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TRADITIONAL AND BIOMEDICAL
HEALTH CARE SYSTEMS IN NORTHWEST ZAMBIA
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
2
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
system.
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
co-exists.
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
rituals.
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
20
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.
References
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1976 "Disease Etiologieslin Non-Western Medical Systems", American
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Frankenberg, Ronald and Joyce Leeson
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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
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FIGURE 1 ANALOGICAL SUBUNITS OF BIOMEDICAL AND
TRADITIONAL MEDICAL SYSTEMS*
*Ira Harrison and Priscillia Ulin (n.d.)
FIGURE 2 UTILIZATION PATTERNS OF TRADITIONAL AND
CHRISTIAN LUVALE
Traditional Medical
Biomedical
Midwifery
Traditional
Luvale
Christian
Luvale
x
x/J
0
(V0
0
o
(
Rituals Herbals
x
x
x
0
0
Taboos Maternal-
child
x 0
x x
x x
Surgery Pharma- Preven-
ceuticals tion
0 classic
(v most commc
x alternate
alternate
most commc
classic
full participation
no participation
partial participation
TABLE I WOMEN'S PARTICIPATION
IN RITUAL THERAPIES BY 'AGE GROUPS (PERCENTAGES)
TRADITIONAL VILLAGE PARTURIENTS
(by age groups) /
15-29
30-44
HOSPITAL PARTURIENT
(by age groups) .
15-29
30-44 45+
No participation
Divination only
Refused to follow
divination
30.6
16.3
Full performances 47.0
according to diviner's ,_
recommendations (includes
minor and spirit possession
rituals)
14.0 13.1 _8-L 58.4
14.0
i4.6
67.4
13.6
6.6
78.8
35.8
4.5
20.0
0
1.5
28.0*
52.2* 80.0*
*Majority are minor rituals and herbals
TABLE 2 BIOMEDICAL FACILITIES AND USAGE
Mission Hospital Staff and Facilities
Registered Nurses
RN : with Midwifery
Medical Assistant
Maternity Assistants
Housekeepers
Dressers
Outdoor Servants
Authorized # beds
Actual # beds
Under 5 clinics weekly
Mobile clinic monthly
Visiting MD biweekly
All Outpatients
average/month
8035
6106
4564
Under 5 Clinics
average/month
452
313
352
Maternity Services
average/month
22
21
25
Government Clinic Staff and Facilities
Medical Assistants
Malaria Assistants
Dressers
Female Helpers
Authorized # beds
Under 5 clinic weekly
Visiting RN or MD monthly
All Outpatients
average/month
1977**
1976
1975
1974
Under 5 Clinic
average/month
3189
* January to April
** January to June
1977*
1976
1973
TABLE 3 FETAL AND INFANT DEATHS IN
VILLAGE AND HOSPITAL PARTURIENTS
(IN PERCENTAGES)
VILLAGE PARTUTIENTS
(by age groups)
15-29
30-44
HOSPITAL PATURIENTS
(by age groups)
45+
15-29
20-44 45+
Fetal Deaths
(miscarriages and
stillbirths)
Infant Deaths
(neonatal and
1 month to 1
yeaw
16.1
33.3
26.5
23.5
20.1
11.8
20.1
8.3*
10.9 7.1
8.5* 17.9*
*Some of the infants of current parturients have not yet experienced these mortality
conditions yet.
TABLE 4 REASONS FOR HOSPITAL PARTURITION* (FREQUENCIES AND PRECENTAGES)
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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