Tropical Doctor, July I976
Traditional and western medicine in Africa: collaboration or confrontation? T. C. Nchinda, MD(London), DTPH, MFCM Formerly Deputy Director of Public Health, Ministry of Health, Yaounde, Cameroon TROPICAL DOCTOR,
1976,6, 133-135
There is a great deal of misapprehension and doubt prevailing in the minds of many people of western orientation regarding the ability of traditional health practitioners in developing countries to diagnose and, indeed, treat diseases. Even the general term of "witch-doctor" given to them is now as outmoded as it is inappropriate in describing practitioners of an ancient art whose skill in handling certain types of medical problems is unsurpassed by western trained doctors. Over the years these traditional health practitioners have provided and are still providing primary health care to large sections of the community. Their clients include the educated and the uneducated alike; the availability of hospitals and health centres and clinics has not hindered use of traditional health treatment. In fact many people are perfectly happy commuting freely between traditional and western treatments. In the light of this seemingly conflicting situation what should be the attitude of members of the medical profession who have obtained scientific training? Should traditional medicine be eliminated by legislation or otherwise? Should it be assimilated and integrated into western medicine or should it be treated with indifference? In other words, should there be collaboration or confrontation between traditional and western medicine? The health situation Africa is too large a continent with differing peoples, cultures, governments, and economic potentials to perrnit anything but broad generalizations to be made about the health services in the different countries. From 1961 to 1970 the countries of the African Region of the World Health Organization allocated an average of 8.6% of their national budgets (in some countries this was as high as 15%) for health. In Cameroon, the health budget in 1972/73 was about 9.5% of the national budget excluding the health components of the budgets of other ministerial departments such as those dealing with community
TRADITIONAL AND WESTERN MEDICINE IN AFRICA
I 133
water supplies, housing, occupational health, agriculture, and veterinary health services. These countries spend an average of USSI.20 per year per inhabitant for health while the United States spends USS242 per inhabitant. The health services in Africa are quantitatively and qualitatively insufficient and maldistributed between the small urban and the large rural population. The problem of providing adequate and comprehensive health services to cover the predominantly rural population in Africa is engaging the full attention of the health administrators in many countries. This is not made any easier by the low economic resources and adverse environmental conditions in some of these countries. Culture and illness People's reactions to illness are linked to a large number of factors one of which is their social and cultural behaviour. Paul (1966) showed in his classic collection of studies that lack of knowledge of the traditional health beliefs of people can be disastrous to health programmes. Many a western-trained doctor has been baffled by the lack of response and apparent stubbornness on the part of some patients to followan otherwise scientifically sound treatment regime. In such cases, the treatment has apparently ignored or gone against the traditional and cultural beliefs of the people. Of course these beliefs are modified by several factors including education, availability of medical care, its success in the treatment of various diseases, the cost and convenience of the service, and the attitude of the personnel. A previous publication (Nchinda 1974) described the integrated pluriprofessional training of health personnel in Cameroon. This concept is now being tried in various ways in the medical schools and in the newer University Centres for Health Sciences in West and Central as well as East Mrica. This training is much better adapted to the health situation in the various countries. This training also lays muchneeded emphasis on preventive and community medicine as well as on the social sciences. TRADITIONAL MEDICINE
Man from the beginning has always had a method of coping with sickness and disease in his community. In spite of all the advances in scientific medicine, the traditional forms of cure have persisted. In the western world, education and increased scientific understanding among the people have contributed to the virtual disappearance offolk medicine although vestiges of this are now appearing in various disguises - faith healing, exorcism, etc. In the develop-
134
I TRADITIONAL AND WESTERN MEDICINE IN AFRICA
ing countries traditional medicine still holds sway and its popularity is undisputed. TRADITIONAL HEALTH PRACTITIONERS
Various types of traditional health practitioners have been described (Read 1966; Ademuwagun 1969; Conco 1970; and Maclean 1971). They fall into the broad groups ofsurgeons, herbalists, and psychiatrists (also called diviners). They all share one characteristic in common which is that they function within the psychological framework of their clients' beliefs, cultures, and expectations. Their clients in turn have faith in the healers because of the healers' traditional authenticity and cultural identification. There is thus mutual trust, confidence, and complete rapport between practitioner and patient. Though lacking in scientific clarity such as characterizes western medical educational systems, the traditional health practitioners have been able to acquire and display extraordinary qualities of mind and to possess remarkable technical skills which enables them to perform their ancient art with as much determination, professionalism, sympathy, and tact as any western-trained doctor. The extent to which people consult traditional health practitioners varies in the different countries of Africa. Maclean (1971) reported that 30% of people in Johannesburg consulted traditional doctors often concurrently with western doctors. Lambo (1971) said that in 1950, 60% of the patient population in a large general hospital in Nigeria had received some traditional treatment. The writer found, in a recent study in Cameroon, that about 20% of sick people in the study area went for traditional treatment either alone or in combination with other forms of treatment. The role of the level of education of the client appears very complex. Morley (1973) reports the case of a reputable surgeon who went to a traditional healer to treat his jaundice. The writer also knows a well-educated and highly placed person who had hemiplegia following a stroke and, after initial treatment by two reputable physicians abandoned the recommended physiotherapy and instead ended up in a traditional practitioner's clinic! People will thus make their own decision firmly about what to do about their illness with the help of or in spite of medical advice. Lambo (1971) attempted to offer an explanation for this by saying that "it would seem that in a conflict situation, the newly acquired and highly differentiated social values, attitudes, and ideologies are more susceptible to damage leaving basic traditional beliefs and moral philosophy functionally overactive."
Tropical Doctor, July I976 THE DILEMMA
The health administrators in Africa find themselves in a dilemma. They are committed to the provision of comprehensive health services to the people in the apparent conflict situation arising from the coexistence of traditional and western medicine. Also, severe financial restraints preclude unlimited increase of the health budget and call for more careful and judicious planning. On the one hand, the effects of western medicine are manifest in the field of communicable disease control, improved maternal and child health services, and effective treatment for many acute diseases. The people flock to the overcrowded out-patients departments of hospitals in ever-increasing numbers, even though the complexity and relative impersonality of these medical institutions, their rigidity and lack of adaptability, induce in their users a feeling of helplessness which, in some cases, almost borders on alienation. On the other hand, traditional medicine, while largely filling the vacuum of shortage and insufficient outreach of western medicine to the general population, has the advantage of proximity to the people. Also, the practitioners approach the people with warmth, consideration, and sympathy that is often lacking in hospital staff. The traditional practitioners not only treat and counsel using therapeutic practices that are consonant with the cultural practices of the people, but also speak with authority using the dialect and idiom of the people. Thus, to the people, traditional medicine fulfills the four criteria of accessibility, availability, acceptability, and dependability. THE BALANCE SHEET - COLLABORATION OR CONFRONTATION?
This discussion makes a strong case for collaboration between western and traditional medicine in Africa, In arriving at this conclusion, two important facts have had to be borne in mind. The pace of modern development is producing varying traumatic effects in the lives and behaviour of people. Psychosomatic illness and other psychological and social maladjustments are becoming as important as communicable diseases while malignant, cardiovascular, and degenerative illnesses will become major problems. This shift in the pattern of illness has not necessarily been matched by any degree of success in finding remedial action. In fact the inability to "cure" these "modern" illnesses as dramatically as curing yaws with penicillin has only gone to increase the frustrations and anxieties of the people, thus pushing them to seek other forms of health care. Resorting to
Tropical Doctor, July HJ7f!
traditional medicine is therefore liable to increase rather than decrease. Another important factor that deserves mention is that many therapeutic practices and methods as well as drugs used by traditional healers have hardly been subjected to much objective analysis. The practice itself is carried out with much secrecy and mysticism and "success" is often difficult to evaluate. The traditional healers no doubt developed that attitude in order to protect their art. However, it is not the scientific justification of its efficacy that counts so much as the fact that the people have strong belief and faith in it, again a strong psychological factor. Ademuwagun (1969) strongly argued the case for collaboration between western and traditional medicine saying, that "the physician and native doctor must respect the knowledge, skill, and competence of each other and function in partnership that reflects division of labour, specialization, and unity of purpose aimed at improving the health attitudes and behaviour of the people...." Already traditional birth attendants are in some countries being assimilated into the peripheral delivery services after a period of training directed towards the practice of asepsis, hygiene, and the recognition of problem cases. Collaboration between traditional and western medicine will take different forms in different countries depending on the outlook of the political authorities and health administrators. Such collaboration should involve several aspects: I. Studies of the drugs and techniques of the traditional health practitioners. 2. Involvement of traditional health practitioners in some community research. 3. Increasing the community health role of the traditional healers in their various areas through ensuring their effective participation in the village health planning and development committees. 4. Involving traditional health practitioners in health education of the community. This can be a very important function if they are adequately trained for it. 5. It has been suggested that some traditional health practitioners could, given the necessary orientation and tools, be used to deliver basic health care to the people of the villages where they live as an extension of their own normal duties as traditional healers. Some form of remuneration could be arranged for them for undertaking these traditional duties and they could be supervised by the local medical officer. In this respect their duties
TRADITIONAL AND WESTERN MEDICINE IN AFRICA
I 135
will bear close resemblance to the Chinese "barefoot doctor". The implementation of this suggestion is probably not so simple and may even be found thoroughly unacceptable to many health administrators who may be unwilling to advocate the use of such "untrained" persons in health care even in situations where the people would otherwise be without any form of health care and where no alternative scheme is contemplated. The particular message carried in these suggestions is for different countries to formulate comprehensive health plans suitable to their own political and social systems. In formulating these plans, however, it would appear inadmissible and an under-utilization of available manpower to ignore or even suppress such an influential body of persons as the traditional health practitioners especially when the trend in Africa today is to increase popular participation in health. Who are more suitable to further this popular participation in health than the traditional health practitioners whose influence in the community is already so great? CONCLUSION
Lambo (1971) described medicine as a powerful instrument of change whose aims, objectives, and felt needs were different in different societies. "There is great need for developing alternative patterns (of providing) health care and experiments can be cautiously tried which may result in valuable innovations," he concluded. It will be important to consider the inclusion of traditional health practitioners in the health team thus encouraging collaboration rather than confrontation between traditional and western medicine.
REFERENCES
Ademuwagun, Z. A. (1969). Publ. Hlth Rep. (Wash.), 84, 1085. Conco, W. Z. (1970). An Analysis of the Traditional Beliefs of the South African Bantu and their Relation to Health and Disease. Dissertation for DTPH at the London School of Hygiene and Tropical Medicine, University of London. Lambo, T. A. (1971). WHO Chron., 25, 343. Maclean, U. (1971). Magical Medicine: A Nigerian Case Study. London: Lane. Morley, D. C. (1973). Paediatric Priorities in Developing Countries. London: Butterworth. Nchinda, T. C. (1974). Tropical Doctor, 4, 41. Paul, B. D. (Ed.) (1966). Health, Culture and Community. New York: Russell Sage Foundation. Read, M. H. (1966). Culture, Health and Disease. London: Tavistock Publications.
Traditional and western medicine in Africa: collaboration or confrontation? T. C. Nchinda, MD(London), DTPH, MFCM Formerly Deputy Director of Public Health, Ministry of Health, Yaounde, Cameroon TROPICAL DOCTOR,
1976,6, 133-135
There is a great deal of misapprehension and doubt prevailing in the minds of many people of western orientation regarding the ability of traditional health practitioners in developing countries to diagnose and, indeed, treat diseases. Even the general term of "witch-doctor" given to them is now as outmoded as it is inappropriate in describing practitioners of an ancient art whose skill in handling certain types of medical problems is unsurpassed by western trained doctors. Over the years these traditional health practitioners have provided and are still providing primary health care to large sections of the community. Their clients include the educated and the uneducated alike; the availability of hospitals and health centres and clinics has not hindered use of traditional health treatment. In fact many people are perfectly happy commuting freely between traditional and western treatments. In the light of this seemingly conflicting situation what should be the attitude of members of the medical profession who have obtained scientific training? Should traditional medicine be eliminated by legislation or otherwise? Should it be assimilated and integrated into western medicine or should it be treated with indifference? In other words, should there be collaboration or confrontation between traditional and western medicine? The health situation Africa is too large a continent with differing peoples, cultures, governments, and economic potentials to perrnit anything but broad generalizations to be made about the health services in the different countries. From 1961 to 1970 the countries of the African Region of the World Health Organization allocated an average of 8.6% of their national budgets (in some countries this was as high as 15%) for health. In Cameroon, the health budget in 1972/73 was about 9.5% of the national budget excluding the health components of the budgets of other ministerial departments such as those dealing with community
TRADITIONAL AND WESTERN MEDICINE IN AFRICA
I 133
water supplies, housing, occupational health, agriculture, and veterinary health services. These countries spend an average of USSI.20 per year per inhabitant for health while the United States spends USS242 per inhabitant. The health services in Africa are quantitatively and qualitatively insufficient and maldistributed between the small urban and the large rural population. The problem of providing adequate and comprehensive health services to cover the predominantly rural population in Africa is engaging the full attention of the health administrators in many countries. This is not made any easier by the low economic resources and adverse environmental conditions in some of these countries. Culture and illness People's reactions to illness are linked to a large number of factors one of which is their social and cultural behaviour. Paul (1966) showed in his classic collection of studies that lack of knowledge of the traditional health beliefs of people can be disastrous to health programmes. Many a western-trained doctor has been baffled by the lack of response and apparent stubbornness on the part of some patients to followan otherwise scientifically sound treatment regime. In such cases, the treatment has apparently ignored or gone against the traditional and cultural beliefs of the people. Of course these beliefs are modified by several factors including education, availability of medical care, its success in the treatment of various diseases, the cost and convenience of the service, and the attitude of the personnel. A previous publication (Nchinda 1974) described the integrated pluriprofessional training of health personnel in Cameroon. This concept is now being tried in various ways in the medical schools and in the newer University Centres for Health Sciences in West and Central as well as East Mrica. This training is much better adapted to the health situation in the various countries. This training also lays muchneeded emphasis on preventive and community medicine as well as on the social sciences. TRADITIONAL MEDICINE
Man from the beginning has always had a method of coping with sickness and disease in his community. In spite of all the advances in scientific medicine, the traditional forms of cure have persisted. In the western world, education and increased scientific understanding among the people have contributed to the virtual disappearance offolk medicine although vestiges of this are now appearing in various disguises - faith healing, exorcism, etc. In the develop-
134
I TRADITIONAL AND WESTERN MEDICINE IN AFRICA
ing countries traditional medicine still holds sway and its popularity is undisputed. TRADITIONAL HEALTH PRACTITIONERS
Various types of traditional health practitioners have been described (Read 1966; Ademuwagun 1969; Conco 1970; and Maclean 1971). They fall into the broad groups ofsurgeons, herbalists, and psychiatrists (also called diviners). They all share one characteristic in common which is that they function within the psychological framework of their clients' beliefs, cultures, and expectations. Their clients in turn have faith in the healers because of the healers' traditional authenticity and cultural identification. There is thus mutual trust, confidence, and complete rapport between practitioner and patient. Though lacking in scientific clarity such as characterizes western medical educational systems, the traditional health practitioners have been able to acquire and display extraordinary qualities of mind and to possess remarkable technical skills which enables them to perform their ancient art with as much determination, professionalism, sympathy, and tact as any western-trained doctor. The extent to which people consult traditional health practitioners varies in the different countries of Africa. Maclean (1971) reported that 30% of people in Johannesburg consulted traditional doctors often concurrently with western doctors. Lambo (1971) said that in 1950, 60% of the patient population in a large general hospital in Nigeria had received some traditional treatment. The writer found, in a recent study in Cameroon, that about 20% of sick people in the study area went for traditional treatment either alone or in combination with other forms of treatment. The role of the level of education of the client appears very complex. Morley (1973) reports the case of a reputable surgeon who went to a traditional healer to treat his jaundice. The writer also knows a well-educated and highly placed person who had hemiplegia following a stroke and, after initial treatment by two reputable physicians abandoned the recommended physiotherapy and instead ended up in a traditional practitioner's clinic! People will thus make their own decision firmly about what to do about their illness with the help of or in spite of medical advice. Lambo (1971) attempted to offer an explanation for this by saying that "it would seem that in a conflict situation, the newly acquired and highly differentiated social values, attitudes, and ideologies are more susceptible to damage leaving basic traditional beliefs and moral philosophy functionally overactive."
Tropical Doctor, July I976 THE DILEMMA
The health administrators in Africa find themselves in a dilemma. They are committed to the provision of comprehensive health services to the people in the apparent conflict situation arising from the coexistence of traditional and western medicine. Also, severe financial restraints preclude unlimited increase of the health budget and call for more careful and judicious planning. On the one hand, the effects of western medicine are manifest in the field of communicable disease control, improved maternal and child health services, and effective treatment for many acute diseases. The people flock to the overcrowded out-patients departments of hospitals in ever-increasing numbers, even though the complexity and relative impersonality of these medical institutions, their rigidity and lack of adaptability, induce in their users a feeling of helplessness which, in some cases, almost borders on alienation. On the other hand, traditional medicine, while largely filling the vacuum of shortage and insufficient outreach of western medicine to the general population, has the advantage of proximity to the people. Also, the practitioners approach the people with warmth, consideration, and sympathy that is often lacking in hospital staff. The traditional practitioners not only treat and counsel using therapeutic practices that are consonant with the cultural practices of the people, but also speak with authority using the dialect and idiom of the people. Thus, to the people, traditional medicine fulfills the four criteria of accessibility, availability, acceptability, and dependability. THE BALANCE SHEET - COLLABORATION OR CONFRONTATION?
This discussion makes a strong case for collaboration between western and traditional medicine in Africa, In arriving at this conclusion, two important facts have had to be borne in mind. The pace of modern development is producing varying traumatic effects in the lives and behaviour of people. Psychosomatic illness and other psychological and social maladjustments are becoming as important as communicable diseases while malignant, cardiovascular, and degenerative illnesses will become major problems. This shift in the pattern of illness has not necessarily been matched by any degree of success in finding remedial action. In fact the inability to "cure" these "modern" illnesses as dramatically as curing yaws with penicillin has only gone to increase the frustrations and anxieties of the people, thus pushing them to seek other forms of health care. Resorting to
Tropical Doctor, July HJ7f!
traditional medicine is therefore liable to increase rather than decrease. Another important factor that deserves mention is that many therapeutic practices and methods as well as drugs used by traditional healers have hardly been subjected to much objective analysis. The practice itself is carried out with much secrecy and mysticism and "success" is often difficult to evaluate. The traditional healers no doubt developed that attitude in order to protect their art. However, it is not the scientific justification of its efficacy that counts so much as the fact that the people have strong belief and faith in it, again a strong psychological factor. Ademuwagun (1969) strongly argued the case for collaboration between western and traditional medicine saying, that "the physician and native doctor must respect the knowledge, skill, and competence of each other and function in partnership that reflects division of labour, specialization, and unity of purpose aimed at improving the health attitudes and behaviour of the people...." Already traditional birth attendants are in some countries being assimilated into the peripheral delivery services after a period of training directed towards the practice of asepsis, hygiene, and the recognition of problem cases. Collaboration between traditional and western medicine will take different forms in different countries depending on the outlook of the political authorities and health administrators. Such collaboration should involve several aspects: I. Studies of the drugs and techniques of the traditional health practitioners. 2. Involvement of traditional health practitioners in some community research. 3. Increasing the community health role of the traditional healers in their various areas through ensuring their effective participation in the village health planning and development committees. 4. Involving traditional health practitioners in health education of the community. This can be a very important function if they are adequately trained for it. 5. It has been suggested that some traditional health practitioners could, given the necessary orientation and tools, be used to deliver basic health care to the people of the villages where they live as an extension of their own normal duties as traditional healers. Some form of remuneration could be arranged for them for undertaking these traditional duties and they could be supervised by the local medical officer. In this respect their duties
TRADITIONAL AND WESTERN MEDICINE IN AFRICA
I 135
will bear close resemblance to the Chinese "barefoot doctor". The implementation of this suggestion is probably not so simple and may even be found thoroughly unacceptable to many health administrators who may be unwilling to advocate the use of such "untrained" persons in health care even in situations where the people would otherwise be without any form of health care and where no alternative scheme is contemplated. The particular message carried in these suggestions is for different countries to formulate comprehensive health plans suitable to their own political and social systems. In formulating these plans, however, it would appear inadmissible and an under-utilization of available manpower to ignore or even suppress such an influential body of persons as the traditional health practitioners especially when the trend in Africa today is to increase popular participation in health. Who are more suitable to further this popular participation in health than the traditional health practitioners whose influence in the community is already so great? CONCLUSION
Lambo (1971) described medicine as a powerful instrument of change whose aims, objectives, and felt needs were different in different societies. "There is great need for developing alternative patterns (of providing) health care and experiments can be cautiously tried which may result in valuable innovations," he concluded. It will be important to consider the inclusion of traditional health practitioners in the health team thus encouraging collaboration rather than confrontation between traditional and western medicine.
REFERENCES
Ademuwagun, Z. A. (1969). Publ. Hlth Rep. (Wash.), 84, 1085. Conco, W. Z. (1970). An Analysis of the Traditional Beliefs of the South African Bantu and their Relation to Health and Disease. Dissertation for DTPH at the London School of Hygiene and Tropical Medicine, University of London. Lambo, T. A. (1971). WHO Chron., 25, 343. Maclean, U. (1971). Magical Medicine: A Nigerian Case Study. London: Lane. Morley, D. C. (1973). Paediatric Priorities in Developing Countries. London: Butterworth. Nchinda, T. C. (1974). Tropical Doctor, 4, 41. Paul, B. D. (Ed.) (1966). Health, Culture and Community. New York: Russell Sage Foundation. Read, M. H. (1966). Culture, Health and Disease. London: Tavistock Publications.
