THE
DILEMMA
WITH
SPECIAL
OF TRADITIONAL REFERENCE
HEALING
TO
NIGERIA
TOLANI ASUNI Neuro-Psychiatric
Hospital.
Aro. Abeokuta.
Nigeria
Abstract-The healing process represents an interaction between patient. therapist. and the socio-cultural environment. This interaction characterizes both traditional and cosmopolitan medicine. The shortage of professional health care staff in rural areas recommends to some that these parallel medical systems be integrated. However. those who most strongly advocate such integration are loreigners. not familiar enough with the problems such policy would generate. In Nigeria. and elsewhere. it is difficult to plan such an integrated system before knowing how many indigenous curers are in practice. what kinds of medical problems they address. and with which kinds or problems they have most success. Integration also poses some serious dilemmas. For instance. although in Nigeria herbalists find dramatic success with some of their potent medicines. they lack an adequate knowledge or the etiects these potions may have on the patient. Another dilemma is raised by the necessity to have written records of patients. their complaints. and the effects of treatment: but illiterate healers will be unable to maintain such files. These and other administrative dilemmas must be foreseen. Finally. the success of traditional healers in treating mentally ill patients rests on the fact that their techniques are clearly related to the relevant cultural premises of the patient. However, if in the course of incorporating them into the official health system it is considered to be necessary to educate them in concepts of germs and infection. it is probable that these new. intrusive concepts of etiology will prove alien and incompatible with their traditional understandings. Moreover, such training would fracture the shared cognitive bond between healers and those who are their patients.
entirely; and this is based on the findings that some urbanised and educated people in developing countries, e.g. Ghana [3]. still consult traditional healers when they have modern medical facilities available. This will suggest that if these modern facilities are acceptable at all, they are not so to the exclusion of the traditional system. There are some areas of health problems in which roles of both traditional and modern are regarded to be complementary. and there are other areas like mental illness in which the modern system is not regarded to be effective. until the contrary is proved, as is the case increasingly where modern psychiatric facilities are available. This problem leads to the examination of the concepts of disease and healing. Where the concept is based on magic. superstition. and religion exclusively. the traditional system based on this concept will be preferred. This preference has led to the extermination of large sections of rural populations by epidemics of smallpox and cholera. since the whole concept of infection and contagion does not enter into consideration. It has been suggested that the traditional healer can be educated to appeciate and take into account the concept of infection and contagion in his system. but the supporters of this suggestion have not dealt with its impact on the totahty of the traditional system. The concept based on magic, superstition. and religion is cohesive and integrated into the religious and socio-cultural setting in which it is practised. To what extent will the introduction of the concept of infection and contagion disturb the cohesion and integration of the social cultural setting’? In some situations. some traditional healers have been using modern antibiotics. but in a rather surreptitious manner. unknown or unstated to their patients. It is conceivable that their image of’power
Most of the vocal and strong proponents of the idea of integrating traditional healing practice into the health care delivery are foreigners to the situation. The knowledgeable and sincere indigenes of the developing countries are usually cautious in advocating such integration. They are, on the other hand, accused by the foreigners of being blind to their tradition and potentials. and biased against traditional healers, partly to preserve their authority and domain. It is because of this lack of agreement that it is proposed in this paper to examine the issue more closely [l]. It has been strongly argued that because of the serious and dire shortage of trained professional personnel in the field of health, a situation which will take many years to improve appreciably. the existing traditional health care delivery system should be utilized and incorporated into the official plan for health services. Another argument which is not as strong is that since the modern health personnel trained in a different setting in the industrially developed countries. they are not in tune with their own people and tradition anymore and therefore cannot be of the maximum benefit professionally to their people [Z]. The first argument is very persuasive because there are more traditional healers than medical practitioners in the population. They are available. they are accessible. and they are acceptable: thereby fulfilling the major criteria for an effective service. These criteria are true for most traditional healing systems in developing countries. The question is how long are they going to be so’? Health care delivery systems are changing: it is to be expected that the traditional health care system will also change in keeping with the trend of change. Some aspects of this trend will be examined later. There is another argument which does not follow
this reasoning
33
34
TOLANI .ASLNI
based on traditional concepts may be undermined and belittled if it is known that they are using modern medicine. This creates a dilemma for the sincere traditional healer: however. if he is sure of himself. he will have no problem in referring such cases to modern medical facilities. Some years ago a man came to the emergency room of a hospital in which I worked. He had great difficulty in breathing and it was obvious that he had an asthmatic attack. In my interrogation. it came to light that he was a traditional healer. He was given an injection of adrenaline which made his breathing easier in a few minutes. When he was better 1 asked him what he would do if he had a patient with a similar problem. His answer was “I will try my best”. He must have tried his best for himself. It was significant to me that he did rlot say that he would send him to the hospital. Of course, it can be argued that this is more of the attribute of or failing of this man rather than that of the system he uses. Does the traditional system allow for failure without the risk of loss of face and prestige? Hardly. Their explanation for failure is one of “heads I win, tails you lose”. If the traditional healer fails in procuring a cure, then the patient or his relatives must have failed to observe all the numerous do’s and don’ts and prescribed iituals correctly. The therapeutic success of any physician derives partly from the expectation of the patients which is a factor of the image of the physician. This is particularly so of the traditional healer whose image of omnipotence is an essential ingredient of his therapeutic success. If the suggestion were to be followed to give him official recognition and incorporate him into the official health delivery system, his professional activities will need to be restricted to areas in which the authorities regard his expertise to be valuable and useful. He may have to be under some supervision and control to comply with some laid down regulations. This will immediately diminish his image of omnipotence, and consequently his therapeutic efficacy. This is a theoretical formulation which needs to be verified in areas where traditional healers have been officially recognized and incorporated into the health care system. On the other hand. it can be made a subject of experimental study in other areas. In doing this. it will be necessary to distinguish between what is primarily a social pathology on the one hand. and what is primarily a psychological and medical pathology on the other. despite the close interwoven relationship between the two. It is likely that the success of the traditional healing practice derives partly from this interwoven relationship, especially in psychiatric cases. Indeed the role of the physician-priest from which most traditional healers emanate is broader than that of a physician or psychiatrist. In addition to helping the individual, he is concerned also with the welfare of the community and the smooth running of the organization of the community. It is perhaps because of this that some people advocate the use of traditional healers. forgetting that the healer-priest role is being broken down by increasing specialisation of roles. If the concept of illness includes social pathology then this advocacy is rational and logical.
On the other hand. others argue that v,hile social pathology should be the concern of the ps>chlatrlsts. inasmuch as his patients’ problei-ns stem partic from this. and the patients have to return to the soclct!. the psychiatrist should concentrate his attention on his patients. and should not centre his attention on social reform. This does not mean that he should be indifferent to social reform. On the other hand he should call attention to the social ills of the soclet! which are known to be conducive to psychlatrlc IIIness. and allow the social reformers to take over from that point. If the psychiatrist feels very strongly about social reform. he can do something about it. not prlmarily as a psychiatrist. but as a concerned citizen with psychiatric expertise. There are other disciplmes like priesthood and social work which encounter 111 their day to day activities the social ills in society. It is therefore not the prerogative of psychlatr! to take over social reform. This applies not only to Industrially developed countries. but also to debelopIng countries. In talking about traditional healing. it has to be emphasised that it varies in kind and number In dlfferent communities. and even withln the same community. Therefore. one has to be cautious about generalisation. In my particular geographical area--Abeokuta in Nigeria-we know that the use of our modern psychiatric facilities by the people is inversely proportional to the distance which our patients travel. In other words, fewer patients from Abeokuta area use the facilities than patients from more distant areas. The reasons for this may include: (a) the stigma attached to psychiatric illness. There is more secrecy in going to traditional healers than in coming to the psychiatric hospital, and since they come from the area it will be more easily known than if they _eo to a traditional healer; (b) the traditional healers m Abeokuta area are famous for their expertise, so local people have them readily at hand to consult. Our impression is that it is the latter reason more than the former that makes people from distant places use the modern psychiatric facilities more frequently than the local people. Prince [4] in his study of traditional healers among the Yorubas distinguished between those of them who are essentially herbalists and those who are essentially oracle men; allowing for some overlap in their functions. He also identified rauwalfia as a major component in their pharmacopeia for psychotic illnesses. This discovery confirms the suggestion that further studies of the herbs and roots used by tradltional healers are strongly indicated. Some work IS now being done in this area in West Africa. As it is known that some traditional healers have very potent and useful herbs, some people use this to support the plea for their official recognition. The problem with this issue is that they know less about the effect of the drugs they use than we know of modern psychotropic drugs. There was the case of a patient who had been receiving apparently potent psychotropic herbs from a traditional healer. He had a side effect of the drug which was involuntary protrusion of his tongue which he bit. The bite became septic and he could not consequently take anytliing by mouth. It was at this stage that he was brought to the psychiatric hospital where his sepsis was
TraditIonal
healing
with special
treated with antibiotic injections. One wondered what could have happened to this man if he had not been taken to a hospital. The traditional healers do not have the means of giving their drugs by injection. Another example of this lack of necessary knowledge of the effect of their herbs was revealed to me on a visit to a traditional healer. There were about four patients sound asleep on the morning of the visit. This was a result of the drugs they had been given. When the healer was asked when they would wake up, his answer was “perhaps tomorrow”. He had no knowledge or means of handling cases in such a state of very deep sleep, e.g. making sure the airway was free, giving fluid by infusion. checking electrolyte balance. giving preventive antibiotics. etc. How many of such cases sleep unto death we will never know. There have been many claims of successful treatment of physical illness by traditional healers. There is no doubt that a number of these claims are true. They become dubious when they involve cases of intractable conditions. They may indeed have successes in these cases. but it has not been possible to verify this. Attention needs to be focussed on these cases. I once had a patient with a classical picture of manicdepressive psychosis. He was sturdy physically. He had a cyclothymic personality and had demonstrated phases of depression and hypomania. It was explained to him that all we could do was to try and keep him on an even keel, as we could not “cure” him. He was promised a cure by a traditional healer to whom he went with my consent. He had been having a regular periodicity of his illness. When the period of his illness came. he did not have it. and I was getting very excited and intrigued about his case. A week or two later. he came back with one of his swings of mood. The claim that traditional healers are more successful with neurotic conditions. stemming from psychosocial factors is understandable: but it needs to be verified. so that one can identify with confidence their area of strength. What is disturbing with some of their therapeutic techniques is to make the patient forever dependent on them. and worse still to enhance or even create in some patients an anxiety state. This is done by projecting to some outside agencyusually an innocent person-the cause of their problems. This projection sometimes limits the range of activities of the patient and also the range and depth of his interpersonal relationships. And yet there are examples of excellent professional intervention. which even modern psychiatry .cannot bear. An anxious and distraught woman consulted a traditional healer with a domestic problem which could .lead to her being kicked out of her marital home by her husband. She was given a rubbery object to put in her mouth any time there was a quarrel. and rather than answer back the cowife. she should bite this object as if she was biting the other woman. This she did. The result was that the quarrels reduced in length and frequency until they stopped completely. She could not bite and answer back at the same time! The question is whether this is a psychiatric problem or not. and yet this is an area in which the traditional healer. as in the case described. can be most successful.
reference
to Nigeria
35
All that has been said so far indicates that there is a dilemma about traditional healing that is shared by the traditional healers. the agencies responsible for providing health services. modern doctors. and the consumer of the services. THE
TRADITIONAL
HEALERS
DILEMMA
A number of traditional healers are aware of the changing socio-cultural scene which affects their practice. In some areas where there are modern medical facilities. they are being consulted less. Not too long ago, one came to ask if I could engage him in the hospital. When I asked him in what capacity and for what role, he said he could be given my retractive cases to treat. Another one came to ask for help. He had some years of schooling before taking over his fathers’ healing practice. When I asked him to specify what help he wanted. it turned out to be how he could organise his practice so that he could get paid by his patients. It was obvious tha! he either had no knowledge of how to get his patients to pay his fees. or what. knowledge he had did not suit the present situation. Some of his patients are in paid employment and if the patient is unable to go to work as a result of his illness. the healer either cannot write to say so, or if even he can write his certificate of unfitness to work will not be accepted by the patient’s employers. In the past. all the healers’ patients were self-employed or employed in family business like joint farming. fishing. or trading. This situation is even more serious when it involves a criminal charge against a person who has had treatment for a psychotic illness. While the traditional healer may be called to give expert evidence in a customary court, he is hardly called in a Magistrate or higher court. He does not keep records to guide his memory. and records which may be subpoenaed by the court. The lack of literacy and consequent lack of records create a problem for traditional healers. Psychotic patients are often put in fetters and chains by traditional healers initially because of the acute stage of the illness, and subsequently, in some cases, for lack of payment of fees to the traditional healer. In some areas. the people are getting to be aware of their fundamental human rights. The traditional healer, like any psychiatrist. cannot interfere with the liberty of any individual. While the psychiatrist knows the law regarding this and he can do the necessary to proteci himself. the traditional healer either does not know the law. or if he does he is not empowered to deal with the legalities. The greatest risk run by traditional healers is the charge of manslaughter when their patients die under their care. Where death certificates become mandatory before burial traditional healers are going to be exposed to difficult problems. as they cannot issue death certificates, certainly not in the form that is required by the law. It can be said that one of the dilemmas of the traditional healers is administrative in nature and can be resolved by changing the laws of the land. This is more easily said than done because of the many involved implications. Even if it were possible to change the laws to accommodate traditional healing, we shall
TOLANI Ascsr
36
stall be left vvith the dilemma of adjusting to the changing socio-cultural scene. Consequently I can only see the role of the traditional healers getting narrower and narrower. but not to the extent of being completely eliminated as they have not been completely eliminated even in technologically developed countries. where it has been possible to split the atom and send man to the moon. THE
DILEM.MA FOR
OF
PROVIDlUG
AGENCIES HE.ALTH
RESPONSIBLE SERVICES
The dilemma facing some of these ‘agencies arises from the suggestions and recommendations that the traditional healers should be incorporated into their systems. for reasons which have been outlined earlier in this paper. Perhaps it does not create a dilemma for countries where the traditional healers are few, circumscribed in their practice. and bound together into a well organised guild with adequate control of their membership and their practice. and with which the governments can negotiate. The fact that most governments of developing countries have not accepted and executed these suggestions and recommendations is a strong indication of their dilemma. This is understandable to a great extent where environmental and public health measures are being pursued very seriously, where great efforts are being made to train health personnel and where at the same time the traditional healers are of various kinds, not all limited and controlled by effective guilds. and where their practice has no limit in range. Any government taking a rational view of the issue will need to know how many and what kind of traditional healers exist in the community. what kind of medical problems they deal with. in what areas they are effective without creating any problems. and other relevant questions. before considering how they can utilise the traditional healers. It seems that the attitude af most governments is to leave them alone and go on with their training programme to provide and make modern facilities available and accessible to everybody. and it is left for the individual to choose between traditional and modern facilities. or to use both. After all. no matter what doubt anyone may have about the traditional healers. it has to be accepted that they are still fulfilling a very useful function in the community. DILEMMA
OF
MODERN
DOCTORS
While most modern doctors appear to be indifferent to traditional healing, there are a few who are vocal in advocating their use. There are stories of some doctors referring physical cases to traditional healers. There are also stories of some doctors using traditional healing pructtces on themselves when they take ill. Doctors who object to traditional healing are those who are on the receiving side of the maltreatment of traditional healers. The pediatrician who sees cases of cancrum oris. Kwashiorkor. or even clouded consciousness due to a mixture of cow urine and other stuff given them to drtnk. is not likely to be enthusiastic about traditional healing. The psychiatrist who
sees cases of extreme physical debtltty. horrible bed sores and u-hip marks all over the body in a psychottc patient exposed to some traditional healing system is not likely to advocate the use of traditional healers. DILEblC1.A
FACI\G
THE
CO\SL
\IER
Perhaps the dilemma facing the consumer IS the greatest and most important of all. He IS taught hygiene and biology at school if he has gone to school. Even if he has not gone to school the publtc health educators teach him something which is different from his :raditional concept of the cause of illness. So when he falls ill he is torn betvveen the traditional service and modern service. In case both may be right and he does not wish to miss out. he uses both. Even when he is hospitalized. his relativjes bring him traditional medicine to use in the hospital. This has led to tragedies in some situations. Even where the younger elements m the community want to use modern service, the pressure from their elders may make them do otherwise. Even where there’is no such family pressure, modern medical services may not be readily available. especially in the rural areas. To confound this dilemma more, they are now getting to hear that the government should use tradittonal healers more. This statement IS born more out of nationalistic attitude than any other reason. A further problem arises because traditional healers cannot issue acceptable health certificates. For example. a young civil servant took ill once in a city far away from home. He left his job and went to hts hometown to be treated with traditional medicine: he did not improve. so he came to the psychiatric hospital. He was given an excuse duty certificate on account of his iilness. He improved with modern treatment and was given a certificate of fitness to resume duty. He returned to the hospital to say that his boss was not prepared to take him back unless he brought a certiticate to cover the period he was with the traditional healer. The doctor felt it would not be right for him to give a certificate to cover a patient for the period when he was not attending the patient. Still another problem centers on the concept of cure. The traditional healer promises complete and absolute cure especially in cases of psychotic illness. and after considerable improvement. he puts the patient through the ritual of sealing off the illness as described by Prince [S] in his report of traditional healing among the Yorubas. The modern psychiatrist does not promise permanent and absolute cure. It is only when he has had relapses after treatment by one traditional healer after another that the patient is brought to the psychiatric hospital. The reverse movement also takes place. After successful treatment in a psychiatric hospital. they fail to come for follow-up and their maintenance medicatton in the hospital. in the expectation of permanent cure. especially if the need for maintenance medication has not been sufficiently emphasised. When the patients have relapses they are taken to tradittonal healers, since the relapses are interpreted as a failure of modern psychiatry to procure permanent cure. Failure to obtain permanent cure brings them back to the psychiatric hospital. The increasing use and proliferation of healing syn-
Traditional
healing with special reference
cretic religious organizations may be partly a result of this dilemma facing the consumer of health services. If a person is confused as to whether to use traditional or modern health service, and there is a neutral facility available. it is only rational for him to get out of the confusion by using the neutral service. This is perhaps an oversimplification of the problem as healing syncretic religious organizations are not always regarded as neutral in the issue. and patients who are attending psychiatric hospitals have been known to use one of the religious organizations at the same time. The usual pattern is that the patient attends one of the religious organizations. sometimes after unsustained consultation with a modern doctor [6]. When he does not improve with the religious sect. he comes back to the hospital. but still keeps his affiliation to the sect. It will appear that the proliferation of these religious sects. in addition to being a result of the dilemma of the consumers. have also added more to it. There are cases who do not know whether they are Moslems or Christians anymore. They are originally Moslems. and as a result of their affiliation with one of these syncretic religious sects because of illness. they assume a Biblical name along with their Koranic name. The situation is even worse when a young Moslem rejects his religion for a syncretic religious sect. thereby incurring the displeasure or even rejection of his family who can give him emotional and social support. This dilemma of the consumer is partly the fault of modern health care which did not take into account the culture and tradition of the people. Some health educators went to a village to educate the villagers about the dangers of house flies in connection with refuse and faeces not properly disposed of. and uncovered food. They took with them a visual aid and they had projected on the screen a large picture of a house fly on which they based their talk. After the session the village heads thanked them for their efforts and trouble and concluded by saying that in their village they only had very small flies. and they were not surprised that such a big fly as projected on the screen could cause so much havoc. This is a very simple example. but it illustrates the way in which mistakes can be made and indeed have been made in introducing modern health service to the people. COOPERATIOS
AliD
INCORPORATION
The question of cooperation of traditional and modern healing practice does not pose a great problem to the consumer. He will use both facilities with or without the knowledge or approval of either. His concept of disease allows for this. While modern medicine can procure a cure. it does not deal with what is regarded as the basic cause of his illness which may be a curse, the vengeance of a god. the evil machinations of another person. etc. The objective of the traditional healing practice in this situation is to counteract the basic cause. thereby making modern medicine effective and lasting in its cure. In other words. the traditional system complements the modern system. It is rather like lighting candles and praying for the recov-
to Nlpena
37
ery of a loved one and after recovery. having a thanksgiving service in church. It creates a problem if the objectives of the two systems are the same. This means that the patient is receiving medication for the same aspect of the illness from two different sources at the same time. This problem is easy .to deal with if the fact IS known. I tell my patients that the two medicines may counteract each other. or lead to overdosage, and that he should try one first. but not use the two together. If a patient has the belief that his illness has been caused through some supernatural means. It may not be necessary to argue this point at the initial stage of treatment. This point may be taken up with the patient and relatives only after the patient is better. Cooperation between the traditional healer and modern doctor depends on the personality of both. the self-confidence of both. and the method of treatment proposed by both. Some traditional healers have brought patients to me and I have not objected to my patient using tradttional healers. provided what is going to be done to the patient does not conflict with my treatment. For example. I do not approve of any traditional medicine to be taken by mouth while the patient is still on my medication. for reasons which I take pains to explain. The traditional healer may feel uneasy about the co-operation, or may feel his status enhanced by the co-operation. depending on the level of expertise and confidence he has. There is no doubt that they feel a sense of competition in which they are at a disadvantage. and for this reason some of them make extravagent claims to be able to treat successfully all types of physical and mental disorders. The impression I have is that most modern doctors are indifferent to traditional healers. They feel disgusted and angry when time and money has been spent on traditional healing without success and the .patient is then brought to them in a very bad shape. It annoys them when they read statements to the effect that because of their scientific training. they have been alienated from the people, and cannot empathise with them. This statement may be true to some extent. but it is not peculiar to developing countries. Doctors, on the whole, tend to use their middle class norms to assess their patients. Only recently some medical students doing their clinical psychiatry with me described a situation as being unfit for human habitation. I had to remind them that their very modern teaching hospital setting does not reflect the general standard in the population. and furthermore. it may be foreign to the generality of the population. 1 once had to have an emergency consultation on the second level of a two storey building. The patient was asked to come up. This elderly lady climbed up the staircase on all fours. It then dawned on me that she might not have had to climb up such a staircase in all her life. and this situation must have been threatening to her. Yet I had taken it for granted. . This question of cooperation between both systems, and incorporation of traditional healing practice into the health care system poses a greater problem for the authorities. It may be helpful to examine closely the situations where traditional healers are reported to have been used and incorporated into the official
TOLANI ASLNI
38
health delivery system. I suspect that in these situations the traditional healers are few. and they form a cohesive body. They deal mainly with psychosocial problems, and they very seldom use herbs. Some methods they use include ritual dancing. vvhich in addition to its cathartic effect also may lead to dissociation. possession. and trance. The therapeutic effect of this has been well documented and related to brain-washing [7]. The objective of therapy may not necessarily be directed to the individual patient. but to the group to which the patient belongs [S]. In another situation. like the Zar, the patient is integrated into the cult group and not his own primary group. In these situations. there is not likely to be much conflict. if any at all between the modern health service and the traditional healing system. In fact the modern health service can learn a lot from the traditional healing practices. HEALING
PROCESS MODERU
IN
TRADITIO%AL
4hD
MEDICI!UE
Healing process is an interaction between the patient, the therapist. and the environment. and this interaction is common to both traditional and modern medicine. The patient goes to the therapist with the expectation and hope of being healed. He has or develops Edith and confidence in the therapist. Without these and other related factors. the healing process may be delayed, arrested or negated. In the interaction these factors may be enhanced or reduced. depending on what happens. The therapist. on the other hand. is seen as having the knowledge and expertise to heal. In addition he has confidence. he uses impressive paraphernalia which enhances his power of suggestion. It may help if he is charismatic. He has status in the society. There are great similarities between the traditional healer and the modern doctor in respect of these factors. What makes a difference is the change in the social order and attitudes. The traditional healer has his awe inspiring paraphernalia in his garb, his dark room. his equipment. such as the modern doctor with his glistening instruments. With the change in attitude about cleanliness, order. etc.. the paraphernalia of the traditional healer is losing some of its awe. The status of the traditional healer as a powerful man in society is diminishing by virtue of the changing social order brought about by education. urbanisation. migration. and other phenomena. His method of flogging. beating. purging, and chaining of patients is being rejected. I doubt very much if any of my patients have run away from the hospital to go to traditional healers. but I know a few who have run away from the traditional healer to come to the psychiatric hospital, sometimes with the traditional healer on their heels. On the other hand, the social and physical environment of the traditional healer is more familiar to the patient. He has his relatives with him during treatment, so he does not feel isolated. He wears his own clothes and eats his familiar food. Perhaps the reason why more patients do not run away from the unpleasant treatment to which they are constantly exposed is the comforting presence of the relatives and the
great expectation of bemg healed. There is also the fear instilled in them by traditional healers that worse things can happen to them if they run away. The major differences in the practices of both traditional healer and modern doctor is that the latter talks only in terms of physical factors as the cause and treatment of illness. whereas the traditional healer evokes factors like the spirit and the supernatural which are understandable to the patient. This leads one to the consideration of the components of human existence. It has always been appreciated that there is more to human life than just the physical body. The aspect of soul or mind was also appreciated. and there w’as great argument as to which of the two was the main factor. The argument raged for a long time. until it was agreed that one could not be separated from the other-psychophysical monism. This problem came up again when psychoanalysis was born and there were those who laid emphasis on the physical and others on the psyche. It is only recently that they are both being considered as complementing each other. In neither pertod was the spirit seriously and persistently considered. If there was suggestion that this was considered. it was swallowed up under the concept of the mind. True enough some of the manifestations of the spirit can readily be explained in terms of the mind. but not all. The term para-psychology was invented to take care of some of these phenomena, but it is doubtful if these can be attributed to the mind-even in its extension. Can it truly be said that the phenomenon of poltergeist, to name only one, is a function of the mind’.’ There are many other such phenomena which cannot be attributed to the function of the mind. even in its extension. True enough it may not fit into the framework of our materialistic and physical concept. but this does not mean that the concept of the spirit is a myth. It may not lend itself readily to our present method of scientific inquiry: it may shake to the root some of our cherished notions: however. these are not adequate reasons for turning our backs on the concept of the spirit. Even if in our concept of body and mind we examine deeply the concept of etiology on which it is rational to base treatment. we find that we stop our enquiry at a convenient level where we can take effecttve action. For example. we discover some organisms as being the Infecting agent, and then we attack the organism or help the body to attack it. The discovery of these organisms is a convenient level. Even at this level we soon find that it is not as simple, for some people exposed to the same organism do not develop the illness. and this leads to the idea of virulence, size of infective agent. immunity, etc. If we pursue our examination beyond the level of the organism we get to the ultimate or infinity-the greatest dilemma which perhaps some traditional healing takes into account. REFEREYCES I.
Ademuwagun Z. A. The relevance of Yoruba medicine men in public health practice in Nigeria. Public health practice in Nigeria. Puhl. Hlrh Rep. 84. U.S. Departmeni of H.E.W., 1969: Kiev A. Tr~rnscultural PSJ-
Traditional
7. 3.
4. 5. 6.
healmg
with special
c,kiurrr. Free Press. New York. 1972: Prince R. Indigenous Yoruba psychiatry. In Mugtc,. &tirh anJ hralinq (Edited by Kiev A.). Free Press. New York. 1964: Torrey F. Tlrr Mind Gums. Bantam Books. New York. 1972: Twumasi P. A. Merlicrtl Srstmms in Ghana. Ghana Publishing Corporation. 1975. Ademuwagun 2. A. 1969. Jahoda G. Traditional healers and other institutions concerned with mental illness m Ghana. Inf. J. so. Ps~x%tur. VII, 1961. Prtnce R. ( 1964. I/-lit/. Asuni T. Vagrant psychotics in Abeokuta. J. nufn. nterl Ass. 63, 1971.
reference
to Nigerta
39
7. Sargent W. Burt/c /or I/U, Mirrtl. Hetncmann. London 1957; 7-/n, Mtnd Pos.\c~.\.sell- Pllwdo
DILEMMA
WITH
SPECIAL
OF TRADITIONAL REFERENCE
HEALING
TO
NIGERIA
TOLANI ASUNI Neuro-Psychiatric
Hospital.
Aro. Abeokuta.
Nigeria
Abstract-The healing process represents an interaction between patient. therapist. and the socio-cultural environment. This interaction characterizes both traditional and cosmopolitan medicine. The shortage of professional health care staff in rural areas recommends to some that these parallel medical systems be integrated. However. those who most strongly advocate such integration are loreigners. not familiar enough with the problems such policy would generate. In Nigeria. and elsewhere. it is difficult to plan such an integrated system before knowing how many indigenous curers are in practice. what kinds of medical problems they address. and with which kinds or problems they have most success. Integration also poses some serious dilemmas. For instance. although in Nigeria herbalists find dramatic success with some of their potent medicines. they lack an adequate knowledge or the etiects these potions may have on the patient. Another dilemma is raised by the necessity to have written records of patients. their complaints. and the effects of treatment: but illiterate healers will be unable to maintain such files. These and other administrative dilemmas must be foreseen. Finally. the success of traditional healers in treating mentally ill patients rests on the fact that their techniques are clearly related to the relevant cultural premises of the patient. However, if in the course of incorporating them into the official health system it is considered to be necessary to educate them in concepts of germs and infection. it is probable that these new. intrusive concepts of etiology will prove alien and incompatible with their traditional understandings. Moreover, such training would fracture the shared cognitive bond between healers and those who are their patients.
entirely; and this is based on the findings that some urbanised and educated people in developing countries, e.g. Ghana [3]. still consult traditional healers when they have modern medical facilities available. This will suggest that if these modern facilities are acceptable at all, they are not so to the exclusion of the traditional system. There are some areas of health problems in which roles of both traditional and modern are regarded to be complementary. and there are other areas like mental illness in which the modern system is not regarded to be effective. until the contrary is proved, as is the case increasingly where modern psychiatric facilities are available. This problem leads to the examination of the concepts of disease and healing. Where the concept is based on magic. superstition. and religion exclusively. the traditional system based on this concept will be preferred. This preference has led to the extermination of large sections of rural populations by epidemics of smallpox and cholera. since the whole concept of infection and contagion does not enter into consideration. It has been suggested that the traditional healer can be educated to appeciate and take into account the concept of infection and contagion in his system. but the supporters of this suggestion have not dealt with its impact on the totahty of the traditional system. The concept based on magic, superstition. and religion is cohesive and integrated into the religious and socio-cultural setting in which it is practised. To what extent will the introduction of the concept of infection and contagion disturb the cohesion and integration of the social cultural setting’? In some situations. some traditional healers have been using modern antibiotics. but in a rather surreptitious manner. unknown or unstated to their patients. It is conceivable that their image of’power
Most of the vocal and strong proponents of the idea of integrating traditional healing practice into the health care delivery are foreigners to the situation. The knowledgeable and sincere indigenes of the developing countries are usually cautious in advocating such integration. They are, on the other hand, accused by the foreigners of being blind to their tradition and potentials. and biased against traditional healers, partly to preserve their authority and domain. It is because of this lack of agreement that it is proposed in this paper to examine the issue more closely [l]. It has been strongly argued that because of the serious and dire shortage of trained professional personnel in the field of health, a situation which will take many years to improve appreciably. the existing traditional health care delivery system should be utilized and incorporated into the official plan for health services. Another argument which is not as strong is that since the modern health personnel trained in a different setting in the industrially developed countries. they are not in tune with their own people and tradition anymore and therefore cannot be of the maximum benefit professionally to their people [Z]. The first argument is very persuasive because there are more traditional healers than medical practitioners in the population. They are available. they are accessible. and they are acceptable: thereby fulfilling the major criteria for an effective service. These criteria are true for most traditional healing systems in developing countries. The question is how long are they going to be so’? Health care delivery systems are changing: it is to be expected that the traditional health care system will also change in keeping with the trend of change. Some aspects of this trend will be examined later. There is another argument which does not follow
this reasoning
33
34
TOLANI .ASLNI
based on traditional concepts may be undermined and belittled if it is known that they are using modern medicine. This creates a dilemma for the sincere traditional healer: however. if he is sure of himself. he will have no problem in referring such cases to modern medical facilities. Some years ago a man came to the emergency room of a hospital in which I worked. He had great difficulty in breathing and it was obvious that he had an asthmatic attack. In my interrogation. it came to light that he was a traditional healer. He was given an injection of adrenaline which made his breathing easier in a few minutes. When he was better 1 asked him what he would do if he had a patient with a similar problem. His answer was “I will try my best”. He must have tried his best for himself. It was significant to me that he did rlot say that he would send him to the hospital. Of course, it can be argued that this is more of the attribute of or failing of this man rather than that of the system he uses. Does the traditional system allow for failure without the risk of loss of face and prestige? Hardly. Their explanation for failure is one of “heads I win, tails you lose”. If the traditional healer fails in procuring a cure, then the patient or his relatives must have failed to observe all the numerous do’s and don’ts and prescribed iituals correctly. The therapeutic success of any physician derives partly from the expectation of the patients which is a factor of the image of the physician. This is particularly so of the traditional healer whose image of omnipotence is an essential ingredient of his therapeutic success. If the suggestion were to be followed to give him official recognition and incorporate him into the official health delivery system, his professional activities will need to be restricted to areas in which the authorities regard his expertise to be valuable and useful. He may have to be under some supervision and control to comply with some laid down regulations. This will immediately diminish his image of omnipotence, and consequently his therapeutic efficacy. This is a theoretical formulation which needs to be verified in areas where traditional healers have been officially recognized and incorporated into the health care system. On the other hand. it can be made a subject of experimental study in other areas. In doing this. it will be necessary to distinguish between what is primarily a social pathology on the one hand. and what is primarily a psychological and medical pathology on the other. despite the close interwoven relationship between the two. It is likely that the success of the traditional healing practice derives partly from this interwoven relationship, especially in psychiatric cases. Indeed the role of the physician-priest from which most traditional healers emanate is broader than that of a physician or psychiatrist. In addition to helping the individual, he is concerned also with the welfare of the community and the smooth running of the organization of the community. It is perhaps because of this that some people advocate the use of traditional healers. forgetting that the healer-priest role is being broken down by increasing specialisation of roles. If the concept of illness includes social pathology then this advocacy is rational and logical.
On the other hand. others argue that v,hile social pathology should be the concern of the ps>chlatrlsts. inasmuch as his patients’ problei-ns stem partic from this. and the patients have to return to the soclct!. the psychiatrist should concentrate his attention on his patients. and should not centre his attention on social reform. This does not mean that he should be indifferent to social reform. On the other hand he should call attention to the social ills of the soclet! which are known to be conducive to psychlatrlc IIIness. and allow the social reformers to take over from that point. If the psychiatrist feels very strongly about social reform. he can do something about it. not prlmarily as a psychiatrist. but as a concerned citizen with psychiatric expertise. There are other disciplmes like priesthood and social work which encounter 111 their day to day activities the social ills in society. It is therefore not the prerogative of psychlatr! to take over social reform. This applies not only to Industrially developed countries. but also to debelopIng countries. In talking about traditional healing. it has to be emphasised that it varies in kind and number In dlfferent communities. and even withln the same community. Therefore. one has to be cautious about generalisation. In my particular geographical area--Abeokuta in Nigeria-we know that the use of our modern psychiatric facilities by the people is inversely proportional to the distance which our patients travel. In other words, fewer patients from Abeokuta area use the facilities than patients from more distant areas. The reasons for this may include: (a) the stigma attached to psychiatric illness. There is more secrecy in going to traditional healers than in coming to the psychiatric hospital, and since they come from the area it will be more easily known than if they _eo to a traditional healer; (b) the traditional healers m Abeokuta area are famous for their expertise, so local people have them readily at hand to consult. Our impression is that it is the latter reason more than the former that makes people from distant places use the modern psychiatric facilities more frequently than the local people. Prince [4] in his study of traditional healers among the Yorubas distinguished between those of them who are essentially herbalists and those who are essentially oracle men; allowing for some overlap in their functions. He also identified rauwalfia as a major component in their pharmacopeia for psychotic illnesses. This discovery confirms the suggestion that further studies of the herbs and roots used by tradltional healers are strongly indicated. Some work IS now being done in this area in West Africa. As it is known that some traditional healers have very potent and useful herbs, some people use this to support the plea for their official recognition. The problem with this issue is that they know less about the effect of the drugs they use than we know of modern psychotropic drugs. There was the case of a patient who had been receiving apparently potent psychotropic herbs from a traditional healer. He had a side effect of the drug which was involuntary protrusion of his tongue which he bit. The bite became septic and he could not consequently take anytliing by mouth. It was at this stage that he was brought to the psychiatric hospital where his sepsis was
TraditIonal
healing
with special
treated with antibiotic injections. One wondered what could have happened to this man if he had not been taken to a hospital. The traditional healers do not have the means of giving their drugs by injection. Another example of this lack of necessary knowledge of the effect of their herbs was revealed to me on a visit to a traditional healer. There were about four patients sound asleep on the morning of the visit. This was a result of the drugs they had been given. When the healer was asked when they would wake up, his answer was “perhaps tomorrow”. He had no knowledge or means of handling cases in such a state of very deep sleep, e.g. making sure the airway was free, giving fluid by infusion. checking electrolyte balance. giving preventive antibiotics. etc. How many of such cases sleep unto death we will never know. There have been many claims of successful treatment of physical illness by traditional healers. There is no doubt that a number of these claims are true. They become dubious when they involve cases of intractable conditions. They may indeed have successes in these cases. but it has not been possible to verify this. Attention needs to be focussed on these cases. I once had a patient with a classical picture of manicdepressive psychosis. He was sturdy physically. He had a cyclothymic personality and had demonstrated phases of depression and hypomania. It was explained to him that all we could do was to try and keep him on an even keel, as we could not “cure” him. He was promised a cure by a traditional healer to whom he went with my consent. He had been having a regular periodicity of his illness. When the period of his illness came. he did not have it. and I was getting very excited and intrigued about his case. A week or two later. he came back with one of his swings of mood. The claim that traditional healers are more successful with neurotic conditions. stemming from psychosocial factors is understandable: but it needs to be verified. so that one can identify with confidence their area of strength. What is disturbing with some of their therapeutic techniques is to make the patient forever dependent on them. and worse still to enhance or even create in some patients an anxiety state. This is done by projecting to some outside agencyusually an innocent person-the cause of their problems. This projection sometimes limits the range of activities of the patient and also the range and depth of his interpersonal relationships. And yet there are examples of excellent professional intervention. which even modern psychiatry .cannot bear. An anxious and distraught woman consulted a traditional healer with a domestic problem which could .lead to her being kicked out of her marital home by her husband. She was given a rubbery object to put in her mouth any time there was a quarrel. and rather than answer back the cowife. she should bite this object as if she was biting the other woman. This she did. The result was that the quarrels reduced in length and frequency until they stopped completely. She could not bite and answer back at the same time! The question is whether this is a psychiatric problem or not. and yet this is an area in which the traditional healer. as in the case described. can be most successful.
reference
to Nigeria
35
All that has been said so far indicates that there is a dilemma about traditional healing that is shared by the traditional healers. the agencies responsible for providing health services. modern doctors. and the consumer of the services. THE
TRADITIONAL
HEALERS
DILEMMA
A number of traditional healers are aware of the changing socio-cultural scene which affects their practice. In some areas where there are modern medical facilities. they are being consulted less. Not too long ago, one came to ask if I could engage him in the hospital. When I asked him in what capacity and for what role, he said he could be given my retractive cases to treat. Another one came to ask for help. He had some years of schooling before taking over his fathers’ healing practice. When I asked him to specify what help he wanted. it turned out to be how he could organise his practice so that he could get paid by his patients. It was obvious tha! he either had no knowledge of how to get his patients to pay his fees. or what. knowledge he had did not suit the present situation. Some of his patients are in paid employment and if the patient is unable to go to work as a result of his illness. the healer either cannot write to say so, or if even he can write his certificate of unfitness to work will not be accepted by the patient’s employers. In the past. all the healers’ patients were self-employed or employed in family business like joint farming. fishing. or trading. This situation is even more serious when it involves a criminal charge against a person who has had treatment for a psychotic illness. While the traditional healer may be called to give expert evidence in a customary court, he is hardly called in a Magistrate or higher court. He does not keep records to guide his memory. and records which may be subpoenaed by the court. The lack of literacy and consequent lack of records create a problem for traditional healers. Psychotic patients are often put in fetters and chains by traditional healers initially because of the acute stage of the illness, and subsequently, in some cases, for lack of payment of fees to the traditional healer. In some areas. the people are getting to be aware of their fundamental human rights. The traditional healer, like any psychiatrist. cannot interfere with the liberty of any individual. While the psychiatrist knows the law regarding this and he can do the necessary to proteci himself. the traditional healer either does not know the law. or if he does he is not empowered to deal with the legalities. The greatest risk run by traditional healers is the charge of manslaughter when their patients die under their care. Where death certificates become mandatory before burial traditional healers are going to be exposed to difficult problems. as they cannot issue death certificates, certainly not in the form that is required by the law. It can be said that one of the dilemmas of the traditional healers is administrative in nature and can be resolved by changing the laws of the land. This is more easily said than done because of the many involved implications. Even if it were possible to change the laws to accommodate traditional healing, we shall
TOLANI Ascsr
36
stall be left vvith the dilemma of adjusting to the changing socio-cultural scene. Consequently I can only see the role of the traditional healers getting narrower and narrower. but not to the extent of being completely eliminated as they have not been completely eliminated even in technologically developed countries. where it has been possible to split the atom and send man to the moon. THE
DILEM.MA FOR
OF
PROVIDlUG
AGENCIES HE.ALTH
RESPONSIBLE SERVICES
The dilemma facing some of these ‘agencies arises from the suggestions and recommendations that the traditional healers should be incorporated into their systems. for reasons which have been outlined earlier in this paper. Perhaps it does not create a dilemma for countries where the traditional healers are few, circumscribed in their practice. and bound together into a well organised guild with adequate control of their membership and their practice. and with which the governments can negotiate. The fact that most governments of developing countries have not accepted and executed these suggestions and recommendations is a strong indication of their dilemma. This is understandable to a great extent where environmental and public health measures are being pursued very seriously, where great efforts are being made to train health personnel and where at the same time the traditional healers are of various kinds, not all limited and controlled by effective guilds. and where their practice has no limit in range. Any government taking a rational view of the issue will need to know how many and what kind of traditional healers exist in the community. what kind of medical problems they deal with. in what areas they are effective without creating any problems. and other relevant questions. before considering how they can utilise the traditional healers. It seems that the attitude af most governments is to leave them alone and go on with their training programme to provide and make modern facilities available and accessible to everybody. and it is left for the individual to choose between traditional and modern facilities. or to use both. After all. no matter what doubt anyone may have about the traditional healers. it has to be accepted that they are still fulfilling a very useful function in the community. DILEMMA
OF
MODERN
DOCTORS
While most modern doctors appear to be indifferent to traditional healing, there are a few who are vocal in advocating their use. There are stories of some doctors referring physical cases to traditional healers. There are also stories of some doctors using traditional healing pructtces on themselves when they take ill. Doctors who object to traditional healing are those who are on the receiving side of the maltreatment of traditional healers. The pediatrician who sees cases of cancrum oris. Kwashiorkor. or even clouded consciousness due to a mixture of cow urine and other stuff given them to drtnk. is not likely to be enthusiastic about traditional healing. The psychiatrist who
sees cases of extreme physical debtltty. horrible bed sores and u-hip marks all over the body in a psychottc patient exposed to some traditional healing system is not likely to advocate the use of traditional healers. DILEblC1.A
FACI\G
THE
CO\SL
\IER
Perhaps the dilemma facing the consumer IS the greatest and most important of all. He IS taught hygiene and biology at school if he has gone to school. Even if he has not gone to school the publtc health educators teach him something which is different from his :raditional concept of the cause of illness. So when he falls ill he is torn betvveen the traditional service and modern service. In case both may be right and he does not wish to miss out. he uses both. Even when he is hospitalized. his relativjes bring him traditional medicine to use in the hospital. This has led to tragedies in some situations. Even where the younger elements m the community want to use modern service, the pressure from their elders may make them do otherwise. Even where there’is no such family pressure, modern medical services may not be readily available. especially in the rural areas. To confound this dilemma more, they are now getting to hear that the government should use tradittonal healers more. This statement IS born more out of nationalistic attitude than any other reason. A further problem arises because traditional healers cannot issue acceptable health certificates. For example. a young civil servant took ill once in a city far away from home. He left his job and went to hts hometown to be treated with traditional medicine: he did not improve. so he came to the psychiatric hospital. He was given an excuse duty certificate on account of his iilness. He improved with modern treatment and was given a certificate of fitness to resume duty. He returned to the hospital to say that his boss was not prepared to take him back unless he brought a certiticate to cover the period he was with the traditional healer. The doctor felt it would not be right for him to give a certificate to cover a patient for the period when he was not attending the patient. Still another problem centers on the concept of cure. The traditional healer promises complete and absolute cure especially in cases of psychotic illness. and after considerable improvement. he puts the patient through the ritual of sealing off the illness as described by Prince [S] in his report of traditional healing among the Yorubas. The modern psychiatrist does not promise permanent and absolute cure. It is only when he has had relapses after treatment by one traditional healer after another that the patient is brought to the psychiatric hospital. The reverse movement also takes place. After successful treatment in a psychiatric hospital. they fail to come for follow-up and their maintenance medicatton in the hospital. in the expectation of permanent cure. especially if the need for maintenance medication has not been sufficiently emphasised. When the patients have relapses they are taken to tradittonal healers, since the relapses are interpreted as a failure of modern psychiatry to procure permanent cure. Failure to obtain permanent cure brings them back to the psychiatric hospital. The increasing use and proliferation of healing syn-
Traditional
healing with special reference
cretic religious organizations may be partly a result of this dilemma facing the consumer of health services. If a person is confused as to whether to use traditional or modern health service, and there is a neutral facility available. it is only rational for him to get out of the confusion by using the neutral service. This is perhaps an oversimplification of the problem as healing syncretic religious organizations are not always regarded as neutral in the issue. and patients who are attending psychiatric hospitals have been known to use one of the religious organizations at the same time. The usual pattern is that the patient attends one of the religious organizations. sometimes after unsustained consultation with a modern doctor [6]. When he does not improve with the religious sect. he comes back to the hospital. but still keeps his affiliation to the sect. It will appear that the proliferation of these religious sects. in addition to being a result of the dilemma of the consumers. have also added more to it. There are cases who do not know whether they are Moslems or Christians anymore. They are originally Moslems. and as a result of their affiliation with one of these syncretic religious sects because of illness. they assume a Biblical name along with their Koranic name. The situation is even worse when a young Moslem rejects his religion for a syncretic religious sect. thereby incurring the displeasure or even rejection of his family who can give him emotional and social support. This dilemma of the consumer is partly the fault of modern health care which did not take into account the culture and tradition of the people. Some health educators went to a village to educate the villagers about the dangers of house flies in connection with refuse and faeces not properly disposed of. and uncovered food. They took with them a visual aid and they had projected on the screen a large picture of a house fly on which they based their talk. After the session the village heads thanked them for their efforts and trouble and concluded by saying that in their village they only had very small flies. and they were not surprised that such a big fly as projected on the screen could cause so much havoc. This is a very simple example. but it illustrates the way in which mistakes can be made and indeed have been made in introducing modern health service to the people. COOPERATIOS
AliD
INCORPORATION
The question of cooperation of traditional and modern healing practice does not pose a great problem to the consumer. He will use both facilities with or without the knowledge or approval of either. His concept of disease allows for this. While modern medicine can procure a cure. it does not deal with what is regarded as the basic cause of his illness which may be a curse, the vengeance of a god. the evil machinations of another person. etc. The objective of the traditional healing practice in this situation is to counteract the basic cause. thereby making modern medicine effective and lasting in its cure. In other words. the traditional system complements the modern system. It is rather like lighting candles and praying for the recov-
to Nlpena
37
ery of a loved one and after recovery. having a thanksgiving service in church. It creates a problem if the objectives of the two systems are the same. This means that the patient is receiving medication for the same aspect of the illness from two different sources at the same time. This problem is easy .to deal with if the fact IS known. I tell my patients that the two medicines may counteract each other. or lead to overdosage, and that he should try one first. but not use the two together. If a patient has the belief that his illness has been caused through some supernatural means. It may not be necessary to argue this point at the initial stage of treatment. This point may be taken up with the patient and relatives only after the patient is better. Cooperation between the traditional healer and modern doctor depends on the personality of both. the self-confidence of both. and the method of treatment proposed by both. Some traditional healers have brought patients to me and I have not objected to my patient using tradttional healers. provided what is going to be done to the patient does not conflict with my treatment. For example. I do not approve of any traditional medicine to be taken by mouth while the patient is still on my medication. for reasons which I take pains to explain. The traditional healer may feel uneasy about the co-operation, or may feel his status enhanced by the co-operation. depending on the level of expertise and confidence he has. There is no doubt that they feel a sense of competition in which they are at a disadvantage. and for this reason some of them make extravagent claims to be able to treat successfully all types of physical and mental disorders. The impression I have is that most modern doctors are indifferent to traditional healers. They feel disgusted and angry when time and money has been spent on traditional healing without success and the .patient is then brought to them in a very bad shape. It annoys them when they read statements to the effect that because of their scientific training. they have been alienated from the people, and cannot empathise with them. This statement may be true to some extent. but it is not peculiar to developing countries. Doctors, on the whole, tend to use their middle class norms to assess their patients. Only recently some medical students doing their clinical psychiatry with me described a situation as being unfit for human habitation. I had to remind them that their very modern teaching hospital setting does not reflect the general standard in the population. and furthermore. it may be foreign to the generality of the population. 1 once had to have an emergency consultation on the second level of a two storey building. The patient was asked to come up. This elderly lady climbed up the staircase on all fours. It then dawned on me that she might not have had to climb up such a staircase in all her life. and this situation must have been threatening to her. Yet I had taken it for granted. . This question of cooperation between both systems, and incorporation of traditional healing practice into the health care system poses a greater problem for the authorities. It may be helpful to examine closely the situations where traditional healers are reported to have been used and incorporated into the official
TOLANI ASLNI
38
health delivery system. I suspect that in these situations the traditional healers are few. and they form a cohesive body. They deal mainly with psychosocial problems, and they very seldom use herbs. Some methods they use include ritual dancing. vvhich in addition to its cathartic effect also may lead to dissociation. possession. and trance. The therapeutic effect of this has been well documented and related to brain-washing [7]. The objective of therapy may not necessarily be directed to the individual patient. but to the group to which the patient belongs [S]. In another situation. like the Zar, the patient is integrated into the cult group and not his own primary group. In these situations. there is not likely to be much conflict. if any at all between the modern health service and the traditional healing system. In fact the modern health service can learn a lot from the traditional healing practices. HEALING
PROCESS MODERU
IN
TRADITIO%AL
4hD
MEDICI!UE
Healing process is an interaction between the patient, the therapist. and the environment. and this interaction is common to both traditional and modern medicine. The patient goes to the therapist with the expectation and hope of being healed. He has or develops Edith and confidence in the therapist. Without these and other related factors. the healing process may be delayed, arrested or negated. In the interaction these factors may be enhanced or reduced. depending on what happens. The therapist. on the other hand. is seen as having the knowledge and expertise to heal. In addition he has confidence. he uses impressive paraphernalia which enhances his power of suggestion. It may help if he is charismatic. He has status in the society. There are great similarities between the traditional healer and the modern doctor in respect of these factors. What makes a difference is the change in the social order and attitudes. The traditional healer has his awe inspiring paraphernalia in his garb, his dark room. his equipment. such as the modern doctor with his glistening instruments. With the change in attitude about cleanliness, order. etc.. the paraphernalia of the traditional healer is losing some of its awe. The status of the traditional healer as a powerful man in society is diminishing by virtue of the changing social order brought about by education. urbanisation. migration. and other phenomena. His method of flogging. beating. purging, and chaining of patients is being rejected. I doubt very much if any of my patients have run away from the hospital to go to traditional healers. but I know a few who have run away from the traditional healer to come to the psychiatric hospital, sometimes with the traditional healer on their heels. On the other hand, the social and physical environment of the traditional healer is more familiar to the patient. He has his relatives with him during treatment, so he does not feel isolated. He wears his own clothes and eats his familiar food. Perhaps the reason why more patients do not run away from the unpleasant treatment to which they are constantly exposed is the comforting presence of the relatives and the
great expectation of bemg healed. There is also the fear instilled in them by traditional healers that worse things can happen to them if they run away. The major differences in the practices of both traditional healer and modern doctor is that the latter talks only in terms of physical factors as the cause and treatment of illness. whereas the traditional healer evokes factors like the spirit and the supernatural which are understandable to the patient. This leads one to the consideration of the components of human existence. It has always been appreciated that there is more to human life than just the physical body. The aspect of soul or mind was also appreciated. and there w’as great argument as to which of the two was the main factor. The argument raged for a long time. until it was agreed that one could not be separated from the other-psychophysical monism. This problem came up again when psychoanalysis was born and there were those who laid emphasis on the physical and others on the psyche. It is only recently that they are both being considered as complementing each other. In neither pertod was the spirit seriously and persistently considered. If there was suggestion that this was considered. it was swallowed up under the concept of the mind. True enough some of the manifestations of the spirit can readily be explained in terms of the mind. but not all. The term para-psychology was invented to take care of some of these phenomena, but it is doubtful if these can be attributed to the mind-even in its extension. Can it truly be said that the phenomenon of poltergeist, to name only one, is a function of the mind’.’ There are many other such phenomena which cannot be attributed to the function of the mind. even in its extension. True enough it may not fit into the framework of our materialistic and physical concept. but this does not mean that the concept of the spirit is a myth. It may not lend itself readily to our present method of scientific inquiry: it may shake to the root some of our cherished notions: however. these are not adequate reasons for turning our backs on the concept of the spirit. Even if in our concept of body and mind we examine deeply the concept of etiology on which it is rational to base treatment. we find that we stop our enquiry at a convenient level where we can take effecttve action. For example. we discover some organisms as being the Infecting agent, and then we attack the organism or help the body to attack it. The discovery of these organisms is a convenient level. Even at this level we soon find that it is not as simple, for some people exposed to the same organism do not develop the illness. and this leads to the idea of virulence, size of infective agent. immunity, etc. If we pursue our examination beyond the level of the organism we get to the ultimate or infinity-the greatest dilemma which perhaps some traditional healing takes into account. REFEREYCES I.
Ademuwagun Z. A. The relevance of Yoruba medicine men in public health practice in Nigeria. Public health practice in Nigeria. Puhl. Hlrh Rep. 84. U.S. Departmeni of H.E.W., 1969: Kiev A. Tr~rnscultural PSJ-
Traditional
7. 3.
4. 5. 6.
healmg
with special
c,kiurrr. Free Press. New York. 1972: Prince R. Indigenous Yoruba psychiatry. In Mugtc,. &tirh anJ hralinq (Edited by Kiev A.). Free Press. New York. 1964: Torrey F. Tlrr Mind Gums. Bantam Books. New York. 1972: Twumasi P. A. Merlicrtl Srstmms in Ghana. Ghana Publishing Corporation. 1975. Ademuwagun 2. A. 1969. Jahoda G. Traditional healers and other institutions concerned with mental illness m Ghana. Inf. J. so. Ps~x%tur. VII, 1961. Prtnce R. ( 1964. I/-lit/. Asuni T. Vagrant psychotics in Abeokuta. J. nufn. nterl Ass. 63, 1971.
reference
to Nigerta
39
7. Sargent W. Burt/c /or I/U, Mirrtl. Hetncmann. London 1957; 7-/n, Mtnd Pos.\c~.\.sell- Pllwdo
