEMS, RECOMMENDATIONS AND CONCLUSIONS
  
  In Katutura, an urban African residential area, people continue to use traditional healers. Traditional healers are part of their culture and provide treatments and healing techniques which are not available through any other health care system. The old assumption that people go to traditional healers because there is no western medicine available is not true. People go to traditional healers because they choose to, not because they have to. However, there are problems that traditional healers in the urban areas face which rural healers are not as likely to confront. For example, in a village setting every person is known to others in the village; however, in the urban areas traditional healers can come from outside the area and their skills are not known to others in the community This leads to a situation where charlatans come, exploit patients and leave. Honest, hardworking traditional healers are left to deal with angry, dissatisfied patients. In addition, charlatans give all traditional healers a bad name whereby people see only the charlatans and claim that all traditional healers are charlatans. Traditional healers in the urban areas are more highly visible to the wider society than those in the rural areas; therefore, if a traditional healer in the urban area makes a mistake, western orientated people are quick to point a finger and use this as an example of how all traditional medicine has failed. Western medical personnel are usually the first to point out problems related to traditional medicine. In addition there are more opportunities in the urban areas leading to increased competition between traditional healers whereby some healers (mostly older healers) are barely able to make a living.
  
  Traditional healers in the urban areas still enjoy a high degree of prestige and popularity. Urban populations in Africa do not forget their culture and use traditional healers as part of their health seeking behaviour. However, it is up to traditional healers themselves to see to it that their reputation is clean. Urban healers have a responsibility to their rural counterparts to practice in a respectable and responsible manner. Traditional healers have much to offer their western counterparts and their dedicated patients. It is part of people's culture and traditional healers are entrusted with the maintenance of customs and culture, which is especially important in the face of the western cultural (including medical) onslaught.
  
  As one old male traditional haler summed up traditional medicine in the urban areas, "Ah, these people today old men are out and witchcraft is in".
  
  REFERENCES
  
  Allais, Carol (ed)1995 Sociology of Health and Illness. Lexicon Publishers:Johannesburg
  
  Cavender, A.P. 1991 "Traditional Medicine and Inclusive Model of Health seeking Behaviour in Zimbabwe". Central African Journal of Medicine, vol. 31, no.11, pp 362 - 365
  
  Dillon-Malone, Clive 1988 Mtumwa Nchimi Healers and Wizadry Beliefs in Zambia". Social Science and Medicine, vol. 26,no.11, pp 1159 - 1172
  
  Edouard, Lindsay
  
  1986 "Traditional Medicine in Botswana-Traditional Healers". (Book review). World Health Forum. vol.7, pp 437 - 438
  
  Gelfand, Michael 1964 Medicine and Customs in Africa. London: E & S. Livingstone LTD.
  
  Lashari, Mohammad Saleh
  
  1984 "Traditional and modern Medicine - Is a Marriage possible?" World Health Forum. vol 5, pp 175 - 177
  
  LeBeau, Debie 1997 "Health Seeking Behaviour in a Multi-ethnic Society", draft paper prepared for the Association for Anthropology in Southern Africa.
  1996 "Health, Illness and Witchcraft", paper presented at the joint conference of the Pan African Anthropological Association and the Association for Anthropology in Southern Africa. September 1996.
  
  1995 "Seeking Health: Models of Health Care and the Hierarchy of resort in
  
  Utilisation Patterns of Traditional and Modern Medicine in Multi-ethnicKatutura, Namibia". PhD proposal presented to the Department of Anthropology, Rhodes University, Grahamstown, SA.
  
  McElroy, Ann and Patricia K. Townsend
  1989 Medical Anthropology: In Ecological Pespective. Westview Press: Colorado.
  
  Ojanuga, Durrenda Nash 1981 "What Doctors think of Traditional Healers - and vice versa". World Health Forum vol.2(3),pp 407-410.
  
  Staugard, Frantslast, 1986 Traditional Health Care in Botswana. In the Professionalisation of African Medicine, Last, Murray and G.L. Chavunduka (ed). Manchester University Press: England.
  
  Traditional Healers Professional Board
  1997 Minutes of Meeting held on September 26,1997.
  Yangni-Angata 1981 "Understanding Traditional Medicine". World Health Forum, Vol. 2(2),Pp 240-244

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