TRADITIONAL MEDICINE
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- TRADITIONAL MEDICINE
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RF_DR.A_6_SUDHA
Int. J. Ment. Health, Vol. 12, No. 3, pp. 30-43
M. E. Sharpe, Inc., 1984
COLLABORATION WITH TRADITIONAL HEALERS:
EXPERIENCE IN REFUGEES* MENTAL CARE
J. P. HIEGEL
Since January 1980,1 have been promoting cooperation.between
modern and traditional medicine in five refugee camps in Thai
land. Initially, I proposed to take advantage of the presence of
many traditional healers in the camps and to utilize their skills in
the mental health care of refugees,1 but the demand for herbal
remedies soon appeared to be very important among the camps’
residents. Therefore, I decided to put particular emphasis on this
cooperation and to involve traditional healers in medical as well
as in psychological care.
An ethnological approach to mental health care is more logical
than an ethnocentric one.2 After three years of close cooperation
with almost one hundred Khmer traditional healers, my col
leagues and I can conclude that many have genuine psychothera
peutic abilities and a deep sense of medical ethics. They are well
aware of their neighbors’ needs, and they are respected and trust
ed by them in return. Moreover, they speak a common language,
rooted in the same cultural background. Therefore, they are often
well equipped to give psychological support to patients and to
help them solve their emotional conflicts, especially when these
conflicts are expressed through cultural beliefs in spirits and
possession.
Supporting traditional healers and involving them in refugees’
Dr. Hiegel was International Red Cross Committee Medical Coordinator
in Thailand from November 1979 until July 1981. He is now Program Di
rector for les Oeuvres Hospitalieres Frangaises de 1’Ordre de Malte, the
French Association of the Sovereign Order of Malta, which is funding the
traditional medicine program in Thailand, in conjunction with Action Inter
nationale contre la Faim, another French organization. His current address
is c/o ICRC, P.O. Box 11-1492, Bangkok, Thailand.
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CO^UAIiTY Hi:ALTH CELL
7 '
Floor)St- Marks Hoad
EAMGAi.0.iE-56o 0U7
COLLABORATION WITH TRADITIONAL HEALERS
health care may be looked upon as useless when one considers
that the camps’ medical facilities are at a much higher level than
those usually found in developing country By coming m larg*
numbers to the traditional medicine centers (TMC ),
p
demonstrate that they still have faith in their healers
modern treatments are easily available and free This fai
understandable: we have observed that herbal remedies and other
traditional healing techniques can successfully treat a wide rang
of somatic diseases, which is why patients have confidence
“’h oX'proach, we try to balance the eontributions of modern
and traditional medicine rather than emphasire one more than the
other In our mental health work, however, we give a particularly
prominent role to the healers and support their efforts in taking
care of patients rather than place ourselves in the dominant posi
tion. Modern psychiatric knowledge and working exPer^nc
within Western institutions can help to expand the trad.Uonal
healers’ area of efficacy, but in our setting we have wan^
avoid forcing the healers to adapt themselves to Western models.
On the contrary, we have adapted our models to complement
traditional practice. The organization of a TMC inside a holding
camp conforms to this attitude, because most of the refugees who
are staying in these camps are likely to go back to the
'T^on^tX mental health program in anote^camp
Phanat Nikhom, usually places more importance
tester
nsvchiatric and psychotherapeutic approach. Phanat Nikhom a
processing and a transit center for refugees whose resettlement
requests are under final consideration, or for those who have
already been accepted by Western countries for resett c^The
current needs of the patients and the resources available to them in
their future are different in this case.3 Thus, greater emphasis is
giver^Western methods in Phanat Nikhom than in the holding
shall not present details here about the mental health pro
gram in Phanat Nikhom because resetUement problems are
specific. The description of the organization of a TMC that fol
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J. P HIEGEL
lows refers to a holding camp, Khao I Dang, which has a current
population of 65,000.
A holding camp TMC
The four traditional medical centers at Khao I Dang camp.jprovide outpatient services, long- or short-lerm day care, and inpa
tient services. All patients are registered and have a consultation
with an experienced traditional healer, or kru, as they are called
by the Khmer people [1,2].4 The kru makes a diagnosis. He then
refers the patient to various specialists in herbal remedies or in
specific healing techniques. All of them work together in one
large treatment room. Patients usually come daily for their treat
ment and have another consultation with a healer at least once a
week.
Mental patients come directly to the TMC or are referred by
the hospital, outpatient clinics, social workers, family members,
or community leaders. Depending on their condition, they are
treated as outpatients or stay during the day with the group of
healers, midwives, and helpers. During acute phases, they re
main at the center at night, with appropriate members of their
family when possible.
Two or three krus and some helpers perform night duty at the
center. They take care of inpatients and go to the hospital when
psychiatric emergencies occur on a ward. In the latter case, they
either treat the patient in the hospital or bring him to the TMC if
the doctor on night duty on the ward agrees.
Two ordinary refugee houses, close to the TMC, provide an
other facility for temporarily accommodating less acutely ill pa
tients who, for psychological reasons, cannot remain at home.
Healers may also take mentally disturbed patients into their own
homes, as they sometimes did in Cambodia, but only with the
prior approval of senior krus, who base their decision upon the
healer’s reputation and the character of his wife.
TYeatment and rehabilitation
Patients who are staying in the TMC with the healers and helpers
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COLLABORATION WITH TRADITIONAL HEALERS
receive valuable psychological support from the whole group. As
a consequence, they usually express a desire to work in the TMC.
They can help prepare traditional remedies or work in the 1MC
garden, growing medicinal plants. They are not pushed to work,
but they receive a salary proportional to their efforts. In this way
we try to avoid having other workers become jealous and reject or
humiliate the patient. Such work also serves as a means of-demonstrating reality to psychotics. Part of the refugee staff at the
TMC is composed of formerly psychotic patients who have
reached a stage of social recovery and become full-time workers
Some physically handicapped refugees who were depressed and
isolated also work in the center.
The TMC’s krus make daily rounds in all the hospital wards.
They may use their own methods in addition to modern ones.
This helps patients feel that nothing is neglected for their recov
ery, and thus is a valuable psychological support. Sometimes a
mother in the pediatric ward doubts whether she has made the
right decision in bringing her child to the hospital and thinks that a
healer would be more qualified to save the child’s life. In allow
ing the krus to practice in the ward, we help prevent the mother
from suffering guilt feelings if the child dies.
Several patients from the surgical ward are brought to the
TMC every day, in the afternoon. They usually suffer from reac
tive depressions following an amputation. They are given a show
er with lustral water (which is believed to have acquired special
power through a ritual performed by a healer), a procedure that
helps such patients avoid thinking too much about their condi
tion. This treatment and the psychological support given the
patients by the whole refugee staff in the TMC are usually suffi
cient for a quick recovery : the various depressive symptoms that
they present—sadness, anorexia, insomnia, adynamia, and with
drawal—generally disappear within a few days without the use of
any psychiatric drugs.
The krus are not opposed to the use of modern drugs in con
junction with their own methods. In fact, they ask for sedatives
whenever they fear for the safety of patients who are restless
during the night and might attempt to leave the center. Only a few
33
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J. P HIEGEL
patients receive chemotherapy, as in most cases recovery pro
ceeds from the effect of the healers’ methods and from the sociotherapeutic role of the TMC. Neurotic or reactive depres
sions, acute anxiety, hysteria crises, and even mild forms of
mt7P T SimpleX °r Paran°id’ PrOviding ''egression is not
too deep, do not usually require any other treatment.
At first the kms were reluctant to become involved with chron
ic schizophrenics, as they knew that Jhey had little charice of
curing these patients and were afraid to spoil their reputation as
successful healers. It was easy to reassure them that psychiatrists
often find themselves m a similar position. The relationship be
tween schizophrenics and the healers is more productive when
these patients receive adequate chemotherapy: by reducing psy
chotic symptoms, chemotherapy tends to expand the opportuni
ties for treatment open to healers. The association of modern
drugs with traditional methods is not always necessary for treat
ing schizophrenics, however. On several occasions patients have
achieved a social recovery without any chemotherapy. The krus
use herbal steam baths, lustral water showers, and traditional
remedies m treating these patients.
The follow-up of patients discharged from the TMC is done by
a Khmer refugee social worker. If necessary, a member of the
nonrefugee staff accomjianies one or two healers on home visits
with the social worker. Counseling is done by the healers, who are
m a good position to do this because they are accepted as elderly
wise, and respected persons.
The staff
The nonrefugee staff working full time in the center consists of a
Western nurse, a Western social worker, and a Thai social worker
A psychologist and I are present part time.
In my opinion, supporting the healers and the other Khmers
working m the center is more useful than establishing a deep
interpersonal relationship with a few patients. The healers can
care for a far greater number of people than we could do by
ourselves, provided they themselves are in good psychological
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COLLABORATION WITH TRADITIONAL HEALERS
condition. Thus, the risk of creating in the patients excessive
psychological dependencies on outsiders is avoided. Several pa
tients have been admitted to the TMC following the departure of
Western relief workers because they had become severely de
pressed or withdrawn. I personally have adopted a direct psycho
therapeutic role on only two occasions, when there was an acute
risk to the patients that could not be reduced in any other way.
The refugee staff, including healers and helpers, numbers over
90 in the main TMC and in its 3 annexes, which afe adjacent to an
outpatient clinic. We expect the staff to give strong psychological
support to other refugees and to care deeply for them. But the
healers and helpers are refugees themselves. They have been
subjected to the same stress, and often must face the same existen:
tial problems as their patients.5 They can have the same reasons
for worry, depression, and anxiety as those who need to be reas
sured and supported by them. Like other refugees, they have been
victims of man-made situations, have been persecuted for their
religious, political, or social backgrounds, and have fled their
homeland to seek asylum in another country. They are no longer
protected by the laws of their own country, and their security is in
the hands of international organizations and the authorities of the
country of asylum. Despite the fact that they are relatively well
protected, they often feel insecure, sometimes for real reasons,
but often because of rumors that spread through the camps.
The self-esteem of refugees is easily wounded, as they are
dependent upon foreign help for their survival and have little
power over their own destiny. Their future is unclear, and many
feel that there are no real solutions for them.
The main role of the nonrefugee staff working in the TMC is to
provide healers and helpers with psychological support that sus
tains their self-esteem and gives them a feeling of pride and
security. The more care we give them, the more care they will
give to others.
Occasionally, however, a general depression has struck the
refugee staff, with a consequent reduction in the efficienty of the
TMC in its mental health functions. The depression and the
subsequent passivity of the group have almost always occurred
35
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J. P. HIEGEL
when a nonrefugee staff member has either lost his motivation
and begun simply doing a routine job or has started to work
mainly for his personal prestige. The result has been a loss of
authority on the part of the krus, particularly of their chief. They
then come to regard their work as merely routine, a job that
provides them with little satisfaction. This problem has been
solved by replacing the relief worker, if necessary, and by
encouraging the krus to develop a new area of activity in the
TMC.
Several aspects of the organization of the centers have psycho
logical functions. Their importance has been confirmed by in
cidents such as the above. The relationship established be
tween healers and nonrefugee staff is based on mutual esteem,
trust, confidence, and respect; tangible proofs of the solid
ity of this relationship need to be given to the refugee
staff [I].6
Regular meetings are held between the staff and the head kru
and his assistants. A weekly general meeting attended by the
whole staff is convened by the head kru. He presents problems
that have previously been discussed in smaller meetings and
proposes solutions to the group. If we have noticed a problem
involving a member of the refugee staff, we do not try to solve it
directly, but inform the head kru of our concern. If he cannot
solve the problem, he may require our help. Our role is mainly to
back the head kru and to show all the staff that we respect him.
This attitude has a direct effect upon his pride and an indirect one
upon the self-esteem of all the staff members who have elected
him as their head. Through this approach we ourselves gain
prestige, because prestige is generated by the respect we show
others.
The self-esteem of the refugee staff is sustained because they
work for their own people, they have many responsibilities, and
they have the power to make decisions. Moreover, they feel that
this experience in a refugee camp promotes a better understand
ing of traditional medicine among hundreds of Westerners and
therefore contributes to acknowledgment of its value.
Y
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COLLABORATION WITH TRADITIONAL HEALERS
Problems and how we deal with them
The number of clients coming to the TMC has always significant
ly increased whenever the level of anxiety and fear rises in the
camp. Several patients were brought to the center at a time when
the sounds of regular fighting at the border could be heard; this
situation reactivated affects linked with previous stresses. The
patients quickly felt secure in the TMC, and their anxiety disap
peared without any medication. The quality of the relationship
that exists among all refugees working in the center helps give
people a feeling of security because they provide mutuaf support
for each other. But nonrefugee staff members also have to provide
reassurances by the nature of their presence; they must not identi
fy too much with the refugees lest they internalize the refugees’
fears and thus unconsciously add to those fears.
There follows an example of the type of problem that can be
appropriately solved through a traditional approach.7
A Western social worker had to deal with a wife-beating
problem in a Lao family. The social worker acted as he would
have done in his own country, requesting a medical examina
tion of the wife and adopting a protective attitude toward her.
He separated her from her husband, whom he blamed com
pletely. The husband, feeling shame, immediately stopped
working. A few days later the social worker noticed that the
wife was behaving strangely, and he wondered if she had told
the truth about her husband’s beating her. In fact, she was
depressed, confused, and sometimes spoke incoherently.
I asked the husband and wife if they thought that they had
offended a spirit, and I discovered that they were both con
vinced that they had. They were immediately more relaxed,
simply because they felt free to share their problem with some
one who was taking their beliefs into account.
They came to the TMC, where the krus explained that a
spirit had taken possession of the woman. The krus made an
offering of candles and incense and gave the couple lustral
water showers. The wife’s symptoms of depression and confu—
Ji
37
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J. P. HIEGEL
Vei7 qUiCkly’ but «~nication between her
Lt h snir? W°manireP,ied’ *oUgh the Khmer bJieved
mat the spirit was speaking through her month tk
required more imporunt offerings-the head tail
a?
-Me oom
buy fte
EҤ~ES==
tor. At one point he became angry with L sniri «
t
ingS Sring^fteT6 t00" h00'64 d°Wn
rev^Tpon h'm 6
might
a"d
h- ta fa« ifhe bee„ M^'d“ XkX
further
others, but the belief in spirits prevented this risk sSri?/h
reputation for stating the truth Th^
Spints have a
spirit played the rnlp nf
•
re’ °n ^1S occas^on the
38
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COLLABORATION WITH TRADITIONAL HEALERS
the problem. Belief in spirits and possession is a defense mecha
nism of the ego, but this belief, combined with appropriate heal
ing techniques, can break down resistance to the expression of
personal affects or interpersonal conflicts. The spirit acted as a
mediator. Its presence allowed the husband and his wife to talk
freely. They unburdened themselves of feelings they could hardly
otherwise have revealed.
Medicine, magic, and religion
Despite the benefits that result from the establishnxent of mutual
understanding between Western practitioners and traditional
healers, there is still considerable resistance to this approach. Not
all relief workers are willing to cooperate with traditional heal
ers; the level of cooperation between the TMC and other medical
or paramedical services has varied from camp to camp. Some
medical people can easily accept the healers’ playing a role in
mental health, but they are more reluctant to acknowledge their
involvement in physical medicine. On the other hand, some
Christian medical doctors sometimes agree with their patients’
receiving herbal remedies, but are opposed to magic healing
techniques.
It is interesting to observe that some modern doctors and some
traditional healers use similar patterns of logic to form their
opinion about the value of methods they themselves do not use.
Western doctors and nurses have seldom had the opportunity to
observe the healers’ practices and to evaluate the success of
traditional treatments, but they may have heard about cases in
which traditional methods have had detrimental effects. The heal
ers may also have had to deal with the mistakes, and the subse
quent failure of the treatment, occasionally made by modern
doctors. Among traditional healers, those who doubt the efficacy
of modern medicine think in exactly the same way as do modern
doctors who discredit traditional medicine as a whole by general
izing from the few failures of which they happen to be aware.
Reluctance to refer patients to each other is rooted in exactly the
same logic.
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J. P. HIEGEL
The existence of TMCs in camps where visitors are welcomed
and everything in the healers’ practice is open to view has helped
many outsiders adopt a more pragmatic attitude toward the use
fulness of traditional medicine in developing countries. Mutual
trust has increased with the developent of cooperation. Neverthe
less, some modern doctors remain rather contemptuous of tradi
tional knowledge and remedies, as if their self-esteem cannot
withstand the anticipatory fear of being eclipsed by the healers,
whose prestige, in their eyes, is unfair and unmerited because it is
not based on scientific knowledge and university degrees.
Many Christian relief workers have no difficulty in respecting
Cambodian beliefs in spirits or in possession and. are therefore
willing to cooperate with traditional healers who work within
such a conceptual framework. Missionaries who had previously
lived m Cambodia and several nuns felt quite comfortable work
ing in TMCs as social workers. They respected the Khmer form
of spirituality and all aspects of the healers’ practices, including
magic cures.
Some Christian doctors, however, think the healers make a
pact with the devil and worship “false gods.” They identify
magic cures with witchcraft practices. According to medical eth
ics, these doctors should provide their patients with all the benefi
cial treatments available in the camp. Some even agree that magic
healing techniques relieve psychological suffering but, as Chris
tians and missionaries, they feel responsible for the spiritual wellbeing of their patients and think it their duty to discourage them
from accepting any kind of treatment involving magic.
The Khmers often attribute their psychological suffering to the
influence of offended spirits or to the effect of black magic insti
gated by personal enemies. Some Christians take this belief liter
ally and believe that conversion to Christianity will help these
patients and free them from fears and anxieties. They fail to
appreciate the role of projection, which is at the root of these
beliefs. From a psychological point of view, a genuine faith often
contributes to people’s well-being. Moreover, faith can also
strengthen the ego’s neurotic defense mechanisms. Some extrem
ist missionaries think that conversion necessarily has a psycho40
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COLLABORATION WITH TRADITIONAL HEALERS
therapeutic effect. In fact, depending upon the personality of the
convert, it can have just the opposite effect. For example, I have
seen three Buddhist refugees who suffered a psychotic episode
after being baptized; they were borderline psychotics and could
not withstand the conflict of identity between the Buddhist and the
Christian parts of themselves. One woman clearly projected her
conflict into her hallucinations: she developed.a ^hallucinatory
psychosis in which she could hear Buddha speaking to her
through one ear and the “Christian God’’ through the other.
The particular characteristics of the superego of psychotics
increase the risk that they will acquire, through evangelization,
the most rigid and severe interpretation of Christianity. A young
Lao presented with a very high degree of psychotic anxiety after
being baptized. His self-esteem had suffered severely as he had
the feeling that his religion, Buddhism, and his cultural beliefs,
and consequently part of his own self, were “bad.” At the same
time as he maintained that he was still Buddhist, he felt much
guilt because he had agreed to become Christian, which seemed
to him to be a betrayal of his father and his ancestors. During a
two-hour session I used careful psychotherapeutic interventions
to point out to him the various aspects of his internal conflict, a
technique that significantly reduced his anxiety.
In such cases involving conflicts between Buddhist and Chris
tian beliefs, it would be dangerous to consider magic cures as a
kind of antidote that could have a psychotherapeutic effect. On
the contrary, this would renew the conflict that these patients have
had to face.
A 27-year-old Khmer exhibited strange behavior, with hallu
cinations and anxiety. He thought he was possessed by a spirit.
He was convinced that the healers could help him and that a
magic cure was the only proper treatment for him. He had
converted to Christianity, however, and he could not bring
himself to request the healers’ help. He was treated with che
motherapy, but he did not improve significantly. Two weeks
later, he came by himself to see the healers in the TMC. They
burned three sticks of incense, recited some mantras, and
threw lustral water on him. The patient was extremely uncom?
41
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lc,
and ,ense during this
.^ureh
—i that he could
fortable, anxious,
=|
Private healer in
Xp^who"13”
‘0 be treated by a
^neythat thepatientwouldZveton^ ' CCrtain am°unt of
patient did not waif he imm
^longings. His eagerness to
need to try to reduce the guih
conflict between his desirea
.o o=»fe"X3“^
re„i“"',ure “
point of view. However we did
Z’pS'
?P°n being cured. But
Started t0 sell his
treatment reflected his
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3 medical and an ethicL
gaVe her lustraJ ^ow-
’WK. she became caio^ t?“ “
■>»»„; ]n
theVeS heard that
practice’ hafl6 hWOrkingin the TMC had
group 10SfapPr°Ved of it- But amongSeK^ in Cambodia, and
group of pnvate healers who had,
ln 1116 camp the
-xxxtr1 r"-" -x oXrto
drive the spirit from thei?b1^yeabX,>0SSeSSed”
t”
hysical pam may satisfy the^aso^^Patlents Were not injured
the pumtive aspect of this tX asoch,sm of some patients and
ciafiXSUpereg0- Such treatmen^maTthe83?1^
re^uirements
y
pa.™- mcc^es COme"?r~
42
<
COLLABORATION WITH TRADITIONAL HEALERS
and from the psychological support given by the entire refugee
staff working in the centers. Thus, modern, trained, mental
health specialists are not obliged to take a preeminent role with
every patient. Moreover, the involvement of traditional healers
and of the community reduces the need for modern psychiatric
drugs. In developing countries, drug-oriented treatments are ex
pensive and often difficult to monitor. An approach that makes
effective use of traditional methods js more.appropriate-.
Notes
1. Details are presented in J. P. Hiegel (1979) General recommendations
concerning psychological care of the Khmer population in camp. Unpub
lished report to the International Red Cross Committee, 27 December 1979.
2. J. P. Hiegel (1982) Psychological needs of refugees. Western psychi
atric and kru Khmers’ approach to the problems. Caring role of TMCs in
the Khmer Holding Camp. Report to U.N. High Commission on Refugees’
Workshop on Mental Health in Primary Health Care Settings. Bangkok,
Thailand.
3. J. P. Hiegel (1982) Presentation concerning mental health services at
U.N. High Commission on Refugees’ Seminar on the Rehabilitation of Dis
abled Refugees. Bangkok, Thailand.
4. J. P. Hiegel (1980) Pour une reconnaissance de la place de la m6decine
traditionnelle dans les soins humanitaires. Report to the International Red
Cross Committee.
5. J. P. Hiegel (1980) Psychological needs of refugees. The Khmers in
Thailand. Report to the International Red Cross Committee.
6. J. P. Hiegel (1980) The role of traditional medicine in Khmer refu
gees’ camps. Report to the International Red Cross Committee.
7. See note 2, above, and J. P. Hiegel (1981) Traditional medicine. Un
published paper.
References
1. Hiegel, J. P. (1981) Le CICR et la mddecine traditionnelle khmere.
Revue Internationale de la Croix-Rouge, 6?(731), 255. (English and Spanish
translations available.)
2. Hiegel, J. P. (1982) Cooperer avec les thdrapeutes traditionnels. Forum
mondial de la Sante, 5(2), 262 Summary from the above paper. English transla
tion: World Health Forum, 3(1), 231.
I
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6UAK
Vol. 7 (1984), 61-79
E
Traditional Medicine is not Primary Health Care:
A Polemic
Boris Velimirovic
)
SUMMARY Following a short history of the WHO Programme on Traditional Medicine
(TM), the WHO Technical Report "The Promotion and Development of Traditional
Medicine" is critically reviewed, as frequently the WHO Programme on TM is con
fused with the Primary Health Care drive of WHO. The lack of precision in all
related definitions and statements of WHO is explained by the fact that no me
dical or cultural anthropologists nor other behavioural scientists are involved
in any of the WHO activities in the field of TM. Whereas good-will and idealis
tic commitment are not questioned, it is criticized that in contrast to innumera
ble WHO Technical Reports, this one neglects scientific and objective dealing
in favour of emotional advocacy of integrating Traditional Medicine into the
Health Services of underserved populations, the latter being regarded by the
author as a perpetuation of unsatisfactory conditions where real illness is con
cerned.
ZUSAMMENFASSUNG Nach kurzer Darstellung der Geschicnte des WHO Programros fur
Traditionelle Medizin wird der WHO Technical Report "Forderung und Entwicklung
der Traditionellen Medizin" kritisch besprochen, da haufig das WHO Programm fur
Traditionelle Medizin mit der Aktion der WHO fur Basisversorgung verwechselt
wird. Der Mangel an Prazision bei alien diesbezuglichen Definitionen und Aussagen seitens der WHO wird damit erklart, daB weder Ethnologen Oder Ethnomediziner noch Wissenschaftier der Verhaltensforschung in irgendeiner der WHO-Aktivitaten auf dem Gebiet der Traditionellen Medizin beschaftigt werden. Wahrend
guter Wille und idealistischer Einsatz nicht angezweifelt werden, wird doch kritisiert, daB im Gegensatz zu unzahligen anderen Technischen Berichten der WHO
(WHO Technical Reports) dieser Bericht wissenschaftliche und objektive Behandlung des Themas vernachlassigt, sich dafiir emotionell fur die Integrierung Traditioneller Medizin in die Gesundheitsdienste benachteiligter Bevolkerungsgruppen einsetzt. Fine solche Integrierung betrachtet der Autor als Verewigung von
unbefriedigenden Bedingungen, wenn es urn wirkliche Krankheiten geht.
/
RESUME L'auteur fait un expose bref sur I’histoire du programme de i'OMS pour la
promotion de la medecine traditionelle , puis il fait des remarques critiques sur
le rapport technique de I'OMS 'TRP 622,1*978), car il constate une confusion du
programme de la medecine traditionelle et de I'activite de I'OMS pour les soms
de santf? primaire. Il constate un manque de definitions precises concernant toutes les declarations de I’OMS qui n’emploie aucun ethnologue ou specialist*; sur
le plan de 1’ethnomedecine. L*auteur ne doute pas de la bonne volcnte et. de
1’engagement, mais il Lui manque la qualification et 1'objectivity des rapports
sur la medecine traditionelle, qui contraste au niveau des autres rapports.
L'engagement emotionnel pour 1’integration de la medecine traditionelle dans les
services samt.aires pour les populations dfesaventagees peut eterniser les condi
tions insuffisantes on cas de maladies graves.
es
Friedr. Vieweg & Sohn Verlag, Braunschweig/Wiesbaden
COMMUNITY HEALTH CELL
47/1, (First Hoor)St. Marks rtoad
VELIMIROVIC
62
I nt roduct ion
I
)
)
The decision to write this polemic came from the experience of a
recent international conference entitled "Traditional Healing and
Contemporary Medicine" (13-15 June 1983, Washington), called by the
US National Council for International Health to afford an opportunity
for discussion on issues pertaining to "Health for All by the Year
2000", a declared WHO goal. As with all conferences with over a hun
dred papers, films, etc., running in several concurrent groups, the
presentations were too many and varied all to be attended (from case
studies about herbalists in Guatemala, Cambodia, Togo, Lesotho, China,
the Amazonian area, training programmes for indigenous healers in Gha
na or for birth attendants in Sudan, to the investigation into beliefs
about and uses of western medicine in various ethnic groups, the role
of Ayurveda in health care planning, etc., as well as the WHO—promoted
use of scientific oral rehydration therapy for diarrhoeal diseases by
lay people or the experience of the Agency for International Develop
ment-funded mass-media and health practice projects, tropical medicine
and, of course, holistic movement items).
This and other meetings of this kind bring two points to mind.
Firstly, that they are largely ignored by the important representati
ves of contemporary medicine, be they from clinical or theoretical
branches, and, secondly, that experienced medical anthropologists re
present a minority; the impression is always of the predominance of
young, enthusiastic participants who appear to have just received
their Ph.D. degree in sociology, to be working towards such a degree,
or not to belong to either of these categories but simply to be belie
vers. Among anthropologists, again only a very few are medically trai
ned, most coming from professional backgrounds not involved in the ac
tual delivery of health care in the developing •or developed world. The
applause which met some trivial generalizations or outright fantasies,
indicating that too many were new to field experience, emphasized that
enthusiasm and sincerity do not protect against self-deception. It
seems that the basic fallacy is the belief that, even if the young anthropologist has mastered (in the best cases) the language of the
country in which he works and the ethnography of the region as a whole
(which is most laudable), then his sincere commitment to the pluralis
tic structure of health care and to exploring the relationship between
the pattern of traditional culture and the ongoing process of social
change for a study period of a year or two, is sufficient for him to
understand a given culture.
This brings to mind Professor Hildebrandt from the Universidad de
los Andes in Bogota (who was of European origin), when asked why he
did not write a book about Colombia answered:"How could I? It is only
20 years that I live and study this country". Even if all biases are
minimized, without a good knowledge of actual medical practices, the
dangers of distorted vision are enormous. This happens also in some
of the European ethnological writers.
Secondly, there was a great deal of haziness about the WHO program
me on traditional medicine, which is often confused with the Primary
Health Care drive of the WHO. Let us examine this briefly.
Manuscript received oct. 19b3. The polemic will be continued ana discussed in the3rd issue of curare Vol. 7 <1984).
Friedr. Vieweg & Sohn Verlag, Braunschweig/Wiesbaden
Traditional Medicine is not Primary Health Care: a Polemic
63
WHO programme on traditional medicine
The WHO programme on traditional medicine (further TM) came formal
ly into being in 1978. It is the only action of the WHO which has not
met with universal approval and acceptance by the health professionals
and which in fact remains highly controversial. The Chief of the WHO
TM programme explains the WHO initiative as follows:"The realization of the prospects
inherent in the use of practitioners of traditional medicine as front-line workers
in the development of national health systems is conditioned by two independent fac
tors: the changed political power that accompanied national independence, and the
low levels of resources that are available to tackle issues of development. The
first factor is related to national group pride and is associated with past heritage
and newly gained national independence. The second factor is linked to utilization
of all available resources" (1).
The first factor speaks for itself and needs no further discussion
The
(see Note 1). The second does justice to the sincerity of the motive
and seems to fit into the objective of maximal extension of health
care to the population lacking it: health for all by the year 2000.
Before we turn to the programme itself, a few chronological data follow to explain its genesis. WHO's interest in traditional birth attendants started with case studies in 1952-54 in Indonesia and the Philippines when, with the assistance of UNICEF, training was initiated
as part of the country’s midwifery programme.
- In 1969 the WHA 22/54 discussed the need to establish pharmaceutical industry
2
Industrial Development Organization)
(with the help of UNIDO-The United Nations
and mentioned that the research in traditional
t------------ - drugs
-may
- yield valuable pharmaceu-
- ltnC?9-nr°thetWHA 24/54
the area
area of
of traditional
traditional medicine
24/54 discussed
discussed the
of practices
practices of
medicine to
to
be diffeientiated from traditional drugs and decided that the issue is too complex and delicate and concentrated on promoting industry in the developing coun
tries trving to use local plant resources.
—
- A meeting"on the training and utilization of traditional birth attendants was hel
at WHO Headquarters in 1972 to develop training programmes, research and studie ,
that could improve the services of these workers (WHO 1^75a^health
- In 1974 a joint UNICEF/WHO study on alternative approaches to meeting ba=ic health
needs in developing countries (2) suggested that, among others, the practitioners
of TM, includina traditional birth attendants, may be trained foi the primary
health care services. This recommendation was endorsed by the Executive Board in
)
1975 (EB 56/R6).
,.
- An unpublished WHO document (2) of 21 November 1975 proposed that WHO collect
data on traditional healers and indigenous systems of medicine, analyse this in
formation, determine the relevance of traditional healing to primary health care
and to the needs of various population groups and suggest the main directives
for action with special regard to the training and utilization of traditional
healers in health systems.
- A consultation on TM was held in Geneva in October 1975, and in January 1976 a
document was presented to the Executive Board. The proposed action outlined in
the document was further reviewed at an international WHO meeting held in New
Dehliin October 1976. This consultation discussed the integration of TM and only
the representatives of two WHO regions endorsed this concept fully.
- Also in 1976 the Regional Committee for Africa discussed "Traditional medici
ne and its role in the development of health services in Africa" (WHO 1976), and
the Regional Committee for South-East Asia adopted a resolution calling for the
promotion of traditional and indigenous systems of medicine in the Region (3). In
the same vear, WHO established a working group in Geneva for the promotion andevelopment of TM. At the same time a task force on indigenous plants for ferti
lity regulation was established and the 29th WHA passed the first resolution on
utilization of TM manpower. It was only after the we 11-popularized WHO/UNDP trip
to China in 1977 that traditional medicine started to be massively promoted by
some countries.
Friedr Vteweg & Sohn Verlag, Braun$chweig/W>esb2den
VELIMIROVIC
64
't which was approved
In 1977, a working group met in Geneva and* proposed a- ------------programme
.a Executive
Board and requested the Director-General and the Regional Direcby the
— -----to develop the traditional medicine programme, to
tors of
o* the WHO
-- to
— continue
-allocate the necessary financial and other resources for this programme and to
cooperate with Member States on this matter. The 30th World Health Assembly (1977)
adopted a resolution (WHA 30.49) urging interested governments to -give importance to the utilization of their traditional systems of medicine with appropriate
regulations as suited to their National Health Services".
- In 1978, the 31st WHA invited countries to use traditional plants, An Expert Com
1984 to
to discuss
discuss the
the role
role of
of TM
TM in primary
mittee meeting is planned for late 1984
'■)
)
health care.
From the very beginning, the WHO programme was uncertain about the
definitions of traditional medicine TM . The one made by a group convened
by the WHO Regional Office for Africa, Brazzaville (3), 1976, was as
follows : "...the sum of all the knowledge and practices, whether explicable oi
not, used in diagnosis, prevention and elimination of physical, mental or social im
balance and relying exclusively on practical experience and observation handed down
from generation to generation, whether verbally or in writing... Traditional medici
ne might also be considered as a solid amalgamation of dynamic medical know-how and
ancestral experience... Traditional African medicine might also be considered to be
the sum total of practices, measures, ingredients and procedures of all kinds, whe
ther material or not, which from time immemorial had enabled the African to guar
against disease, to alleviate his sufferings and to cure
- The African
Regional Office group also adopted a definition of the traditional
healer, as follows: "...a person who is recognized by the community in which he
lives as competent to provide health care 1by using vegetable, animal and mineral
_.i the social, cultural and religious
substances and certain other methods based: on
background as well as on the knowledge, attitudes and beliefs that are prevalent in
the community regarding physical,, mental and social well-being and the causation of
disease and disability (3)".
The story of a report
exAiiAuj-w*. was specifically
11/ tailored for the AfriWhile the above definition
implicitly
adopted
by
the
WHO Working Group in the
can context, it was
-—r--------WHO Technical KeuuiL,
Report, "The Promotion and Development of Traditional
is ----factually incorrect. Africa has never had an
Medicine” (4). This
------- —
unique system of
of TM
TM but
but only
only a
a vast
vast variety
variety of different beliefs and
’ . Chino,
Sri Lanka and Pakistan, true systems
practices, while in
China, India,
1
(classical
Ayurvedic and Unani...) of TM existed
(classical tninese,
Chinese, herbalist.
1
for centuries and are still widely practised. They have some theoreti
cal pathophysiological reasoning from which practices are derive ,
while African practices were empiric. None is a solid dynamic amal
gamation of medical know-how and ancestral experience"and none has
managed to "guard against disease", see the important killer diseases
which have decimated African, Asian (and, formerly, also European)
populations until the advent of the modern preventive and therapeutic
measures discovered by scientific medicine.
The WHO Technical Group was composed of a psychologist, two advo
cates of TM (Ayurvedic and Unani), one physiologist involved in Asian
science and medicine, two pharmacognosists and one professor of commu
nity medicine. There was no medical, cultural or behavioural anthropo
logist present, nor any anong the 12 WHO members from the secretariat. In
the whole process of the preparation of the WHO TM programme, medical
anthropologists did not participate, a stranae exclusion of the ^ly
professional group which, for years, has been involved in the study of
this field. The only exception was a PAHO working group to which we
will refer later. Neither was there a medical anthropologist among _he
editors of the WHO published book (1983) "Traditional Medicine and
health care coverage" (5). which leans heavily on an a^ocacy °f TM
and in which the editors were not keen to publish any critical notes
Friedr. Viewetj & Sohn Verlag. Braunschweig/Wiesbaden
Trudi t. ioua j Mp, i •; <_ j
js
net Primary Health Caro: a Polemic
65
(in fact the Organization reserves right to revise the text). This may
be one of the reasons for the lack of semantic clarity and of precise
use of words for concepts that have been well defined by anthropolo
gists.
I
)
In fact, two categories are often confused even by (non-medical)
anthropologists, i.e. •’traditional" and "alternative" medicine. "The
first category (traditional medicine, sometimes called, for example,
peasant, ethno-, tribal, or village medicine, depending on the subject
matter) represents simply the healing methods of traditional societies
whether elaborate or not. Alternative medicine (also termed para-, ho
listic, fringe, unorthodox, or natural medicine, etc. comprises the rather
newer therapeutic techniques like homoeopathy or chiropractics or me
thods like sensitivity training, endogenous endocrinotherapy, anthroposophical medicine, and many others not fully accepted by scientific
medicine or by health authorities. The confusion is increased by the
fact that the two categories frequently overlap, as in the case of
yoga, acupuncture, or the use of plant medicines- traditional techni
ques frequently used in industrial countries by the practitioners of
alternative medicine. The distinction is further complicated by the
use of some modern drugs by proponents of unorthodox medicine or
through adaptation to modern technologies (6)".
The WHO technical report n° 622 of 1978 (4) is the only one, among
several hundreds of technical reports of the Organization, which has
departed from a high technical standard toward a promotional advocacy.
It notes that professional health personnel regard TM as a practice
"on the decline and of no importance", but states "that this was a
serious fallacy in so far as culture itself, of which traditional me
dicine was an integral part, was neither static nor dead".
There is hardly anybody among ethnologists or social anthropolo
gists who has not failed to note, with regret, that traditional cul
tures are rapidly disintegrating everywhere. Whatever name is given to
this process, urbanization, modernization, industrialization, cultural
unification, progress, exploitation or wholly inconveniently, but most
commonly, "acculturation", this process has begun and is felt even in
the most distant rural areas. As a consequence, many worthy cultures
have been reduced to a culture of poverty. Medical beliefs and prac
tices begin to reflect more social class characteristics and limited
educational opportunities than the true culture specific features.
"Culture was defined generally as the sum total of the life-style, society
patterns, beliefs, attitudes and the commonly accepted organized ways in which a
community attempted to solve its life problems. Cultural change and development
take place with the acquisition of new knowledge or with a change in the surroun
dings of the people, who need to adapt in order to survive or to achieve a new life
equilibrium. In this context of cultural evolution, traditional medicine has always
developed and preserved its role of providing health care in all communities"(4).
But a few lines later the Report admits: "However, as traditional medicine
in some developing countries has tended to stagnate through not exploiting the ra
pid discoveries of science and technology for its own development, it has kept a
slow pace of change in. comparison with medicine as practised in the industrialized
countries, which keeps abreast of scientific and technological innovations to the
extent that it is often exclusively referred to as modern medicine"(4).
The very reason why TM has been superseded is that it had no builtin correction mechanism. The stagnation is the product of a lack of a
methodology of its own to carry out a permanent revision and critical
reassessment. TM has not helped indigenous people against cholera and
other enteric infections, sleeping sickness, schistosomiasis, trachoma,
onchocercosis, and other filariases, malaria, tuberculosis, and other di
seases which have decimated traditional people and has kept them in
the vicious cycle of sickness, poverty, exploitation and lack of deveFried’’. Vieweg & Sohn Verlag, Braunschweig/Wiesbaden
VELIM1ROV1C
66
lopment. It has not prevented death rates today averaging 93 per 1000
births and rates of infant mortality as high as 200 per 1000 in some
developing countries. This is then the praised "new life equilibrium".
All this does not prevent the Report stating (without a trace of an
skepticism) what at best can be an. assumption: Traditional medicine
been
shown tc have intrinsic utility, it should be promoted and its potential developed
for the wider use and benefit of mankind” and ”thai it needs to be fjiven due reco
gnition and developed so as to improve its efficacy, safety, availability and wider
application at low cost. It is already the people's own health care system and is
well accepted by them. It has certain advantages over imported systems of medicine
in any setting because, as an integral part of the people's culture, it is parti
cularly effective in solving certain cultural health problems. It has and does
freely contribute to scientific and universal medicine. Its recognition, promotion,
and development would secure due respect for a people's culture and heritage (4).
1)
(
There are, of course, many examples that illness perception, medical
beliefs, attitudes or some of the behavioural risk factors, etc., are
closely related to ethnicity or culture sensu lato and that there is a
a cultural context in the choice of therapy. However, the primary ob
jective of modern medicine today is not to solve cultural health pro
blems, in fact TM has accommodated itself with these problems and is
part of the problem. The people’s culture should be protected as much
as possible but TM is that part of culture least worthy of protection
(as compared with language,art, music, oral traditon, poetry,etc., which must
be protected by all means. MAHLER, Director-General of the WHO, belie
ves that culture (together with illiteracy and apathy) has been used
all too often as an excuse for lack of action. "And when we invoke
cultural barriers, we invoke another escape mechanism. For culture is
ever-changing and it is our duty both to conform to culture, to under
stand it and to accelerate its evolution in the right direction"(7).
An active process of change by education is meant here by involving
teachers, community workers, social workers, civic and religious lea
ders, trade unions, women’s organizations and various occupational
groups by better informing people through mass media, enlightening
the whole population on the prevailing health problems in their coun
try and their community and on the most appropriate method of pre
venting them and controlling them. All this requires understanding
and taking due consideration of the social forces that cause people
to act as they do. In concrete terms, there is a need for a change in
beliefs of disease causation and treatments. This means for example that tu
berculosis does not cane when a man or woman with fever indulges in sexual
intercourse, that leprosy or blindness are not a just punishment for
the sins of a previous life, that disease is not caused by eating
food touched by a low caste or by eating in the morning before taking
a ritual ablution, that disease is not the result of the wrath of
evil spirits, the evil eye, a breach of taboo, sorcery or a combina
tion of these. In the same way, one has to enlighten that the cure
for scabies is not cats’ or rabbits’ urine, that an eye infection
cannot be helped by the juice of green chilli or by blowing tobacco
smoke into the eye, nor can malaria be treated with a mixture of seven bed-bugs with seven betel leaves and seven peppers, that
tnat smearing
smeaiu
measles with red earth, worshipping and offering to some Goddess in
the event of pertussis, wearing magical beads round the neck for
j are neither preventions
jaundice and worshipping snails for leprosy
nor cures. For
For all
all o:
of tnese,
these, there
------- are effective and cheap scientific
medicines. Whether one should encourage that the child properly vaccr
nated against measles or whooping cough, and that the properly treated
tuberculosis, malaria or leprosy patient still wear "protectrye glass
beads or worship their deity, is then, and only then, an irrelevant
matter. But there will be no place anymore at the end of the twentieth century for the widely practised sucking of a stone
stone from the head.
Friedr. Vieweg & Sohn Verl»g, Br*un$chwfcig/Wiesb»den
Tr.idi t ional Medicine is not Primary Health Care: a Polemic
1
)
67
To protect TM in the hope of solving the health coverage of the world po
pulation by the year 2000 (among the many claims of advocates) is no
more than wishful thinking. Certainly most herbal remedies are inno
cuous, bone-setters can sometimes be equally effective as orthope
dists; thorn-pullers, noil and women's experts or barber-surgeons can
sometimes help as much as they did in the not too distant past of Eu
rope. It is known that villagers are not always eager to make use of
the dispensaries or hospitals at their disposal, even if these are
free and easily accessible, because the evil eye remover, the exorcist, priest or charm maker is more culturally acceptable or more
trusted. "In spite of the widespread operation and even £some limited
effectiveness (either psychological or empirical)”, ROEMER (8) writes
"their overall impact today on the health of the people must be consi
dered negative. It is perhaps less important that their ministrations
are usually medically worthless (if not sometimes harmful) than that
they have the effect of misleading sick people and delaying the pro
curement of sound medical care". There is a danger that the recently
observed change in the practice of parallel medicine,(the use of po
tions and the sale of uncontrolled, homeprepared "syrups", the use of
discarded, water-filled antibiotics containers, the hundred times re
peated use of discarded, unsterilized syringes) may bring new harms,
e.g. hepatitis B, to the trusting people.
Integration of what?
The main thrust of the WHO report is the outright advocacy of in
tegration of TM into offical medicine. It is said that "traditional
medicine has a unique and holistic approach - i.e. that of viewing man
in his totality within a wide ecological spectrum and of emphasizing
the viewpoint that ill health or disease is brought about by an imba
lance, or disequilibrium, of man in his total ecological system and
not only by the causative agent and pathogenic evolution"(4).
The "holistic approach" (discussed in another article which will fol
low) is the banner-bearer of the integrationist wave. If this term
has any meaning, it indeed applies to the TM concerned with the pa
tient's mind and soul, as well as with his body (more the former than
the latter in fact) and therefore some claims are valid, e.g. anxiety
reduction or a form of psychiatric intervention (see note 2,p.78). But
measles can be prevented only by vaccination and not by drinking uri
ne (or whatever substitutes are there when harmful or offensive prac
tices have been eliminated) , and polio is certainly not due to a dis
environ-
turbance of spiritual and physical factors in the personal environ
___ •healers
__i__ may of- course
---> mediate tct.ccr.
----ment. Indigenous
between ththe community
customs and the particular set of religious beliefs which can
’ ' in
• many
■
oe disturbed
ways. But
But to
to call
call this
this a a "tot?!
"total ecological
reductionism and semantic sloppiness.
system amounts to inadmissible
1..
Suggested procedures were thought (4) to be:
- an evaluation of therapeutic claims in order to select those types of treatment
easily adoptable for wider public use;
- where research in traditional medicaments is already progressing, drugs ano medici
nal plants, which have already been studied, could be prepared for immediate public
use, their production and manufacture being financed from state resources;
- more research to investigate all aspects of traditional medicine to improve methods, techniques and the composition of traditional medicaments;
- at the psychological level the collection of information on the positive aspects,
in order to communicate suer, knowledge to the political decision-makers and pro
fessional personnel employing other systems of medicine, and eventually motivate
them to accept ano actively participate in the application of traditional medicine
in public real tn care systems.
Friedr. Vieweg & Sohn Verlag, Breunschweig/Wierbaden
VEI.J MIROVIC
68
To shorten the duration of this public education process, the Mee
ting saw tne need for an "educational revolution in some countries,
during which there would be curricular reforms and revision of trai
ning programmes for medical and other health personnel to respond to
the needs of our time"(4).
Jumping on the bandwagon
i
The WHO programme gives TM recognition, before the above tasks are
achieved, by incorporating traditional practitioners into community
development programmes. This is thought to be possible by inducing the
population to believe that traditional remedies are not second-rate
medicine and by retraining traditional practitioners for use in pri
mary health care. TM has become respectable and many authors have
started, wrongly identifying it with PHC, community participation and
community workers. One of the proponents of integration has become the
US AID office of health, known for generous funding. Indeed some or
ganizations, such as Medical Mission Sisters from the USA, active in
22 developing countries, have become ardent propagators of the WHO TM
recognition-quest and even claim that they participated in the training
of TBAs at their Holy Family Hospital in Techiman in Ghana five years
before the WHO report. An elaborate training programme is set up fol
lowed by a 4-member team of teachers to visit the trainees etc., but
praise themselves, above all, that attention of American film-makers
has been mobilized for a 90 minute colour feature film for American
and World fund-raising agencies' consumption. The illusion that TM is
primary health care will be complete. Instead of "educational revolu
tion", it looks as if an educational contrarevolution is going on.
Each of the supposed advantages of integration is questionable:
- it dees not offer reciprocal benefit to each system, but is unilateral;
- it does not improve health care knowledge;
- it does not enhance the quality of the practitioners or only moderately so, again
unilaterally; and
- it. does not promote knowledge relating to primary health care.
The report notes :
(
"even where the policy was favourable, certain constraints were still- noticeable:
1. Payment of lip-service to the integration process.
2. Fear of the possibly harmful iatrogenic effects of traditional medicine.
3. Doubtful status of the products of integrated training in current social and
professional hierarchies.
4. Resistance by intransigent advocates of one or anothei system.
5. Fear of litigation, since the legal apparatus tends to protect only the entren
ched system, to encourage monopoly, and even to proscribe other systems (4).
The language again includes words such as hierarchies, intransigent,
entrenched system, monopoly, etc. What is xisted among the guiding
principles and prerequisites for integration amounts to the admission
of profound problems: "Seme guiding principles could be applied to most situa
tions to facilitate the integration process. A major constraint is the current lack
of information,- the results of a preliminary survey and the assembly of factual
data validated on modern scientific principles could be used to help to convince
decision-makers, professional health personnel, and the population at large of the
value of integration, usually through training programmes and strategies, such as
’the development of a common pharmacology to serve as a bridge between the various
’< systems. It would also be necessary to owJiin
ond J it-an"cial tjUppcrt and ensure eventual success (emphasis added). Another preiequis^te
would be the early establishment of a dialogue among practitioners of the diffe
rent systems in order to eliminate prejudices and to help them co develop more
acceptable attitudes. The demystification of several aspects of medicine would axso
facilitate communication, between practitioners and the general population (4).
Friedr. Vitweg & Sohn Veri*g Br*unjchweig/Wiesb»den
Tr.idi tic.::Al M'-.:i
tie
Primary Hvalti; Care:
a Pulrmic
69
What is obvious is that few health authorities would give a priori
guarantees of sociopolitical acceptability and legal recognition, or
grant financial support without first having information about the
true usefulness of the local traditional practices. In spite of over
claims, this information is .lacking, as the report has been obliged
to admit. We stated :
(
)
"This knowledge cannot be achieved other than by scientific methods
-i.e. by systematic and unbiased observation, and by the due examina
tion of data by the trained mind, which will lead to classification,
general rules, verification of hypothese, further observations and ex
periments and the alteration of assumptions. The scientific method is
a search for judgements to which universal assent may be obtained
(that is of those who understand the judgement). This notion is con
tained in the idea of progress of medicine. This idea does not mean
exclusion of traditional medicine if it could make genuine contribu
tions to health care. Science does not exclude tradition and precious
heritage, it involves a developing tradition. But the above methods
are the minimum requirements before one can step from inductions to
deductions to be presented to governments, to those who will make the
decisions. Without them one cannot give responsible judgement but only
one that is untenable, ill-chosen, irrelevant or badly made. What is
needed, therefore, is a body of tested hard facts to clarify the role
of TM today (6)."
The language of the WHO report is not dispassionate and objective.
For example: "The tremendous success of the Chinese experience in the
integration of western medicine and Chinese traditional medicine con
tinues to provide the shining example of the potential which lies in
integration for the promotion and development of systems of traditio
nal medicine (4)".
)
In fact, Chinese experience is contested, also in China as has been
repeatedly reported in the press in the last few years (9). Few people
know that so-called barefoot doctors, whose role is emphasized now,
are not a traditional but a new category of health personnel. Indeed
there is a rapid change and return to competitive examinations and
speciality training in China. Indeed, one should go to Honcj Kong to
study the role of Chinese medicine. Among five million people (90%
Chinese), there are still some who use hornets, pulverised horns of
various animals or human sperm as omnipotent heal-all. However, the
overwhelming majority use the Government scientific medicine services
(500.000 hospitalizations in 1980 and 13 million treatments in out
patient clinics- exactly double the amount of 10 years previous) in
spite of all the proclamation at international congresses of the vir
tues of traditional medicine. Is this net a sign of a mistrust of the
culturally accepted indigenous medicine or is it a sign of its ineffi
ciency?
The WHO report gees on about the approaches to integration: "It was considered
that a cautious approach would have to be adopted to achieve success. The process
could begin with basic research on educational systems, together with an investi
gation of ancient literature, fundamental principles, common drugs in use, princi
ples of diet, problems of environmental hygiene, and other areas which are of inte
rest to all the systems of medicine practised. Adequate knowledge in these fields
having been acquired, the mechanisms of integration could then be worked out for
implementation. The initial attempt at integration, for most countries, should be
by research and studies in traditional medicine, with a view to assessing its
claims and validating them, on scientific bases. Once this was done, acceptability
would increase and integration into existing health care systems would be possible
and even easy to achieve. It was observed that the greatest resistance to integra
tion often came from administrative intransigence, and therefore the national pcli-
Friedr. Vieweg & Sohn Verlag, Braunschweig/Wiesbaden
VEbIMIROVIC
70
tical decision-makers would have tc be convinced of the need for such action. The
concept of integration is certainly not -easy (4).” It admits that adequate .knowled
ge and objective evaluation are not available but it then passes over to concentra
te on advocacy!
The report senses the problems and incongruency of the integration.
Fundamental problems which make integration very difficult, or even
impossible in certain settings, were identified, among others, as
follows:
-"Emphasis on the cultural formulation of traditional medicine.
- Impossibility of integrating certain aspects of traditional medicine based on spi
ritual, moral or other fundamental principles - e.g. exorcism and special healing
arts associated with spiritualism.
- Commercial motives which control the modes of practice in certain settings.
- Fundamental differences between the concepts of life, health and disease - concepts
upon which the underlying philosophies of the various medical systems are founded
(4)".
(
■)
Nevertheless, in spite of this correct statement, the report pro
ceeds, without previous studies to promote the outright integration
of traditional and modern scientific medicine and health practices.
It goes on to state that WHO could promote integration by:
"1)Encouraging and collaborating with Member States to develop and formulate natio
nal policies directed towards integration;
2) Encouraging dialogue between the practitioners of the various systems;
3) Recommending the use of integrated teaching programmes in educational and trai
ning systems;
4) Promoting integrated research on traditional medicine;"
Among the measures recommended by the report on the national level is: "Repiace• ment of existing council or board members with more receptive people who would ap
preciate the need for change to meet present-day exigencies (4)" (emphasis added).
The report also focused on the development of the existing manpower
categories, orientation of professional health personnel, to relevant
systems of traditional medicine and to traditional birth attendants,
who are a widely known category, to modern maternal and child care,
"also on the training in Ayurveda, Siddha, Unani and Yoga,, training
in Chinese traditional medicine, including acupunture, integrated
training of the various types of practitioner, consideration of psy
chological and cultural factors in training traditional manpower ca
tegories, instructors and supervisors (4)'*.
This was all recommended without preliminary studies or any speci
fication about where and how this should be done; neither was there
any questioning as to whether it is at all feasible to do it in all but
exceptional situations. Orientation of TBAs where possible (age factor)
(10) could replace using cow dung on the umbilical stump with a clean
dressing, oral rehydration could be given effectively if conditions
were favourable. But does this mean training in Ayurveda, Siddha,
Unani and Yoga etc., should be promoted all over the world? That mo
dern physicians should be trained together with various other types
of practitioners? In most concrete cases, this would mean teaching a
combination of various sets of beliefs with the scientific principles
the modern physician is expected to have and use and which are not
compatible. The report is silent about the quality of care - lack of
its control - probably as this is not possible tc enforce in the rural
setting. Anyone can suck the stones out of the kidney, expelling bad
blood by incision, as in the Middle Ages, practise female genital mu
tilation, etc. But can a physician dispense with the basic reasoning
behind the skills he has learned in his technical studies, even if
he is maximally sympathetic to the inductive observational empiric
learning ?
Friedr. Vieweg & Sohn Verlag. Braunichweig/Wietbaden
Traditional Medicine is
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Primary Health Care: a Polemic
71
Even in acupunture which has gained a degree of acceptance inmany
European countries, there is still much controversy on how this should
be taught and no agreement has been reached about the manpower to be
allowed to practise it or on methods for its evaluation. TM should
neither be ridiculed in its original form nor in its contemporary
p^ctiles! Hen in the face of hakims or their aids ritually using
stethoscopes without being able to understand what they hear. If
scientific medicine is to be carried into rural areas, then it is
cessary for medical practitioners to acquire considerable kno^e^®
of the general concepts of cultural and social organization and spe
cific knowledge of rural life and culture” wrota McKim (11) al^ady
in 1955. "The successful establishment of effective medicine here
appears to depend largely on the degree to which scientific .edicine
practice can divest itself of certain western cultural accretions and
clothe itself in the social homespun of the Indian village . Modern
medlclnl must respect feeling, piety, Philantrophy, sympathy famxly_
structure, relatives, even change where required outward forms or oe
livery (e.g. physician who does not himself Prepare
candicine but writes prescriptions is considered ineffective) but it can
not "mplomise on ?he basic principles of science. When ,°r example,
Ethiopian indigenous healers "wageshos
cut out a child s uvula as
treatment for a fever, no compromise is possible.
Stereotypes
experienced medical anthropologists,
FOSTER (12) , one of the most
traditional medicine that have been
warns
popularize^ove^the^ast generation which are worth quoting in ex
tensive: Traditional medicine is holistic, modem medicme sees on^
"One of the principal arguments advanced in favour of co-opting tra
ditional curers is^hat they know the family background of their pa
tients and can hence weigh psychological as”*11** nt villages this
in deridina what to do. In relatively isolated peasant villages tnis
is certainly true. But many areas are increasingly subject to P°P““
lation movement. Traditional healers inevitably will know muchless
about most of their patients than in stable villages.
Even 1 st.
hl a villaaes the cures for such illnesses as empache, mal de 030,
si:to ^d9Miish:eCem to be remarkably standardized. Sufferers are
treated much in the same way by the same curandero
th«J;**te^he
knowledge of the family plays a minimal role m therapy.
family-oriented, holistic argument for the incorP°”^°"
tional curers into contemporary health services would appear to be
far weaker than it is often thought to be .
(
)
Traditional curers are relatively old, hiMu resvccted people in ^^iTcare^
and because of their status they should be valuable allies m primary health care.
It is certainly true that elderly herbalists with a profound knowledge
of traditional remedies, or famous ^^’ns-i^P^e confidence in thei
patients. But to assume that because they fulfil this roie
traditional setting they will do so in another setting is careless g
neralizing. Aguirre BELTRAN (13) whose practical experience
how
ducina health services to traditional peoples is unrivaled, tell
>
•n the early years of the National Indian Institute’s work in Chiapas
he and his colleagues assumed that working through local shamans would
fL??itate the introduction of health services. They were astonxshed
to find enormous resistance to this approach. Old and P^^™*?*50ple were found not to be the best intermediaries for socio- ulura
change. Specialized health training for young literate peopieproved
to be a more practical approach to the problems encountered. This IS
not to arque that mature traditional curers who enjoy high yesPec^
ver be considered for new health roles. But Aguirre Bejtrans experien
ce shows that a particular stereotype should not be automatically
accepted.
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72
VEI.1MJR0VIC
inui :
i. r'iillneitst inic t.uo uaL>::irriu.:: Lne j'ier.i,, i'. nc.:.
:::ick!.y cure; i.he ;:ccondt "folk'* illnesze:’, the very cxii'icnce of
■jhich yl.yi'ioianr, deny. This adversary model, perhaps the first medical
anthropology model, has been widely accepted as a predictor of the
choices in care that will be made by traditional peoples. It does
appear to nave had some validity in the early years following the in
troduction of modern medicine but, after a fairly short time, it no
longer has much predictive value. The striking thing, in many parts of
the world, is that today where the services of a physician have been
available for a sufficient length of time and are accessible, he is
the first choice of most people for most complaints (14) (15).
Physicians practising in traditional settings frequently are ignorant of tra
ditional medicine; they fail to understand its vocabulary and its underlying ra
tionale and hence they have difficulties in communicating with their patients. Like
the adversary model, this is another early stereotype developed by an
thropologists. Yet, it may often fail to describe reality, rhe author
has been impressed with the physician's skills in eliciting informa
tion by use of traditional vocabularies and disease concepts. Far from
not understanding these usages and beliefs, they are perfectly fami
liar with them and they know how to use them to best advantage to ob
tain the information they need for their diagnosis. Probably many re
searchers are guilty of underestimating the insight and sensitivity
that physicians must display when many of their patients are traditio
nal peoples. (12).
Official Medical Roles for Traditional Curers and Traditional Medicine? Foster
writes: "In asking this question, it is natural to consider experience
gained to date. Most of it is limited to two areas: the upgrading of
indigenous midwives, and the use of traditional curers for mental ill
ness. But success with midwives and mental illness treatment does not
necessarily mean that other curers can easily be incorporated into
official health services. In the case of pregnancy, both midwife and
physician agree about the onset of the condition, its course and dura
tion, and its probable outcome. In the absence of conplications, both
do about the same thing. With respect to the treatment of mental ill
ness, psychiatry is the least exact of all forms of medicine, the
field in which - at least in stress-induced conditions - it. is most diffi
cult to predict the outcome. The symbolic and supportive roles of tra
ditional curers do often seem to lead to successful outcomes, at least
to the alleviation of symptoms in sufficient degree so that a patient
can continue to live at home.
(
/
But beyond these two fields, the problems become more difficult.
When the physician diagnoses a malignant tumour requiring surgery,
and the medicine man an intruded disease object that can be removed by
sucking, are there real grounds for cooperation? The greatest danger
in the use of traditional curers, it has often been noted, is that in
really serious cases the patient may be brought to the physician when
it. is too late to help. With respect to the general question of the
desirability of incorporating traditional curers into contemporary
health services, one feels that most anthropologists want the idea to
work.
Yet even with this bias, considerable skepticism was expressed by
a number of anthropologists as to 'how feasible this approach is' , and
reasons were cited as to 'why incorporation of traditional healers
into official health systems probably would not work well', among them
the fact that removing healers from their neighbournood environments
and subsuming them within a clinical organization and setting would
destroy tne therapeutic advantages provided by the intimate magicoreligious ambiance of their home consultation rooms (16), would entail
a denial of TM practices (17). Some, even for reasons of political
and professional reality, doubt that there is much role for indigenous
midwives (10)
(18).
Friedr. Vieweg & Sohn Verlag, Braunschweig/Wiesbaden
r adit i cni.i 1 Xc-.i i ci n*. i s
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)
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ry Hea 1 h Car<•: a P'’-•»i::
73
"Still another reason to doubt the practicality of incorporating
traditional curers into official medicine is pointed out by Wagner (1 S3
in his study of the Navabo: there are not as many singers as in the
past, and those remaining appear to be less knowledgable and less com
petent than in former times. Reliance upon "white medicine" probably
explains this decline. Wagner's point is true of much - perhaps most of the developing world. Serious consideration of incorporating tradi
tional personnel into contemporary health systems is based on a false
assumption: that traditional curers continue to be produced at the sa
me rate as in the past. Abundant evidence indicates that this is not
the case. Wherever the matter has been investigated the same situation
recurs: many curers a generation ago; few, and less-prepared curers
today. Do doubts as to the advisability of incorporating traditional
curers into official health services mean that anthropologists feel
traditional medicine can be ignored? The answer, clearly, is "no".
Probably all anthropologists agree that health personnel should know
more about, and understand and appreciate, the contributions tradi
tional (and "alternative") medicine makes, and can continue to make,
to health care. The ability of practitioners of modern medicine to
modify their normal practices to more nearly meet patient expectations
is one example of how this understanding can contribute to better me
dical care." (12)
In the field of mental health, a "cooperative relationship" between
traditional and professional mental health care providers has been
suggested (16). The most viable alternative to attempts to incorporate
traditional curers into official medicine may well be the training of
people who are full participants in their own cultures in medical
knowledge of official medicine (20).
Apprehension about the measuring rods
The success of the WHO initiative to promote TM is, in the words of
its speakers: "The growing interest in the subject, large numbers of Jet<_ers of
enquiry, numerous international conferences that have been held or are being planned
with or without WHO collaboration. There is, in addition, a growing volume of arti
cles on related themes appearing in scientific journals and lay publications while
many institutes and agencies are seeking to associate themselves with WHO as colla
borating and training centres, or in making films on different aspects of
(1).
All the above is true, but what does it prove?
Letters of enquiry in Europe have been mostly from staunch belie
vers of alternative groups (not from those interested in traditional
medicine) hoping for legitimization of their ideas, rejected by offi
cial medicine; conferences on anything are held where there are sudden
ly funds to hold them. No doubt WHO has a considerable moving force,
which persists with some delay effect even when the original impulse
ceases, as manifested by the flood of books on this topic which appear
yearly. The printing machine starts rolling, not only for valuable
books of medical anthropologists always interested in the studies of
healing consciousness and culture cohesiveness but also and particu
larly for lay publications written by lay people and by what Sir Peter
Medawar calls "intellectual underworld". There is always pressure in
the form of requests for collaborating centres in any field: an infla
tionary tendency engendered by the respect which such centres generally
carry. And above all, "the field of traditional medicine is an area
where various groups with different vested interests, including com
mercial interests, are trying to gain greater prestige and attention;
some would like to have WHO's backing for these purposes" (1).
One should, of course, not confuse the interest in the subject of TM
per se with the definite increase in interest in and attention given
to the developing world. Faculties of ethnology, formerly attracted
10-20 students; today there are 2000 in West-Berlin alone. For many
Friedr. Vieweg & Sohn Verlag, Braunschweig/Wiesbaden
VEI.IM1ROVIC
74
aspirants of doctoral degrees at the Universities, and sociologists
constructing their own reality in so-called empirical research, medi
cal anthropology, ethnomedicine is an attractive field. More students,
including young physicians and nurses go today to developing countries
than ever before, to have a different life experience looking for an
enlightenment, for alternative to the technologized societies of the
West. They all find themselves confronted with health and sociocultu
ral phenomena for which they have not been prepared and some are sus
ceptible to the influence of anecdotal evidence. One should separate
from this general interest the laudable efforts of medical anthropolo
gists to make contributions to clinical praxis, to make anthropology
relevant and useful for the needs of clinicians, enabling them to pro
vide broader patient care including nursing and bring closer the cul
tural conception of mental health and therapy.
)■
Even WHO seems to have been apprehensive about the side effects of
the process set in motion so that the Chief of the TM programme in
WHO (1983) suggests: "What is imperative now is that WHO should stand
back and evaluate the traditional medicine programme”, though this
still may imply that "such a critical analysis will serve to identify,
classify and develop the different disciplines involved, and map out
clear grounds for further programme growth", it also admits thus that
the initiative was launched without a very clear idea of what it would
bring. The two major lines of action have been outlined (1) as:
Evaluation of traditional medicine and practices to separate myths from real
ity". It is not difficult to predict that traditional medicine may be found to
be inconsistent or even, in many cases, outright antagonistic to the goal of a
assuring the best possible status of health for all people.
- " Research into traditional medicine as part of a national health system as not
much is know about possibilities that exist for making use of TM in national health
delivery systems in countries willing to use it". This is what medical anthropo
logists who started such studies long before WHO's initiative have maintained all
along. One may predict that this will down only to "setting herbal gardens at
familiy and community levels to ensure that safe herbal remedies are available to
self-care" (ll; an inoccuous and useful part of many aspects of TM.
Furthermore, WHO puts emphasis on training which is beset by the
uncertainty of how to train traditional practitioners and.perhaps
even the doubts that this is possible or advisable (except for tradi
tional birth attendants, where they are trainable.
Primary health care versus unrealistic expectations
(
)
High humanitarian intention behind the WHO initiative, motivated by
the wish that access to health be extended to all people, is not de
nied. If anyone, the WHO has cognizance that, unfortunately, large
segments of the people in the developing world have no recourse to mo
dern medical attention and that, with the doubling of its population
every 32 years, the situation is serious. Sincerity is thus not con
tested but we submit that the TM initiative was a mistake, a confusion
between objectives and methods. Emotional self-indulgence, added by
the political pressure from countries where some systems of TM have
operated for centuries, has pushed the resolution through at the WHO
Assembly.
• This mechanism is simple; it usually suffices to have a few promoting countries
for a resolution to be presented. In the quest for consensus, voting is rarely re
sorted to and acceptance is usually by acclamation (as was the case with TM). rhe
countries which consider the resolution irrelevant to them may sometimes anstain or
accept out. of courtesy. Such resolutions de not oblige anyhow, but, once accepted,
the resolution gains respectability and may be quoted at will and for any purpose.
Friedr. Vieweg & Sohn Verlag. Braunjchweig/Wietbaden
Traditional Medicine is not Primary Health Care: a Polemic
1
■
)
75
The political influences in TM maintenance in some countries after
their national transformation are well-documented (see Note 1). The
climate of opinion was favourable. Many people have no idea of the lag
in development of modern health service programmes in rural areas in
developing countries, some may be condescending or uninformed about
the merits or lack of them or the way in which the people help them
selves in the absence of medical and health care. After all, TM is
physically and economically accessible. However, the WHO initiative
may have released unrealistic expectations and detracted from the main
goal of assuring adequate primary health care for all. Far from being
a step forward in providing this missing care, it seems in fact to be
a reactionary step behind, it tends to institutionalize the status quo,
it creates double standards - one for rural areas and another for urban
centres and those who have the economic means to procure good or bet
ter care for themselves. It assumes implicitly that nothing could
change in the years ahead in the countries which have presently no
adequate health services, and thus negates WHO's own drive to develop
primary health services everywhere. It suggests that people cannot be
educated and staff cannot be rapidly trained in countries where the
overwhelming majority of the population is younger than 15 years, nu
merous examples to the contrary from recent history notwithstanding.
As has been documented in WHO publications (21,22) there is no need to
copy any model in the organization, staffing, etc. from the commercia
lized medicine in the West; there is a range of devices and innovative
modes at hand to suit needs of any set of circumstances in even the
poorest of the developing countries. Economic difficulties are not de
nied (see Note 2) but they are no excuse for lack of will and action.
The attempt to train indigenous healers that might incorporate them
into the modern system is perhaps possible in some places, but is a
poor substitute for the true development of scientific health care.
It retards efforts in this direction by pretending that something is
being done or relegates the responsibility to traditional healers in
stead of trying, as difficult as it may be, to bring something new to
an underseived population.
If the objective was the rapid achievement of coverage, the study
of traditional medicine is only of secondary importance.• What matters
here is any imaginative approach to establish primary, basic, low-cost,
health workers for the people, reorienting the thinking of health
personnel and creating a new type of health worker according to the
needs of the country, culture and level of socioeconomic development.
Any innovation or creation of new types of health force could be
considered that might involve the community and fit into particular
political and social situations (6). In India, for example, young li
terate, married local girls have been hired and trained as Female
Village Workers, a programme for a variety of tasks from family plan
ning to diarrhoeal disease treatment and tetanus immunization. If
the economic development of a country is the goal, the transformation
of a society’s social structure and of its traditional institutions
is a precondition,* in this process, TM is marginal at best or an
hindrance at the worst (6).
The WHO resolution cannot be reversed and neither would this be
politically possible in an increasingly politicized organization. For
tunately, there now seems te be a more sober, more realistic tone dis
cernible in the fundamental documents of the WHO. In the "Global Stra
tegy for Health for All by the Year 2000", a 90 pages script (23), pu
blished by WHO in 198!, and in the 1983 documents*, the role of TM is
*CPC/MIM/» 3 Annex 5, p.31 and 33, Common framework and format for evaluation the
strategies for’Health for All by the Year 2000’(Health Manpower Development).
Frieor. Vieweg & Sohn Vedag. Braunschweig/Wiesbaden
76
VEIJMIROVIC
mentioned only very discretely and vaguely: "At the same time, full atten
tion will be given to the reorientation and retraining as necessary of existing
nealth workers, including measures to enable them to assume an active role in com
munity health education. Consideration will also be given to the d<?veloj»ment of new
categories of health workers, to the involvement and reorientation as necessary of
traditional medical practitioneis and birth attendants where applicable and to the
use of voluntary health workers".**
Emphasis is today on health workers, their retraining, community
involvement. This requires not only participatory efforts but also a
system coordination with other sectors (economic, educational, etc)
and a mechanism for constant improvement in order to deliver continu
ously equitable health services and the achievement of modern medicine.
There is no mention of integration and the whole effort appears now to
be concentrated on research in phytotherapy and birth attendants where
applicable. Rational debate would center now, it seems, around the
issues of cost and utility. Justly so!
J
Finally a word about the attempt to use traditional practitioners
for delivery of oral rehydration salt for treatment of diarrhoea. ORS
is so simple and so effective that it can and should be given by each
mother to her child. It is, at the same time, both a medicament and
nutrition and there is no need for an intermediary. It is understan
dable why proponents of TM want to enhance the respect of traditional
practitioners by giving them a truly effective treatment tool, but
the propagation of ORS is best done by the health and educational sys
tem and the problem of its availability and distribution cannot ob
viously be solved by traditional practitioners.
The long-term trend (and, of course, the relatively short one until
the year 2000 as well) Roemer writes: "is clearly towards reduction
of the dependance of rural people on primitive medicine and a heighten
ed utilization of scientific sercives that are offered" (8).
The advocates of TM may continue to ask:
J
- Wnat damage is done if we cannot give people something better?
- TM will disappear by itself in time, so let them use what there is,
what they have,now.
- People are well able to distinguish between a situation when TM can
be used (for minor ailments) and one where scientific medicine is
needed, so let TM diminish the burden on health services or some might
use both lay and professional care - what is wrong in that? Many high
ranking organizational administrators, after a visit shorter than that
of the average tourist, are able to say: "It (TM) works; I have seen
it for myself", and how scientific is scientific medicine anyhow?"
- Are the thousands of drugs produced by the pharmaceutical industry
all scientific?
- Are they all tested for efficacy and justified by controlled trials?
- Is the usage of really scientific drugs, such as antibiotics in dai
ly practice, scientific?
- Is the overuse of X-ray examination by many physicians a comforting
ritual or medically justified? A group of top radiologists convened by
the World Health Organization concluded that many are "not worthwhile"
and are a "major source of population exposure to man-made ionizing
radiation".
’'Incidentally the best. PHC village handbooks ever to be published did not originate
from WHO but from the Hesperian Foundation in the USA: "Where there is no doctor”,
the most widely used health care manual, printed in 20 languages, and "Helping
Health Wotkers Learn", used in developing countries. WHO has produced a much less
successful, hybrid book, "The Primary Health Worker, working guide for training,
guidelines for adaptation", Geneva 1980.
Friedr. Vieweg & Sohn Verlag. Braunschweig/Wiesbaden
Modi
is
r Pr'.7;.C »rv: a
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77
- Why does also the developed world not make as much use of vaccinations as it could?
- Is the attitude of a scientific practitioner not to inform the Pa~
tient about his state of health, the nature of his disease, etc., stil i
a responsible and ethical one?
All those questions are valid but are irrelevant in respect to TM.
They are not easily discussed but should be asked and eventually sol
ved; however the developed world has gone a long way in providing
primary health care to its population. They can be solved by stricter re
quirements on science and ethics within the context of modern medicine.
TM on the other hand may ’be» an obstacle to the provisions of adequate
main goal and objective of the present.
primary health care, the
t
What health care for the people?
What policy option have the governments vis a-vis medical care of
their peoples? A preamble of the WHO Constitution affirms:"Governments
have a responsibility for the health of their people which can be ful
filled only by the provision of adequate health and social measures .
The World Health Assembly 1970 Resolution 23,61 states that the most
important condition for the attainment by all peoples of the highest
possible level of health "is the development of efficient national
health systems in all countries." This can be achieved, inter alia,
"through the establishment of a nation-wide system of health services
based on a aencral national plan and local planning (Rec.1), the
provision for the whole population of the country of the highest pos
sible level of skilled, universally available preventive and curative
medical care" (Rec.4), "the extensive application in every country of
the results of oin world ntedieal research and public health
practice" (Recommendation 5).(Emphasis added).
Thus. can governments be neutral in the question of what kind of
health care do their people receive? The role of WHO in the solution
of particulars which arise with legislative and administrative provi
sions dealing with therapeutic and prophylactic care and health pro
tection in general is very limited indeed since they lie within the
jurisdiction of the different nations but this does not preclude WHO
from engaging in the scientific study of these problems, for which it
is well equipped in view of its position as an intergovernmental or
ganization. In respect to TM, WHO should be doing just that instead
of being a TM advocate. The question to be answered clearly and dis
passionately is "how useful are particular medical practices, skills
and personnel against identifiable medical problems (24).
One certainly should look for alternatives, particulary when large
institutions, sometimes coercive and always expensive organizations,
with their all- regulating blueprints encroach, when human sympathy
gets lost. But we submit that the viable alternatives are not TM in
developing countries (or various alternative movements in the deve
loped world) outside of scientific medicine. They are to be found
within modern medicine in the search for better, cheaper, less mar
ket-oriented and bureaucratic ways to arganize it, in the quest for
better skills and knowledge and for a more humane form of delivery o^
health care in the frame of more equitable economic relations.
¥
note
*
*
1
rne f'rs* nlact- ■=, rvcnqiiition that, contemporary traditional prac.ict-s do n.
..
he h X.t achievements ot the ancient civilization. Secondly there xs Un oolie.
that the decline of indigenous culture, science, and religion is in great measure
attributable to their suppression during long periods of foreign tule and the imp
Lion of alien cultures. The third feature follows loojcally from the second, i...
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78
VELIM1ROVIC
the demand for state patronage from the new nationalist regimes for the restoration
of indigenous values. The consequence of these attitudes is the development of a
political orientation on the part of revivalist leaders, of a demand for governmen
tal interference in areas from which most modern secular states have either tended
to remove themselves or on which they have been prevented from imposing political
criteria by the existence of independent interest and professional organizations.
(
>
These common features of revivalist movements are apparent also in the Ayurvedic
movement, which began to receive political support first in the Indian National
Congress, which passed annual resolutions demanding the Governments'patronage for
Ayurveda from 1920 onwards. With the gradual development of representative institu
tions and the increasing entry of Indians into the executive councils and legisla
tures in the provinces, the patronage of the provincial governments began to be ex
tended to both the granting of assistance to the instruction in Ayurveda and the
establishment of new Ayurvedic educational institutions. The modern medical system
occupied a clear position of superiority in government allocations, in educational
standards, and in the extent of internal professionalization. In order to change the
balance between the two systems, the leaders of the Ayurvedic movement adopted the
political strategy after Independence of demanding full state support to make it
possible for Ayurveda to attain what it had not been able to achieve by its own
efforts. One of the main tactics used to make this political strategy effective was
to identify Ayurveda with nationalism, national independence, and national aspira
tions. In other words, the strategy of the Ayurvedic leaders was to confront the
political leadership of independent India in its attempts to deal with problems of
medical education and medical relief with political demands which had nothing to do
with educational or scientific standards.
Specifically, the demand was made immediately after Independence that the emancipa
tion of Ayurveda should go along with the political emancipation of the country
through wholehearted government patronage and its declaration that, henceforth,
Ayurveda would be the national system of treatment. In consequence there was a
creation of a large and entrenched educational establishment producing hundreds of
graduates annually, qualified neither in Ayurvedic nor in modern medicine, but who
demand the status and privileges of modern medical graduates. Thus, the Ayurvedic
movement presents an unusual case of penetration of the political system by educa
tional interests who have failed to establish a viable educational structure and
used the political system to maintain themselves. The vast majority - perhaps as
many as ninety per cent - of the students of Ayurveda were failures in secondary
school, unable to gain admission to a modern medical school or to some other modern
professional school and who went to the Ayurvedic colleges as a last resort.
)
Pure Ayurveda cannot possibly cope with the major public health needs of rural India
- the control and cure of infectious and communicable diseases. Moreover, for the
last forty years, the system of medical education in Ayurveda, which has been pre
dominant in most of the Ayurvedic colleges, has been what is known as the integrated
or mixed system, in which both Ayurvedic and modern medical subjects are taught.
Both the pure Ayurvedists and the proponents of scientific medicine agree that this
system has produced thousands of poorly trained practitioners of medicine unquali
fied in either system, making use of dangerous drugs about which they have inade
quate knowledge. (Based on an unpublished research manuscript by P.R. BRASS).
NOTE 2
YOUNG (1983) writes that "Traditional healers who treat psychiatric ailments are a
class apart for two reasons (35). First of all they provide a service which is gene
rally given low priority in the official health sector", "Second, psychiatric synptomatology is deeply embedded in culturally specific systems of meaning and communica
tion; the universalistic claims of modern psychiatric medicine are frequently pro
blematic and the relative efficacy of many of its practices is uncertain".
The above article is a valuable analysis and attempts to provide answers to the uti
lization sf TM in modern primary health care. The author (an anthropologist) however
is probably not familiar with Ayurvedic, Unani and Chinese drugs which he considers
as equally effective as scientific drugs and believes that they can be "intercala
ted” into the armamentarium of the official medical sector. He is however careful to
stipulate certain safeguards as to how this could be done without harm!no the patients.
Friedr. Vieweg & Sohn Verlag, Braunschwetg/Wiesbaden
r
Traditional Medicine is not Primary Health Car*'. a Polemic.
79
REFERENCES
(1) AKEREIE, O.
(1983): Which way for traditional medicine. World Health,p.3-4
(2) DJUKANOVIC and MACH (1975): Alternative Approaches to Meeting Basic Health Needs
in Developing Countries. Geneva. WHO.
(3) DJUKANOVIC and MACH (1976): Afro Technical Heport Series, N°l, (African tradi
tional medicine. Report of the Regional Expert Committee), pp.3-4.
(4) DJUKANOVIC--and-MACH (1978): Promotion and development ci traditional medicine.
Tech.Rep. Series 622. Geneva: WHO.
(5) BANNERMAN (Ed.) (1983): Traditional, medicine and health care coverage, Geneva: WHO
(6) VELIMIROVIC, H.
(1982): Round Table. Traditional Medicine in Modern Health Care.
World Health Forum vol.3, N*l:24-26.
(7) MAHLER, H. (1983): Health for All - Everyone'a Concern. World Health, 2-4, AprilMay. Geneva: WHO.
(8) ROEMER M.I.
M.I. (1976): Health Care Systems in World Perspective. Ann Arbor:
Health Administration Press, University of Michigan.
(
R.& v. SIDEL (1982): The Health of China; Current Conflicts in Medical
and Human Services for One Billion People, Boston: Beacon Press.
(9) SIDEL
(10)VELIMIROVIC
H. & VELIMIROVIC
B.
(1978): Use of Traditional Birth Attendants.
Curare 1:85.
(11) McKIM M. (1955): Western Medicine in a Village of Northern India, in "Health,
Culture and Corrmunity".P.239.
PAUL.B.D. Ed. Russell, Sage Found., N.York
(12) FOSTER G. (1978): Preface to the book: Modern Medicine and Medical Anthropology
in the United States-Mexico Border Population. Ed. VELIMIROVIC (25).
(13) BELTRAN AGUIRRE G.
10-13.
(1978): Training Programs in Intercultural Medicine,in (25):
(14JMOORE L. Augustin quoting (1978): Medical Anthropology in a Border Context,
in (25):43-48.
(15) VELIMIROVIC H. (1972): Krankenheilung bei zwei Philippinischen Gruppen, bei
den Tagalog am Taalsee in Batangas und den Kankanai-Igorot in der Provinz Denguet auf Luzon. Phil. Diss., FU Berlin.
(16) CHENEY Ch. & ADAMS G.L. (1978): Lay Healing and Mental Health in the MexicanAmerican Barrio, in (25):81-86.
(17)KEARNEY M.: Espirituaiismo as an Alternative Medical Tradition in the Border
Area, in (25):67-72.
(18) KAY M. (1978): Parallel, Alternative or Collaborative: Curanderismo in Tucson,
Arizona, in (25):87-95.
<
(19) WAGNER R.M. (1978): Peyotism, Traditional Religion and Modern Medicine .-Changing
Healing Traditions in the Border Area, in (25):139-146.
(20) JUSTICE W.L. (1978): Training Across Cultural Barriers. The experience with the
Indian Health Services with the Community Health Medic Training Programme, in
(25): 96-108.
(21) JU6TICE-K.L-. (1979): Training and Utilization of Auxiliary Personnel for Rural
Health Teams in Developing Countries. Rep. WHO Expert Conmittee TPS 632, Geneva:
WHO.
(22) JUSTICE W.X. (1978): Utilization of Auxiliaries and Conunuaity Leasers in Health
Programmes in Rural Areas. Report of a meeting. Scient. Publ. 296. Houston/
Texas: PAHO.
(23)JUSTICE-WJE. (1981): Global Strategy for Health for All by the Year 2000.
Geneva: WHO:p.66.
(24)YOUNG A. (1983). The Relevance of Traditional Medical Cultures to Modern Prima
ry Health Care. Soc. Set. Med. Vo)
17, N" 16, pp. 1205-1211.
(25)VELIMIROVIC B. Ed. (1978): Modern Medicine and Medical Anthropology in thu.
United Statcs-Mexico Border Population. Washincton:PAHO.
Friedr. Vieweg & Sohn Verlag, Braunjchweig/Wiesbaden
'''A.'
0277-9536/87 53.00 + 0.00
Soc. Sei. Med. Vol. 24. No. 2. pp. 177-181. 1987
Copyright C '987 Pergamon Journals Ltd
Printed in Great Britain. All rights reserved
THE BEST OF BOTH WORLDS: BRINGING TRADITIONAL
MEDICINE UP TO DATE
Olayiwola Akerele
World Heai'.h Organization. 1211 Geneva 27. Switzerland
Abstract-If there is to be any real improvement in the health of the underserved populations of the world
there will have to be full utilization of all available resources, human and material This is fu"dan^nld'
to lhe primary health care approach. Traditional practitioners constitute the most abundant and. in many
cases valuable health resources present in the community. They are important and mfluenha members
of their communities who should be associated with any move to develop health services at the local level.
There have been varying responses to a number of key WHO resolutions that call on Member Slates to
develop traditional medicine activities as part of their national health serv.ces. Some as^ of
of WHO Collaborating Centres for Traditional Medicine and some current acuv.ties of the tradmona
medicine programme are described. A number of guiding principles which may help the Orgamzalion
other international and donor agencies working in this area are also suggested.
The resurgence of interest in traditional medicine has
been matched by significant work in different aspects
of traditional systems of medicine by academics and
analysts mainly outside the aegis of WHO. While
these efforts are acknowledged and encouraged, it
would be beyond the scope ot this paper to attempt
any review or resume of lhe distinguished work that
has been done in traditional medicine. One might
ask. though, what role an international organization,
such as WHO, has to play in the development and
the contribution of traditional systems of medicine
called for further research, as new problems are
constantly emerging. In addition, there arc also reso
lutions of the Executive Board and Regional Com
mittees of WHO which call for the intensification of
efforts in the development of national traditional
medicine programmes.
The improvement of the health of all underserved
populations, through the full utilization at commu
nity level of available resources, both human and
material, is fundamental to the primary health care
approach. By securing the cooperation of traditional
practitioners. Member Stales arc utilizing one of the
most abundant and valuable health resources that
they have to extend health coverage. Traditional
practitioners are, as a rule, important and influential
members of their communities, and they should be
associated with any move to develop health services
expansion of traditional medicine activities. The an
swer is that WHO is fulfilling its constitutional
responsibility to act as the directing and coordinating
authority on international health work [I]. As such,
in those countries in which traditional medicine is
widely practised, WHO is mandated to ensure that
what is of value in their traditional systems of
(
medicine is made use of in lhe health services.
The countries themselves constitute lhe governing
bodies of WHO—they decide collectively how the
Organization should proceed and develop policies
that promote an awareness that there are still useful
elements of traditional medicine that could be incor
porated into national health systems. This article
attempts to present an overview of WHO’s in
volvement in traditional medicine.
It is now ten years since lhe
I
World
at the local level.
However, in spite of the universal call for tradi
tional medicine to play a role in the development ol
primary health care, there are still many countries
where only lip service is being paid to this principle.
Other countries have initialed programmes that have
had io be abandoned because they were introduced
without lhe necessary preparatory policy formulation
and appropriate strategies for implementation.
Where, then, do we stand today? What are the
main thrusts of the WHO Programme in Traditional
Medicine? What progress has been achieved and what
Health
Assembly drew attention to the manpower reserve
constituted by practitioners of traditional medicine
(resolution WHA29.72). In 1977. it urged Member
Slates to utilize their traditional systems of medicine
(resolution WHA30.49) and then, a year later, it
are the prospects for the future?
highlighted the importance of medicinal plants in the
i
WHO’S KOI.F.
health care systems of many developing countries
(resolution WHA3I.33). In lhe same year, the Inter
national Conference on Primary Health Care, held in
Alma-Ata, U.S.S.R. [2]—a milestone in lhe history ol
public health—recommended that governments give
high priority to the utilization of traditional medicine
practitioners and traditional birth attendants, and
incorporate proven traditional remedies into national
drug policies and regulations. It also emphasized that
Traditional medicine comprises those practices
based on beliefs that were in existence, often for
hundreds of years, before the development and
spread of modern scientific medicine and which are
still in use today. They vary widely m different
countries in keeping wilh their social and cultural
heritage and traditions.
Generally speaking, however, traditional medicine
177
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COMMUN/TY .4 - -,
47/L(First Fl
/
178
Olayiwola Akerele
has been separated from the mainstream of modern
medicine. A basic approach, therefore, has been to
promote the bringing together of modern scientific
medicine with the proven useful traditional practices
within the framework of the local health system. The
first step here is the formulation of relevant national
policies and decisions on this question, as well as.
under certain circumstances, supporting the elabo
ration of a legal framework for the practice of
traditional medicine. A recent example is the WHO
Consultation on Approaches for Developing Policies
on Traditional Practitioners, including Traditional
Birth Attendants, which was held in New Delhi in
February 1985. This consultation considered policy
issues from a global perspective. The participants,
from the six regions of WHO, represented the various
disciplines involved in traditional medicine and in
cluded administrators, the legal profession, sociolo
gists, anthropologists, educators, and practitioners of
traditional medicine themselves. The report [3] of the
consultation, representing the collective views of the
participants on the utilization of traditional health
practitioners in primary health care and the actions
required to develop and promote policies for the
mobilization of their potential, has been forwarded to
ministries of health by the respective WHO Regional
Offices. As a result, national workshops are being
planned to examine existing policies and the extent to
which they can adequately support the establishment
of national programmes of traditional medicine.
Training
I
The promotion of suitable policies is thus an
essential first step. Once policy is established, the next
step is to favourably influence the attitudes of both
traditional practitioners and scientific health workers
and further refine their knowledge and skills. On the
one hand, specific training programmes need to be
elaborated for traditional practitioners. On the other
hand, elements of traditional medicine need to be
introduced into the already established curricula of
training programmes for other health workers. These
actions should promote greater acceptance of the
usefulness of traditional medicine and lead to a wider
adoption of traditional practices. They should also
facilitate the transfer of information on traditional
medicine practices from other parts of the world.
All health staff, but particularly medical and nurs
ing students, need to be made aware of the place of
traditional medicine in their culture, its strengths and
its weaknesses, and of the use that may be made of
it. Similarly, traditional practitioners need to be
approached with understanding and recognition of
their skills so as to encourage them to share their
knowledge and to play a part- in
■ the national 'health
'•iservice, usually after a short period of special
training.
The training of traditional birth attendants in
aseptic delivery techniques and simple antenatal and
* Decision Making in the Select ion and Use of-Traditional
Medicine in National Primary Health Care Programmes.
An Inter-Regional Workshop co-sponsored by the
World Health Organization and the Danish Inter
national Development Agency (DANIDA). Bangkok.
Thailand. 24 November to 5 December 1985
postpartum care is a good example of the possibilities
that exist for collaboration between the traditional
and modern health care sectors; this is an area in
which WHO has been active for many years [4]. ..
Another example of training, is the standard
ization of dosages of plant extracts used in traditional
medicine and which could be used in primary health
care programmes. Nationals with responsibilities for
drug quality control and with advanced degrees in
chemistry or pharmacy have been trained to select the
best methods of assaying and standardizing medicinal
plant extracts and to prepare standard protocols of
chemical or bioassay methods. The aim is to improve
the efficacy and safety of remedies derived from
medicinal plants, many of which contain pharma
cologically active agents that in an overdose may
have harmful effects.*
The WHO programme is collaborating with coun
tries in identifying ways in which traditional prac
titioners can be trained and mobilized to play an
effective role in the health system without destroying
their individuality. Efforts will continue in a number
of countries to upgrade the skills and knowledge of
traditional practitioners. At the same lime, analysis
will be undertaken to identify proven elements of
traditional medicine practices that could be utilized
by other health workers as well as the type of training
that traditional practitioners should receive, such as
instruction in simple aseptic techniques.
i
Evaluation
Evaluation is the most difficult and yet the most
needed field of endeavour. If a generalization may be
permitted, one might say that traditional medicine
has the support of the population and the opposition
of the health professions. Perhaps the most important
task for WHO, therefore, is to continue to promote
informed opinion on the subject so that traditional
medicine is neither blindly endorsed nor rejected by
health authorities, but is examined carefully and with
an open mind.
Briefly, the aim of the evaluation component of the
WHO programme is to put traditional medicine on a
scientific basis by:
1. Critical examination of traditional materia
medica and practices.
2. Accurate identification of the plants and other
natural products used.
3. Identification of useful remedies and practices
and suppression of those that are patently ineffective
or unsafe.
4. Promotion of further research and exchange
of information.
Countries where traditional medicine is widely
practised arc therefore being encouraged to re
examine their systems of traditional medicine and
practices by undertaking multidisciplinary studies
into the efficacy and the safety of traditional reme
dies. Such an examination, qf course, is much easier
in systems of medicine for wfiich the philosophy and
educational content are well documented than in the
case of traditional remedies handed down from gen
eration to generation by word of mouth. However, in
spite of the difficulties encountered, the examination
of all these systems shows that they hold great
f
Bringing traditional medicine up to date
I
I
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promise of a rich harvest that can benefit mankind,
especially in the field of ethno-pharmacology.
Medicinal plants constitute a most important ele
ment in traditional medicine, in most developing
countries the flora remains virtually unexplored from
the point of view of practical utilization, yet past
experience shows that many valuable drugs have been
derived from plants and information that a plant is
utilized in traditional medicine is often an indication
that it is worth scientific study. WHO will continue
to play a role in sketching out the main lines of action
needed for the identification and introduction of
traditional medicinal remedies into national primary
health care programmes and stand ready to be an
active partner with all interested countries. Further
success will depend heavily on the resources chan
nelled to these endeavours by Member Stales.
A fundamental approach to the development of
national programmes of traditional medicine has
been to strengthen national efforts for research in
traditional medicine within an overall national re
search strategy. Through a study of traditional med
icine, a more accurate and complete knowledge of
useful and effective traditional practices, as well as
potentially harmful ones, is being developed. For this
purpose, national research capacities are strength
ened through activities to develop manpower and
upgrade research facilities. In those countries where
little has been done, initial efforts are being concen
trated on studies aimed at identifying traditional
practices. Encouragement and support are being
given to local studies on traditional medicinal plants
as a means of reducing expenditures on imported
drugs, thereby promoting economic self-reliance.
Countries will continue to be supported in their
efforts to prepare an inventory of effective traditional
practices and techniques.
WHO will continue to identify, in developing and
developed countries, institutions which arc carrying
out research on folk remedies used by traditional
practitioners in (heir clhno-botanical. medicoanthropological. experimental pharmacology and
clinical aspects as well as on the epidemiological
follow-up of their use.
Other national research centres will be identified as
reference centres with a view to developing collab
orative activities, linking institutions with each other,
as part of inter-country and inter-regional networks
on (he basis of culture and subject specificity. Such
centres will also take the lead in research methodo
logical studies and advanced training. They will
receive support to upgrade staff, improve facilities,
and expand activities.
biic^radon info national health care systems
All of this is not a short-term undertaking but one
that will take many years. In the meantime, we can
still take steps to incorporate those aspects of tra
ditional medicine which have been shown to be
beneficial and desirable into national health systems.
Where traditional medicine is well established and
seen as a valuable asset for health promotion, tra
•Inter-Regional Seminar on the role of Traditional Medi
cine in Primary Health Care in China Guangdong
Province and Guangxi Autonomous Region. China,
n 21 OctoK-r I9S5
179
ditional practitioners should become involved in the
process which strengthens links between traditional
medicine and the health delivery system. They should
help in the identification of problems associated with
the establishment of linkages at the local level. They
should be involved in the planning, implementation,
and evaluation of community health activities so as
to enhance working relationships between themselves
and other members of the health team. First and
foremost, of course, the traditional practitioners
should be involved in the evaluation of their own
practices so as to facilitate the ready acceptance by
their peers of suggestions for changes, including the
assumption of new responsibilities—for example, in
health education.
What this implies for WHO is:
1. Support for the elaboration and imple
mentation of appropriate national policies and a legal
framework for the practice of traditional medicine.
2. Development of a practical coordinating
mechanism between health institutions, related social
sectors, and community agencies, including oper
ational research into the utilization of traditional
medicine practices and practitioners in health
services.
A key role for WHO is therefore to disseminate
widely the results of national efforts to incorporate
safe and useful traditional medicine practices in their
respective national health systems. Specifically, infor
mation on national policies, legislation, traditional
medicine practices, research experiences, and training
programmes will continue to be shared through
various avenues, including newsletters and wor^-z
shops. An international newsletter is already being
published three times a year'by the WHO Collabo
rating Centre at the University of Illinois (U.S.A.j. It
is being supplied, free of charge, to researchers in
developing countries through the WHO Regional
Offices and WHO Representatives. As for the work
shops, the participants will be mainly those already
involved in traditional medicine; care will be taken to
see that those sharing a common cultural heritage in
traditional medicine are grouped together. Another
way has been the introduction by the WHO Regional
Office for the Western Pacific of an international
nomenclature of acupuncture that has facilitated the
exchange of information and experience between, and
even within, countries on the clinical applications of
this traditional form of treatment and on current
research.
Technical cooperation among countries sharing
common interests will be promoted to encourage a
more rapid and effective development of the pro
gramme within countries, in areas such as provision
of information on assessment of standards, toxicity/
safety, stability, pharmacology, and other aspects of
traditional medicine remedies. An example of the
application of traditional medicine in primary health
care is the Inter-Regional Seminar designed to give
those responsible for health policy at the national
level an opportunity for studying the utilization of
traditional Chinese medicine in primary health care
and for discussing and examining the possibilities of
adopting comparable approaches in the provision of
health services in their own countries.*
180
Olayiwola Akerele
WHO COLLABORATING CENTRES
In starting this important programme. WHO fell
that the first essential step was to secure the interest
and involvement of those already working in tra
ditional medicine around the world and to build up
a network of specialized institutions and individuals
possessing the required expertise, motivation, and
enthusiasm to contribute to programme develop
ment. This has been done by establishing a number
of collaborating centres in the different disciplines
that constitute traditional medicine. At present, 21
such centres have been designated. There are five in
Africa, three in the Americas, two in Europe, one in
the Eastern Mediterranean, eight in the Western
Pacific, and two in South-East Asia.
This type of association between WHO and the
scientific community is mutually beneficial, serving to
give international recognition to the individual insti
tution designated and to make available to WHO
their expertise, on which the Organization can call on
behalf of Member States. Such assistance covers a
whole range of activities, for example:
1. Situational analysis of the potential role of
traditional practices and practitioners in national
primary health care programmes.
2. Development of policies and legislation for the
incorporation of traditional medicine into health
systems.
3. Support to multidisciplinary investigations
and surveys of local traditional medicine practices,
and the use of plants of medicinal value.
4. Collection, analysis, and dissemination of
information from countries and regions on successful
activities, projects, and programmes on traditional
medicine.
The network of Collaborating Centres forms the
backbone of the organization’s programme in tra
ditional medicine.
ISSUES TO BE ADDRESSED |6|
The list of issues given below is by no means
exhaustive. However, taken together, these arc key
questions that need to be answered before the design
of any viable national primary health care pro
gramme that successfully involves traditional health
practitioners.
How can the formal health services work with
traditional practitioners for the benefit of the popu
lation? So far. traditional practitioners have been
excluded from exercising any responsibility in most
national health services.
How can a traditional medicine organized structure
be created? Without a clearly defined structure,
through which traditional health practitioners them
selves can be heard and which could be a regulatory
body in relation to ethical and professional matters,
there is likely to be chaos.
How can health professionals and others be sen
sitized and oriented so that they may support the
national traditional medicine programme.' If lhev are
not brought into a constructive relationship with the
programme, they will continue with their biases and
hamper government efforts to put traditional medi
cine on a sound footing.
How should health legislation concerning traditional
medicine be reviewed? Most of the present legislation
in this field is out-dated or irrelevant and needs to be
revised to conform with the new policies adopted.
In any case, a reasonable and enforceable legislation
would greatly enhance the implementation of tra
ditional medicine activities.
What should the role of bilateral and multilateral
assistance be? Any external support should be con
sistent with government policies and priorities,
otherwise, it may lead to unnecessary and wasteful
investment in esoteric projects which have no direct
relevance to the peoples’s health needs.
How can a country develop a national drug policy
that includes traditional remedies? Importing drugs
is always very costly and consumes scarce foreign
currency. Developing traditional remedies of proven
efficacy and quality will not only promote economic
self-reliance but will have a ripple effect, encouraging
research workers to investigate other traditional
remedies more carefully.
How can an up-to-date research and development
policy in traditional medicine be formulated? At
present, research policies in most countries do not
reflect the role of traditional medicine in health
services. New research and development policies
could greatly assist institutions in addressing the
critical problems now being faced.
How can traditional medicine activities be financed?
The introduction of traditional medicine will require
adequate budgetary appropriations. A sound pro
gramme and budget that maximizes the effective use
of all available resources needs to be evolved.
GUIDING PRINCIPLES |6|
In developing the programme certain guiding prin
ciples have emerged which may be of help not only
for WHO and its Member States but also to other
international and donor agencies working in (his
area. These principles are as follows.
1. There is no single or simple approach to the
problem of how to involve traditional practitioners in
national health systems, especially at the primary
health care level. Dedicated and sincere action on the
part of all concerned will be required to foster a
collective effort to generate and implement policies
best suited to any given country.
2. The first step could be the establishment of a
National Council for Traditional Medicine, that
could be charged with responsibility for preparing a
national strategy and laying down a broad plan of
action to be followed by government. The council
should be multidisciplinary and multisectoral in
nature, with appropriate representation of the differ
ent types of traditional practitioner involved.
3. Major policy issues, including as a minimum
all those described in the preceding section, need to
be identified, priorities determined and mechanisms
established to propose the various options and
courses of action open to government, with ad-hoc
groups being formed to tackle specific issues.
4. Adequate finance should be assured under the
government’s regular budget for the support and
promotion of traditional medicine acti\nies. l-xlcrnal
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181
Bringing traditional medicine up to date
finance should be considered as only supplementary
to the government’s main effort.
5. In parallel, it will be necessary to undertake a
survey of the national situation in respect of the
practitioners, the population’s preference and needs,
resources, special problems, etc., upon which a sound
national health plan reflecting the role of traditional
medicine may be formulated.
Practitioners of traditional medicine should be
engaged in these activities and the results should be
made widely known to the general public as well as
to utilize those elements of traditional medicine
which have intrinsic value and which can improve the
quality and coverage of health care delivered by their
national health services. In this modern age. the rich
heritage of traditional medicine should not remain
the exclusive or esoteric interest of only a few.
“For too long, traditional and “modern" medicine have
followed their own separate paths in mutual antipathy. But
their aims are surely identical: the improvement of human
health and. hence, improvement of the quality of life (7).
REFERENCES
to the health professions.
CONCLUSION
There is no longer any doubt about the value of
incorporating traditional medicine into modern
health care. It is happening—it is part of to-day s
reality. It is happening for many different reasons
but. fundamentally, because people believe that tra
ditional practices have values that they are willing to
subscribe to. What is still unclear is how the articu
lation of the two systems will be brought about in
different settings. Will it happen in an atmosphere of
goodwill or of hostility? Will it be pursued purpose
fully or will it be acknowledged reluctantly? Will
governments and medical practitioners play a leading
role or will they be mere spectators?
WHO’s primary concern is to encourage countries
1. Basic Documents, 34th edn. WHO. Geneva. 1984.
2. Primary Health Care. Report of the International Con
ference on Primary Health Care, Alma-Ata, U.S.S.R.,
6-12 September 1978, "Health for AU" Series. No. 1.
WHO. Geneva. 1978.
3. Report of the Consultation on Approaches for Policy]
Development for Traditional Health Practitioners. In- I
eluding Traditional Birth Attendants. WHO. Geneva. I
1985.'
-4
4. Mangay Maglacas A. and Pizurki H. (Ed.) The Tra
ditional Birth Attendant in Seven Countries: Case Studies
in Ulilicalion and Training. WHO. Geneva. 1981 (Public
Health Paper No. 75).
5. Farnsworth N. R. Wtd Hlth Forum 6. 76-80 1985.
6. Akerele O. Towards the utilization of traditional medi
cine in national health services. Am. J. Chin. Med. 14.
2-10. 1986.
7. Mahler H. The Staff of Aesculapius. Wld Hlth 3.
November. 1977.
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Newsletter
November 1986
Number 9
Centre d’Etudes de 1’Inde et de 1’Asie du Sud EHESS, 54 bd Raspail, 75006 Paris, France
International Association for the
IASTAM Study of Traditional Asian Medicine
Members of Council: Dr. A. Akahori (Yawata-shi/
Japan), Dr. V. Brun (Copenhagen/Denmark), Prof.
J.C. BUrgel (Bern/Switzerland) , Dr. G.M. Carstairs
(London/U.K.), Prof. T.H. Chan (Taichung/Taiwan),
Prof. W.S. Hong (Seoul/Korea), Prof. A. Kleinman
(Cambridge/U.S.A.), Dr. Y.C. Kong (Hongkong),
Prof. Ch. Leslie (Newark/U.S.A.), Dr. L. Rapgay
(Dharamsala/India), Dr. F. Meyer (Paris/France),
Dr. G.J. Meulenbeld (Groningen/The Netherlands),
Prof. R.K. Mutatkar (Pune/1 ndia), Dr. R.B. Sutrisno
(Jakarta Timur/Indonesia) , Dr. Khin Tint (Camden/
Australia).
President: Prof. P.U. Unschuld (Munich/W. Germany).
Vicft-Presidents: Prof. Ma Kanwen (Bei jing/China),
Hakim M. Said (Islamabad/Pakistan), Prof. K.N.
Udupa (Varanasi/India) . Honorary Fellows: Dr. Li
Jingwei (Beijing/China), Prof. J. Needham (Cambridge/U.K.), Dr. Y. Otsuka (Tokyo/Japan), Prof.
S. Reddy (Hyderabad/India). Secretary-General:
Dr. M. Weiss (Cambridge/U.S.A.). Associate Secre
tary: Dr. D. Wujastyk (London/U.K.). Associate
Administrator: Ms. J. Parkinson (Canberra/Austra1ia).
Publications Editor: Dr. F. Zimmermann (Paris/
France). Treasurer: Prof. M. Lock (Montreal/Canada) .
All our energies are applied to the
task of strengthening the Newsletter,
to make it into a useful tool and to
establish a forum for the discussion
and review of recent publications and
meetings. Plans are on the way for a
more ambitious Journal but, given the
necessary funds and the large number
of collaborators to be mobilized, a
first issue cannot be scheduled to
appear before 1989. Meantime, the News
letter will serve as a prototype, to
help building an audience and to estab
lish an homogeneous albeit interdisci
plinary field of studies.
Two co-editors are joining Francis
Zimmermann in the venture: Dr. (Mrs.)
Catherine Despeux, a scholar of Chinese
medical history, and Dr. Fernand Meyer,
MD., already an officer of IASTAM and a
scholar of Tibetan medical anthropology.
Moreover, this issue of the Newsletter
is published with the financial help of
the French CNRS, through RCP 798 ”Histoire des Techniques et des Sciences en
Chine, au Japon et en Coree”.
See more details in page 3.
Fifteen papers were presented at the
FIRST INTERNATIONAL SYMPOSIUM ON TRADI
TIONAL CHINESE MEDICAL LITERATURE, or
ganized by Prof. Paul U. Unschuld,
President of IASTAM, at the Institute
for the History of Medicine, University
of Munich, W. Germany, August 25-29,
1986. Several afternoon sessions were
also devoted to the discussion of texts.
Although each of the participants rep
resented a different approach to inter
preting and rendering ancient Chinese
medical texts, they spent together a
week of fruitful exchanges in a very
harmonious atmosphere.
The Proceedings of the Symposium will
be published by D. Reidel Publishing Co.
(Dordrecht/Holland) in 1987.
SEE REPORT IN P. 7 TO 13
important books reviewed
JUDITH JUSTICE on Primary Health Care
Page 2
KENNETH 6. ZYSK on the Vedas
Pages 4 & 6
obituary
VAYASKARA N.S. MOOSS
Pages 5 & 6
1
Next issue will be Number 10 to be published
in May 1987
COMMUNITY HEALTH CELL
^7/1, (First Floor)St. Marks Hoad
&ANGALOBE-560 001
cent articles and books on rural health
in the Third World, as well as in pol
icy statements and other documents from
the international agencies" (p. 61).
One may question the efficacy of such
a rhetoric. Moreover, health policies
are suffering from a striking fickle
ness. "Policy changes came too fast and
frequently for the Nepali system to
absorb them. Within a decade, interna
tional policy shifted from vertical
approaches, to integrated basic health
services, to community participation,
to primary health care. By mid-June
1979, the focus of international policy
was already shifting away from primary
health care toward infant diarrheal-disease control - in effect, a new
vertical program. Conferences and re
ports on infant survival were then re
ceiving priority attention" (p. 62).
Nothing followed but confusion at the
village level.
Judith Justice does not tell us enough
about the role of traditional medicine
in the global health care system, but
one suspects (1) that the official
health policies have gone against tradi
tional medicine, by systematically
substituting functionaries for local
healers, (2) that these policies have
failed, and (3) that traditional doctors
have still a card to play. "Nepalis
willingly used both traditional and mod
ern medicine. It often appeared that
only planners and government health
practitioners perceived conflict between
different medical systems. Interviews
with patients in Chittre and other dis
tricts showed that those who did seek
treatment at health facilities chose the
facility because of location and quality
of care rather than type of medical sys
tem. if the Ayurvedic clinic was close
by, the patient went there rather than
to the health post... Traditional
healers are part of the local community,
whereas most government health workers
come from urban areas outside the com
munity and have a higher social status.
[Most of them] disenchanted with the
isolation and discomforts of rural life
[are essentially] interested in finding
a way to transfer out. [Not so good a
mood] for encouraging community involve
ment” (p. 95-6). Traditional medicine
might be more akin than health bureauc
racy to the PHC philosophy!
Judith Justice
Policies3 Plans, & People
(culture and Health Development in Nepal)
Berkeley/Luos Angeles/London: University of
California Press, 1986
ISBN 0.520.05424.5
202pp.
Practitioners among us, members of
IASTAM, as well as historians and anthro
pologists are concerned in the planning
of health policies and the activity of
international funding agencies. Either we
may try to locate a suitable function for
traditional medicine within a given na
tionwide system of health care, or we may
try to discover the hidden causes that
top often render health programs unsuit
able for the local conditions and cultures.
In both cases, in pursuing both goals which are compatible, both within the scope
of IASTAM, provided we mean social science
research, not propaganda -, we do not study
Asian medical traditions as simply anti
quarians would do, that is, for their
curiosity value! Asian medical traditions
are part and parcel of a health system,
they should be set back in the more general
context of Culture and Health Development
policies. This is the reason why a review
of Judith Justice's book is right in place
in IASTAM Newletter.
Why do health care programs often fail to
achieve their long-term goals in developing
countries? Using Nepal's rural health pro
gram as an example, she shows how the fail
ure to take cultural factors into account,
as the planning process moves from inter
national policy making to national planning
and finally to the delivery of services at
the village level, has too often resulted
in ineffective programs.
"Primary Health Care evolved as a concept
from the social experiments being carried
out in China, North Vietnam, and Cuba, es
pecially the Chinese model of the 'barefoot
doctor'...”, in the 1970s (p. 59). Else
where (for instance, in Nepal) at that time
another approach predominated: the 'verti
cal' (disease-specific) health programs to
control smallpox, malaria, leprosy, tuber
culosis. "But since then the international
health agencies have been promoting Primary
Health Care as the solution to the health
problems of developed as well as developping
countries. The rhetoric and jargon of Pri
mary Health Care are prominent in many re
2
[nra Newsletter
IASIAM
international Association for the
Study of Traditional Asian Medicine
Our three Co-Editors represent three different
cultural areas and three different approaches:
support for the mailings of the News
letter .
All mail regarding IASTAM and the
Newsletter should be addressed to:
Dr. Francis Zimmermann,
Publications Editor of IASTAM
Centre d’Etudes de 1’Inde
et de 1’Asie du Sud,
Ecole des Hautes Etudes
en Sciences Sociales
• Madame (Dr.) Catherine DESPEUX
teaches Chinese at the National
Institute of Oriental Languages
(INALCO), and she is in charge of the
section on Medicine in a research group
on the History of Science and Technol
ogy of China, Japan and Korea, directed
by Professor Jacques Gernet at the
College de France*. This group has
given us direct financial support to
print this issue of the Newsletter.
Write to:
Dr. Catherine Despeux
RCP 798
College de France
11, place Marcelin Berthelot
75231 Paris Cedex 05
France
54, boulevard Raspail
75006 Paris, France
IASTAM’s intellectual field should not
be comprised of the mere juxtaposition
of different cultural areas ignoring one
another. That is why we refuse to divide
the 16 pages of the Newsletter into fixed
domains enjoying fixed allotments of
printing space under the exclusive re
sponsibility of a specialized editor. On
the contrary, the Newsletter should
depict an interdisciplinary field,the
cross-cultural fertilization of research,
a variegated landscape, where Sanskritists
can learn about Japan, and vice versa.
Moreover, we would like to give ’’Medicine”
an extensive meaning, to include all the
related natural sciences and techniques
such as Pharmacy, Botany, Agriculture,
and all the ethnosciences of Asia, that
is, traditional sciences that are embedded
in Asian soils, since - as one may say Asian medicine is closely related to Asian
landscapes. It is the reason why, for
example, a review of Augustin Berque’s
marvelous new book on Japanese landscapes
(next page) is right in order. It is just
because of this variegation that writ
ing the Newsletter gives pleasure to its
editors.
• Dr. Fernand MEYER, MD., a medical
anthropologist at the CNRS [Centre
National de la Recherche Scientifique],
does research on Tibetan medicine. He
is a member of the research group on
Ethnoscience based at the Museum
d’Histoire Naturelle, and the Editor of
the Bulletin d’Ethnomedecine.
Write to:
Dr. Fernand Meyer
Laboratoire d’Ethnobiologie
Museum National d’Histoire Naturelle
57, rue Cuvier
75005 Paris, France
• Dr. Francis ZIMMERMANN, a Sanskritist and a researcher at the CNRS (Phil
osophy Dept.), is attached to the Center
for South Asian Studies of the EHESS
[Ecole des Hautes Etudes en Sciences
Sociales], where the Newsletter also is
based. The EHESS has given us f inancial
*A CNRS [Centre National de la Recherche
Scientifique] project, RCP [Recherche
Cooperative sur Programme] no. 798, on
"Histoire des Techniques et des Sciences
en Chine, au Japon et en Coree”.
Let us mention a few other members of RCP 798,
who research into Medicine, Pharmacy and the Natu-
Francis Zimmermann
ral Sciences: Francesca BRAY, Christian MALET,
Georges METAILIE, Frederic OBRINGER, Elisabeth
ROCHAT DE LA VALLEE (who is the new Treasurer of
IASTAM-Europe), Frangoise SABBAN.
3
contents illustrate this implicit valu
ation of internal diseases caused by
demonic entities:
Kenneth G. Zysk
Religious Healing in the Veda3
With translations and annotations of
medical hymns from the Rgveda and the
Atharvaveda and renderings from the
corresponding ritual texts
Philadelphia: The American Philosophical
Society, 1985 (Transactions of the American
Philosophical Society, Volume 75, Part 7, 1985)
IS^N 0 87169 757 2
I. Internal Diseases
A. related to ya'ksma and/or takman [pp. 12-48]
B. not closely related to them (e.g. ascites,
insanity, worms...)[49-7l]
II. External Diseases (wounds, fractures, blood-loss, skin disorders) [72-89]
III. Medicines (water, ’jalasa’ [? urine], simples)
[90-102].
Curiously enough, a reader of Benveniste and
Dumezil would recognize in this table of contents
a trifunctional division (charms in I, surgery in
II, medicines in III), which was apparently not
among the conscious intentions of the author.
xviii-311pp.
From the Preface: "Our aim is to understand the
particular group of demonic beings and forces
which were considered to have brought about disease
and the religious rites by which these malady
causing demons were evicted and kept away. The
hymns employed in the rites are the principal
sources of information and have been translated in
their entirety. An examination and a translation
of later ritual prescriptions provide continuity
in the tradition and offer a basis for comparison
with the practices found in the earlier hymns. The
selection of hymns is based on the data which they
contain rather than exclusively on the traditional
classification of the charms offered in the bhaisajya (medical) section of the Kausika Sutra (25-367.
[.J.] The work is divided into two major sections:
continued in page 6
Fudo
Augustin Berque
Le Sauvage et 1'Artifice,
Les gaponais devant la nature
Paris: Gallimard, 1986
ISBN 2 07 070677 X
515pp.
FF 140
A tentative translation of this typi
cally artful title would be: ’’Wildness
and Artfulness. Japanese attitudes in the
face of Nature.” Nature, i.e. the natural
scenery, landscapes, milieus, hills and
waters, herbs and trees, the cycle of the
seasons, and much more than that, the
values of natural life, the idealization
of our natural roots. In the face of Na
ture, Japanese attitudes are ambivalent.
On the one hand, the surrounding land
scape is ignored, either neglected or
devastated. On the other hand, the high
est cultural values are invested in the
art of gardening, and in the philosophy
of fudo, a Japanese word for ’’milieu,
climate, temperament”.
Augustin Berque is a professional ge
ographer turned linguist and anthropol
ogist. Written in a superb literary
style, this book is from someone who
truly fell in love with Japan. It de
constructs and recreates from inside the
Japanese apperception of the natural
world. What does this book have to do
with medecine? Everything indeed, as soon
as you are willing to admit that medicine
is a meteorology, an ecology, an art of
gardening ourselves and our soil!
the first examines the various diseases which af
flicted the Vedic people and the treatments used to
cure them. Translations of the particular hymns
devoted to the eradication of specific maladies
ancj symptoms and to the consecration of the medi
cines are offered in their appropriate places. The
classification of internal and external diseases
and medicines has been suggested by the hymns them
selves [pp. 12-102]. The second section encompasses
the textual annotations to the individual hymns
[pp. 103-256]-"
Apart from various indices, a short glossary of
plant-names, and an exhaustive "specialized bibli
ography" [pp. 277-290], a very useful appendix is
devoted to a critical bibliographic history of the
most significant studies on traditional Indian
medicine in western languages ["Bibliographical
Esf>ay", pp. 261-276].
The hymns translated and annotated here
were selected and classified on an empir
ical basis. It is interesting to note the
outstanding predominance of internal dis
eases - the exemplar being ’y4ksma’ (con
sumption) or ’takman’ (fever) -, and the
relatively unimportant position of medi
cines in the panoply of healing methods
(where charms predominate, surgery being
occasionally mentioned). The table of
4
(Wil
Newsletter
IASTAM
[ntemational Association for the
Study of Traditional Asian Medicine
OBITUARY
N .
I am very sad to announce the death
of Ashtavaidyan Vayaskara N.S. Mooss,
on September 5, 1986 in Kottayam,
Kerala, South India. Born on November
6, 1912, Dr. Mooss was a Nambudiri
brahmin belonging to one of the famous
Ashtavaidya lineages of Ayurvedic
physicians. He first studied Sanskrit
under his father and Pandalam Krishna
Variyar (1859-1932), a famous scholar
(See K. Kunjunni Raja, The Contr'ibu-
tion of Kerala to Sanskrit Literature,
Madras, 1958, p. 267). Although they
were very orthodox, these noble brahmin
families have traditionally been open
and receptive to English education, and
young N.S. Mooss went to the Church
Missionary Society High School and later
to the C.M.S. College, where he could
develop his taste for English and his
aptitude for botany and the natural
sciences, while he was learning Sans
krit and Ayurveda privately through the
gurukulavasa system of education.
In 1936, his father gave him per
mission to launch a Journal, which was
sponsored by the Maharajah of Travancore:
Vaidya Sarathy3 An Anglo-Vernacular
Monthly Medical Journal (XIII vols.
publ., Kottayam, 1936-1948). A printing
press was imported from Germany, just
before the war, which is still working
today. Dr. Mooss started publishing
bits by bits in each issue of the jour
nal an edition of the Kairali commentary
on the Astahgahrdayasamhita, UttaraSthana3 each time printing a few hundred
copies more, which were bound together
afterwards and made up the first book
from the Vaidya Sarathy Press. Author,
editor, proof-reader, press manager: Dr.
Mooss did everything himself for the
fifty books or so he published in Sans
krit, Malayalam, and English. Marvels of
ingenuity, in decyphering manuscripts or
identifying medicinal plants, and millions
of hours of solitary but quiet work went
into a series of Ayurvedic books that will
continued next page
5
Pictures taken by Dr. Mitchell Weiss 1981
continued from page 5
last for ever. In the late 1970s, N.S.
Mooss’s achievements were being recog
nized in the West and he was corre
sponding with all the best scholars, or
receiving them in his study, lending his
manuscripts and his unrivalled knowledge
of Ayurveda with an exquisite modesty.
Alas, his son had died at the age of
twenty. But his daughters gave him grand
sons who, one may hope, will keep alive
the values of Sanskrit culture to which
Dr. Mooss was so passionately dedicated.
Dr. Mooss truly is to me the most vener
able and inspiring incarnation of the
learned tradition of India, and a very
dear friend and Guru. I studied Ayurveda
with him in 1974, 1976-78, and sporadi
cally between 1981 and 1984. But we had
common projects still on their way: first
of all, an edition of the Hvdya^ which I
hope to complete and bring out within the
next few years. A small tribute will be
paid to the memory of my Guru in a forth
coming book devoted to the classical
tradition of Ayurveda in Kerala.
Francis Zimmermann
Books by Vayaskara N.S. Mooss can be
ordered for by writing to:
The Vaidya Sarathy Press
Vayaskara
Kottayam, Kerala State 686 001
India
Let us mention at least a few titles:
[Special] Ayurvedic Treatments of
Kerala [1944], 3rd. ed. augm., 1983
Ayurvedic Flora Medica, 2nd ed., 1977
Single Drug Remedies, 1976
Indu's Paribhasa or Discourse on
Pharmaceutics, ed. & trans1., 1979
Ganas of Vahata, ed. & trans1., 1980
Vahata's Astdhgahrdayasamhita, Kalpasthana, ed. & transl., 1984
But N.S. Mooss was best known for his
truly admirable editions of Vahata’s
Medical Collection, and some of its
medieval commentaries, especially:
t Vahata'_s Astahgahrdayasamhita with the
Sasilekha commentary by Indu, Six vols.,
1963-1978. All available except Vol. I
which should be obtained by all means,
however. Essential to a Sanskrit library!
Recently published:
Madanadinighantu, 1985; announced in
IASTAM Newsletterno. 8 (June 1986).
Abhidhanamanjari [1st ed. 1946] has been
reprinted; I shall provide a short index
6
before it is bound.
continued from page 4
KENNETH G. ZYSK Religious Healing in the Vedas
To do Kenneth Zysk full justice, we
should cite at least a sample of his
erudite and exhaustive annotations. This
is a philological tool, thus offered to
the students of Ayurveda and the Vedas,
that is bound to become a text-book, but
in a very specialized field. It will
help to homogenize this field, which has
until now been split into two camps: the
philologists, and the historians of medi
cine. Each and every translation, com
mentary or reference offered by K. Zysk
will be checked, challenged, elaborated
upon either by Vedic scholars or by a few
medical historians who have access to the
Sanskrit texts. Both groups of interested
scholars will like to argue about the way
K. Zysk selected the hymns he studies,
or the way he has delimited his subject:
’’religious healing”. Some would like to
say that, in the Vedas, everything is
religious, and everything has connections
with healing, and that the Vedic corpus
of texts should have been tackled as a
whole. [For a structuralist approach to
the nexus of ideas/myths/hymns/rites/etc.
connecting religion and healing: See
Charles Malamoud & Jean-Pierre Vernant,
eds. Corps des Dieux, Paris: Gallimard,
1986.] But K. Zysk had good reasons,
practical reasons, to focus on philologi
cal problems in the nomenclature and the
identification of internal diseases, or
diseases which, although they are intruded
upon the body by demonic attacks, yet
prefigure the later Ayurvedic conception
of internal diseases, exemplars of which
are Fevers and Consumption.
Just a few lines about takman, a dis
ease-demon [and a syndrome] which bears a
very close resemblance to malarial fever.
’’The chief symptom which the takman-victim
exhibits is a hot-cold fever-syndrome. He
also suffers from severe headaches, pound
ing in the eyes [] thirst, and redness
and soreness of the joints. He is often
jaundiced, coughs [] takman has a special
connection with the yellow color of
jaundice []”. I skip the detailed refer
ences, and the difficult terms (left
untranslated, but with discussions and
hypotheses). And this is too short to be
fair to the meticulous exposition offered
by K. Zysk: a medico-philological mono
graph which is hitherto unparalleled.
pira Newsletter
IASTAM International Association for the
Study of Traditional Asian Medicine
The First International Symposium
on Traditional Chinese Medical
Literature^ An IASTAM Meeting held in
Munich/W. Germany, August 25-29, 1986
The Symposium Agenda
• PRESENTATION OF PAPERS
Wolfgang BAUER (Munich) "Chinese Studies and
the Issue of Fachprosa Research"
MA KANWEN (Beijing) "Classical Chinese
Medical Literature in Contemporary China"
Akira AKAHORI (Kyoto) "The Interpretation of
Classical Chinese Texts in Contemporary
Japan: Achievements, Approaches and
Problems"
Jutta KOLLESCH (Berlin) "Ancient Greek and
Latin Medical Texts and the Issue of their
Reception”
Erhart KAHLE (Wurzburg) "The Philological
Rendering of Arabic Medical Texts into
Modern Western Languages"
Francis ZIMMERMANN (Paris) "Terminological
Problems in the Process of Editing and
Translating Sanskrit Medical Texts"
0
Paul ZMIEWSKI (Taipei) "Rectifying the Names:
Suggestions for Standardizing Chinese
Medical Terminology"
Elisabeth ROCHAT DE LA VALLEE (Paris) "Obstacles
to the Translation of Classic Chinese Medical
Texts into Western Languages"
Paul UNSCHULD (Munich) "Terminological Problems
Associated with, and Experiences Gained in,
the Process of Editinq a Commentated Nan-ching Translation"*
ZHENG J1NSHENG (Beijing) "The Collation and Anno
tation of the Rare Book Lu Ch’an-yen pen-ts’ao"
Paul 0. BUELL (Seattle & Bellinqham/Washinqton)
The Yin shan cheng yao, a Sino-Uighur
Dietary. Synopsis, Evaluations, Problems"
Jurgen KOVACS (laipei) "Linguistic Considerations
on the Translation of Chinese Medical Texts"
CHANG HSIEN-CHEH (Taichung) "The Pen-ts’ao pei-yao.
A Modern Internretation of its Terminoloqv"
Ute ENGELHARDT (Munich) "Translating and Inter
preting the Fu-ch’i ching i lun. Experiences
Gained from Editing a T’ang Dynasty Taoist
Medical Treatise"
Constantin MILSKY (Paris) "In Search of a Trans
lation Strategy for the Terms of Chinese
♦Paul U. UNSCHULD, Nan-Ching. The Classic of
Difficult Issues, Translated and Annotated,
Traditional Medicine”
0
• DISCUSSION OF TEXTS (afternoon sessions)
Huan-ti nei-ching (E. Rochat de la Vallee)
Nan-ching (P. Unschuld)
Yin shan cheng yao (P. Buell)
Yin hai ching wei (J. Kovacs)
Fu-ch’i chinq i lun (ll. Enqelhardt)
Chen ch!iu chia i ching (C. Milsky)
i ch
SYMFOSIUM
This meeting organized by Prof. Paul
U. UNSCHULD, President of IASTAM, was
not meant to be a symposium on Chinese
medicine in general, but on Chinese
medical LITERATURE, and furthermore,
not on the history of medical litera
ture, but on the various processings
to which texts are to be submitted by
their editors, commentators, and trans
lators, before they become readable and
reliable. All participants were scholars
pursuing textual studies, who addressed
the various problems arising from our
current philological procedures in the
collation of manuscripts, and in the
edition, annotation, and translation of
classic texts. It was, in a sense, a
symposium on Chinese medical PHILOLOGY,
but with certain qualifications. In the
opinion of quite a few participants,
the terminological problems encountered
in the study of Asian medical texts are
related to the logical frame of mind of
the Asian doctor, or to the logical
structure of the Asian medical discourse.
Terminological problems, here, extend
beyond the field of Philology, and to
address a number of important issues
like, for example, that of polysemy in
the names of diseases or drugs, we must
enter the field of EPISTEMOLOGY.
Paul Unschuld’s nice and truly inspired
idea was to invite scholars of Greek,
Arabic, and Sanskrit medical texts, and
to make them contribute to this inquiry
into the Sinologists’ problems and
methods, thus giving the symposium a
comparative dimension. The first day was
devoted to this cross-cultural approach.
Comparison appears to be very fruitful,
continued next page
Berkeley-Los Angeles-London: University of
California Press, 1986. viii-760pp. I.S.B. Number:
0.520.05572.9. Review to appear in the next issue.
I
continued from page 7
especially between Chinese and Sanskrit.
Fallowing Paul Unschuld’s suggestion,
and to meet the comparative goals of
IASTAM, the main part of the present
report will (tentatively) parallel Ma
Kanwen’s paper on Chinese texts with F.
Zimmermann’s paper on Sanskrit texts.
Ffom the manuscripts of these two papers
(which are still in the process of being
revised), we are extracting a few sig
nificant passages akin to the central
preoccupations of the Munich Symposium
participants, that is, terminological
problems in editing, annotating, and
translating classical texts.
This report may not be quoted without permission.
All extracts from papers presented at our IASTAM
meeting in Munich are being printed here for
private circulation to the members of IASTAM.
Ma Kanwen
On Chinese Texts
into a deplorable state, and very few
Chinese medical classics were then col
lated and printed [] The founding of the
People’s Republic of China opened broad
vistas for the study and development of
traditional Chinese medicine [] A large
number of books dealing with its various
branches have been published [] At a
conference on collating and publishing
medical classics sponsored and organized
by the Ministry of Public Health in 1982,
plans were worked out to publish 686
texts, out of which 11 were listed as key
works: Su Wen, Ling Shu, Huang Di Nel
Jing Tai Su, Nan Jing, Mai Jing, Shen Nu
Ben Cao Jing, Zhong Zang Jing, Shang Han
Lun, Jing Gui Yao Lue, Zhen Jiu Jia Yi
Jing, Zhu Bing Yuan Hou Lun. Among the
classics to be collated, annotated and
published, there are not a few rare ones
that have not been published for several
hundred years, since their [first] coming
out, such as Young Shi Jia Gang Fang*
written by Young Tang (1178), Wei Shi Jia
Gang Fang** by Wei Jian (1228), Huo You
Kou Yi*** by Zeng Shi Rong (1294), Zu
Ji**** by Shi Pei Ran (1640), etc. []
[] Since most of the ancient works were
written on bamboo strips or silks and
were passed through many hands and spread
from place to place, different copies of
a same work were made, and mistakes such
*
by
as miswritten characters, omissions, etc.
happened. So, during the reign of Emperor
**
by
*
Han Chen in 26 BC., the government organ
***
by
ized a group of medical officials headed
by the court physician Li Zhuguo to col
****
by
late and revise the royal collections for
medical books preserved at the Mi Fu, the
national royal library. This was the first To train personnel capable of editing,
annotating, collating and revising Chinese
time for collating and revising medical
books sponsored and organized by a govern
ment in the history of Chinese medicine.
rI was about to write this report, when I received
Later on, more and more medical books were
from Co—Editor Catherine Despeux a copy of one of
collated and revised not only by official
her recent books, which appears to be a French
organizations but also by private efforts.
translation of the classic text mentioned by Ma
Scholars such as Wang Shuhe of the 3rd
Kanwen as the one revised by Wang Shuhe. A most
cent. AD., who rearranged and collated the
interesting encounter:
'Shanghan Zabing Lun (Treatise on Febrile
Shanghanluriy Le traits des "coups de
Diseases Caused by Cold and Miscellaneous
frold" de Zhang Zhongging
Traduction de CATHERINE DESPEUX
t*
$'•]
PARIS: Editions de la Tisserande [1 bis, cite des
Fleurs, 7501? Paris], 1985
202pp.
Presentation: The author, Zhang Zhongjing (150-219), and his main commentators; a few introduc
tory pages on Chinese pharmacology; a summary of
the treatise. Translation, with detailed notes
and several indices (of ingredients, of recipes,
of pulse symptoms, and a general index including
names of diseases). A nice book, carefully
written and well-produced, a review of which will
^appear in one of our next issues. F.Z.
a
[were the first philologists...]
In the Ming and Qing periods, many phys
icians and scholars devoted themselves to
the work of annotating, collating and re
vising medical classics. [] Unfortunately,
in the later part of the last century and
at the beginning of our century, with the
tendency to negate the [value of] tradi
tional Chinese medicine, [its] study fell
NOT FOR CITATION WITHOUT PERMISSION
8
medical classics, special courses were
run by the China Institute for the His
tory of Medicine and Medical Literature
attached to the China Academy of Tradi
tional Chinese Medicine []
0
Promising scientific results have been
obtained through exploring the treasure
house -[of classical texts]. For instance,
a researcher of the Institute for Chinese
Materia Medica of the China Academy of
Traditional Chinese Medicine, in seeking
for new anti-malarial drugs had come
across a passage in the Zhou Hou Bei Ji
Fang (A Handbook of Prescriptions for
Emergencies) written by Ge Hong (c. 231341 AD), which aroused her attention:
"Take a handful of sweet wormwood, soak
it in a Sheng (about a liter) of water,
squeeze out the juice and drink it all”
for treating malarial fever [Vol. 3,
saying that, after a book has been
copied three times, characters like
will become
, and
become
It is only through high quality colla
tion work - which includes contrasting
or comparative collation, rational
collation, etc. - that mistakes such as
omissions, disarranged and miswritten
characters, typographical errors, wrong
annotations, wrong punctuations, etc.,
made either in the past or in the pres
ent age, can be corrected.
The bulk of Prof. Ma Kanwen’s contribution
comprises detailed examples of this kind of
philological work: corrections through colla
tion. Only a few samples can be printed here.
DISARRANGEMENTS. Case 3
In Su Wen (Shang Gu Tain Zhen Lun 1, Vol. 1)
the
,
.
Zhi Han Re Zhu Nue Fang 16]. She began
to wonder if soaking the sweet wormwood
had been done to avoid the high tempera
ture of boiling or brewing, which might
have destroyed the antimalarial properties
it contained. She and her colleagues set
out to extract it with ether instead of
boiling water or alcohol, and to make
new chemical analyses. Using their sample
on mice infected with malaria (Plasmodium
berghei), they found that the malaria
parasites disappeared. Subsequent clinical
use with humans in case of malignant and
tertian malaria also had good results.
Later on they isolated an effective mono
mer against malaria and got a pure white
crystal which they named Qing Hao Su,
which was then put into clinical tests in
6,000 cases and proved effective on all
types of malaria, with quicker results and
lower toxicity than chloroquine and other
drugs []
.
M
Mi
is an example of obvious disorder or disarrange
ment of the original bamboo strips as judged from
the literary style and the context of the pass
age. The style is not coherent with the context;
the first sentence is too long while the second
is too short, and, if we look to the context,
we see that the female menopause problem is the
one discussed, so it is illogical that a male
physiological problem is dealt with. Let the
whole passage be rearranged as follows:^
And it is now rational not only in its literary
style, but also according to logic.
WRONG ANNOTATIONS
A striking mistake is that dealing with the
problem of Tong Jia
or Tong Jie 15.
•
Tong Jia is a special learning of ancient Chinese
scholars dealing with phonology. Tong Jia means
that characters of the same sound can be inter
There are many problems associated with
changeable; characters of the same sound can be
the collation, annotation and revision of
used to take one another’s place in a phrase, an
Chinese medical classics. [What is at stake expression or a sentence. Hence it is also called
is] how to improve the quality of the
Tong Jie which literally means borrowed, in com
[philological] work, so that the Chinese
mon. Without the knowledge of Tong Jia, mistakes
medical classics can be of better service
are unavoidable in the work of collation, annota
to the exploration, study and development
tion and revision of Chinese medical classics,
of traditional Chinese medicine as well as even among well-known scholars like Yang Shang
the welfare of the people[]
Shan and Wang Bing. MISTAKES dealing with Tong
Most of the classic texts were written
Jia, Case 1
without punctuations, which makes them
In Su Wen (Si Qi Tiao Shen Da Lun 2, Vol. 1),
difficult to read. They were often copied
in the passaae:
and recopied by many hands. There is a
9
i
the character
was explained ac
’’wearing” by Yang ihang Shan, and as
’’admire” by Wang Bing. Both of them were out
standing scholars and physicians who really did
valuable work on the Su Wen and Ling Shu and ex
erted great influence on the study of Nei Jing
among the later generations. Both, however, got
it wrong when explaining the character
Their mistakes had been accepted for many gener
ations, when Hua Shou
of the Yuan
Dynasty pointed out that
understood as
or
should be
. Later, Hu Shu
translated, as ch1i for example into
’’vital energy”, etc.] It seems better
to transliterate them with suitable
notes, rather than translating them
[thus saying ch ’ i, and not ’’vital en
ergy]. Since the accurate translation
of terms of traditional Chinese medicine
or the standardization of their trans
lation still needs concerted efforts, I
think that cooperation between scholars
and medical workers of China and other
countries of the world is also needed.
extracted & condensed by F.Z.
of the Qing Dynasty pointed out that
should be pronounced as Ta
according to the Sho Wen die Zi
, which
means go against or run counter to.
[Hundreds of examples are adduced, to illustrate
various kinds of mistaken characters, sentences,
and how to correct them.]
0
[The final section of Ma Kanwen’s paper deals
with ’Problems associated with the translation of
Chinese medical classics into foreign languages’.
First, the translator should select a good edition
of the Chinese text.]
Once some wrong annotations or commen
taries rendered by scholars of the past
or present have been adopted, the trans
lation inevitably will produce more mis
understandings. For instance, the wrong
commentary offered by Wang Bing in Su
Wen for the passage:
which 1 have cited in the preceding sec
tion of this paper has been adopted in
the English translation of the Nei Jing
by Dr. Ilza Veith [Huang Ti Nei Ching Su
Wen] The Yellow Emperor's Classic of
Internal Medicine, Chapters 1-34 (Berke
ley: California Press, 1949), p. 105,
who translates as: ”Tao was practiced by
the sages and admired by the ignorant
people” [’admired’ instead of ’thwarted’
or ’gone against’!].
The second problem related to transla
tion is how to stick to the genuine
meaning of the text. The third is that
translators sometimes are lacking knowl
edge of Chinese history, philosophy, or
literature. The fourth problem is that
translations sometimes are incomplete.
[Various illustrations are provided. A
closely related question is that of the
polysemous characters that are too often
10
Zimmermann
On Sanskrit Texts
[From texts to discourse]
The Collections of Su^ruta and Caraka
have never been edited properly. Although
they represented tremendous achievements
of Indian scholarship when published one
century ago, the editions available in
print will have to be recast some time on
the basis of new manuscripts and modern
philological tools. We are not ready yet
for this arduous task; terminological
problems have to be dealt with first.
The logical consistency of technical terms
is essential, when we want to establish a
reliable text; this has been shown recent
ly by Priya Vrata Sharma [Carakasamhita,
Text with English Transl., Varanasi:
Chaukhambha Orientalia, 1981, Vol. I, pp.
xvi-xxii], the first scholar in recent
times to provide us with a list of quite
convincing emendations of the currently
accepted text of the Collection of Caraka.
Another expert in that kind of philologi
cal work is Ronald E. Emmerick. Hundreds
of decisions are made in his edition of
the Siddhasara [Wiesbaden: Franz Steiner,
1980, Vol. I: The Sanskrit text], to
select ’’correct readings”, and to emend
wrong ones. Whereas, for example, most of
the manuscripts say [3.31.9] that barley
cures meda ’’obesity”, wrong reading, the
editor restores the correct reading:
barley cures meha ’’urinary disease”, on
the basis of what he calls the tradition
(i.e. what Caraka, Su^ruta say about
barley); his choice is dictated to Emmerick
by parallels and concordances with other
classic texts. A graphic mistake of
’da’
for
’ha’ is corrected on mere philologi
cal grounds. I think, however, that we
should go one step further. What kind
are ideas, inferences (e.g. amrta ’’im
mortal", abhisyandin "which produces
fluxions”). The distinction is not an
absolute one; it is context-sensitive.
Objects are ideas, and ideas are objects.
Names are often made from adjectives,
and we could translate amrta as "The
Immortal”: the name connotes the hardi
ness of the aerial roots of Tinospora
cordifolia. Adjectives are often made
from names [] However, these two kinds
of terms will exert different functions
in the medical texts. Both kinds of
terms are submitted to a huge process of
language inflation. There are many many
"names” to designate one and the same
object (a drug, a disease, a bodily part
or process), and many many "adjectives H
to convey one and the same idea []
We should not be mistaken in transla
ting an "adjective” as if it were a
"name": e.g. abhisyandin most often
means "which produces fluxions” (which
is the idea of a physiological process,
an inference put forward in the course
of a diagnosis), and sometimes means
"one who suffers from conjunctivitis”
(which designates a disease thus objec
tified). The modern reader, or the trans
lator, should avoid objectifying terms
that are not so in the original discourse
[] We should also find ways of conveying
to the modern reader the wealth of names
and the cognitive value of this ’polyonymous’ style of terminology. In my opin
ion, any attempt to standardize our
translations and to reduce all polyonyms
(names mutually substitutive to designate
one and the same object) to only one En
glish, French, or Latin translation comes
totally off the point []
0
[Illusory metaphors]
The metaphorical connotation, in quite
a few technical terms, which, for that
reason, most translators use to keep un
translated, is an illusion. [For example,]
dosa, which is the most common term for
naming the humors, the three humors of
Ayurvedic medicine - wind, bile, phlegm -,
generally means "defect, fault" in Sans
krit. [Compare Sydenham's phrase: "the
peccant humors".] When entering the med
ical field, when becoming a technical
term, the Sanskrit word dosa underwent
*Reviewed in IASTAM Newsletter no. 5, August 1984,
a change of meaning AND of referent, to
P- 8.
n
CONTINUED IN PAGE 13
of a tradition is it, that allows ’’er
rors” to creep upon so easily? One may
wonder whether distinguishing ’’correct”
readings from wrong ones does not
amount to ill-treating a fundamentally
polysemous discourse, where several
readings, all valid, may be superim
posed to one another in a given techni
cal term. Therefore, facing all kinds
of terminological problems, not only
those of a purely textual nature but
also those related to the modes of
thought involved, we should address
ourselves not only to the philological
task of establishing reliable texts,
but also to the epistemological task of
dissecting, deconstructing, cross-exam
ining their logical structure.
This paper is more limited indeed,
than the vast program thus outlined!
I would like to present a few remarks
on five kinds of terminological problems
(in editing and translating Sanskrit
medical texts) that arise from the nature
of the language itself: 1) How to deal
with a fundamental distinction between
terms for objects (roughly speaking,
names of drugs, diseases, etc.) and
terms for ideas (adjectives, and others);
2) problems of rhetoric related to the
superabundance of metaphorical terms
(or terms that deceitfully seem to be
metaphorical without being so); 3) how
to tackle the plurality of levels of
language, and especially, the linkage
(or diglossia) between Sanskrit and the
vernacular; 4) how to account for stylis
tic features like versification, or the
interplay of synonyms; 5) changes through
time, obsolescence of some terms, emerg
ence of new names [See G. Jan Meulenbeld,
"The surveying of Sanskrit medical liter
ature”, Proceedings... on Priorities in
the Study of Indian Medicine, Groningen,
1983, pp. 31-120, spec. p. 38 f.]*.
0
[Terms for objects, terms for ideas]
[] This is not a linguistic distinction
between names and adjectives, although it
amounts to it in the final analysis, but
a logical distinction between terms with
referents that are objects of the natural
world (e.g. amrta, the plant Tinospora
cordifolia), and terms with referents that
Mawangdui Hanmu boshu, Wenwu chubanshe,
P1"8’ 1985
%<
In 1973 a number of manuscripts and
wooden slats, partly related to medicine,
were discovered inside tomb number Three
of the Mawangdui site, about 10 km from
Changsha(Hunan). As the tomb is known to
have been closed in 168 BC, and some of
the manuscripts are dated from -294 to
-227, these documents would date back to
the Qin or East Han period. Since the
discovery was made, several studies on
these manuscripts have been published,
most of them in the Wenwu review.
All the documents related to medicine
are being made available in the present
publication, which includes reproductions
of the 11 manuscripts and of the 4 groups
of wooden slats, followed by their tran
script into modern Chinese, and notes.
The list of the titles given to these
documents is as follows:
MANUSCRIPTS
1 Moxibustion book of the eleven lower and upper
member vessels
2 Moxibustion of the eleven yin-yang vessels (A)
5 Methods of spygmology
4 Death prognosis based upon yin and yang pulses
5 Prescriptions for 52 illnesses
6 Abstinence of cereals and absorption of pneuma
7 Moxibustion of the eleven yin-yang vessels (B)
8 Illustrations of daoyin postures
9 Recipes for nourishing the vital energy
10 Various therapeutical recipes
11 Book of obstetrics
BAMBOO SLATS
1 Ten questions
2 The art of yin-yang union
3 Various recipes of interdicts
4 Remarks about the supreme way in this world
(Chinese titles are given at the bottom of this
page) 0
priceless documents for the study of
Chinese medical history. They give us
a better understanding of the formation
of some theoretical points in Chinese
medicine, and they show that techniques
described in the texts several centuries
later were already known in the East
Han period.
The two documents on Moxibustion of
the eleven vessels are similar to chapter
12 of the Lingshu, while presenting a
more archaic state of the system. The
part that treats of death prognosis based
upon pulses (the manuscript is in very
bad condition) corresponds to the end nf
that same chapter 12 of the Lingshu.
Besides, the text on the diagnosis based
on pulses has been nearly fully recon
structed from another version discovered
among the wooden slats of Zhongjia shan
in the area of Jiangling (Hubei): see
article in Wenwu, no. 1, 1985, pp. 9-15.
The obstetrical book refers mostly to
interdicts to be observed during preg
nancy. It is nearly similar to Prescrip
tions in Obstetrics (Xu Zhicai suiyue
yangtai fang)* by Xu Zhicai, physician
of the Six Dynasties, a lost work but
quoted in A Thousand Golden Ounces Rem
edies (Qianj in yaofang)** by Sun Simiao.
It already expounds the different evol
ution phases of the embryo. It mentions
a reckoning process to determine and
decide the sex of the child to be born.
This detail is also found in the wooden
slats discovered in Yunmeng: see, by
Rao Zongyi, Yunmeng Shuihudi Qin jian,
part on ren zi***, Hong Kong, 1982.
The other documents deal with various
processes for nourishing and maintaining
vital energy: abstinence from cereals,
breathing processes, and the propitious
times for nourishing oneself with energy
according to the season, the lunation,
the hour of the day (These parts resemble
the Linyang zi mingjing****). Bed tech
niques are also dealt with, including
how to cure sexual diseases, how to keep
potency, to increase one’s energy and to
join yin and yang.
These documents have been partly present
ed to westerners by Michael Loewe’s paper
’’The manuscripts from tomb number Three”,
in R.P. Kramers ed. China. Continuity and
Catherine Despeux
Change, Papers given at the 27th Congress
of| Chinese Studies [Aug. 31-Sept. 5, 1980],
Transliterations
Zurich, 1982. Moreover, one of these manusclipts has been studied and translated into
0 Zubi shiyi mai jiu jing
Afc f:-r
English by Donald Harper, The Wu-shih-erh
Yinyang shiyi mai jiu jing fi
ping fang. Translation and Prolegoma, Thesis Maifa
on microfilm, Michigan, 1982. These are
12
MUNICH SYMPOSIUM CONTINUED FROM PAGE 11
Yinyang mai sihou
Wushier bing fang
Quegu shiqi
Yinyangshiyi mai jiu jing
Daoyin tu
Yangsheng fang
Za liao fang
Taichan shu
-f
ft
-r•r '' fife
4
i
/I
Shi wen
He yinyang
Za jin fang
Tianxia zhidao tan
T i. it
*
/j
♦♦
♦**
***♦
designate ’’the humors” with the whole
array of their connotations, which are
the same as in European humoralism:
humors are bodily fluids and pathogenic
factors at the same time. We should dis
tinguish between three semantic fields:
(1) the primary, etymological, general
meaning (dos£ ’’defect, vice”); (2) the
technical~Texactly, ’catachrestic’]
meaning (’’humors”); (3) a derivative,
metaphorical meaning, when we speak of
the humors as ’’peccant”, ’’morbific fac
tors”, which can only be the case in a
limited number of occurrences. But in
most of the thousands of cases when dosa
is used in Ayurvedic texts, it is just
to designate the humors, without any
metaphorical connotation. To translate it
as ’’morbific entities*’ amounts to re-integrating into the medical discourse
a metaphor which was no longer perceived
as such. Same rhetorical effect, when the
translator refuses to translate dosa,
pretending it is untranslatable []
0
[Anachronistic terms]
Misunderstandings that arise from
changes of meaning through time are often
aggravated by the substitution of new
frames of reference for the older ones.
[] Anatomy and the mapping of diseases on
the body have become part of the modern
diagnosis, [while] the localization of
diseases was much more elusive and roving
in humoral medicine. Therefore, the
translation of Sanskrit names of diseases
into a modern language is liable to be too
precise, too restrictive [] Sanskrit
abhisyanda, for instance, designates a
whole set of diseases due to fluxions, of
which ’’.conjunctivitis” is only one poss
ible exemplification. [Conjunctivitis is
a ’monothetic' category, while abhisyanda
is polymorphous.] A prefixed dot (or any
suitable symbol) should indicate the
discrepancy [a time-lag as well as a logi
cal gap] between Sanskrit abhisyanda and
its translation as ’’.conjunctivitis” []
fp
■i i $ $
4’
ivi
FOR PAPERS
Asian Folklore Studies
K semi-annual journal, is planning for one issue,
maybe the fall issue of 1987, devoted to tradi
tional medicine.
”We are looking and calling for papers which
discuss traditional forms of medicine or rituals
of healing especially in relation to oral tradi
tions, e.g. mythology (explanation of causes for
sicknesses or their healing) or other traditions
as there may be. It could also be a discussion of
e.g. medical herbs or other types of medicine, the
stories or traditions related to their origin or
the reason of their effectiveness. It would even
be possible to treat the specialists, e.g. the
formation of a healer or shaman, their self-under
standing and the ways their clients explain the
shamans’ power.”
Write to:
Peter Knecht, Editor
ASIAN FOLKLORE STUDIES
Nanzan University
18 Yamazato-cho, Showa-ku
466 Nagoya, JAPAN
I nd i at
Debiprasad Chattopadhyaya, Ed.
Studies in the History of Science in
India, Two volumes, New Delhi: Editorial
Enterprises Publ. [L-1/1O, Hauz Khas,
New Delhi 110 016], 1982
xxv-viii-884pp.
Rs. 300
Volume I contains valuable extracts
from some of the best authorities on the
history of medicine, chemistry and botany
in India: Mukhopadhyaya, Hoernle, Jolly,
D. Chattopadhyaya himself (his 1979 paper
on Caraka), Bodding (Santal medicine),
Filliozat (on Al-Biruni and Indian al
chemy), Ray, Majumdar (botany).
NOT FOR CITATION WITHOUT PERMISSION. These extracts
still need revision, and they are too short to give
a fair account of our views. These are unsolved
problems, it is still an open debate. For example,
readers may have noticed that FZ’s remarks on
translating dosa do not match MK’s remarks on
NOT translating ch’i. Much more still has to come
on this major issue.
13
India Seen From Roma
Jacques Andre & Jean Filliozat
L'Inde Vue de Rome, Textes 'Latvns de
I’antiquite relatifs d t'lnde, Paris:
other oriental languages, traces a
striking number of names (found in the
Latin sources) back to Tamil and Mal
ayalam .
^S^pp.
FF 300
ISBN 2 251 32 864 5
Editions Belles Lettres, 1986
Everything the Romans knew about pep
per, sugarcane, voyages across the Ara
bian sea, and the strange peoples of far
away India... This is an exhaustive col
lection of Latin texts and testimonia or
fragments of lost works related to India,
edited with a line by line French trans
lation, a scholarly commentary, and sev
eral indices. A must for all historians
of the ancient materia medica, of the
spice trade, and of the relationships
between Europe and India. Prof. J. Andre
is a well-known expert in Latin cuisine,
botany and other realia. See his Noms de
Plantes dans la Rome Antique (Plant-names
in ancient Roma), Paris: Belles Lettres,
1985, reviewed in IASTAM Newsletter, 7
(Nov. 1985), p. 5. Late lamented Prof. J.
Filliozat wrote most of the commentary,
and played a major role in the transla
tion. This new book should be used along
with a previous one by the same two co
authors: Pline 1’Ancien (Pliny the Elder),
Histoire Naturetief Livre VI, 2e partie
Foodwaiys
Marie-Claude Mahias
Delivrance et ConvivraUte^ Le systeme
culinazre des Jaina [Liberation and
Conviviality, Foodways of the Jainas],
Paris: Editions de la Maison des Scien
ces de 1'Homme, 1985
326pp. FF 175
ISBN 2 7351 0125 8
A rich, vivid, well-written ethnogra
phy of food and foodways among Jainas
in Delhi today. Dr. (Mrs.) Mahias, a
member of the CNRS (Anthropology), has
combined thick description of things
eaten and culinary techniques with an
analysis of religious rules (enforcing
vegetarianism), and of rituals involving
special foods. Medical anthropologists
should read chapter 9, which treats of
foods raw and cooked, the classification
of savors (an ethnographic counterpart
to the classical doctrine of rasas) and
tastes (an ethnography of gustation),
and finally, foods hot and cold. Some
readers will enjoy the wealth of illus
trations: not only the various maps,
tables, figures and photographs, but also
quite a few line drawings to illustrate
technical gestures. Other readers will
enjoy the meticulous transliteration of
Hindi words and the various indices and
glossaries, which enhance the usefulness
of this publication.
(§§ 46-106, on Asia, India), Ed. & transl.
into French, with comment., appendix
(Pliny’s India), index and maps, Paris:
Belles Lettres, 1980 (ISBN 2.251.01156.0).
The texts are given in chronological
order, stretching over a time span of
eight centuries, from Plautus - a boast
from the Bragging Soldier (205 BC) that
he broke an elephant’s arm in India! through Isidore of Seville (late Vlth
cent. AD), whose Etymologies contained
vivid descriptions of Indian gems and
spices. Among hundreds of small dis
coveries resulting from J. Andre & J.
A Workshop organized by the European Ayurvedic
Filliozat’s patient work of collection
Society and sponsored by the Wellcome Trust was
and collation: the earliest mention of
held from 2 to 4 September 1985 in London. Dr. G.
Indian sugarcane in Roma is to be found
Jan Meulenbeld (De Zwaan 11, 9781 JX Bedum, The
in a three-line verse fragment from Varro
Netherlands) and Dr. Dominik Wujastyk (The Wellcome
Atacinus (85-35 BC), through its quotation Institute for the History of Medicine, 183 Euston
by Isidore... But this is only one out of
Road, London NW1 2BP, U.K.) are at present editing
about 125 Latin authors alluding to or
the Proceedings, which are to appear soon under
dwelling upon things Indian, whose rel
the title Studies in Indian Medical History. The
evant extracts are collected here.
following papers were read at the meeting:
To us, historians of Asian medicine, the
Dr. G.J. Meulenbeld ’’Reflections on the basic
most precious feature in this book is the
concepts of Indian pharmacology”, Dr. J. Laping
’’index of original names”, compiled by
”0n Madhavacikitsa”, Dr. R.P. Das ”0n the identi
Jean Filliozat’s son, M. Pierre-Sylvain
fication of a Vedic plant”, Prof. R.E. Emmerick
Filliozat (himself an outstanding Sanskrit ’’Epilepsy according to the rGyud-bzi”, Ms. M.
scholar), which, apart from Sanskrit, and
Winder ’’The meaning of vaidurya in Sanskrit and
14
Tibetan”, Dr. A. Rosu ’’Autour des carres magiques
en Inde”, Ms. W. Ernst ’’Native lunatic asylums in
early 19th cent. British India”, Prof. G.M.
Carstairs ’’Contrasting treatment of witches in
three communities in Mewar”, Dr. 0. Wujastyk ”A
pious fraud: The claims for pre-Jennerian smallpox
vaccination in India”, Dr. T. Patterson ’’The
relationship of Indian and European practitioners
of medicine from the 16th cent.”, Dr. A. Comba
’’Carakasamhita, sarirasthana I, and Vaisesikadarsana”, Prof. R. Labadie ’’Centella asiatica in
perspective: An evaluative account”, Dr. B.
Hochkirchen ’’Results of a video based analysis of
consultations in four Ayurvedic medical practices”,
Dr. J. taping ’’Dialogue in research on traditional
Indian medicine”, Dr. H. Bakker ’’Methodological
considerations concerning critical editions of
anonymous Sanskrit texts”.
Paul D. BUELL (Western Washington University)
and Christopher MUENCH (University of California
at San Francisco), ’’Chinese Medical Recipes From
Frontier Seattle”, in The Annals of The Chinese
Historical Society of The Pacific Northwest, an
annual publication, 1984, pp. 100-143.
[The same issue contains papers on Lycium
chinense as a ethnohistorical marker, on South
Chinese foodways, on birds, and various other
historical, ethnolinguistic, and political
history topics.
Write to: Chinese Historical Society of the
Pacific Northwest, 9105, 40th Avenue, N.E.,
Seattle, Washington 98115, USA]
record of the earliest era of Chinese settlement in
Seattle. Several appendices provide complete lists
of the titles, types and therapeutical indications
of the recipes, and a translation of a few sample
recipes.
Indian
czih i Idhood
Helene Stork
Enfances Indiennes 3 Etude de Psycho'Logie trans cut turell e et comparee du
geuna enfant
[Indian Childhoods, A study in infant
cross-cultural psychiatry], Paris:
Editions du Centurion [17, rue de Babylone, 75006 Paris], 1986 [In French]
ISBN 2 227 00510 6
240pp.
FF120
Dr. H. Stork, MD., combines the study
of Sanskrit ayurvedic texts on paediatrics
with ethnographic film-making, to describe
and analyse mother-infant relationships
and the learning of bodily techniques in
South India.
CONTENTS: 1/ From infant psychopathology to infant
cross-cultural psychology. II/ History, methods &
aims of child cross-cultural psychology. Ill/ An
approach to infancy in South India. IV/ Cultural
representations of Mother and Baby in the classic
texts [Interesting quotations from Anantakumara’s
Yogaratnasamuccaya]. V/ Gestures and postures in
mothering, ethnographic filming in South India
[with line drawings based on photograms; useful
notes on the drugs used, see p. 151-2; also on
cradles, feeding bottles made from conch-shells;
the vernacular language is Tamil]. VI/ Baby’s
psychology. VII/ Mothering.
A nice, unassuming, well-written little book, by
an extremely well qualified researcher.
This article includes a reproduction and dis
cussion of an old recipe book, the Yao-fang,
’’Medicinal Recipes”, which was originally a
prized possession of the important Wah-Chong
Company founded by Seattle Chinese pioneer Chin
Hock in 1868. It is a compilation containing the best
m cd L cz: ± r i cb
personal recipes of the members of Seattle’s early
B i k> 1 &
Chinese community. Although the drugs were first
provided by the Wah-Chong Co., the work itself was
z 3RD INTERNATIONAL SYMPOSIUM ON MEDICINE IN
community property, benefiting all during a time
BIBLE AND TALMUD, JERUSALEM, DECEMBER 7—9
when there were no professional Chinese physicians
1987
to serve the community. The main section of the
Themes of the symposium:
work probably dates to the 1870s and 1880s. In its
The image of man, body and soul, the meaning of
present form, the Yao-fang is a small, tradition
life and death, the meaning of disease and healing,
ally bound manuscript volume of 181 pages, contain
wholeness and holiness, purity/impurity and dietary
ing 166 titled and untitled recipes. These are
rules, etc., according to the Bible and Talmud, and
’basic’ recipes, to address specific diseases and
to Exegesis (Medieval & Renaissance).
symptoms rather than the more abstract disease
For more information write to:
categories common to professional Chinese physicians.
Professor Samuel S. Kottek
But they are still in use in a modified form by a
contemporary practitioner. As an historical and medi Division of the History of Medicine
The Hebrew University of Jerusalem
cal document, the Yao-fang represents a treasury of
Hadassah Medical School
clinical experience, as yet little affected by
91120 Jerusalem, Israel
Western influences. As a social document, it is a
y
15
Thai
haa 1 i n<^
An example of convergences, in the current
production of books. Two excellent papers
complement one another.
• Stanley J. TAMBIAH, ”A Thai cult of healing
through meditation” [originally publ. in Culture,
Medicine and Psychiatry 1 (1977): 97-132], is
reprinted in his collected essays Culture,
Thought, and Social Action, An Anthropological
Perspective, Cambridge, Mass.: Harvard U.P.,
1985 [ISBN 0 674 17969 2, 'tllpp., US$ 30], with
other famous papers of his on magic, pragmatics,
ethnoscience, etc.
• Charles F. KAYES, ’’The interpretative basis of
depression”, in Arthur Kleinman and Byron Good,
eds., Culture and Depression, Studies in the
Anthropology and Cross-Cultural Psychiatry of
Affect and Disorder, Berkeley: U. of California
Press, 1985 [ISBN 0 520 05493 8, 555pp.], a
fascinating book which contains also papers on
Sri Lanka, Iran, China, etc. Ch. KAYES is an
expert in Thai Buddhism, and one of the major
protagonists in the ’ethnosociological’ debate
on ’’Karma and Rebirth”. See Charles F. Kayes and
E. Valentine Daniel, eds., Karma, An Anthropologi
cal Inquiry, Berkeley: U. of California Press,
1983 .
1 icat i on
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o.nrnu.ei 1 membership
of US $
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Members residing outside of regions where
there are Chapters should send their dues
directly to:
Dr. Margaret Lock, IASTAM Treasurer
McGill University
Department of Humanities and
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McIntyre Medical Science Building
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Members of IASTAM/Europe, lASTAM/India,
IASTAM/Malaysia, lASTAM/North America,
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C/o Prof. K.N. Udupa, President of lASTAM-India
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MALAYSIA
MASTAM Treasurer
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IASTAM
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ADDRESS
NORTH AMERICA
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TAIWAN
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16
i
o
c
c
A
S
O
N
A
L
P
A
P
E
R
f
NON-FORMAL EDUCATION INFORMATION CENTER
COLLEGE OF EDUCATION
MICHIGAN STATE UNIVERSITY
EAST LANSING, MICHIGAN 48824
s
■i'
A*
me'Juo ■; ;c-iid ciicle
[organization & bulletin office]
326, V Main, 1st Block
Korarnangala# Banflalore-560034
OCCASIONAL PAPER #7
Medicine Showmen and the Communication
of Health Information in Mexico
Joseph J. Simoni, Luis Alberto Vargas,
and Leticia Casillas
1982
NON-FORMAL EDUCATION INFORMATION CENTER
j -
College of Education, Michigan State University
* ;
237 Erickson Hall
East Lansing, Michigan 48824, USA
(517) 355-5522
■
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-
r S’
COMMUNITY
;« '"cm
9
FOREWORD
Through its series of Occasional Papers^ the NFE Information
Center seeks to provide a forum for the exchange of ideas among
those pioneering in the study and practice of non-formal education.
In dynamicrelatively new fields of inquiry and experimentation
it is especially important to bring "ideas in progress" to the
light of collegial scrutiny.
We intend the papers in this series
to provoke critical discussion and to contribute to the growth of
knowledge about non-formal education.
In this paperj the three authors show, through a description
of their research, how Mexican medicine showmen can be effective
in disseminating health-related information. Based on many years
of research and experience. the authors designed and conducted a
controlled research project in infant nutrition.
The results
they share with us suggest that showmen are effective communication channels, and that, through the showmen, it is possible for.
health education programs to have an impact on individuals f
knowledge, attitudes and behavior.
This research also indicates
that medicine showmen can influence urban and more highly
educated populations as well as poor, rural ones.
We are very grateful to the authors for bringing their work
to our attention and for allowing us to share it with development
planners and practitioners in the Ron-Formal Education Network.
(ii)
£
■ .K*
’
-1
*
We extend special thanks to Joe Simoni who represented the team
of researchers during the final preparation of this Occasional
Paper.
I
As always3 we invite your comments and contributions to
enrich the dialogue concerning important issues in non-formal
education.
Mary Joy Pigozzi
i.
Director
Don-Formal Education
Information Center
(iii)
•1
ACKNOWLEDGMENTS
This paper was originally prepared for presentation at
the 32nd Annual Conference of the International Communication
Association in Boston, Massachusetts, 2-7 May 1982.
Research on which this paper is based was supported by
the following organizations:
the Inter-American Foundation,
the Mexican National Council of Science and Technology
(CONACYT), Universidad Nacional Autonoma de Mexico (UNAM),
and West Virginia University.
This series of Occasional Papers is published by the Non-Formal
Education Information Center in cooperation with the Agency for
International Development (Science and Technology BureaUj Office
of Education). The views expressed in this paper are those of
the authors and do not nea&escc^ily represent the NFE Information
Center or AID.
(iv)
TABLE OF CONTENTS
*■
Page
I.
INTRODUCTION
1
II.
METHODOLOGY
3
III.
FINDINGS
9
IV.
CONCLUSIONS
14
V.
DISCUSSION
15
VI.
REFERENCES
17
ABOUT THE AUTHORS
18
f
I
(v)
MEDICINE SHOWMEN AND THE COMMUNICATION OF HEALTH
INFORMATION IN MEXICO
Joseph J. Simoni, Luis Alberto Vargas,
and Leticia Casillas
I.
INTRODUCTION
MEROLICOS are Mexican medicine showmen whose counterparts can
be found in many other developing areas of the world.
Merolicos
frequent marketplaces and other common meeting places, like areas
near subway stations, and town squares, but they also work spots
where crowds are not usually found.
With ventriloquism, mental
telepathy, snake handling, clown acts, medicinal recipes, and other
kinds of crowd-pleasing performances, they attract the public and
in the end always offer for sale some medicinal product.
Initial research into the relationships between medicine
showmen and their patrons suggested that communications on the
medicine-show model might not only be favored by many of the poor.
but might be especially effective in combining the persuasive
advantages of mass media and interpersonal communication channels.
Results (Simoni and Ball, 1975) disclosed that the patrons of
medicine showmen often return again and again, and are not just
passers-by stopping to be entertained for a few moments.
They
regard the showmen as honest and credible, and they value very
highly the showmen’s ability to explain clearly.
Showmen were
-2-
observed to talk to as many as 250 people, and to sell to as many
as 70 people, in a period of about two-and-a-half hours.
From 1976 field results it was concluded that the most meaning
ful differentiation between patrons and non-patrons of Mexican
medicine showmen is made not in terms of their health orientations
(scientific, mixed, or folk-traditional), but in terms of their
curiosity and eagerness for information regarding scientific medicine, and their belief in the showmen.
For example, results
indicated that 25 percent of patrons and 50 percent of non-patrons
exhibited folk-traditional health orientations.
However, patrons
who exhibit folk-traditional health orientations are definitely
different from their non-patron counterparts in that they are
interested in hearing more about ’’scientific medicine” from the
medicine showmen (Simoni and Ball, 1977a).
Further developments led to the preparation of a proposal for
a pilot project, which was submitted by the Institute of Anthro
pological Research at the Universidad Nacional Autonoma de Mexico
(UNAM) in Mexico City to the Mexican National Council of Science
and Technology (CONACYT).
That proposal was approved by CONACYT
and endorsed by the Mexican National Health Council.
Funding
through CONACYT and financial support from the Inter-American
Foundation, UNAM, and West Virginia University made the pilot
!
project possible.
Past research had suggested that communication on the medicine-show model would greatly enhance public health efforts
■i
-3-
in many developing areas, and that it would be especially effective
in supporting and facilitating existing public health programs.
Medicine showmen talk to many people at one time, and utilize
their understanding of local culture and language to enhance their
The mass media characteristics could be used to
effectiveness .
develop and maintain social climates favorable to the acceptance
of new health-care norms, while the interpersonal channel charac
teristics could provide the person-to-person contact which is so
critical in influencing the actual adoption of innovative behavior
in developing areas.
The major objective of the pilot project was
to substantiate the value of using medicine shows as part of public
health programs.
Specifically, the results presented here speak
to three questions:
(1) Are medicine showmen actually able to
effect changes in health related knowledge, attitudes and behavior
of their audiences?
rural areas?
(2) Are medicine showmen effective only in
(3) Are medicine showmen only effective with the
least educated?
II.
METHODOLOGY
Selection of Communities
Twelve communities (6 test — 6 control) were selected for
the purposes of the project.
Six of them were colonias near the
peripheries of the cities of Oaxaca, Morelia, and Mexico.
The
remaining six were rural communities from the states of Oaxaca and
medico friend circle
[organization & bulletin office]
326, V Main, 1st Block
Koramangala/ Bangaiore-5G0034
-4-
Michoacan, and the Distrito Federal (D. F.).
used for the project because:
These areas were
a) they provided a representative
sample of a good part of Mexico, b) the research team has had
intensive research experience in all the three areas, and c) the
research team enjoyed excellent rapport with showmen in all three
areas.
*
The twelve communities were selected according to the
following criteria.
(1) Each of them had to be more or less self-
contained and not too large. so as to be of workable size for both
project implementation and evaluation.
(2) Each community must
have had no history of previous localized interpersonal attempts
at the kind of nutrition education to be employed as part of the
project.
Selection of the Medicine Showmen
Five showmen were selected to work with the project.
were selected on the basis of:
They
a) their observed expertise,
b) their experience in the regions to be worked, c) their past
honesty in dealings with Simoni, and d) their apparent interest
in contributing to attemps at improved public health education.
Message Content
Since 1979 was the International Year of the Child, and since
Vargas and Casillas possessed expertise in the general area of
nutrition and growth, we decided to focus the message content on
-5-
the nutrition of infants up to 1 year of age.
During the message
preparation stage, we instructed the showmen to emphasize the
following points.
1.
The value of breastfeeding to at least 1 year of age.
2.
The name and function of the first breast secretion,
colostrum.
3.
A recommendation for mothers to cleanse their breasts with
camomile tea before breastfeeding.
4.
A recommendation for early supplementary feeding, with
continued lactation for infants.
Indicated supplementary
feeding entailed:
a)
Fruit Juices (orange, apple, tomato) at 15 days of age;
b)
Fruit at 2 months;
c)
A "magic meal" of puree of beans, the juice from the
beans, and some other product like tortilla or cracker
at 3 months;
d)
Vegetables at 4 months;
e)
Egg yolks at 5 months;
f)
Meat at 6 months.
5.
The value of vitamin drops for babies.
6.
The functions of vitamins A, C, and D.
Infant nutrition, what babies should or should not eat, and
what mothers should or should not do if they want their babies to
be healthy, are all popular topics of conversation for families
-6-
with infants.
Furthermore, improved infant nutrition and general
infant care are major objectives for many health-oriented organi
zations which attempt to disseminate information, utilizing
both mass media and interpersonal channels of communication.
This
presented a problem, for we had to have some way of discerning
the separate impact of communications from the medicine showmen.
We dealt with the problem in three ways.
We first incor-
porated into the message two items of information which we knew
were not being disseminated through any other channels, the
recommendation for mothers to cleanse their breasts with camomile
tea, and the idea of the "magic meal."
Secondly, we decided to
emphasize the name and function of the first breast secretion,
colostrum.
We felt that even though a small percentage of the
public which we hoped to reach would be aware of colostrum. it
was not an item of information greatly emphasized as part of
other health communication efforts.
Lastly, we made plans to
incorporate into the evaluation instruments questions pertaining
!
1
to the sources of information or knowledge indicated by respon
dents .
Message Preparation
This phase of the project merits a separate paper focusing
on the dynamics of developing cooperative working relationships
between medicine showmen and academics, and between medicine
I
-7-
showmen themselves when their audience was made up of academics.
For this paper, though, we will simply outline the phase in three
parts.
The showmen spent 3 weeks working with us in Mexico City.
The first week was very relaxed, giving everyone a chance to get
acquainted, and giving the academics an opportunity to learn from
showmen about communicating with the public.
much more structured.
The second week was
The showmen attended class-like sessions
and were instructed as to the message we wanted them to communi
cate, and the reasons, including scientific rationales, for the
importance of each segment of the message.
At the end of the
second week we asked each of them to develop a medicine-show
routine incorporating all segments of the message.
We emphasized
that the routines should be developed according to their
individual styles, and that we only sought uniformity in the
correctness of the message content.
For example, we wanted them
all to recommend the ’’magic meal” for infants at 3 months of age.
and not for 2 or 5 months of age.
During the third week, the
showmen initially presented their routines, made changes based on
constructive criticism from us and their fellow merolicos, and
practiced again and again until they all felt comfortable and
ready to try them on the public.
At the end of the week we had
*
them practice near one of the metro stations in Mexico City.
r
-8-
Communication the Message
After the medicine showmen were ready to begin the field
phase of the project, we waited for about a month before having
them actually start.
Easter Holy Week was nearing, and it is
difficult to get anything done during that time in Mexico.
Therefore, this phase of the project, to last 3 months, began
the week after Easter, in late April of 1979.
In Oaxaca and the Federal District the showmen worked in
pairs.
In Michoacan the fifth showman worked alone.
In each of
the three areas there were two test sites, a marginal colonia and
a rural village.
The showmen worked each site only once a week
for a period of about 3 hours.
Within each site they moved
around to different locations, covering three different spots each
visit.
In conference with the showmen, we determined which
locations would be used.
We tried to select places where crowds
would more readily gather for the medicine shows, and we wanted
the showmen to work a number of locations within each test site
so that they might reach as many people as possible.
As things
worked out, each designated location or spot was worked three or
four times during the 3 months.
Evaluation
r
After the medicine showmen had worked for 3 months communieating the message. we waited another 2 months before carrying
J
♦
-9-
out the field segment of the evaluation phase.
Social workers and
nurses, trained to administer the interview instruments, first
surveyed 20 percent of the households in both the test sites and
control sites in order to provide us with measurements of the
communication impact of the medicine shows.
They interviewed
mothers, first preference being for mothers of infants less than
1 year old; second preference being for mothers of pre-schoolers
older than 1 year; and so on.
This major segment of our sample
included 400 women from test sites and 344 women from control
sites.
All interviews, at every test site and control site, were
completed during a period from 60 to 75 days after the final
communication of the message.
The findings which follow are
products of a first stage analysis of data gathered during those
interviews.
To support the findings, we also have tape record-
ings of all the medicine shows, and field notes about many of
the shows that we personally observed during the course of the
project.
III.
FINDINGS
The data reported here focus on the clearest indicators of
*
r
the impact of the medicine shows presented by the merolicos, the
responses to questions dealing with breastfeeding hygiene, the
’’magic meal,’’ and the first breast secretion, colostrum.
Not
1,
medico friend circle
-10-
[organization & bulletin office]
326, V Main, 1st Block
Koramangala> Banflalore-560034
only do these responses clearly indicate the impact, but they also
deal with all three areas of potential impact, those being know
ledge, attitudes, and behavior.
In the knowledge area the results are impressive.
the ’’magic meal,
its contents.
Regarding
24 percent of the mothers retained knowledge of
Also, for the total sample of mothers, the data
5
indicated that the showmen were able to cause a 17 percent increase
in the number of mothers knowledgeable about colostrum.
Responses to the question asking about advice for nursing
mothers indicate that medicine showmen can change attitudes or,
in this case, recommendations for behavior.
Nineteen percent of
mothers in the test group recommended camomile tea for cleansing
breasts before breastfeeding.
We can safely assume that, as with
control counterparts, before their exposure to the medicine,shows
they would have recommended some other form of hygiene, or nothing
at all.
Therefore, their responses at least 2 months after
exposure to the medicine shows constitute changed attitudes or
ways of thinking about breastfeeding hygiene.
Knowledge and attitudes are important, but what do the data
indicate as to the medicine showmen’s potential for changing
behavior?
Mothers who were breastfeeding at the time of the
interviews were asked what they actually were using to cleanse
their breasts before nursing their children.
Whereas not even one
individual in the control group indicated the use of camomile tea,
-11-
8 percent of the breastfeeding mothers in the test group said
that they used camomile tea.
This is an unambiguous illustration
of the ability of the merolicos to change behavior.
to the first question is a definite YES.
The answer
Medicine showmen in
Mexico are more than passing attractions.
%
The
Are medicine showmen effective only in rural areas?
traditional popular perspective of parties pretending knowledge
of merolicos has been that medicine showmen may have some
influence in rural areas, but not in urban areas.
The three urban
areas utilized in this study, Mexico City, Morelia, and Oaxaca,
all have more than 200,000 inhabitants.
What impact did the
medicine showmen have with this urban segment?
In the knowledge area the results are again impressive.
*
Regarding the ’’magic meal” 26 percent of the mothers in the urban
test group (N=201) retained knowledge of its contents.
Also, for
the total urban sample, the data indicate that the showmen were
able to cause a 21 percent increase in the number of mothers
knowledgeable about colostrum.
Whereas 23 percent of the urban
control group indicated knowledge, 44 percent of the urban test
group did so.
Responses to the question asking about advice for nursing
mothers indicate that medicine showmen can influence attitudes of
urban populations.
*
Fifteen percent of mothers in the urban test
group recommended camomile tea for cleansing breasts before
COMMON,. ¥ L- ALTH CELL
(First f loo.) J . hRoad
BANGAtOdt 500 001
-12-
breastfeeding.
As indicated above, these responses constitute
changed attitudes or ways of thinking about breastfeeding hygiene.
What do the data indicate as to the medicine showmen’s
potential for changing actual behavior of urban residents?
When
mothers in the urban areas were asked what they actually were using to
cleanse their breasts before breastfeeding their children, 9 per-
cent of the test group said they used camomile tea.
to the second question is a definite NO.
The answer
Medicine showmen are
effective in both rural and urban areas.
The third and last question dealt with in this paper focuses
on the medicine showmen’s effectiveness with the more educated
segment of the population.
The popular perspective of those who
claim to ’’know all” about merolicos is that only uneducated or
relatively uneducated people listen to the medicine showmen and
are influenced by them.
However, based on our data, we must
disagree.
For the purpose of analysis we divided the sample into those
having achieved a low level of education, third grade or less,
and those having achieved a higher level of education, fourth
grade or more.
impressive.
Again, in the knowledge area, the results are
Regarding the ’’magic meal" only 19 percent of
mothers with a low level of education, compared to 34 percent of
mothers with a higher level of education, retained knowledge of its
contents.
Also, the data indicate that the showmen were able to
cause only an 11 percent increase in the number of mothers with
-13-
a low level of education who were knowledgeable about colostrum,
but a 30 percent increase in the number of knowledgeable mothers
with a higher level of education.
Responses to the question asking about advice for nursing
mothers indicate that medicine showmen can also change attitudes
of mothers with a higher level of education.
Twenty-three per-
cent of the test-group mothers with a higher educational level
recommended camomile tea for cleansing breasts before breastfeeding.
This can be compared with 18 percent of test-group
mothers with a low level of education who made the same
recommendation.
Regarding the medicine showmen’s ability to change behavior,
as indicated above, mothers who were breastfeeding at the time of
the interviews were asked what they actually were using to cleanse
their breasts before nursing their children.
The data show that
5 percent of test-group mothers with a low level of education said
they were using camomile tea.
This can be compared with 14 per-
cent of test-group mothers with a higer level of education who
also said they were using camomile tea.
Thus the answer to our
third question is again a definite NO.
Medicine showmen are not
only effective with the uneducated or relatively uneducated.
The
more educated listen to them too, and are also influenced by them.
4
r
-14-
IV.
CONCLUSIONS
medico friend circle
[organization & bulletin office]
326, V Main, 1st Block
Koramangela, Bangalore-560034
In the light of earlier research results, and the data from
this pilot project, we can enthusiastically endorse the idea of
using medicine shows as part of public health programs.
In this
project, merolicos or medicine showmen have demonstrated their
abilities to effect changes in knowledge, attitudes and behaviors
of their audiences.
Furthermore, we are enthusiastic because the
test was a rigorous one.
A.
The challenge consisted of the following:
Test communities with histories of unwillingness to
cooperate with government-sponsored programs.
The state
health agency had withdrawn its program from one of the
rural test sites, and one of the test colonias was a
mushroom settlement not legally recognized by the local
government.
B.
Test populations with low levels of education.
Ninety-
one percent of the mothers interviewed had not gone past
primary school.
Sixty-four percent had not gone past
third grade.
C.
Attempting to communicate a rather lengthy message con-
sisting of more than ten parts.
D.
Attempting to change attitudes and behavior about things
steeped in tradition and culture.
Infant nutrition is
a subject about which everyone has an idea or opinion.
-15-
E.
Working during the rainy season.
This resulted in having
to change work plans, working in the rain, etc.
F.
Communicating the message during only a 3-month period.
This resulted in each test community being worked a
maximum of only 40 hours.
G.
Conducting the evaluation interviews in each test commu
nity only after at least 2 months had passed since the
last medicine show.
V.
DISCUSSION
The idea of using merolicos as part of community health programs
is now based on seven years of research and experience.
It makes
sense in terms of (a) our knowledge of target subcultures and
communities, (b) our knowledge of various communication media and
their potentials for communicating health information to these
targets, (c) the comparatively low potential cost, when compared
with other health communication efforts, and (d) the relatively low
potential cost, relative to the potential benefits or results.
Infant-nutrition information, of course, is just an example.
Information on venereal diseases, gastro-intestinal disorders,
heart disease, or just about any other health-related topic could
be disseminated by medicine showmen.
them.
We know people listen to
We know people will gain knowledge and change both attitudes
and behaviors as a result of their contact with medicine showmen.
-16-
We believe medicine showmen should be integrated into ongoing public
health programs.
-17-
VI.
REFERENCES
medico friend circle
[organization & bulletin office]
326, V Main, 1st Block
Koramangala, Bangalore-560 034
Lin, Nan and Ronald S. Burt. Roles of Differential Information
Channels in the Process of Innovation Diffusion. 1973.
International Center for Social Research, Albany, New York,
USA.
Quasi-Mass Communication: A Neglected Area.”
Menzel, Herbert.
Public Opinion Quarterly. Vol. 35, No. 3, 1971. pp. 406409.
►
Simoni, Joseph J. and Richard Ball. "Institutionalized Medical
Exploitation: The Case of the Mexican Medicine Huckster.”
Sociological Symposium. Summer 1978.
. ’’Huckster-Styled Communication — Its
Potential Role in Community Health Programs.” Paper pre
sented at the Annual Meeting of the Rural Sociological
Society, 1977. (a)
. ”La Diffusion de Informacion Sobre la
Salud: Lo Que los Merolicos Nos Pueden Ensenar.” Salud
Publica de Mexico. Vol. 19, No. 2, March-April 1977. (b)
. "The Mexican Medicine Huckster: He Must
Be Doing Something Right." Sociology of Work and Occupations:
An International Journal. Vol. 4, No. 3, August 1977. (c)
Can We Learn from Medicine Hucksters? ft
The Journal of Communication. Vol 25, Summer 1975. pp. 174181.
II
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-18-
ABOUT THE AUTHORS
Dr. Joseph J. Simoni is a sociologist with the Department of
Sociology and Anthropology at West Virginia University.
He now
teaches courses in introductory sociology3 community3 community
development3 and ethnic groups.
His major research interests are
health communicationand social histories of ethnic groups in
«
Appalachiasocial change^ and development.
For the last nine
yearsj with much appreciated support and sacrifices of his wife^
Pat, and their two children, Susanne and Joanna, he has been
studying medicine showmen in Mexico.
Dr. Luis Alberto Vargas obtained his medical degree from the
National University of Mexico, his Master's degree in Anthropology
from the National School of Anthropology in Mexico, and his Ph.D.
in Anthropology from the University of Paris.
He is currently a
researcher and the academic secretary of the Institute for
Anthropological Research at the National University of Mexico.
He has recently been a visiting researcher at the Department of
Anthropology at Michigan State University.
His area of interest
are medical and physical anthropology, including human growth,
nutrition, health eduction, and ergonomics.
Dr. Leticia E. Casillas obtained her medical degree from the
National University of Mexico.
She specialized in social pedi
atrics in the Universities of Madrid and Paris.
Currently she is
preparing her dissertation to obtain a Master's degree in Physical
Anthropology, while serving as head of the section of Medical
Anthropology in the Direction of Medical Services at the National
University of Mexico.
Her main areas of interest are nutrition,
variability of Mexican populations, human growth, and health
education.
*
UNIVERSITY OF TORONTO
Institute for the History and Philosophy of Science and Technology
TORONTO, CANADA
M5S 1A1
July 15, 1982
Luis A.V. Barreto:
I was interested to read your work.
It has relatively little historical
analysis in it. I felt as I was
reading it that you saw western
medicine in the past; as being
exactly what it is now.
I am looking forward to working
with you next term.
Pauline Mazumdar
4?A' «
. ’-A' '
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CHAPTER 6
■X
Traditional Chinese medicine
I
-a
Wang Pei1
i
The splendid culture of the ancient times had a rich store of medicine
some elements of which, with the development of modern medicine, were
discarded while others were preserved and handed down to posterity A
few were further developed and spread far and wide among the people.
Iraditional medicine has made a great contribution to the welfare of all
nations in the world.
In the present era of highly developed modern medicine, it is r
necessary
to give due regard to the traditional medicine of all nations , as our
experience m the development of traditional Chinese medicine has shown
We firmly believe that the integration of traditional medicine with modern
medicine helps to correct the deficiencies of each and will certainly promote
the development of medical science in the future.
Traditional Chinese medicine, with its rich clinical experience, its unique
theoretical system and its extensive literature has served to combat illness
among the Chinese people over many centuries. It represents the
crystallization of the Chinese people’s wisdom and experience. What has
proved effective in clinical practice has been preserved, handed down from
generation to generation, and continually improved upon. A few examples
only are given below.
The early stage of medical activities dates from the beginning of human
some y. The historica documents of ancient China contained some legends
about it, but the earliest recorded history of traditional medicine was in
Lr? n B C k
JA'Tne
,he Shan£ dynasty- Certai" oracle-bone
writings, the oldest form of Chinese writing carved on scapulae and
tor orse sheHs and used for divination, that were unearthed from the ruins
of the Ym dynasty bear inscriptions naming and describing various kinds
of illnesses and indicating elementary methods for the classification of
diseases, f or instance, head disease was called Ji Shou; eye disease, Ji Mu\
' D,rector. Central Laboratory. Academy of Traditional Chinese Medicine, Beijing. China.
68
W
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o
f
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sdicine
Wang Pei1
nad a rich store of medicine,
mt of modern medicine, were
zianded down to posterity. A
and wide among the people.
Tibution to the welfare of all
>dern medicine, it is necessary
xicine of all nations, as our
Chinese medicine has shown,
utional medicine with modern
a.ch an^ will certainly promote
nture.
clinical experience, its unique
has served to combat illness
x:en,_ries. It represents the
mi and experience. What has
preserved, handed down from
□roved upon. A few examples
rrom the beginning of human
Zhina contained some legends
traditional medicine was in
ynasty. Certain oracle-bone
ng carved on scapulae and
eere unearthed from the ruins
and describing various kinds
ods for the classification of
j Ji Shou; eye disease, Ji Mu;
lai Chinese Medicine, Beijing, China.
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TRADITIONAL CHINESE MEDICINE
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69
ear disease, Ji Er; abdominal ailment, Ji Fu; diseases of the foot, Ji Zu and
so forth. The character
(gu), which means a venomous insect, was
formerly written like
, which indicates that there are parasites in the
abdomen; and the character
(qu), meaning decayed tooth, was written
like
, which indicates that a tooth is being eaten by insects. These are
the earliest records on dental caries and parasites.
More remarkable yet are the notions of hygiene and preventive measures
appearing between 1400 and 1200 b.c. For instance, the character T^-(yu),
meaning “bath”, was formerly written like
on oracle bones. indicates
“person”,/^ “water”, and
“bath tub”. Oracle bones also record
“sprinkling of water to remove the dust, sweeping, and getting rid of
insects”. These excavated cultural relics from the ruins of the Yin dynasty
show that there were already at that time sties and folds for domestic
animals, lavatories and drainage trenches.
The Book of Rites, a manual of ceremonies written in the Zhou dynasty
(1100 to 800 b.c.), records that there were specialized doctors in four
departments, namely: nutrition, internal medicine, surgery, and veterinary
medicine. It also stipulates that “Doctors are in charge of medical laws and
decrees”. “If one gets ill one should be treated. If one dies of a certain
disease, the cause of death should be recorded and made known among the
doctors.” This is probably the earliest medical case-recording system. It
also makes it a rule to assess doctors’ knowledge and skills annually so as
to determine their salary grade. The famous medical book of our country.
Internal Classic or Yellow Emperor’s Internal Classic, the oldest and most
comprehensive work on medicine still extant, which appeared around 300
b.c., is a combination of medical theory and clinical practice (7). This book
is in 18 volumes; it emphasizes the basic theory of traditional Chinese
medicine and contains substantial information on hygiene, clinical
symptoms, prescriptions and drugs, acupuncture and moxibustion, and so
forth.
The theory of yin-yang, viscera and bowels, and meridians recorded in
the Internal Classic has become the foundation for the basic theory of
traditional Chinese medicine. Anatomy was already in the embryonic stage
and some anatomical data were analysed. For instance, the length of the
digestive tract, from pharynx to rectum, was measured by adding up the
length of different segments; the recorded length was similar to that found
by modern anatomical measurement. Over 300 signs and symptoms were
also described. For instance, in dealing with the symptoms of cervical
lymphatic tuberculosis, the book also correctly portrays its relation with
visceral tuberculosis. Besides medicinal treatment, the Internal Classic
records many non-medicinal therapies such as acupuncture and moxibus
tion, massage, ciao yinq (a combination of deep breathing and self-massage)
and so forth. Of special significance is the detailed record on the treatment
of ascites by abdominal tapping. A thin needle was inserted at guanyuan
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TRADITIONAL MEDICINE AND HEALTH CARE COVERAGE
point, 7J cm below the umbilicus; the abdomen was then punctured with a
hollow needle to drain the ascitic fluid, the needle being kept in the
abdominal cavity until the fluid had drained to a certain degree. A tight
abdominal bandage was then applied to avoid adverse effects resulting
from the sudden change in intra-abdominal pressure. Such an operation
and postoperative procedure reflect the wisdom and the medical knowledge
of ancient doctors. The Internal Classic still remains an essential textbook
in the colleges and schools of traditional Chinese medicine.
From the Chin and Han dynasties down to the Ming dynasty (a.d. 1700)
the empirical medicine of China forged ahead with great success. For
instance, the Chinese medical scientists invented the method of variolation
or inoculation to prevent smallpox. It was an important invention in the
history of human preventive medicine and one that pioneered modern
immunology. At the time of Song Zheng-zong (a.d. 998-1022), a Taoist
priest in the Mount E-mei had the son of Minister Wang Dan inoculated.
Towards the latter part of the 16th century, variolation was widely used in
China. In 1688, Russia sent doctors to Peking to learn this method, and it
was thereby introduced to Turkey and Europe. It was only after
inoculation with cowpox had been invented by Jenner in 1796 that
variolation was gradually abandoned.
There are various kinds of treatment in traditional Chinese medicine.
Some original non-medicinal treatments such as acupuncture, moxibustion
and massage were introduced over 3000 years ago. Some very rich
experience has also been gained in using natural herbal medicines to treat
diseases. Drug anaesthesia was applied in laparotomy in the 2nd century;
harelip operation was performed in the 3rd century; the treatment of
scabies, tinea and carbuncles by mercurial ointment was used in the 4th
century; couching of cataract with gold needles was adopted in the 5th
century; and false teeth with amalgam were introduced in the 7th century.
The treatment of vertebral fracture by suspension, reduction, etc. was
introduced in the 12th century. These are perhaps some of the earliest
methods of treatment recorded in the history of medicine.
China also has a rich store of books on pharmacology. The Xin Xia Ben
Cao (Newly Revised Materia Medica) of the Tang dynasty in the 7th
century is the earliest pharmacopoeia promulgated by the government. In
the 12th century, the Song dynasty published Tai-Pin Hui-Min He Ji Ju
Jang which is the world's earliest prescription book of pharmacy issued by
the government. In the 17th century, during the Ming dynasty, in his Ben
Cao Gang Mu (Compendium of Materia Medica), Li Shi-zhen, the worldfamous pharmacognosist, collected 1892 kinds of herbal drugs and 11000
prescriptions. Charles, Darwin in The Tariation of Animals and Plants under
Domestication referred to the Ben Cao Gang Mu as a Chinese
encyclopaedia.
Io date, traditional Chinese medicine has generated over 10 000 medical
books, 5000 kinds of herbal drugs, and a rich experience of clinical
therapy. Traditional Chinese medicine and pharmacology have not only
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HEALTH CARE COVERAGE
TRADITIONAL CHINESE MEDICINE
end omen was then punctured with a
and, the needle being kept in the
trained to a certain degree. A tight
to avoid adverse effects resulting
rminal pressure. Such an operation
■wisdom and the medical knowledge
r still remains an essential textbook
nal C ?se medicine.
*wn to .^e Ming dynasty (a.d. 1700)
ied ahead with great success. For
invented the method of variolation
•was an important invention in the
a I one that pioneered modern
:ng-zong (a.d. 998-1022), a Taoist
of Minister Wang Dan inoculated.
zury, variolation was widely used in
Peking to learn this method, and it
and Europe. It was only after
nvented by Jenner in 1796 that
in traditional Chinese medicine,
such as acupuncture, moxibustion
*000 years ago. Some very rich
_ natural herbal medicines to treat
in laparotomy in the 2nd century;
ae 3rd century; the treatment of
rial ointment was used in the 4th
. needles was adopted in the 5th
/ere ii
duced in the 7th century.
suspension, reduction, etc. was
are perhaps some of the earliest
■ust / of medicine.
n pharmacology. The Xin Xiu Ben
of the Tang dynasty in the 7th
omulgated by the government. In
dished Tai-Pin Hui-Min He Ji Ju
□lion book of pharmacy issued by
ring the Ming dynasty, in his Ben
Medica), Li Shi-zhen, the world
kinds of herbal drugs and 11 000
lalion of Animals and Plants under
^ao Gang Mu as a Chinese
las generated over 10000 medical
id a rich experience of clinical
nd pharmacology have not only
71
contributed much to the development and prosperity of the Chinese people,
but have also had an important influence on the development of medical
science in general.
It is a matter for regret that, for various historical reasons, traditional
Chinese medicine was not able to participate earlier in the experimental
sciences. For many decades, modern or Western medicine has forged
rapidly ahead whereas the progress of traditional Chinese medicine since
the Ming and Qing dynasties has been much slower in comparison. Under
such unfavourable conditions, there have been two different attitudes
toward .traditional Chinese medicine: one tendency was to eliminate the
system and replace it by modern medicine, or eliminate the practice but
preserve its effective drugs and prescriptions only; and the other was to
accept this precious legacy and develop it with modern scientific knowledge
and methods into a unified medicine and pharmacology with the
characteristic style of China.
In 1929 the central government of Kuomintang passed a bill “to ban the
traditional medicine in order to clear the way for developing medical
work”. But they did not succeed in banning and replacing it. In the first
place, people in the vast rural areas and both the common people and the
upper class in many cities earnestly believed in traditional medicine.
Secondly, the use of traditional Chinese medicine and medicinal herbs did
yield rather satisfactory results in the treatment of diseases, including some
diseases intractable by modern medicine. Traditional remedies could reduce
symptoms and even produce remission. Moreover, Chinese medicinal herbs
were readily available at low cost, were convenient and simple to use, and
had veiy few side-effects. They therefore enjoyed much popularity with the
vast majority of people. Thirdly, traditional medicine had a unique
theoretical system which can neither be replaced nor explained by modern
science, including the theory of yin-yang, vital energy and blood, and so
forth. Traditional Chinese medicine has thus survived and has never been
eliminated in spite of the persecution it suffered before the liberation.
However, it was only after the founding of the People’s Republic of China
that traditional Chinese medicine entered a new period of development.
The liberation
Since the founding of the new China, our Government has attached
great importance to traditional Chinese medicine, giving energetic support
to it and taking effective measures to speed up its modernization.
To foster unity between Chinese and Western-trained doctors” is one of
the four principal policies for health work laid down by the Government
since the inauguration of the People’s Republic of China. Later, the policy
on traditional Chinese medicine was formulated according to the actual
needs of our country. The main points of the policy are as follows:
1
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traditional medicine and health care coverage
traditional Chinese' medicine^1015’ SyStematlze
systematize and raise the level of
t
so as to give full
E
O) to organize ways for Western-trained
doctors to learn and study
traditional Chinese medicine;
(4) to modernize traditional medicine and pharmacology gradually
'■’t
I
lhe
Stern me^lcine m a planned and
rational way;
(6) to protect, utilize and develop the resources of Chinese medicinal herbs.
I
In order to ensure the implementation of '
of this policy, a parent
organization in charge of traditional medicine has
1been established parent
’
—
s
within
the Government. The Ministry of Public Health has
... ..~j set up a bureau of
: also
CHnesTmed^nrias'relaS
yo-tJe'iLrltiom
and eschewed. It was onlv X rhe ! h!® ’
u was d,Scr,m,nated against
hospitals of Western medicine
°
eh™s m
cJ.«
j
.“s
i
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ni* f
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ree mc^,ca^ care- In the
„ciI,
above the county level and almost all th
I
t[adlllonal medicine
'
J in HP n
, 91 Coun,y and municipal hospitals
had
been established
-------- J in 102 municipalities and counties in Hunan province.
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-ALTH care coverage
zmatize and raise the level of
I
zninese doctors so as to give full
i
:d doctors to learn and study
II
z pha
cology gradually;
ae and conduct research on the
■stern medicine in a planned and
I
nrc^- of Chinese medicinal herbs.
non oi
of this policy,
policy. a parent
xine has been established within
Health has set up a bureau of
traditional medicine have also
iicipal bureaux of public health,
traditional medicine policy and
it, traditional Chinese medicine
i
fI
tors and the condition of the
mdously. Before the liberation,
and was discriminated against
ton that Chinese medicine gained
rrs of traditional medicine have
^tive medical organizations such
mstitr
Chinese medicine and
art oi ee medical care. In the
ments of traditional medicine
iavr ill been accommodated.
io master some modern science
cipalities have organized various
ies for teachers of traditional
onal doctors to study and raise
ve brought about fundamental
academic position of traditional
1I
f
is in the hospitals of traditional
ospitals of traditional medicine
TRADITIONAL CHINESE MEDICINE
73
not including the provincial hospitals and the general hospitals where
traditional Chinese medicine has the chief position. These traditional
hospitals have assumed a great many medical functions. For example, in
the traditional hospital of Chang De, the number of outpatients has
reached 3700000, while 20880 patients have been hospitalized since its
establishment.
In addition, the barefoot doctors working in the rural areas have all
received appropriate training in both Western and traditional methods of
treatment, but most of them mainly apply acupuncture and herbal
treatment These 1 600000 barefoot doctors have greatly contributed to the
medical service in the rural areas, which have an estimated population of
800 million.
The educational and training curriculum for traditional Chinese medicine
has been strengthened. At present, there are 24 institutions of higher
learning for traditional medicine with 18 000 students, and 18 secondary
schools with 10 000 students. Moreover, the students in the Western
medical colleges are also obliged to pursue courses in traditional medicine.
Faculties of traditional Chinese medicine have been established in 11
Western medical colleges.
The production of Chinese herbal medicines has increased, and has
gradually developed into an industrial system in the last 30 years. The staff
engaged in purchasing, processing and supplying medicinal herbs now total
220 000. The area under cultivation of medicinal herbs has reached
6 million mu (400000 hectares). The amount of medicinal herbs purchased
totals 13 million tonnes. At present there are more than 800 pharma
ceutical factories with 80000 workers in them, which produce some 2000
varieties of medicinal herbs. With increasing modernization in the
pharmaceutical factories, the quality of herbal medicine has greatly
improved. During the nationwide quality appraisal drive in 1979, herbal
medicine won three gold and four silver medals.
Efforts made to integrate traditional Chinese medicine with Western
medicine have proved truly worth while. Only through close cooperation
between the traditional and Western-trained doctors, each learning from
the other, and especially through the study of traditional Chinese medicine
with modern scientific knowledge and technology, can the development of
traditional Chinese medicine proceed more speedily. For many years, the
Central Government, provinces and municipalities have organized many
orientation courses for Western-trained doctors to study traditional
Chinese medicine; thus many doctors specialized in both Western and
traditional medicine have been trained. Now, there are three types of
hospitals of Western medicine
doctor in our country—namely, traditional. Western-trained, and Western-
dicine; the larger hospitals with
rcH laboratories to explore the
iditional Chinese medicine with
county and municipal hospitals
ind counties in Hunan province.
trained with qualifications in traditional medicine. These categories arc
advancing along the road to an integration of traditional and Western
medicine to achieve a unified new medicine and pharmacology. We have
obtained encouraging results from scientific research on the combination of
Chinese and Western medicine, for example in the fields of acupuncture
It
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TRADITIONAL MEDICINE AND HEALTH CARE COVERAGE
and moxibustion, acupuncture analgesia, acute abdominal conditions,
burns, injury of bones and joints, anal fistulas, lithiasis of the urinary tract,
cardiovascular diseases, cataract, and respiratory diseases in infants. The
effect of the combined treatment of the above-mentioned conditions is
much better than that of either system applied alone. Applying modern
scientific knowledge and technology, encouraging research results have
been obtained also regarding the hypotheses on which traditional medicine
is based. These include the theory of yin-yang, visceral manifestations, vital
energy and blood, meridians, the method of promoting the blood
circulation and relieving stasis, reinforcing vitality, etc.
*
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i
Traditional Chinese medicine certainly deserves attention and high
priority. It contains some scientific elements which will surely make a
contribution to mankind if we conscientiously explore and systematize it by
modern scientific method and technology. A more realistic policy is
required to protect and develop the system instead of discriminating
against it or trying to eliminate or replace it. Only thus can traditional
Chinese medicine develop and progress. The integration of the two systems
requires careful study. These two schools of medicine should be mutually
supporting and complementary and there should be no strife. Traditional
medicine could then contribute more to the welfare of mankind. Much has
already been gained from traditional Chinese medicine in the field of public
health and in the development of medical science. We would like to share
this experience with all interested health workers.
It is encouraging to note that more and more countries have become
interested in traditional Chinese medicine. One hundred and fifty scientists
and doctors from 34 countries and territories attended the Symposium on
Acupuncture and Acupuncture Anaesthesia held in Beijing in 1979 and this
kind of international activity will no doubt increase.
What are the future prospects of traditional Chinese medicine? An
analysis of our 30 years’ experience tells us that traditional Chinese
medicine will continue to develop steadily through the judicious application
of modern science and technology. The combined treatment of certain
intractable conditions such as malignant tumours, cardiovascular and
degenerative diseases and senility is likely to be more efficacious. The nonsurgical treatment of certain diseases such as acute abdominal conditions
will be popularized so that it can alleviate patients’ suffering and reduce
medical expenditure. At the same lime, the mechanism of its therapeutic
eflect and basic theory will be further elucidated. Consequently, the
integration of Chinese medicine and Western medicine has a particularly
bright fulure.
Science and technology are the common wealth of mankind. Traditional
Chinese medicine is an old and yet quite a young science, and its
9
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TRADITIONAL CHINESE MEDICINE
ff-'.'
1
ons,
act.
The
s is
(ern
ave
:ine
ital
)od
I
development and improvement naturally require the common efTorts of
scientists all over the world. Traditional Chinese medicine will always have
an important role in the cultural exchange between the Chinese people and
the people of other countries. Let us carry on the exchange and the
cooperation our ancestors initiated!
REFERENCE
(/) Veith, I., transl.. The Yellow Emperor's classic of internal medicine
University of California Press, 1967.
;gh
a
by
is.
ng
lal
ns
lly
al
as
lie
re
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i
le
is
n
is
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75
Berkeley, CA,
1 Review of Folk Medicine
Primer on Traditional
Chinese Medicine
Editors Note: The following is a reprint of the Primer on Traditional Chinese
Medicine, produced by the Acupuncture Therapeutic and Research Center, Inc.
INTRODUCTION
raditional Chinese
Medicine is the
result of thousands
of years of struggle
against disease
through the use of theory and practice
which are closely linked with the observation of natural events or
phenomena.
The Chinese have developed a
system of health care which has been
proven to be effective in resolving
disease processes over the years. The
Chinese experience primarily shows us
that the role of Chinese Medicine in
Public Health Care can be most
beneficial to people in communities, in
both rural and urban areas.
For our part, it is essential to venture
into Traditional Chinese Medicine’s
use for our purposes to be able to
develop an applicable system that is
potentially easy to apply, easy to teach,
low cost, and effective.
Faced with today’s rising cost, par
ticularly medical care and drugs, we can
not but see the relevance of pro
pagating Traditional Chinese
Medicine.
This primer’s primary objective is to
be able to:
1. inform the’reader regarding the
principles and methods involved in
Traditional Chinese Medicine
2. familiarize the reader with the dif
ferent Traditional Chinese modali
ties of treatment, and
Proper diet means:
3. impress upon the reader the impor
tance of a systematized approach in
the use of Traditional Chinese
Medicine.
1) one must eat a balanced diet con
taining the required amounts of
nutrients, proteins, vitamins,
minerals, and so on;
2) one must eat on time with regula-
A. What are the principles,
theories, and concepts of Tradi
tional Chinese Medicine?
rity;
3) one must not eat too much nor too
little; and
The different theories and principles
governing Traditional Chinese
Medicine will be found quite similar to
thrf other types of Medicine particularly
in the concept of maintaining health.
This involves the idea in what the
Chinese call “yang sheng,” literally
translated as, to nurture life. This
basically means that to stay healthy,
one nurtures life properly.
Nurturing life properly involves the
following processes of proper diet, ade
quate amounts of rest, and proper
adaption to stress.
4) one must have the proper attitude to
eating, preferrably avoiding emo
tional upsets during meals.
Adequate rest means:
1) a balance
schedules;
of
rest
and
work
2) proper length of rest, which is as required, eight hours a day;
3) one must sleep early, wake up to be
able to face the new stresses the next
day; and
4) one must have the proper attitude to
resting, preferably avoiding emoTAM BALAN 9
r
tional upsets or quarrels prior to
sleep, and also preferably resolving
these before bedtime.
Adaption to stress means:
1) strengthening of the body to with
stand external stress, such as
changes in climate or weather, to
provide adequate protection against
natural elements of wind, heat, cold,
humidity, etc.
2) to learn how to control the different
emotions, to be able to give vent to
those emotions of sadness, anger,
frustration, depression, worry, fear,
and happiness at the proper time,
meaning one must get angry when it
is time to get angry and not to re
main angry for an extended period
of time by resolving the root of the
anger; excessive worrying upsets us
since we can not sleep nor eat well
when we worry.
Proper exercise done regularly
definitely helps the body maintain
strength and cultivates body resistance
against disease.
All in all, Chinese Medicine sees the
relationship of these factors and sum
marizes them all into one word reflec'
tive of a healthy status, which is
balance — balance of diet, rest, and
stress.
The Chinese Medical theory that is
used to expound balance is what is .
known as yin and yang. Briefly, this
seems to be a relationship between two
10 TAMBALAN
factors, events, or entities which are
constantly in antagonism with each
other. However, their existence is
mutually dependent on each other,
such that, without one, the other can
no longer exist.
As an example, the concept of light
exists primarily because there is the
concept of day. Without the concept of
day, there will be no concept of night
and vice-versa. However, night and day
are quite opposed to each other, one
being dark, the other light; one being
cool, the other hot, and so on.
Traditionally, the concept of yin and
yang is believed to be universal and has
the following relationships. They are
yin and yang transforming into the
other — night becomes day and day
becomes night. Yin and yang define
each other, such that what is light is
that which is not dark. They control
and are dependent on each other as
previously discussed.
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To make things simple and easier to
understand, yin is personified or ex
emplified by night and all of its
characteristics like night is dark, cool,
quiet, passive, etc. while yang is its op
posite, day being bright, warm, noisy,
active, etc.
When applied to health and balance,
yin and yang is used in the following
sense: as far as diet is concerned, one
must eat the proper amounts of food,
hot and cold in nature. By hot and cold
food, what is meant is the type of
characteristic the food gives off. For ex
ample, fats, beef, pepper, coffee all pro
vide a warming sensation to the body;
whereas, vegetables, water, pork,
melons all provide a cooling effect.
The various forms of yin and yang
are thus applied in a similar sense in
maintaining bodily health. It is quite
clear that there is a dynamism that
must be understood for one to truly
maintain health.
B.What are the different modali
ties of treatment of Traditional
Chinese Medicine?
Traditional Chinese Medicine is a
system of health care which uses con
cepts of body energy, known as “Qi”
(pronounced “chee.”) However, Qi is
quite universal in a sense that the
Chinese maintain that energy or qi ex
ists and manifests itself all throughout
nature like the sun rising and setting,
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the planets moving in a proper move
ment, and the like.
The theory is quite similar to the idea
that energy exists in various forms like
electrical energy, heat and radiant
energy, magnetic, chemical, and
mechanical energy and that all these
are transformed to one form or
another. In our body, there is a
multitude of manifestations of energy
like electrochemical, electromagnetic,
and biochemical energies which the
Chinese have all referred to as qi.
It is quite obvious the Chinese have
used terms best suited to their culture
and environment for their particular
time, for them to understand the work
ings of the body and nature as a whole.
As far as-the body is concerned, it is
run as a system which transforms
various substances to energy or qi,
these substances being primarily the
nutrients we get from food and air we
breathe in. The body is also perceived
to circulate energy or qi. Its manifes
tations are seen as body movements.
Lastly, the body also stores adequate
amounts of energy for future use as in
cases of emergency, wherein one calls
on unusual amounts of energy for
unusual use of energy like lifting a
heavy cabinet during a fire. Such are
the manifestations that our body has
qL
According to Traditional Chinese
concepts, the different modalities simp
ly influence the production of qi (ex
traction of qi from substances), the cir
culation and the storage of qi.
The various modalities of Traditional
Chinese Medicine are the following:
1) Acupuncture — This term is derived
from the words “acus” and
“pungere” which mean needle punc
ture. This modality makes use of fine
filament needles inserted into pre
determined sites called acupuncture
points. These have been observed
through the years to have a distinct
and particular effect on the body’s
qi.
2) Pressure therapy, called “tuina,” also
known as remedial massage — This
makes use of pressure and massage
techniques over acupuncture points
to be able to influence the body qi.
3) Moxibustion — It is an ancient tech
nique of burning herbs over body
areas to be able to redirect qi flow.
This is a modified form of cauteri
zation using dried herbs, mainly
from a plant called Artemesia
vulgaris, or damong maria to be able
to eliminate cold and move qi in the
body.
4) Cupping or more commonly known
as ventosa — This employs the use
of a vacuum made by flaming a cup
or a glass and rapidly attaching this
to the body skin. This is commonly
used to move stagnant qi and
eliminate cold in the body.
5) Chinese Herbal Medicine — Lastly,
this modality of treatment uses
diverse forms of drugs taken from
plants, animal, and mineral
resources. These are prepared to be
taken by an individual to be able to
influence qi circulation, to
strengthen resistance of the body’s
condition against disease. It is an en
tire field in itself and due to its com
plexity and the diversity of drug ac
tion, we feel it would be more ap
propriately called Chinese Phar
macology.
C.What are the ailments that res
pond best to Traditional
Chinese Medicine, particularly
acupuncture?
For thousands of years, the Chinese
have used acupuncture and other
modalities of Traditional Chinese
Medicine for a multitude of diseases, all
of which are diagnosed and analyzed
according to Traditional Chinese
Medicine principles. However, the
principles and terminology used in
Traditional Chinese Medicine differ
from that of modern 'Western
Medicine.
What is most commonly accepted in
today’s use of acupuncture is its great
role in controlling pain. Pain is often
seen as a circulatory disorder involving
qi wherein flow of qi is disrupted,
leading to a slowing down (stagnation)
or complete stop (obstruction). For ef
fective control of pain using acupunc
ture, proper methods of identification
or analysis of the cause and the loca
tion of stagnation or obstruction is
necessary.
The different methods of diagnosis
used by Traditional Chinese Medicine
are the same as those utilized by
modern Medicine, namely — inspec
tion, palpitation, auscultation, and ask
ing questions regarding the patient’s ill
ness. It is important to note that this
type of medicine was developed at a
TAMBALAN 11
time wherein a practitioner had to sole
ly rely on his senses, unlike today
wherein our senses are further aided by
technology such as the microscope,
scans, etc.
Thus, the methods of diagnosis em
phasize or center on gross findings such
as general appearance of his face, the
color, shape, and moisture of the
tongue, the qualities of pulse felt, the
patient’s relationship to his environ
ment, both internal and external, by
asking a multitude of questions regard
ing different bodily processes. These in
clude questions on diet, appetite, thirst,
bowel movement, urinary habits, sleep,
and in women, menstrual flow.
The Traditional Chinese Medicine
practitioner then collates all data
gathered and interprets this as a pat
tern of illness, imbalance, or dishar
mony and only from there, proceec ? to
treat it accordingly. Failure to d'agnese
a case, therefore, will usually result .n a
treatment failure. The same applies to
Western Medicine.
Experience world-wide points to the
fact that acupuncture and Traditional
Chinese Medicine, as a whole are also
effective-in dealing with health pro
blems other than pain. It is at this point
that there is a need to fully compre
hend its function and use in terms of
modern medical parameters and this
clearly involves extensive clinical
aching soreness, distention, electrical
sensation, heaviness or numbness, and
warmth, all of which may stay in one
place or radiate through the normal
course of qi flow.
Patients must not be hungry, ex- cessively tired, overly nervous, and
must have slept well prior to treatment.
Pregnant patients and children below
seven years old must preferably be
treated with extreme caution.
People with the following conditions
must not be treated until after a more
suitable period of time: drunken pa
tients or those who have taken alcoho
lic beverages, patients under the in-
research.
D.What will the patient ex
perience while undergoing acu
puncture treatment?
j
I
Acupuncture treatment deals with
direct intervention with the flow of qi.
It is therefore important for the patient
to experience “de qi” or needle sensa
tion. This simply means that needling a
particular point requires that qi must
be gotten or felt for one to be able to
manipulate it.
The sensations involved are any
one or a combination of the following:
12 TAMBALAN
fluence of addicting drugs, and patients
with serious illness wherein qi level is
very low, for what qi can be
manipulated when there is little left.
Precautions for patients after
acupuncture treatment are the follow
ing:
1) to refrain from excessive work or ex
ercise so as not to disrupt qi flow
that has been influenced to regain
balance;
2) to refrain from intake of alcoholic
beverages’ which will retard qi flow;
and
3) to avoid exposure of punctured
areas to water to avoid potential
disruption of qi flow.
AFTERWORD
All in all, it is clearly seen that Tradi
tional Chinese Medicine offers a
distinct alternative to most of our
health problems. We must actively
evaluate and propagate that which is
valuable and disregard those without
basis. .
I
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The Acupuncture Therapeutic and Research Center, Inc. (ATRC) is a non
stock, non-profit institution that is designed to:
1) propagate acupuncture and other forms of 1 raditional Chinese Medicine;
2) define in a scientific manner the treatment and preventive capabilities, limita
tions of acupuncture, moxibustion, and other forms of Traditional Chinese
Medicine,
3) provide the venue for the synthesis of Western and Traditional Chinese
Medicine; and
4) make acupuncture and other*forms of Traditional Chinese Medicine more ac
cessible, particularly to the marginalized sectors of society.
This is our response to the cal! for the development of effective, low cost, and
safe alternative health services.
*
ACUPUNCTURE THERAPEUTIC AND RESEARCH CENTER, INC.
120-A Speaker Perez St.
La Loma, Quezon City
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C.’ CiL G. 11 El MAN
•‘H l-.h A COLD. STARVE A [•EVER,• - FOLK. MODELS OF
•NFEC7I0L !?: A’..' ELGLISIl SUBUiMWs COMM UNI I’Y, AND
lili’.iK F.l.L,\ HO?< TO M FDICA L TREATM ENT
IJ7.
I. lab f.’.■.a iidi’.'s a ’■.nkily-hcld coavcption uf illness, rd itcil to pciccivcJ
il'.-ifrx-. in l.i-.Iy tc- •.pa.-’.i'j.-v - 'Cni!'.-jnd ‘Colds* on one hand, ‘Fevers’ on the other - in
a:i
• ".'••nhin rvr.unnr.''’' cn •>.' oiihMits of L'-ndcn. Ta.- rd.-.(ionship betv.ecn (Ids
!• s
d;l, n .d th.-.t of the local f.:i: ily physicians i; analysed, to show how bioni.’dical
if line;-’. ?:;•! co..: .-ihs. y ;rt-tily -he
th?; ry r.f diicj-.e, far front cliallcit,.:?;-. the
n ; in.jd.-i. ;• •u-hy rcr.fi.r.jc i'. Ite : •■.lies v.hich ..■••mot be <denlifkal.ly and biomy
jc .tided arc iiocriL’h-s prescribed by the physicians to meet their patients’ need to ‘ntal-.c
sc ^e* of biomediva'. treat.re nt in terms of their folk modd of illness. At the intcilace
between phy-.ician and patient, biomedical dhjno-.ci and treatment are more ‘negotiable’
L‘ an pie»;i j.dy realised - and this has important implications for the delivery of health
IN I ROD’.JCTION
'.'.Uvh of
h in n-jnth.cpo!-''gy has dealt with folk beii.'fs and
p.-jcti .e: r-.-l-,.:i'g to
h: i!:? ucn-V.c>t ?rn ..nd nun-mdustrialhed world. An
of ;..N\ ;ch tmr. I:?.;, been largely neglect: i i?- the persistence of such folk
b.l.efs in .hi
. ;-.i,t:.d:ir!y in an v.rban contrxt. Most studies of indigenous
r. C'-’L I lyj.ci'.is t-> Furor .• : nd North An.er;c:•. have dealt with those of ethnic
r. i.tor'irs •' .?*’ ■ •!
inr. i r'-nu.v
s i.t
regions. Thc.-u is
ohen an implicit .
■■.'■.•cn t!:;•.'. in the ct'L.s. .•:« leant, most cdultsarc fam/har
v. .th the .•■'< p.-tliic i.r io.”.:••die./1 mode! of disease of lhe medical profession,
u.rd
‘
a few elderly or ur.educ.’ed people, or those who follow
’. hernative medicine’, t’r. basic premises of cause and effect in disease arc largely
a. • .epLd. ’Ik? pj’-lic, rftc; all, Lev..' he:.-, expo;for many year; to inform'ition
a.■cut medr.n meiieme via books, the schools, tlie popular press, radio and
t- '^vision, .md hc.dih cdio.-1 paripidcts produced by the gcvernmutU; in
Britain ;• v'.ianLrly, si;:ce
fonnetmn of the National lleaHi Ser-.;./- in
1 -'d.-, — v.i’kh ;;u:’.f.>ii‘;*ed five and. unrestricted access to ii'..',(!ical cate - tf.’ie
li ;
contact wp.h doctors .•’.nd with their ways of thhil.im;.
N?vcr!:.<?l •< iiuT:’/ fol’; concepts of idnes.i remain uachar.g.d. Tlie purpose of
t! li paper is to explain why such beliefs persisL and to describe how biomedical
t Im ent and concepts (tor c.xample, the gi.rrn theory of disease), nl'-iiounh
originnti-;.; ir, a dtffe.ent conceptual system, are easily incorporated iiuo the folk
/
I
CECIL G. ULLMAN
model without challenging its basic premises. In fact, they may serve to reinforce
it. This is particularly true in the context of family medicine, and I hope to show
how in ibis situation - at the interface between general practitioner and
patient — the biomedical model of disease is ‘adapted in such a way as to make
sense’ in terms of the folk model of illness. As a result of this process it can be
shown how many of the diagnoses and treatment given by family physicians
cannot be justified in purely scientific or rational biomedical terms; but only in
terms of the patients’ need to ‘make sense’ of this treatment in terms of their
folk beliefs about illness. This has important implications for the delivery of
health care, and indeed for tlie whole notion of what does or docs not constitute
a ‘tieatment’ in medical terms. Eisenberg (1977) has noted how physicians
employ both everyday and biomedical models in practice, even though these are
not logically compatible; that is, in our society “clinicians mediate between
medical models of disease and popular models of illness, just as do the patients
who employ concurrently the services of herbalists, shamans, and doctors. The
resolution of the tensions between contradictory models occurs in practical
action" (1977:19) The process of resolution or adaptation is described by
Stimson and Webb (1975) in the context of consultations in general practice in
Great Britain. They see such consultations as a process of negotiation between
doctor and patient, whereby each tries to influence the other regarding the
outcome of the consultation, the diagnosis given, the treatment prescribed. Their
evidence suggests that ‘There is so much room for variability in diagnosis, even
with seemingly ‘hard’ information such as the results of X-ray photographs, that
diagnosis is not the cut-and-dried scientific exercise that it is often made out to
be" (Stimson and Webb, 1975:37). What they fail to stress is that this
negotiation is not only between individuals, but between two systems of
thought, lay and professional, folk and biomedical; that is, between two
seemingly incompatible systems for the explanation and alleviation of
misfortune. For the interaction to be successful to the patient, there must be
agreement between doctor and patient on certain key concepts, and on the
physician’s interpretation of the patient’s problem; according to Fabrcga
(1975:972) “it is probably an agreed upon social consensus which includes the
practitioner and the sick person (or his surrogates), that is required for a medical
action to be judged as beneficial or helpful". When it is attained, tills consensus
has its effect on both folk and biomedical models of ill-health, as will be shown.
In particular, my research suggests that tlie folk model is more functional and
more resistant to change, than had been realised, and that there are various
explanations for this.
This paper - which arises from my own experience as a family physician describes a folk model of illness in an ordinary English suburban community on
tire outskirts of London; it outlines certain widely-held beliefs about illness
related to perceived changes in body temperature in such a community — beliefs
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C'./.'ur.r, Medicine and Psychiatry 2 (1973) 107-137. All Rights Reserved.
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:».’, cei i-,’ : \lvea r:.v:
109
which can be suinmati'/.d in the phrase "Feed a Gold, Starve a Fever”, and
which ’.o s- ;.’.? c.xLinl :;rc common ihrcnjuuit the British Isles. Although the
tuburb it r.ow part of lit? great metropolis, it is a study of the ‘ethnomedicine’
of the area, which in Hughes’ dcfmiticn is “(hose beliefs and practices relating to
disease which arc the p uducls of indi genous cultural development and are not
explicitly derived from the conceptual framework of modern medicine”
(1968:38). It is also a study of the effect of these beliefs on the diagnoses and
treatments given by trie general practitioners, the local representatives of
biomedicine, to their patients.
SOURCE OF DATA
The material was collected in a four-year period since 1973, during which time I
have worked as a general practitioner or family physician for the British National
Health Service2 in Stanmore, Middlesex. It is based on my own experience, as
well as on interviews with patients, district nurses, receptionists, and with seven
of my general practiaonar colleagues who practice in Stanmore, or in the
neighbouring suburb of Edgware. The quotations used in the paper are from
those interviews. In addition I have used published material on drug prescribing
under the N.H.S. from a number of sources.
Although technically in the county of Middlesex, Stanmore is a peripheral
suburb of London, at the edge of the ‘green belt’ of open countryside. It is
about 12 miles from the centre of Westminster. Until 1936 it was open
countryside and marshland, but in that year the ‘Laing Housing Estate’ of
detached and semidetached suburban houses was built. The inhabitants were
drawn either from London, or fiorn the surrounding villages in Middlesex, with a
small number from abroad. Many of the present-day inhabitants, in their 60’s
and 70’s, moved into die area as young couples in the 1930’s; while others arc
their dr-cendants, or new arri.'als mai.'-.’y after the last war. It is a predominately
middle-class suburban community, with strong values of order, balance, and
social respectability. The area is in no way isolated from the rest of London; it is
served by tlie same bus routes, Underground network, and other facilities, as
well as the same newspapers, and radio and television programmes. Most doctor’s
su.-gi'.-i.’s, or clinics, ir. the area arc located in ordinary houses converted for this
purpose. There are several large hospitals only a few miles away.
GENERAL PRACTICE IN GREAT BRITAIN
Under the British National Health Service the entire population has access to
free medical care, at both general practice and hospital levels. Each patient
belongs to the ‘list’ of a general practitioner in their area, though there is some
choice as to which doctor’s list they can join, provided it is still within the area.
110
CECIL G. HELMAN
Consultations between patients and family physicians are free of charge, and
take place at specified times at the surgery, or by house-call for emergencies at
other times. A small fee is paid by the patient for each item of drugs prescribed
by the doctor; the fee is paid directly to the pharmacist who dispenses the drug.
It is estimated (Levitt, 1976) that there are about 26 000 general practitioners in
Britain, and that .each one has an average list size of 2347 patients. Levitt
estimates that about 75% of symptoms are treated by the patients themselves,
without going to a doctor (1976:95), but of those who do seek professional
medical treatment for ill-health, the NHS general practitioner is the first point of
contact for about 90% of these people (1976:97). The general practitioner is
therefore the main interface between biomedical concepts and’lay beliefs about
illness. The majority of the patients seen by a general practitioner suffer from
minor complaints, with no risk to life or permanent disability; in the studies
quoted by Levitt (1976:95) 62% of the conditions seen commonly fall in this
group. Only about 13% are major, life-threatening conditions, and these are
mostly referred for hospital treatment. In general, the conditions of ill-health to
be described below fall into the category of minor complaints, yet they form a
large proportion of the workload of the average general practitioner3.
•ILLNESS’ AND ‘DISEASE’
The analytical distinction between illness and disease is one that has been made
by several authors (see Eisenberg; 1977, Fabrega, 1973:91-93, 218—223, and
1975:969-975; Cassell, 1976:47-83; Mitchell, 1977:17-19; Lewis, 1975:146151). In general, the term ‘disease’ has been used to describe the pathological
processes and entities of the biomedical model; diseases are defined “on the basis
of deviations and malfunctions of the chemical and physiologic systems of the
body” (Fabrega, 1975:971). What constitutes ‘normal’ physiological and
chemical variables is clearly defined within a fairly narrow numerical range, and
is assumed to be shared by all members of the human species. Each disease in
biomedicine is “an abstract biological ‘thing’ or condition that is, generally
speaking, independent of social behaviour” (1975:969); that is, every named
disease has its own particular personality and life history, and these entities are
largely independent of the personal attributes of the patients suffering from the
disease. To the Western-trained doctor, therefore, the aim of therapy is primarily
the identification and treatment of named diseases, using the scientific paradigm
and definitions of modern biomedicine: which is the culturally-specific system
of the West for explaining and treating ill-health. By contrast, ‘illness is an
altogether vaguer term, embodying the patient’s subjective perception, or
sometimes the perception of those around him, of a condition of impaired
well-being. Fox (1968), Fabrega (1973) and roster (1976), all of whom have
1
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112
CECIL G. HELMAN
Hi
studied :he medied systems of the non Westcm world, point out how illness in
those r-jicr.s has many dimensions: social, moral, psychological, as well as
physical. Upl2n.db.1S fur ill-health are part of wider systems for the
explanation of misforiune. which usually embody a variety of aetiologies; for
example, in Prince’s Jt-.idy of the Yoruba (1964) misfortunes, including
ill-hcalth, can be caused by natural agents (diet, insects, woims etc.),
preternatural agents (witchcraft, sorcery) or supernatural causes (gods, Orisas,
ancestors); and” Foster (1976) also divides folk aetiologies of illness into
‘personalistic’ systems (illness due to the active and purposeful intervention of
an agent, whether human or non-human), and ‘naturalistic’ systems (where
illness I, explained in impersonal terms, as being due to natural forces or
conditions, such as cold, damp, and so on) (1976:773-781). In these societies
there are cHturaUy-spccific systems for explaining illness in these terms, and
there are as many of these systems as there, are different cultural groups. In
dealing with what therefore constitutes ‘illness’ here in the West, the literature is
less helpful. Fabrega (1975:973). Casscli (1976) and Eisenberg (1977) have all
pointed out that in trie West it is possible to feel ‘ill’ without having an
identifiable disease in biomedical terms, and- to have a biomedically-deftned
disease without feeling ill (for example a raised blood pressure, or early
carcinoma). Biomedicine can be seen as the world-view of a professional
sub-culture, the medical profession. Contrasted with tins, is the patient’s
perspccLvo oi subjectively experienced ill-health; in Eisenberg’s phrase “patients
suffer ‘i-mess’; physicians diagnose and treat ‘diseases’ ” (1977:11). Diagnosis is
therefore the ordering 01 the patient's experience into the disease entities of
biomedicine, but neglecting those that do not fall within the classification. In
Cassell’s view, this removes biomedicine from its traditional healing role, for he
sees illn.-ss in holistic terms as human suffering that includes disease, but has'a
much wider definition: one should "use the word ‘illness’ to stand for what the
patient ice's wnen he goes to the doctor, and ‘disease* for what he has on the
way home. Disease, then, is something an organ has; illness is something a man
has (1976:48.). it is therefore a problem of two#partially overlapping schemes
of classification, whereby the symptoms and signs of illness/disease are grouped
into pathological entities, in both folk and biomedical models.
However, a major drawback of many studies of illness in the urban West, both
in Europe and North America, is that folk beliefs about illness have not been
studied as systems, cut rather as a vague area of subjective symptomsand signs
beyond the territory of biomedicine. It is not only in die non-industrialised
world that folk models of illness have strong moral and social dimensions, both
personalistic’ and ‘naturalistic’ theories of aetiology, and which ask the question
"Wiry me?” as well as “How?” In addition, folk theories of what constitutes
‘normality’ also form part of such models, and these definitions of ‘normality’
often bear little relation to the biomedical definitions4 .
A further point is that the rational and scientific nature of biomedicine, in
practice, is often over-estimated. Fabrega (1973:218—223) for example, in his
comparison of the Western biomedical system and the indigenous medical
system of Zinacantan, gives the impression of biomedicine as a monolithic and
quite inflexible system of beliefs and practices. However, not only is there wide
variation in medical practices in different Western communities5 but also
within the same country. My research indicates that in Great Britain, at least,
biomedicine at the general practitioner level is more flexible than had been
realised; and that due to the process of 'negotiation* at the consultation the
‘operational’ model of the general practitioners bears a closer resemblance to the
folk model, in some respects, than to the official model of biomedicine that
exists in the hospitals, medical schools, and medical textbooks. Eisenberg
(1977:13) has suggested that the patterning of illness is influenced by medical
concepts, but the reverse seems also to be the case — particularly in general
practice, as will be described.
“FEED A COLD, STARVE A FEVER” - THE FOLK MODEL OF INFECTION
IN STANMORE
The phrase “Feed a Cold, Starve a Fever” is a common aphorism in the area. It
arises from a folk model, or scheme of classification, of illness which is widely
accepted by the patients; and it relates to those conditions of impaired
well-being which the patients perceive as disequilibrium, and regard as ‘illness’,
and which concern perceived changes in body temperature — either ‘hotter’ than
normal, or ‘colder’. In general, these feelings of abnormal temperature change
are purely subjective; they bear little or no relation to biomedical definitions of
‘normal’ body temperature as 98.4° F or 37° C, as measured orally on a
thermometer. The conditions where the patients ‘feels hot’ are classified as
Fevers, those where he ‘feels cdld’ in his body are classified either as Cfiills or
Colds. Both Fevers and Colds/Cliills are states of being — both classified as
abnormal — which, in the folk model have different causes, different effects, and
thus require different treatments.
There are two important principles underlying this folk classification of
‘illness-misfortune’: (1) the relation of man with nature, i.e. with the natural
environment, in Colds and Chills, and (2) the relation of man to man, which
exists within human society, in Fevers.
To a large extent the area covered by the folk model — which I have set out
schematically in Figure 1 — corresponds to that area of disorders which
biomedicine classifies as Infectious Diseases: that is, acute or chronic in*
flamraatory conditions where the causative agent is known to be either a virus
or a bacterium. These disorders, which occur very commonly in general
.
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CECIL G. HELMAN
114
•Ttr.D A COLD, STARVE /\ !■ EVER”
113
STRUCTURAL ANALYSIS OF THE FOLK SYSTEM
COLD
HOT
111 E >r,
and Throat
FEVER ♦- NASAL CONGESTION
OR DISCHARGE
(2) Chest
FEVER + PRODUCTIVE COUGH
(3) Abdomen
WET
FEVER + DIARRHOEA AND
ABDOMINAL DISCOMFORT
(4) Urinary System
FEVER + URINARY FREQUENCY
AND BURNING
In Figure 1 I have listed the common groups of symptoms which relate to, or are
accompanied by, perceived changes in body temperature. There are four
diagnostic categories in all (see Figure 2); the basic division is between ‘Hot’ and
‘Cold’ conditions,’ but in addition there is a further division into Tt'er’ and 'Dry'
conditions. ‘Wet’ conditions are those where the temperature change is
accompanied by other symptoms, and with a seemingly abnormal amount of
‘Fluid’ being present - either still within the body, or else emerging from its
orifices; this ‘Fluid’ includes sputum, phlegm, nasal and sinus discharge, vomitus,
urine, and loose stools. The symptoms here include nasal congestion or
discharge, sinus congestion, productive coughs, ‘congested’ chests, diarrhoea, and
urinary frequency. ‘Dry’ conditions are those where the abnormal temperature
change is the only, or the paramount symptom — such as a subjective feeling of
being cold, shivering or rigours on one hand — and a feeling of being ‘hot’,
perhaps with a dry throat, flushed skin, slight unproductive cough, and possibly
delirium, on the other. Skin rashes usually occur on the ‘Hot’ side of the
classification. Other subsidiary symptoms — including pain — may occur in one
form or another on both sides of the temperature division.
(1) Ear, Nose, and Throat
COLO + NASAL CONGESTION
OR DISCHARGE, WATERY
EYES. 'SINUS’ CONGESTION
(2) Chest
COLD + NON-PRODUCTIVE
COUGH
(3) Abdomen
COLD + LOOSE STOOLS AND
SLIGHT ABDOMINAL DIS
COMFORT
(4) Urinary System
COLD + SLIGHT URINARY
FREQUENCY BUT NO PAIN
(5) Skin
FEVER + RASH + NASAL DIS
CHARGE OR COUGH
DRV
FEVER + DRY SKIN, FLUSHED
FACE, DHY THRCAT, NON
PRODUCTIVE COUGH
COLO + SHIVERING, RIGOURS,
MALAISE. VAGUE MUSCULAR
ACHES.
i
WET
Fig. I. The Folk Classification of common 'Hot' and 'Cold' Symptoms
i
practice6, include disorders known as: upper respiratory tract infections;
influenza: coryza; bronchitis; pneumonia; sinusitis; urinary tract infections;
gastroenteritis; childhood fevers (e.g. rubella); and several others. This classi
fication overlaps, io some extent, the area covered by the folk model, but as will
be described there are significant differences. Illnesses associated with temper
ature change are common in all sections of the population, as are the often
associated symptoms of cough or rhinitis. Cough is apparently the commonest
symptom complained of in general practice (see Morrell, 1972:297), and it is
common even among those who do not consult the doctor: in Dunnell and
Cartwright’s study (197?.;! 1) 32% of adults reported “cough, catarrh, or
phlegm” in a sample two-week period, while 18% had suffered from “cold,
influenza, or rhinitis”. To describe the folk model it is necessary to adopt a
diachronic approach: what follows is mainly the folk classification reported by
older patients; those born during or since World War.Two, while sharing the
basic underlying classification, have introduced new elements, particularly with
regard to the germ theory.
DRY
HOT
COLD
HOT
WET
WET
COLD
WET
HOT
DRY
COLD
DRY
DRY
Fig. 2.
HOT
COLD
FEVER
COLD
FLUID
FLUID
FEVER
COLD
Fig. 3.
Thus there are four basic compartments into which most common symptoms
relating to temperature change can be fitted (see Figure 3): ‘Hot/Wet’ (Fever
plus Fluid), ‘Hot/Dry’ (Fever), ‘Cold/Wet’ (Cold plus Fluid), and ‘Cold/Dry’
(Cold). Obviously these compartments are not watertight; there is always some
overlap betv/een divisions. In addition, not all conditions associated with
abnormal temperature changes have been included; only the commonest, as
encountered in general practice.
(A) ‘Chills’and 'Colds’
These aie explained as being due to the penetration of the environment — across
the boundary of skin — into the human organism. They are part of the
relationship of man to the natural environment; in particular to the idea of
. ‘i
I.
.'.I’.Vi;
T-I.'.’L
115
116
oanger v.iihuui’ ; rd ‘.safety within’ the boundaries of the human body. The
o! th.-.a
arc areas of lowered tcr.ipeiaturc in the tiatural
- cither as d:-mp or rain {i.c. ‘Cold/Wet’), or cold winds and
draught., t Colc/Dry ). In general, ‘Cold/V.ct’ conditions in the environment may
cause ‘C'j!J'V.ci‘ conditions in the body, and ‘Cold/Dry’ may cause ‘Cold/Dry’
conditions oi illness, though trie division is by no means rigid. Dampness is
considered dangerous in most situations, as is rain. Wind is dangerous if it is
lower than body temperature, and is called a draught. Wind at body
temperature, or above it, poses no threat, and is merely ‘fresh air’. Night air,
though, whether warm or cold, is considered dangerous by many of the older
patients; it is different in quality from day air, and often "the children get sick if
you leave the bedroom windows open at niaht”.
These cold forces in the environment are impersonal, and not linked to any
social relationships.
The protective boundary of the human being is skin, but also clothes. All
areas of s.<in, though, if exposed to damp or draughts, can be penetrated by the
cold ("tiic damp goes right through you”, "I was chilled to the bone”). The
actual rome of entry of the cold, is through the skin itself. Some areas of skin
are more vulnerable than others:- in particular, the top of the head, the back of
the neck, and the feet. These parts of the body must be specially protected from
draughts and damp. Colds were explained as occurring when any of these areas
were inadvertently exposed to damp or draughts: e.g. after "getting one’s feet
wet”, “walkin? around with damp socks on”, “going outside with damp hair”,
going Out into the rain, without a hat on", "stepping into a puddle”, "getting
caught in the rain”, and so on. Among men, there is a particular sense of
increased vulnerability to ‘head Colds’ after a haircut - when the back and top
of the head arc unprotected against environmental cold by their normal covering
ofhair.
I Liinr. it is significant, incidently, that the two most vulnerable areas to
cold - the he::.I and the feet - arc. in a sense, the most public parts of the
clothed body, and the parts most passive to being acted upon by the
environment. I would argue that the hands and face, while both ‘public’, are
considered less vulnerable as they actively manipulate the environment, and in a
sense ‘join’ die person to the environment.
In addition to parts of the body especially vulnerable to cold, there are
certain stales intermediate between hot and cold environments, or between body
temperatures, where the intermediate zone is considered most dangerous to the
human being — as far as Colds and Chills go. For example:
(1) Body temperature changes, from hot to cold: e.g. "Coing into a cold
room (or outside) after a hot bath”, “sitting in a draught after a hot bath”,
"walking on cold floor when you have a Fever"-all which occur within the
home.
I
CECIL G. HELMAN
(2) Changes in environmental temperature, from hot to cold, on leaving the
home (or other building): Older patients explained the increased incidence of
Colds in winter as being due to a drop in body temperature when one leaves a
modem centrally-heated house for the outside. Younger patients think this
occurs because “the Germs breed more” in a hot, centrally-heated house. Other
examples here are “going outdoors when you have a Fever”, “going out into the
cold after a hot bath”, and so on.
(3) Changes in season: November (damp), and February (cold winds) are
both considered dangerous months, but most dangerous of all is autumn - where
the ‘hot’ summer is changing to the ‘cold’ winter.
(4) Changes in geography: One patient has explained that there are more
Colds (‘summer Colds’) in summer these days because, since cheap air-flights and
holidays became available 10—15 years ago, people return from ‘hot’ Spain or
Italy to ‘cold’ Britain after their summer vacations, and in the change over of
temperature they “catch Cold”.
In all these cases there appears to be an intermediate, dangerous zone,
between hot and cold states - when the former gives way to the latter. This may
reflect an underlying schematic dichotomy between ‘Hot’ inside (body, home),
and ‘Cold outside (nature, the natural environment). Mary Douglas (1970) has
pointed out how in many primitive classificatory systems, special dangerous
Qualities are ascribed to states of transition, marginality, or anomaly. She notes
Van Gennep’s observation of the danger inherent in states of social transition
(1970:116), but it would appear that this applies also to intermediate zones
between changes in temperature, as described in the above examples.
Although Colds do not, at least in the view of older patients, originate in
other people, they are caused - as one middle-aged patient put it - “by doing
something abnormal”. That is, by putting oneself in one of the situations of
danger or risk mentioned above. There is the strong implication of personal
responsibility for the condition, which has been caused by one’s own
carelessness, stupidity, or lack of foresight. You get a Cold when you “don’t
dress properly”, “go outside after washing your hair”, “allow your head to get
wet , walk barefoot on a cold floor”, “wash your hair when you don’t feel
well”, and so on. Making oneself, or part of oneself, vulnerable to cold causes
one to catch Cold”. Colds, therefore, are a by-product of one’s personal battle
with the environment. They are one’s own responsibility, and no one else could
be blamed for them. If, despite adequate precautions such as proper clothing,
etc, one still got a Cold, it was still your responsibility. Poor people tended to
get more Colds as they are “less responsible”.
Once the cold has penetrated the boundaries of the human organism, it can
travel. It can move from the damp head, down to the nose (causing a “runny
nose”), the sinuses (“Sinusitis”, “a head Cold”), the chest (causing a slight
cough - “a Cold on the chest”). It can travel even further downwards to the
I
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t
IW ' qvr A !TV| Q"
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117
118
to
.„,gu.. abJun,.;.□! dixoiaiort ;llll| possib|y sli„|1( |ooie„in, of
• •a., o.- te H,.. |lbl!%!;r- ;n
dl,co,n(brt.1|„l s|i..llt rrequcncv bi;|10
bu.mn: nn.auon or fever. From rb.np feet it can rr.ijratc upwards lo cause the
- omaJ. C.III1 or a ' (.lull
the bhij.kr” already mentioned, or even further
'dl nf ,1KSe
bv"“ Su’0 r"
accompanied
dLmroTi
18
p0ssibly by somc muscular
>.omfo.t. In ar.uit.on, a direct draught can also cause the Colds and Chills, but
t; .s occurs less frequently; usually a direct draught on the lower back (while
silting in , drauglit ) causes a ■'Chill on the kidneys" which is described either
a . uscu.ar pa." the lumbar region, or vague lower back discomfort, perhaps
"itn some urinary frequency.
"ki'hiw
bCl0W 111C
("stom:lch Clli»'. "bidder Cliill',
I
■ n-.y Chcl ) and Cou/s above it (a "head Cold", a "Cold in the sinuses", "a'
Cold on the chest", "a Cold that's gone to my chest")
defcns's'bv^1' With cnv;ro':men,al co!d' °'ae ’hould strengthen one's own
bolV ’
re"’8
eat" n-oo T" * f'0'n
'
y' aV°idinS dr?U5htS
(B) ‘Fevers’
Illnesses in this group are aU characterised by conditions which begin with, or are
accompanied by, a feeling of abnormally raised body temperature. In general,
they are more severe, longer-lasting, and potentially more dangerous than those
in the ‘Cold’ group. All are said to be due to the actions of entities known as
Germs , ‘Bugs’, or ‘Viruses’. These terms are not used in the strict biomedical
sense; to most people, who have never looked down a microscope and seen ‘a
Germ’, and who who have no other perceptual evidence for their existence,
Germs remain a hypothesis, a theory of causality. Although the terms are
borrowed from biomedicine, folk theories of Germs are rooted in the folk
classification of Fevers and ChiUs, rather than in modern microbiology.
When asked about the attributes of Germs most patients give the following
description: Germs are described as living, invisible, malevolent entities. They
have no free existence in nature, but exist only in or among people. They are
thought of as occurring in a cloud of tiny particles, or as a tiny, invisible, single
‘insect’. They traverse the spaces between people by travelling in the air, or°in
the breath. Germs causing gastro-intestinal symptoms are seen as more
‘insect-like’ (‘Bugs’), and are larger in size than those Germs causing other
symptoms. Germs have personalities; these are expressed in, and can be
recognised by, the various symptoms they cause. (For example, “I’ve got that
Germ, doctor, you know - the one that gives you the dry cough and the watery
eyes , or the one that gives you diarrhoea, and makes you bring up”). The
Germ, however, may only reveal its true personality in stages, during the course
of the disease.
In their effect, Germs are single; you are only attacked by one Germ at a
cZ::rv°.nSS “ Dre'Vef’S YeaS!' Mul‘iVile' Haliborange, Sanatogen, and
X a i
°nt
PU' “ - if y°U Went Oll‘dw- af'- having
co" "(J -'' ■V0U
"Jrm
i the tonic was on ally in one's battle with
' 'so-r.'n'n’7rL'?'
a" ail!C' and body Sl^’gtheners, though, was food,
severely
m v b i°
pene!ra,ed bX “ld
'he post and were
severely ..1, may be left wuh a permanent “weakness" in that part of their body
__ pe.m. ,en. gap m their defences against the environment. They may have a
they
.h" f
£ a"d Ofl." "'r3P| UP th3t 3rea Pa"icularly warmly when
3
m2y‘••S0bctarn,H2land “run in families”, or
tIUn Skin” Wh‘Ch iS abnorma]1y vulnerable to cold
The area of Stanmore is known by the patienfs as a
damp, dangerous area as
far as Colds go. People in the area are reputed to suffer
many respiratory
by thedXil'i0 ba "b"'is said 'o be due to "dampness" retained
T
'
’ le area’
*s the residue of marshes drained in the 193O’s.
prcbl-mTd °s 11 C|0'U'°r CI,i11- iS y0Ur °W" resP°nsibilily; f is your own
F
4 c
well as tonics and vitamins, which arc also perceived as a type of nutriment, in
addition, he must if necessary be shifted from the ‘Wet’ to the ‘Dry’ state - not
by expelling or washing out the Fluids, but by drying them up. These Fluids are
considered part of the body, and should be conserved, with the aid of nasal
drops, decongestant tablets, inhalations, and drugs to solidify the loose stools.
Older remedies used as decongestants include goose fat, Vicks, and Friar's
balsam. Pain accompanying these symptoms is to be treated by analgesics such as
aspirin, anadrn, paracetamol, and several others. By these various methods both
folk and medical treatments aim to restore the previous equilibrium, and a
normal’ temperature.
The only social dimensions of Colds and Chills are the implications of
personal carelessness that they carry, and also for the social embarrassment of a
red nose, rhinitis, bloodshot eyes, etc. “For appearance’s sake”, said one patient,
‘you get rid of them as soon as possible”.
damP' and bu"di"S up the
IUn’ by °°Od fC°d a:id patcnt 't0:|ics'. If you "did not
"build H
1 ' W-.C m°re liab'e !° deVe'OP 3 C0ld' I>COp,c ,00k toni“
bu d llr mse ves up against the threat of cold; older patent tonics used
.nchmed Parruhs Food. Vifeayi;n, Cod Liver Oil and Mult Extract, and Virol
els-f
u
penc’-fm
’ SJC
CECIL G. HELMAN
t0 ‘uooihfe a caring community around you than a
normal)'b.'-k t V'.arn“h',a"d t0 nove Ih" patient from 'Cold' (or 'colder' than
botf's r 7
nemaJ ' V addin!! hC3‘ 01 lhC f°lrn Of hct drinks' hot-water
bou..s, , q
a warin bed, and so on; and in giving him the means to generate
n <eat, especially by ample warm food (“Feed a Cold, Starve a Fever"), as
I
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•>
*
I •
"I I I n A ( UI.I), si ARVE A I I,VI K,:
121
icl.ited to th? pic..nee of exce-.. Hirai. It is as though the Germ matures into a
‘Im: liquid* in" 1: th..1 body.
Ih: tr. iim.-at o: ruvers, in Hre folk nujdcl, aims firstly to move the patient
from the 'Hot* state back to a 'normal* temperature, and secondly to move him
firm the *i)ry’ to the ’Wet* state (•■■?j below).
Metho::*; of dealing with Germs — the living, malevolent entities who
temporarily invade and disrupt the body, or parts of it - fall into three main
categories:
(1) Expulsion: In al! these methods fluids are used to “washout” or liquefy
the Germ, so that it can be "washed out of the system”. Fluids are taken
in by' mouth as a iorm of treatment, and the appearance of a more ‘Wet’
symptom indicates that the Germ is being diluted and “washed out”, usually via
the orifices through which it entered the body. Examples of this are:
— From the chest — the aim in chest infections associated with Fever is die
expulsion of fluid from the chest, carrying with it the infecting Germ - “getting
it ofl your chest", "coughing up the muck”, "clearing the chest”, “getting it
(the phlegm) out of your system", and so on. Patients often complain that their
cough is still unproductive and “dry", that it "hasn’t broken” or "hasn’t
loosened" so that they can “cough it off my chest". A variety of fluids are used
as expectorants here; including tea, honey, hot water, cough medicine, and other
liquids, and these also have a soothing effect on the throat. “I gargled with salt
water to get the catarrh out," said one patient, "and I always swallow a bit of it
to loo.*en the cough”.
-From the howels - especially in the presence of diarrhoea and vomiting
with the Fever. Here the therapy consists primarily of drinking lots of fluids, so
as to “flush out" trie Infection.
— From the urinary tract - especially if there is urinary frequency and pain
on mictuili.on, accompanied by Fever — once again treatment consists of
drinking large amounts of fluid “to flush it (die Germ) out of one’s system”.
— Through the skin — usually by induced sweating. The appearance of sweat
fluid on the skin, which often accompanies a drop Ln the Fever, is taken-as
evidence tliat tire Germ or infection is leaving the body through the skin. The
aim of treatment, therefore, is to "sweat it out" or “sweat it off". Various fluids
and other remedies7 are used for this purpose, including hot drinks, honey,
curtain tyn.'S ci tea, as well as aspirins and other patent anti-pyretics, wliich are
always ingested with large amounts of fluid. The appearance of a skin rash is also
welcomed, as the Germ is now "showing itself”, and is on its way out of the
body; this ;s especially true in measles where the fever often drops when the rash
appears.
Germs can also be dealt with by:
(2) Starvation — as in the phrase “Feed a Cold, Starve a Fever”. I think the
122
CECIL G. HELMAN
implication of this advice to reduce the food intake of a feverish patient is that
as the Bugs or Germs are living entities to starve theirTiost is to starve the
Germs, and they will eventually die or leave the body, and so end their
possession8.
(3) Killing the Genus in situ - since World War Two, and the discovery of
the anti-microbial drugs, it is generally accepted by most of the patients that
antibiotics and sulphonamides are the specific agents for killing the Germ in situ,
without the need to expel or starve it. This is particularly true of those Germs
causing high Fevers and severe illness, which do not respond to home remedies.
The drugs are taken into the body as an external force to kill the Germ in situ, in
a battle lasting up to ten days.
The signs of expulsion, death, or starvation of the Germ are a return to what
is perceived as normal body temperature, a subjective feeling of being less ill, and
the appearance of excess liquid being expelled from the body (as phlegm, nasal
catarrh, urine, or loose stools), which then gradually dries up — as well as the
disappearance of all other associated symptoms.
Germ infections imply, or bring into being, social relationships: as sources
of infection, a caring community about the victim, and as an informal
‘community of suffering’ of those afflicted by the same type of Germ. Questions
often asked of doctors or their receptionists in the area are: “Is there a Bug (like
mine) going around?”, “Is there a Germ floating around?", “Have you had
anyone else in with the ’flu?", “Is there Chicken Pox in the area?". They arc
relieved if the answer is in the affirmative, and to find that they have “got
something normal” and are part of a community of victims.
It should be noted that this description of ‘Germs’ as hypotheses, or theories
of causality, of illness in the folk model in Stanmore, has a similarity to
equivalent theories of disease causation in many non-literate societies, par
ticularly with spirit possession? In these societies 'spirits’ take the place of
‘Germs’ as causal entities of disease, and like them are invisible, amoral, malign,
and capricious in their choice of victims. The victim is therefore blameless, and
possession by these pathogenic spirits is a culturally accepted experience, and a
way of mobilising a caring community around the ill person (sec Lewis, I. M.,
1971:66-99). However, a much wider range of disorders are caused by these
spirits, than those included in the Fever/Colds model described above.
IMPACT OF THE BIOMEDICAL GERM THEORY OF DISEASE ON THE
FOLK MODEL
There is an increasing difference, as regards the Germ explanation of disease,
between older and younger patients in the area — especially those born during
or since World War Two, who constitute the first ‘antibiotic generation’.
••ri ! I) \ '-nf |\ ST \!IV!’ \ EEVI R"
124
123
Alihmiph the bac'.c:iologic.il discoveries of Pasteur and Koch were made at the
on ! of
I'/t’.i CenMiy.biomcdic i! f.erm theory of disease seems to have
only g.n.r.'d widespread currency among the lay public since the influenza
pandemi-.-s of 1913/19. However, it is only since the last War, and the
introcedkm of specific amimicrobial dru,;s, that the Germ theory has come to
e.xplain :> wider range of illness in the folk model. A probable reason for this is
that since the establishment of the N.H.S. in 1948, with its guarantee of free
medical care to-the entire population, more people consult doctors and for a
wider range of disorders - disorders that they would previously have borne in
what one writer calls “the imposed silence of poverty” (Inglis, 1964:18). This
■means that ‘Fevers’ and ‘Chills’ in the fo’k classification, that would previously
have b.en treated by folk remedies alone, are now brought to N.H.S.
doctors — particularly general practitioners — for diagnosis and treatment.
Nevertheless, the basic conceptual system of tire Fevers/Colds/Chills model has
remained largely unaltered; Germs arc still hypotheses, and there is little lay
knowledge of their characteristics, or of the difference between Germs and
Viruses, terms vvhich a;c used interchangeably by the patients. The main
differences between younger and older patients regarding the folk model, are as
follows: the conception of Germs as active causative agents of illness has
spread to include several (though not all) conditions on the ‘Cold’ side of the
classification. Younger patients are more likely to blame ‘Germs’ or ‘Viruses’ for
these conditions. Because Colds and Chills are due to these active agents, they
can be killed, expelled or starved like the Germs causing Fevers. Hence the
increasing demand, on the part of the prtients, for specific ‘anti-Germ’ drugs and
the prcisure put on doctors to prescribe antibiotics for even minor viral
infections. While a Cold is now often considered to be caused by a Germ, some
sense of personal responsibility for the condition still remains; bad clothing,
inadcouate nutrition, exposure to damp or cold — all make you more vulnerable
to Coles, as before.10 Nevertheless, on the ‘Cold’ side of the spectrum, the
amount of personal responsibility for illness seems to have declined. At the same
time, ‘Cold’ illnesses have become more social in prigin, effect, and dangers; they
now arise more from within human society, and create more of a caring
community around the victim titan previously. Colds and Chills are now
dangerous to other people, especially children and the very old. Young mothers
often ask “My child’s got a Cold; can she mix with other children?”, or remark
"I didn’t go round to her place yesterday because her child’s got a Cold”. It
seems that there is an incieased sense of danger in human relationships, and they
are now all tinged with a new anxiety, the threat of infection. Whether or not .
this new feai expresses or echoes other stresses in the social system, one cannot
be sure. Nevertheless, in a small way, the threat of infection is used to avoid
social contacts, or to mobilise a perhaps unwilling community around the
patient. Tins ‘medicalisation' of Colds and ChiUs extends also beyond the
CI CILC. HELMAN
original confines of the folk classification; for example, a wide range of mood
changes, from aggression to depression, are now being ascribed by patients to
Germ infection. In this medicalisation of internal moods, the folk Germ theory
provides a useful escape route to the patient — “I’m feeling low and depressed. I
must have picked up a Virus", or “He was rather aggressive on Sunday, and I
wondered if he hadn’t picked up a Germ"; so that, increasingly, the hypothesis
of Germ infection is now being used to explain behaviour changes. Depression
due to Viruses, is now added to "post-Viral depression", in the folk classification
of younger patients. Also, both “stomach Chills" and “bladder Chills" are now
increasingly being ascribed to Germ infection, except by the older generation;
they are now often thought to be due to “a Germ in the water (urine)”, rather
than “a Chill on the bladder", or to a “stomach Bug" rather than a “stomach
Chill” or “something you ate”. In both cases, the infection requires active
medical help to destroy or expel the Germ. In general, as the hypothesis of
‘Germ infection’ has spread to cover a wider range of illness and behaviour,
illness has become more social and dangerous, and the process of seeking medical
treatment for it is increasingly common.
•'I
I
CONSENSUS AND CURE
The social process that begins with illness, and hopefully ends with cure, begins
with a state of discomfort or disequilibrium perceived by the patient, or by
those associated with him. In the Fevers/Colds/ChiJls model, the basic minimum
definition of ‘illness’ is a subjectively experienced change in body temperature,
on either side of ‘normal’, and which is usually accompanied by other
symptoms; so that the units of the folk model are clusters of symptoms forming
what might be termed ‘illness entities’. These are predominantly composed of
subjective symptoms, while objective corroboration of the symptoms (for
example, by measuring the body temperature with a thermometer) is less
commonly called upon as an integral part of defining oneself as ‘ill’. By contrast,
the units of the biomedical model are named diseases, which are composed of
symptoms plus objectively verifiable physical signs. At the interface between
these two systems, a consensus must be achieved by doctor and patient regarding
the interpretation of the patient’s symptoms, and the treatment to be given. My
research concentrated on the nature of that consensus, on the vocabulary used in
consultations, and on the diagnoses and treatment given to patients by GPsin the
area; particularly those patients suffering from symptoms v/ithin the Fevers/
Colds/Chills model of illness.
It should be pointed out that apparently most patients suffer from some
pathological symptom or symptoms, most of the time. In Dunnell and
Cartwright’s study (1972:8-13) 91% of adults in a random interview reported
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•T' l i'.\ rni.li. ‘■.r\ P.Vil.A ri-V! R”
125
ih.it they had it.-d unc or iiv.?ic abuonn il symptoms in the two weeks precedin'’,
the iatcr.ic.v, while only !'? • bad consulted a doctor during that time. Most
iila:;.; is treated by s.'IT-m ? Jic-.iiion; it is estimated that only about one-third of
ah illne.s reaches a medical agency (1972:13). The remainder arc treated by
self-pre. ertbed folk or patent remedies bought at a pharmacy. Self-mcdication is
thcicfore much more common than drugs prescribed by a doctor, and also the
illness seen by a doctor is only the tip of an ‘iceberg of illness’ in the general
population. Only-thcse cases of illness brought to the CP’s attention could be
included, therefore, in this study.
DIAGNOSIS OE ‘FEVERS’, ‘COLDS’, AND ‘CHILLS’
The initial diagnosis of ‘illness’ is usually made by the patient himself, and
expressed in the terms of the folk model (“I’ve got a Cold”), and is usually dealt
with by self-medication. However, there is a liierarchy of advice as to the.
diagnosis, and the treatment required. This hierarchy includes friends and
relatives, the local pharmacist, the doctor’s receptionist, and finally — in the
minority of cases—the doctor; (see Dunnell and Cartwright, 1972:96—
98 - 57i3 of adults questioned in their survey regarded the local pharmacist as a
good person to ask advice when not feeling well). The threshold at which the
doctor is consulted varies with individuals, and between social classes; the
impression is that under the N'.H.S. the threshold for consultation is dropping
for most conditions. Diagnosis, as given by the GP, is the organisation of the
patient; symptoms and b.istory into a named and standardised entity, the
biomedical disease. The patient’s symptoms and experience pass from the private
to (he public domain, and become a recognisable part of the biomedical model
of misfortune. For this to be acceptable to both sides, a concensus must be
negotiated; diagnosis, as Fabrega (1975:972) has said, “is an .attempt to establish
a consensus for purposes of action”. No diagnosis would be acceptable to
patients, it appears, unices il was to a large extent consonant with their world
view, and particularly with their interpretatfon of illness. The impact of
biomedical concepts on this world view are less than had been thought. Despite
exhortations in medical textbooks, for example “D(octor) should never forget
that P(aticnt) is already equipped with all kinds of ideas about the nature of
disease. Many of these arc stereotypes, and attacking them is an essential part of
any therapeutic strategy” (Crystal, 1976:49), the language and concepts used by
GPs in consultations with patients suffering from Fcvers/Colds/Chills was in the
idiom of the folk model, not the biomedical one. The patients usually presented
lists of symptoms, often accompanied by questions like “Is there a Bug going
around?”, “I’m feeling ill - is there a Virus around?”, “Have you had anyone
else come in with a tummy Chill?”, “Is there Chicken Pox in the area?”, “Have
126
CECIL G. HELMAN
there been any children in recently with German Measles?”, and so on. The
answer from the GP was usually in the affirmative, and the patients were relieved
to find that there is a “Bug going around”, and they are blameless and not
socially deviant in their behaviour; they also no longer feel uneasy or unsure of
their condition, particularly as their illness is now a disease within the
biomedical world — and by definition capable of being cured, or at least
palliated. The diagnoses given by the GPs, which provided a unified expla
nation of the patients’ vague feelings of illness or unease, were also couched
in the folk idiom; for example: “You’ve picked up a Germ”, “You’ve got a
’flu Bug”, “It’s a Viral infection”, “It’s just a tummy Bug — there’s one going
around”, “It’s just an ordinary Cold”, “I’m afraid it’s gone to your chest”,
“Your chest is clear now — the infection’s gone”, “You’ve got a Germ in the
water”, “It’s only the Chicken Pox”, “Oh yes, is that the one where you’ve got a
runny nose, watery eyes, and you lose your voice? I’ve seen a dozen already this
week”, and so on1 *. These explanations do not satisfy all patients; nevertheless
the majority find such diagnoses, although vague, a satisfactory diagnosis of their
condition. Even if a more precise and ‘biomedical’ diagnosis is given, it often
turns out to be also vague and non-specific. This is partly due to the fact that
diagnosis in general practice, where the average consultation time between GP
and patient is 5—6 minutes (Morrell, 1971:454; Marsh and Kaim-Caudle,
1976:132) is usually based on traditional rather than modern forms of
biomedical divination — such as listening, looking, feeling, touching, smelling,
and so on; and by numerous questions relating to the patient’s feelings,
experiences, and behaviour up to that point in time. A minority of patients are
referred for hospital investigations, such as blood tests or X-rays (also a form of
‘seeing’), or referred to specialists in out-patients departments. In general
practice precise differentiation between viral and bacterial infections is often
impossible to make (due especially to the time factor involved), or else
unreliable. Aetiological agents of infection are often loosely termed “Germs” or
“Viruses” by the GPs, when speaking to patients, rather than a precise definition
of the type of bacterium (e.g., Streptococcus, Staphylococcus) or virus
(Coxsackie virus, ECHO virus) responsible for the condition. Pressure of work,
and the self-limiting nature of many infections, makes it impracticable to always
undertake bacteriological or viral laboratory studies, such as throat swabs, blood
cultures, stool cultures, etc. The diagnosis “an infection" is commonly given,
without identifying the causative organism more precisely. Even if more precise
diagnoses are given, they are also often couched, as mentioned above, in what
to the patients seems a vague way; for example, “upper respiratory tract
infection”, “a viral infection”, "gastroenteritis”, “influenza”, “bronchitis”,
“urinary tract infection”, “chest infection” and so on. The effect of this
vagueness of diagnosis, from the perspective of the patients is, I think, to
confirm and strengthen the ‘illness entities’— clusters of subjective symptoms
( O!.L),.r.T.'.!,.V:- A i EV!.::
128
127
s behaviour chances - that constitute the folk model of illness, rather than
. i;u prcci .e iii.jm.'dic :1 ‘dt.-.’a^s’ on this lay model. This vagueness of
•r.uses given extends also io the anatomical model used by both patients and
in order to achieve a diagnosis bused on mutual understanding, broad
of the body are coalesced into: “a chest infection”, “a tummy bug”,
• j cold in the head”, “gastric ’flu", “an infection in the sinuses”, or “a urinary
. •fection”. So, to a large extent, as far as diagnosis goes, what might be termed
: .. •operation:!!’ model of the GP in practice bears a closer relationship to the
folk model than to the official biomedical model of hospital medicine; and may
mcrefore serve to reinforce tint foil: model. The entities into which the patients’
symptoms arc organised in diagnosis often bear a closer resemblance to the
■. mptom groupings of the folk model than to biomedically-dcfined diseases.
Much of this org-uusation of symptoms, in the area, is done not by the GBs
but by their receptionists - who are often consulted personally or by phone by
the patients at the surgery, and often they make the decision as to whether they
arc ill enough to justify seeing lire doctor. In general, the doctors’ receptionists
act as paiamedical diagnosers and advisers, and reduce even further the number
cf patients who actually get to see the GP. In dress and manner they often
mimic the doctors; wear white coats, speak in a voice of authority, and often
make confident diagnoses on minor complaints based on their years of
experience in the practice.
To some extent diagnosis itself is a cure; especially in those conditions likely
to be self-limiting, and where the patient’s unease is a marked feature of the
condition. This phenomenon was well put by one Phineas Parkhurst Quimby, a
f.-.mous folk-healer, born in New England in 1802 — “I tell the patient his
troubles, and what he thinks is his disease, and my explanation is the cure. If I
succeed in correcting his errors I change the fluids in the system, and establish
the patient in health. The truth is the cure” (Rose, 1971:62). From my own
study and experience, it would appear that in general practice the ‘language of
truth’ in most consultations was the idiom of tiic folk model, rather than that of
the biomedical model.
TREATMENT OF TEVERS1. •COLDS’, AND ‘CHILLS’
Treatment commonly prescribed by general practitioners for disorders within
the Fevers/Colds/Chills model can also be seen to ‘make sense’ within the
conceptions of that model. More important, though, is that many of these
prescribed treatments cannot be fully justified in scientific, biomedical terms; it
is almost as if, in some cases, the patients are treating themselves, using the
doctor as a source of fol': remedies — rather than a pharmacy, or a supermarket.
An important aspect of any GP consultation under the N.H.S. is the handing
over to the patient of the E.C.10 prescription form, which is then handed to a
CECII.G. HELMAN
local pharmacist in exchange for the prescribed drugs. The majority of patients
attending a GP are given such a prescription for one or more medicines. In a
sense, many GPs regard all patients who consult them as being, by definition, in
some way ‘ill’; even if it is only the ‘illness’ of over-anxiety. This attitude is
expressed by one Professor of Community Medicine (Marinker, 1976) - “A
patient is not necessarily someone who has a medical problem; he is rather
someone who comes to ask a doctor for help. It is the act of asking, or in the
case of those who cannot ask for themselves, of being presented to the doctor,
that constitutes that relationship of which we call one half doctor and the other
half patient” (1976:18). A result of this over-medicalisation of the population is
that more and more minor illnesses that were explained by folk models, and
treated by folk remedies, are now brought within the sphere of biomedical
treatment. Nevertheless, as the examples below indicate, the biomedical
treatment itself can be incorporated into, and be explained by, the folk model
itself; and thus helps the patients ‘make sense’ of the treatment given. Examples
of this are:
(1) General Advice (From Doctors or R eceptionists)
“Drink a lot of fluid”, (for influenza, cystitis, diarrhoea);
"Stay in bed, and keep warm: take warm drinks”12 , (for a Cold);
“Don’t smoke now, or it’ll go down to your chest”, (for a Cold);
“The rash is a good sign; it shows that the infection is coming out of the
system”, (measles);
“Yes, there is a tummy Bug going around. Starve yourself and take only sips of
water for 24 hours; otherwise, the more you feed it (the Bug), the more it’ll
enjoy itself and cause dianhoea and sickness”. (Advice given by a receptionist
to a patient with diarrhoea and vomiting).
I
(2) Cough Medicines
According to Wilkes (1974: 98-103), a Professor of Community Care and
General Practice, an estimated six million gallons of cough mixtures are
prescribed in Britain every year under the N.H.S. (this excludes the vast quantity
of self-prescribed patent cough medicines sold over th$ counter). Of the about
sixty million N.H.S. prescriptions written every quarter, about 5% (i.e. 3 million
prescriptions) are for cough mixtures. In a winter quarter they can form the
single largest group of drugs prescribed, exceeding antibiotics, tranquillisers, and
antipyretics. At the same time, most medical authorities cast doubt on the
pharmacological effectiveness of cough medicines; in some views this is
negligible. Wilkes (1976: 98-99) discounts their therapeutic value, except as
reassurance, particularly in coughs likely to be self-limiting, as most are. He
"I i l li A < di l>. .‘.l.'.r.Vi: A I I VI I:"
1 ?,9
. i;'.-te.::l hoi oi :.v..'.'t dr'!'.'., which will be just as cll’cclive; (must cough
•; ate v-::y
an 1 bri -.hi'y colouicd. as well as having a syrupy
cvn •:
la tlii. tiicy ec'.iu the traditi >n.ii cough remcdi.'s of honey in warm
milk, or in he:b.i! tea\ The ofticial British National Formulary (Harman,
1976--7f.: 63}, .v.r.n di.’f-.i-.mtiating betwevn expectorantsand cough suppress-.
ants, the two types of couc.b. medicine, stales - “Despite this distinction many
preparations contain both expectorant and sedative drugs, and this perhaps
reflrcts tb.: lack, of evidence ’hot the ingredients have any relevant pharmaco
logical effect”. In other words, about six million gallons of relatively useless
culouied ’...'ter is prescribed every year in Britain. My hypothesis is that a major
reason for this is that the cough medicine, in the terms of the widespread
Fevers/Colds/Chills folk model, can be seen as something that will expel or
“wash out” or dilute the external entity causing the feverish cough; that is, a
Ger.m.Tliis cannoi be pro\ed conclusively; obviously cough linctuses do have a
limited soothing or pharmacological action. Nevertheless, the flood of cough
medicine in Britain, in association with conditions where increased fluid intake is
considered b.'neFi'i?.!, docs seem to me to be suggestive. Cough medicines that
are medically prescribed arc on’y part of the total amount consumed; the
majority of cough medicine seems to be self-prescribed (see Dunnell and
Carlwrig’-.t, 1972: 26-29, IO7-.,O9). I think that the widespread use of a
remedy such as cough medicines, in the face of biomedical doubt as to its
effectiveness, can be explained (if only in part) by the patients’ need to ‘make
sense’ of treatment for their illness in terms of their indigenous medical system.
s'.;,
(3) Antipyretics
These arc probably the most widely used medicines, both prescribed and nonprcscribvd. Again quoting Dunnell and Cartwright’s figures, 41 % of adults interviev.'-r.! in a random smip'.e had taken aspirin or other analgesic-anti-pyrctic
dr'.:/a in the two w'sks p;eced'.ng the interview (1972.100). In my study,
anti-pyretic dr.r.s were widely prescribed,' or suggested, to patients by the GPs;
particularly in the c.-.se of viral infections, but also in all other cases of raised
body temperature- within the Fevers group of disorders. These drugs have two
effects; the relief of pain or discomfort, and also the reduction of body
temperature if this is abnormally raised. Most medical textbooks cast doubt on
the effectiveness, or even desirability, of prescribing anti-pyretic drugs to
patients v. ith a raised body temperature, unless the fever would be deleterious to
the patient for some oilier reason; a moderate fever may well be a protective
physioloitictil mechanism, and also symptomatic improvement caused by the
drug may cause the patient to be ambulatory while still infectious, and so spread
the infection around.1 J Nevertheless, large amounts of anti-pyretics are
prescribed and consumed; fiom the biomedical viewpoint this is symptomatic
130
Cl ( II.G. Ill I.MAN
treatment for discomfort from sinus blockage, sore throats etc., as well as
reducing the temperature. There is no evidence of any curative effect of
anti-pyretics on, for example, the common cold or upper respiratory infections,
(see Goodman and Gilman, 1965:313-314, 328-329). From the patients’
perspective, in the Fevers/Colds/Chills model, the antipyretics are curative in
that they are seen to induce sweating - and thus the expulsion of the Germ
through the skin — and thereby return the temperature back to normal.7
(4) Antibiotics
These are generally known by the patients “to kill Germs”, particularly Germs
that cannot be expelled, starved, or otherwise eliminated. The patients do not
differentiate between bacteria - where antibiotics are effective - and viral
infections, where they are not. Nor, it must be said, do many GPs make this
differentiation in practice; whether by a more thorough examination, or by
laboratory investigations. A result of this is that, in the rushed consultations in
general practice, antibiotics are often prescribed for viral infections; and an
effect of this is to confirm in the patients’ minds that “Germs" are a group of
homogenous entities, with no differentiation between viruses and bacteria, and
therefore that all or most Fevers require antibiotic therapy. The constant
demand by patients, especially the younger ones, for antibiotics is evidence of
this attitude, as is the vast number of antibiotics prescribed annually.1 4 From
the patients’ perspective, antibiotics are seen as a force introduced into the body
to fight and kill the Germ in situ, with the body being the passive battlefield in
this struggle. The GPs’ reluctance, or inability, to differentiate between viruses
and bacteria - or between different strains of bacteria15 - has led to a vast
amount of overprescribing of antibiotics, numerous side-effects, and the
development of resistant strains of bacteria; at the same time it has served to
reinforce the folk model’s conception of ‘Germs’ as being all of one type, and so
requiring the same type of treatment.
(5) Nasal Drops, Sprays, and Inhalations
These are widely used, both by self-medication, and prescribed by the GP. They
are considered particularly useful by the patients in ‘Cold/\Vet’ conditions, such
as coryza, or early influenza, and the aim of treatment from the perspective of
the folk model is to move the patient from the ‘Wet’ to the ‘Dry’ state,
/lithough these are frequently used, and frequently prescribed (“I’ll give you
something to dry up that Cold”), most medical authorities cast doubt on their
safety in the long term, particularly on their effect on the nasal mucous
membrane. In the opinion of one medical writer (Harrison, 1976), “The only
nasal drops which can be prescribed with complete confidence regarding
II) A (•(.Il I), M AUVE A I I VEH"
131
v o’ u;-: -i.'v.l •.’ificacy are i-.'»:onic s iline sululiun. J’>y sniffing Up such a
or-’p..;? :
u'.u./'.y m ; !•: al heme by dL.^'.ving one teaspoon of salt in a glass
of f.pil v.ater, the n.iii-n’.t may tc.tdily remove secretions and crusts with both
ef:k.-.:y and safety.
simple douche system makes this remedy even more
effect? e” (!97(i:72 -73). Demtle this common sense advice, a great number of
rasa! dtop, and c-lt.-r local prepiations are prescribed by GPs, though the
number is failing. The point is that Colds, which were usually treated by
self-medication, arc now increasingly being treated by doctors. A larger portion
than before of the ‘Cold’ side of the folk model is being treated by general
practitioner.;; and m the patients’ perspective this gives almost equal weight to
both ’Cold’ and ‘Hot’ sides of the folk model.
132
Antipyretic-Analccsic-t Dcucngestant (e.g., ‘Trlogasic’)
Antipy:e*.ic-Ana!;”S'c+ Decongestant + Cough Suppressant (e.g., ‘Triotussic’,
‘Vicks MediNite’)
Antipyretie-Analgesic + Decongestant + ‘Tonic’ (Vitamin C) (e.g., ‘Uniflu plus
Crcgovitc ‘C’)
iielman
Antipyretic-Analgesic + Decongestant + Stimulant (Caffeine) (e.g.,
‘Emprazil’)17
Antipyretic-Analgesic + ‘Tonic’ (Vitamin C) (e.g., ‘Beecham’s Powders’)
Decongestant + Cough Suppressant + Expectorant (e.g., ‘Antitussin’)
Decongestant + Cough Suppressant (e.g., ‘Actifcd Compound Linctus’)
Cough Suppressant + Expectorant (e.g., ‘Terpolin’)
I
These examples are mainly concerned with disorders of the respiratory system;
combination drugs do not exist for all the symptom-clusters within the
Fevers/Colds/Chills model. Nevertheless they do provide an example of how
biomedical treatment, whether prescribed by a doctor or self-prescribed, can fit
into the folk model without challenging its basic premises; in fact, especially in
the case of medically prescribed drugs, they may actually serve to reinforce it.
In several of the examples of treatment for common Fevers or Colds that are
given above, there is little or no biomedical justification for that treatment; it
would seem that many prescriptions are given more to ‘fit in’ with the folk
model, rather than on strictly rational or scientific biomedical grounds. The folk
model still exerts a potent influence on the prescribing habits of many GPs.
(6) O:l:cr j 'roprlctaiy h cparat tour.
A wide variety of proprietary preparations are available which provide
symptomatic treatment for conditions in the Fevers/Colds/Clulls model. Some of
these (especially ‘Cold’ or ‘flu’ medicines) can be bought over the counter in
pharmacies or supermarkets, while others can only be obtained with a doctors
pre>c.ipiio:>. The s'cmt’icr.u.cc of these preparations is that they treat a cluster of
symptoms which constitute the folk model, rather than treating the cause (for
example, a virus) of the biomedical disease; in other word.;, they treat ‘illness’
rattier than ‘disease’. They are palliative rather than curative, and are widely
prescribed by GPs for conditions that arc likely to be self-limiting, or as an
adjunct to curative therapy. From the perspective of the folk conception of
illness, the-e symptomatic treatments arc i>ften seen as curative, preparations
which reduce b:\er, relieve sinus or nasal congestion, induce sweating, aid
expectoration, and so on, are conceived of as specific cures for the clusters of
symptoms that make up th.-; ‘illness entities’ ot the Fevers/Colds/Chills model.
Drue; v.bich palliate a whole cluster of symptoms simultaneously - especially if
prescribed by a doctor — tend to reinforce a folk model ol ‘illness’, rather than
educate the p u.ient; in the nnluie of biomedical ‘disease’. In the Fevers/
Cc’.ds/Citii'.i model described here, a number of proprietary preparations are
available which treat simultaneously a number of symptoms within the folk
model. Often Vhamin C is included as a ‘tonic’ in a modern form, especially in
building up one’s energy to fight a Cold. Examples of commonly used
combination drugs’ 6 are:
cecii.
DISCUSSION AND CONCLUSIONS
I
Although the conditions that fall within the Fevers/Colds/Chills model are in
general trivial and non-life-threatening, they are extremely common in the
population at large, and are frequently encountered in general practice. As such
they provide a useful source of data for any study of the persistence of
folk beliefs about illness in a Western, urban community; a community long
exposed to information about biomedicine, and which is in frequent contact
with the medical profession. The creation of the National Health Service in
1948, which brought free medical care to the entire population, also converted
the entire population into potential patients. A wide variety of folk beliefs and
folk remedies relating to illness, which, largely for economic reasons, had
remained untouched by the medical profession prior to 1948, were suddenly
brought into contact with the concepts and treatments of biomedicine. The
Fevers/Colds/Chills model described above is just one example of such a folk
system. Despite the impact of information about the true nature of microbial
infections, the basic underlying classification of ‘Fevers’, 'Colds’, and ‘Chills’
seems to have remained largely unchanged. It is suggested that a reason for thif is
that GPs in the area studied (and presumably in other parts of the country”)
give their patients diagnoses and treatment which clearly ’make sense’ in the
terms of reference of the folk model. Biomedical concepts are tailored to fit in
more closely with the patients’ model in the consultation; partly to avoid
‘cognitive dissonance’ in the interpretation of the illness; partly because most
I.B
coadt!;.':- m
134
CECIL G. HELMAN
l evef./t'rLl '( mils mnJd are sell-limiti.i; and not life-
‘•’■•““•I • ” ’ ,’»”t :n ti.v!:;;; ih.’in symnlomitticully the GPs are less
t
. to
l,i,
it tli.-n they would be in more danrerous
condemn;. Th : n: ’->l com ::l:;.tinn time ; of only a few mianlcs per patient
also make it diilkdit to be more relentifically exact in diagnosis and treatment,
and afiord lie doctor kxs opportunity to dispute or tamper with folk models of
ihnes;. (“JR.b," as one GE put it, ‘‘isn't to educate - it’s to cure”). Tlie effect
of these :..cio.-sjs to reinforce, in the patients’ minds, many aspects of their
traditional lolk models of illness, and the traditional remedies used for them.
It would seem, therefore, that in some respects the ‘operational model’used
°fn a.da,y l° day taSlS by the Gl s is closcr t0 tl'at of thc lay n^dcl than to the
ofuml bromed'cal model of disease - as found in hospital medicine, the medical
textbooks, and the medical schools. However, this effect on the prescribing
habits or CPs is by no means always benign; many of the drugs prescribed have
undesirable side-effects, both in thc short- and die long-term. Antibiotics,
aniipyrctics, and even anti-hlstamines may all cause dangerous side-effects. In
add:::on, thc cost cf N.U.S.-prescribed drugs is spiralling in Britain*9.. If six
mdiscn gal.ons of cough medicine are annually prescribed by doctors, in the face
cf b;omed:.al doubt as to its pharmacological effectiveness, a case might be
maJ? for the much wider tuc of harmless ‘placebo’ drugs--at least in those
conditions knu.-n to be trivial and self-limiting. The increased use of traditional
rcme hes by patients should be encouraged, provided that they are free of
harmful sidr-cfrccls, and that the doctor i; confident that biomedical treatment
cannot improve on the traditional remedies - in safety, or in effectiveness. If life
is being ‘m. dicaliscd’, as lllich has suggested - that is, brought under the aegis of
tae momodical model cf misfortune - then at least one can ensure that the
treatments prescribed are not dangerous to the patients in any way. As thc
common d nditions within rhe Fevcrs/CoUs/Chills model are now firmly within
the mom.-d eal sphere of influence, at least m Britain, it is important that doctors
should be more aware of the traditional medical systems of their patients, and of
the c-;?:t o:
e syr-ems on their own prescribing habit;..
Contrary to its ordinal intention, the National Hinllk Service in Britain may
have remforced :he ‘folk healer' aspect of its General Ptaciilioners; a much wider
renge of li:? experience and misfortune is now being dealt with by GPs - not
only a wkvr range of illness and disease than formerly, but also psychological
ernes, hie crises (such as bereavement, divorce, etc.), and ah thc normal
oio.c;;.::, •nndrr.’rks, such as birth, childhood, puberty, menopause, and death
n
ege of preventive medicine, the GP deals increasingly with healthy people
uiom.'u:;-..y dcuae.l), rJr immunisations, ante-natal climes, cervical smear
c.mius. baoy clinics, and so on. The more intimate and long-term relationship
between GP and patient that this brings about does not seem to have drastically
c unged folk models of illness. The Fevers/Colds,'Chills model is one example of
this, but undoubtedly there are many others that remain to be studied, with the
eventual aim of improving health care, with less side-effects to the patient.
The Surgery, Stanmore, Middlesex
NOTES
1 I have used the term ‘biomedicine’ throughout the paper; in Fabrega’s definition it is
"The whole medical complex in Western nations, which includes knowledge, practices,
organisations, and social roles” (1975:969). It is therefore "our own culturally specific
perspective about what disease is, and how medical treatment should be pursued”
(1975:969). It is the world-view of a professional subculture, the medical profession.
The term ‘biomedicine’ is rarely used in British anthropological or medical writings.
2 Thc history and sociology of the British National Health Senice are well described Ln
Stacey (1976), and Levitt (1976). In Stacey's book, see Gill's article (1976:10-12) fora
history o( the N.H.S. and of the medical systems which preceded it.
3 See Levitt (1976:96. Table 4). She quotes a study of the ‘Annual Morbidity Experience .
in Average British General Practice of 2,500 Persons (i.c., numbers of patients suffering
from the diseases that the doctor may expect to sec each year).’ Of the patients seen,
1365 had ‘Minor Illness',288 had ’Major Illness’, while 558 had ‘Chronic Illness'. Of the
Minor conditions, 674 had Upper Respiratory Infections, 84 had Acute Otitis Media,
51 had Acute Urinary Infections, and 53 had ‘Common Digestive Disorders’ (which
presumably includes Gastio-entvritis). Cf the ‘Majo:’ conditions, 184 patients had
Pneumonia and Acute Bronchitis.
4 Many medical anthropologists have noted that definitions of ’normality’ in health differ
between cultural group, and social classes. In Britain there are significant differences in
the definition of ‘illness’, and in the threshold at which it is brought to a doctor,
between the different socio-economic classes. For a study of this, see Cartwright and
O Brien (1976:77-94).
5 For example, see Camp’s article (1976:70-76) on the medical use of hydros and spas in
France ("la thermalisme”). In France there are over a hundred of these spas and hydros
to which half a million patients are referred by their family physicians every year. This
practice is now almost unknown in Britain, though ‘hydrotherapy’ flourished here from
the 17 th century. French spas are supervised by ’thermal specialists’, many of whom are
doctors who have taken a ‘diploma in hydrology’.
6 See Levitt (1976:98. Table 4).
7 One popular book of folk remedies (Mellor, 1975) puts this concept in a similar way;
tor example, the treatment she recommends for the common Cold is: “Hot lemonade
with a pinch of cinnamon and a little honey in it, and hot elderflower-and-mint tea, with
a pinch of composition powder in it, will induce sweating and excretion of
waste-products through the skin. The body should be rubbed down with a rough towel;
this will remove the sweat, and will induce further sweating and further elimination of
unwanted debris through the pores of the skin” (1975:89).
8 Cf. Mellor (1975:66) on the treatment o! "Dronchitis and Broncho-Pneumonia” - “The
best way to cure both of these ailments is to fast, on juices only, for a day or two. A cup
of hot elderflower-and-mint tea should be taken every half hour until sweating begins,
then only every hour. The sweat should be removed with a dry towel.”
9 See Lewis, I. M. (1971:66-99) for a description of the “malign pathogenic spirits” who
cause illness by possession of the victim’s body, in parts of Africa and elsewhere. In
these societies ‘spirits’ are hypotheses for the causation of illness. These spirits are
capricious and amoral in their attacks, and their victims are considered blameless.
Among the Luo of Kenya, for example, “amoral, malevolent spirits of external origin".
i :>nn n,
a i i vi
135 •
cxi .!i.:;
I: ilv: anc ; •!<’: mlt, r.n: .e a v. :J.e v.ni.-ty of .il liictions, especially among
::.n (T,'71:.?l). la «:th-r VimiJ’r *acicties. these spirits “strike without rhyme or
r--/ • n; er at i/. u v.i:; nut any •.u’r.’jni: •! cau-e '.•■hivii can be tefcrrcd to soci il conduct.
Th,-/ are not cwd-.err.cJ ’•■•i-h nun’s bci-r-iour to man. They have no interest in
deAid;.:; the
jde of so..;//, a:.J those who succumb to their unwelcome
a;:.'a:i -ns are ir.or
b::.:..“ (1971:71).
10 An i:i'..l-^uate d::t. c-c i .-.“.y. is now i.-.ctcasinf.ly blamed for Colds. Cf. Mellor
(1975:39) - a Cold :i “Nature's way of forcing you to icst, so that >our body can
tbiow out unwanted debris that has accumulated in the blood. An unclean bloodstream,
lo.-J-.d v. ith ut.-.anted debris, iTovides a favourable breeding ground for the common
coil vins, which c;«r.not live and multiply Ln a clean bloodstream because it tequires
waste-.mutter >'.:i which to f'eu. I; pains entry into the body via the nose or mouth, but,
if waste-matter is not preu ol in the blood, it will have nothing to feed on and will soon
die and be excreted, toother with other unwanted debris, through the eliminative
ort.v.-.s of the body. A clean bloodstream is, therefore, the bos' insurance against all
foims of perms, i.-.c’..: ling the cold-vl-us and the 'flu-virus.*’
11 Gac patient v.hor.i 1 diagnosed as having a “viral infection", replied “That means you
don’t know what’s wrong with me, doctor.’’
12 Similar ? J vice for the common cold can be found in many rnedhal textbooks; in
Maclean .•’nd Scott (1963:173; for example, treatment of the common cold includes bed
rest in a warm room, togithrr with hot dunks .-nd a hot bath.
13 Sc; Gcoiiman and xiiin’.un (1962:323); am! Chatton, M.ugcn, and Brainerd (1970:5 — 6).
14 See Trvthowan (.197:’:749) - In 1972, in England, 36 million prescriptions for
’A.r.;-lnDrugs’ ’.ve’c issued by Gi’s in the N.H.S., at a total cost to the state of
£23.7 m.llion. Thi- amour.t exdud'** anti-infective drugs prescribed under the N.H.S. in
V/.-.l.’s, Scetljr.d, and Northern Irelar.d, and those prescribed by hospital doctors.
15 Medical textbooks stress the fact that viruses are not susceptible to antibiotic therapy;
s;e G.acod and O'Gndy (1968:427), and British National formulary (Harman,
1576:115).
16 Details rtf all p;-’.<criV'Me proprietary drugs available in the United Kingdom, together
with th hr nb-ar."..'.■vbi;:.:.coruUlucnts, can be found in the monthly publication
‘.'•II.'.'.S’ (‘Mor.di'y Index of M..’d:c:'.l Specialities’), pjhlidb’d by Haymarket Publishing
Compary, London. It is sent f:ee each month to most doctors in the UK. Some patent
remedies arc not included in il, especially those that can be bought in pharmacies and
supermarkets.
17 E.nprazil’s sloga::, written on each box, is: ‘‘Clears the nose, eases aches and
p •ins - Helps yn:i c :rry on th.-oti -h th»- cold."
18 Byrne and Long's study (1976) of consultations between CPs and patients in several
au.is ii. Br:!;:: , includes tta.uciipts of a few conversations which seem to exemplify
i!p >inis; fur exam;-!:, in •: -.c ccnve;citicn between DiDoctor) and P(l’atient): D.
"Hello, come in, ho.v ire you?" P. “Got a cold .. ." D. "Il's the fashion this week,
everybody’s got it. Well, now, how's the breathing going, any different?" P. “Not so
bail, doctor, can't grumble. I feel a bit better than I did before.” D. "That’s a good sign.
Arc yo i cm:at a'l?" P. "A bit. Just pot a bad chest, just my arms you know."
D. “it's the cold and damp - that sort of thing . .(1976: 93-94).
19 Sec Trethowan (1975:749) - In England only, in 1972, 255.9 million prescriptions
were issued by General Practitioners Ln the N.H.S., with a total cost to the state of
£155.1 million.
REFERENCES
Blacow, Norman W.
1972 Martindale: The Extra Pharmacopoeia, 26th Edition. London: Pharmaceutical
Press. P. 223.
136
CECILG. HELMAN
Byrne, Patrick S. and Barrio Long
1976 Doctors Talking to Patients: A Study of the Verbal Behaviour of General
Practitioners Consulting in their Surgeries. London: Her Majesty’s Stationery
Office. Pp. 93-94.
Camp, John
1976 Therapeutic Mud-Slinging. World Medicine 11: 70-76.
Cartwright, Ann and. Maureen O’Brien
1976 Social class variations in health care and in the nature of general practitioner
consultations. In The Sociology of the National Health Service, Margaret Stacey,
ed. London: Croom Helm. Pp. 77—94.
Cassell, Eric J.
1976 The Healer’s Art: A New Approach to the Doctor-Patient Relationship. New
York: Lippincott. Pp. 47-83.
Chatton, M. J., Sheldon Margen and H. Brainerd, eds.
1970 Handbook of Medical Treatment. Los Altos: Lange, pp. 5 -6.
Crystal, David
1976 The diagnosis of sociolinguistic problems in doctor patient interaction. In
Language and Communication in Medical Practice, B. Tanner, cd. London:
Hodder and Stoughton. P. 49.
Douglas, Mary
1970 Purity and Dinger: An Analysis of Concepts of Pollution and Taboo. London:
Penguin Books.
Dunnell, Karen and Ann Cartwright
1972 Medicine Takers, Prescribers, and Hoarders. London: Routledge and Kegan Paul.
Eisenberg, Leon
1977 Disease and illness: Distinctions between professional and popular ideas of
sickness. Culture, Medicine and Psychiatry 1:9-23.
Fabrega, Horacio
1973 Illness and Shamanistic Curing in Zinancantan: An Ethnomedical Analysis.
Stanford: Stanford University Press.
1975 The need for an ethnomedical science. Science 189:969—975. ,
Foster, George M.
1976 Disease aetiologies in non-Westem medical systems. American Anthropologist
78:773-781.
Fox, Renee C.
1968 Illness. In International Encyclopaedia of the Social Sciences, Vol. 7:90-95. New
York: Free Press/Macmillan.
Garrod, Lawrence P. and Francis O’Grady
1968 Antibiotics and Chemotherapy. London: Livingstone. Pp. 255,427.
Gill, Derek G.
1976 The reorganisation of the National Health Service: Some sociological aspects
with special references to the role of the community physician. In The
Sociology of the National Health Service. Margaret Stacey, ed. London: Croom
Heim. Pp. 9-21.
Goodman, Louis S. and Alfred Gilman
1965 The Pharmacological Basis of Therapeutics. New York: Macmillan, London:
Collier—Macmillan. Pp. 313-314, 328, 329.
Harman, J. B. et al., eds.
1976 British National Formulary 1976-78. London: British Medical Association.
Pp. 63, 115.
Harrison, D. F. N.
1976 Nasal Drops, Sprays and Inhalations. Prescribers Journal 16:69-74.
Hughes, Charles C.
I
I
-*#1*
•TEED A COLD, STARVE A l EVER”
137
1968
Ethnomedicir.e. hi International Encyclopaedia of the Social Sciences, Vol.
10:87-93. New York: Free Press/Macrnillan.
,
Inglis, Brian
'
1964 fringe Medicine. London: Faber and Faber.
Levitt, Ruth
1976 The Reorganised National Health Service. London: Croom Helm.
Lewis, Gilbert
1975 Knowledge of Illness in a Sepik Society. London: The Athlone Press. Pp.
146-151.
Lewis, I. M.
1971 Ecstatic Religion: An Anthropological Study of Spirit Possession and Shamanism.
London: Penguin Books.
Maclean, Kenneth and George Scott
1968 Medical Treatment, Vol. 1. London: J. & A. Churchill. P. 178.
Marinker, Marshall
1976 The myth of family medicine. World Medicine 11:17-19.
Marsh, Geoffrey and Peter Kaim-Caudlc
1976 Team Care in General Practice. London: Croom Helm.
Mellor, Constance
1975 Natural Remedies for Common Ailments. St. Albans: Mayflower Books.
Mitchell, William E.
1977 Changing Others: The Anthropological Study of Therapeutic Systems. Medical
Anthropology Newsletters, No. 3:15-19.
Morrell. D. C.
1971 Expressions of morbidity in general practice. British Medical Journal 2:454.
1972 Symptom interpretation in general practice. Journal of the Royal College of
General Practitioners 22:297-309.
Prince, Raymond
1964 Indigenous Yoruba psychiatry. In Magic, Faith, and Healing. Ari Kiev, ed. New
York: The Free Press. Pp. 84-118.
Rose, Louis
1971 Faith Healing. London: Penguin Books.
Stacey, Margaret, ed.
1976 The Sociology of the National Health Service. London: Croom Helm.
Slintson, Gerry and Barbara Webb
1975 Going to See the Doctor — The Consultation Process in General Practice. London:
Routledge and Kcgan Paul.
Trethowan, W. H.
1975 Pills for personal problems. British Medical Journal 3:749-751.
Wilkes, E. ,
1974 The treatment of cough in general practice. Prescribers Journal 14:98-103.
I
. i
I
r
A CASS FOR COALITION OF MEDICAL SYSTEMS
H ■-«» ,.
!■ .
■
«
«. —■ ■ ■
■■
—
— —
—»■
< .
f..
.■—
■ ■ ■. .
—-• ■ ■— —
.-w
—. .
■
..
Paper presented by
Dr. R.J. Agni hot ri/
Senior Physician (Ayurveda)/
C. G. H.S. Ayurvedic Hospital/
Ali Ganj, Lodhi Road/New Delhi,
[
at the THIRD INTERNATIONAL CONGRESS
ON TRADITIONAL ASIAN MEDICINE HOTEL-OBEROI TOWERS, BOMBAY
4th-7th January,
1990.
r
f
i
COMMUNITY HEALTH CELL
47/1, (First Floor)St. Marks Road
BANGALORE - 560 001
s'
Introduction
Independent India1 s former President,
Philosopher Dr. Sarwapalli Radhakri s jnan said
that, Indian Philosophy does not stand
for
either ’this* or that, but it stands for both
■V
•this* and 'that1 .
people.
Indians are pragmatic
They riiether have any sentimental
attachment or detachment like 'our medical
(
system1 or ’their medical system’.
They take
good points from all the medical systems and
discard bad elements of all the systems
and
form their independent judgment as to which
system is beneficial in what circumstances.
The main thesis of this paper may be summed up
i
in short as (1) Coalition (of Medical Systems)
without Quackery; and
(2)
Moderation in Medicine.
!• Coalition without quackery.:.
.
■■
In the book "Culture Disease and Healing"
5
J
■
edited by David Dandy in Chapter No.57 written by
■
Charles M. Leslie titled "Pluralism & Integration
in the Indian and Chinese Medical Systems"
ft'-
the
■
following observations have been made in respect
of medical scene in India:-
Sc 7
bi*'.
(1) Professionalised Indian Medicine is not in
practice isolated from cosmopolitan medicine,
K-
■
I
(In India what we understand by Allopathic or
1
Modem Medicine is termed as cosmopolitan
medicine- in that book) .
(2) The Integration of Indigenous and cosmopolitan
f
■ .y-b
medicine is even more obinious when one adopts
the perspective of Laymen, for throughout
'l
Indian society they utilise whatever form
of medi cal knowledge and practice are available
to them.
They are less concerned with whether
5 ■ h
'J
the therapy is indigenous or foreign,traditional
or modem than with how much it will cost ?
i
' 'i1-
Whether or not it will work, how long it will
take ?
I
and whether the physician will treat
them in a sympathetic manner.
7
V
(3) Part-time practitioners far out number full-time
I
practitioners in the Indian Medical System.
In 1965 a Community Development Block with
" 'j
Fft-
|
80,000 people had 59 full-time and 300 part-time
Indigenous Medical Practitioners.
I
In the same
!
ar a district in South India with a population
•r
----- contd./-
. •1
-a. •'
■'
- 2 of 1, 20,000 had 6 Doctors 30 full-time
practitioners of Ayurvedic & Unani Medicine
and 598 part-time practitioners.
(4) Well-known Ayurvedic & Unani Physicians will
have brothers,
sons and other kinsmen who are
cosmopolitan Medical Doctors or we could put
this other way round and say that many
cosmopolitan Medical Practitioners have kinsmen
who practice Indigenous Medicine.
These observations of Medical Anthropologists
about Indian Medical scene are fairly objective.
In India ipso-facto coalition of Medical
Systems already exist.
B ut in its present form it
is leading to quackery.
To erradicate quackery
profession had to adopt and assimilate the good
qualities of quacks.
As the vedic dectum goes 1 A A No
Bhadraha Kritavo Yantu Vishvataha'
let noble thoughts
come to us from all sides - even from the side of the
medicines’
enemy the quack.
There was a news item in the newspaper
“The Times of India” dated 1-10-89 captioned "Where
every fifth Doctor is a quack
G. V. Krishnan.
it
written by Shri -
He has raised many issues there.
But here I only deal with the portion which is
relevant in the pr r
t ext.
As I have told
earlier to erradicate qurckery qualified Doctors
should assimilate the g
qualities of quacks.
The news item referred
e tells that "The thing
about quacks is their po; ularity. They are responsive
contd./-
- 3 to patient
mainly poor and unlettered.
While nost
qualified ‘“octors limit their practice to clinic hours
and do no
make house visits quacks appear to have
earned put 1c goodwill because of their willingness
to go
an} where at any time for any case in response
to call from patients.”
Here I want to comment that
assumption of qualified doctors that deliveries.
diseases and deaths do not occur outside their clinic
1
hours is also a form of quackery.
'r
When foreign missionaries and so called
quacks are responsive to the poor and unlettered
patients, why a qualified Indian Doctor should not
be so ?
Why he is so reluctant to work in remote
difficult rural areas.
Whether his religion does
not teach him sympathy and compassion for his fellow
beings ?
It is also reported in this news item that
in case of Village women attempting suicide by -consuming
insecticides following family quarrels - ’’the neighbourhood
quack helps out the family while qualified medicalmen
would not touch the case without referring it to the
Police as medico-legal case.
Any Doctor worth the
name knows that how much important it is to treat such
patient very promptly.
As justice delayed is justice
denied - in the same way Medical treatment delayed in
such emergencies is treatment denied. In this connection
I want to quote recent Supereme Court of India Judgment
which says that in case of road accidents and head injuries medical treatment should be provided promptly
first, legal formalities may follow later. Laws should
contd./-
4
be amended to facilitate Doct-
s first to attend
emergencies without wasting precious time in legal
formalities which may go aga.
st the interest of
the health of the individual
:on cemed.
There are al no st alv ays alternative ways of
dealing with various medical situations.
If one system
of Medicine cannot deal successfully with a certain
medical situation and other systems deal with
it
appropriately, then the practitioner of earlier
system need not feel humilated or feel that he has
sustained 'loss of face’ or ’cut of nose1.
If a
person’s disease is cured, pain is relieved or health
status enhanced, it would be strange if some doctor
is grieved over the matter.
Noble profession of
medicine should be put at such a high pedistel where
petty conflicting vested interests cannot play havoc.
Cross referal of ‘Patients from one system of
Medicine to other should be as smooth and formal
a s in the case of referal from one speciality to
the other in the same system.
It should be guided
by the consideration for the welfare of patients.
False personal prestige should not come in the way.
2. Moderation in Medicine:
Health promotion & maintenance disease
prevention and cure. these objects should be achieved
through moderate means extreme positions should not
be adopted to achieve these goals.
This principle
of moderation is termed ’Madhyama Marg* or ’Golden Mean*
in Ayurveda & Budhistic Philosphy.
Thus, legitimate
pleasures of flesh should have preference over cilibacy.
con td.. /-
5 •
While enjoying sensual and sexual pleasures restra.
is preferred to over-indulgence in them.
Ordinari.'' A
natural child birth should be preferred to interve tional
obst ritics.
While treating diseases non-drug ther py
should be preferred to drug therapy. Simple Ayurve* ic
& Homoeopathic drugs should have preference over
cosmoplitain Medicines which have potential for
adverse reactions.
Drug therapy should be preferred
over surgical operations.
And surgical operations
over organ transplants.
In short, initially and in
the earlier stages of diseases simple home remedies
should be used.
In complicated cases where there is
no other option sophisticated diagnostic and
therapatic technologies should be used.
It is said
t hat some Californian women had prophylactic mastectomies
to prevent the possibility of breast cancer.
Such
actions go against the interest of the women conemed
an^d as also_.pf_ her husband and children.
Nearer home
in a district o£ Andhra Pradesh all the women in the
age group of 45 to 50 who were rich enough to pay for
the operation, bad hystractomies to avoid uterine
t urno rs.
Such extreme steps for prevention of diseases
are absurd.
It is like saying • Na rahe bans Na baje
bansri* if there were no bamboos there would not be
flute-playing.
no
If there arc no heads there would be
headaches.
It is said that c ;-
c
result of its media
being pre-occupied with health U. S.
has become the
most over medicated. over-opt. ted, over inoculated.
anxiety ridden country in th
.orld.
Health education
cont d./-
6 is good but such overdose of it is bad.
Mother ai> . infant both know instinctively
that breast feeding is mutually beneficial but some
modem mothers do
,ot feed their babies on the breast
for the fear that in the process they may lose their
sex appeal and beauty.
In Africa infants fed on baby
foods died of mal-nutrition.
Then W.H.O.
started
arguing in favour of breast feeding, which is encouraged
X
by all the traditional medical systems sinceantiquity.
v
All over the World traditionally many
restrictions were put on sexual activities.
After the
availability of various contraceptive devices.
-
as
there is no fear of unwanted pregnancies. these
restrictions were ridicluded as conservative Victorian
val ues.
But recently with the spread of AIDs, many
older restrictions on sex seem sensible and necessary.
Therefore, many older practices and beliefs need to
be reassessed more objectively.
3.
Adverse reactions of crugs:
We read now and then in daily newspapers
about the deaths caused by anaphylactic reactions to
the administration of penicillin injections. Sometimes
even the test doses of penicillin prove to be fatal.
Penicillin is the most important single drug which
has made.people suspecious of synthetic chemicals
of modem medicine.
are immediate.
Adverse reactions to penicillin
There are instances of delayed reactions
to the administration of drugs not only on the patient
but also on his/her progeny e. g. , chloroquine given to
contd./*
7
pregnant women may produce a retinopathy Ln the child
4 to 5 years after delivery and diethylstilboestrol
administered to a pregnant woman in ear • y pregnancy
many years later, produce vaginal carcinoma in her
adolescent daughter.
Adverse drug reac4 ion s of
modern medicines are so numerous that ncw-a-days
even text books of adverse drug reactions are being
written and some quarterly periodicals are being
published on the subject of adverse drug reactions.
■
Because of such publications, urban dwellers of
metropolitan cities of India now want to go through
the literature about the medicines prescribed by
their physicians and it is only when they find them
to be safe then they are ready to consume them.
In
U. S. A. the situation is even more horrible from the
point of view of Doctors.
There, the Doctors face
litigations from their clients regarding real and/or
imagined adverse reactions of drugs prescribed for
them by their Doctors.
Apart from adverse drug reactions, another
point is that the modern diagnostic and therapeutic
technologies are not cost effective.
The
early
detection of incurable disease with the help of
modem diagnostic technologies may do no more than
prolong the period of worry for the patient and the
family.
The benefits that high technology promises
of postponing death or reducing disability.
sometimes
exact too high a price, as only a minority of patients
stand to benefit from technology. too much attention to
cont d./-
8
them diverts resources from manf others/ who pay
the price in the inadequacy of provision for their
needs.
But there is potential
larm also for those
whose condition can be influenced by technology for
most interventions involve disc ^mfort and some are
hazardous.
Postponing death of an unconcious patient
for a period of six months at enormous cost for his
family puts his heirs in debt for the rest of their
lives.
Compare this situation with that of First
Mughal Emperor Babar/ who bargained his life
that of his son Humayun.
for
All Indian languages have
a common idiom used by elders which is addressed to
God imploring him to take their life, instead
their children’s.
of
It seems that their prayer was
mostly answered by God in the affirmative. But for
the disease, children are made to last longer
in
comparison to their elders, whose days or ye^TTs of
life are numbered.
I mean to say here that elders
should accept the inevitability of death with grace
and dignity as it is a part and parcel of life itself.
With a view to compensate for the deficiencies
of modern medicine W. H.O. has broad-based its Health
Care Delivery System to include traditional medicine
al so.
By traditional medicine is meant, the sum total
of all knowledge and practices whether they can be
explained or not used in the prevention, diagnosis
and elimination of physical, mental or social inbalances
and relaying exclusively on practical experience and
observations handed down from generation to generation
whether orally or in writing.
contd./-
9
4. Conclu ion:
tant bronchodilators of modem medicine
sometimes
ause tremors in hand and palpitation.
Therefore
if these medicines are used in smaller
doses ale igwith Ayurvedic medicines such as
Chavanap< rash. Chitraka Haritaki which improve the
immunity of respiratory system, such a regimen will
be beneficial for the patient, without the above said
side-effects of medicines.
My personal experience
suggests that such a combination will help the
patient in the case of respiratory diseases.
Similarly using astringent and better
medicines such as Kutaja, Jateephala and Opium
described in Ayurvedic system will help in diarrheal
diseases and mild purgatives such as Senna,
Glyesrrizaglibra etc., will help in diseases of
digestive system where constipation is the main —.
problem. Many drugs formerly used for intestinal
infections in modem medicine have adverse reaction
on optic nerve, prolonged use of them, may result in
blindness. The milder drugs of Ayurveda help the
patient of digestive system without any adverse
reactions. Though there is no other go than to take
recourse to modern medicines in medical and surgical
emergencies.
Doctors of modem medicine and Ayurveda
should sit together with open mind and cooperative
3Ptitude, with the help of drugs o*f both the systems
and following beneficial practices of traditional
cultures we can hope to achieve health for all by
2000 A.D. in an economical way.
---------The End—
THE HINDU, Sunday, May 18,1997
V
Blow to goodness
Supply of drinking water was her one-point mission. And this was
her undoing. The message of the murder of Leelavathy,
Villapuram councillor, is loud and clear. A woman in politics will
be tolerated only if she has high level connections or if she is
prepared to overlook the loot of political ruffians,
says MYTHILY S1VARAMAN
PRI1 24 began like any other day in the
life of Leelavathy. the 40-year- old
JL Jkcouncillor of Villapuram (ward 59)
Madurai Corporation. Early in the day she
made a tour of some of the streets in her ward her daily routine - giving instructions to the
Corporation Division Office to attend to some
repair work. On returning home, her eldest
I daughter Kalavathy offered her a hot cup of
I tea. Remembering that there was no cooking
oil in the house, Leelavathy hurried to the shop
close by and never returned to have that tea.
Minutes after she left home, around 8 a.m.
and quite close to the grocery shop she was
hacked to death by armed men, her body
sustaining more than 2 5 stab injuries. It was a
stone's throw from the building in which her
family had lived in a rented room for over two
decades.
The rest is recent history with journals
churning out various versions of the killing by
unnamed eye witnesses. Her low profile
campaign, costing a pittance in sharp contrast
to the extravagam campaign of her opponent,
had given the people of the ward a chance to
say "No" to the hooliganism prevalent in the
area. And this, in an area which was far from
stronhold of the CPI(M), whose candidate she
was; Her victory was a surprise to many.
Villapuram had for long been dependent on
water brought by Corporation tankers and sold
to the people for a fee, levied by local thugs. All
attempts to lay water pipes from a water source
to Villapuram had been scuttled in the past, as
selling water was fetching a mafia around Rs.
3 5,000 a month. Leelavathy had. during the
election campaign, promised that she would
bring the residents free pipe-borne water, if
elected. Contrary to
dominant political
norms, she had meant
what she had said.
Supply of drinking
water, thus became
almost her one-point
mission. And this was
her undoing.
In her very first
council meeting she
had raised the issue of
misuse of water
distribution b}' the
anti-socials. She did
not however, take on
the local goondas in a
spirit of recklessness.
She was discrete,
avoiding direct
encounters with them
and concentrated on
squabbles because of it? Kuppusaaiy's
response, “No debts and no squabbles’’ sounds
unbelievable until one becomes aware of the
family's life style, untouched by the
consumerist culture. Leelavathy had so few
decent sarees that her better off co-workers
offered to get her a few new sarees to wear
during the campaign and later as a councillor
attending city functions.
The offer was gently declined. Leelavathy’s
three daughters, Kalavathy. Durga and Tania,
aged 19.17 and 15, have been brought up
with the same values that the parents
practised in their personal and public lives hard work, social awareness and minimal
concern for possessions of any kind. In the
aftermath of the tragedy, they have conducted
themselves with admirable fortitude and
composure. The tiny one room which the five
of them occupied, with a small nook in the wall
to accommodate the stove and a few utensils,
had a big loom in it. A small table fan and a
portable black and white TV stood in a corner
unobtrusively.
Asked what changes he perceived in his wife
after she became active in the Left movement,
Kuppusamy recalled that she had given up her
habit of writing Sri Ramajayam 108 times a
day - “1 guess she found little time for this,
overpowered by her new interests. She did not,
however, neglect her obligations to attend
larger family occasions." A middle class
woman employee reminisced about the visits
of Leelavathy to her office to enrol members in
AIDWA. She was rather shy and would not
talk much on her own. Yet, she was rarely
found wanting in any discussion on the
organisation. On one such visit to an office, a
working woman complained that another
CPI(M) councillor had
not attended to some
problem in her locality.
The very next day,
Leelavathy returned to
the office bringing along
the concerned
councillor to explain
what has in fact been
done about the problem.
She was far from the
archetypal image of the
aggressive female ready
to take on local thugs
and irksome opposition
party members. Her face
wore a serene
expression rarely
reflecting the tension of
the row over water
supply and contending
with local vested
the bureaucracy to act
fast on the pipeline.
Three days before her
_ gory murder, a trial
. run of the water pipe
was held and
Leelavathy who gulped a mouthful of it. was
overjoyed. A contenant in the building said, “In
all these 25 years nobody bothered to get us
drinking water. But in six months time she got
us what we had always longer for.”
Avoiding confrontation, however, did not
mean remaining silent on the issue of
rowdyism which had plaugued that area for so
- it was aptly named “Villain puram!”
long that
On April 9. the CPI(M) did something
unthinkable in the area by coming down
heavily on anti-social forces during a dharna
held to focus on several issues, including the
water issue, monitoring of ration shops and
illicit liquor browing. Leelavathi had presided
over this meeting. This was preceded by
another dharna and bandh organised by local
: shopowners to condemn extortion of
“mamool.” Leelavathy had presided over this
as well. She had hoped that such actions
would embolden the local community to stand
up to the underworld.
She had also shown considerable concern in
upgrading facilities at the local Secondary
School, houses in a rented building without
water facilities. With painstaking efforts she
managed to find an available piece of land under illegal occupation, for the school to have
its own building. This also irked the vested
interests. On the day of counting of votes, the
losing Party had engaged in violence and
destruction while Leelavathi, with exceptional
guts, remained on the spot.
Leelavathy’s involvement in social concerns
began in 1985 when she was encouraged by
her husband to join the Democratic Youth
Federation of India (DYFI). Kuppusamy, a
longtime member of DYFI and worker in a
stainless steel workshop, recalling those days,
said: “If I did not motivate her to join the
organisation what right do I have to say that it
should enroll women members. Soon we
became the only couple to be members of
DYFI’s Madurai district committee, though
later, I lagged behind while she became its
State Committee member.” On further probing,
he said. "I did feel a bit jealous first, but I
realised the need to promote women to higher
posts in such organisations as there were none
or very few at such levels of authority."
In 1992, Leelavathy. a member of the
Handloom Workers' Union, became one of its
State Vice-Presidents. Born in a Saurashtra
family of handloom weavers, she learnt
weaving only when her husband was dismissed
from work while attempting to form a union,
to keep the homefire burning. Ironically, her
parents, who had managed to educate her up
to the class 10 had not wanted her to become a
weaver.
Her rise in the CPI(M) to the Madurai district
committee was well earned by her hard and
committed work. It was only natural that she
should have become active in the All India
Democratic Women's Association (AIDWA), a
growing organisation, needing activists with
deep insights into women’s issues. When she
died, she was a full-time activist in AIDWA and
a member of its State Committee.
Leelavathy’s life is an example of how
women with grit can get involved in public life
' despite many odds. As her involvement
demanded ever more of her time, her daughter
replaced her at the family loom, supplementing
I her father’s Rs. 300 a week with her own Rs.
30 a day. How did the family manage to
I balance its budget on such a meagre income?
I Did the family have outstanding debts or
neighbour, said, "Her
ready smile at all times
would light up her face.
When will I see such a
smile again?”
Like Thomas Beckett,
of whom it was said. “Beckett dead was more
dangerous than Beckett alive", it can be said
that Leelavathy dead had become more of a
force to reckon with than Leelavathy alive.
Leelavathy who remained a relatively obscure
local politician until that fateful day. has
become a national symbol of the rare political
breed - the principled and honest politician
struggling to survive against the hordes of
degenerate and depraved thieves
masquerading as politicians.
Her funeral reflected the groundswell of
admiration and gratitude that the people of
Madurai - a city fast becoming notorious for its
dons and dadhas - had come to feel for their
crusader. It was a mammoth procession
belying all expectations and in a sense, stood
out in sharp contrast to the speed with which
witnesses to the killing fled the scene and shops
downed shutters, leaving the hapless woman
to fight the armed bullies single handed on that
dark day. Scores of people are coming to meet
the family every day, - including a bus load of
students from a secondary school in Periyar
district - to pay their homage to a woman who
became a martyr in the cause of political
probity.
In her local area, she has become a symbol of
the people's struggle for water. After the
slaying, the people of the ward have turned
back water tankers saying it is the tankers that
caused Leelavathy’s death. Instead, they opted
for a long walk to fetch water. Ten days after
her death, when the pipe water arrived, a
woman took the first pitcher of water to pour
on the spot Leelavathy was killed.
The critics of 33 per cent reservation in lawmaking bodies say it would lead to “betis, biwis
and behans" to assume office as proxy for their
male relatives, which would not enhance
women's status in any way. Leelavathy was no
proxy candidate and had been fielded in the
fray, on her own merit. But her killing makes it
clear that the politician-criminal- police nexus
would not brook the likes of Leelavathy
trespassing into their terrain.
The message of the murder is loud and clear.
A woman in politics will be tolerated only on
certain conditions - high level connections (of
the “biwi, beti" sort), prepared to share with or
overlook the loot of political ruffians and the
absence of a will or a mind of one's own.
Puppets who can be operated from behind or
dummies who simply lend their feminine
presence, now constitutionally mandatory, are
welcome. Women who take their office
seriously, want to cleanse politics of muck and
dirt and respond to the aspirations of the
people are not to be allowed. If they fail to take
the hint, they can do so only at a risk to their
own lives. The document “Towards Beijing - A
Perspective from the Women's Movement"
(1995) said - “Today women’s political
participation is facing new challenges in the
form of corruption, criminalisation and
communalisation of politics which threatens
to further restrict women’s space in politics.
The political milieu as it is constructed today
pushes women out of politics. Criminal
intimidation is likely to increase as people’s
protest against their deprivation and
dispossession grows. The women's movement
will have to raise the issue and fight the policies
that are giving a fillip to criminalisation.
To shy away from the political arena fearing
Leelavathy’s fate would serve only to toughen
the likes of her killers. She died to constantly
remind us of this.■
T RIBUTE
-
?
■
7. RECOMMENDATIONS
In making its recommendations, the Meeting took into consideration
the fact that traditional systems of medicine remain the major source of
health care for more than two-thirds of the world’s population, and that
impressive progress has been made in certain developing countries, such
as China and India, through the integration of traditional with western
z systems, and the application of modem science and technology to
the promotion and development of traditional medicine. (Resolution
WHA30.49, ‘urging interested governments to give adequate importance
to the utilization of their traditional systems of medicine, was also given
due consideration, as were the contents of the Organization’s magazine
World Health, whose November ! 977 issue, as stated earlier, was devoted
to the subject of traditional medicines
The following recommendations were made :
i
7.3 Collection and dissemination of information pertaining to traditional
medicine
7.1 General
The World Health Organization should use all the possible resources
at its command to continue to promote and develop traditional medicine.
This can be done :
(1) By promoting the formulation and declaration of specific national
policies for the encouragement, support and development of tra
ditional systems of medicine indigenous to the Member States, and by
undertaking administrative, organizational and budgetary commitments
to meet this objective. The elements for such a policy should include the
legal recognition of traditional medicine, and the integration of tra
ditional medicine into national comprehensive health care systems,
including primary health care.(2) By establishing a committee of experts which would advise on the
programmes of promotion and development of traditional medicine,
monitor and coordinate research efforts, evaluate programmes for replan
ning and the proper reorientation of strategies. This committee should
be composed of persons specialized in the different areas of traditional
medicine from the various WHO regions.
7.2 National and international policy support for the promotion
of traditional medicine
(1) Efforts to promote international cooperation between developed
and developing countries, and particularly technical cooperation among
36
iiWU—M ..
developing countries (TCDC), in the field of traditional medicine are
essential.
(2) National governments should favour the policy of integrating tra
ditional medicine into their general comprehensive health care system in
order to facilitate the realization of health care goals.
(3) The organizers of the forthcoming International Conference on
Primary Health Care, at Alma-Ata, USSR, should consider the import
ance and necessity of fully utilizing and developing the vast manpower
currently existing, in the form of traditional medicine practitioners, in
order to make effective health care available to underserved populations.
(4) WHO should explore the possibility of convening an international
conference on traditional medicine specifically to discuss the utilization
of traditional medicine in primary health care systems as a means of
helping to fulfil the objective of health care for all people by the year 2000.
Lack of information was considered the greatest initial barrier to
assessing the feasibility of national health plans. Organized efforts should
therefore be made without further delay to ensure the collection of infor
mation and dissemination through:
(1) Promotion of collection of basic information by surveys on :
I
— traditional medicine personnel categories in practice (census),
— traditional medicine centres or functioning services,
— utilization of practitioners of traditional medicine in health ser
vices,
— diseases known to have been successfully treated by traditional
healers,
— traditional medicine drugs, preparations or medicaments, tra
ditional medicine pharmacopoeias,
— determinants of manpower needs for primary health care services,
— collaborating factors and supportive infrastructure for the pro
motion of traditional medicine,
— literary resources to gather information and compile bibliographies
on traditional medicine.
(2) Special meetings, such as conferences, seminars and workshops.
(3) Publications, such as journals and bibliographies.
37
1
'd
•
(6) Incorporation of self-evaluating mechanisms for continuous evalu
ation, and feedback in order to improve the techniques or to reorient the
programmes whenever necessary.
Dept, of Community
icln9
Su lohrfi Medical College
7.6 Manpower development
BaHR.Ure-540 034.
7.4 Educational programmes
*
Following the collection and analysis of the relevant information,
educationalpfogrammefc'-could beT planned and executed with the follow-
(I*) ToH^cfucate the community on new health policy and to enlist its
support and cooperation.
(2) To change the unfavourable attitudes of members of the health
and allied professions.
(3) To disseminate information on traditional medicine for use and
application.
(4) To assure the people that the new policies and approaches are in
support of the practice of traditional medicine, and that they are aimed
at enhancing it for safety, efficacy and wider use at low cost.
(5) To assure traditional medicine practitioners that they will be the
promoters and dispensers of the new health care system in their own
cultural setting.
(6) To stress that where traditional medicine drugs have been studied
and adverse side-effects (iatrogenic effects) eliminated, the drugs should
be produced in the same or similar form for general use.
fr-
I
The promotion of traditional medicine in health care services and
especially in primary health care should be intensified by :
38
s
Coordinated steps should be taken by Member States in collaboration
with WHO to promote manpower development in traditional medicine
by:
(1) Training the various categories of traditional medicine workers
(including those with limited skills), such as traditional birth attendants
and bone-setters.
(2) Encouraging traditional medicine practitioners to form clubs or
societies as a means of checking harmful practices, eliminating quacks
and charlatans, assuring continuous informal education, cultural loyalty,
and the conservation of a high level of professional ethics and practice.
(3) Organizing educational activities in traditional medicine either by
establishing new training centres or by revising existing curricula to
include subjects related to traditional medicine.
8
!
Lastly, technical education boards, chairs for traditional medicine in
medical schools, and new institutes could be created, and a directorate
of traditional medicine could also be set up in health ministries.
7.5 Application of traditional medicine to primary health care
(1) Application of appropriate technology to health care improvement
based on simplicity, safety, efficacy and availability at low cost.
(2) Selection of lists of essential plants, drugs, or techniques employed
in traditional medicine, for use in public health services and particularly
in primary health care.
(3) Approval of proved useful methods and techniques, such as acu
puncture and Yoga, for use in public health services.
(4) Integration of traditional medicine and western medicine in train
ing programmes at various levels.
(5) Introduction of traditional medicine into public hospitals, dis
pensaries and health centres. The functions of traditional medicine
practitioners should be carefully coordinated to ensure efficiency.
I
i
7.7 Multidisciplinary research programme
A planned multidisciplinary research programme should be formu
lated and implemented in collaboration with Member countries, as
follows:
I
(1) Operational research on traditional medicine in health care
systems.
(2) Various aspects of medicinal plant research, such as plant identi
fication, classification, phytochemistry, pharmacology, and laboratory
and clinical trials for therapy.
(3) Studies in psychosocial and cultural aspects and behavioural
patterns.
(4) Manpower development and health team training, including devel
opment of effective training methods.
39
ii
:■
f
■St
I
%
(5) Role of traditional medicine in other fields of medical research,
such as fertility regulation, treatment of infertility, control of tropical
endemic diseases, cancer therapy, the care of drug-dependent persons,
and the ageing process.
(6) Validation of popular traditional medicine therapies.
(7) Promotion of research activities on the integration of various
s systems of medicine.
Annex
Films on Acupuncture Anaesthesia and Chinese Herbology
Two films were shown on developments in traditional medicine in
China during the last decade. The following points that emerged were of
significance to the Meeting’s discussions :
(8) Establishment of national institutes for research into traditional
medicine.
I
— the importance of applying modem science and technology in
research on traditional medicine,
— the extent to which integration of traditional and western medicine
could contribute to and even revolutionize health care,
i
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— the tremendous potential for healing possessed by the properties
of the plants,
— the importance of teamwork and good team spirit in the organiz
ation of basic health services,
— the need to give the health of the rural masses the important place
it deserves,
— the need for a spirit of self-reliance in planning total community
action programmes for development.
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COMMUNITY HEALTH CELL
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Design hr Peler Paces /ram a w„odearcni’ in Chur. Switzerland.
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Contents
■•1
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...»
/
fab 1
f
The staff of Aesculapius
by H Mahler
3
Malaysia's bomohs
by J. Dauth
4
Balance between man and
nature
by X. Lozoya
8
The Science of Life
by P N V Kurup
12
Ayurvedic training
by K N Udupa
15
WHO's Programme
b\ R H Bannerman
16
New status for the hilot
b. A Mangav Angara
18
Study Tour in China
22
Plants that heal
by 0 Ampofo
26
News Page
31
M/odd Health a|.;,dars m Ar.aju E nglish
French. German. Italian Persian Portu
huese. Russian and Spanish
Articles and photograpfir n. » ■ODynqhTed
Ina. be reproduced provider! c t-mii is given
I the World Health OrganiA.i ■ - Signed
Irncles do not necessarily refier t WHO s
Jews
Vorid Health. WHO
|v Appia. 1211 Geneva 2 7 S'/utzeriand
I
r
The staff of Aesculapius
BY DR HALFDAN MAHLER
Dmctor-Genenil of the World Health Organization
If we had to justify the inclusion mately eliminated. The neglected 80 per include personal hygiene, mother and
of traditional medicine within cent of the world's population have their child care (including family planning),
the compass of the World rights too; they too have an equal claim nutritional guidance, immunization
J Health Organizatio:>n, we need to health care, to protection from the against the major infectious diseases, ele
look no further than the oppo- killer diseases of childhood, to primary mentary treatment of all age groups for
Rue nage. The emblem of who superim- health care for mothers and children, to the common diseases and injury, and a
Mmo
on the globe the staff of Aescula- treatment for those ills that mankind has basic understanding of sanitation and
ancient god of medicine, entwined long ago learnt to control if not to cure.
environmental hygiene. They can at the
.. snake. The god’s serpents were said
Two years ago we in who pledged same time be weaned away from any
JU
the wounds and lesions of the sick ourselves to an ambitious target; to pro practices that might pose possible risks
Mu their sleep and thus to heal them.
vide health for all by the year 2000. This for their patients.
H l or far too long, traditional systems of ambitious goal is, quite simply, beyond
The age-old arts of the herbalists too
Mlnedicine and “modern” medicine have the scope of the present health care sys
must be tapped. Many of the plants
Wiione their separate ways in mutual anti- tems and personnel trained in modern familiar to the “wise-woman" or the
■ratliv. Yet are not their goals identical— medicine. With but 23 years to go, and “witch-doctor” really do have the heal
i! prove the health of mankind and since it is unlikely that the least devel ing powers that tradition attaches to
■hejcoy the quality of life? Only the oped countries can even dream of having them; the pharmacopoeia of modern
■blinkered mind would assume that each enough of the orthodox type of person medicine would be poorer if one
■uis nothing to learn from the other.
nel, it is clear that unorthodox solutions removed from it all the preparations,
Unfortunately that divergence be- must be sought. The training of health chemicals and compounds whose origins
■wcen the two systems of medicine has auxiliaries, traditional midwives and
lie in herbs, funguses, flowers, fruits and
■ilmost exactly paralleled the division of healers may seem very disagreeable to roots.
■he world between the rich and the poor. some policy makers, but if the solution
Let us not be in any doubt; modern
■ oo d'ten the privileged and well-to-do, is the right one to help people, we should medicine has a great deal still to learn
■vii in large towns and cities, enjoy have the courage to insist that this is the from the collector of herbs. And already
■ccess to all the complex technology and best policy in the long run, and is by no a number of Ministries of Health, in the
■fesaving apparatus of modern medi- means an expedient acceptance of an developing countries especially, are care
■nc. Tens of millions of people have no inferior solution.
fully analysing the potions and decoc
■uch access; for them the traditional
This is why who has proposed that the tions used by traditional healers to deter
■^ler, the herbalist and the traditional o
_________
_ of traditional healers who mine whether their active ingredients
great
numbers
■<rth attendant are the only agents of practise today in virtually every country have healing powers that “science” has
■calth care to whom they can turn. Not of
< " the
’ world
*7 should
12 not ’ be overlooked, overlooked. Whatever the outcome of
■<fi n c most of the rural areas of deve- For the most part they are;already
’
living such scientific testing, there is no doubt
■pn g countries without a single quali- in those remote communities, intimately that the judicious use of such herbs, flow
(■d physician, but on the average they involved with the life there, conscious of ers and other plants for palliative purpo
9° not have more than one auxiliary their neighbours' needs and trusted by ses in primary health care can make a
■jalth worker for 10,000 persons. In them. Many such healers have already major contribution towards reducing a
parts of the world, even when
__ undergone elaborate training in ancient developing country's drug bill.
mdern medical care is available, the systems of medicine that had evolved
The present issue of World Health
M'n’ix actually prefer the traditional reliable methods of treatment and pat illustrates just a few of the aspects of
l*a
horn they know and trust.
terns of medication long before modern traditional medicine in different parts of
he political winds of change that medicine came along. Other healers have the world, and indicates the contribution
been sweeping the world in recent had their skills handed down through the that its practitioners could make towards
l'ades have been matched by winds of generations—the distillation of a surpris- better health care, and primary health
ange in community hea’th: a newly ing degree of practical knowledge, skills care in particular—an aspect to be high
akened global social conscience and wisdom about the physical, mental lighted at the who conference on pri
quires that the health gap between rich and psychological ills of mankind.
mary health care scheduled for 1978 at
G poor within countries and between
"Provided
—J they are willing, such tradi Alma Ata in the Soviet Union.
Un’iies should be narrowed and ulti- tional healers and local midwives can, at
Given goodwill on both sides, such an
a very moderate expense, be trained to army of healers, traditional birth atten
'r‘: ■"tial
dants and herbalists can help to make
’onal herbalist sells his wares in a the level where they can Provide ademarket. (Photo WHOjD. Henrioud) Quate and acceptable health care under our goal of health care for all by the year
suitable supervision. Such training might 2000 attainable.
fH111
J
Malaysia^ bomohs
►
7o treat a mentally-ill young woman,, the healer staged
a kind of theatrical performance in which her closest
relatives and fellow-villagers each had a role to play
BY JURGEN DAUTH
S “The sky suddenly went dark
rl and the jungle fell silent”, a Porw tuguese seaman wrote nearly 200
years ago, describing his first en31 counter with a Malayan bomoh.
The magic of these spiritual healers may
not run to such extremes but, all the
same, the people of the Malacca peninsu
la ascribe supernatural powers to the
bomohs which are still being demon
strated to this day, according to popular
belief. Didn’t a bomoh cause the hitherto
incessant monsoon rains to stop for a
day at the request of the Ruler of Sara
wak? Didn’t another invoke blazing sun
shine for the open-air boxing match of
Mohammed Ali (formerly Cassius Clay)
some three years ago, while rain poured
down in torrents all round the stadium?
I he Malaysians are convinced that these
hings happened.
However, Professor Paul Chen of the
Medical Faculty of the University of
.Malaya foresees a more important
sphere of influence for the traditional
nedicine men. In his view the bomohs
’•ave always had an essential role to play
:i the nation’s health care, and he is coninced that magic ritual and the psychoerapeutic understanding derived from
by the Malaysian medicine man,
well as his subtle knowledge of the
baling powers of Nature, represent im
portant contributions to medical science.
Jertainly Malaysia will need its bomohs
or some time to come, since at present
mly 2,350 modern physicians supply
wealth care to the 12 million Malaysians
vhile there are 20,000 practising bomohs
Tfering their services.
Whether they are Malays, Indians or
Chinese, whether Moslems, Hindus,
Buddhists or Christians, all of them
remain to this day firmly rooted in the
belief in spirits, their influence on the
soul and their lifegiving power known asH
semanganat. They have not the least ■
doubt that illness is caused by evil spirits.
And only the bomoh has mastered heir
tongue, can overcome them or can onjure up guardian spirits to take their
place.
The
i ne meaicai
medical treatment undertaken Ib\
the bomoh invariably revolves aroundJ a
ritual exorcism. The bomoh hands out
amulets against the “evil eye” cor prescribes magic spells which are ba^< 1 on
astrological lines and may be writ i on
paper, the leaf of a plant or on kjther
hide. Texts and magic symbols may be
taken from the Koran in the case of
Moslems, while the Chinese Buddhists
. and Taoists swear by the traditions of
their homelands, and the Christians con
tent themselves with reciting the ! ord's
Prayer backwards.
The bomoh may put a medium io a
trance in order to arrive at a diagnosis or
he lets the illness declare itself from the
mouth of a hypnotised patient. Incantatory music on an instrument called a
gamelan, dances and burnt offerings m
which the hair or finger-nails of the
patient play a major role—compk the
ritual.
The enlightened student of meu.cine
*
may
loftily dismiss all this ceremonial as
Above: A Malaysian bomoh prepares a
so
much
charlatanry, but that would he
herbal offering to ward offevil spirits.
too hasty a judgment. Because on closer j
study black magic is seen as only a
Right: A basis ofpractical knowledge un
superficial
framework to prepare the
derlies the spiritual healer’s rulings on when
to eat certain fruits or when they are
patient for the real medical treatment, h
forbidden—taboo.
is precisely in this that Professor ( hen
sees
the special advantage tha the
(Photos WHO/J. Dauth)
bomohs have over the modern doctoi.
!
il
•3^..,
In Malaysia as in most countries of propriate diets or physiology- for exert
th world the doctor hardly has the ing a favourable influence on the course the blood-pressure to make "bleedin»unnecessary.
L
tu . to concern himself about the psych of an illness.
The
tropical
vegetation
and
r
ic origins of many illnesses, and the top•Il
The modern practice of medicine in
heavy doctor-patient relationship, gener Malaysia makes use ot the bomoh as an fauna, with their rich variety of
ally speaking, permits only a scientific assistant at childbirth, for instance, often are the sources of the bomoh's pi,, 1 aapproach. Yet for a long time scientific in collaboration with a state-trained mid copoeia, and stocking it is based tUpt.|)
the knowledge handed down o'
over (hc
medicine has acknowledged that on its wife. And nobody would wish to deny
centuries
that
for
every
poison
in
own it is incapable of getting to the root that the psychological attitude of the
u a Uni
there is a natural antidote.
of sickness.
mother-to-be has great influence on the
I he sap ol the mangrove trees ''Cr\ c.
The bomoh. on the other hand, says course of a ‘*naturar childbirth. Individ
as
a remedy for bowel and sn
Professor Chen, lives in the village where ual bomohsare also entrusted with carry
’!V ch
disorders,
causing vomiting
he has inherited his skills from his fore ing out mass immunization and help
h
purges the intestines. The beiei
lathers, and where he is a respected and the doctors with such tasks as smallpox
prescribed for parasitic worms. ,
trusted person. He is personally ac vaccination.
ic
dried roots ol the pomegranate can
quainted with every one of his fellow
As regards operations, the bomoh strengthen this action. Pineapple juicecanls
villagers and knows what goes on behind limits himself to ritual bleeding. Accord
the scenes. He can make use of the ing to local belief, blood is the bearer of a remedy for indigestion and overeating *
knowledge that a healthy body needs a the life force and must not be overbur Skin eruptions, often originating from |
healthy spirit in a way that few doctors dened. Thus opening an artery may be poisonous plants or insect bites."can hc I
<
can. So long as belief in spirits is a fact of prescribed for headaches and vertigo; i .ared up by the application of te.
In
rural
areas,
sexually
tran>
t
|
■
life, it is useless to inveigh against magic either the skin is pierced or leeches are
I-J
ritual. In any case, superstition is far applied. The bomoh obtains antiseptic diseases are very rare, yet even fo
the
bomoh
has
a
cure.
Against
s\
phi||
S
I
from being confined only to developing preparations from extracts of plants or
he
may
use
the
root
of
a
certain
leginmI
j
countries—it maintains a clandestine from the poison sacs of certain sea-fish.
nous
plant
which
he
calls
“
hantu
'
o,
I
hold even among the crews of moon Painkilling potions can be distilled from
spirit. The remedy for gonorrhoea ■
bound spaceships.
the areka-nut, better known as the betel sounds rather more drastic; a certain I.,
On the East coast of Malaysia I watch nut. The right dose of poison taken from
ed an exorcism of evil spirits carried out one particular fish can sufficiently lower green beetle is made into a powder and I '
added to the patient's food. Even
'ic I
on a well-born but mentally disturbed
surprising
for
the
scientist
is
the
cu
>i
young woman. The bomoh had staged a
toothache in children: a hair from lie
kind of theatrical production in which
tail of an elephant. Against rheumat ism.
the woman's closest relatives and her
the
Dayaks of Malaysian Borneo insist,
fellow-villagers each had roles to play. It
the
best
remedy is tiger-fat.
was noteworthy that the actors in this
For
sure,
rekgiouc
little play had to demonstrate warm af
volved
for
declaring
certain plants taboo
fection for the patient. Embraces, friend
and
forbidding
the
combination
i(■ .’i
ly gestures and tender caresses were
tain
foods,
but
there
can
be
no
hl
much in evidence. The play took on an
that here too there is a basis of p;\
increasingly frenetic character with
knowledge. Thus mangoes are not caicn
dance-like movements, until those taking
with
sugar, nor water-melons with honc\
part fell into a trance and finally reached
nor
heart
of coconut-palm with shellfbii
total physical exhaustion. The coaxing of
or oysters. Such combinations .in
the evil spirit which had caused the^illviewed as poisonous or at least higlih
ness with an offering of food until it
indigestible. Beef, mutton, mangoc Hid
could be caught in a container and
pumpkins are to be avoided in c;
rd F
packed oil on a “journey without
fever, eye diseases or gonorrhoea,
ile
return down the river was merely a
eggs and milk are recommended. (
die
ritual appendage. The young woman was
other hand. eggs, dried fish and bo-(>\\ H
now considered to be cured? I heard that
sugar are stricken from the menu in ill*'
the bomoh had passed the whole of the
case
of bronchial troubles. And ’the
previous day before the ceremony in the
worm
of night blindness" rises to the
house of her family so as to “get in touch
eyes
if
one eats only sweet potatoes or
with the spirit’ . Only in its outward
bananas.
Vitamin A deficiency c.
he
Above: Before applying the healing power
ppearance does this treatment differ
avoided
by
a
special
diet
of
fish,
n
di
of
his
hands,
the
bomoh
tells
his
patients
to
irom what is accepted in the industriaor liver.
breathe deeply and then puts them into a
zed world as group therapy under ex
trance.
Many more examples could be goe”
pensive psychiatrists.
of the bomoh's pharmacopoeia. In Pro
The bomoh also works extensively
Right: A healer shows off his totem—the
fessor Chen s opinion it contains man}
w'ith taboos which are invested with
source of his magic powers. So long as
hidden
virtues which amount to tlK‘
magic powers. Certain foods are forbid
belief in spirits is a fact of life, it is useless
stored-up
knowledge of an entire clicnus'
den, the physical stresses on the patient
to inveigh against magic ritual. After all,
try
laboratory.
Closer study of this Hiltl
are limited or specific rituals are used to
superstition is far from being confined only
be
of
value
to
modern medicine,
ce
soothe his nerves. This too is a very
to developing countries : it is to be met with
ic
one
discounts
the
special
links
vvi
practical means—among simple people
even among the crews ofspaceships heading
its
supernatural;
yet
this
too
may
h
t
.
for
the
moon!
(Photos
WHO
(J.
Dauth
)
who know little of modern hygiene, ap11
psychological advantages.
,z-’'
F
SB
1
1
B Mt
i
w
Balance between man and natin
BY XAVIER LOZOYA
Among the countries forming
that part of the American con
tinent known as Mesoamerica.
Mexico enjoys a special position
■er.Bill thanks to the pre-Colombian
cultures which once nourished on its
territory. The wide variety of climates
and soils found here meant that its in
habitants acquired a profound know
ledge of medicinal plants and hence of
medical science itself. The ancient Mex
icans collected, catalogued and used
these plants, integrating them into a
vision of the universe whose basis was as
much practical as religious. Although no
precise documentation remains to us
about the experimentation that must
have been undertaken at that time, the
information that has been handed down
testifies to a broad understanding of the
curative properties of Mexico's flora.
The chronicles and manuscripts of that
bygone age contain descriptions of nou
rishing botanical gardens and parks with
rich collections of plants, as well as quite
precise information about their use.
Ever since the fusion of cultures that
followed the Spanish Conquest in the
16th century. Western medicine has tried
to analyse the ancient medical wisdom,
hoping to find among such cultural relics
as remain a correct interpretation of the
\ ision left by those early explorers. In the
course of time a wide spectrum of evi
dence has emerged from a variety of
cultural sources, all of it tending to conarm the balance that exists between man
nd nature.
As the centuries have unfolded, the
ch grain of native knowledge has steadly evolved among the mixed-blooded
population of Mexico. Rooted in past
civilizations and nourished by fresh in
sights into the art of medicine, that grain
has ripened into methods of treatment
which are quite distinct from those based
on modern science, and nourishes today
as what we call “traditional medicine”.
Unequal development, which in conR
temporary society mainly takes the form
ot an unequal distribution of resources,
means that not all the population is able
to benefit from health care. The result is
that 40 per cent of Mexico’s population
today still has recourse to traditional
medicine -the medicine of the poorwhich is enshrouded in magic and mys
tery.
On the world scene, the study of her
bal medicine in Mexico is of special
interest because of three factors: its rich
heritage of curative plants, the continued
use of such plants among a large propor
tion of the population, and the wealth of
available information -whether historic,
archaeological, botanical or traditional.
Moreover Mexico, as a developing coun
try, is grappling with the reality of vast
public health problems. The efforts made
so far to introduce “Western” forms of
_
Above: Traditional medicine in Mexico is
rooted in the rich soil offolk-wisdom hand
ed down from earlier civilizations.
Right: This old man in the marketplace of
Oaxaca, south-central Mexico, is the prod
uct of the fusion of cultures that followed
the Spanish Conquest in the 16th century.
Today, 40 per cent of the country's popula
tion still has recourse to traditional medi
cine, enshrouded in magic and mystery but
still based on a very practical framework.
( Photos WHO)
medical care are still far from meeiing
the demands of a fast-growing popul;i.
tion. In the framework of such
•■I. *
economic and historic realities. Mu
.n
traditional medicine and the me<
■al
plants themselves are crucially imp< mi ■
to the future development of national
public health policies.
If we are to elevate the various combi
nations of treatments and drugs to ilkpoint where traditional medicine occu
pies the position it deserves, we ha\ .- to
re-examine and re-value popular
i’
cine so as to bring it level with the
1ern scientific knowledge which n< m
serves the health of many people. In
order to undertake this laborious task. a
complete analysis is needed of all inlor
mation relating to medicinal plants, ilkway they are used and their characteris
tics. These studies will enable us to
C
the advantagesand benefits of the ]
!l
cal, empirical knowledge which ha III
vived the passage of time. When submit
ted to rigorous scientific analysis, ilkresults could give rise to a new type of
research going far beyond the limits ol
chemical and pharmacological anahsis.
but not dissociating itself from the illri::l
ropological reality in which trad
medicine is so deeply rooted.
Starting from this multidiscip .iA
standpoint and with the object of pi*'I
moting and justifying the usefulness of
Mexican medicine, the Mexican Institute
of Medicinal Plants (imeplam) has
porated its activities within the resc i rc li
programme of Appropriate Teclu
at the Third World Centre for Eco
and Social Studies (ceestem).
I
We have plenty of information about
Mexican medical plants and will coniine
ourselves here to those with special im
portance for public health, which have
been given priority in imeplam’s research
programme.
cf
Our Institute's systematic sim
111
medicinal plants first of all enlai.
a
interdisciplinary effort to colk
-
■
I
Balance between man and nature
r-
Left: A symbol of Mexico, the maguey ct /M
flourishes everywhere. Its fleshy leaves vi\ / a
juice which is fermented into pulque, he
national drink.
(Photo WHO I
it
Right: This housewife in the Yucatan peninsu-1
la takes for granted the fact that the plains
growing around her home have medicinal uses.
The study of such plants should serve to
upgrade the status of popular knowledge. nd
thus lend scientific support to the practh ol
traditional medicine.
(Photo WHO/P. Almasy)
bibliography of everything published in scientific support to the practice of tradi
between these substances and the c ;i- )
Mexico from the 16th century until mod tional medicine.
live effects attributed to the ,
ern times, and to subject it to different
Here are some of the most popular remained obscure. Its very extensive
talevels of interpretation, classification and Mexican plants, representing the three
puts it among the most important pl. uh
analysis. This also enabled us to start groups to which priority was given.
il
in Mexican traditional medicine.
creating a bank of information on medic
Casimiroa
edulis.
Rutaceae.
Amoni
’
inal plants, already in full swing and Plants with cardiovascular
the sweet edible fruits described bv ihc if
illustrating in part what we know about properties:
Aztecs figure those of the Casimimj .1;
plants with cardiovascular, anti-diabetic
Talauma mexicana (D.C.) Don. Mag- edulis. a tree mentioned in the desc ip- /(.
and anti-parasitic properties. This infor noliaceae. This large tree with beautiful
tions of the period by the nam cl
mation is being compared with modern Howers has been known and used since
I
“Cochitzapotl" the fruit that b
botanical studies with the object of iden pre-Hispanic times; its name in Nahuatl
sleep. Today, its use is very widesj id
tifying a group of medicinal plants which (the language of the Aztecs) is Yoloxalmost everywhere in Mexico for ihc
may then be submitted to a global study. ochitl or Heart Flower, and was given
beneficial effects on the blood pressure I
. Examining the existing data in Mexico because of the properties attributed to its
which are attributed to its leaves and Hs c
reveals that, although medicinal plants Hower, bark and leaves as cardiac stimu
seeds. Certainly this is the most favoured
have been the object of research under lants.
traditional prescription for producing •>
taken at various times and according to
A decoction made from the leaves and slight but long-lasting regularisatio ul j
•he different trends of scientific thought Howers is still used to treat various car
the blood pressure.
.hat have inHuenced Mexican science, diac ailments. Scientific research into this
lc
Although this fruit has been repc d
•he vast majority of studies made have plant dates from the last century when
ly studied over the years, the ex pern *en
been undertaken unilaterally, aiming at chemical and pharmacological studies’ tai proof of its action on the blood I
isolating the active ingredients but confirmed its tonic effect on the heart
pressure has only recently come to light I
without ever succeeding in creating a increasing the heartbeat, and regularis
in our laboratories. We have determined I
national pharmaceutical industry. That ing cardiac contractions.
how the active ingredient present in ihc I ]■
is why most studies, while providing
The chemical composition of the
useful preliminary information, ought Talauma was at least partially discovered aqueous extracts used as popular rcinc I
rather to be combined with a social around the 1950s, when it was found to dies actually functions. The propci
tributed to the fruit of “soothing <
l’ I
objective that of upgrading the status include certain alkaloids such as talausleep has been confirmed as res
I
of popular knowledge, so as to lend- mine and aztequine. But the relationship
from reduced blood pressure susi. *cd I k
ri
I
■' JU.
'''
1
■ .
T*'
*
4^
f
V'
I’
II
t?
l\' lilation of the blood vessels; acting without apparent side-effects. Toxicologh he autonomic nervous system, this
•cal considerations will require further
?'ii .i itates the spontaneous onset of sleep,
study. Traditional medicine also uses
uses
The decoction made from
the
Casimiroa
two
other
kinds
of
Chenopodium
—
foeti---------- —....... —i
nlso contains another substance possess- dium and graveolens for the same pur
pur-
ng powerful properties as a constrictor pose.
>1 the womb, which explains why this
Cucurbita maxima, D. Cucurbitaceae.
ilant is not prescribed for pregnant The seeds of pumpkins cultivated in the
of Mexico;,
Mexico are
i
",,nenhot lowlands of
re used
by local
people
in
the
form
of
an
aqueous
emul
0 its with anti-parasitic
sion.
or
as
a
refreshing
drink
mixed
with
pi perties:
sugar, for treating various intestinal
Chenopodium
ambrosioides,
L. parasites. These remedies have proved
henopodiaceae. Known in Mexico by effective against tapeworm. They are
te name “Yapotzotl". its Spanish name also used to treat different forms of
' I pazo4e and its US name American intestinal parasites since they are often,
"’rnseed. It figures in the recipe of though incorrectly, substituted for the
■ 1 Mexican dishes and is widely used seeds
of Cucurbita pepo L.. which has
parasite-expellent. A herbaceous similar but much less specific properties.
'I..
with a strong odour reminiscent of
•u'aphor and a sharp spicy flavour, it Plants with anti-diabetic
^es its anti-parasitic activity to the properties:
olatile oil w ith a concentration of 0.35
Tecoma mollis. H.B.K. Begoniaceae.
ei‘ccnt contained in its leaves.
Under a great variety of popular names,
Il also contains such alkaloids as que- depending on the region of origin, the
"dupine. colina and tannin, as well as “nixtalaxochitl" refers as much io
idole. Its effects are powerful and T. Mollis as to T. Stans, all well-known
i)
immes of the plant administered in in traditional medicine for their anti
k orm of a decoction suffices to pro- diabetic action. It is often associated
a rapid parasite-expellent effect with Leucophyllum tenaxum, which ix
i
similarly employed. Pharmacological
Pharmacological
studies have shown that aqueous extracts
of Tecoma administered orally cause an
increase in the level of glucose in the
blood and thus help to palliate the tvpes
of diabetes for which this treatment is
particularly indicated.
Coutarea Latiflora, D.C. Rubiaceae.
Commonly called “Copalchi", the bark
of this shrub is traditionally known for
its anti-diabetic effect. Its diuretic
erties in particular are valid for diabetics,
and the increased volume of urine elimi
nated is accompanied within 24 hours by
a diminution in the amount of glucose
secreted, and results in a general im
provement in the patient's condition.
Traditionally the bark is used in powder
form decocted in alcohol and adminis
tered orally.
There are many such representative
examples of traditional medicinal plants.
The more they are investigated and stud
ied in the light of a science which once
more reverts to serving the public good,
the more they will contribute to the
development of a system of medicine
adapted to the needs, the cultural
demands and the overall health of our
country.
■
11
1
The science of hfe
BY P. N. V. KURUP
g Human
nature
instinctively
seeks relief from pain and disease.
This
basic
instinct
SJjVM prompted man, through the
influenced by local civilization, religion
food which again is composed of these
and tradition, and have evolved through
very elements that replenish or nourish
trial and error, keen observation, intui
the body. Man is therefore a nr.
tion, accumulated experience, folk cus cosm within themacro< »sm, the uni
1
>c.
ages, to analyse the phenomenon
toms and ancestral beliefs. With the
since all the basic constituents i
he
of nature and obtain clues to help him development of civilization these systems
universe are also present in him.
ameliorate pain and disease. His ex attained some scientific status. The
When there is an imbalance in an\ or
periences led to empirical methods of concepts regarding the nature of disease
all of these essential attributes of the
healing which in due course crystallized
)
and its underlying causes are based on
body, the individual falls prey to sick
into distinct systems of medical practice.
the fundamental doctrines of each sys
ness. The mind of a person is classified *
Although modern or “western” medi tem. Whereas the early founders of mod broadly into three categories—satva.
cine is generally accepted throughout the ern medicine initiated the pattern of ob rajas and thamas. This science also clas
) world, yet it has not been able to reach serving the sequence of symptoms for sifies the person according to his co li
the remote rural areas of the world for diagnosis and prognosis, traditional
tution and natural disposition into s en ►
various reasons. The developing coun
medicine had a highly developed science distinct types based on the tii.ee
tries, with
their meagre
financial
not only for diagnosis and prognosis but
humours. The identification of these
resources, cannot avail themselves of the also for determining the cause and treat characteristics in a person gives impor- ►
services of modern medicine in view of ment of diseases. Urine, stool and spu
tant clues to the physicians as to how to ?
( the huge investment involved in estab tum tests were conducted by traditional treat the disease and bring the body back *
lishing and maintaining modern clinics
practitioners many centuries before these
to its original harmony and health. Thus
and hospitals. The traditional systems of techniques were known to modern medi Ayurveda looks at the whole bod\
id ►
mind, and not merely at external or
J medicine, however, still tend the health cine.
needs of most rural populations of the
A number of well-defined and wellnal factors as the contributing cans, of
world, and find patronage also in urban
developed traditional systems are pre
the disease, in deciding the appropriate
areas.
valent
in
various
parts
of
the
world.
remedy.
1
The traditional healers, herbalists, spi Among them, Ayurveda, Unani and
Il is a fully developed science, with
ritualists. and birth attendants constitute
Chinese medicine occupy the foremost
eight different branches covering the
I a vast resource of practitioners outside place as the most ancient and best devel whole of medical science. A w ide range
the official
health
services.
Their
oped of these systems. Nature cure and
of books written by scholars and spe
methods of diagnosis and treatment vary
Yoga also have followers in many parts
isls have enriched the classical and
>n1 from region to region, and some of their of the world for their therapeutic value temporary literature of Ayurveda Ih
practices are similar to modern medicine.
and in general as a means to maintain
i
materia medica is stupendous and
l;or example, in certain tribal communi
positive health and well-being.
tains as many as 8,000 published recipev
ties the traditional healer applies his ear
Ayurveda literally means the Science
This may be an under-estimate if unpub
close to the patient's chest to listen to the of Life. The doctrine of Ayurveda postu
lished recipes held as “family secrets" b\
heart beats and diagnose disease.
lates life as the union of body, the senses.
traditional practitioners are also taken
Such practices as cupping, cauterizamind and the soul; the living man or the
into account. Some 1,200 drugs are in
ion or showering mineral water over the
man of action is said to be a wellfrequent use either in the form of s gle
head (for curing headaches), when admi balanced combination of three humours,
drugs or as compound formulation hi
nistered by the practitioners, are said to seven basic tissues and three excretions.
the South-East Asia Region, as mai
1 be effective in curing metabolic and
Everything in the universe including the
800 pharmacies arc active in the pri\ate
psychic disorders. In South-East Asia the physical body is composed of five ele
and public sectors, and many emplo)
chanting of mantras (mystic incanta ments or substances (panchabhutas),
tions) to cure jaundice and even snake
namely prithvi, ap, tejas, vayu and akaA paliem undei i'oin^ Thirumma! treuimeni.
biles is still a prevalent practice.
sha. These elements combine in different
which
his body is covered with medicalcd
Such traditional methods, grounded in
proportions to suit the specific needs of
and massaged delicately by hand or fool "ll'
some kind of rudimentary medical prac different structures and functions of
o] the accepted technicpies of Avurveda
tice. have mellowed in the course of time
the body, whose growth and develop
"science of Hfe".
(Photo WHO P. K >r
into well-defined and distinct systems ment depend on its nutrition, that is, on
th<
□uri
nicr
ven
my
)f 1
si<
>sifi
satj
> cli
ons
sev
thi
.-
.
1
1
MwbtoA^k
npj
ow
sq
pr
)e
1
a.
nf
ts’
*
drugs are determined according to' the
temperaments. As in Ayurveda, Ui
physicians attach great important
diet as well as medication.
The Siddha System of medicine
tised in Tamil-speaking parts of
East Asia also has a long and rich iru<iY
tion. Its unique feature is that it makes
extensive use of minerals and metal?
especially mercurial preparations, ;iihi
has made notable advances in developnp
organic compounds for treating \ ■:
diseases.
"
’
The Tibetan system of medic
drawn considerable knowledge
Ayurveda and has been influenced b\ i|lc
Chinese system. It also makes use of
drugs of plant, mineral and animal on.
gin. Cauterization at special points in i|lc
head is carried out by Tibetan pracii!ilt|1
ers in treating mental disorders.
Pulse examination has attained
Ji
degree of perfection especially n he
Ayurvedic, Unani and Tibetan systems,
which have established a correlation be
tween pulse behaviour and humoral im
balance. The institutionally trained tra-[
ditional practitioners now take advan-j
tage of modern diagnostic aids in •hen I
day-to-day practice.
Within many of these tradition.,
I
terns, facilities are available for impaii
ing systematic and comprehensive Irani
Cauterization, the application of heat, is centres in the human body which are ing at graduate and postgraduate levels
a recognized form of treatment for certain termed marma. To treat diseases in or In fact institutional training is almost a
mental disorders under the Tibetan system of originating from these marmas, certain century old in this region. In India alone
medicine, which draws on both Ayurveda and highly effective techniques are practised there are about 500,000 practitiom
a
Chinese traditional healing.
in South India. The process, called quarter of whom have received r
ir
(Photo WHO/P. Kurup)
Thirummal, consists of applying medi training in recognized institutions,
h
cated oil all over the body followed by number about 115. Of these, 98 co
modern techniques for the manufacture various types of delicate massage not exclusively offer training in Ayurveda.
of medicines. Traditional methods of only by hand but by foot as well.
and most are affiliated to the universities 1
preparing such drugs are so simple that
Pizhichal and Navarakizhi are other The curriculum
_____
____ _of train- c
and ....
the _period
they could be easily adopted anywhere in ways of treating various diseases of the ing in most of these institutions in Vndi.i|r*
the world.
nervous system or of musculo-skeletal have
have now
now been
been made
made uniform
uniform I lief'
A broad spectrum of therapeutic origin and other chronic conditions. Piz- degree
course
in
these
systems
degree course in these systems is
is ' -.idj1
methods and techniques available to this hichal is a process in which the physician over a period of five and a half
science ensures that it commands im drips medicated oil in a thin continuous including an internship of one yea
mense popularity. The Panchakarma stream at constant temperature and pres
The students are also instruct! m
treatment, involving five special techni sure on to the body and immediately modern practice in some of these insum-i
ques, is considered the most important applies massage. In Navarakizhi, a cer tions, though most of the time is dcvotcJ
for metabolic management and for pro tain variety of rice is cooked in a mixture to teaching subjects within the medical
viding detoxicating and purifying effects of herbal decoction and milk, and the system concerned. Other practitioners
while conferring other therapeutic bene- jelly-like semi-solid mass is then tied up have acquired professional knowledge]
’>ts. This is especially beneficial in the in a small cloth sac. The practitioner and skill through their forefathers
is
aseof neurological disorders, metabolic massages the patient with this sac, mois working as apprentices under hen
ic
liseases, digestive disorders and respira- tening in from time to time by dipping it practitioners; 239 hospitals and
in io •c
:ory ailmen ts.
le
into the same hot herbal decoction.
dispensaries offering treatment in
Rasayana chikitsa is another techni
c
The Unani System owes its origin to systems also exist in India.
que which not only rejuvenates the body Greece but has absorbed a great deal
In integrating these systems within ;‘i
and enables the patient to live longer, but from native medical systems during its national health care programme, the ln’sl ftec
also builds up resistance against various long journey through the Arabiani coun- task
iasK should
snouio be
ne to make a proper
j.
up 3a c
diseases.
tries. This is again based on lthe
' theory of praisal of the manpower availabl. to Te(
A few other techniques which are of the humours. The temperament of each traditional systems of medicine, it
mi- ^Vi
comparatively later origin deserve men individual is expressed according to the petence and its capacity. Appn
itc top
tion. Ayurveda recognizes certain vital preponderance of these humours, and training in the shape of refresl
or Jo
li
’rientation courses should then be ofed to the different categories of tradinal practitioners. For example in the
ming programme for birth attendants,
•iiiphasis should be on basic education
cgarding pregnancy and childbirth,
ivgiene, gynaecological complications
ind the basic principles of infant and
•hiId care. After providing appropriate
i lining, all thr medical expertise can be
orbed into the main stream of general
Ith services for the rural population,
hat the largest number of people can
K’liefit from an effective and personlized service.
These traditional practitioners corn
ua nd the implicit faith and confidence of
heir rural clientele, as they form an
gral part of the village life. They can
it most of the common ailments
ch constitute almost 80 per cent of
cases. Treatment in these systems is
meh cheaper, and is especially effective
i dealing with chronic ailments, allergic
onditions and psychosomatic diseases,
hey make use of locally available herbs
nd other ingredients in their day-to-day
ctice, and often write out prescrip. is with detailed instructions for pre. mg the decoction to be taken by the
uiient. The services of traditional heals and practitioners could therefore be
ulized with advantage at primary health
•ntres in remote rural areas.
If the health care delivery system is to
• ich the maximum number of people in
shortest possible time, and is to
mie a real instrument in alleviating
uiiian suffering, an open-minded aproach devoid of rigid dogmas is called
>r. No single system can thrive or be
•ieful to all irrespective of its origin,
'cation or merit. Anything that is good
all these systems should be made
dable, while false claims or ineffective
tices and faulty approaches that may
urrenlly in vogue should be eliminatI through intensive and systematic
search.
In our anxiety to make an effective,
miprehensive community health service
a liable as soon as possible to the maxn number of people, the available
rial,
financial
and
manpower
aces that are rooted in traditional
cal practices should not be over"Ked. In order to reach the masses in
e developing countries, there must be
°per planning as well as a building up
health care facilities with all the lim
'd resources available. Against this
1 eround the traditional systems of
ine and their rich heritage can play
' I role as an additional or alternative
’ oach in a country's Health Delivery
^gramme.
■
J^urvedic training
BY K. N. UDUPA
India is one of the few Asian
countries where Ayurveda
13 has been given due recognition as a system of medi
al cine for providing health
care to the people. Although there
are references to Ayurvedic princi
ples in Vedic literature written about
2000 B.C.. the present available li
terature on Ayurveda starts with
Sushruta Samhita and Charaka Sam
hita, compiled some time during the
fifth Century B.C. From these ancient
documents it appears that education
in this science was initially imparted
to highly selected groups of stu
dents.
In more recent times it has taken
more than a century for a standard
ized and acceptable training pro
gramme to be introduced in most of
the Ayurvedic colleges in India. The
admission standard, and the duration
of the course and internship training,
are quite similar to the training in
modern medical colleges. Thus after
12 years of education in science and
humanities, five years of training in
various Ayurvedic subjects are en
visaged. Peculiar to this training is a
thorough grounding in basic princi
ples—the philosophical aspects of
life, the body-mind relationship, the
"humours" of the body and their
function, including the best methods
for leading a healthy life according to
the body's constitution and the tern
perament.
The technical methodology of cli
nical examination is similar to mo
dern medicine, the primary methods
being the clinical history and a five
fold physical examination using the
five senses. However, greater em
phasis is given to the constitutional
aspects of patients, their nutritional
status and their psychosomatic in
tegrity The pulse examination forms
an important part of the clinical
methodology The patient is exami
ned and treated as a whole, unlike
the modern medical approach where
a large number of specialists may be
involved simultaneously in such an
examination.
is
The
undergraduate
curriculum
comprises
radiology,
pathology,
radiology.
parasitology, microbiology and prac
tical
laboratory
instruction
The
Ayurvedic principles of surgery, gy
naecology, child health and other
allied subjects are also taught The
training in surgery includes the prin
ciples of management of different
types of fracture, and various opera
tive and palliative procedures for
such conditions as urinary stones,
piles, fistulae, goitre, lymphadenitis
and hernia.
Students wanting to undertake
further studies are admitted to post
graduate courses eading to the
award of a Doctorate of Ayurvedic
Medicine These consist of three
years of postgraduate training In the
first year, the postgraduates receive
advanced training in applied basic
medical sciences, both Ayurvedic
and modern. In the second and third
years they are allowed to specialize
in one of the five major disciplines—
internal medicine. Ayurvedic surgery,
obstetrics and gynaecology, materia
medica or the basic principles of
Ayurveda.
Doctor of Philosophy degrees in
various specialities can also be ob
tained at some universities This has
led to considerable output of re
search material which could prove
very useful in modernizing Ayurvedic
investigation and treatment
Thus training in Ayurveda, both at
the undergraduate and postgraduate
level, has undergone a rapid change
in recent years. Modernization conti
nues and in due course the differ
ence between the pattern.of modern
medical training and Ayurvedic train
mg will be minimal, to the point
where trained Ayurvedic and modern
doctors should prove complementary
to each other Their services could
then be utilized for health care at
various levels, and a better coopera
tive attitude between the two types
of practitioners should contribute to
wards improving the health care of
India's vast population both in urban
and rural areas
■
f
15
WHO’s
Programme
The approach will focus on the psychosocial and
anthropological aspects of traditional medicine,
on acupuncture and other healing methods, and
on the claims made for herbs and medicinal plants
BY R. H. BANNERMAN
Traditional and indigenous syspj terns of medicine have persisted
jl for many centuries, even in parts
H of the world where modern
health care is readily available.
The idea of mobilizing the manpower
component of traditional medicine for
purposes of primary health care, particu
larly in rural areas, has been gaining
ground in many countries in recent
years. An initial beginning was made
with
traditional
birth
attendants,
because of the acute shortage of trained
midwives.
A meeting on the training and utiliza
tion of traditional birth attendants was
held in 1972 at who headquarters in
order to develop the kind of training
programmes, research and studies that
could improve the services of these work
ers in their respective communities.
In 1974 a joint unicef/who study on
alternative approaches to meeting basic
health needs in developing countries
recommended the mobilization and
training of practitioners of traditional
medicine, including traditional birth at26
tendants, for primary health care services.
to implement training, service and
This was endorsed the following year by
research programmes.
an Executive Board resolution and the
June 1976 saw the foundation at WHO
idea was given support at the World headquarters of a working group for the
Health Assembly in 1977. when a resolu promotion and development of tradi- .
tion sponsored by several Third World tional medicine. Its aim was to coordiMember States was passed by acclama- nate the various activities relating to the
tion for the promotion and development subject, and it prepared a programme
of training and research in traditional
with the following objectives:
medicine.
to foster a realistic approach to tradi
Several Member States have already tional medicine so as to promote and
initiated training programmes for the further contribute to health care;
traditional birth attendants, and orienta
to explore the merits of traditional
tion courses and seminars for other medicine in the light of modern science
health professionals.
so as to maximize useful and effective
In 1976. who's Regional Committee practices and discourage harmful ones;
for Africa had “Traditional Medicine
to promote the integration of proven
and its Role in the Development of valuable knowledge and skills in tradi
Health Services in Africa" as the topic
tional and modern medicine.
tor technical discussion. The Regional
High priority will be given to the devel
Committee for South-East Asia also oping countries particularly with regard
adopted a resolution in the same year
to primary health care within the context
calling for the promotion of traditional
of the country's political structure, eco
and indigenous systems of medicine in
nomic resources and development plans.
the Region. This was followed by a semi
Execution of the programme will be
nar in Colombo. Sri Lanka, that made effected in close collaboration with the
regional offices and, primarily, at the
pragmatic recommendations about how
/
I
/
I
p.
I
/)/
H. Bannerman (fight).
Secretary
of with the results of surveys and research
T ...
,
3 > Working
--- Group
------ r on T " ‘
drug bjlls of many developing countries.
//
will no do.b, ass« „s
greeted hy Chinese Vice-Premier Chi
Traditional healers and some modern
'^g-Kuei during
’ recent Study Tour on development of meaningful training pro physicians depend to a large extent on
£ v,^htional Medicine
for the- various
Health grammes
. .
-------- - categories of
J Services in China (jeepage
( • >n Community
herbs and medicinal plants for treat
23) (Photo. WHO) Petitioners of traditional
-------1 medicine,
ment.
The story of herbal medicines is a
Doctors, rnurse/midwives, other health
ountry level and with
fasemating
one-quinine, until recently
active
community
workers
and
r ;HI'cipation.
-J students of health sciences
was
the
only
cure for malaria; morphia
will all be eencouraged to undergo orien£ 1
suggested approaches include the
rcmamsa most effective pain-reliever;
tation in traditional medicine where
’ n ation of national health policies
------- • ap- rauwolha is still widely used for the
propria te.
|
o contain provisions concerning
control of hypertension and certain forms
Multidisciplinary investigations into
‘‘d’Konal medicine and mechanisms of
of
psychiatric disorder, and herbal pre
J > ^nat.on, and better utilization of systems of traditional medicine will be
parations have been used for many
■e
' “sefu elements of traditional medi- encouraged, and special attention will be decades to treat rheumatoid arthritis.
the country’s health care sys- given to laboratory and clinical investi
Recently, we have received serious
tne administrative machinery gations for identifying effective remedies
claims (hat herbs are being used in
ft
I to ensure effective planning uti- composing medicinal plants, animal
Ulina,
tropical Africa and Central
products and mineral substances Inves
'
" and supervision of practitioners
America
for the control of diabetes mel'"ditional medicine will be reviewed tigations will also be conducted into the
inus. All these claims have to be invest
psychosocial and anthropological asHl) ‘he context of the national health
igated scientifically and authenticated.
ire delivery system.
pects of traditional medicine, as well as
There are clear indications of a major
ie mechanisms of acupuncture and
J questionnaire
quesuonnaire has
has already been
breakthrough in therapeutics and health
" .«ned for the collection of all avail- other healing methods.
care
delivery, and those of us involved in
Wherever possible, priority will be
. 1 "’formatton concerning practitionthe
traditional medicine programme
rm,|hC 7mot,on and development
™^!imed'Cine’theirtra,nin8 of ^tllocal
share fully the goal of our Director’ vices .«
to .be
the community. Thc
The aanaGeneral, that we should achieve total
information collected, together such action should effectively reduce the
health care coverage for all people by the
ii
2
•fll
;iJ
I
ant
on
on u
^3
*■
New status for the hilot
When 75 per cent of births turned out still to be
handled by hilots—traditional birth attendants—
the Philippines7 Department of Health decided to
re-train them and bring them into the health team
BY AMANSIA MANGAY-ANGARA
Traditional birth attendants—
hilots—have probably been
JI practising their skills in the PhilW ippines since the earliest history
-31 of the country's predominantly
■ Malay population. This is suggested by
H the similarity of hilot practices with
those of the bidan of Malaysia and the
■ dukun of Indonesia. Such practices prohably emerged out of the necessity for
11 mutual help among womenfolk in the
■ > ill villages many centuries before
■ i dern medicine was introduced to the
M country.
W In the traditional village society there
■ have always been such categories of indi■ genous healers as the herbalist, the bone
■ seller, the faith healer and the hilot. The
■ latter usually confines her activities to
■ < ndance at birth and to the care of the
born child. Her services vary but
:n include offering such assistance
■ ^ith household chores as is traditionally
■ demanded by good neighbourly practice
■ m the village. It is largely through main■ laming this combination of services to
■ lb mother, the child and the household
I
the hilot has survived and continues
i
• accepted by the local community to
li
present day even though modern
Hc.iiih care has since become available to
hie rural population.
I nfortunately, the hilot’s practices
hiive time and again contributed to
Maternal and infant morbidity and mor
Ill
I
Kosa Ravniundo. a fradiiional birth at•>it. dons a plastic apron before bathing a
'orn child, as she has been taught during
V > nd training.
(Phorto WHO!J. Abcede)
Traditional Birth Attendants
Still the greatest barrier to realizing
the proper potential of traditional
birth attendants (TBAs) today is the
resistance of some professional health
workers. But TBAs still deliver twothirds of the babies injthe world.
In Asia, Africa and Latin America
they are accorded, for the most part,
very high prestige in their villages.
Several countries have already started
on-going training programmes for
these women, to ensure that they
offer safe midwifery practices where
they will be most effective. Other
countries are beginning to encourage
them and give them additional
training so as to gain for them
increasing involvement in primary
health care activities.
Several countries have also tried to
explore their full potential in family
planning programmes. They have
proved capable of making useful con
tributions to family planning com
munication activities in Indonesia
(where they are known as dukuns),
Malaysia (as bidans), Mexico (as
parteras) and India (as dais). There is
probably no reasonable alternative for
government maternal health and
family planning programmes but to
join hands with TBAs. The findings
and recommendations of various
studies have repeatedly shown that
they enjoy a relatively high degree
of credibility in the eyes of villagers
and the urban poor, while their
potential for incorporation as partners
in public health work is a very
practical reality.
tality. She performs very few manipula
tions during childbirth; the newborn is
passively received under cover of a cloth
to conceal the mother's private parts.
Although some complications in the
mother may result from errors of omis
sion by the birth attendant, such as fai
lure to protect the perineum, others may
follow acts of commission such as apply
ing manual pressure on the fundus of the
uterus to facilitate expulsion of the fetus,
causing a subsequent rupture. In the case
of the newborn child, errors of commis
sion are frequent; it is common for the
umbilical cord to be cut with a non
sterilized knife or bamboo blade and the
application of some powder, chopped
tobacco leaves or even dried horse
manure on the cord dressing. Practices of
this nature are responsible for the high
incidence of tetanus of the newborn in
the Philippines.
Until around the early 1950s the
Government's general attitude had been
to discourage hilot practice and to pro
mote their replacement by trained
licensed midwives. In 1954, the Depart
ment of Health reviewed the prevailing
status of midwifery services and found
that a large proportion of births (about
75 per cent) were attended by traditional
midwives. While infant and mortality
rales were high, available trained health
manpower was grossly insufficient to
meet the demands for midwifery ser\ ices,
particularly in the rural areas.
Largely as a consequence of these find
ings, and of the realization that while the
country’s population was rapidly on the
increase its health resources were insuffi
cient, a revised strategy was evolved.
Study Tour in China
1
1
Left: The simplest of equipment suffice^
prepare traditional herbal medicaments 'i
roll them into pellets. The pharmacopoeia
traditional Chinese medicine has long pro]
to be a great storehouse of knowledge. J
(Photo WHOfR. Bannerman)
1
Right: Health students practising acupunct^t
techniques on each other. An acupunc^K
needle carefully planted above this girl’s nX;
will act as a local anaesthetic. The applicatm
ofacupuncturefor local andgeneral anaestfi^/^
is well developed in China, and is used ei|||
for major abdominal operations.
(Photo WHO/L. Ambrose)
------------------ -------------
g
il
We saw the highly successful treatment of extensive burns in the general
wards by the application of only one set
of surgical dressings medicated with
medicinal herbs and without resort to
specially equipped intensive care units;
the management of fractures by employ
ing small padded splints; and the care of
patients with acute abdominal condi
tions such as perforated peptic ulcer,
appendicitis and extra-uterine pregnan
cy all ol these by combined traditional
Chinese and "Western" methods. All
these could be readily replicated in many
developing countries. The techniques for
preparing medicinal herbs and plants as
powders, tablets and liquid extracts us
ing relatively simple locally manufac
tured equipment proved of great interest
to us. What might perhaps be more
difficult to emulate is the capacity for
hard work, resourcefulness, motivation
24
and discipline we encountered in every
community we visited.
wish to follow it as a profession can
become fully qualified doctors through
further training in colleges. Work as a
WH: Is the famous barefoot doctor part barefoot doctor has now become an im
of the traditional system or is he regarded portant entry point to medical college
as a totally modern phenomenon of and university. On the average, they
spend about two-thirds of their time each
Chinese public health ?
year in agricultural work and industry
and the rest in health work. They are
Bannerman: The well-known barefoot very much a part of their communitv and
doctor is very much part of the tradi are selected initially for health work by
tional Chinese system. They used to be members of the communitv.
called ‘•peasant doctors", but acquired
the title '•barefoot doctor" not because WH; } our colleagues during the Study
they walk barefoot but as a reminder of Tour came from all parts of the world. Do
the fact that many of them spent a you feel that they had ideas to offer whidt
greater part of their time with other C hina might find worthwhile taking up and
members of the community in the rice adapting ?
paddy fields.
Barefoot doctors arc trained in the first Bannerman: We were asked this ques
instance for six months, and those who
tion in various forms during the toUTshow keen interest in health work and
None of us could really make any COP’
New status for the hilot
o ♦
* /©
il
•'i
Left: Hilot Asuncion Saginsin pays a m
natal visit to a patient. The Philippic
Government hqs introduced a teaching pt
gramme to make hilot practice safer for ffidi
ers and to encourage the traditional bit
attendants to seek guidance from train
health personnel when needed.
Right: Nurse Felicitas Bautista graphic
explains to a class of hilots-in-trainin^
basic steps to be taken when attending A
eries.
(Photos WHO!J. Aba
This included some concessions to hilot
practice in localities where the services of
practising physicians or registered mid
wives were not available. Within this new
policy frame, traditional birth attendants
would receive such training and orienta
tion on hygienic procedures and routine
midwifery practices as would promote
the safety of the mother and the newborn
child; they would also be given health
staff supervision and guidance in the
course of their work.
In 1954, with who and unicef assis
tance, the Department of Health initiat
ed the training of hilots as part of the
country’s midwifery
training
pro
gramme. Priority was given first to staff
involved in teaching and supervision
such as nurse-midwife supervisors at the
central level, then at the regional and
later at the provincial and local levels.
This was followed by a teaching pro-
gramme to make hilot practice safer for
mothers and to encourage the birth at
tendants to seek guidance and assistance
from the trained health personnel.
This training was first conducted by a
provincial nurse supervisor who had
herself undergone training under the
midwifery training programme. Her un
derstudy was a nurse or midwife of the
rural health unit or pucriculture (mother
and child health) centre, who took over
as instructor of subsequent hilot classes.
The classes are usually organized in
groups often, and the course consists of
12 weekly or bi-weekly meetings each
lasting three hours. Instruction is given
in the local dialect. A hilot who satisfac
torily completes a course is given a
UNICEF midwifery kit and issued with a
record book to insert the necessary infor
mation needed to register the birth of the
child she has delivered or report any
■w
birth which has not yet been registered.
After training, the birth attendants orga
nize themselves into a local association
which holds monthly follow-up meet
ings. Al these meetings, the nurse or
midwife of the rural health unit inspects
their kits and evaluates reports of their
activities.
Now that official recognition has been
given to the trained hilots, and with the
increasing acceptance of the health aux
iliary or aide in providing health care,
the hi lot is being encouraged to get
herself involved in a wider variety of
community health activities. These in
clude helping to notify communicable
diseases, organizing mothers’ classes,
registering births, helping to arrange
mother and child referrals to the health
centre or hospital, participating in the
housekeeping at the health centre, assist
ing in community immunization round-
20
■
fl
el
ft1
14
-It i\ wrrii
r l
V 1
\
s'-,...,
.
(
and collaborating in the family plan
programme by motivating mothers
t
following up those who accept the
<>■ hccs. (On the whole, hilot training and
He broadening of her participation in
immunity health work have forged
nonger links between the traditional
'" lb attendant and the local health staff.
' has thus become an important
ce in the local health service even
i she is still not a member of the
team. She receives neither comc"s.uion. honorarium nor daily wages
her services. The remuneration she
'‘evivcs from the mother may be in the
'll)]
ol a gift or sometimes in cash, but
loi e o lien her services amount to simple
*1 goodwill and good neighbourn
ii
i
Government's goal of ultimately
ng the hilots with licensed mids remains unchanged. But consider-
ing the limited resources and the magni
tude of existing health problems, it will
take some considerable time before the
Government's goal can be achieved.
Therefore the stop-gap arrangements for
training the hilot and involving her in
health services are proceeding with more
active Government support as well as the
endorsement of various sectors of the
local community. Increasing attention is
being given to the hilot as a potential'
health manpower resource capable of
being trained and guided to respond to
local community health demands, partic
ularly for mother and child care.
With a view to obtaining more accu
rate information about the hilot man
power resources in the country, the
Department of Health carried out a
nationwide survey in 1974 with the help
of a who grant. The objective was to
obtain information on the number of
traditional birth attendants in practice,
where they live and other useful data
which would enable central and local
hilot registries to be drawn up. More
than 31,000 hilots—both men and wom
en —were identified. On the basis of the
findings it was calculated that the total
number who were in practice was be
tween 38.000 and 40,000, or roughly a
ratio of one hilot for every huremgav
the smallest local administrative unit
with an average population of 1,000 to
2.000. The registries that have since come
into existence will help in identifying
those birth attendants who need training
and in locating their homes, and will
thereby facilitate their supervision by the
local health personnel. The registries will
be kept constantly up-to-date and will
furnish other useful information which
will help in designing the hilot training
courses in the coming years.
■
Fx'-^
r' '^1-^
- ^^ ^£9
l,x>
Tr
it
h F
Study Tour in Chin
ommunity health specialists and senior health administrators from 29 developing countries c
verged on Peking in August to begin a Study Tour on traditional Chinese medicine arran
tindei the auspices of who and undp. Dr Bannerman of Ghana acted as Team Leader to
L’loup, and is also the Secretary of the Working Group on Traditional Medicine at who he
alters. On his return to Geneva he was interviewed for this special issue of World Hea
\\ H : Dr Bannerman, what was the objec
tive of this Study I our involving so manv
v ’tor health officials from the developing
< ntries ?
y
Bannerman: As was emphasized by the given to the rural areas where <30 per c
late Chairman Mao, traditional Chinese of the population live. The doctors
medicine has a great storehouse of now community oriented and 70 per c
knowledge. Chinese pharmacology is of the graduate doctors work in ri
therefore being integrated and various areas. The “mass-movement” has b
B xnerman: The main purpose was to institutes and hospitals for the practice of
responsible for the virtual extinction
give participants the opportunity to Chinese medicine have been established.
the four pests- rats, flies, mosquitos l
study how China has harnessed its pre
At the first national health conference bed-bugs.
cious legacy of traditional medicine to held in 1950. three principles were
the needs of its vast rural populations, adopted: firstly, to serve the workers,
WH: What did you see which might
und has combined the traditional peasantsand soldiers; secondly, the pre
regarded as the kind of simple medi
(Tinese system with “Western” medi- vention of disease; and thirdly, integra
technology that might well be transfer,
' ■ The group had the opportunity to tion of traditional Chinese and “West
to and adapted by other countries ?
si .dy the training of health personnel ern” medicine. In 1953, Premier Chou
including practitioners of traditional En-Lai endorsed the fourth principle:
Bannerman: Offhand, I would say t
( hinese medicine and the barefoot doc “to combine health work with mass
use of acupuncture for the treatment
tors. We also learnt something about the movement”. The people are educated to
disease, the relief of pain and for pi
use of medicinal herbs, the preparation combat disease by themselves and not to
poses of anaesthesia. About 70 disea;
find production of pharmaceuticals and rely exclusively on health workers.
can be treated with acupuncture alo
•f use of special methods
- . suchi as acuThe difference between “orthodox”
p cture for treating various disorders and “traditional” medicine is therefore and some 200 when used in combinati
with herbal medicines. Training in t
■i
lor anaesthesia. The study was in fact much less pronounced in China. Many use of acupuncture is essential, if t
p Htisectorah and we were exposed to of the orthodox-train cd doctors receive
trans! r ol this technique is to be tri
•gi icultural and irrigation projects. orientation in traditional Chinese medi
beneficial. The equipment is relative
lousing schemes, rural development and cine and practise both systems. It has
simple and. in essence, all that one nee
'O forth.
therefore become difficult to draw a defi is the acupuncture needle which can
nite line between the two. Their attempts inserted into the appropriate point ai
I' One gets the impression that the at integration have evolved into what
rotated to and fro with the index (ing
on which is very noticeable in the rest they now call the ‘New' traditional
and thumb. But recently an electric
ie world between "orthodox" and Chinese medicine, which can be de machine has been developed which intr
hlionaT medicine is much less pro- scribed as the application of modern
duces regular electrical pulsations to t
"unced tn C hina. Is this the case, and to scientific principles to the traditional
needle and thus produces the desin
kit degree has the older system been C hinese system. The integration of tradi- effect.
'kgitiled with more modern aspects of tional Chinese and modern
medicine- iis
----- --------------I he application of acupuncture f<
now an established policy and is by no purposes of local and regional anaesth
means an expedient. Veteran practition sia is well developed. Many procedur
ers
are involved in shaping the 'New' on the head and neck, such as dem
icran herb grower shows a icani of
traditional
Chinese medicine. Some extractions, and eye. ear, nose and thro,
// workers how to (/islbiguish medieinal
during a plain-gathering session on the leach in medical colleges and are often operations were demonstrated. We ah
consulted in matters relating to medici saw major abdominal operations lit
d Mount Huangshan. China.
nal herbs and plants.
total hysterectomy and prostatectomy
WHOjChinese Ministry of Health)
In 1965. priority in health work was all under acupuncture anaesthesia.
n
•n
suggestions. We have to remind
ves that China has a population of
climated 850 million. The basic
cccssiiies such as electricity, water sup'ly. adequate sewerage and refuse d.is'osal were available equally in both ur;<n and rural areas. The people apd!' ;•( I well nourished and adequately
I»
: everybody was well clothed and
0
wore rags or went barefoot. We
Cl
>ld that there was total employiem with generous pension schemes for
’’men al 55 years and men at 60, adeeducational facilities and, of
‘’urse. total health care for all. There
ts no evidence whatsoever of the infla"n;i| v trends that have recently gripped
If
I
’ of the world. In a situation like
Ils
could only marvel and wish a
id
people greater success.
I*1 'C could,
____ , however, be greater
eehanization especially in
i
agricul-
ture—provided that did not cause unem
ployment in any way. 1 personally con
sidered the absence of private motor cars
from the roads a great boon, and the use
of bicycles contributory to good health.
WH : It will no doubt take some time for
the ideas e.xehanged during the Study
Tour to he evaluated. What use is WHO
going to make of its new view on tradi
tional Chinese medicine ?
Bannerman: We prepared a question
naire for the participants before the tour
started and happily there was 100 per
cent response. Every participant stated
that the lour was truly worthwhile and
should be repealed for other, smaller
groups on a yearly or even twice-yearly
basis. Many took the opportunity to re
examine their own priorities and decided
that national priorities in several coun
tries required urgent review. Health
problems were never presented in isola
tion and the part played by agriculture,
housing, jobs, water supply, and educa
tion (academic, technical and political)
were all very obvious to the discerning
eye. The developing countries certainly
have a great deal to learn from China,
and who could well make an in-depth
study of the ‘New’ traditional Chinese
system, particularly in terms of cost
benefits and technical cooperation, with
a view to adapting the system for use in
various developing countries that might
be interested.
The most attractive feature to us from
the developing countries is the extent to
which China has improved the quality of
life of her people and achieved total
health coverage within one generation.
There is no such parallel in ancient or
modern history. China is unique!
■
Plants that heal
Ji
l il.
ii I
li;
Plant screening has often yielded poor results because
traditional healers were not involved; but the advice of
good healers ensures at least a 50/50 chance of success
i
BY OKU AMPOFO
-«
_____ ________I
ft
t’r
I
i
5
When, some years ago, I started
I
showing interest in African traM&'y ditional medicine, like many
other investigators in this field I
KXM3I doubted the efficacy of any of
the claims made by our local healers.
Time soon proved me wrong, and luck
too came to my aid. It was not difficult to
establish contact with two well-known
herbalists in my district and they were
most willing to pass on their age-long
knowledge. They were both octoge
I
J
find a taxi to carry the patient to my clinic.
particularly to find substitutes for if
On her return she was surprised to see
ported drugs. Here are two examples.^.
the patient washing her baby. Her bleed
The Public Health Department of (S
ing had been arrested by one of the
Medical School recently asked us to tn
old herbalists who lived a few yards
them to fight an epidemic of guinS
away. It was this incident which first put
worm in three nearby villages. In pl
me in touch with this herbalist. I later vious years, attempts had been madeW
learnt of some interesting cures from
treat the yearly epidemic with a cottm
other local herbalists, found out about
nation of procaine penicillin and a
their methods and tried them out in my
ferent proprietary drugs. The 88 peojj
practice. As Director of the new Centre
involved in this trial included 18 c®
for Scientific Research into Plant Medi
dren, 20 bed-ridden adults and 50 am®
narians with long years of practice
cine in Ghana, I now have greater oppor
behind them and were trusted and re
lant adults. These were divided into tw
tunity for doing clinical trials with tradi
spected by their patients.
groups ol 44 people each. The first grQK
tional methods.
1 also learned to respect them for then
was put on a decoction of pieces of rCfi
Il is my contention that to achieve any
wide knowledge of plants and diseases
ol Comb return mucronatum^ a knoi
success in the field of research into tradi
their frankness and wealth of human
worm-expeller, at a calculated doseM
tional medicine, we have first to acquire
experience. Every other week I would go
.03 gm, kilo. The second group was giwl
our knowledge from the traditional heal
w'ith one of them into the bush, collect
a decoction of Mitragyna stipulosa whM
er himself, try out his methods clinically
plants and learn about their uses. These
looks like Conibretum mucronatum’, d!
and then, if successful, subject them to
old herbalists were great botanists and
calculated dose was .06 gm/kilo. Patie®8
scientific analysis. Many plant screening
knew something about every plant we
were examined twice weekly.
Is
programmes have not yielded any fruifsaw in the bush. They each’ identified at
Alter one week, examination reveal®
ful results because traditional healers
least _00 plants with healing properties.
that there was complete extrusion of dl
have not been involved in these trialsThese traditional herbalists treated a
worms
in 43 out of 44 in the first
but experience shows that with the ad
Wide variety of diseases and injuries,
(i.e. 97.7 per cent) and there was maricjP
vice of the good healers there is al least a
apait from offering maternal and child
ieduction in the inflammation aroilfe
chance of success.
care. One day, one of our modern-trained
In our clinical trials with medicinal
district midwives was faced with a case of
Herbalistsy/z lta centre for African iraditUk
plants, our aim 1has not____
only
been
to
find
wdicine
learnJ how to prepare and prod
haemorrhage, and
<
he later told me that she actually ran to
icures for diseases in which “VVt
roots
so
as
to make the best of their heA
“Western”
medicine is ineffective but also
properties.
P-r-fc :.
(Photo WHO/R. da M
—
)
more
26
■j
Plants that heal
t
/ ^|
I
I
. -- fafiM
J
i'l
1
■
i- I
.t
Hilleria
latifolia —
Phytolaccaceae
Jh .
ihJ
Securidaca
longipedunculata —
Polygalaceae
__________________________
i
Left: Hilleria latifolia has been
as afilaricide in cases ofguinea-worm m
tion. The bark of Securidaca longipedudA
is useful in treating psoriasis and also /un
convulsive properties. Myrianthus arbom
decoction madefrom its bark appears em
against diabetes. When suitably prepaid
root of Picralima nitida can heal the
disease herpes zoster in the space of
weeks.
J
Myrianthus arboreus - Moraceae
Picralima
nitida Apocynaceae
Right: This woman has come to const
healer at a centre for traditional medi
Such healers are respected in their loca^
munities for their wide knowledge ofJ
and diseases as well as for their understtn
and wealth of human experience.
(Photo WHO!R. da Silva)
J
I
!
i
the lesions. The wounds healed com
pletely after two weeks with local appli
cation of sterile palm oil. In the second
group, there was complete extrusion of
worms in 23 out of the 44 cases (i.e. 52.2
per cent), with healing of the wounds
after local application of palm oil in two
weeks. Thus, it was proved that Combretum mucronatuni—as the traditional her
balists claim—is indeed a true expullent
of guinea-worm.
We were also able to prove that the
leaves of Elaeophorbia drupifera and Hil
leria latifolia, taken in combination in a
palm soup preparation, act as a filaricide
in guinea-worm infestation.
Skin diseases have particularly en
gaged our attention and we have had
success in the treatment of coccal infec
tions, epidermophytons, allergy and
herpes zoster. Four traditional treat
ments of herpes zoster are particularly
interesting. The local application of the
Howers of Hoshmdia opposita and red
cola nut, chewed together and sprayed
on the lesion twice a day, often heals it
within a fortnight. The local application
of guava leaves, ground into paste with
28
kaolin or white clay and Piper guineense
twice a day, heals the infection in about
ten days. Alternatively, the root of Picra
lima nitida is charred with Piper
guineense and ground into fine powder,
mixed with kernel oil and applied to the
infected area with cotton wool twice
daily; for internal application, the black
powder is mixed in alcohol and taken,
one dessertspoonful thrice daily, to allay
pains; this treatment is very effective and
healing takes place in 10-14 days. But
perhaps the most dramatic form of treat
ment is the use of the root bark of Bala
nites aegyptiaca. ground into fine pow
der. then made into a paste with water
and applied to the infected area morning
and night; healing occurs from five to
seven days. A similar result is obtained
with Securidaea longipedunculata root
bark, which is also useful in treating
psoriasis and possesses anti-convulsive
properties.
Guinea-worm and herpes zoster are
some of the diseases for which modern
medicine has so far no effective remedy.
Traditional African medicine appears to
be more effective.
Two other diseases for which tTM
tional African medicine appears to'J
more effective and less risky than mP
ern medicine are diabetes mellitus u
bronchial asthma. For some years nra
we have been studying the work of ha
balists who treat diabetes mellitus, sew
of whose remedies come mainly frOi
herbal preparations. In particular, 0
anti-diabetic activity of herbs of W
Loganiaceae family has been confirm
by our University of Science and Tfl
nology. One teacher herbalist claim®
high as 75 per cent of “cures" among®
diabetic patients treated with the
niaceae family. He has successfully tiW
ed a patient who developed gangrene®
ketosis even though he was on ins®
injections. A thorough investigationJft
the anti-diabetic property of the Zx®
niaceae seems to be called for.
The combination of Canthiurh^fi
Myrianthus bark as decoction or alcojjjfi
ic “bitters" also appears effective.
patient had his diabetes mellitus arrrfH
when he was treated with this extraC®3
two months. His fasting blood sugasfc
been normal since. Another colle®5
ji fdio practises dentistry in England perE Hiaded a physician friend to try the
dcoholic extract on two English patients
id dth juvenile diabetes five years ago.
d'ler two months treatment, it made no
npression on one case but the second
* n oved considerably and her fasting
k
sugar has remained normal ever
Ilk
They were both on insulin. Costus
=ie hleehteri is another plant claimed by
d ‘inc herbalists to be effective against
ahetes mellitus, and our observation is
=as hat this plant is effective in some early
ais use''
j I
m the ust^of Bridelia ferruginea for
=st- i'i
Hing diabetes mellitus that I have
K TM d more experience
, .________
r for
and hope
in p'licalment ofdiabetes. Of the 12’ cases
’dci treatment. I have selected three as
lo^ing typical reactions to the plant.
Salient M. A., a woman aged 49 years.
-4 Parted in May 1976 and had been
cci \ mg insulin injections, 44 units daily
rI
last two years. Her fasting blood
as 242 mgm/100 mi. The patient
(>k worried, did not want any more
'iiliiand preferred herbal treatment.
ic
^as put on one dessertspoonful of
H--'
powdered Sclerocarya birrea leaves twice
daily but at the end of the third week, her
fasting blood sugar had risen to
340 mgm/100 ml. Treatment was discon
tinued and the patient was put on a chlor
propamide preparation, 250 mg twice
daily for ten weeks. There was mild im
provement but the patient wanted to try
another herbal treatment. In August
1976, she was put on Costus schlechteri
as recommended by a herbalist. Her fast
ing blood sugar rose to 250 mgm% and it
was decided to try Bridelia ferrugineaten leaves boiled with one pint of water,
one teacupful to be taken three times
daily as recommended by a herbalist.
There was a steady lowering of the fast
ing blood sugar till it became normal
after 12 weeks, and it has since remained
normal.
Patient L.B., a woman aged 45 years,
reported for treatment of her hyperten
sion. Routine examination revealed that
she had diabetes mellitus with fasting
blood sugar of 370 mgm%. We decided
not to give her any “Western” drugs and
put her straight on Bridelia ferruginea—
20 leaves boiled in a pint of water, one
teacupful being taken three times daily.
After one week the fasting blood sugar
came down by 120 mgm% and conti
nued to fall till it became normal after 11
weeks. It has since remained normal.
Incidentally, no treatment was given for
her hypertension which also automati
cally fell from 180/90 to 140/90.
Mrs T.O.. aged 59 years, is another
t\ pical case. She has been a diabetic since
1969, and first reported to us in April
1975 for a prescription for more of the
proprietary tablets which she had been
taking daily. Her fasting blood sugar was
252 mgm% and it ranged between
190 mg and 285 mg for 16 months until
October 1976 when we decided to put her
on Bridelia leaves. There was no signifi
cant change for three months and the
dosage was increased by 50 per cent.
After another two months, the dose was
doubled as the fasting blood sugar conti
nued to rise. There was still no significant
change for two months and the patient
was put back on her tablets. It was then
discovered that the patient had been
secretly taking both Bridelia and the
tablets together and we concluded that
nn
KJ-’’'
Mi
Hi
wf-A'
f
A___________________________________
many plants available for bronchial asth
ma the following have been most widely
used at our Centre: Desmodium adscendens—Papilionaceae, Thonningia san
(Photo WHO!R. da Silva)
guinea—Balanophoraceae, and Deinbol
lia pinnata—Sapindaceae.
The leaves of Desmodium adscendens
this may have accounted for the ineffec can be given in the form of dry powder,
tiveness of the former. It would appear one to two teaspoonfuls. according to
that the traditional drug and the modern age. in warm water in three divided doses
one acted as antagonists here. This is per day. or it can be made into alcoholic
true of other patients who are over extract. Thonningia sanguinea root is pulanxious to get well and take both drugs, verized and dried. Two dessertspoonfuls
while patients who take alcohol during of the
’ powder are mixed thoroughly in
Bridelia treatment also show no inf- ten ounces of honey and given in doses of
pro vein ent.
one teaspoonful to one tablespoonful
My own experience in the prophylactic thrice daily. This loo can also be pre
use of plants for bronchial asthma will be pared in the form of alcoholic extract.
supported by Professor Marian Addy, Dry. powdered Deinbollia pinnatu root
who has used the same materials in ex bark is used differently: one to two teas
perimental animals. Drugs used for poonfuls of the powder may be taken
bronchial asthma in modern medicine according to age in palm soup every
are mainly applied during attacks other day for two to three weeks, and it
whereas medicinal plants can be used can also be taken in soda water.
prophylactically until attacks are well
Each of these preparations is capable
reduced or completely eliminated. Of the of deferring bronchial asthma attacks
-------------- j or
Watched by two village women, a herbalist
explains the contents of a pot of mixed herbs
and roots to a visitmg official (in white suit).
J~C
30
*
1_
_
1
•
i
. 1
even stopping them, especially in chil- !
dren. But the best result we have ob
tained at our Centre is the administra- I
tion of a combination of Desmodium
adscendens and either Thonningia or
Deinbollia.
We undertook a “double blind" clini
cal trial during which 12 randomly
selected patients were treated with place
bo herbs, that is, drugs having no
therapeutic value, for three months and
then for a second period of three months
with combinations of Desmodium, Deinbollia and Thonningia. The results were
quite clear. All the patients continued to
have asthmatic attacks during placebo '
treatment, but eight of them had no ,
attacks during the herbal therapv. Some ,*
of the remaining four had decreased j
attacks, but the response to the com
bined herbs was judged less than satis*
factory. From our point of view the^
is no question that Desmodium and
the other herbal preparation produced *
satisfactory response in 75 per cent ofthc
■
patients.
w
*
*
1
I
ji
r.
>••••• ••••••• ••• ••• ••• ••••••
»•••••• ••••••• •••__ • •• •••••••
>•••••• ••••••• ••• ••• • •• •••••••
---------•••
•••
•••
• •• •••
jte • •• ••••••• ••• ••• • •• ••••••
• •• ••••••• ••• ••• • •• •••••••
••• ••••••• ••• ••• ••• ••••••
••• ••• •••
••• • •• •••••••
•••
••••••• !••••••••••
••••••
---------— ••• ••••••• ••••••••••• •••••••
••• ••• ••••••• •••••••••• ••••••
---------
•••••• ••••• •••••
••••• •••••••
••••••• ••••••• •••••••
•••••••
• •••••• ••••••• ••••••• •••••••
••• •••••• •••••• ••••••
•••••••••• ••••••
c:;::::
•••••••••• •••••••••••••••••
•••••• ------------------------------------• ••
• ••
• ••
• ••
Authors of the month
moos
DrH. Mahler is Director-General
of the World Health Organization.
Mr J. Dauth, formerly Press Offi
cer at the Embassy of the Federal
Republic of Germany in Malaysia,
is now working as a journalist in
Malaysia.
Dr X. Lozoya is the Co-ordinator
of the Mexican Institute for the
Study of Medicinal Plants
(IMEPLAM) in Mexico City.
Dr P.N.V. Kurup is Adviser to
the Government of India for Indi
genous Systems of Medicine.
Dr K. N. Udupa is Professor of
Surgery and Director of the Insti
tute of Medical Sciences at Banaras
Hindu University, Varanasi, India.
DrR. H. Bannerman is Secretary
of the Working Group on Tradi
tional Medicine at WHO head
quarters in Geneva.
Dr A. Mangay-Angara is Chief of
the Division of Maternal and
Child Health, Department of
Health, Philippines.
Dr O. Ampofo is Director of the
Centre for Scientific Research into
Plant Medicine at MampongAkwapim, Ghana.
PORTUGAL AND
’ HO WORK
OGETHER
; Portugal's health authorities first inv led environmental health experts
i
•i n WHO to visit the country in
4, following a sudden outbreak
holera. In October 1976, at the
it yernment's
request,
a
joint
.VHO/World Bank team carried out
.’i extensive country-wide sector
■tudy of the water supply and waste
2lisposal conditions. This study pro4 ’d Portugal with an overall pic4 .
of the existing situation, indi,.j g d the constraints that were then
** miting the development of this vital
actor, and suggested an action
uogramme for immediate and long■erm improvements.
I)iie result of the activities that fol-■
j >■ >d was the convening of a semiJh on "project preparation and
"v. uation" organized by WHO and
'eld in Lisbon last July. Thirty-five
'ortuguese engineers participated
the seminar, which gave them an
nportunity to acquaint themselves
■ Hh new trends in planning, design,
■i economic and financial evalua-
a project of assistance to the
*sic sanitation sector, with backing
>m WHO and the UN Develop: ent Programme (UNDP), has just
. Hited, at an estimated cost of US
000. The project will last for
id a half years and WHO has
designated
as
Executing
1 y. A further result of the 1 976
study was the identification
^uch investment projects as water
•:jply and sewerage for Lisbon and
:>()r to, the second-largest city. The
Si : Bank is expected to assist in
a ng these schemes, and in the
tance a loan is being consid
er the improvement of LisJn s water supply.
WORLD
HEALTH
GREETING CARDS
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given the task of designing this sea
son's greetings cards for the Organi
zation. In full colour and with the
theme "Through to a better world",
the cards may be ordered from: The
WHO Staff Association, WHO, 1 211
Geneva 27, Switzerland, or from any
of WHO's Regional Offices in Alex
andria, Brazzaville, Copenhagen,
Manila, New Delhi and Washington.
The price is US $3 or 8 Swiss francs
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r-?';
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•h
11
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iffi ■
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cc^UWITy health cell
P 4KSt F,OOr) St- Mar,<S
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''riiilot in
<’P ^-O9?.HX,
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^AMGALOBE - 560 001
AJ nght»
^Ofessional •-
i
associations, ethics
escipline among
WUB4
HeALERs OF Nigeria
CS AND
InoNAL
**
DCP—ntofp^^OO^
oA.6Mpc,~f-our yor.
y
""'^'yon^
,an- ,badan.
--ssrr »-“».•' a S“"" a
mx
tra^itiona|
Scalers [);' T^ere are rules md § POlnts lor balers fn Po,’ferat«on of Ynr / aleS,c locations in were
and
•ns.
if
siB®®1
I
k
and
co^rnents and ha®s/elating
nas aftempted
y the ^cussants.
t I
fI
’X'KODCCn1
o.x
I
^’igeri;
Medicine
systems p- '
,!he Practice of
he,lin« IbundT'pH^ medic^ in .
of detej
is acts ra^^tfleir mern^
”"««”"' s
"™ "LXri“; *'“"-'2
I
a*ocU£eS*!!r
=«”££ss
^■nmumcac.on ,s
trad^nal heu,^^ nd ^scip/ine
lnS GO(Jn(riej P^,ee '* fes -''J j. 'f'. " and
I
■J Professional ncc
dlc,ne is
associations kerSocia(ions in
professi°'>. and cl^Pf a reS'«er of
- ^cihered to bv af, to ensure that
P"nlsflmen( in 'ca‘Si./««>r-oners by
;.\p ^/essional
f
XXX.xS-XSST11'""S2"
“»S
’-“to ;Tf,b"'~XaX
M "3»'
““»■«»
"■«
I S'
I
year of forrm*'
ass^C!ations knn
nanies of
^her
to
th°ef
M;XJT,hb°dy* MregiX 'S USI'a"y ... - wh
healers were reo 0C,aUcns "ere still and t0 ,nd‘cate
',:e P“bbX no°rf ,Ces/pr
®°t,o7°- doc7 ground
of ihc "7Sted ,0
a b^tlOninSar,,^ on raX7e!"n’s’and
.... .
a Parrented throunS^ Professiona°asso °r.s;ate
branches,
I
science in
I
°UtIine their ob^TtlOnS’ift,'is 'vaS hno°riCaJ
*ere allowed tc»
r
The two lit.^
to1
to the scantv'^^b-bahsts
7hc second pn.t , ' ad"lonal healers,
rCCOrds
'
III
.««“! tafc„" S'" « »« m2 135
been
'"mature abo(. ’ ‘.here has been no I Mt,°n of (ratro,bnB the nr
C P'^sionai ? acc°unt in the
P^iminncy sta^Z °f ‘r?dl''Ona| S'-bOd,es «">7'iona'healers^
^n'‘study o^ y'o' ?'
ditional heal
phe detaik ^r» JOnna,re is reflect- > Sc healers. The
study, the selectinhe Srclccti^ oi toWn. l,} TabJes 2 and
&
‘S' 'X ■'»“« [^“"d St S:
pFo/f?siona!
associations f ^°rt of One ot‘ the
assoc,^ions
t_ •••c niain
...........
have not been Z
the N'gerian t‘ T,'“hi“
»u,cn
«»..
''-hether t;ley haP
'°us'-v Sported rS
'’ea,ers
boner
whose
si^
hca
^
(Hus
1
st
^r^onal
‘he pubfc by 4 .
Of P^tectinJif0''"’""'0'’ On
Vlewcd about how?°St ‘S shown in Fk \rhe pracby 'J> of Punishn,ent • ' /<‘he ln,c'«‘ of
Jomless condition Ie dla^nos^ hyperten 2 WHS inler‘/.nd/or Other formi
87
“■A»»p4?EXtd'“A"~2Xpuo for gonorrhoea advorS!^
I
T*
i
I
89
Yoruba traditional healers of Nigeria
'i
Fie 3 Advertisement sign on the wall of the house of a traditional healer. This sign-post is meant to
i
i
ELEMU, the renowned medicine-man .
I
I
NUMSCR
OF COMPAQ:
THE FEDERATION OF NIGERIA
g
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THE COMPANIES ACT (CAP. 37)
!
CHMIPAttV
LIMITfill MY
RESILTS
SHAME*
c.
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and
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SUBSTITUTED
B
AXITIC^DS OF ASNOClATIttJI
OF
THE WEST AFRICAN (AIYEDERO) HERBAL HOSPITAL LTD. K
—
|
lacorortted UK------------------------------ .“day
t--------------------------------------•19
’-------- p
of
Name of Solicitor*.
g
aaaaia
wea a
Fig. 3 was purchased and tested in vitro for effects on
isolated cultures of Neisseria gonorrhoea organisms.
Of the 165 herbalists involved in the questionnaire
aspect of the study, only 156 filled the questionnaire
sufficiently well to be included in the -analysis of
results. The results of the study are shown below and
in Tables I, 2 and 3 and Figs 1-5.
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Fig. 4. An attempt at founding a herbal hospital. This is
the cover of the hospital’s constitution (the venture failed).
Professional ussocialions
Herbalist or traditional healers’ associations have
existed among Yoruba since the 19th century. In the
early stages, such associations were confined to indi
vidual communities. The “Oloriawo” or “Babasegun ,
“the head of those who keep secrets’* or “father of the
healers”, was the designation for the head of such
associations. Since most of the people are illiterates,
very scanty records of their activities are available.
Towards the end of the 19th century the herbalists
became aware of the need to form regional associ
ations. Hence, about 1886 (Table 1) the Ekiti-parapo
Herbalist Association and the Rejc Medical Herba
lists Association were formed in Ekiti and Ijebu-Igbo
areas. Although these associations served primarily
the interests of communities in their areas, herbalists
from other towns and villages in the Yoruba speaking
areas subscribed to them. Other associations were
later formed. The objectives of these associations in
those early days were:
(a) To afford herbalists the opportunity of meeting
and knowing themselves;
(b) To provide a forum for members to cooperate in
their practice by identifying specialists in specific
problems and referring relevant difficult cases to such
persons;
I
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D. D. O OviiBOLA
AdmiAi^trotwe
3. Okonln u/on Lone
Centre
Oov-Otoivo
%
MUSHIN
£
A.
Kb
/1
®crtcf t calc
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C^»«« 13 to
■IJyti.t
if-'-
5
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fJi fuay
co^-v
‘fiea-cat
a^a
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Be(>> sn instract sn of ’-lotr.oa
Sj fne
pju^orf 0‘ zhe
n<. cordor.ee u,dh O'f.C'.ei 4 poreJropr Cr.3 of :7.t
rie'ncron^/n zf tne
of fi-<)e.r,^r
herfo’,^ .Jnj „Oi
pcsseS tre
tes:
in L Ouser/ n. on er Le.e. of tne fnj. t\osr.not.Of o' .-s.n3iLU/<..on cna .5 r.erefy ajarom tr.s ce<j_.e.'
efficiency
fhis ce'tificote a hereby seoiea uno 9^
Dated
aoy of
7 >9
I
Fig. 5. A certificate issued to registered members of a herbalist association.
Table I. Herbalist associations among the Yoruba
Name of association
Akoko United Herbalist Association
Association of Nigeria Medical Herbalists
Beje Medical Herbalists Association. Ijebu
Egbe Aiyegunle Herbalist Association
Ekiti-parapo Herbalist Association
Ewedaiyepo Nigeria Herbalist Association
Federation of Herbal Indigenous
Practitioners
Gbcgbesele Aiyelola Herbalist Association
General African Medical Herbal Organisation
of Nigeria (GAMHON; also called Amalgamatioin
of Nigeria Medical Herbalists)
Ijebu-Mure Herbalists Association
Ijunmun-parapo Herbalists Association.
; Lagos African School of Herbalist Association
Nig. Herbalist Research Association
Ogo-Oluwa Herbalist Association
Taiyesc Herbalist Association
Union of Nig. Medical Herbalists
United Nig. Medical Herbalist
Western Herbalists College
Probable year
of formation*
I
Comments
1945
1908
18S6
1950
1S86
Functioning
Functioning
Functioning
Defunct
Functioning
Functioning
1945
1930
Functioning
Functioning
1945
1S8S
1930
1935
1950
1955
1950
1930
1950
1950
Functioning
Functioning
Defunct
DefunctDefunct
Functioning
Defunct
Functioning
Defunct
Defunct
•These dates were those given b) m\ informants and were not authenticated since
there were no written records in most cases.
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oruba traditional healers
of Nigeria
Table 2. ^2^222:rddn'Onal healers/midwives
No.
Questions
M
(d)
I
Yes
No
No response
Can a herbalist,traditioHa,
midwife be intimate with a
Patient who is of the opposite sex?
74
78
4
Yes
No
No response
became
£
148
8
Yes
No
No response
(c) To provide a forum
for the c
forum for
'"‘-■n' in the knowledge of iheCOhn''bUrUS impr0Ve'
of the her^hsTs
exchange of ideas on herba! remedies
S thr°Ugh
mcdLL P'CSCrVe and enSUre thE
of traditional
,4
29
115
12
Yes
No
No response
Is there ;any disciplinary body
for cases‘ of misconduct?
pohtically’consci'ous a^d'a™^''of
Number of
respondents
Possible options
(b) Can a herbalist/traditional
mid wifeactively canvass for
patients?
91
I
135
15
6
pampltas"1 eontaVninu ‘’thrireon0^''0''5 PUb'ished
Abortive attempts were also mud , Utlon (F,8- 4)hospitals. It was also the
de ‘o cslabhsh herbal
ations to assess the qua, tv
berbaUst “soei.'ists who wished to' bX
ed8e°fhCTba-
'vere registered along the lines L
aSSOciario^
interviews. Certificates of nrr.fi '
memoer through
government for trade unions Am
d d°""’ b>' the some associations to success^"^- WerC issued b>
these associations became m
oliler func'ions,
shows the certificate issued bv nPP 'TT' F'8Ure 5
government recognition and
f°r aSitati°n for
onc
tbe herbalist
‘he -ore import regTh' shows ‘ associations.
among the Yoruba.
8
herbahst associations
I
aliens were charged* withh[eheb°Ve a'mS' these associ-
I
"wi'' “
"a"’^
■"g-up guideiines and codes ofX'ct to^^’
:
t' “?"d
The response pattern to (h profeiS,onal associations.
ia Tables 2 and 3 '‘bJ5“est-onnaire are'shown
3- Dtsctphnary actions against
___________ 2b,e 1 Offences foi*r which herbalists can
be disciplined
I
______________ of offences
intimate with a female patient__________ ——
Procuring abortion
Number of respondents*
-committing aduIleryw.th[hew.feora
professional colleague
Preparing harmful medicines
USi"« hi‘ Penis as applicator to oush a
drug into a female patients vagina
Stealing
Si°aXd“,i0"’S ''-mgs
^xx?inga=under&isepre,e!,cc
SSSFr-^iona.
association
i not accompanied by her husband or rehlion
Cmen!s by thc heal<fer about his competence
fCJking secrets
Obidea
response
‘ Several herbalists named two or
oiore offences.
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79
34
30
19
17
15
13
13
11
10
9
9
8
7
5
5
5
2
4
8
3
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members could take the form of fines, suspension or
dismissal from the association, or handing over to the
police for prosecution if a criminal offense had been
committed. The type of disciplinary action taken
would depend on the gravity of the oflcnse commit
ted. The associations set up disciplinary bodies from
among their members.
Figures 1-5 depict various features on matters
related to advertisements, professional associations
and the practice of traditional medicine. The healer
whose sign-post is in Fig. 2, who claims to treat
hypertension and cardiovascular diseases, does not
know how to measure blood pressure! He claimed to
treat “hypertension” with herbal concoctions whose
components were not disclosed. The drug advertised
for treating gonorrhoea in Fig. 3 showed no pharma
cological activity in in vitro tests on cultures of
Neisseria gonorrhoea.
DISCISSION
t'
'I<§
D. D. O. Oyhbola
There are several herbalist associations among Yor
uba traditional healers. Efforts to make them form one
professional body have so far been unsuccessful
although some of the associations have combined to
form G.A.M.H.O.M. (Table 1). However, the latter is
not an all-embracing association of Yoruba tra
ditional healers. This proliferation of professional as
sociations makes a central control of the practice of
traditional healers difficult and weakens their bar
gaining power with the government Table 1 also
shows that the herbalists have felt the need and have
attempted to establish a herbal college and a herbal
research unit. Figure 1 butresses the latter and Fig. 4
the former.
The herbalists, like Western-trained doctors, have
tried to protect the interest of the society they serve
by having ethics that bound the practice of their pro
fession (Table 3). From Table 2, it will be noted that
apart from public advertisement on which opinion is
divided, most of the herbalists agreed that it is unpro
fessional to canvas for patients, have intimate re
lationship with a patient and it is possible to disci
pline erring members. Some of the culpable acts in
Table 3 are similar to what would constitute an infa
mous act if committed by the present-day practi
tioners of scientific medicine. It is difficult to imagine
how the healer whose sign-post is in Fig. 2 could treat
hypertension without a proper method of diagnosis of
the disease. This casts serious doubts about his claim.
His practice may be mere deceit of a gullible clientelle. It is important to protect the public from this
type of practitioner. Also, the much advertised
gonorrhoea medicine (Fig. 3) had no eflect on plates
of Neisseria organisms cultured in vitro. Although in
vivo tests were not done, the cflects of anti-biotics can
usually be demonstrated in vitro. The absence of ac
tivity in in vitro tests puts the efficacy of this medicine
in doubt. Again, the dangers of patients with gonor
rhoea infection purchasing a worthless medicine for
treating their condition cannot be over-emphasized.
In the course of the larger study [6], it was dis
covered that the professional associations wield
tremendous influence over their members. Their co
operation and support will be needed if proposals to
utilize traditional healers for health care delivery in
the developing countries is to be successful. They arc
also indispensable in research ventures into tra
ditional medical systems. It is important that further
studies be carried out to identity the herbalist associ
ations in the major ethnic groups in Nigeria and
other African countries. The Western-trained doctors
and government health policy makers should liaison
with such associations to ensure success if and when
the proposal of the W.H.O. [1.8] that traditional
healers in Africa should be integrated or at least,
should cooperate with scientific doctors in the deliv
ery of health care is implemented.
2?
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Acknowledgements—'I am grateful to Prince A. Adegboyega
and all the other herbalists who participated in this study.
The herbalists kindly gave permission to publish the
photographs. Miss Monica Ikekhua gave secretarial assist
ance.
h
REFERENCES
1. W.H.O. Health Manpower development, paper EB
57/21. Add. 2, p. 3, W.H.O. 57th session. 1976.
2. Maclean Catherine M. U. Traditional medicincc and
its practitioners in Ibadan. J. Trap. Med. Hyg. 63. 237.
1965.
3. Adcmuwagun Z. A. The relevance,of ’i oruba medicine
men in Public Health Practice in Nigeria. Pub. Hlth
Rep. 84. 1085. 1969.
4. Harrison Ira E. Traditional healers: a neglected source
of manpower in newly independent countries. J. Soc.
Hlth Nig. 9, 11, 1974.
;
5. Adcmuwagun Z. A. The challenge of the co-existence of
orthodox and traditional medicine in Nigeria. £. Afr.
Med. J. 53, 21. 1976.
6. Oyebola D. D. O. Studies on the traditional medical
care among the Yoruba of Nigeria. M.D. Thesis, Uni
versity of Ibadan, 1977.
7. Oyebola D. D. O. Some aspects of Yoruba Traditional
Heealers and their practises. Trans. R. Soc. Trop. Med
Hvg. 74, 318, 1980.
8. W.H.O. African Traditional Medicine, pp. 5-14. AfroTechnical Report series. No. 1 Brazzaville. 1975.
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Pergunion Prev» Lid
S"<. Sci
Vol. I5B. pp 93 io 102, 19X1
Printed m Gre.ii Brium
J
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PROFESSIONAL ASSOCIATIONS, ETHICS AND DISCIPLINE
AMONG YORUBA TRADITIONAL HEALERS OF NIGERIA
by D. D. O. Oyebola
Hi
DISCUSSION
by
R. H. Bannernun
Gilles Bi beau
Frederick L. Dunn
Gabriel B. Fosu
Kris Heggenhougen
Una Maclean
Andras Zempleni
'his study relates to traditional medicine amongst the
Recently, some health administrators in the devel
/orubas—a major ethnic group in Western Nigeria oping countries have recommended the inclusion of
omprising some 14 million of the total population of traditional healers in primary health care services on
“0 million in Nigeria. The first section of the report
the grounds that traditional medicine is holistic and
vas published in Soc. Sci. Med. 14A, 23-29.
the healers know the socio-cultural background of
Readers would be well advised to read the first
their patients, and are highly respected and experi
rticle in order to gain belter appreciation of this enced in their work. Economic factors, distance, time,
eport. Although, the study relates to a particular eth traditional beliefs and shortage of health pro
ic group—the Yorubas, there are many aspects com fessionals, particularly in rural areas, have also
mon to tropical African Communities in general, and
influenced the above recommendation. Training and
=he statements that scientific or western and tra- orientation programmes have already been developed
iitional systems of medicine co-exist effectively and
in several countries for suitable healers and tra■hat 80-90% of the populations depend almost exclus- ditional birth attendants especially. Provided they are
vely on traditional healers especially for primary willing, such traditional health workers can, at a very ealth care are statements of fact. There is no vacuum moderate expense, be trained to the level where they
nywhere and each community over the years has can provide adequate acceptable health care.
F
eveloped its own health care system in rational reCertain governments are already encouraging the
ponse to the perceived causes of illness.
development of the type of professional associations
The often quoted statement that “some 80% of the described in this study, with the enactment of appro
" pie in the developing countries have no health priate legislation for licensure and registration. The
-sfre system at all” is therefore totally erroneous and more enlightened laws aim at enabling the healers to
lisleading. These people depend on their traditional assume some doctor-functions and with adequate
pd indigenous health care systems and their healers, legal protection in the performance of those tasks.
practitioners of traditional medicine and traditional They also provide assurance to patients that the per
iirth attendants or so-called native midwives are sons undertaking the health care have been properly
ideed their primary health care workers.
trained.
The belief that illness arises from supernatural
Tire type of professionalism regarding quality con
4uses and indicates the. displeasure of ancestral gods
trol, more ethical and rational development of tra
jd evil spirits, or is the eft'ect of black magic is still ditional medical practice will no doubt assist in the
eld by many communities in the Third World coun- achievement of better collaboration and possible inte
lies. and to some extent, this is also true of the indus- gration of the various health care systems.
’rialized countries. It is therefore wrong to attribute
Present health care systems place most of the devel
jagical, irrational and superstitious ideas to any oping countries in a dilemma. Either we continue to
ioup of countries or levels of industrial or edu- aim at a type of medical care which cannot, in the
ttional development. Naturalistic causes of illness foreseeable future, be extended to cover all needs; or
•je favoured in the industrialized countries, but the we revise our ideas on types of medical care and de
defence is that the two approaches to health care are livery systems. Dr Oyebola’s study report is therefore
i»mplcmentary and that with the swing of the pendu- timely and there is little doubt that the time is now
m greater attention should be paid to the tra- opportune for clearly defined policy decisions at the
^iotial, indigenous or alternative systems which
highest governmental level and the enactment of
ling comfort to very large numbers of people everyrealistic legislation for the recognition, control and
■here.
development of traditional and indigenous systems of
93
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R. H. Banni rmax el al
individuals but above all as corporate bodies, exerlinJSj
pressure on Ministries of Health and health officials.
had sometimes the impression, in reading Dr Oyeboiia
that healers arc waiting for recognition by WHO andj
local governments without active participation in tl^a
debate: in fact, they took the initiative and they
still protagonists in the process.
jS
I disagree with the position advocated by Dr OjuS
bola concerning his sociological description of thj*
healers’ professional associations. My close work witjfl
healers’ associations in Zaire has convinced me thiS
R. H. Bannerman
national associations cannot exist for the time bcin?^
Tradi lion al M edi cin c
and this, for the benefit of healers, because vario^j
WHO, Switzerland
territorial regions, different categories of healers aa®
more easily represented through many parallel associg
ations. This pluralism must be stimulated and ornjB
the coexistence of associations can really maintai»«
democratic participation of individual healers. I
It is quite usual among non-specialists to think that not against federation, concertalion and cooperatiae®
traditional healers are individualistically-minded between associations, but my feeling is that efforeffi
peoples, refusing any collaboration with colleagues, must be preferably, at this stage, directed at develc.-j®
because this would mean sharing of personal “secret” mg strong local, regional, limited associations; Li®
knowledge. Through a short historical approach, Dr national healers’ associations I am aware of, in man^fc
Oyebola has demonstrated, on the contrary, how African countries, appear to me as purely legal empiwS
deep are the roots of solidarity and communication forms without any power of mobilization. SocioloaS
between healers: the foundation of the profession on cal characteristics of efficient healers* associations ex®
initiation and the public acknowledgement of their be reduced everywhere to the two following traitsw
social status by a formal appellation have indeed first, they arc rooted in a geographical area, or in isS
always situated healers within a corporate body. particular form of therapy (herbalists, ritual prie.M*g
Among ritualists and priest-healers, this solidarity has healers, spiritualists,...); second, they are highly px^E
even taken in the remote past, in the form of formal sonalized, in the sense that leadership is assumed bm
associations with regular meetings, control over indi a healer of great fame in the area. Only associations
vidual practice by elders in the initiation, and collec with these two characteristics have shown th.'-.gft
tive therapy in few occasions. I would suggest that Dr capacity for “bargaining power”. As a second ster3
Oyebola makes a distinction between individual her national-level associations will slowly evolve from thfg
balists and healers working at a shrine or within a incentive given to the formation of local association^
ritual, because these two categories of healers were but governments musfr be careful in their promotion,
not traditionally in the same position, regarding re of such an unrealistic national administrative striw
lations with initiators and colleagues. Their proximity ture. To guide this process towards a national assoc-Oa
to modern associations is therefore evidently different. ation, I think it necessary to provide a permanc^
Colonial administration and bureaucracy in inde minimal structure: for example, regular meetina®
pendent countries have more recently pushed healers between local leaders associations.
The Health Ministry, in any African State, mx-4g
to use new legal forms of solidarity expressed in
numerous modern associations. These new adminis rely very much on local healers’ associations for
trative structures can surely be considered as a con action taken within the realm of traditional medicir.«
tinuation of former solidarities, but Dr Oyebola has These associations constitute, according to me,
not stressed enough, according to me, the rupture only channel allowing continuous contacts wiS^f
with the tradition. Any comparative study of constitu healers of any level and in anv area of the countr®
tions and statutes regulating these associations reveals . Many responsibilities must be delegated to the boariijj
a tremendous abuse of legal terms which mean very of local leaders associations: for example, only per?J
little to healers, and researchers must evidently read, review can really lead to decision concerning ‘‘who jw
behind explicit aims of the associations, what they a healer”, and new services of inspection creaT4c
really want. It is not enough to note that associations within few African Health Ministries, with the aim
have assigned themselves as main objectives, census delivering individual licences, would take advan t;:?^
and registration of healers, enforcement of ethical to document their certification on the technics^,
code with fines for malpractice, defence of profession, advice given by local associations. In my opinion, tb®
first stage towards recognition of traditional medicii®
etc.; in fact, these associations have multiplied in
African cities, since the Independence mainly, for two goes with the necessity for anybody who considef^J
more fundamental reasons that Dr Oyebola has not
himself as a healer to seek his membership within «
explicitly stated: first, healers try to define themselves local association. Health Ministries must entrust th^8
and their therapeutic activities within modern society, associations and rely on decisions taken by healed#
in proposing a new space to occupy; second, formal colleagues, in many areas of concern: census, registry®
associations intend to force governments to make de tion, evaluation leading to individual licences, codi^
cisions regarding legal status of traditional medicine cation of professional rules, etc. In our proposal FA
and individual licences for practice. Healers have the Zairian government after a three-years reseani®
on healers, we constituted healers’ associations
attained a new visibility in modern Africa, not only as
health care. Happily, these initial steps have already
been taken by certain third world countries.
Finally, we must remind ourselves that much of
modern medicine has stemmed from traditional medi
cine. Should the health professions acknowledge the
healers and traditional birth attendants? Or is it wiser
to leave things as they are? What is regarded as
unorthodox today may well become highly Orthodox
before the close of this decade.
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Discussion
center of gravity for the new health national policy
regarding formal utilization of traditional healers in
the official health delivery system (see Bibeau, Corin.
Mulinda and Alii (1979). Abridged Report published
(English version) by International Development
Research Center. Box 8500, Ottawa KlG 3H9,
Canada).
Dr Oyebola has discussed extensively the relations
between associations and codes of ethics. Professional
ethics have always existed among healers, and its
writing down is conjectural, having become a necess
ity within the modern Africal context. Examination of
written deontological codes enables me to say that the
first concern for healers is to adapt former regulations
to modernity without betraying them. Articles devel
oped in these codes are dedicated to such problems as
use of traditional solvents (oil, water, alcohol) for
drug preparations, prices for consultations, disposal
of devices which served during therapy, use of etio
logical categories for interpretation of disease (for
.> '.ample, sanction put on healers referring too often
witchcrafi in their interpretation), minimal facilities
to hospitalize patients, community-context for indi
vidual treatment, etc. Most healers still recognize that
they arc obliged to perform their therapeutic activities
according to regulations, and these regulations are
still, in their majority, very clear. What has dramati
cally changed is the contextual setting of the practice,
and healer associations have the duty to guide their
members in this difficult work of adapting former
rules to modernity. Deontological codes represent
substantial efforts made by healers in this direction.
They are not existing, first of all, as a prevention
against quacks, or a locus for disciplinary actions
against erring members.
My last comment relates to the two sign-posts on
hypertension and gonorrhoea treatments. I do not
know why Dr Oyebola has limited his investigation
to two negative cases, when researchers have stressed
positive outcomes in many other disease situations.
This limitation can be interpreted as a refusal of the
science dimension within traditional medicine and I
..-’would like to know Dr Oyebola’s exact position on
is problem. I question the method followed to study
treatments efficacy: it is not because a healer does not
use apparatus to measure hypertension that he is
unable to “cure” it. And what does “curing” hyper
tension mean?
The problems raised by Dr Oyebola regarding pro
fessionalization among traditional healers are impor
tant. but authors should approach these problems
with tools developed - by medical sociology, which
would provide relevant interpretation. I understand
(hat it is not always possible for biologists, physiolo. gists and physicians to have a parallel formal training
in sociology or anthropology, but when they study
multidimensional problems, it would, be very helpful
for. (hem to work within a team research.
r
Giles Bi beau
Sillery, France
Dr Oyebola’s report on the professional associations
of traditional Yoruba healers in Nigeria comes at a
time of growing recognition of the continuing impor
95
tance of traditional medicine in its many forms
throughout the world; of the complexity and diversity
of these traditions, even within supposedly culturally
homogeneous settings; and of the extent to which
each of these traditions is regulated and sanctioned,
officially and/or unofficially, within its own social
context.
The demonstration—as in this paper and other
recent contributions—that such institutions exist will
not surprise many social scientists. Reports of this
sort should help, however, to increase awareness,
understanding, and acceptance of traditional healers
by those of the cosmopolitan medical profession. In
many countries cosmopolitan practitioners complete
their training with little, if any. exposure to the alter
native (i.e. non-cosmopolitan. non-“scienlific”,
non-“Western”) forms of medical care that may be
available within their country or region. Even now
few medical school curricula include required instruc
tion in this area. Elective instruction in comparative
medical systems does not meet the need. Optional
courses generally attract students who are already
aware of, interested in. and receptive to the possibili
ties for interaction between or among diverse “sys
tems” of medical care. In my view an introduction to
comparative medical systems (to include study 'of
reports such as the present one) should be a part of
the core curriculum of any school in the health
sciences.
The only point in Dr Oyebola’s paper that I would
question is his statement (from his informants) that
Yoruba associations have existed (only) since the 19th
century. It may not be possible to prove it in this
particular case, but I should guess that the origins of
these Nigerian associations are ancient indeed. I sug
gest, in other words, that some form of healer’s associ
ation, however local and small in scale, can be founif
in any society that supports traditional healers—that
is to say in any society, past or present.
I should also like to expand the author’s opening
point about the co-existence and patronization of
medical systems. It is not only in many developing
countries that such conditions exist. The state of
national development may influence the relative “im
portance” of various systems of care but some degree
of medical pluralism is surely universal.
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Frederick L. Dunn
Department of Epidemiology and
International Health
University of California, U.S.A.
In spite of the numerous studies on traditional
healers. Dr Oyebola’s lucidly written and thought
provoking article is probably the first attempt to
address the central issue of professional associations
in traditional medicine.
As the author rightly points out. the existence of
traditional healers associations is not a new phenom
enon. However, they were mainly organized at the
community level and served useful social and pro
fessional purposes (e.g. referral and consultation).
They had a network of communication channels
(eaves-dropping, gossip, etc.) through which they
-i
i- •
1
L
• t
’ i
■
1
96
R. H. Bannerman ct al.
gathered information to help them in their practice.
As noted by the author, attempts to organize them at
the national level are recent. Such efforts have not
always been successful for several reasons, notably
internal strife for leadership positions and difficulties
in legitimation and integration into the national
health care system. Nevertheless, with the support of
the government some progress has been made in
some areas, a good example being the formation of
the Institute for Herbal and Plant Medicine in
Ghana.
The advantages of having accredited traditional
healers associations arc many. The author aptly
points out “Their cooperation and support will be
needed if proposal to utilize traditional healers for
health care delivery in developing countries is to be
successful. They are also indispensable in research
ventures into traditional medical systems". These are
plausible reasons, and they bring into a sharp focus
some of the basic issues that should be tackled before
any meaningful integration becomes possible. Some of
these issues have been raised by Dr Oyebola. and I
would like to comment on them.
The ease with which new professionals are acceptc^d
into the health care delivery system depends very
much on the attitudes of physicians. They usually
make the decision as to when and how to use the new
professionals. Their decision is based on whether the
services of the new professionals are perceived as role
elevating or role-threatening to them [!]. However,
instead of coining to grips with this basic reality in
the case of traditional healers, the reason often given
for keeping them away is that they are untrainable
because they hold superstitious beliefs, and because
their practice is secret it is difficult to evaluate. Also,
they are regarded as quacks because they claim to
cure disease which they can’t cure. Oyebola echoes
these apprehensions when he states “The healer
whose sign-post is in Fig. 2, who claims to treat
hypertension and cardiovascular diseases, does not
know how to measure blood pressure. He claimed to
treat “hypertension” .with herbal concoctions whose
components were not disclosed. The drug advertised
for treating gonorrhoea in Fig. 3 showed no
pharmacological activity in vitro tests on cultures of
Neisseria gonorrhoea".
I believe that not knowing how to measure blood
pressure should not be taken as sufficient evidence to
cast doubt on the efficacy of traditional medicine. The
observation of Oyebola is based on only one person
and is not statistically valid. On the other hand, if the
traditional healer is the only one speciaEzing in the
treatment of hypertension and cardiovascular diseases
in the area under investigation, then it might be
worthwhile to subject hypertensive patients (diag
nosed by scientific methods) to treatment by this her
balist under controlled conditions to enable us to
make a better assessment.
Another important aspect that has been stated re
peatedly is that traditional healers have a different
method of diagnosis and treatment [2J. Thus the
investigator should have posed questions to find out
how native doctors diagnose hypertension and car
diovascular diseases which do not have to conform to
western standards. Their claim to contact some super
natural beings and good ancestral spirits in their
treatment should not be dismissed as superstitious.
think that until an independent observer can confinjg
or disprove the reality of these paranormal phenoms
ena, it will be difficult to make such statements as E-JS
Oyebola makes above Obviously. Dr Oyebola aa(8
many others seem to be influenced by their mode effi
training in “scientific” approaches to diagnosis. SoirAf
doubts about traditional medicine, i believe, may US
removed if physicians would “condescend” tg
undergo the type of training available to tradition?®
healers (minimum of 3 years for fetish priests rS
Ghana). Then with the added advantage of thi®
scientific analytical mind help to settle the issues. T:®
case of acupuncture is relevant here.
$
This is not to argue that everything tradition^
healers do is beneficial. There are frauds everywhea*.
It is not inconceivable that some native healers
be phonies. Generally speaking, however, unlike ith-j|
erant drug hawkers they are genuine and well mearj|
ing people. They treat many patients who get well ar»
are never seen by Western trained physicians [3], ®
agree with Dr Oyebola that there is a need to sepy®
ate quacks from genuine practitioners, and one w;®
to do this is to organize them under accredited pr j»
fessional bodies.
The second point is that it is not uncommon,
in scientific medicine, to come across cases where®
drug may have potent in vivo effect but without.®
vitro action. Diethylcarbamazine, trade name bar.®
cide, is a good example. Its elHcacy as an aaitifiiarick®
is only realized in vivo [4], It is possible that a mete®
olite of some compoundfs) ia the concoction £
responsible for the therapeutic etfficacy. It is, howev:«
difficult to subject such a conooction, which may
crude, and, therefore, corU!'.'.m many substances,
careful scientific investigau:> a. One can only go ab«'^
this by trying to isolate an actfvie principle(s) from
concoction and test for its effectiveness in vitro andi#
vivo.
Undoubtedly, Dr Oyebola has done an excelled
job by bringing into focus
central but hitherjg
neglected issue for health professionals in developir®
countries who are being encouraged to work with
ditional healers. Traditional healers are willing to t:S
on many aspects of their practice if the investigation
are made in good faith and from a genuine desire £
learn and help. I hope that Dr Oyebola’s insight^*
discussion will stimulate further research in this
portant area.
g
Gabriel B. Fosu
Department of Sociology
Brown University, U.S.A.
REFERENCES
.1I
,
1. Record J. C. and Greenlick M. R. New health p'j
fessionals and the physician role: an Ihypothesis frv-$B
741(1075).
Kaiser experience. Puhi. Hlih Rep. 90. 241
(1975). :
2. Twumasi P. A. Medical Systems in Ghana. Ghana P :!p
lishing Co., Tema, 1975.
v
3. Fosu G. B. Disease classification in rural Ghar.jtj
framework and implications for health behaviour. J.
paper presented at an international conference on
gration of Theory and Policy in Population Sfua'-^.
University of Ghana. Sept 18- 25. 1977.
I
3
■4
•5
,
H ■!
Discussion
4. Hawking F. The chemotherapy of filarial infections.
Pharmacol. Rec. 7. 279. 1955.
Dr Oyebola’s discussion of professional associations
for traditional healers points to some of the central
issues in the current resurgence of interest in tra
ditional medicine, and is most timely in view of the
deliberations which arc now taking place about the
advisability, feasibility and consequences of a closer
official relationship between traditional healers and
the cosmopolitan medical system.
The recent call for “Health for all by the year 2000"
has placed a renewed emphasis on primary health
care, particularly in rural areas. Tied to this emphasis
is a recognition that the goal cannot be reached if
reliance is made cn cosmopolitan medicine alone.
Not even with concerted training and employment of
-/ se Practitioners. Hospital Assistants, “Barefoot
L..ctors” and other types of village health workers, in
combination with physicians, would this goal appear
realizable. The feeling is that traditional practitioners
must be officially brought into the picture, especially
since “indigenous health practitioners are there
already” [ 1 ]. Dr Oyebola is not alone in stating that
such healers are the main source of health care for
more than 80% of rural populations in many coun
tries. A resurgence of interest in, and promotion for
an official reliance on, traditional medicine can now
be noted throughout the world.
This interest has in part been legitimized by the
WHO, which has made repeated recommendations
for member nations to integrate traditional healers
into the national health care systems, or at least
establish a cooperative relationship with them, when
ever possible. This was again reiterated within the
1978 “Declaration of Alma Ata” [2], the same year in
which the WHO also published the report on “The
promotion and development of traditional medicine”
[3]. The WHO Traditional Medicine Group which
bi.', been functioning for several years and serves as a
‘I? ring house on issues related to traditional medi
cine is currently preparing a handbook on traditional
medicine for health administrators which should be
available in early 1981 and would presumably offer
guidelines for collaboration.
Physicians in control of national health care sys
tems and especially those within the hierarchy of
national (cosmopolitan) medical associations, how
ever. still seem to be quite skeptical about integration
and even about collaboration. One can, of course,
point to numerous cases, in “developed” and “de
veloping” countries, where collaboration between
cosmopolitan and traditional healers have taken
place, but to establish a national policy for such col
laboration seems to be quite another matter. The, by
now. almost fashionable criticism of physicians which
relates the reluctance to collaborate with a desire for
medical monopoly, defense of status and maintenance
of superior income possibilities should not blind us to
the fact'that some of the hesitancy in wanting to deal
with traditional healers is often motivated by a direct
concern for the welfare of patients. There are valid
reasons for skepticism of certain traditional healing
97
practices. One should be careful, however, in too
easily pointing to some of the detrimental results of
traditional treatments as it is by no means certain
that their damage equals (or surpasses) that of the
estimated 20% of all illnesses which are due to
(cosmopolitan medical) iatrogenic causes. Faults can
be found on both sides. Surveillance, censure, guid
ance, training and examination should be required for
all practitioners, and one mechanism for this could be
professional associations.
The hesitancy to collaborate is often caused by
neither self-serving nor by validly skeptical reasons
but is rather a consequence of ignorance about tra
ditional healers and about their capabilities. This is
particularly the case in relation to so-called “folk”
practitioners within local medical “systems” [4] and
many of the “popular medicine” practitioners [5] who
are quite individualistic, have little standardized train
ing and go through no uniform final exam or cen
trally monitored period of intern-, or preceptor-ship.
In most countries it is the folk healers, the herbalists,
bone setters, spiritualists, spirit mediums (and the
“popular” injection doctors) and others including the
more uniformly definable midwives, who make up the
majority, if not all, traditional healers.
Professional associations for herbalists and other
folk healers could presumably overcome this lack of
knowledge by generating information about the
healers they represent. Through such associations it is
presumed that an overview of the training and capa
bilities of healers, and the types of treatment modali
ties used, will be revealed more easily and will be
better understood by physicians and others. Such as
sociations are also expected to have a certain amount
of control over the members by having established
mechanisms for ascertaining professional competency
and ethical conduct. Dr Oyebola points to the impor- '
tance of this as well as to the problems new associ- *
ations face in assuring such competency and ethical
conduct (i.e. mention of the questionable claims made '
by members of an association about their ability to
treat hypertension and gonorrhoea).
National and international research and study
groups, which are working with traditional healers
and their professional associations, where these exist,
have been established in many countries and serve to
overcome the information gap. The Division for the
Documentation of Traditional Medicine at the
National Museum in Kuala Lumpur and the Tra
ditional Medicine Research Unit at the University of
Dar es Salaam are but two of numerous examples. A
further example is the International Association for
the Study of Traditional Asian Medicine which was
formed after a week-long conference in Canberra in
September, 1979, where practitioners and students of
different traditional Asian, and cosmopolitan, medi
cine met. Papers from such collaborative research
groups and meetings are increasingly appearing in the
medical and health care literature with whole issues of
certain journals being devoted to the subject (c.g.
UNESCO Courier July, 1979 [6J; Hemisphere July/
Aug., 1979 [7], Social Science and Medicine, of course,
has long been in the forefront in providing such infor
mation.
The question of whether or not traditional healers
should be licenced or registered before being officially
r
11:11
!|
Ni
“'I
it| i
yy
•f'i!
i-b
n
Ti
W;!b
•1 i-
k'
IN
■iHi
i
I.
I
I
Ii
I
n
I
I
98
•(
R. H. Bannerman et al.
seeking a solution to their problems [9, 10]. So,
recognized is central to the issue being discussed. It naturally, questions arise: “With whom does one col
has been argued, however, that one result of such laborate?” “Who are to be integrated0” “Who docs
licensing could be the creation of a subservient role
one include in an official health care service policy,
for traditional healers and a (possibly drastic) change and “What do these healers do, anyway?” These are
in their healing practices. This is one of the reasons questions asked by physicians who might recognize
why as a first step, the WHO [8] and others have “some good” done by traditional healers, but who
suggested professional associations of traditional fear that any kind of official recognition would open a ;
practioners should be established.
Pandora’s box and would set a precedent for the
In a number of countries where traditional medi eventual approval and promotion of every conceiy- .
cine associations are being formed, nol. all practi- able type of healer and healing therapy. Tins would
tioners arc eager to join; the majority of indivtdual- hold true even if professional traditional medicine
istic and proud folk healers arc often skeptical of the associations existed, and especially if one association
benefit they will gain from such associations, a skepti represented all traditional healers in a country. Is Dr
cism which does not necessarily arise out of incompe Oycbola advocating the creation of such all-encom
tence or from a wish to be secretive. Healers are
passing associations?
aware that initiators of such associations are some
The situation in Malaysia may serve to add to Dr
times motivated by special interest, political or sell Oyebola's discussion. The Malaysian Association of
serving considerations rather than by the potential Traditional Malay Medicine was formed m
benefit to the healers and their patients. However, i. still has relatively few members, probably lesb than
official recognition is to be predicated on membership 700 as of 1979. but is designed to represent what is
in a orofcssional association, and it is likely that tms estimated to be more than 2000 full-time and 20.C-A)
will be a minimum requirement imposed by many part-time folk healers, or bomohs, m the country [11 J.
ministries of health, then membership m such associ It is most likely that as time goes on a substantial
ations can only increase.
number of these bomohs will join the Association.
It should also be pointed out that, contrary to wha
The Association was established mainly through the
is generally believed, the folk healers with whom I
initiation of the chief anti-drug addiction officer of he
have spoken in Southeast Asia express the desire for major political party, who is now the president of the
their practice to come under government scrutiny and association although he himself is not a heaLr
to be -scientifically" evaluated since, as they are conn- fl2 131. He has long urged the government to recog
dent in their knowledge and capabilities, they leel nize the Malay healers for their capabilities in treating
such evaluation would provide official recognition
and rehabilitating heroin addicts. The formation of
and legitimation. It may be possible that such investi the Association is no doubt seen as one mechanism
gations could be carried out by the professional along the road to such a recognition. This may .be a
associations themselves through special committees
valid interpretation, and the motivation is no doubt
which could function in collaboration with cosmo humanitarian, but the creation of an all-encompassing
politan practitioners and others. Many associations association could also complicate the official rvcco
have already helped outside researchers carry out nition of those healers treating addicts.
studies of their members and their therapies, as Dr.
Recent research is beginning to indicate that certain
Oyebola indicates was fiis own experience, an
a
u
nrnohs mav
have certain,
••—»1—uxpar
bomohs
may have
certain, pw^iuiy
possibly'substantia
been mine as well. It may be worth Pror"°hng th. bo^h.^
treatment and rehabilitation
establishment of a separate research committee for a
minist o(y!Cia|s and physicians may be
such newly established associations;.Dr Oyebola seeb [ ,
official*recognition to some of the “drug
the associations; as “indispensable in research ven
p
,”8r)e<-n;te this potentially positive inclination
___
tures into traditional medical svstems
systems”” and
and also
also bomohs . Despite this poiemidi y p
points to the fact that the Yoruba herbalists have
called for the establishment of a herbal research unit.
In Asia the situation is somewhat different from these bomohs. The fear is that even i recognition b
Africa, as mentioned by Dr Oyebola, and might be
restricted to those treating addicts, all ^°rnojis’
more conducive to collaboration. This is due to the are a very mixed group indeed, could feel that e,
existence of regional, learned, medical systems, chief
This fear is propelled by the S
of which are the Ayurvedic, Unani and Chinese, with
n an
iwci.
.u iuuiuviiS
—i ft
•
early to tell 3
‘ long established and standardized courses of training,
are grouped together. It is still too <
examinations and professional associations governing
whether this Association will soon be able to present
both the capabilities as well as the conduct of thenan overview of its membership or have any specific J
members. The contemporary interest in traditional
gate-keeping mechanisms to ensure a desired level ot K
on the part of its different J
medicine is in fact largely due to information about
therapeutic capability
intersystem collaboration said to be taking place in meXs"il iTaTs^loo early to know whether separ- |
China Thus in many Asian countries there is substan ate or sub-groups of bomohs, herbalists, bone setters
pc
tial official recognition of, or at least a relatively re
like, will be created.
spectful coexistence with, such traditional medical andA the
slightly older, and somewhat different associ- |
practices even if there is not always collaboration
ation, exists in Malaysia, namely the Malaysian As 5
As elsewhere, in Asia there are also a multitude of sociation of Malay Medicine Sellers (PUBR*>
other folk and popular healers, including traditional
was formed in 1974 and claims to have about 400
medicine sellers promoting a wide variety of wares,
members, some of whom are also bomohs. The as- g
medical pluralism fluorishes, patients go back and sociation cannot yet present a particularly accurate
forth between cosmopolitan and traditional healers
, __
II
a
i
99
Discussion
iew of its members nor of their wares. This is
ccause such information is fell to be unnecess>ut because a number of circumstances make it
jIt for the association to obtain such inforn. The PUBRA leadership facilitated a recent
[16] which indicated that these vendors sell
ranging from a variety of roots and herps to
t medicines, with herbal “body strengthener”
aphrodisiac” mixtures being particularly popuhe membership included people knowledgeable
traditional Chinese, as well as Malay, herbal
•incs. those who had a number of quite complirccipes at their fingertips and could easily
lize and name numerous medicinal plants, and
who sold ready-mixed preparations and did not
any particular “medical" or “healing” knowlAlthough the association is less than 7 years old,
embership list was found to be quite out of date,
it least 25/,, of those listed having moved, died
longer selling medicine. All of these problems
.y' '.ludablc in view of lack of money for organarposes and because of (he character of the
ership itself which makes communication diffi>ut they point out that the problems faced by
tssociations are not necessarily similar to those
' associations being formed for other “professio;roups.
ittempting to gain recognition for folk healers in
,sia joint meetings, including an elaborate 2 day
ence, have been held between the new “bomoh”
ation and the more established Malaysian
se Association and the Malaysian Horneo-Ayurtiddha Physicians’ Association. As mentioned,
embers of these latter associations belong to
al medical systems and enjoy more of a positive
mship with cosmopolitan practitioners than do
is. By linking itself with these associations and
couraging the formation of a Federation of
sian Associations of Traditional Medicine, it
k presumed that not only traditional medicine
i is to be promoted but that it is hoped that the
ers of the “bomoh” association, who are the
ikely to be recognized, will gain recognition
[/ 1 ch a linkage. The situation in Malaysia is,
Sc. quite complex, as it is in most countries,
may well be that there are certain political
erations which motivate the more established
ttions to join ranks with the new “bomoh” asjn, so that both sides have something to gain,
tly a federation representing all the traditional
in Malaysia could have considerable influence,
e is no doubt a great deal of truth to Dr OyeStatement that the “proliferation of professional
.tions [in N’geria] makes a central control of
cactice of traditional healers difficult and
their bargaining power with the governAn association which could claim to represent
traditional (Yoruba) healers in Nigeria, or the
han 20,000 bomohs in Malaysia, would wield
srable political power which could bring about
ttfc reactions to the association’s members. But
also other factors than mere size which
le the reaction to traditional healers. We must
imind that not all herbalists, let alone all tra
il folk healers in a country, arc the same and
r- a variety of reasons, certain types of healers
are more readily “acceptable” to ministries of health
and cosmopolitan medical practitioners than others.
Traditional midwives/birth-attendants, who are
often classified as belonging within the rubric of “tra
ditional medicine”, are a sub-group of “traditional
practitioners” which has already gained wide accept
ance throughout the world. Traditional mid-wives
have been “integrated” into national health service
schemes in many countries. If such midwives were
members of an all encompassing central association
of traditional medicine this would not necessarily
mean that such an association could enforce a greater
acceptance for them than they already have, nor that
it could bring about greater acceptance for all its
members because one sub-group of its membership
had been integrated. In fact, as in the case of Malay
sia, any suggestion that all members of an association
should be officially recognized because a group of its
members receive a favorable reaction could cause a
restrain in the reaction to such a sub-group as well.
As Dr Oyebola indicates, it is most probable that
the ’ cooperation and support [of professional associ
ations] will be needed if proposals to utilize tra
ditional healers for health care delivery in developing
countries is to be successful”. But it would seem that
if a central association did exist it would serve its
membership best, and use the political power it did
have most appropriately, if it made a clear distinction
between the different categories of folk healers, devel
oped guidelines for ascertaining the competency of
the members separately for each sub-group, although
mechanisms for maintaining ethical conduct could be
instituted universally, and made it quite clear that it
was not assumed that all traditional healers were the
same nor that the collaboration with certain tra
ditional healers necessarily presumed the approval of
others.
H. K. Heggenhougen
London School of Hygiene and
Tropical Medicine
U.K.
I
•I !
1
!
i
i
REFERENCES
1. Pillsbury B. L. K. Reaching the rural poor: indigenous
health practitioners are there already. Discussion
Paper No. I. U.S.A.I.D., 1979.
2. Declaration of Alma-Ata. Contact 47, Oct, 197S.
3. WHO The promotion and development of traditional
medicine. Technical Report Scries 622, Geneva, 1978.
4. Dunn F. L. Traditional Asian medicine and cosmopoli
tan medicine as adaptive systems. In Asian Medical
Systems (Edited by Leslie C.). Univ. California Press,
Berkeley, 1976.
5. Leslie C. M. Pluralism and integration in the Indian
and Chinese medical systems. In Callure. Disease, and
Healing Studies in Medical Anthropology (Edited by
Landy D.), pp. 511-517. Macmillan. New York, 1977.
6. UNESCO Courier 32, July. 1979.
7. Hemisphere 23, No. 4, July/Aug.. 1979.
8. Op. cit. [3].
9. Op. cit. [5],
10. Heggenhougen H. K. Bomohs, doctors and sinschs—
medical pluralism in Malaysia. Soc. Sci. Med. 14B, in
press. 1980.
11. Chen P. C. Y. Medical systems in Malaysia: cultural
bases and differential use. Soc. Sci. Med. 9. 171, 1975.
I
I
I
.1
L
s
100
(
i
i
i
I
ii
R. H. Bannerman ct al.
12. Hcggenhougen H. K. Meeting of .Malaysian traditional munity. This is a feature of Yoruba society which has
been remarked upon by Peter Lloyd.
healers. Med. Anlhrop. Newslett. 10, 9, 1979.
I entirely agree with Dr Oyebola. however, that the
13. Hcggenhougen H. K. Traditional Malay medicine as
proliferation of existing associations makes it exceed
sociation formed. Med. Anfhrop. Newslett. 9. 8, 1978.
14. Hcggenhougen H. K. and Navaratnam V. An evalu ingly difficult to establish any kind of formal link
ation cf folk healers in the treatment of drug addicts in between them and the representatives of scientific
Malaysia—a retrospective follow-up study. Report of medicine. Bui this whole topic of syncretism is
the National Drug Dependence Research Project, Uni- an enormously complicated one. It cannot be
versiti Sains Malaysia Siri Monograf, Penang, forth approached merely on the basis of two confronting
coming.
groups of experts or specialists, scientific medical doc
" • therapy
‘
15. "
Herbal
ini the war on drug addiction.
UNESCO Courier July. 38. 1979; excerpts taken from tors on the one hand and the totality of Yoruba
Traditional therapies in drug dependence management. healers on the other. There are subdivisions and sus
Paper submitted to UNESCO by Heggenhougen H. K. picions on both sides.
Nor should the activities of African healers be
and Navaratnam V.
16. Heggenhougen H. K. forthcoming. Traditional Malay regarded simply in terms of their utilization of sub
medicine sellers in Malaysia, Medical Journal of stances which may be pharmacologically active.
Malaysia.
Many observers have remarked on the relative insig
nificance of the pharmacological element, at least in
so far as the operations of the Babalawo or diviner
priests are concerned. This point was, for instance,
expressly
made by Michael Warren and his colleagues
As'ociations involving traditional healers arc un
doubtedly very common in Nigeria among the Yor in a monograph on Yoruba medicines published by
uba. Out of a sample of 100 such healers studied in the institute of African Studies in Logon (1973).
I believe that much sifting and sorting has to be
the city of Ibadan in the mid-sixties it was found that
89 belonged to some kind of club. 25 different associ done and that a clear distinction needs to be drawn
ations were quoted by name, many of them being in between the kinds of conditions which traditional
the nature of local herbal guilds rather than pro practitioners are able to ameliorate and those in
.... latter
r
which their advice and operations may be positively
fessional organizations. The
term implies
responsibility for organizing a long process of system- disadvantageous to the patient. To take one example,
atic training and, whereas such healers do study for the treatment of young children by local herbalists is
• aegis
• ofr tne
*’ ? almost invariably harmful. The presence of traditional
years, it does not take place under the
healers should not be made an excuse by Govern
association.
The Ibadan healers we interviewed had begun to ments who wish to avoid responsibilities in the field
pick up their knowledge at about the age of 8 or 9. of maternal and child care or who will not expend
20% of them came from families in which healing was adequate resources upon the public health side of
an art or craft, handed down through many gener medicine by preventing those communicable diseases
ations. The remainder had been trained by individual which are known to cause the most childhood mor
medical or priestly experts. Taken on whilst very bidity and mortality.
Secondly, it is a mistake to analyse the activities of
young, they first worked under the guidance of an
older man, carrying out a variety of menial tasks the most revered healers purely in terms of a medical
before being gradually entrusted with more important model. Although some practitioners are primarily
ones. The length of this medieval type of apprentice herbalists, or bone setters, or circumcisors, there is a
ship varied, averaging 8 or 9 years. But some healers large group who deal with the social and psychologi
had studied for over 15 years and 6 declared that they cal disturbances in the lives of their clients. It is better
were still
still learning.
learning. The
The herbalists
herbalists built
built up
up aa know!knowl to regard these individuals as sources of spiritual or
‘
edge of many different herbs and naturally occurring religious support than to look upon them as purof veyors of esoteric physical treatments. Indeed there is
substances and their utilization in the
t‘..-manufacture
-----different kinds of medicines. There was never any an interesting example of a degree of syncretism
suggestion of organized group training, however, the already having been achieved between the therapeutic
approaches of this type of priestly Yoruba healer and
young boys were essentially assistants or acolytes.
Many of the herbalists in town advertised their ac those of a different religion. The prophets of the
Aladura Churches continue to wield the
tivities by means of sign boards, in exactly the same separist,
—--------------.
*
•
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way as sellers of bicycle parts or gramophone records charisma of their pagan counterparts and oiler help
specifimighi do. But some of the Babalawo (diviner priests) for psychiatrically disturbed patients whilst specih" rejecting the
:• : use of any drugs whatsoever. They
expressed a positive dislike of secular associations, cally
I hey
One declared that if a healer’s skills were sufficient use “the power of the Word” plus sanctified oil and
they would soon become known without any necess water and Christian symbols.
However, there is so little published material about
ity for public advertisements or special pressure to
the
activities of different kinds of African healers and
attract people to him.
What has not yet been definitely established is the way in which they go about their work, organize
whether the associations of herbalists that do exist treatments and relate to one another and to other
have sprung up simply in response to recent competi types of counsellors and practitioners that a paper
tion from scientific medicine or whether at least a like Dr Oyebola’s is immensely useful. Doctors and
proportion of them are manifestations of the tendency medical anthropologists throughout the continent
of the urban Yoruba to join clubs which represent to should be encouraged to make detailed notes on the
their occupational or social functions in the com- nature of traditional practice within their own locality.
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Discussion
101
it is only in this way that we can begin to build up a
y picture of the real diversity and worth of African
medicine and escape from the over-simplification of
misleading stereotypes.
lion de la blen-noraggie. Ils peuvent sc croirc affectes
par ces maux sans Petre au sens bio-medical. C'est un
fait d’observation courant que la diffusion de la
terminologie “cosmopolite” engendre cn Afrique,
comme aillaurs, de singuliers contrats de langage entre
Una Maclean
les pretendus specialistes et les soi-disanl malades.
1'iiiuersity of Edinburgh
L’auto-diagnostic du “paludisme” et 1'application
Scotland
extremement liberate de ce label medical (aux maux
de ventre, aux nausee aux fievres de toutes sortes, aux
affections hepatiques...) en est 1’exemple le plus
banal. Sans se faire I’avocat du diable, l’on peut sup
.e court article du Dr Oycbola leve un gros lievre poser que les deux “charlatans” mis en cause -comme
Jevant tous ceu.x qui s'interrogent sur les modalites de du reste leurs collcgues plus discrets et prudents—
I
■integration des praticiens traditionnels dans les beneficicnt de la resolution spontanee de certaines
’ . ystemes natioiuux de soins des pays africains. Je conditions pathologiques presentees par leurs clients
’• . -.'.ulignerai d'abord qu’il nous apporte des infor- (soux le denominations d’ “hypertension” ou de “blen1
mations peu diftusces ct done precieuses sur 1’ancien- norragie"), voire qu’ils offrant a ceux-ci des remedes
1 -’etc et sur le degre de professionnalisation a ma con- efficaces dans d'autres registres que ceux qu’ils affi• naissance exceptionnels—en Afrique Occidental des chant sur leurs panneaux public! la ires. Je veux dire
« i .-erijr-urs yoruba. Que les 156 “herboristes” de son seulement par la que les criteres objectifs retenus par
‘ • ich.f r-a ion auibi- solihai uue definition plus le Dr Oycbola (le test in vitro ct I’absence de m-sure
i »recise de celte population) appartiennent tous a une de 1 hypertension) ne suffisent pas pour prouver I’inefj ou a plusieurs associations professionnelles reunies ficacite therapeutique globale des deux guerisseurs
‘ ; lutour des objectifs liberaux enumeres dans Particle, epingles.
I soucicuses de controler la competence de leurs
Mais, I’essentiel du propos n’est pas la. Le Dr Oye; membres el regies par des codes de conduite suscep- bola aborde de fa(?on tranchante et je dirais par 1c
!?btes de servir de support a des sanctions, appliquees bout le plus facile—mais> comment lui en tenir
1
•< cas echeant par I'organe disciplinaire de 1’associa- riqueur?— plusieurs questions centrales pour laverur
ticn... tout ecci modifie nos idees repues sur la faib- des medecines africaines. La diversite et la dispersion
tesse panafricame de la professionnalisation medicale ethnique considerables des traditions medicales afri
I
en comparaison notamment avec les medecines asisti- caines et de leurs praticiens semblent un obstacle
ques.
majour—objectif, ethique, politique—a ieur integra
Les deux cas epingles par le Dr Oyebola, les ques- tion dans les systemes nationaux de soins. Est-ce que
•ions generates qu’il souleve et celles que nous les associations professionnelles de guerisseurs, le ou
1
) .omrnes en droit de lui poser en prennent d’autant elles existent ou celles que les initiatives des interesses
plus de relief. A vrai dire, il ne nous dit pas clairement eux-memes pourraienl susciter, la ou elles n’existent
•lejis ce textc si les deux guerisseurs incrimines appar- pas,
pas, sont
sont aa meme
meme de
de ss’’organiser
organiser en
en quelque
, structure
non—a----une—
de ces associationsj profession- institutionnelle iiium-cuiuiquc
* •iennent ou ---multi-ethnique ucucmuve.'/
(federative?) capable de
nclles et qu^es sortes de sanctions pourraient-ils peoocier Ieur reconnaissance officielle face
‘ncourir si imefficache de leurs traitements—notam- sen tan ts de la medecine cosmopolite? A supposer
ment dans le ces de la blennorrgie—etait rniss> en qu’une telle evolution soil concevable et souhaitable,
’ evidence par leurs pairs: eu somme,
s
il ne precise pas quel les garanties de competence, quel systeme
•Imrz r-ellc mesure et eventuellement par
j
quels d admission et de sanctions, quels codes deontologii •nb}\ les associations medicates yoruba cxercent un queS pourraient-elles proposer en contrepartie de
* controle eflectif sur fefficacite des soins dispenses par celte legalisation d’une sorte d' “ordre des medecine
t leurs membres lorsque ceux-ci se disent specialistes de traditionnels”? Et surtout a qui? L’on sail que le corps
maladies dont 1 evolution est controlable sans le con- medical
—
• occidental
• • • • fa^onne
■ par 1’ethique hippocraticours des outils de la medecine cosmopolite. Il me que tend a recuser les interventions de la justice dans
. rcpOudre peut-etre que sa question est precisement la. ses affaires internes et fonctionne bien sou vent comme
Mais alors en quoi consiste, “evaluation de la con- un corps juridique autonome. Compte tenu des rapnaissance” du candidal
par les membres des associ
t
...
roci- ports de force actuels, est-il imaginable qu’un etat
ations et <quelle place tientje'controle du charlatanis- africain puisse legaliser des institutions medicales
n:: entendu au sens yoruba—dans leurs codes deon- issues de la tradition sans Ieur imposer du meme coup
tologiques? Le lecteur reste sur sa faim quant a ce la juridiction propre—et rethiquc--de la medecine
point important.
cosmopolite?
e
tji Par ailleurs, les deux ces examines se caracterisent
Les exemples choisis par 1c Dr Oyebola sont parJ par la publicise donnee au traitemeht de deux aflec- lants a cel egard: ils appartiennent au registre des
Lons designees en tormes cspruntes au vocabulaire demarches mcdicales objeciivetnenl efticaecs (ou ineffi«l; biomedical.
»\'ous observons des phenomenes simi- caces selon les criteres enonces par la medecine occire
lairus dans beaucoup de villes ct de marches de dentale. Lidee sous—-jacente—que je n’attribue pas a
ft
urousse ouest-africains. Ils ,ont un autre caractere hauteur—est ciaire: s’il convient de proteger le public
"tsompeur” que j’aurais, pour me part, souligne. A la contre les pratiques objectivcment inefficaces. Ton
is
t! difference du Dr Oycbola, les clients des guerisseurs pourrait eventuellement legaliser celles dont I’efficaii !nc.nmincs-pas plus que leurs “therapeutes”—ne disc't5j.auir^ cte objectivement verifiee par la science
posent pas de moyens scientifiques pour rnesurer 1’hy- medicale? Autrement"dit?
, choisisso parmi ces
rv*rf«»n c ■ /it. mnr :
__
•
.
pertension ou pour identifier et pour suivre Icvolu- demarches
celles qui satisfont aux exigences de nos
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102
R. H. Bannerman ei al.
tests scientifiques et appuyons-nous sur les organis raison de demander des comptes aux guerisseurs yoruba qui s’avcnturcnt dans le champ semantique de la
ations professionnclles de ceux qui les pratiqucnt
medecine occidcntale. Mais, la direction dans laquelle
pour redefinir’ct pour ma it riser le charlatanisme.
sa
recherche nous oriente me semble receler aussi le
Malheurcuscnient — et le Dr Oyebola ne 1’ignore certainement pas—Pecrasante majorite des demarches danger de la meconnaissance des arts de guerison afrimedicales propremenl africaines nc se preterit pas a cains et le risque de leur assujettisement professionel
de telles procedures de verification experimentales. et ethique a la medecine dominante. Quitte a ctre le
Les ressorts de leur efi'icacite sont a rechercher dans cas echeant heurtes par leurs demarches ou par leur
I’interaction des variables biophysiques et symboli- deontologie, nous avons a decouvrir, et non a superqucs, psycho’ogiques et sociales que nos connaissance viser, les arts de guerison cn question. Les efforts
actuelles ne permettent pas d’abstraire du contexte d’integration des guerisseurs africains dans les
semantique ou dies exercent lours eflets. Le guerisseur, systemes nationaux de soins risquent de manquer leur
but tant que I’anthropologie medicale n’aura mis en
ses concepts, son statut professionnel, ses outils therapeutiques, sa deontologie ... sont partie integrants de evidence les mecanismes originaux qui differencient
ce contexte et de cctte interaction qui requiert genera- ces arts de la medecine posilivistc de 1’Occident et qui
permettront d etablir les bases juridiques de leur auto
lement la recherche d’un consensus social, plus ou
nomic.
moins large, autour de Paction medicale entreprise.
La professionnalisation et 1’ofticialisation des medecines africaines sous la tutalle scientifique et ethique t
Andras Zampleni
de la medecine cosmopolite modifierait considerableC.-V.R.S., Paris
ment les conditions d exercice et pur consequent leifiFrance
cacite de ces rnedecines. Assuremenl, le Dr Oyebola a
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