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Title: Traditional and biomedical health care systems in northwest Zambia
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Full Text


Anita Spring
University of Florida

The Politics of Health Care Delivery in Contemporary Africa: Syracuse
University First Maxwell Africa Colloquia Series, March 2, 1979

Policy makers in Africa have given much consideration to improving the

health and health care delivery systems of people in their countries. One

of the issues confronting these policy makers is what to do with the sys-

tems of traditional medicine that already exist. Should the systems be

discouraged or banned? Even if desired, that is probably unenforceable?

Alternative policies have been suggested, such as utilization of tradi-

tional healers in the modern health sector along the lines of China's bare-

foot doctors. While policy makers, with the help of international groups

such as World Health Organization, have been thinking about coordinating

and integrating these systems, consumers have been doing this without much

difficulty. Patients have been utilizing both the biomedical and tradi-

tional systems and their practitioners as it seems appropriate to them.

This paper deals with health care delivery at the local level rather

than at the national policy making level. The theme is that health care

consumers make rational decisions and utilize options based on their knowl-

edge and beliefs about each system. Consumers are drawn to traditional

and/or biomedical cures which they view as complementary rather than con-

flicting. Policy makers must take into account the patterns of decision

making by the people who are the citizens and users of a particular service.

It is essential that national political leaders who make policy concerning

the biomedical system include in their calculations, the beliefs, preferences,

and experiences of their constituencies.

Charles Leslie writes "with the possible exception of a few small and

very isolated societies, all medical systems in the world today are plural-

istic" (1978:xii). This paper describes and analyzes a plural system in a


local area of rural Zambia which combines traditional and cosmopolitan

medicine. Participation in these medical systems sometimes overlaps, coin-

cides, or is mutually exclusive. Some people recognize conceptual distinc-

tions between the two systems and prefer one or the other based on expediency,

selecting from the range of treatments and services based on diverse cri-

teria. A major tenet of the paper is that Christians and traditional

religionists differ significantly in their faith and participation in

these two systems.

A conceptual framework which looks at the components and analogs of

"traditional medical" and 'biomedical" (cosmopolitan) systems can be used

to conceptualize and deal with the complex interaction of these two medical

systems within a given social group (Harrison and Ulin, n.d.). The scheme

(Figure 1) distinguishes between the "Traditional Medical" system, with its

components of traditional midwifery, herbalism, ritual manipulations and

taboos (prescriptive and preventive), and the "Biomedical" system with its

components of maternal and child health services, pharmaceutical services,

surgery and preventive medicine.

The scheme is quite neat as each aspect of the traditional medical

system links up with the biomedical system, and vice versa. Hence, herba-

lism finds its counterpart in pharmaceutical services, and traditional

midwifery corresponds to the area of maternal and child health. The

surgical aspects of cosmopolitan medicine find their correlates in manipula-

tive rituals. The authors specify bone-setting, blood letting, and foreign

object extraction as examples of these rituals: however, it is important

to note that this actually covers only some aspects of curative rituals.

Finally, traditional taboos with their aim of prescribing appropriate health

behavior, on the one hand, and prohibiting actions which may threaten

health, on the other, correspond to preventive health measures in the bio-

medical system. An aim of authors Harrison and Ulin who devised this

scheme is to document the conditions and contexts where collaboration be-

tween the two systems may or may not be feasible, with an eye to aiding

health planners. I find this scheme to be a heuristic model useful to

describe the Luvale traditional system and the biomedical system as it

actually exists, and to pinpoint usage by various groups of individuals.

By way of a brief introduction, the Luvale are a matrilineal society

of 300,000 hoe agriculturalists and fisherpeople who reside along the

Zambezi River and its tributaries in Northwestern Province, Zambia. There

are Luvale people in Angola and Zaire as well. They are organized into a

series of chieftancies, have a long history of commercial activities, and

may be described as modernizers. Their traditional medical and religious

systems have been described by C.M.N. White (1949, 1961) and the present

author. They are neighbors of the Ndembu Lunda people whose ritual and

symbolic systems have been studied by Victor Turner (1967, 1968, 1969).

The Luvale share very similar beliefs with other Central African peoples:

a removed high god, the spirit world, ideas of how sickness are caused and

methods of curing.

In general, Luvale and surrounding peoples have a traditional medical

system which Foster calls personalistic. By this he means that people

explain the nature of sickness as being due to "the active, purposeful

intervention of an agent, who may be human, nonhuman or super-

natural. (Foster, 1976:775). The sick person may be victimized by

witch or sorceror, ancestor or spirit, deity or powerful divine being,

often as punishment or in aggressive retaliation. As such, sickness is

part of a generalized notion of misfortune and, according to Foster, the

curer's primary roles become diagnostic. This categorization suggests that

all sicknesses have causative agents and there is little room for accident

and chance. This model only partially explains the Luvale system. There

are a great many sicknesses that are considered natural, especially in the

initial stages, and as such lack a causative agent. Here is where a large

repertoire of herbal treatments are employed and curers are true doctors,

not diagnosticians. In fact, Luvale traditional medical treatment of most

sicknesses commences with herbal remedies administered by the patient or

knowledgeable lay people. However, if the patient worsens or for any acute

or festering sicknesses, divination is mandated to pinpoint the cause and

recommend the appropriate treatment. The diviner identifies the cause of a

sickness (such as ancestral wrath, witchcraft or sorcery, improper behavior)

and suggests herbal, ritual, and proscriptive therapies, singly or in

combination. There are many alternative treatments within the traditional

medical system itself and presently, in combination with the biomedical


Two significant aspects in terms of choosing one or the other medical

system are the categories of illness and disease, and people's belief in

each system. The term illnesses, as used here, refers to socially defined

categories of sickness: these categories reflect how individuals perceive

and interpret changes in bodily states. Diseases, by contrast, are defined

by biological criteria (Lewis: 1976). The list of Luvale illnesses and

treatments is long and I have discussed them elsewhere (Spring 1976 b).

People believe that only the traditional medical system can cure some ill-

nesses such as barrenness, "watery and cold vagina," post-partum weakness,

weak penis, "rotten sperms," madness, kakale (described below), and some

chest and limb ailments. The traditional medical system also has categories

and treatments for such diseases as gonorrhea, bilharzia, elephatiasis,

leprosy, chickenpox, earache, backache, diarrhea, worms, and wounds. People

recognize that the biomedical system can also treat these and, in fact, is

successful in treating fevers, respiratory and gastro-intestinal ailments,

tumors and maternity complications. But there is no absolute notion that

certain sicknesses can only be cured by one system.

It is common to treat a sickness with herbals from a skilled herbal

doctor and then progress to various rituals performed by spirit possession

doctors if necessary. Luvale are skilled herbalists and people believe

that herbals have chemotherapeutic properties. For example, the crushed

roots of muyise (Securidaca longipedunculata) are used to commit suicide

when inserted anally or vaginally. There are many recorded cases and autop-

sies documenting this usage. Yet root scrapings are soaked to make a thick

paste which is used as a poultice for swollen legs. The boiled leaves of

the plant are drunk for coughs and colds and the steam inhaled during

possession rituals. In fact, chemical analysis shows that the plant con-

tains methyl salicylate, saponins, tannin, steroid glucoside, primaverose,

glucose, and xylose (Watt and Breyer-Branwijk 1962: 855). Hence it is not

unreasonable that herbals are viewed as efficacious and on a par with cos-

mopolitan pharmaceuticals.

There are many varieties of spirit possession rituals for sick adults

and children. All are elaborate, public, multiphasic events which also

include the use of herbal treatments. Rituals are always costly and involve

high social involvement for the patient and his or her family, but they are

based on the patient's physiological illness (Spring 1978). Victor Turner

has described several of these spirit possession rituals as performed by

the neighboring Ndembu in his excellent books, viz., Forest of Symbols,

The Drums of Affliction, and The Ritual Process, but he looks mostly at

social-conflict as the reason for enacting these ritual. Most herbal and

ritual therapies include the wearing of prophylactic amulets and the obser-

vation of various proscriptions which fall under the category of Taboo in

the Harrison and Ulin scheme. Finally, traditional midwifery utilizes

manipulative skills, herbals, amulets, and minor rituals for different cases.

The Luvale patient never attends a divination or engages a practi-

tioner personally. Various relatives consult one or more diviners on the

patient's behalf. Janzen,in a book The Quest for Therapy in Lower Zaire

which describes a closely related group,notes that the kinspeople who

surround the patient and "arrange for therapeutic consultation" may be

called a "therapy managing group." In Luvale society, this consists of

family members and friends living nearby who will manage the therapy and,

as Janzen notes, exercise "a brokerage function between the sufferer and

the specialists, whether this be for a hernia operation by a Western doctor

or a plant cure known to a traditional practitioner..." (1978: 4).

Only with recovery or death is therapy concluded. The lay therapy

managing group has an obligation to continue to seek treatment until one of

these two ends is reached. A whole cadre of specialists cater to these

therapeutic needs. These include male diviners, herbal and spirit possession

doctors of both sexes, and female midwives. The number of practitioners is

large and medical treatment costly, as each specialist consulted charges a

fee. Specialists who have cured people successfully are most in demand.

There is a bonus to being ill and recovering; the patient may become a

potential practitioner.by apprenticing himself or herself to the healer.

Individuals may take up a calling to be practitioners based on age, family

history, and personal volition.

I carried out research in 1970-1972 and 1977. People's faith and

participation in the fourfold traditional medical system was high. Within

the general local area of 13,000 persons and the specific research site of

2500 persons, I was personally able to attend and follow the course of

therapies for over 30 spirit possession rituals, dozens of minor rituals,

and scores of herbal treatments: these were just a fraction of the rituals

and treatments being performed. During the period approximately fifty

percent of all births were delivered by village midwives (several were

observed), while the other half utilized the maternity hospital in the area.

I also interviewed 300 women concerning their illnesses, childbirths, and

use of traditional and biomedical therapies (see Spring 1976a and 1976b).

These women were divided into village parturients (150 women) and hospital

parturients (197 women).

Within the area of maternal and child health, it was possible to

observe and quantify the utilization of the traditional medical system.

Table I gives the participation in ritual therapies by women who employed

traditional midwifery and hospital services, respectively. The charts

show that age and usage of traditional cures are correlated: older women,

even those who are hospital parturients, had more ritual and herbal treat-

ments than younger women. At the same time, users of hospital facilities

employed the personalistic diagnostic procedures less frequently than their

traditional counterparts. Also, there are some women who deliver in the

villages, but do not seek other indigenous diagnoses and they rely on

biomedical services treatment.

Clearly, people who participate in the traditional medical system also

can utilize the biomedical system, either in part or fully. Cosmopolitan

medicine was introduced in the 1920s by American missionaries who combined

healing with proselytizing. The first Christian group was the Plymouth

Brethren (Christian Mission in Many Lands), and they continue to be the most

successful. The Brethren, a fundamental Protestant religion, do not allow

their members to drink, dance or smoke. As carriers of western culture and

a new religion, they subscribe to the view that, if one accepts Christianity,

many aspects of traditional African culture become unacceptable. Christians

are forbidden to attend any event in which dancing, drumming or traditional

singing occurs, which is precisely the context of curing rituals. They

also cannot utilize protective amulets since these have ritual antecedents.

(Some people feel it is healthier to be a Christian because one gives up

drinking and traditional therapies.) Two parts of the traditional medical

system are automatically and by edict eliminated from their repertoire of

health care. Purely herbal treatments and traditional midwifery are not

defined as anti-Christian per se, but they are disavowed by all biomedical

health practitioners. Nevertheless, they may be utilized in varying degrees

by Christians and their families precisely because they are part of "home

remedies". Christians use all aspects of the biomedical system. To be a

Christian is to change one's life style in terms of religion, health care,

marriage patterns and recreation. Christians consider themselves modern

and frequently are wealthier than non-Christians, as many own and manage

stores and small businesses in the area. In some families all members are

Christians, while in others only certain individuals are. In the local

settlement there are three churches, two of which are Brethren. Regular

church-goers consisted of no more than 10-15 percent of the population

(approximately 200-300 persons). However, the percentage of Christians is

higher in the settlements closer to the Mission (perhaps 30 percent) and

almost unanimous for those who actually reside on Mission grounds. Over

the years the Brethren have built a good reputation for biomedical therapy,

especially maternity services, and operate a hospital in the area staffed

with highly trained (European and American) midwife-nurses, Zambian birth

helpers, orderlies and dressers and a visiting American or British doctor

(see Table 2).

In 1955, at the request of the local people, the government built a

clinic three miles from the Mission Hospital. It is staffed by orderlies

and dressers, who have had short courses? an expatriate doctor and a Dutch

volunteer nurses visit monthly. In subsequent years, government operated

hospital facilities in the town (which is fifty miles away) also have in-

creased. People utilize prenatal and maternity services, such as the

Mission Hospital, the children's under-5 clinics, immunization programs,

and general in-and out-patient services at both facilities. All services

are free but an in-patient must provide his or her blankets and food.

Usually, one or more members of the therapy managing group also stay at

the hospital or clinic to help their relative. Attendance at these various

facilities is high, especially in relation to the number of health care

professionals (see Table 2).

The population utilizing these services is approximately 13,000.

Combining monthly totals of both Mission Hospital and Government clinic,

it might appear that everyone attended about once a month. In fact, sick

persons may go many times to receive medication for the same sickness, and

they are counted each time. The practice of cosmopolitan medicine, espe-

cially in the government clinic with its few trained people, often becomes

reduced to simply dispensing medicines. Luvale have high usage of tradi-

tional herbals, and they are desirous of biomedical pharmaceuticals as well.

They readily accept medicines given to them. Injections are considered the

most "modern" and efficacious, but "things to drink" and tablets are

regarded highly. Pharmaceutical services are valued because people believe

taking a great deal of medicine is efficacious, and medicines from both

systems are combined freely.

Considering maternal and child health services, utilization of the

Mission's maternity services has been increasing steadily in the past 25

years because the highly competent staff has reduced maternal and.infant

mortality dramatically and people perceive this (Spring 1976a, 1976b).

Perhaps more than considering the number of visits to clinics, it is useful

to compare the results of subscribers to traditional and biomedical systems,

realizing that often people do not limit their usage to only one system (as

will be discussed below). The tendency to seek biomedical treatment is

reflected in the differences between village and hospital parturients in

terms of complications of pregnancy, fetal deaths, and child mortality.

It should be noted that 96.3 percent of the village parturients have had

only village deliveries, whereas only 48 percent of the hospital partur-

ients had hospital deliveries exclusively. It is expected that the

percentage of hospital maternity cases will continue to increase.

Nevertheless, comparing the two populations (Table 3) shows that the rate /

< of fetal deaths is twice as high for village as for hospital parturients

-- -- (31 percent compared with 15.1 percent). Also significant is the fact that

many of the stillbirths and neonatal deaths among the hospital parturients

occurred during previous village parturition. Furthermore, the infants of

village parturients have higher mortality rates than their hospital counter-

parts, even though some of the infants of current hospital parturients have

not yet experienced these mortality conditions.

Women who delivered in hospital were asked during their confinement

why they preferred hospital parturition. Table 4 shows that 33.1 percent

perceived village deliveries negatively; another 28.8 percent had positive

images of hospital parturition; 25.2 percent utilized the service because

it was free. Only about 15 percent of these women were practicing Christians,

although 45.2 percent had some schooling where they were exposed to

Christianity. It is worth noting that women who utilized hospital services

had reduced participation in traditional rituals, even though the majority

were not Christians (see Table 1).

The Luvale patterns may be contrasted with the study of the usage of

health care facilities among urban Zambians by Frankenberg and Leeson

(1976). They found a polarization in the usage of cosmopolitan and tradi-

tional doctors. Physicians were inexpensive and sought for acute sicknesses

with physiological aetiologies whereas traditional doctors were expensive

and sought for misfortune with social aetiologies, i.e., survivors con-

sulted them concerning chronic sicknesses. Although Frankenberg and Leeson

may be correct in their analysis of Zambian urbanites, rural people use

traditional doctors for acute sicknesses with physiological aetiologies also.

In fact, many anthropologists continue to believe that traditional medical

systems are only magico-symbolic and that biomedical systems do not rest on

faith. Janzen in his study on Zaire notes that he "needed to ask questions

such as 'Why would a well-educated teacher or nurse resort to African thera-

pies lacking any clear chemotherapeutic component defined only by the

symbolic?'" (1978: 33), implying again that sickness is socially created

and therapies are only magical. Many Central African herbals are

efficacious as chemotherapeutic agents, and educated people believe in them.

It must be pointed out that subscribers to cosmopolitan medicine must place

their faith in the physicians or hospital as well as in the penicillin.

This is clearly seen among the Luvale who say the Mission Hospital is better

than the government clinic and who prefer particular nurses and physicians

over others.

The decision to choose the biomedical rather than the traditional

medical, or vice versa, depends on many factors. With no transportation

other than by foot or bicycle, the degree of proximity to hospital or

clinic is significant. In one case, a Christian woman who lived nine miles

from the hospital was told during her pre-natal check-up that delivery

would occur within 24 hours. Sent home to get her blankets and supplies

she was unable to return in time and had to employ a traditional midwife.

Persons who do not have a therapy managing group because their relatives

are away or they are new in the area (such as refugees from Angola) might

initially seek the biomedical treatment because it is free; they can attend

individually; and they do not require a broker. People who are not Chris-

tians but wish to consider themselves modern often go to the hospital. In

the case of one delivery which I observed, labor commenced in the village

and the midwives believed they could handle the complicated case. But a

feud occurred between the husband who supported the midwives and the wife's

matrilineal relatives who believed hospital delivery was appropriate for

their educated daughter-a fortunate decision as intensive life saving

turned out to be necessary. The decision was not based on physiological

events but on belief systems.

Many individuals in fact seek treatment from both biomedical as well as

from the traditional medical system; others use only one. Several divergent

patterns emerge (see Figure 2) which reflect either Christian or non-

Christian utilization of health care facilities. In terms of traditional

religionists, a classic pattern is the usage of the traditional medical

system (pattern A). These people reject biomedical services or live quite

far from them. But the most common pattern (pattern B) has been for these

people to utilize the biomedical maternal and child health care services in

varying degrees in addition to the traditional medical services. Even

village midwives send their patients to the clinic for confirmation of

pregnancy, and only approximately half of pre-natal clinic patients deliver

in the hospital (Ms. Joyce Finch, personal communication ). Traditional

mothers tend to utilize the widely popularized "Under 5 Clinics" for sick

and well children, often in combination with herbals and rituals. Immuni-

zations and medicines are dispensed during these clinics. Thus, people are

partially utilizing pharmaceutical and prevention services as well. Finally

an alternate pattern (pattern C) is that some non-Christians combine vir-

tually all aspects of the traditional and medical systems at one time or

another, using a variety of criteria which may change with each illness.

In terms of maternity services, mission nurses note that the traditional

ritual known as "curing or washing the baby" is carried out in the hospital

after hours. Spirit possession and herbal doctors may perform their serv-

ices to pre-or post-operative patients on hospital grounds. In essence,

traditional religionists add the biomedical system totally or in parts to

the traditional medical system and combine them as they see fit, concep-

tually and in terms of expediency.

One example of this is the case of Linda, whose family included many

herbal and spirit possession doctors. She miscarried her first pregnancy.

She was given many amulets and herbal prescriptions and her second preg-

nancy was attended by traditional midwives. But the baby died a month

later. After consulting diviners her relatives discovered she was afflicted

by ancestral spirits, and several large possession rituals were held in

public. During her third pregnancy, medicines and a possession ritual were

employed. She also attended the pre-natal clinic and was taken to the

hospital for delivery. Following delivery, mother and baby utilized both

traditional herbals and rituals and attended post-natal and "Under 5 Clinics."

Maternal and child health services were freely interspersed with all tradi-

tional components.

On the other hand, most good Christians categorically reject the tradi-

tional medical system (pattern F), but occasionally are forced to rely on

traditional midwifery as noted above. A second common pattern (pattern E)

is to employ all aspects of the biomedical system but utilize herbal reme-

dies as well. Part of the reason for this is that "over the counter

medicines"-aspirin, malarial suppressants, laxatives, antidiarrheals, etc.-

are only sometimes available in stores. They are costly and just beginning

to take their place along Luvale herbal "home remedies." However, even

Christians believe in the chemotherapeutic properties of herbal remedies.

Occasionally, a third alternate usage pattern (pattern D) is that Christians

in desperation will employ minor, private rituals which are enacted in

combination with herbal medications. The treatment may be prompted by the

non-Christian members of a therapy managing group and may be carried out

somewhat furtively. This procedure usually occurs for sick children. Like

parents elsewhere, even Christians and believers in cosmopolitan medicine

are willing to utilize a treatment from another medical system, hope that

it will cure a sick child.

An example of this is the case of Mary, who had several years of school-

ing and was married to a Christian. When their seven year old daughter

became feverish, Mary took the child to the clinic. The child fainted after

receiving an injection and was taken home where her symptoms were inter-

preted as kakale, a Luvale illness whose symptoms include paleness, vacant

stares, foaming at the mouth, clenching the fists, and fever; it probably

is malaria. Herbal remedies were begun by the grandmother, and subsequently

two additional herbal doctors were employed who administered medicines.

Some of Mary's non-Christian family even sought advise from three diviners.

The first recommended a spirit possession ritual which was impossible for

the family to carry out; the second and third advised a private, minor

ritual with herbal medications. This was acceptable to the family but

enacted away from the Christians and without fanfare. The child recovered-

most probably because the anthropologist was also requested to give medicine

and administered treatment for malaria. However, one herbalist was credited

and received a large fee. In this case the mother sought biomedical treat-
(but was given the wrong medication).
ment on her own for acute illness/ Some of the therapy managing group later

pursued traditional treatments, also for acute illness while others solici-

ted the pharmaceutical services of the anthropologist.

In sum, it is clear that consumers of health care need to believe in

the merits of the medical system to which they subscribe. The notion pre-

sented here is that the significant influences affecting choice are based

on faith in a system and its pharmacopoeia primarily, but expediency,

financial resources, and hopelessness influence secondarily. Traditional

religionists accept the biomedical maternal and child health services

because they see good results and have come to believe that those services

really help. They are also free. But people would not think of foregoing

the ritual, herbal and proscriptive aspects of the traditional medical

system which address underlying casualty, on the one hand, and provide

efficacious therapy on the other. Hence a variety of utilization patterns


Both traditionalists and Christians accept some or all of the bio-

medical system because they believe in ingesting herbals and/or pharma-

ceuticals to cure sickness. People seek alternatives within the herbalist

tradition on the one hand and it is easy and convenient to add a new

pharmacopoeia on the other. Christians, a small subset of the population,

have changed their usage because of edict. But even Christians, who put

faith in the biomedical system as being consistent with their modern life-

style, often rely on herbals or in desperation undergo traditional minor


I have discussed Luvale and Northwest Zambian usage of the traditional

and biomedical health systems and therapies in terms of belief systems. A

consideration of the providers of health care in terms of delivery and

policy making is useful. If governments such as Zambia consider using

traditional healers in health care they need data on the attitudes of

modern and traditional practitioners towards each other, and information

on where traditional healers could fit into the biomedical system. I did

not collect quantitative data along the lines of Imperato (197L-75) as

to whether or not a particular category of health workers would support

cooperation with health workers of the other system. But it is possible

to give observational data on this subject. In general, biomedical

personnel in Zambia do not distinguish between herbalists, diviners and

possession doctors (some individuals are two or more of these) but call

them all "witch doctors." Midwives or traditional birth attendants are

differentiated, even though many of these women are also herbalists and

spirit possession doctors. For the most part, traditional healers are

perceived negatively because biomedical personnel so often see the failures

of the "village" (traditional) treatments. (Patients are brought late in

the course of the disease and are "stuffed" with herbal medications.)

Furthermore, the methods of traditional healers are viewed as unhygienic.

Christian medical workers see traditional healers as anti-Christian and

close to the devil, that is, undoing the work of the missionaries. (Messing

(1976) accuses medical missionaries in Ethiopia as having sub-colonial

attitudes towards traditional medicine and healers, and this is the case in

Zambia as well). However, it seems that midwives, especially those who

become Christians, are better received by the health workers and could be

easily incorporated in the biomedical system as they pose very little

threat to the system.

In terms of traditional health professionals' views of the biomedical

staff, midwives send their patients to maternity (ante-natal) clinics for

confirmation of pregnancy and to receive medicine as noted above. The

midwives showed me breathing techniques learned from European midwives.

Spirit possession doctors do not discourage their patients from hospital

deliveries either. Both of these specialists perform various rituals on

the hospital grounds. Herbalists and diviners use hospital facilities for

themselves, their family and patients. But they believe European medicine

cannot cure everything. They supplement their own cures with biomedical

ones. If they give medicine and the patient recovers, they claim that their
that with socialized medicine
treatments were efficacious and demand payment. (They know/the biomedical

services are free so that patient will not have another bill.) The situa-

tion might be different if people had to pay for biomedical services and

drugs as elsewhere in Africa.

I believe traditional healers would be quite willing to share their

knowledge with biomedical health workers under certain circumstances which

can be considered under two headings: renumeration and knowledge exchange.

In the indigenous system, people learn ritual cures and herbal remedies

because they experienced an illness, recovered, and paid money to the curer

for the treatment and an additional sum to learn the medicines and gain the

power. "Tree or herb that I paid for, not just looked at" is a Luvale

proverb meaning that without payment, transfer of the knowledge is value-

less. But at the same time, traditional healers know that the biomedical

system is free and that perhaps they could forego payment on a reciprocal

exchange of knowledge and medicine.

Harrison ad Dunlop (1974-75) and Singer (1976), note that there are

pros and cons to incorporating traditional healers in health care delivery.

On the positive side, traditional healers could help in the health care

"people-power" shortage. They know the indigenous culture and belief sys-

tem, are available locally, have interpersonal and therapeutic skills, and

have a recognized status. On the other hand, there are problems concerning

their training and their work and status in relation to other health

workers. Their emphasis on curative rather than preventive medicine may be

a limitation. Some questions of the use of traditional healers in primary

health care involve whether or not they are useful only when no one else

is available or if they have something to offer in terms of

their own treatments. Certainly, the data coming in from Nigeria suggests

that traditional healers there have enormous contributions to make, par-

ticularly in terms of psychosomatic medicine. Furthermore, this contribu-

tion is recognized by the many Nigerian biomedical professionals within the

country who are in decision-making positions. It is in places such as

Nigeria where some traditional healers are already working with the bio-

medical system and the question is how to incorporate more.

The situation in Zambia differs. Many educated, Christian Zambians

still respect traditional ways and sometimes utilize these treatments. Con-

sumers, I have argued, do not have much problem using both systems, but

expatriates and some doctors trained in the cosmopolitan system may. At

the present time, there are more non-Zambians than Zambian physicians and

nurses and these people have.little respect for traditional healers or see

them as curiosities at best. Traditional birth attendants are the exception

and they could easily provide maternal and child health services and family


However, even if the political decision makers suddenly decide to follow

the recommendations of international agencies and attempt to include tradi-

tional healers, it is my contention that the incorporation of these healers

would require more support of medical personnel at all levels and this may

be possible only when there are more Zambian biomedical professionals.


Foster, George M.
1976 "Disease Etiologieslin Non-Western Medical Systems", American
Anthropologist 78:4:773-782.

Frankenberg, Ronald and Joyce Leeson
1976 "Disease, Illness and Sickness: Social Aspect of the Choice of
Healers in a Lusaka Suburb", in J.B. Loudon, ed.,
Social Anthropology and Medicine, London: Academic Press,
pp. 223-258.

Harrison, Ira and David Dunlop, eds.
1974-75 "Traditional Healers: Use and Non-use in Health Care
Delivery", Rural Africana, 26

Harrison, Ira and Priscilla Ulin, eds.
n.d. Traditional Healing: Continuity, Discontinuity and Consequence
(in preparation).

Imperato, Pascal
1974-75 "Traditional Medical Practitioners Among the Bambara of Mali
and Their Role in the Modern Health Care-Delivery System",
Rural Africana, 26:41-53.

Janzen, John
1978 The Quest for Therapy in Lower Zaire. Berkeley, California:
University of California Press.

Lewis, Gilbert
1976 "A view of Sickness in New Guinea", in J.B. Loudon, ed.,
Social Anthropology and Medicine, London: Academic Press,
pp. 49-103.

Messing, Simon
1976 "Traditional Healing and the New Health Center", Conch VIII:
1 and 2:52-64.

Singer, Philip, ed.
1976 "Traditional Healing: New Science or New Colonialism?" Conch
VIII: 1 and 2.

Spring, Anita
1976a "An Indigenous Therapeutic Style and Its Consequences for
Natality", in J. Marshall and S. Polgar, eds., Culture
Natality, and Family Planning. Chapel Hill, North Carolina:
Carolina Population Center, pp. 99-125.

1976b Women's Rituals and Natality Among the Luvale of Zambia,
Ph.D. Dissertation, Cornell University.

1978a "Epidemiology of Spirit Possession" in J. Hoch-Smith and A.
Spring, eds. Women in Ritual and Symbolic Roles. New York:
Plenum Press, pp. 165-190.

1978b "A Population 'Crisis' Comes to Zambia:
Presume'", paper presented at the annual
for Applied Anthropolgy, Merida, Mexico,

Or 'Dr. Malthus, I
meeting of the Society
April 5.

Turner, Victor W.

1967 The Forest of Symbols: Aspects of Ndembu Ritual.
Ithaca: Cornell University Press.

1968 The Drums of Affliction. Oxford: Clarendon Press.

1969 The Ritual Process: Structure and Anti-Structure.
Chicago: Aldine,

Watt, John and Maria Breyer-Branwijk
1962 The Medicinal and Poisonous Plants
Africa. Edinburgh and London: E.

White, C. M. N.
1949 "Stratification and Modern Changes
Africa, 18: 324-331.

of Southern and Eastern
& S. Livingstone.

in an Ancestral Cult",

1961 "Elements in Luvale Beliefs and Rituals", Rhodes-Livingstone
Paper, No. 32.


*Ira Harrison and Priscillia Ulin (n.d.)


Traditional Medical







Rituals Herbals



Taboos Maternal-

x 0
x x
x x

Surgery Pharma- Preven-
ceuticals tion

0 classic
(v most commc
x alternate

most commc

full participation
no participation
partial participation


(by age groups) /



(by age groups) .


30-44 45+

No participation

Divination only

Refused to follow



Full performances 47.0
according to diviner's ,_
recommendations (includes
minor and spirit possession

14.0 13.1 _8-L 58.4













52.2* 80.0*

*Majority are minor rituals and herbals


Mission Hospital Staff and Facilities

Registered Nurses
RN : with Midwifery
Medical Assistant
Maternity Assistants
Outdoor Servants

Authorized # beds
Actual # beds

Under 5 clinics weekly
Mobile clinic monthly
Visiting MD biweekly

All Outpatients


Under 5 Clinics


Maternity Services


Government Clinic Staff and Facilities

Medical Assistants
Malaria Assistants
Female Helpers

Authorized # beds

Under 5 clinic weekly
Visiting RN or MD monthly

All Outpatients


Under 5 Clinic


* January to April

** January to June



(by age groups)



(by age groups)



20-44 45+

Fetal Deaths
(miscarriages and

Infant Deaths
(neonatal and
1 month to 1









10.9 7.1

8.5* 17.9*

*Some of the infants of current parturients have not yet experienced these mortality
conditions yet.


1. To escape high payment of midwives 35

SUB-TOTAL: Economic reasons 35 25.2%

2. Nurses have good medicines 32
3. "Educated women should go to the hospital" 8

SUB-TOTAL: Positive images of hospital deliveries 40 28.8

4. Fear of retained placenta 20
5. "Too many fingers in the vagina make it swollen" 7
6. Difficulties in previous village deliveries 6
7. Previous child died in village deliveries 3
8. "If baby dies in womb, they cannot get it out" 2
9. "Too many women in the house" 2
10. "They make you push too hard" 2
11. "You have to go for divination" 4

SUB-TOTAL: Negative images of village deliveries 46 33.1

12. "I was sick" 8
13. Referred through prenatal clinic 3
14. "I am too old" 3
15. "No one to care for me in the village" 2
16. "I am too young" 1
17. "To rest" 1

SUB-TOTAL: Personal situattons- and miscellaneous 18 12.9

TOTAL 139 100.0%

*139 out of 197 Hospital Parturients responding.

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