CONVERGENCE IN EURO-MODERN AND AFRO-TRADITIONAL MEDICINES: PEN-3 Conceptual Model of Analysis to Ethnomedicine Practices for Increased Choices to Meet Increasing Demand for Healthcare Services in Africa.
By Peter-Rhaina Gwokto, Str8talk Magazine, 2017-06-24
Most developing countries, especially those in Africa, suffer severe shortage of modern medical doctors and healthcare personnel. There are two distinct providers of health care in Africa and, indeed, most developing countries: first the ethnotraditional or pre scientific who practice traditional cures, and second, the western or euro-scientific who provide modern healthcare. Although the two may structurally co exist, they nevertheless, remain functionally separate. Ethnomedicine is the most approached by 80% of Africa’s rural and to some extent, low-income populations in urban centersi.
This paper examines innovations in the practice of ethnomedicine and the possibilities for articulating ethno healthcare practices towards a non-explosive convergence with modern medicine. It is expected that partial or total convergence will increase choice in the care delivery system thereby providing accessible, effective, adequate, acceptable, and efficient minimum care for all.
The PEN 3 model of analysisii is used to examine two critical associations in the practice of ethnomedicine. These are first, the influence of culture on traditional cures and practices, especially the symbiosis that characterizes their relationship. Second, how community health education is influencing the relationship between ethnotraditional behavior patterns and ethnomedicine practices.
THE PRACTICE OF ETHNOMEDICINE
Despite the scientific, economic and cultural dominance of developed Western nations in Third World countries, indigenous forms of healing and beliefs remain vigorous in many countries of Africa[iii]. However, a greater part of the contributions made by ethnomedicine to overall health care delivery in Africa remains obscure and scientifically unproven, crude, often ineffective and dangerously annihilating by their long‑term consequences. This leaves a smaller, but nonetheless a vital area that calls for modern methods of scientific research and evaluation.
As we begin to unravel the paradoxical potency of ethnomedicine in Africa, there are several questions which require concerted answers, including: Is traditional medicine effective? To what extent have national health policies addressed ethnomedicine as a vital alternative to scarce, generally inaccessible and expensive western medicine? And, what measures have been implemented to curb excessive use and rampant abuse of traditional medicine.
First, here are a few illustrations about the environment in which ethnomedicine have thrived since time immemorial. Culture and beliefs, the poverty of African individuals, households and nations, and the natural environment are some key factors which continue to shape and influence the practice of ethnomedicine. Together they make the modus operandi for determining disease cause, treatment and prevention.
At any one time, the traditional health care delivery system exhibits three types of practitioners. They are distinguished by area of specialization – typically a pseudo professional categorization that sharply contrasts with the western-type diagnostician, psychiatrist, pharmacist, surgeon, gynaecologist and pathologist, to name a few. There is the herbalist who uses herbal and other organic concoctions to treat known and unknown illneses. There is the diviner or fortune teller who functions within a seemingly supernatural and spiritually charged entity and acts as an intermediary with the ancestral shades[iv]. And there is the faith healer (a recent addition) who integrates soul-searching religious orthodoxies and traditional spiritual values into a complex and supposedly therapeutic interpretation that is based exclusively on his understanding of the circumstances surrounding the illness. Treatment is incomplete unless the doctor, diviner and the faith healer have sequentially performed their roles, presented their views, and administered remedial curatives. This horizontal stages of treatment is akin to the modern process in which rehabilitation or counseling may follow physical or psychological therapy.
When a person is ill, the Zulu believe that both the body and spirit are affected and for health to return, both physical and spiritual treatment is necessary. They are adept to the idea that while Western medicine is appropriate for treating the physical side of illnesses, the spiritual aspects are better understood by traditional healers”[v]. With the advent of modern medicine, a shift towards consolidating and preserving the values of ethnomedicine has occurred such that both modern and traditional health practices have had to differentiate between the etiology, diagnosis and prognosis of a disease.
In a majority of African cultures and communities, a distinction is often made between diseases or conditions which are African and those that are foreign. Those that are African are thought to be best treated by ethnomedicine practitioners while the foreign, modern medicine. So how does one distinguish between disease conditions that are African and those that are foreign. For example, the Swazi believe that cholera is a European illness and gonorrhea is a Swazi disease. The commonly held view is that gonorrhea is transmitted through sorcery[vi]. It is such accompanying unscientific beliefs and explanations, scientifically unproven diagnoses, and rudimentary treatment practice that pose great health risks and inhibit the possibilities for convergence between modern and traditional medicine.
There has also been a tendency to associate disease contraction with breached societal norms, values, culture, and beliefs. This, in fact, dilutes the severity of an illness and as such, effective treatment may come but only too late for the victim who will have been either maimed or dead. The perception towards likhubalo (drop), or gonorrhea in Southern Africa given above, offers a vivid example.[vii]. It is purported to be an act by a possessive husband who attempts to ensure the fidelity of his wife by making a small ‘drop’ from his penis that will remain in her vagina for the duration he is way from home. On the one hand, the irony in this association arises from the totally wrong assumption that if another man had sexual intercourse with the infected woman, he will develop likhubalo symptoms while the woman remained asymptomatic[viii]. This is simply not true. On the other hand, treatment made from a concoction of herbs smeared on the man’s penis has been found to offer effective cure.
It is evident from the above observations that ethnomedicine lacks the basis for understanding and interpreting the etiology and cause of most diseases. Modern medicine can only benefit from research into the effectiveness of traditional therapy.
Another critical trend in ethnomedicine has been the abuse of oxidizing chemical compounds by traditional healers. Tribal enemas have, for a long time, been used widely as purgatives for indications of psychosis, constipation, headache, psychiatric disturbances, sexual dysfunctions and gonorrhea. However, recent research[ix] found that the inclusion of lethal and injurious substances such as potassium dichromate as ingredients of traditional medicine, have not only resulted in renal failures, perforation of the rectum, gastro‑intestinal hemorrhage, and hepatocellular dysfunction, but have also alerted modern physicians of dichromate poisoning and the challenge of preventing illicit, corrupt and harmful ethnomedicine practices. Between January 1980 and November 1989, nine patients were admitted in Baragwanath Hospital in Soweto following traditional medical usage for the treatment of unknown diseases. All had bloody diarrhea and vomiting, one suffered perforation of the rectum, one died after taking dichromate solution orally, all had 4‑6 times more concentration of red blood‑cells than plasma.
Stimulated by increasing competition and a crude show of competence in modern medical vocabulary, the above addition of injurious chemical agents has been compounded by the precarious increase in the abuse of modern clinical practice technology. For example, the traditional administration of enema using truncated cow horn has been replaced with the hypodermic syringe. Aggravating this problem is the fact that formerly pure herbal concoctions now contain industrial agents such as turpentine, chloroxynenol antiseptic (Dettol), ginger, pepper, soap, vinegar, copper sulphate, battery acid and potassium permanganate. Incorporating modern tools of dispensing and industrial chemical agents in a practice which traditionally relied on less oxidizing herbal remedies such as roots, tree bark, bulbs and leaves, indicates the magnitude to which ethnomedicine has deviated from being the most accessible and affordable alternative health care provider.
The examples cited above do not necessarily suggest that ethnomedicine in Africa is dangerous and ineffective and, therefore, should be banned. Although ethnomedicine is premised on beliefs rooted in remote supernatural and spiritual shades that are alien to modern sector practitioners[x], modern medicine has, itself, gained abundantly from African traditional medicine. For example, dental complications are rare because chewing sticks commonly used in the removal of plaque have been tested and found to contain fluoride ions as well as anti-microbial, anticariogenic, anti‑inflammatory, antihypertensive, antimalarial and astringent properties[xi]. Nineteenth century ophthalmologists also obtained the first miotic, originally named physostigmine and later ‘Eserine’ from the physostigma venenosum (Calabar Bean) used by the Efik of Old Calabar to poison criminals in acts of mercy executions[xii].
Outside Africa, “traditional Chinese medicine with its rich clinical experience, its unique theoretical system and its extensive literature”[xiii], has ensured greater health for the region and the world at large. Acceptance and crediting of many Chinese medicines orthodox practices such as acupuncture by the West however leaves a number of semantic question to be answered about the effectiveness of African medicine. Is there a Western bias against typically African medicine despite the history of curative traditional medicine and the continent’s ecological endowments. Not much resources and research have been directed towards studying the potency of African medicine.
One practice that has been recognized widely is that of the traditional birth attendant (TBAs). For generations TBAs have been prominent and continue to be the most accessed ‘midwives’ in Africa. Countries such as Zimbabwe and Nigeria have not only integrated limited modern technology but have also facilitated TBA practices by teaching safe methods especially in cleanliness and sterilization of delivery tools such as scissors, razors, clothes, and water (Green,1988).
THE INTER‑RELATIONSHIP BETWEEN CULTURE AND ETHNOMEDICINE
In any study of ethnomedicine and its practice, avoiding overlap between the culture of a people and its ritualistic way of diagnosis and treatment is near impossible. On the contrary, all customary norms and rituals surrounding, for example, birth, weaning, marriage, age-group induction, tribal body and facial marks, and death are manipulated to achieve one ultimate objective for the community at large: its health. This means the definition of anything harmful also varies from one culture to another.
In fact, not all existing facets of African culture and ethnomedicine can be ascribed to be effective in restoring and insuring a person’s health. A society’s attitudes and behaviour in respect to sickness presents a useful dimension for assessing obstructions and delays caused when patients are readied through certain customary rituals before modern medical interventions. For the majority, interpretating disease etiology in a logical scientific manner is further inhibited by high illiteracy rates, low levels of health education and the increasing dominance of traditional healers in unscientific diagnosis, therapy and sometimes, prognosis.
For example, a qualitative study[xiv] of the views and experiences of a female isangoma (Zulu traditional healer) taken to explore her potential roles in AIDS/HIV prevention found that although she had accurate knowledge of the transmission mechanisms, risk groups and prevention strategies, her “questionable beliefs included a nazi conspiracy as the source of AIDS, a string ritual to prevent promiscuity, and a conviction that she could treat AIDS”[xv]. In this case, the dilemma to modern medicine in any instance of convergence is that despite her questionable beliefs, the isangoma is an important point for disseminating information on AIDS/HIV transmission and prevention in rural and poor urban communities.
Another study of lay people’s perspectives on illness and therapeutics among the Kel Tamasheq nomads of Mali[xvi] and the Rajasthani Indians[xvii], found that ‘hot/cold’ illness (or tekushe/ tessumde in Tamasheq) and ‘hot/cold’ therapeutic foods and medicines are commonly associated with etiology or cause of a condition as well as the implications for appropriate treatment. The expressions lyeto and ngico are used by the author’s Acholi tribe in Northern Uganda to refer to hot and cold, respectively. Having lyeto means a body state of high fever and a condition of extreme ngico (resulting in shivers) is often a state of malaria.
‘Heat’ and ‘cold’, though humorous in application, do not only relate to casual categories like fever, malaria, ulcers, boils or rashes but also conditions under which a sickness may be caused. A belief held by Indians of Rajasthani origin in Africa is that dath (venereal disease) arises from excessive sexual activity or from copulating with a polluting (hot) menstruating woman. And small-pox is said to be caused by intense heat from the wrath of an angered goddess called Sil Mata (Cool Mother). In this example and that stated above, restoring the balance between ‘hot’ and ‘cold’ can, therefore, be ascertained as the vital equation for normal health.
Among the Acholi measles is reputed to ‘dislike’ cold water, public paths, roads or walkways, modern medicine, and hospitals. Patients – often children – are barred from drinking cold water (a warm drink of boiled lagada roots (elephant-grass) is constantly available by the fire-place). Alcohol is not permitted proximal to the patient and parents are prohibited from indulging in any sexual activities. No physical signs or allergies exist to prove this superstitions. However, a child’s body smeared with mashed leaves of a tamarind tree often results in the “coming out” (often itchy spots or rashes) of measles.
Although the ultimate cure comes from the medicinal contents of lagada roots and tamarind leaves, beliefs and superstitions are revered and strictly adhered to in order to combat what Lambert[xviii] refers to as “time‑bound” illness. The “coming out” of measles is an indication that recovery or return to normalcy is in progress. Most cultures have their ways of dealing with the sick although the procedures involved may sometimes exacerbate the illness or generate another. The major problem in a “time‑bound” illness is waiting for the “coming out”. It is shrouded with uncertainty which may well result in death from a simple ailment if modern medicine is not sought.
Suffice it to say that some cultural practices also inflict detrimental body alterations that affect a person’s natural senses. Such practices are noted for their delirious effects on health. The Maasai of Kenya and Tanzania slice and elongate their ears into patterns which reduce the pinae ability to collect sound-waves, hence, disabling hearing ability. Female circumcision or infibulation among the Kikuyu, Pokot, and Suk of east Africa (intended to alleviate the pains of birth) and among the Somali (to ensure virginity), constitute “culture‑bound syndromes”[xix]. The same study also linked the performance of ovulectomies on newborns in Northern Nigeria to the high incidence of early childhood anemia[xx].
Another of the author’s personal experience is from the Kordofan Nubian/Arab and coastal Swahili women of Sudan and East Africa, respectively. Both women groups have the practice of sitting over a little shallow hole dug in the courtyard grounds and filled with incense poured on smoldering charcoal. Whereas this act of using incense smoke to absorb away excessive vaginal fluids is done to sexually satisfy male partners, its health complications on women are possibly two‑folds. First, it may cause bruises which facilitate transmission of venereal diseases and HIV/AIDS, and secondly, wounds, painful menstruations, and cancer of the uterus may be associated with the same practice.
A study by Makerere University‑Case Western Reserve University[xxi] found that cultural determinants of health behaviors serve as critical barriers to health behavior change and that their ramifications with regards to AIDS (commonly known as “Slim” because of weight loss) in Uganda needed to be fully explored. 37% case and 20% control of female respondents “identified occasions when a woman is traditionally expected to have sex with men other than her husband. These occasions included: rituals round the birth of twins, last funeral-rites especially that of her husband,…and weddings, when the bride’s paternal aunt might have sex with the groom before the bride does”[xxii].
The incompatibility and disagreement between ethnomedicine and modern medicine is more rigid in Africa than in other regions of the Third World. For example, although traditional healers in Nigeria have trained in family planning and primary health care, there is an explosive cultural distance between indigenous traditional practitioners and the educated modern African doctors. Economic and prestige competition between these two care providers coupled with the ease of circumventing tedious registrations and providing scientific evidence has made traditional healing a financially lucrative practice. This conflict has culminated into low salaries for the modern medical practitioners[xxiii].
HEALTH EDUCATION AND TRADITIONAL PRACTICES
Since traditional medicine is the most accessible health care system for the rural poor in Africa, it can be argued that all that governments and policy-makers ought to do is to promote health education in order to foster its safe practice. Although supernatural or “African” explanations is the basis for understanding traditional practices, health education remains a lacking imperative for modernizing and improving safer trends in ethnomedicine.
Health education should emphasize reduction and elimination of health risk activities[xxiv]. The major impediment to health education in Africa is the bond between culture and ethnomedicine. This means, “a conceptual model for health education programs in developing countries must address cultural sensitivity and cultural appropriateness”[xxv] and yet streamline safer traditional practices.
It is also pointed that promoting health education in relation to how people respond is a crucial for determining both disease incidence and prevalence. “The rigid hierarchical approach of some health education must be examined, as it assumes a medical cultural imperialism, in which the Western allopathic medical model is superior”[xxvi]. The problem with this inferiority/superiority complex is that privileged individuals and households have drawn the under-endowed groups in their quest for modern medicine and in doing so have curtailed scientific advances in effective traditional treatments and therapies. Yet for traditional medicine, the requirements are cheap, easy to find, and basic – little time, attention, skills and finance.
Studies indicate that more than 14 million children below the age of 5 die yearly in developing countries due to diarrhea, pneumonia, gastroenteritis, respiratory infections, malnutrition, and malaria[xxvii]. Governments have been slow at promoting the use of curative herbs and roots and modern medicine, fearing the competition, has contributed less by way of research in ethnomedicine. The result: poverty is heightening partly because low-income individuals and households are compelled to resorted to expensive modern medicine due to the declining number of traditional providers.
If health education is to succede, it is important that both traditional healers and their community clients are beneficiaries. Unfortunately, progress in health education is also limited by factors other than poverty of African communities and nations. First, high illiteracy (as opposed to public education) and high fertility exit. And secondly, social, political, and economic disruptions are frequent due to changes in lifestyles[xxviii] as well as bureaucratic power struggles in governments.
Disparities have also emerged between groups of researchers. Some have argued for emphasis on rural and urban health education services and primary health care (PHC) while others have stressed female literacy[xxix]. This is not unexpected since a greater burden of the household health responsibility in African communities is shouldered by women – for example in providing food, water, sanitation (general cleanliness), and nursing. Consider the impacts of the following CARE‑Bangladesh Rural Maintenance Program (RMP)[xxx] if it were undertaken in Africa with the participation, among others, of traditional healers, and TBAs: The Women’s Health Education (WHE) which targeted poor women in rural areas, was designed to teach women how to prevent and treat health problems. As in Africa, the high mortality rates which were prevalent in Bangladesh were found to result from preventable and curable cases of nutritional deficiencies, anemia, diarrhea, scabies, lice, tetanus, heat stroke and worms. Since RMP women and their families represented the poorest, least educated members of the rural community, they were the most susceptible to diseases and family deaths than the general population. Hence, “knowledge of public health measures such as immunization, proper hygiene and nutrition, and safe drinking water can be conveyed through primary health education”[xxxi] which includes participation of men-folks and traditional healers.
In Tanzania where “Villagization” (Ujamaa or togetherness) has improved primary health education, continuous emphasis is placed on general cleanliness, poor sanitation, lack of latrines, unsafe water, and related diseases[xxxii]. The Tanzanian illustration is important because traditional healers and birth attendants are known to be unhygienic by their reliance on ancient tools of dispensing such as, pots, knives, blades, and calabashes, as well as applying herbs in their natural state; that is, without cleaning, washing or sterilizing but just dusting or wiping them. With unhygienic conditions, the mediums of contamination are enhanced.
Another focus of health education needs to be directed at behavioral change in young people, especially, with respect to sexually transmitted diseases (STDs) and unwanted pregnancies. Although most STDs can be treated, a recent addition in the form of HIV/AIDS has proved invincible to medical advances. Recent WHO (2000) statistics puts the number of infected people in sub-Saharan Africa alone at 24.5 million. One way to limit the spread of HIV/AIDS and viral STD is health education focused on behavioral change[xxxiii]. Behavioral change is also the observation made by the isangoma mentioned above. Given her understanding of the transmission mechanisms, she recognized that “prostitutes and sexually active teenagers were at high risks”[xxxiv] and she even gave counseling and distributed condoms.
Studies also show that the median age at first sexual intercourse in Africa is 14‑15, while it is 16-18 in the USA, Britain and France, and 20‑23 in Canada. In contrast, only 4‑6% of adolescents in Africa can obtain contraceptives. In Kenya, 44% of patients with STD were aged 15‑25. Of this, the incidence among women under 20 was 57%. In Uganda the same study recorded the highest incidence among women aged 15‑19. And in Kinshasa (Zaire), 10% women and 4% men aged 15‑19 were found seropositive for HIV[xxxv].
In a study of health problems associated with urban poverty, education setbacks, teenage parenthood and the gap between the rich and the poor were seen as crucial factors in the health care systems for both developed and developing countries. Until there is a “comprehensive program that incorporates medical, social and economic intervention”[xxxvi] a greater percentage of the African population will continue to rely on ethnomedicine.
Furthermore, owing to exponential population growth, poor levels of hygiene, and increasing urban poverty, shanty towns and slums sprawl the urban environments of African cities and towns. countries have grown slums in which inadequate water supply, garbage collection services and surface-water drainage have all combined to create favorable reservoirs of communicable diseases such as malaria, lymphatic filariasis, and schistosomiasis. Such conditions are arguably conducive environments for crime, prostitution, drug abuse and, above all, illicit, illegal, deceptive and dangerous ethnomedicine practices. Social marketing of prevention measures and authentic traditional medicine is important in these environments.
POSSIBILITIES FOR LINKING MODERN AND TRADITIONAL HEALTH CARE SYSTEMS
Three alternative options have been proposed for the integration of traditional and modern health care systems[xxxvii]. The first is that of incorporation. It suggests that, since traditional healers are influential, respected, accepted and most approached for treatment by their communities, their roles are similar to that of rural or village health workers. The integration of sangomas and inyangas as ‘first‑line’ practitioners has been realized at the Madadeni hospital in Natal (Republic of South Africa) where patients with chronic diseases receive regular modern medicine from them instead of traveling the distance to hospital each time treatment is required[xxxviii].
The second alternative is that of co‑operation in which both the traditional and western medicine are expected to “remain essentially autonomous and each retains its own methods of operation and explanation…a patient may for example consult a western trained health worker for curative treatment and a traditional healer for cultural explanations for the causes of illness”[xxxix]. The Acholi people in Uganda approach traditional healers during and after cure. Often, these visits are attempted to answer questions such as: why was the individual, in particular, singled out for infection by the disease?; Why that in that family and not another?. Answers to these questions are normally understood as the causes of diseases and offer preventive steps against future infections.
However, the idea of co‑operation based on such mutual arrangements is not really feasible. Patients are essentially being denied knowledge of the true causes of their diseases and future prevention measures may be ignored while the patient grapples with supernatural puzzles rather than practical remedies. There are no real checks and balances.
The third alternative is total integration. This is a case in which the two systems may be amalgamated and expected to function simultaneously. It may recommend the provision of a combination of both Western and traditional treatment, or the suggestion of both traditional and modern understanding in the explanation of illness. In some countries of sub‑Saharan Africa, viz., Nigeria, Uganda, Kenya and South Africa, traditional birth attendants are permitted “traditional herbs to induce labor and bathing the newborn infant in water treated with traditional remedies to protect the child, but at the same time using Western apparatus for cutting and treating the umbilical cord”[xl].
The above options for linkage are not without controversies. The following section addresses some of these controversies.
Although the linkage between traditional and modern health practices can be forged through one or a combination of the above alternatives, a number of limitations may still prevail. The following arguments suggest why ethnomedicine should not be totally integrated with modern medicine.
First, the limitation of health resources in Africa and the availability to traditional healers have been deemed as appropriate substitutes if public health goals are to attained in the foreseeable future[xli]. In every rural and most urban communities in Africa, there exist traditional practitioners specializing in either child delivery, preparation of traditional medicines, or counseling.
Second, many Africans use refer to traditional healers because of the belief in African healing for African diseases. However, although there is, apparently, no place for the Western health care system, it is suggested that emphasis on it “should not be at the expense of traditional care”[xlii]. This argument simply proposes a form of collaboration in which the two systems remain autonomous.
Third, traditional medicines are often effective on illnesses such as diarrhea, headaches, swellings and in sedating pains. The unstandardized procedures in treatment can, however, be cruel and risky as they involve deep cuts in the flesh on which the anticipated cure may be rubbed or implanted to directly enter the human blood system. Sometimes this is done using rusty razor-blades or other home‑made gadgets.
Fourth, traditional medicines are seen to be most often harmful[xliii]. In almost all cases, there are no recommended doses. Healing is often the objective regardless of the amount of medicine taken. This medicine may (especially in types used to induce vomiting in malaria and cough victims) result in heart failures and resistance to antibiotics and other vaccines.
Fifth, traditional medicine is viewed as belonging to pre-civilization. Besides its explanation of diseases causes in supernatural terms, it also creates disharmony in the communities concerned since it often levels blames on neighbors or kin. Even if a form of integration were forged, referrals would still favor Western medicine and practices while the traditional functions as a last resort.
Sixth, it is believed that fear abounds in both systems regarding proper fees and remuneration. Each system also fears that the dominant role of the other will erode and jeopardize its status. Finally, there are practical obstacles to integration such that “whereas in Western medical circles there are guidelines for formal registration based on official qualification, and in some cases experience, there is no clear equivalent for traditional healers”[xliv]. This means that given the secrecy involved in traditional healing regarding individual creativity and discoveries in medicine, dubious practices can pass undetected. Furthermore, unlike in China where hospitals for traditional practitioners exist side by side with modern hospitals, the problem of financing traditional practices in Africa poses the greatest limitation to their advancement.
Last but not least, this paper will attempt to evaluate safety in traditional healing practices and the effectiveness of ethnomedicine effectiveness by using the PEN-3 model of analysis.
THE PEN‑3 CONCEPTUAL MODEL.
Briefly defined, the proposed model of analysis consists of three interrelated dimensions for evaluating culturally appropriate health measures in African countries[xlv]. The first PEN relates to evaluating the behaviors of Persons, Extended families and Neighborhoods (PEN) to find which ones are important and manageable. It attempts to make the determination by considering three factors which constitute the second aspect of the model. These factors perform the following: Predispose knowledge, attitudes values and perceptions; Enable societal, systematic or structural forces that may be a barrier to change. For example, availability of resources and types of services such as traditional medicine, and; Nurture, for example the family, peers and kinship (PEN).
The possibility of linking the two health care delivery systems depends on the extent to which the modern system is capable of determining appropriate health beliefs, practices and behaviors in the traditional system. The determination of important and manageable factors is feasible if the identified factors are evaluated on the basis of their Positive, Exotic and Negative implications. This constitutes the third PEN in the model of analysis.
Positive behavior recognize practices and beliefs that reduce the problem of disease transmission and spread. For example, the prohibition of sexual intercourse before marriage, the use of traditional herbs to induce labor, and the acceptance of traditional medicines which have effective curative potential. As suggested in the second alternative for linking traditional and modern health services, co-operation could opted because it permits the selection of elements that are effective from each system, thereby reducing stress on one system. Furthermore, co-operation offers a diversity of services which addresses the disparities in economic status and the accessibility of respective individuals and households in a society to the health care system whose costs they can afford.
Exotic behavior and practices, meanwhile, are negligible in as long as they cause no physical harm to persons and the modern system. For example, the removal of the ‘evil eye’ by circling chili paper around a child’s head by Rajasthani Indians, wearing of numerous amulets to keep away evil spirits, and offering animal sacrifices to feed spirits with blood they yearn for are behaviors which represent a certain life‑style, status and prestige. In most instances they are arrogant and harmless even to the traditional system.
Negative behavior and practices are a critical factor in traditional healing practices. The majority of these behavior patterns relate to practices that are non‑healing and not disease-oriented. Unfortunately, they are often recommended and implemented by the same individuals who claim to be healers and highly knowledgeable of traditional medicine. This is one reason why any attempt to link the two system by first separating culture from ethnomedicine is futile and unproductive. Such negative behaviors as cited earlier include: attending to birth without proper hygienic tools and in unhealthy environments, female circumcision in Somalia, Kenya, Uganda and Mali, child ovulectomy in Northern Nigeria, ear slicing among the Maasai, tribal tattoos, using mixing industrial chemical agents with traditional enemas and administering them as purgatives using syringes and, drying the vagina with smoke from incense.
Negative traditional behavior and practices by far, outweigh those that are positive and exotic. Using the PEN-3 model of analysis as depicted above, suggests that in attempting to link traditional and modern health services, chances that the bulk of ethnomedicine will be disqualified are greater. This is one reason why it may not be feasible to adopt any one of the three alternatives for linkage.
Traditional healers require a simple community education program. to challenge the complexity of their preconceived ideas about the nature of diseases and disease transmission. Apart form sticking to hygienic conditions, their prescriptions should remain without western ingredients.
The media, and discussion groups composed of clients and traditional practitioners and group leaders are important. The information, which should be clear, simple and specific, should not carry frightening messages because this gives partial communication and the fear of losing their occupation. The cooperation of the media was important in stimulating a new awareness of health and the opportunities for self help and community initiatives among Australian Aborigines[xlvi]. In turn, these practitioners can, in their rural areas, transmit information through traditional channels like theatre, dance and music has been proven effective[xlvii].
The determination of negative ethno cultural health-related behavior and practices for which change is required and of the positive health behavior and practices for which rewards need to be accorded is of profound necessity if public health care is to be attained through a linkage of traditional and modern health systems.
As discussed above, while there is the necessity to foster ethnomedicine as a vital alternative to modern medicine for most of the rural poor in Africa, there still exists an imperative need to reform the methods of practices inherent in the traditional system. Only then can governments and people be held responsible for any unforeseen consequences. As for the current situation, traditional medicine, however inappropriate, will prevail in both rural and urban areas to meet the health needs of individuals and households with limited entitlement.
That it is possible to integrate or incorporate or have a collaboration between modern and traditional medicine, remains an area that requires further investigation, especially in Africa where the intricacy of tradition, culture and belief systems are difficult to disentangle from each other.
However, some governments have succeeded in forging marginal linkage. In Zimbabwe despite official recognition of traditional healers, there is both formal and informal resistance to policies addressing the integration. Despite the high poverty in Mozambique, the illegalization of traditional healers on the “grounds that healers were and potentially still are, part of the old feudal system, unproductive, giving support to chiefs, furthering superstition and liable to exploit the poor in their need”[xlviii], has drastically inhibited the growth of traditional medicine. And, in Swaziland, attempts to recognize traditional healers have continued since the 1940s.
Nevertheless, the traditional health system in Africa is growing despite negligence on the part of health policy makers. As Western medicines become expensive day by day and increasingly inaccessible, more and more Africans are resorting to traditional cures.
Simple (appropriate) health technology and easy to understand scientific knowledge should be availed to traditional practitioners at little or no costs. And since it is believed that the main health problems in developing countries are directly related to poor community health education, imparting knowledge is a priority for changing behavior and cultural practices which impede health reform. Using thee PEN‑3 model of analysis facilitates the assessment and the selection of what is appropriate, sustainable and productive in the traditional health care practice.
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[i]. Good, Charles, 1987.
[iv].Freeman et. al., 1992.
[v]. Mtalane, 1993, p.94
[vi]. Green, 1992; Mtalane, 1993.
[vii].Many Swazi males work the mines of the Republic of South Africa. The majority leave their families at home and choose to live in the congested dormitories owned by the mining companies. Unfortunate, mining areas are also potent habitats for prostitutes who service miners. After months or years the miners visit their families at home, only sometimes, they may be carrying gonorrhoea.
[ix].Dunn, et. al., 1991; Wood, et al., 1990.
[xii].Albert, Daniel, 1992.
[xiii].Wang Pei, 1983, p.68.
[xv].Ibid., 1992, p.423.
[xix].Heggenhaugen et. al., 1986.
[xxi].McGrath et. al., 1993.
[xxii].ibid. 1993, p.433.
[xxiv].Airhihenbuwa, 1990, p.56.
[xxv].ibid. 1990, p.54.
[xxvi].Heggenhaugen, 1986, p.1238.
[xxvii].Karungula, 1986; Buddulph, 1993.
[xxx].Sloss et. al., 1991.
[xxxi].ibid. 1991, p.959.
[xxxii].Karungula, 1992, p.116.
[xxxiii].Leslie-Harwit, et. al., 1989; Magezi, 1991.
[xxxiv].Abdool-Karim, 1993, p.424.
[xxxv].Leslie-Harwit, et. al., 1989.
[xxxvi].Kaye, 1989, pp.649-650.
[xxxvii].Freeman et. al., 1992.
[xxxix].ibid., 1992, p.1184.
[xl].ibid. 1992, p.1185.
[xlii].Freeman et. al., 1992, p.1186.
[xliv].Freeman et. al., 1992, p.1188.
[xlviii].Freeman et. al., 1992, p.1189.