SW

Scr 6

Mrd..

Vol.

11. pp.

705 to 713. Pergamon

Press

1977. Printed

in Great Britain.

TRADITIONAL MEDICINE: AN AGENDA FOR MEDICAL GEOGRAPHY CHARLESM. GOOD Department of Geography, Virginia Polytechnic Institute and State University, Blacksburg, Virginia Abstract-Traditional medical systems coexist and complement Western scientific or “modem” medicine throughout Africa, Asia and Latin America. At least 2.3 billion people, or 56% of the world’s population, continue to rely upon traditional practitioners and healing techniques for treatment af a wide variety of physical and mental illnesses. The persistence of traditional medicine may be attributed largely to its consumer orientation and reputation for being accessible, available, acceptable, and dependable. Modem medical services reach only a fraction of the population in most Third *orld countries. T’hey are likely to continue to provide only a small part of the total available hgth care for the foreseeable future. Recently, the World Health Organization and some individual govemments, health professionals, and social scientists have drawn attention to the vast manpower resoun$es of traditional medicine. Collaboration with or integration of traditional practitioners may be a m-s of expanding primary care in the modern health sector. Yet lack of information is the greatest initial barrier to assessing the feasibility of such proposals in relationship to national health goals and ihealth planning. Although there are a number of sophisticated studies of traditional medical system& even the most primitive geographic questions about the organization and behavioral patterns of traditional medicine have not been asked. It is proposed that medical geographers recognize traditional medicine as a majoc and immediate problem area for basic and applied research. The rationale for geographic study is explained and essential lines of inquiry are suggested

INTRODUCllON

Medical geographers have only recently discovered that locational analysis of health care processes and health services planning is a logical and essential complement to their time-honored ecological approach to disease distribution. Works by Shannon and Dever [l], Pyle [2], and de Vise [3] exemplify contributions in this area. Smith’s new monograph [4] and numerous other studies [S, 63 are also repre sentative of an expanding concern with problems of health services organization, delivery, and utilization. However, to date most geographic studies have focused on technologically advanced countries, particularly the United States [7-lo], Sweden [ll], and the Soviet Union [12]. Analyses of problems of the modem health care sector in Third World countries are rare [13-151, and geographical and policyoriented investigations of traditional or indigenous medical systems in Africa, Asia and Latin America are practically non-existent. In this paper I propose that traditional medicine be recognized as a major field for basic and applied research in medical geography. I review the nature and functional setting of traditional medicine today, including its relationship to Western or “modem” scientific medicine; describe important aspects of alternative health system policies; explain a rationaIe for involving medical geographers in this field; and suggest possible lines of geographic research. The regional setting is the Third World in general and Africa in particular. PLURAL SY!STEMS OF MEDICINE

Modern scientific medicine is generally

Western in orientation,

naturalistic

viewed as in approach, and

positivistic in methodology [la]. In most Third World countries today the modern (official) health services reach only a fraction of the population, and there is growing recognition that they represent a rather small and unimportant element of the total awihble health care [17J. T&is pattern is likely to persist into the foreseeable fqture, regardless of incremental expansion of modesn health facilities and professional staff, and despip a massive endemic burden of illnear Well-known reasons for this discrepancy between the availability of vs the potential demand for modern health services include physical inacoessibiity, because facilitiizs are few in number and unevenly distributed relative to existing transportation [18]; clustering of heal* services and professionals in larger urban centemat the expense of rural areas [17,19,20] ; inadequate financial resources and administrative systems [21, 221; and the appropriately termed phenomenon of %ultural distance”. The latter appears where the orgrinization, practitioners, and procedures of modem &dicine are selectively but fundamentally at variance with customary beliefs (including concepts of disea#$ values, symbols of commuhication, and behavior patterns of the local populations In other words, even where modem scientific health services are plbysically present, social and cultural factors may prevbt their use for many illnesses. A study of Cali, Colombia, for example, found that although the doctor-to-population ratio is 1:910, 17% of children who die are not seen by a physician, and another 19% recieve no medical attention during the two days before death [ln. Whether the lack of modern health services is real or perceived, a very large pmoportion of people in rural and urban areas of hrica, Asia, and Latin America rely upon traditiorial[mdigenous medical practitioners for primary care. Traditional medicine,

705

706

CHARLES

although nonscientific in the Western biomedical view, is logical (internally consistent), valid, and relevant in its own behavioral settings. Utilization of traditional medicine is deeply rooted in the beliefs, values, social organization, and customary behavior patterns of the practicing communities [23]. Providers and users are interconnected through the shared “psychological reality” of culture [24]. Traditional concepts of disease causation range from magical-supernatural and supernatural-natural to physical-empirical [23, 25, 261. Practitioners available to a particular community typically include herbalists, diagnosticians (diviners), spiritualists, surgeons, midwives, bonesetters and others. Functional overlap of specializations is not uncommon. Forms of treatment in different areas, often employed concurrently, include medicinal (plants and patent medicines), dietetic, physiotherapentic, psychotherapentic, physical (e.g. acupuncture, suture, splinting), operative (e.g. removal of cataracts and uvula, circumcision, craniotomy), and magicoreligious [25,27-J Types of traditional medical systems range from the ancient, highly organized, and codified Ayurvedic, Siddha (both Indian), Unani-Tibbi (essentially Moslem) and indigenous Chinese systems of medicine generally associated with literate societies, to the somewhat less sophisticated systems of healing indigenous to nonliterate peoples of tropical Africa and the Americas. Great variation in organizational complexity and conceptual development is thus characteristic of traditional medicine in the Third World, even within a region such as East Africa. The Luo of Western Kenya, for example, were quite advanced in comparison to many other local societies. They had a knowledge of anatomy; conducted post-mortem examinations; developed many effective, non-supematural treatments; could “correctly” describe at least 19 diseases; and were able to distinguish primary from secondary syphilis [273. The traditional and modem labels represent a medical spectrum which embodies many levels of knowledge and skills, types of role adaptation, and degrees of legitimacy. Marginal, self-styled “fringe” practitioners are also a factor within this framework. Wielding hypodermic needles, antibiotics, and stethoscopes, they manipulate ‘popular sentiments and beliefs flowing from traditional medicine and modem medicine” [28]. Capacity for borrowing and change varies from one system to another and some, such as Malaysian Chinese medicine, are both modem.and traditional. In essence, then, the term “traditional” does not imply a lack of change, and “modem” does not imply an absence of tradition [29, 303. Today, traditional medicine coexists with, complements, and competes against Western scientific medicine throughout most of the Third World; and it is by no means moribund in many communities in the United States [31]. In Africa, traditional medicine enjoys undisputed popularity and is paramount over extensive areas. This is hardly surprising for a continent which has, according to the World Health Organization, the “lowest recorded (modem) medical density on the globe” [32]. In Kenya, for example, a recent study estimates that overall only 15% of local women deliver under modem medical supervision, while in Ethiopia more than 85% of the population

M. Goon is beyond the reach of modem health services [33, 34-J. Moreover, reliance upon traditional medicine should not be dismissed as an essentially rural phenomenon which is likely to soon disppear under pressure of modernization. In post-colonial Zaire, for example, thousands of traditional and self-styled practitioners have migrated from the countryside into burgeoning cities such as Kinshasha, where their number is currently estimated to exceed 10,000 [35]. Whereas scientific medicine, largely through the official health services, continues to demonstrate its strength in communicable disease control, improved maternal and child health, and treatment of many acute diseases, traditional medicine survives because it “fills the vacuum of shortage and insufficient outreach of western medicine to the general population” [21]. It also has the advantage of cultural, psychological, and physical proximity to the people. Predictably, however, official health services in the underdeveloped countries have generally “been reluctant to recognize and evaluate the contribution traditional healers are making to the physical, and particularly the psychological, welfare of populations and have tended to disparage rather than cooperate with the traditional systems” [36]. Today, it is increasingly difficult for practitioners in the Western, technologically more powerful medical system (Landy’s “culture of reference”) to continue to disregard their counterparts in the adaptive, successful, and often innovative traditional system (“culture of orientation”) [37]. Along with traditional medicine’s strong appeal in rural and peasant communities, urbanization and accompanying social change are creating new opportunities for a wide variety of practitioners to flourish. As already noted, growing numbers also incorporate and elaborate Western medical elements. One of the most powerful arguments for dialog and cooperation is simply the fact that a large proportion of people who seek medical treatment commute freely between the two systems according to their expectation of a cure. Indeed in Zaire both the Western and traditional African systems of healing “pervade all parts of society;” and in great contrast to most African countries, “both have received the sound legitimation of contemporary political authorities” [38]. To deny the existence, legitimacy and social utility of plural therapeutic systems is to diminish the potential for understanding and influencing the health status of a community. Consequently, the scientifically-based government health services in many underdeveloped countries face a professional dilemma: should there be collaboration or confrontation with traditional medicine [21]? A RATIONALE

FOR

GEOGRAPHIC

RESEARCH

A categorical answer to the collaboration issue is unwise because of the great diversity of traditional medical systems and the varied political and social settings in which they function. In few, if any, countries is there enough systematic information about the providers, consumers, and organization of traditional medicine to permit informed discussion of alternatives and the potential consequences of policy decisions. Although there are excellent and useful studies of tra-

Traditional medicine: an agenda for medical geography ditional/ethno-medicine contributed by anthropologists C39-433, medical sociologists [44], public health specialists and physicians [25, 28, 29, 45-483, historians [49] and others, little cognitive awareness of the geographic features of medical systems or the spatial processes underlying them is evident in these works. Here, then, is an extremely critical niche for basic and applied research in medical geography which has been almost totally overlooked. The geography of traditional medicine focuses attention upon a major realm of human existence which is closely interwoven with the culture and quality of life in Third World societies at every scale and social tier, in both rural and urban milieux. In this regard medical geographers are challenged by a formidable, but fascinating, three-part research agenda. First, there is an opportunity to make valuable contributions, as specialists in other fields have done, to humanistic and scientific understanding of traditional health-related institutions, behavior and medical landscapes. Second, even the most primitive geographic questions about the organization of traditional medicine have not been asked in otherwise sophisticated studies. The need to collect, describe, analyze, and interpret basic locational information is a high priority task which requires extensive fieldwork and participant-observation in the very best social science tradition. Third, medical geographers can lend vital practical assistance to health planners and policy-makers in Third World countries by providing a sound base of information about all types of health resources, including traditional medical practitioners, which might be mobilized to expand and improve the costly but meager health services offered by the modern sector. This question of the policy reletmce of traditional medicine in comprehensive health planning is a crucial one for medical geographers interested in human development, and it is one that has recently begun to attract official attention within the international health community. AN EXPANDED ROLE FOR TRADITIONAL MEDICAL PRACTITIONERS?

Medical geographers need to be fully aware of several issues which impinge directly on any consideration of a possible innovative, increased role for contemporary traditional medicine. In the order of their brief discussion below, these are (1) assessments of need; (2) elements of conflict between plural medical systems; (3) the strength of traditional medicine; and (4) the arguments of advocates for and against an expanded role. In African countries few problems of national significance warrant as much immediate attention as the sensitive reciprocal relationships among characteristically high (or unusually low) population growth rates, massive health care needs, and plural medical systems. This observation also applies to many Asian and Latin American nations. The urgency and scope of this problem has recently drawn the World Health Organization’s attention to the role of traditional healers. A special W.H.O. memorandum, “Health Manpower Development-Training and Utilization of Traditional Healers and Their Collaboration with Health Care Delivery Systems”, emphasizes that these

707

practitioners form the basic core of primary health manpower for roughly 90% of rural populations in the Third World Given the appropriate orientation, training, and tools, this substantial reserve of unorthodox medical personnel could be tapped to bring improved primary care to millions of people [36]. Noting the dearth of systematic information on healers and healing practices (and I would add to this the forms and patterns of traditional illness behavior), the W.H.O. document proposed further activity with the following objectives [36]: (1) To collect all available data on traditional healers and indigenous systems of medicine-the results of survey and research findings, of studies of traditional practices, and of training programs for traditional healers and indigenous practitioners. (2) To analyze the available information in order to determine the relevance of traditional healing to the primary health care needs of the various populations (3) To study, in the field, existing systems of traditional or indigenous medicine in each region. (4) To suggest the main directions for action with special regard to the training and utilization of traditional healers in the health system. (5) To make suggestions for further action in this field by: (a) Member States, and (b) the W.H.O. Secretariat. The W.H.O. also recommends that interested Member States consider: (1) adjusting existing information systems and national health reports in order to include data on the services of traditional healers and indigenous medical systems; and (2) supporting research with the aim of improving the services of traditional healers. Examples include studies of the pharmacological and other properties of herbal medicines; production of and clir$zal experiments with therapeutic substances; and so&-anthropological studies of cultural factors relating to health and disease. Despite expanding interest in the potentialities of cooperation between traditional and modem practitioners, inertia, misunderstand@, and lack of objective analysis continue to hinder feasibility studies. With regard to Africa, in particular, arguments against the formal recognition and integration of traditional healers usually focus on their alleged quackery, superstitious beliefs, mysticism, and secrecy. The procedures and success of traditional therapies are frequently ‘difiicult to evaluate in terms of the orthodox criteria of Western scient@c medicine, and are often considered highly suspect at best Further compounding the problem is the s@ong persistence of the “witchdoctor” caricature and s&ilar stereotypes concerning the role of spirits, witchcraft, black magic, the evil eye, taboos, and ancestors. Western observers also frequently assume, incorrectly, that African concepts of disease etiology and well-being are dependent upon magical and supernatural phenomena and exclude ideas of natural or physical causation. On the other hand, scientific medicine also lmderestimates the importance and power of witchcraft, magic, and superstition in sickness and health. It thereby tends to overlook and misinterpret sociointerpersonal factors as well as the tentral concept which underpins the practice of tradi-

708

CBAWS M. GC~JD

tional medicine; namely, that “the state of the and the state of the body reflect each other” As the psychiatrists Swift and Asumi point out, Kato, those who say that witches and witchcraft exist

mind [SO]. citing don’t

“confuse the language of one area with the facts of another. For those who believe in it, witchcraft does exist. One can draw the analogy of belief in God. For the atheist God does not exist; but for the believer God does exist as a powerful force” [So].

A recent review of traditional medical beliefs in East Africa concludes that professional recognition of indigenous practitioners would “undercut much of the painstaking progress made by Western medicine” [27]. Numerous speci6c examples of traditional prao tices which yield negative consequences for health could be marshalled to support this position [25l. Nevertheless, there is far greater evidence that, on balance, traditional medicine continues to perform, as it has for centuries, more of a positive than a negative function. What other explanation could account for its present vitality and strong syncretic adaptability, and the fact that “traditional healers are widely patronized by literates” [Sl, 52]? Moreover, increasing numbers of Western-trained African health administrators and medical practitioners stress the positive contributions of traditional medicine to health and social wellbeing. Traditional healers, argues N&it&, “acquire and display extraordinary qualities of mind and... 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” [21]. Furthermore, they approach their clients with consideration, warmth, and sympathy, qualities which are often scarce in hospital staff. Indeed, although everincreasing numbers of people continue to swell the already overcrowded out-patient departments of African hospitals, it is not without cost. Nchinda suggests that the complexity, relative impersonality, rigidity, and inflexibility of these modern medical institutions induces a sense of helplessness in their users which, in some cases, borders on alienation [21]. Nigerian health educator Z. A. Ademuwagun reinforces these views. He recommends using traditional healers and midwives in public health programs because they: (1) can help fill the vacuum in health care created by manpower shortages and the high cost of training modem health workers; (2) possess skills in dispensing curative, preventive, and rehabilitative care; (3) use. an astute approach to human ecology and health; (4) belong to the same culture as their patients, sharing common beliefs, values and symbols of communication; (5) are effective in some aspects of psychosomatic medicine (e.g. lack of conception) and in the use of plant medicines for syrnptomatic treatment; (6) are not hindered by inadequate transportation in rural areas; and (7) have skills in interpersonal relations, including the ability to counsel with sympathy, identification, and concern and to establish trust and complete rapport with the patient c531. Ademuwagun also notes that even among orthodox health practitioners there is no doubt that traditional healers and midwives will be performing their func-

tions well into the future. They “cannot be dismissed with a wave of the hand” and are “a potential force to reckon with.. . in regard to what they can do and undo to affect modem health care positively or adversely” [54]. What is now needed, he argues, . . . is research to provide specific data necessary for developing specific operational action projects in selected areas for harmonizing the health-care services of traditional healers/midwives and orthodox medical practitioners. To start acting in this way is to face the reality of the situation instead of continually engaging in make-believe, falling prey to false parochial pride, and aping the proverbial ostrich in our attitude toward the traditional healer/midwife. In the interest of health consumers specific areas of cooperation between the traditional healer/midwife and the orthodox practitioners are crucial; this is apart from the need for this cooperation in regard to the problem of shortage of qualii!ed orthodox personnel” [54].

HEALTH CARE ALTERNATIVES AND PUBLIC POLICY

Third World health officials who wish to formulate policies to rationalize the linkages between their countries’ traditional and modem health care systems have at least two operational large-scale models and a number of smaller experiments from which to learn. China’s “barefoot doctors’* are among the best known and most innovative examples of collaboration between traditional and modem medicine. Estimated at a ratio of 1:800 persons in 1972, they provide “the final link between the peasants and the medical services, under close supervision of mobile medical teams” [55, 561. By integrating traditional practitioners such as herbalists and acupuncturists with doctors and nurses trained in Western medicine, China has realized remarkable advances in infectious disease control, nutritional standards, and in the distribution of maternal and child-health (MCH) and family planning services. “Barefoot doctors” have been accorded substantial credit for China’s reported success in reducing fertility [57, 58-j. Investigations in India discovered that government health services are used by only lO-20% of the rural population. Recent studies also confirm the feasibility of integrating indigenous healers into the Indian government health system, particularly within the family planning network. In the Johns Hopkins University Rural Health Research Functional Analysis Study, Neumann and Bhatia found in the Punjab that the majority of Indian practitioners of ayuruedic and ununi medicine (desi system) favor family planning, are willing or anxious to cooperate with government health personnel, already provide family planning counseling, perform abortions, and are willing to use modem (allopathic) methods and drugs [59]. Certain Indian states already operate a dual medical system with provision for Ayurvedic dispensaries, clinics, and hospitals, while others provide completely integrated services by Ayurvedic practitioners and certified doctors with university degrees in modem medicine [36]. In Africa, there are relatively few examples of either the formal recognition or use of traditional healers in modem health services. Dunlop’s analysis of government policy toward traditional practitioners in

Traditional medicine: an agenda for medical geography nine African countries for which some limited information exists indicates that five (Ghana, Mali, Nigeria, Zaire and Botswana) have or are considering a form of legalization-mainly licensing of herbalists and other practitioners. None are adopting an illegalization strategy. All of the countries (including Liberia,

Ethiopia, Uganda and Tanzania) provide a degree of “informal tacit recognition” of the traditional systems, such as through personnel training (three), research (two), and acknowledge that “complementary services” are provided (nine). Six countries have “informal communication linkage” between personnel in the traditional and modern sectors “leading to mutual respect and referrals” [60]. One of the better known local African experiments is in Western Nigeria, where traditional Yoruba healers (babalawo) are used as psychiatric diagnosticians and aides by the Nigerian psychiatrist T. A. Lambo and associates in the Aro neuropsychiatric hospital settlement at Abeokuta [45, 613. ln Ghana, official recognition of traditional medicine occurred in 1962 with the inauguration of the “Ghana Psychic and Traditional Healers Association” at Larteh. This has since become a nationwide organization of herbalists, diagnostician-therapists, and midwives. In 1973, the Ghana Government established the Centre for Scientific Research into Plant Medicine (C.S.R.P.M.) at Mampong-Akwapim under the direction of Dr. Oku Ampofo, the first Ghanaian to graduate (in 1940) from a British medical school [52, 621. Today, the C.S.R.P.M. serves both as a research center, collaborating with traditional herbalists and several research departments of the University of Ghana at Legon and Kumasi, and a clinic. Patients come three times a week, about 25 of them at a time, which makes more than 3500 consultations a year. In 1974, the Centre treated with a high percentage of success 52 cases of asthma, 124 cases of rheumatism, 111 cases of piles, 84 cases of gastritis 31 anemia cases, 25 skin infection cases, 6 cases of peptic ulcer. In addition, patients

who were suffering from malaria, idiopathic epilepsy, infer tious hepatitis, and early cases of prostatic hypertrophy were also treated [62]. The Ghana Government also envisages another paramedical function for traditional practitioners. Under the National Family Planning Program for 1973-1978, one of the operational targets is to recruit and train traditional birth attendants to provide health and family-planning services at the village level [63]. Other experiments designed to improve health which involve traditional medicine include the Danfa Project in southern Ghana [64,65], the rural health project in Ibarapa in Nigeria health care villages in Senegal

[54], and the mental [66].

AN AGENDA FOR MEDICAL GEOGRAPHY

Whether the subject is disease ecology or the provision of medical care, the approach of medical geography is systems-oriented, strongly synthesizing, and holistic-embracing the diverse social, cultural, economic, physical, and biological elements of environment [67]. It bridges the social sciences, humanities, and natural sciences by focusing on the spatial organization of health-related human behav-

709

ior, the processes and resulting patterns of man-environment interrelations, and the implications of man’s actions-including their past and present survival value. In practical terms, “medical geography adds strength to the locational aspects of all kinds of health planning, particularly in relation to location of resources, service areas, and community assessment”

cw

Basic and applied research on traditional medicine are needed: the two are interdependent. Indigenous and foreign medical geographers are both in positions to contribute to scientific and humanistic understanding of traditional medicine’s role in society and health. As previously noted, the classical geographic “what, where, when, how and why” questions have not been asked of traditional medicine. There is an initial need for quantitative, mappable information about the numbers, types, and locational attributes of traditional practitioners Little is known about the effects of relative location, distance, and environmental perception on the accessibility and use of traditional and/or modern health services, and on morbidity. Apparently, in mauy traditional medical systems the practitioner-to-population ratios compare favorably with, and in some cases even surpass, levels typical of the most technologically advanced societies (Table 1). And there is the intriguing suggestion of rather consistently proportional regional ratios of healers to people. To date, however, evidence of the density, pattern, or dispersion of traditional medical services is scanty. The available literature suggests that patrons of traditional medicine have the geographic advantage, rarely found where modem medicine predominates, of relatively continuous access to their traditional practitioners. N&in& provides strong support for this view. He asserts that traditional medicine survives because it satisfies four essential users’ criteria: “accessibility, availability, acceptability, and dependability” [21],. With basic locational information about traditional practitioners on hand it will be possible to analyze and interpret how the interaction of providers and consumers of traditional med&ine is organized as a geographic and social system. The elements will include centers of activity, probably arranged as a hierarchy; flows of people connecting them within social place-to-place varinetworks; “surfaces”, r&ctirig ations in the intensity of medically-related transactions; peripheral locations; &rd the territorial zones in which illness-related behavior occurs in definable patterns. Medical geographers need to consider how and why the patterns of tr~dido~l medical organization differ from one society and locale to another, and what implications those variations may have for human health. Evidence of ‘important distinctions between rural and urban-based traditional medicine is emerging. As towns swell w@h people, the changing social conditions of modern urban life produce a less integrated society in terms of family and kin-group relations. Swantz’s study of urban social change in Dar-es-Salaam, for example, shows that the traditional Zar~mo medicine man i(mgu.nga) has preserved his role in urban society by skillfully adapting to the changing, more individualistic and less ethnicoriented social conditions of his clientele. lndeed, he argues persuasively that the triaditional mgunga is the

CHARLESM. GOOD

710

Table 1. Traditional medical practitioners (TMPs) as health manpower No. of

TMPS GHANA:

Techimaa

Ratio TMPs (0 populstioll

63

I:843

263

I:137

Local Authority [69] GHANA: Dnnla Project [65]

I:532

NIGERIA: Ibadan [45]

TANZANIA: Dar es .w@am [44]

700+

CHINA

(People’s Republic) 1563

1:357-I:454

I:800 I : 1450

WEST

MALAYSIA

LiccttredTMPs only. Est. number 126. or 1:421. Re&ered traditional birth attendants only (48% ma*) in total wtndation of 36.138. Meanlength of practia 23 yeara Mean No. of deliveries~A’/year = 6.9. Reed on urban sample gMlemlizedto city a* laae Wcstem (modem) pmctitionns e*t 1:30.000. Sk [53]. Practicing Zaramo medicine men (full-time watwqa). Traditional medicine “is one of the larger occupntiottal groupiqa in the city even thou&~it fails to appear on oclxptional SltrVCyS” Barefoot doctora (1972)

I:4410

Practitioners of “Chinese” medicine, 1966 estimate. Full and ramrt-time bonroh. Majority arc farmem. Full-tim bomoh. Many

I:3122

spcialin. Tditiond

I:441

1291

INDIA [70, 713

Comment8

I:1300

Chinese sin-seh in PeninsuLr Mahvsia. “Arc still the prim&y sowce of mwJica1attention for most villagers.”

Sources in brackets.

“most important public figure in the cultural life of the average Zaramo” [44]. Clearly, geographic investigation of rural and urban traditional medicine could make important contributions to modernization theory and also yield valuable insights applicable to health planning. There is little doubt, at least, that the delivery of modem health services, including diffision of medically-significant hygienic practices, family planning, and other information, could be enhanced by adapting some of the social principles which underlie the spatial structure of traditional medicine. Many studies suggest that people are increasingly pragmatic in selecting between traditional or modern medical care. Nevertheless, the hypothesis that attitudes toward the use of one or both systems are increasingly less bound by custom and more dependent on the “expectation of cure” needs careful evaluation. In rural areas, reliance on traditional therapies is very extensive if not exclusive, and it is to be expected that dependence would rise sharply with increasing distance and travel time to health centers, hospitals, and towns. Here, again, in the absence of systematic research findings the significance of geographic factors, including locational decision-making by medical practitioners and their clients, is purely speculative. The medical geographer planning to conduct field study of traditional medicine must practice humanistic social science in its broadest expression. Ideally, he must be prepared to observe and learn about the local culture by immersion and participation in it. In this regard African, Asian, and Latin American

scholars have obvious advantages over those from the United States and Europe. The hypothesized relationships proposed in Table 2 illustrate some of the basic elements of geography in traditional medicine. They are presented as a means of stimulating discussion and wider interest among geographers in the empirical and theoretical aspects of traditional medicine, and in its interaction with Western medicine. CONCLUSION

Traditional medicine is a powerful and pervasive force in contemporary societies of the Third World Probably more than 2.3 billion people, or 56% of the world’s population, continue to rely upon traditional systems of healing to cure various physical and mental illnesses [72]. Western medicine is widely superimposed on indigenous medicine, and the coexistence and selective use of both systems is today the single most dominant feature of Third World medical culture patterns. With a few important exceptions, there is little dialogue between traditional and Western-trained medical practitioners. Indigenous health scientists and the W.H.O. now recognize that policies which isolate practitioners from one another have little positive influence on health care. Nevertheless, it is practically impossible in most countries for health authorities to intelligently evaluate the merits of collaboration because systematic knowledge of their traditional

711

Traditional medicine: an agenda for medical geography

Table 2. Traditional medicine: geographic and behavioral variables with hypothetical relationships NUMBER, SPATIAL ARRANGEMENT. and DISPERSION OF TRADITIONAL MEDICAL PRACTITIONERS (TMP) Distribution of population Density .d popuktion Religious prekmnce of Community Patterning (forms Functional category of Mobility pat&m d population of organizations in which TMP (hnbalirt, midwife, popuktion (cedcnLocation ol/aoxssibility to localized groups of peopk diagnostician_ etc.) mry, nomadic. etc.) interact in households and medical Ieso”rca (e.g. occuptional profile or Educational kvel of shrina’ materin media). kbl grows) population pOpllkti0ll Age-sex S~1T”ct”IC 0r popuMedian income 0r populatioa Rules established by TMP Ext.3a 0r w~tcmization ktion

pdesd04 a&tbns

or populsti~n

FACTORS INFLUENCING DECISION TO SEEK TREATMENT IN TRADITIONAL OR MODERN (scimtiflc) MEDICAL SYSTEM Authority pattern of house Awareness 0r PltelnPtirn Acuteness or chronicicy Results or previous hold uni+cial group in Pmci~ede~p&pn~y0r or sympt0m trclltmultstrptegics diagnosis cure Accessibility to a modern Status of person in Length of time required Immcdkte finawial status mdieal rtitity (tim+ household for cuI+ distance, arpmdirwe) VARIATIONS IN SPATIAL ORGANIZATION Community patterning Locally-based tank grovp vocation 0r m08tpmtiArea1 variations in gioun practitioners housing quality Sizeand dirtribution of Frquency/s~rength of social linkages with urban ethnic group adjacent rural areas

OF URBAN-BASED TRADITIONAL MEDICAL SYSTEMS Migrant ethnic group Special&d polyethnic Ati homogeneity/betere intwaction sty 0rti0+c0~0mif Agesex pro6le dr sutus ethnic group Clustering or diipemion

VARIATlONS IN SPATIAL ORGANIZATION Community patterning Ethnic group Accenibility to modern Frequency/strength 0r social linkages with medical mica (disadjacent urban poputana. time, cost) lotions

OF RURAL-BASED TRADITIONAL MEDICAL SYSTEMS SpetiaI stability-mobility ~oati0a 0r m08t or community organization prestigiow practitionus Specialiaion of TMR (e.g. shrine priest hula. midwile)

DEPENDENCE ON RURAL TRADITIONAL ~agth 0r rnidcncein urb Kinship tics in rural areas M Efkaivcnn~ of initial tre*tment in modem Accenibility of TMP (dir-

MEDICAL SERVICES BY URBAN-BASED POPULATION Household activity field Type d health cam needed Social rektionsbip 10 TMP (=-vpe=i=d)

scetol

0r spec*lin pnaiti~ns~

~xpcetlocy

PLED0r employment

0r ells

blla, till& cat)

ATTlTUDE OF TMP TOWARD COOPBRATION WITH MODERN (SCIENTIFIC) MEDICAL PERSONNEL Educational kvcl Quality 0r pmiou crpaEthnicgroup Attachmmt to traditional Sex culture base iena with modem medial Religion 0r TMP Area 0r spccidintion Frequency 0r colltactwith rbe b=s pcr-=J modem practitioners illneah inter-system referral (Ymctiac

ConRptualiition/uxonc.my/ nrplanation0r illness (C& dishamlony with supernatu~l row interpersonal problems, physiological, broken tabwss

FACTORS INFLUENCDJG CONSUMERS Perceived etxcacy of treatmat stmtegks (TMPS repuntion sccid mlationship to TMP

Inr0mti00 u)-

(rtily.

CHOICE OF TRADITIONAL PRACTITIONER Relative I”cxxsI 0r prior Accemibllity compared to trealmcnt in modrnl medical other TMP8 (time. dir sector Ma, cod) tigth 0r kdm~j io Common knguage, bdidr lac&lity value orialPtion R&&Xl Ethnicity

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AlTlTUDE OF MODERN MEDICAL PERSONNEL TOWARD COOPERATlON WITH TRADITIONAL wty 0r ~lpai~ with Quality or preview Persoaal reliance on TMPl by modem sector personnel TMPS prior to ~fedonal rdanl or cooperation tduing rzdu~aliotr 0r TMP sex 0r relpOndmt Education ol respondat hn~ti0d ~atcg0~ 0r TMP

Conaptuali7atioa/taxonomy 0r illness Kinship ties in rural areas

MEDICAL PRACI-ITIONERS ten(th or proradolvlapcr-

USE OF TRADITIONAL MEDICINE AMONG BLITE (AFRICAN) FAMILIES ~cpth or childd~ I~OWhtm08p 0r modcra kdge of traditional cues private pmctitiona Father’s literacy level Father’s occup&m

medical subsystems does not exist, Access to this kind of information is a high priority if government policies for cooperation, partial integration, or legal separation of traditional and modern medicine are to be seriously developed and studied It is proposed that medical geographers can be very useful as unob trusive facilitators of more comprehensive health planning by developing, through careful field studies, a body of information about the nature and organization of traditional medical systems. Substantive and theoretical knowledge of the geography of traditional medicine, and its interrelationships with modem medicine, is fundamentally germane to achieving better health among people of the Third World At the same time, medical geographers have the oppor-

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tunity to add fresh conceptual insights to the expanding body of knowledge about ttaditional medicine de veloped in fields such as medic+ anthropology, medical sociology, and community ihealth. Can a future for traditional inedicine be predicted? Rapid and socially revolutioniaing changes associated with urbanization and the res@ucturing of economic life are producing dramatic and often traumatic consequences at the level of the individual and family in most areas of the Third World Nchinda observes in the case of Africa that ps chosomatic maladies, mental illness, and other soK opathic disorders are becoming as important as uknmunicable diseases. Cancer, cardiovascular disease, and degenerative illnesses are predictable major problems on the horizon.

712

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Furthermore, the gradual drift toward a “Western” disease profile has not been accompanied by any marked progress in curative and preventive measures In fact the inability to “cure” these “modem” illnesses as dramatically as curing yaws with penicillin has only gone to increase the frustrations and anxieties of people, thus pushing them to seek other forms of health care. Resorting to traditional medicine is therefore liable to increase rather than decrease [21]. There is also another potential outcome which is of more than passing theoretical interest to students of social science in medicine. Should many traditional

practitioners be successfully co-opted by the modem health services, the future of traditional medicine as it is understood today will be predictably brief. Acknowledgement--The author wishes to thank Dr. James B. Campbell for his thoughtful criticism of this paper.

REFERENCES 1. Shannon G. W. and Dever G. E. A. Health Care Delivery: Spatial Perspectives. McGraw-Hill, New York 1974. 2. Pyle G. F. The geography of health care. The Geographv of Health und Disease (Edited bv Hunter J. M.l. i&p.-7, pp. 15@84. Depa&e@ of &graphy, U& versity of North Carolina at Chapel Hill. Studies in Geog. No. 6, 1974. 3. devise P. Misused and Misplaced Hospitals and Doctors: A Locational Analysis of the Urban Health Care Crisis. Association of American Geographers, Cornmission on College Geography, Resource Paper No. 22; Association of American Geographers, Washing-

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Nigeria: the pattern of utilization of health services in lbarapa d&ion. Rural Africana 26, 56, 1974-75. 55. Side1 V. W. The barefoot doctors of the Peonle’s Republic of China. New Engl. J. Med. 286, 1292, i972. 56. Chabot H. T. J. The Chinese system of health care. Trop. Geog. Med. 28, 5117, 1976. 57. Chen P.-C. China’s population program at the grass roots level. Studies in Family Planning 4, 219, 1973. 58. Luukaine-n T. Health and family planning services in the Chinese People’s Reuublic. Studies in Familv Plan_ ning 3, 1965, 1972. 59. Bhardwaj S. Attitude toward different systems of medicine: a survev of four villages in the Puniab-India. Sot. Sci. & Med., 603, 1975.60. Dunlop D. W. Alternatives to “modem” health delivery systems in Africa: public policy issues of traditional health systems. Sot. Sci. & Med 9, 581, 1975. 61. Lamb0 T. A. The village of Aro. hncet ii, 513, 1964. 62. Danysz P. Oku Ampofo and phytotherapy in Ghana. AfriCanEnvironment(ENDA. Dakarj 1. 116. 1975. * 63. &mar A. A. Ghana.’ In Fa&ly P&ins ‘Programs: World Review, 1974. Studies in Family Planning 6, 283, 1975. 64. Neumann A. K.. Sai F. T. and Dodu S. Danfa comprehensive rural health and Emily planning project: Ghana. Environmental Child Health. Monog. 32, 39, 1974. 65. Neumann A. K., Ampofo D. A. et al. Traditional birth attendants--a key & rural maternal and child health and family planning services. Enoironmentaland Child Health. 32, 21, 1974. 66. Editorial Board Aftican Environment (ENDA, Dakur) 1, 7, 1975. 67. Hunter J. M. (Ed) The Geography of Health and Disease. Dept. of Geography, Uhiversity of North Carolina at Chapel Hill. Studies in Geog. No. 6, 1974. 68. Armstrong R. W. Medical geography and health planning in the United States. In Medical Geography: Techniques and Field Methods (Edited by McGlashan N.), p. 128. Methuen, Londotl, 1972 69. Warren D. M. Bono traditional healers. Rural A$% cana. Winter 1974-75, pp. 25-26. 70. Neumann A. K. and Bhatia J. C. Family planning and indigenous medicine practitioners. Sot. Sci. & Med. 7, 509, 1973. 71. Leslie C. Modem ’ India’s ancient medicine. TransAction. June, 1969, pp. 46-55. estimate based on the com7‘2. This is a very contiative bined rural populations of Third World countries It arbitrarily excludes urban populations everywhere, and rural populations of the U.S.A. and Canada; Argentina and Uruguay; Northern, We&m, Eastern, and Southern Europe; the U.S.S.R.; Australia and New Zealand; and Israel. If 50% of the 1976 urban population (944.2 million) in underdeveloped countries can also be said to rely in some degree upon traditional medicine, the proportion of the world’s population dependent on non-western medical system increases to 67”/, or 2.8 billion people. Population dati sources: The Environmental Fur& “World Population Estimates,” 1975 and 1976. Washington, D.C. 1975, 1976.

Traditional medicine: an agenda for medical geography.

SW Scr 6 Mrd.. Vol. 11. pp. 705 to 713. Pergamon Press 1977. Printed in Great Britain. TRADITIONAL MEDICINE: AN AGENDA FOR MEDICAL GEOGRAPHY...
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