- Email: [email protected]
Ethnomedicine and biomedicine linking
Sot. Sci. Med.
0277-9536/82/2 I IX17-08$03.00/0 Copyright 0 1982Pergamon Press Ltd
Vol. 16. pp. IX17to 1824.1982 Printed in Great Britain. All rights reserved
ETHNOMEDICINE
AND BIOMEDICINE
LINKING
A. K. NEUMANNand P. LAURO School of Public Health. University of California. Los Angeles. CA 90024, U.S.A. Abstract-This paper considers the integration of the biomedical establishment with traditional medical care systems given the urgent need for health care services by the underserved masses in developing countries. The difficulties of identifying and categorizing indigenous practitioners are outlined. Several strategies are suggested for standardizing, professionalizing, or otherwise mobilizing traditional healers in the movement to achieve the World Health Organization’s goal of “health for all by the year 2000”. The potential benefits as well as the constraints related to such efforts are described. As examples of what attempts are being made today to link modern and traditional health care systems, programs in the People’s Republic of China, India. Ghana, the Philippines and Indonesia are summarized. The paper concludes with some recommendations as well as some predictions for the next 20 years.
INTRODUCTION
As pressures for “Health for all by the year 2000” [l] mount and the enormous volume of unmet needs and the staggering cost of meeting them are calculated. there is a very human tendency to look for low-cost, quick, simplistic solutions. One of these is to recruit, train in Western medicine and link the ubiquitous indigenous medicine practitioners to the modern medicine or biomedicine’system and thus solve much of the problem of providing modern primary health care for the underserved rural masses. As a physician who became a disciple of Ben Paul more than 20 years ago (senior author) and who subsequently has been involved in in-depth ethnomedicine research as well as rural health program development (both authors), one would venture to say that much more information needs to be gathered before sweeping generalizations can be made. Moreover, it is asserted that, although medical anthropologists have already done much good work, their finest hour is yet to come. The trend for medical anthropologists to study indigenous medicine as a system is very desirable and essential if effective linkage between biomedicine and ethnomedicine is going to be achieved to any significant degree. This paper will explore factors contributing to the growth of interest in traditional medicine, identify types of linkages. discuss reasons for and against linkage between ethnomedicine and biomedicine, discuss practical steps to bring about such linkages and what is needed to institutionalize the linkages, briefly analyze some examples and make some recommendations in an attempt to look into the future. At this point a plea is made for all, but especially the biomedicine establishment, to acknowledge the importance of tradition and culture and the fact that traditional medicine is essentially an outgrdwth and expression of culture. It must be understood that many of the practices of traditional medicine practitioners are designed to preserve cultural institutions and to help the patient live at peace with his family. clan. village. tribe and inner self [Z-4]. The traditional medicine practitioner has intrinsically a broader social role to play. is more community oriented than the typical biomedicine clinician. Curing physical dis-
ease in the sense of the biomedicine clinician is only part of the role of the indigenous medicine practitioner, and it is only in this limited sphere that biomedicine can make a contribution to traditional medicine, developing countries and rural health. It is the position of this paper that services need the social, Spiritual component of traditional medicine and the clinical component of biomedicine. THE NEED
FOR HEALTH CARE
Leaders and planners in the developing nations of the world have come to realize that progress in the area of overall economic development is intricately related to the general health status of the population. They now understand that funds allocated for health programs do indeed constitute in economic terms not only a sound but also an essential investment. Furthermore, the need for services is as large in scope as it is urgent. Estimates indicate that 70 to perhaps 80:/ of the population of lesser developed countries have little or no access to basic health services. The masses of rural inhabitants are becoming increasingly aware of what is achievable through modern medical care and governments are increasingly pressured to provide modern health services. This is occurring precisely as world inflation mounts and the financial situation of countries who do not produce oil steadily worsens. These countries find it impossible to expand the health services network using expensively staffed hospitals and health centers. Effective low-cost health care delivery systems will have to be devised. Thus, the matter is not one of upgrading the technology of present systems in the developing countries, but rather concerns the more basic issue of taking the initial steps to promote and maintain the general health and welfare of all individuals and communities and entails a massive expansion of primary health services. This important issue was. in fact, the theme of a joint WHO/UNICEF Ata. USSR. in September.
conference held in Alma 1978. About 2000 partici-
pants representing 150 nations. international agencies and private voluntary organizations unanimously agreed that primary health care must constitute an integral part of each nation’s total development strat-
1817
1818
A. K. NEUMANN and P.
egy. Acknowledging the need as a ‘burning necessity” [S. p. 71. the national delegations pledged their support of the goal of primary health care for all by the year 2000. Although all consider this goal to be laudable, clearly it will be difficult to accomplish. Planners in those nations whose welfare and development are at stake are disheartened as they contemplate the enormous amounts of resources that will be necessary to expand their existing health services so as to reach the underserved majority with even primary health care. The report of the Alma Ata conference in fact emphasized the need to develop innovative ways to assure that primary health care reaches the huge underserved populations of the developing nations. The report further asserts that planning and policy decisions not be conceived as simply a matter of extending the delivery of basic health services. That is. a system which views the masses as passive recipients decreases the likelihood that a program will be appropriate, acceptable, or speedily implemented. Taylor has stated the problem succinctly by noting that we need to “find out not how to do things for people but how to work with them on their priorities” [6, p. 671. The consensus of opinion suggests that in the past there has been some gap that refuses to be bridged or filled in regarding the application of modern scientific medicine to cultures that are neither modern nor scientific. The failures of programs are often blamed on the conflicting values and practices of two systems which have been identified by the terms biomedicine and ethnomedicine. Biomedicine is understood to refer to the historically Western, scientific, hospital-based, technology oriented system. Ethnomedicine refers to the practices of traditional healers who rely on indigenous medicines and/or ritual to treat the sick. Risking oversimplification, one can make.a further generalization when distinguishing between the two approaches. Biomedicine is concerned with the objective, scientific management of a pathophysiologic process. Ethnomedicine deals subjectively with the whole alteration. In other words, the medical doctor treats the disease while the traditional healer treats the person (who happens to be ill). Thus, while ethnomedicine is scorned for its lack of a solid scientific foundation. biomedicine is criticized for its impersonality. The medicines of one may be faulting in biological potency, yet the other has lost that special something that used to be provided by the family doctor who went house to house with his little black bag [7]. Once the issue of medical care is viewed in this manner, the conclusion is then drawn that the ideal primary care includes elements of both systems. The success of primary health care in many developing countries will depend upon the use of community health workers, selected from the general population and trained in basic biomedical procedures. This view has led to the initiation of programs throughout the world to prepare local citizens to take on the titles of barefoot doctor, health promoter, nursing auxiliary and SO on. However, this integration of the biomedical establishment with community resources does not solve the problem for those who view the important gap as that which separates modern medicine from traditional medicine.
LA~RO
Thus. for some planners and international health workers who formerly disdained any perpetuation of traditional medicine. some linkage of the two systems may become essential. For the moment. one thing that is made clear by an assessment of the money and biomedical resources at hand is that modern medicine and all its trappings simply cannot be made available to all the world’s people in the foreseeable future. The millions of isolated rural poor in particular will remain neglected if they are to wait until sufficient numbers of doctors and nurses are trained and health centers are built to serve their hard-to-reach and sometimes less-than-inviting communities and villages. In the final analysis. common sense indicates that much could be accomplished and relatively quickly, by somehow tapping the resources that are already available locally. The questions are: how. time frame. at what cost and with what results? With regard to the discussion of linking modern with traditional systems. an objection is sometimes put forth by cultural purists. The objection is that since ethnomedicine already serves those populations in question. biomedicine need not be concerned with extending itself to so-called underserved areas. To answer this objection one notes that the shortage of personnel quite possibly is a reality of ethnomedicine as it is of biomedicine. Many recent studies have documented a decline in the numbers of indigenous practitioners [Z]. Second. modern health care undeniably has its body of practices and procedures which reduce morbidity and mortality in many instances when traditional medicine fails to do so. Third, although resistance to biomedicine is still frequently noted, numerous studies done in various parts of the developing world indicate a trend toward the increasing acceptance of and even a preference for modern medical techniques and therapies [Z, 81. In many cases the indigenous practitioners have themselves adopted some of the medications and instruments of Western medicine. An important fact often ignored by supporters of one medical system or the other is that to view the controversy as a simple either/or issue is to misconceive the true situation. In nearly every cultural setting, including modern Western cultures, health care systems are pluralistic. Given equal access to multiple treatment resources. consumers resort to one or another depending on their perception of the nature of the illness, the time needed to obtain care, and the anticipated costs [9]. Or health care resources may be sought according to a predictable sequence. beginning with minor self-care in the home and proceeding through a series of increasingly specialized major treatments until the point where a satisfactory outcome is obtained [lo]. DIFFICULTIES
IN IDENTIFYING
PRACTITIONERS
Unfortunately. this enlightened understanding of the pluralism of medical care systems further complicates the problem of linking biomedicine and ethnomeditine for the purposes of securing primary health care for all. Even before beginning to consider how to integrate the biomedical establishment with ethnomeditine. policy makers must determine which categories
Ethnomedicine and biomedicine linking of indigenous practitioners ought to be approached. There is general agreement that the ubiquitous traditional birth attendant (TBA) is a valuable resource in the community and potentially an important element in the primary health care movement [I 1-J.In fact, many countries have already begun training programs to increase the skills and expertise of TBAs. However, with regard to others such as herbalists and spiritual healers there is no consensus of opion as to the benefits to be derived through attempts at col!aboration. In instances when ethnomedicine differs drastically from biomedicine with regard to disease etiology, diagnosis and treatment, the two systems are often viewed as basically incompatible. In any event national planners and international agencies should not proceed with the identification of individuals potentially trainable in some biomedical procedures without first enumerating the varieties of local medical practitioners and defining their current roles and status in their communities. This initial task may be a costly, time consuming endeavor in many countries where the population includes numerous tribes or subcultures, each with its distinct categories of indigenous healers, As a preliminary measure, one might find it useful to consider four general categories of indigenous practitioners: 1. Spiritual or magico-religious healers. 2. Herbalists. 3. Technical specialists such as bonesetters. 4. Traditional birth attendants. Although the functions of these practitioners may overlap to some degree while other healers may not fit into these categories at all, these groupings will facilitate an understanding of the traditional medical care systems of most cultures. This identifjcation procedure should determine the degree to whtch the ethnomedical establishment is interested in or resistant to collaboration with biomedical practitioners and/or formally established government programs. Traditional medicine may prove to be an unwilling ally that will have to be won over to a belief that integration is possible and desirable. Similarly, regional or community level government health professionals may or may not be as eager as central authorities are to initiate an ongoing working relationship with indigenous healers. Finally, some attempt should be made to ascertain how the population-the communities and villages-would react to organization or procedural changes in their traditional medical systems. General apathy or pockets of resistance among the ranks of any group would seriously hinder the implementation of collaborative programs. POSSIBLE
STRATEGIES
FOR ‘LINKAGE
Beyond these preliminary obstacles lies the major question of determining what is.meant by the integration of biomedicine and ethnomedicine. Certainly, it implies more than peaceful coexistence, given the urgent need to maximize the use of all available health practitioners. The goal of primary health care. with its task oriented approach to improving the health and welfare of all people seems rather to call
1819
for the active promotion of what might be termed beneficial coexistence. This could be accomplished in several ways, most of which relate to professionalizing somehow the traditional practitioners. This implies identifying the professionals and controlling the quacks. Some of the possibilities for linking biomedicine and ethnomedicine are as follows: 1. Institute a government licensing program and license those indigenous practitioners known to have completed a specific, recognized training period or apprenticeship and who can demonstrate a predetermined level of competence in their work. This would encourage those in practice to upgrade their skills and might inspire others to take up this now high-status occupation, while also helping to control quackery. 2. Formalize selected categories of practitioners to an even greater extent by supporting the founding and operation of schools that produce herbalists, homeopaths, acupuncturists and other non-biomedical specialists. 3. Invite selected traditional practitioners to participate in a training course designed to ‘upgrade’ their skills as per the norms of the biomedical establishment. Supply them free of charge or at low cost with basic supplies and medications. Provide angoing supervision, continuing education and a resupply of materials as necessary. 4. Train selected practitioners (as just noted) and officially hire them as employees of the Ministry of Health. 5. Recruit a local, licensed traditional practitioner to be part of the team in every rural health outpost. This person could instruct the staff in the essentials of ethnomedicine and also serve as a link between the health center and the community. 6. Organize workshops for government health personnel in which they are given appropriate cross-cultural training, with specific emphasis on the beliefs and practices of traditional medicine. 7. Finance research into the pharmacopoeia of traditional medicine, especially with regard to medicinal plants. Prepare manuals and didactic materials with a view to standardizing procedures and preserving the art/science of these locally available medicines. Include this information in health education programs in rural areas. 8. Modify biomedicine establishment training programs, especially those for physicians, nurses and midwives to include elements of traditional medicine with a view towards personalizing the practice of biomedicine and promoting appreciation of traditional beliefs and practices. POSSIBLE
BENEFITS
One must consider the potential positive effects of linking biomedicine with ethnomedicine. In an ideal situation, all parties concerned stand to benefit. National gooernments
Many of the developing countries are struggling desperately for economic survival and their productivity is. to a great extent, dependent upon the health of their citizens. As noted previously, governments are aware that health programs are an essential
1820
A. K. NEUMANN
investiment. They further realize that making use of already existing community resources. such as indigenous practitioners, is a relatively inexpensive way to expand health services.
and P.
LAURO
national or local health care systems and an assessment of the time, effort and cost that would be required for the revision of existing legislation. SUCCESSES IN LINKING
Biomedical professionals
The biomedical establishment. as well as the national governments, stand to benefit by collabotating with traditional medicine. Government health professionals and international agencies have been less than successful in the past, often because their approaches and practices have been culturally or technologically inappropriate. Increased communication with indigenous health practitioners would help to bridge the gaps and make biomedicine more effective in communities and villages. Another advantage for biomedicine is that the escessive demands now made upon its insufficient number of health professionals would be greatly relieved if local health resources were mobilized to share the work load. Indigenous practitioners
They would benefit from the opportunity to increase their skills and knowledge, whether by simple contact with or actual training in biomedical procedures. And the acquisition of new skills is likely to translate into’s potential for increased income. General population
The obvious benefits of integrating modern scientific medicine and traditional system would go to the populations served. All would have better access to health care and the quality of care could be significantly improved. Treatment would be sought in a system with specified performance standards. In addition, the linking of the ethnomedical with the biomedical would increase the likelihood of appropriate referral for severe or special cases of disease or injury. And for those individuals or populations to whom government health services are not particularly palatable, their traditional healers associated with those services could encourage and persuade them to reconsider. CONSTRAINTS
Although in theory integration of the modern and the traditional is workable and desirable, there are decided constraints. Most significantly, there is a lack of sufficient information to enable health systems planners to commit substantial resources to establishing linkages on a significant scale so as to achieve a measure of permanency. Information needed in each country and possibly on a regional or district basis within any given country would include the following: 1. Numbers and kinds of traditional healers, their practices and their effectiveness. 2. Current standards and controls in the practice of traditional medicine, including training, the existence of professional associations. the use of peer review mechanisms. 3. Assessment of anticipated costs and personnel needs for the implementation of a large scale effort to link biomedicine and traditional systems. 4. Legal constraints relating to reorganizing
BIO>lEDICISE
AND ETHNOMEDICINE
In terms of hundreds of millions of people affected. the successes in linking biomedicine and ethnomeditine are considerable. The most noteworthy programs have been carried out in India and People’s Republic of China (PRC). In Latin America and probably also in the South Pacific and Oceania the relationship between modern and traditional medical systems can be best described as peaceful coexistence. In Africa. in the colonial era, which ended not so long ago. the practice of traditional medicine was illegal in many countries and there was on occasion active persecution of traditional medicine practitioners. Only in recent years have there been experimental schemes working toward establishing linkages between ethnomedicine and biomedicine. Noteworthy work is being done in Ghana and Nigeria. The kinds of traditional practitioners involved in the programs in India. and the PRC are primarily herbalists. Almost everywhere else where there are attempts at linkage. traditional birth attendants are involved. In India and the PRC the practice of herbalism has an ancient and honorable tradition with written texts dating back thousands of years, well established training centers, professional associations. codes of ethics and mechanisms for enforcing them. According to personal communications, few herbalists in the PRC have become barefoot doctors, for most prefer to practice solely traditional Chinese medicine. Since the role of traditional birth attendants is primarily dictated by the nature of pregnancy and the birth process and is relatively straight forward. TBAs and the biomedical establishment have a basis for working together. Around the world experimental projects to upgrade TBA skills by means of training programs have been quite successful. The problem is to provide for long term supervision. resupply of sterile items and refresher training. In the eyes of many health planners such efforts that are being made to link modern and traditional systems of medical care are seen as resulting in a slow-down of the expansion of the biomedical system of clinics and local health centers. Others, however, see linkage as a desirable and necessary extension of the biomedical system in order to serve the people better. Unfortunately, not enough hard data exist regarding costs, effects and benefits of various alternatives so as to enable wise decision-making at the national level. Examples of medical systems and special programs in People’s Republic of China. India. Ghana, The Philippines and Indonesia will serve to illustrate how some governments have approached the question of linkage to ethnomedicine and biomedicine. Medicine and health care in People’s Republic of China
By the time that Western medicine was introduced into China by medical missionaries in the nineteenth century. Chinese
the highly developed system of traditional medicine had been thriving for 4000 years.
Ethnomedicine and biomedicine linking Despite the persistence of traditional Chinese medicine through the ages and its deep roots in Chinese pilosophy and religion, modern Western medicine was able to superimpose itself beginning in the nineteenth century. The governments of the early 1900s favored Western medicine but did little to promote its spread (or any other health and welfare programs) among the masses. The government which came to power in 1949 recognized the urgent need to develop an adequate health care program for the masses and recognized that some sort of linkage of Western and traditional medicine would improve the quantity and quality of health services. Western-style urban medical personnel were persuaded to enroll in a course in Chinese medicine which had been recently incorporated into the university curriculum and these professionals were then transferred to rural service for one year. Meanwhile, traditional doctors were assigned to hospitals and clinics and in 1955 the Academy of Traditional Medicine was established. The integration of traditional Chinese medicine and Western medicine continues. In the medical schools the new curriculum includes modern scientific subjects as well as the full range of traditional practices. Acupuncture anesthesia was developed in 1958, and in most hospitals the department of anesthesiology now includes trained acupuncturists. Similarly, hospitals supplement their treatments with traditional medicines. Finally. in the countryside traditional practitioners have been identified and their practices modified to include modern hygiene and scientific knowledge. Medicine and health care in India
Although the highly developed systems of medicine of the ancient Egyptians. Romans, and Greeks have all decayed, India stands with the PRC in that its history of Ayurveda, the traditional Indian medicine, probably dates back to more than 3000 years [15]. The practice of medicine in India today incorporates a second traditional system which has figured significantly in the country for about 700 years. Unani medicine embodies the Greek traditions adopted by the Arabs and then brought to India by the Muslim conquerors very early in the twelfth century. Not long after the endaof the period of Mogul rule in India in the early eighteenth century, Western medicine was introduced by Europeans in the early 1800s. Western medicine was almost immediately relegated a position of prestige for being modern and scientific, yet the majority of the population continued to be served primarily by traditional systems. Perhaps in recognition of the omnipresence and usefulness of ancient systems of healing, as .early as the 1920s the first all-India conference was held to consider renewed official support of Ayurvedic medicine. In 1926 research on indigenous drugs was sponsored by the India Research Association for the purpose of preparing a pharmacopoeia. In 1949 the Chopra Committee report recommended that immediate steps be taken to bring about the synthesis of Indian and Western medicine. The Dave Committee of I955 made specific suggestions regarding the establishments of standards for the training and licensing of indigenous practitioners. Finally. in 1959 came the Report qf r/w Commitree
1821
to Assess and Evaluate the Present Status of Avurl;edic System of Medicine, sponsored by the Ministry of
Health of the Government of India. This report noted that the health care needs of 800/, of the population were actually served by Vaidyas and Hakims, the traditional physicians of Ayurveda and Unani respectively. The committee concluded that it was futile to condemn the Ayurvedic system when patients were benefitting from it every day all over the country. The final report included over 80 specific recommendations under the headings of training. research, pharmaceutical products and status of practice [12]. In 1981 the Government of India launched a national program to evaluate the functioning of TBAs. These facts and the findings of the various Indian government committees over the years call for a critical assessment of the roles of the Vaidyas and Hakims, the place of modern medicine and the potential fvor integrating the traditional systems with modern health care efforts. Training TBAs in Ghana
In addition to a host of herbalists. spiritualists and bonesetters, the traditional medical care system in Ghana includes the village midwives. The traditional birth attendant (TBA) play a significant role in rural maternal and child care in countries like Ghana where a majority of deliveries are attended by untrained personnel. TBAs deliver two-thirds of the babies in the world [l l] and work in areas where it is unlikely that access to modern medical care will be available in the foreseeable future. In view of these observations, the training of TBAs has been undertaken in several countires. Ghana is a West African country which has initiated an organized effort to study traditional medicine via the Danfa Rural Health Project. a joint venture of the University of Ghana and UCLA. A program was initiated to register TBAs and elicit information on their knowledge and practices [13]. Studies revealed that the typical TBA was an illiterate. elderly man or woman farmer who practiced midwifery part-time. A training course consisting initially of eight and subsequently of sixteen 3-hr sessions was developed and included the following elements: 1. Monitoring of pregnant women during the antepartum period. 2. Recognition/referral of high risk women or complicated cases. 3. Proper care of the umbilical cord. 4. Promotion of improved maternal and child health practices and family planning. The course was delivered by a nurse midwife and two public health nurses. with two physicans as resource persons. Upon graduation, each TBA was given a certificate and a midwifery kit. Once back in their villages. the TBAs were supervised by means of follow-up visits from their instructors. Continuing education was also provided by means of monthly refresher classes. The Danfa TBA training program conveys a sense of what must be done in order to link traditional systems with the biomedical establishment. First of all. it was necessary to gain the confidence of the
1822
A. K. NEUMANNand P. LAURO
villagers and obtain a list of traditional birth attendants. This was accomplished with a diplomatic approach to village elders. chiefs. healers and rank and file villagers themselves. The next step was to interview almost all TBAs. A small percentage which had initially refused to be interviewed eventually consented. The vast majority, about 85% were interested in participating without remunerations in a training program to upgrade their skills. The TBAs were trained in groups of twelve to sixteen in a village central to the group. Because the average age of the TBAs was 62 years and transport was a decided problem, it was necessary to visit each village a day or two in advance of the training seesion as a reminder, pick up the TBAs on the day of the session, and then to return them to their villages. The content of the training program was limited and nonformal education techniques were used involving charts, models, role playing, etc. Since more than 90”/, of the group were illiterate, written texts could not be employed. The final examination was designed by the Ghanaian instructional staff and consisted of a play. each act of which portrayed one of the principal lessions of the training course. The play was presented to assembled villagers of the training cluster on the last day of the course. Having completed the training program, some of the TBAs felt they should be salaried by the Ministry of Health. Although this was clearly not the aim of the program, the Ministry did encourage TBAs to charge higher fees provided they implemented their new skills. In addition, while the TBA recruitment and training program was underway, a health education program for villagers was launched. The purpose was to share with them essential elements of the training program and to convey the message that TBAs were engaging in a program to upgrade their skills at their own expense and on their own time. The villagers were informed to look for certain features which would indicate that TBA skills had indeed improved and were encouraged to increase remuneration for services accordingly. Common to past programs where the passage of time removed the evidence of previous TBA training efforts was that there had been no follow-up, supervision, resupply of materials, or in-service training. In Ghana quite senior personnel were involved in such activities although it is now felt that this could be done by relatively more junior personnel. For example, the midwives employed in most of Ghana’s local health centers are not very busy because most women remain in their villages and look to TBAs for birth assistance. Given suitable in-service training and supervision, the health center midwife could be considered a candidate for managing much of the TBA training and supervision. The Danfa TBA training program is being gradually replicated throughout the country. In order for this to be accomplished, suitable instructions and directives had to be issued by the Ministry of Health. Nurse midwives in the health centers in whose jurisdictions TBA training courses are to be held now receive suitable inlservice training as do heads of health centers, district health officers, regional chief nursing officers and others. Eventually the curriculum of the schools which train biomedical personnel in the
first place will have to be modified to reflect the new policies already being implemented at the periphery. Budgets will have to be augmented to account for additional transportation needs. supplies for midwifery kits and record keeping functions. The need for ongoing supervision and refresher classes for TBAs who have completed training also implies the need for additional budgetry and administrative resources. The obstacles mentioned here are similar to those noted by WHO during its conference on birth attendants in Mexico City in 1979 [Ill and cannot be overcome without the maximum efficient utilization of all current Ministry of Health personnel and financial resources. Furthermore, strategies designed for nationwide replication will almost certainly have to be modified according to local circumstances. In this regard, community studies carried out by person with medical anthropologic skills would be most appropriate as a preliminary measure in the preparation of a TBA training program. Training TBAs
in the Philippines
The Philippines provide an example of a nationwide effort to train TBAs. In the post World War II era the policy of the government of the Philippines was to discourage the practice of traditional medicine. But in 1954 a government survey indicated that TBAs or hilots delivered 7580% of all babies. Unable to provide the services of modern doctors and nursemidwives, the government decided to stop discouraging the use of hilots. In fact, a large-scale pilot training program for hilots was instituted, eventually carried out by both the Ministry of Health and a private organization [ 14,153. Traditionally the highly respected hilots provided massage and assistance at delivery, administered herbal medicines, gave advice about marriage, fertility control and child rearing and to some extent engaged in medical practices. The training program that was developed for them emphasized hygienic practices, routine delivery and family planning education. More recent programs include instruction in birth registration and the distribution of contraceptive materials. Some hilots are specially selected for further training so as to become hilots aids who supervise the work of their colleagues and serve as a liaison with the health unit personnel. The hilot training program was interrupted in the early 1970s to permit comprehensive evaluation. As a result the decision was made to institutionalize the program and to train all of the estimated more than 30,000 hilots in the Philippines. Laws were changed to legalize the functioning of trained hilots and to sanction their practice of midwifery in localities where doctors and registered midwives were not available to offer their services. Finally, a program of supervision and resupply of materials has been established through the Philippines. Training TBAs in Indonrsia
The program in Indonesia represents another example of an extensive effort of a national government to link TBAs with the Health Ministry while also expanding the role of TBAs to include specific responsibilities for family planning services and maternal and child health. The number of TBAs or
Ethnomedicine
and biomedicine linking
bajis potentially to be involved is more than 75,000. They attend at least 85% of all birth in Indonesia and are highly respected in their communities. In addition to giving delivery assistance and advice on matters relating to fertility, the dukun bajis make use of herbal medicines and play a role in maintaining magico-religious customs. The first government school for traditional midwives was opened as early as 1850 but closed 25 years later. It reopened in 1910 and several others were established subsequently. In 1952 UNICEF began to sponsor training programs and to distribute midwifery kits as part of a worldwide effort to upgrade the skills of TBAs so that by the 1970s an estimated half of Indonesia’s dukun bajis had completed formal training programs. Finally, in 1973 the National Family Planning Program sought to recruit TBAs who were interested in an intensive 2-day family planning seminar so as to join subsequently in efforts to motivate the public. It was found that the dukun bajis. like TBAs throughout the world, see the provision of family planning services part of their function and were in fact already responsible for referring a small but steady stream of women to family planning centers.
dukun
CONCLUSIONS
AND
RECOMMENDATlONS
The conclusions noted here are based upon a review of the literature and discussions with primary health care workers and government officials from many developing areas. The senior author also drew upon in-depth personal experience in elaborating viable, lasting linkages between ethnomedicine and biomedicine in a manner which results in improved services to the public at a cost no greater than alternatives such as an expansion of the existing biomedicine network. Some general conclusions are as follows: 1. The cultures and belief systems of most nonWestern societies are primarily oriented to personal relationships and to the individual’s relationship to soul and spirits. Being at peace with the family, clan, village. tribe and ancestral spirits is of the utmost importance. Ethnomedicine and its practices spring directly from this system of beliefs. To destroy the traditional medical care system is equivalent to destroying a vital element of culture. Biomedicine is of great scientific value but does not address issues vital to the psychological well-being of individuals who are products of traditional cultures. 2. Therefore. the ideal appraoch to optimizing the physical and mental health of most people is an approach in which elements of ethnomedicine and biomedicine supplement and complement each other. Each group will have to understand the basic philosophy of the other. 3. There is a legacy of mutual misunderstanding and mistrust on the part of both ethnomedicine and biomedicine practitioners. Moreover. it is easier for many traditional healers to assimilate different techniques than it is for Western-trained professionals who often are in the shizophrenic position of having been steeped in traditional healing values as children,
1823
noting that respected relatives still cling to the old ways and yet following their own professional training which espouses a rejection of indigenous medicine. 4. There is a significant shortage of hard data on most aspects of the problem of integrating ethnomeditine and biomedicine. Here medical anthropologists can play an invaluable role, especially if willing to assume a task-oriented posture and work with biomedicine health sector planners [IO]. 5. A growing number of developing countries are upgrading and expanding their health planning units and developing linkages with rural health teaching units which are frequently university based. These are good points of association for medical anthropologists where effective input can be made into the biomedicine planning process directly through the Ministry of Health as well as indirectly through the educational system. 6. Political pressures are being exerted by the rural masses for enhanced social welfare services and increased real productivity. This must be done expeditiously and at minimal cost while preserving the integrity of cultures. Medical anthropologists working for the integration of biomedicine and ethnomedicine could help facilitate the understanding that would alleviate some of these pressures. 7. If health services in less developed countries are to be optimized and include efficient, effective linkage between ethnomedicine and biomedicine. some specific questions must be answered: (a) What is the understanding of and attitude towards biomedicine by leading traditional practitioners? (b) What is the understanding of and attitude toward ethnomedicine by teachers of modern Western medicine and by health service planners and managers? (c) What are possible linkage mechanisms and which ones seem most feasible? (d) How do ethnomedicine and biomedicine practitioners feel about the alternative linkage strategies? (e) What means exist for evaluating both systems’ effectiveness in rural areas? (f) What were the successes/failures and costs. of past efforts? (g) Are there and will there be sufficient numbers of traditional practitioners so as to warrant promoting collaboration with them as a way to meet the need for primary health care?
SOME
PREDICTIONS TWENTY
FOR THE
NEXT
YEARS
Recommendations and ideals notwithstanding, there is much that can be said regarding what is likely to come about as government planners and managers of health care systems examine realistically the circumstances in which they find themselves. Perhaps the three most important factors to be dealt with in seeking to expand health care services are: (1) rapidly increasing demands and needs for services; (2) the finite character of financial and other resources, which seriously limits the capabilities of modern medicine: and (3) the pervasiveness and persistence of tra-
1824
A. K. NEUMANNand P. LAURO
ditional medicine. Given these observations and accounting for current trends. one can make the following predictions : 1. The movement to recruit and train traditional birth attendants and effectively link them to the biomedicine system will gain momentum and be refined. There will be greater selectivity in the recruiting and training of TBAs and their roles will broaden. 2. As community mental health problems increase in the wake of modernization and it becomes painfully clear that Western psychiatry is ineffective, there will be a gradual, linkage with traditional spiritual healers. 3. The technical specialists, such as bonesetters, will continue to function independently as they have for ages. 4. Herbalists are such a varied group as to make generalization difficult. Where they are organized, have training schools, texts, standardized medications and professional associations, such as in India and the PRC, they will officially work in parallel with the biomedical establishment in a mutual advantageous manner. In other areas some will be effectively coopted by the biomedicine establishment either by being hired to function according to modern scientific protocol or by deciding it is economically advisable to employ Western medications and procedures. 5. Efforts to control quacks and charlatans will increase. 6. Some biomedical professionals will acknowledge the need to learn more about traditional medicine and its sociocultural, holistic approach will be better practitioners for this knowledge. However, modern medical education will continue to emphasize superspecialized curative medicine. 7. Medical anthropology as a discipline will grow in importance and prestige, will attract more biomedical professionals and will play an important role in the difficult task of bringing about effective, beneficial linkages between ethnomedicine and biomedicine. 8. The supply of medical doctors will be insufficient to meet the’growing health care needs. Attempts to induce physicians to remote rural areas in both developed and lesser developed countries will continue to meet with limited success. 9. Government efforts to recruit and train community health workers (CHWs) to provide health care will continue and will expand. Although trained in modern medical techniques, as actual members of the communities they serve, these CHWs will represent a linkage of the traditional culture and the biomedical establishment. 10. Greater efforts will be made through health education programs to increase the general level of knowledge of the masses in the areas of health, nutrition and family planning. The aim of such programs will be to promote a self-help approach and thereby reduce demands placed on already strained health care resources. 11. More practical research will be forthcoming in the area of the linkage of modern and traditional medicine. Governments will give more attention particularly to the classification and analysis of herbal and other traditional remedies while the study of the
practice of indigenous medicine will remain of interest primarily from an anthropological point of view. 12. Patterns of provision of health services will remain complex and multiple sources of care will continue to exist side by side. Indigenous practitioners will contribute to this phenomenon by modifying their practices and adding selected modern procedures and medications to their repertoires. 13. Many countries will reduce social welfare sector expenditures outright or will not increase them fast enough to compensate for inflation and population growth. As a higher priority is given to military spending, the time will come when pressure by the masses will force countries to reduce armaments in favor of programs which improve the quality of life. 14. In general, the managers of the health sector will seek to develop efficiently the full potential of limited biomedical resources. As part of this process although most will recognize that indigenous medicine is not likely to be completely displaced, linkage of the modern and the traditional will be given less attention than it deserves.
REFERENCES
1. Executive Board of the World Health Organization. Srrategies for Heulth for All bj, rhr Yeur 2000. World Health Organization. Geneva, 1979. 2. Foster G. M. and Anderson B. G. Medicnl Anthropology. Wiley. New York. 1978. 3. Lambo T. A. Traditional African cultures ahd Western medicine. In Medicine and Culture (Edited by Poynter F.N.L.). Wellcome Institute of Medicine, London, 1969. 4. Fabrega H. Ethnomedicine and medical science. Med. Anthrop. 2, 11-29, 1978. 5. Director-General of World Health Organization and Executive Director of United Nations Childrens’s Fund. Primar_v Health Care. World Health Organization, Geneva, 1978. 6. Taylor C. E. Development and the transition of global health. Med. Anthrop. 2, 59-70, 1978. 7. Eisenberg L. The search for care. In Doing Better and Feeling Worse (Edited by Knowles J. H.). W. W. Norton. New York. 1977. a. Neumann A. K. et al. Role of the indigenous medicine practitioner in two areas of India: report of a study. Sot. Sci. Med. 5. 137-149. 1971. 9. Nichter M. Patterns of resort in the use of therapy systems and their significance for health planning in South Asia. Med. Anthrop. 2. 29-58. 1978. 10. Woods C. M. Alternative curing strategies in a changing medical situation. Med. Anrhrop. 1, 25-53, 1977. 11. World Health Organization. Inter-regional consultation on traditional birth attendants. Mexico City, 1979. 12. Ministry of Health. Report qf the Cow&tee to Assess and Evaluate the Present Sratus of Ayrrrcedic System of Medicine. Government of India. Calcutta. 1959. 13. Ampofo D. A. et (II. The training of traditional birth
attendant in Ghana: Experience of the Danfa Rural Health Project. Trop. Geogrl. Med. 29. 197-203, 1977. 14. Traditional midwives and family planning. Popul. Rep. Series J, No. 22, May 1980. 15. Verderse M de L. The Traditional Birth Attendant in maternal and child health and family planning. World Health Organization, Geneva. 1974.
0277-9536/82/2 I IX17-08$03.00/0 Copyright 0 1982Pergamon Press Ltd
Vol. 16. pp. IX17to 1824.1982 Printed in Great Britain. All rights reserved
ETHNOMEDICINE
AND BIOMEDICINE
LINKING
A. K. NEUMANNand P. LAURO School of Public Health. University of California. Los Angeles. CA 90024, U.S.A. Abstract-This paper considers the integration of the biomedical establishment with traditional medical care systems given the urgent need for health care services by the underserved masses in developing countries. The difficulties of identifying and categorizing indigenous practitioners are outlined. Several strategies are suggested for standardizing, professionalizing, or otherwise mobilizing traditional healers in the movement to achieve the World Health Organization’s goal of “health for all by the year 2000”. The potential benefits as well as the constraints related to such efforts are described. As examples of what attempts are being made today to link modern and traditional health care systems, programs in the People’s Republic of China, India. Ghana, the Philippines and Indonesia are summarized. The paper concludes with some recommendations as well as some predictions for the next 20 years.
INTRODUCTION
As pressures for “Health for all by the year 2000” [l] mount and the enormous volume of unmet needs and the staggering cost of meeting them are calculated. there is a very human tendency to look for low-cost, quick, simplistic solutions. One of these is to recruit, train in Western medicine and link the ubiquitous indigenous medicine practitioners to the modern medicine or biomedicine’system and thus solve much of the problem of providing modern primary health care for the underserved rural masses. As a physician who became a disciple of Ben Paul more than 20 years ago (senior author) and who subsequently has been involved in in-depth ethnomedicine research as well as rural health program development (both authors), one would venture to say that much more information needs to be gathered before sweeping generalizations can be made. Moreover, it is asserted that, although medical anthropologists have already done much good work, their finest hour is yet to come. The trend for medical anthropologists to study indigenous medicine as a system is very desirable and essential if effective linkage between biomedicine and ethnomedicine is going to be achieved to any significant degree. This paper will explore factors contributing to the growth of interest in traditional medicine, identify types of linkages. discuss reasons for and against linkage between ethnomedicine and biomedicine, discuss practical steps to bring about such linkages and what is needed to institutionalize the linkages, briefly analyze some examples and make some recommendations in an attempt to look into the future. At this point a plea is made for all, but especially the biomedicine establishment, to acknowledge the importance of tradition and culture and the fact that traditional medicine is essentially an outgrdwth and expression of culture. It must be understood that many of the practices of traditional medicine practitioners are designed to preserve cultural institutions and to help the patient live at peace with his family. clan. village. tribe and inner self [Z-4]. The traditional medicine practitioner has intrinsically a broader social role to play. is more community oriented than the typical biomedicine clinician. Curing physical dis-
ease in the sense of the biomedicine clinician is only part of the role of the indigenous medicine practitioner, and it is only in this limited sphere that biomedicine can make a contribution to traditional medicine, developing countries and rural health. It is the position of this paper that services need the social, Spiritual component of traditional medicine and the clinical component of biomedicine. THE NEED
FOR HEALTH CARE
Leaders and planners in the developing nations of the world have come to realize that progress in the area of overall economic development is intricately related to the general health status of the population. They now understand that funds allocated for health programs do indeed constitute in economic terms not only a sound but also an essential investment. Furthermore, the need for services is as large in scope as it is urgent. Estimates indicate that 70 to perhaps 80:/ of the population of lesser developed countries have little or no access to basic health services. The masses of rural inhabitants are becoming increasingly aware of what is achievable through modern medical care and governments are increasingly pressured to provide modern health services. This is occurring precisely as world inflation mounts and the financial situation of countries who do not produce oil steadily worsens. These countries find it impossible to expand the health services network using expensively staffed hospitals and health centers. Effective low-cost health care delivery systems will have to be devised. Thus, the matter is not one of upgrading the technology of present systems in the developing countries, but rather concerns the more basic issue of taking the initial steps to promote and maintain the general health and welfare of all individuals and communities and entails a massive expansion of primary health services. This important issue was. in fact, the theme of a joint WHO/UNICEF Ata. USSR. in September.
conference held in Alma 1978. About 2000 partici-
pants representing 150 nations. international agencies and private voluntary organizations unanimously agreed that primary health care must constitute an integral part of each nation’s total development strat-
1817
1818
A. K. NEUMANN and P.
egy. Acknowledging the need as a ‘burning necessity” [S. p. 71. the national delegations pledged their support of the goal of primary health care for all by the year 2000. Although all consider this goal to be laudable, clearly it will be difficult to accomplish. Planners in those nations whose welfare and development are at stake are disheartened as they contemplate the enormous amounts of resources that will be necessary to expand their existing health services so as to reach the underserved majority with even primary health care. The report of the Alma Ata conference in fact emphasized the need to develop innovative ways to assure that primary health care reaches the huge underserved populations of the developing nations. The report further asserts that planning and policy decisions not be conceived as simply a matter of extending the delivery of basic health services. That is. a system which views the masses as passive recipients decreases the likelihood that a program will be appropriate, acceptable, or speedily implemented. Taylor has stated the problem succinctly by noting that we need to “find out not how to do things for people but how to work with them on their priorities” [6, p. 671. The consensus of opinion suggests that in the past there has been some gap that refuses to be bridged or filled in regarding the application of modern scientific medicine to cultures that are neither modern nor scientific. The failures of programs are often blamed on the conflicting values and practices of two systems which have been identified by the terms biomedicine and ethnomedicine. Biomedicine is understood to refer to the historically Western, scientific, hospital-based, technology oriented system. Ethnomedicine refers to the practices of traditional healers who rely on indigenous medicines and/or ritual to treat the sick. Risking oversimplification, one can make.a further generalization when distinguishing between the two approaches. Biomedicine is concerned with the objective, scientific management of a pathophysiologic process. Ethnomedicine deals subjectively with the whole alteration. In other words, the medical doctor treats the disease while the traditional healer treats the person (who happens to be ill). Thus, while ethnomedicine is scorned for its lack of a solid scientific foundation. biomedicine is criticized for its impersonality. The medicines of one may be faulting in biological potency, yet the other has lost that special something that used to be provided by the family doctor who went house to house with his little black bag [7]. Once the issue of medical care is viewed in this manner, the conclusion is then drawn that the ideal primary care includes elements of both systems. The success of primary health care in many developing countries will depend upon the use of community health workers, selected from the general population and trained in basic biomedical procedures. This view has led to the initiation of programs throughout the world to prepare local citizens to take on the titles of barefoot doctor, health promoter, nursing auxiliary and SO on. However, this integration of the biomedical establishment with community resources does not solve the problem for those who view the important gap as that which separates modern medicine from traditional medicine.
LA~RO
Thus. for some planners and international health workers who formerly disdained any perpetuation of traditional medicine. some linkage of the two systems may become essential. For the moment. one thing that is made clear by an assessment of the money and biomedical resources at hand is that modern medicine and all its trappings simply cannot be made available to all the world’s people in the foreseeable future. The millions of isolated rural poor in particular will remain neglected if they are to wait until sufficient numbers of doctors and nurses are trained and health centers are built to serve their hard-to-reach and sometimes less-than-inviting communities and villages. In the final analysis. common sense indicates that much could be accomplished and relatively quickly, by somehow tapping the resources that are already available locally. The questions are: how. time frame. at what cost and with what results? With regard to the discussion of linking modern with traditional systems. an objection is sometimes put forth by cultural purists. The objection is that since ethnomedicine already serves those populations in question. biomedicine need not be concerned with extending itself to so-called underserved areas. To answer this objection one notes that the shortage of personnel quite possibly is a reality of ethnomedicine as it is of biomedicine. Many recent studies have documented a decline in the numbers of indigenous practitioners [Z]. Second. modern health care undeniably has its body of practices and procedures which reduce morbidity and mortality in many instances when traditional medicine fails to do so. Third, although resistance to biomedicine is still frequently noted, numerous studies done in various parts of the developing world indicate a trend toward the increasing acceptance of and even a preference for modern medical techniques and therapies [Z, 81. In many cases the indigenous practitioners have themselves adopted some of the medications and instruments of Western medicine. An important fact often ignored by supporters of one medical system or the other is that to view the controversy as a simple either/or issue is to misconceive the true situation. In nearly every cultural setting, including modern Western cultures, health care systems are pluralistic. Given equal access to multiple treatment resources. consumers resort to one or another depending on their perception of the nature of the illness, the time needed to obtain care, and the anticipated costs [9]. Or health care resources may be sought according to a predictable sequence. beginning with minor self-care in the home and proceeding through a series of increasingly specialized major treatments until the point where a satisfactory outcome is obtained [lo]. DIFFICULTIES
IN IDENTIFYING
PRACTITIONERS
Unfortunately. this enlightened understanding of the pluralism of medical care systems further complicates the problem of linking biomedicine and ethnomeditine for the purposes of securing primary health care for all. Even before beginning to consider how to integrate the biomedical establishment with ethnomeditine. policy makers must determine which categories
Ethnomedicine and biomedicine linking of indigenous practitioners ought to be approached. There is general agreement that the ubiquitous traditional birth attendant (TBA) is a valuable resource in the community and potentially an important element in the primary health care movement [I 1-J.In fact, many countries have already begun training programs to increase the skills and expertise of TBAs. However, with regard to others such as herbalists and spiritual healers there is no consensus of opion as to the benefits to be derived through attempts at col!aboration. In instances when ethnomedicine differs drastically from biomedicine with regard to disease etiology, diagnosis and treatment, the two systems are often viewed as basically incompatible. In any event national planners and international agencies should not proceed with the identification of individuals potentially trainable in some biomedical procedures without first enumerating the varieties of local medical practitioners and defining their current roles and status in their communities. This initial task may be a costly, time consuming endeavor in many countries where the population includes numerous tribes or subcultures, each with its distinct categories of indigenous healers, As a preliminary measure, one might find it useful to consider four general categories of indigenous practitioners: 1. Spiritual or magico-religious healers. 2. Herbalists. 3. Technical specialists such as bonesetters. 4. Traditional birth attendants. Although the functions of these practitioners may overlap to some degree while other healers may not fit into these categories at all, these groupings will facilitate an understanding of the traditional medical care systems of most cultures. This identifjcation procedure should determine the degree to whtch the ethnomedical establishment is interested in or resistant to collaboration with biomedical practitioners and/or formally established government programs. Traditional medicine may prove to be an unwilling ally that will have to be won over to a belief that integration is possible and desirable. Similarly, regional or community level government health professionals may or may not be as eager as central authorities are to initiate an ongoing working relationship with indigenous healers. Finally, some attempt should be made to ascertain how the population-the communities and villages-would react to organization or procedural changes in their traditional medical systems. General apathy or pockets of resistance among the ranks of any group would seriously hinder the implementation of collaborative programs. POSSIBLE
STRATEGIES
FOR ‘LINKAGE
Beyond these preliminary obstacles lies the major question of determining what is.meant by the integration of biomedicine and ethnomedicine. Certainly, it implies more than peaceful coexistence, given the urgent need to maximize the use of all available health practitioners. The goal of primary health care. with its task oriented approach to improving the health and welfare of all people seems rather to call
1819
for the active promotion of what might be termed beneficial coexistence. This could be accomplished in several ways, most of which relate to professionalizing somehow the traditional practitioners. This implies identifying the professionals and controlling the quacks. Some of the possibilities for linking biomedicine and ethnomedicine are as follows: 1. Institute a government licensing program and license those indigenous practitioners known to have completed a specific, recognized training period or apprenticeship and who can demonstrate a predetermined level of competence in their work. This would encourage those in practice to upgrade their skills and might inspire others to take up this now high-status occupation, while also helping to control quackery. 2. Formalize selected categories of practitioners to an even greater extent by supporting the founding and operation of schools that produce herbalists, homeopaths, acupuncturists and other non-biomedical specialists. 3. Invite selected traditional practitioners to participate in a training course designed to ‘upgrade’ their skills as per the norms of the biomedical establishment. Supply them free of charge or at low cost with basic supplies and medications. Provide angoing supervision, continuing education and a resupply of materials as necessary. 4. Train selected practitioners (as just noted) and officially hire them as employees of the Ministry of Health. 5. Recruit a local, licensed traditional practitioner to be part of the team in every rural health outpost. This person could instruct the staff in the essentials of ethnomedicine and also serve as a link between the health center and the community. 6. Organize workshops for government health personnel in which they are given appropriate cross-cultural training, with specific emphasis on the beliefs and practices of traditional medicine. 7. Finance research into the pharmacopoeia of traditional medicine, especially with regard to medicinal plants. Prepare manuals and didactic materials with a view to standardizing procedures and preserving the art/science of these locally available medicines. Include this information in health education programs in rural areas. 8. Modify biomedicine establishment training programs, especially those for physicians, nurses and midwives to include elements of traditional medicine with a view towards personalizing the practice of biomedicine and promoting appreciation of traditional beliefs and practices. POSSIBLE
BENEFITS
One must consider the potential positive effects of linking biomedicine with ethnomedicine. In an ideal situation, all parties concerned stand to benefit. National gooernments
Many of the developing countries are struggling desperately for economic survival and their productivity is. to a great extent, dependent upon the health of their citizens. As noted previously, governments are aware that health programs are an essential
1820
A. K. NEUMANN
investiment. They further realize that making use of already existing community resources. such as indigenous practitioners, is a relatively inexpensive way to expand health services.
and P.
LAURO
national or local health care systems and an assessment of the time, effort and cost that would be required for the revision of existing legislation. SUCCESSES IN LINKING
Biomedical professionals
The biomedical establishment. as well as the national governments, stand to benefit by collabotating with traditional medicine. Government health professionals and international agencies have been less than successful in the past, often because their approaches and practices have been culturally or technologically inappropriate. Increased communication with indigenous health practitioners would help to bridge the gaps and make biomedicine more effective in communities and villages. Another advantage for biomedicine is that the escessive demands now made upon its insufficient number of health professionals would be greatly relieved if local health resources were mobilized to share the work load. Indigenous practitioners
They would benefit from the opportunity to increase their skills and knowledge, whether by simple contact with or actual training in biomedical procedures. And the acquisition of new skills is likely to translate into’s potential for increased income. General population
The obvious benefits of integrating modern scientific medicine and traditional system would go to the populations served. All would have better access to health care and the quality of care could be significantly improved. Treatment would be sought in a system with specified performance standards. In addition, the linking of the ethnomedical with the biomedical would increase the likelihood of appropriate referral for severe or special cases of disease or injury. And for those individuals or populations to whom government health services are not particularly palatable, their traditional healers associated with those services could encourage and persuade them to reconsider. CONSTRAINTS
Although in theory integration of the modern and the traditional is workable and desirable, there are decided constraints. Most significantly, there is a lack of sufficient information to enable health systems planners to commit substantial resources to establishing linkages on a significant scale so as to achieve a measure of permanency. Information needed in each country and possibly on a regional or district basis within any given country would include the following: 1. Numbers and kinds of traditional healers, their practices and their effectiveness. 2. Current standards and controls in the practice of traditional medicine, including training, the existence of professional associations. the use of peer review mechanisms. 3. Assessment of anticipated costs and personnel needs for the implementation of a large scale effort to link biomedicine and traditional systems. 4. Legal constraints relating to reorganizing
BIO>lEDICISE
AND ETHNOMEDICINE
In terms of hundreds of millions of people affected. the successes in linking biomedicine and ethnomeditine are considerable. The most noteworthy programs have been carried out in India and People’s Republic of China (PRC). In Latin America and probably also in the South Pacific and Oceania the relationship between modern and traditional medical systems can be best described as peaceful coexistence. In Africa. in the colonial era, which ended not so long ago. the practice of traditional medicine was illegal in many countries and there was on occasion active persecution of traditional medicine practitioners. Only in recent years have there been experimental schemes working toward establishing linkages between ethnomedicine and biomedicine. Noteworthy work is being done in Ghana and Nigeria. The kinds of traditional practitioners involved in the programs in India. and the PRC are primarily herbalists. Almost everywhere else where there are attempts at linkage. traditional birth attendants are involved. In India and the PRC the practice of herbalism has an ancient and honorable tradition with written texts dating back thousands of years, well established training centers, professional associations. codes of ethics and mechanisms for enforcing them. According to personal communications, few herbalists in the PRC have become barefoot doctors, for most prefer to practice solely traditional Chinese medicine. Since the role of traditional birth attendants is primarily dictated by the nature of pregnancy and the birth process and is relatively straight forward. TBAs and the biomedical establishment have a basis for working together. Around the world experimental projects to upgrade TBA skills by means of training programs have been quite successful. The problem is to provide for long term supervision. resupply of sterile items and refresher training. In the eyes of many health planners such efforts that are being made to link modern and traditional systems of medical care are seen as resulting in a slow-down of the expansion of the biomedical system of clinics and local health centers. Others, however, see linkage as a desirable and necessary extension of the biomedical system in order to serve the people better. Unfortunately, not enough hard data exist regarding costs, effects and benefits of various alternatives so as to enable wise decision-making at the national level. Examples of medical systems and special programs in People’s Republic of China. India. Ghana, The Philippines and Indonesia will serve to illustrate how some governments have approached the question of linkage to ethnomedicine and biomedicine. Medicine and health care in People’s Republic of China
By the time that Western medicine was introduced into China by medical missionaries in the nineteenth century. Chinese
the highly developed system of traditional medicine had been thriving for 4000 years.
Ethnomedicine and biomedicine linking Despite the persistence of traditional Chinese medicine through the ages and its deep roots in Chinese pilosophy and religion, modern Western medicine was able to superimpose itself beginning in the nineteenth century. The governments of the early 1900s favored Western medicine but did little to promote its spread (or any other health and welfare programs) among the masses. The government which came to power in 1949 recognized the urgent need to develop an adequate health care program for the masses and recognized that some sort of linkage of Western and traditional medicine would improve the quantity and quality of health services. Western-style urban medical personnel were persuaded to enroll in a course in Chinese medicine which had been recently incorporated into the university curriculum and these professionals were then transferred to rural service for one year. Meanwhile, traditional doctors were assigned to hospitals and clinics and in 1955 the Academy of Traditional Medicine was established. The integration of traditional Chinese medicine and Western medicine continues. In the medical schools the new curriculum includes modern scientific subjects as well as the full range of traditional practices. Acupuncture anesthesia was developed in 1958, and in most hospitals the department of anesthesiology now includes trained acupuncturists. Similarly, hospitals supplement their treatments with traditional medicines. Finally. in the countryside traditional practitioners have been identified and their practices modified to include modern hygiene and scientific knowledge. Medicine and health care in India
Although the highly developed systems of medicine of the ancient Egyptians. Romans, and Greeks have all decayed, India stands with the PRC in that its history of Ayurveda, the traditional Indian medicine, probably dates back to more than 3000 years [15]. The practice of medicine in India today incorporates a second traditional system which has figured significantly in the country for about 700 years. Unani medicine embodies the Greek traditions adopted by the Arabs and then brought to India by the Muslim conquerors very early in the twelfth century. Not long after the endaof the period of Mogul rule in India in the early eighteenth century, Western medicine was introduced by Europeans in the early 1800s. Western medicine was almost immediately relegated a position of prestige for being modern and scientific, yet the majority of the population continued to be served primarily by traditional systems. Perhaps in recognition of the omnipresence and usefulness of ancient systems of healing, as .early as the 1920s the first all-India conference was held to consider renewed official support of Ayurvedic medicine. In 1926 research on indigenous drugs was sponsored by the India Research Association for the purpose of preparing a pharmacopoeia. In 1949 the Chopra Committee report recommended that immediate steps be taken to bring about the synthesis of Indian and Western medicine. The Dave Committee of I955 made specific suggestions regarding the establishments of standards for the training and licensing of indigenous practitioners. Finally. in 1959 came the Report qf r/w Commitree
1821
to Assess and Evaluate the Present Status of Avurl;edic System of Medicine, sponsored by the Ministry of
Health of the Government of India. This report noted that the health care needs of 800/, of the population were actually served by Vaidyas and Hakims, the traditional physicians of Ayurveda and Unani respectively. The committee concluded that it was futile to condemn the Ayurvedic system when patients were benefitting from it every day all over the country. The final report included over 80 specific recommendations under the headings of training. research, pharmaceutical products and status of practice [12]. In 1981 the Government of India launched a national program to evaluate the functioning of TBAs. These facts and the findings of the various Indian government committees over the years call for a critical assessment of the roles of the Vaidyas and Hakims, the place of modern medicine and the potential fvor integrating the traditional systems with modern health care efforts. Training TBAs in Ghana
In addition to a host of herbalists. spiritualists and bonesetters, the traditional medical care system in Ghana includes the village midwives. The traditional birth attendant (TBA) play a significant role in rural maternal and child care in countries like Ghana where a majority of deliveries are attended by untrained personnel. TBAs deliver two-thirds of the babies in the world [l l] and work in areas where it is unlikely that access to modern medical care will be available in the foreseeable future. In view of these observations, the training of TBAs has been undertaken in several countires. Ghana is a West African country which has initiated an organized effort to study traditional medicine via the Danfa Rural Health Project. a joint venture of the University of Ghana and UCLA. A program was initiated to register TBAs and elicit information on their knowledge and practices [13]. Studies revealed that the typical TBA was an illiterate. elderly man or woman farmer who practiced midwifery part-time. A training course consisting initially of eight and subsequently of sixteen 3-hr sessions was developed and included the following elements: 1. Monitoring of pregnant women during the antepartum period. 2. Recognition/referral of high risk women or complicated cases. 3. Proper care of the umbilical cord. 4. Promotion of improved maternal and child health practices and family planning. The course was delivered by a nurse midwife and two public health nurses. with two physicans as resource persons. Upon graduation, each TBA was given a certificate and a midwifery kit. Once back in their villages. the TBAs were supervised by means of follow-up visits from their instructors. Continuing education was also provided by means of monthly refresher classes. The Danfa TBA training program conveys a sense of what must be done in order to link traditional systems with the biomedical establishment. First of all. it was necessary to gain the confidence of the
1822
A. K. NEUMANNand P. LAURO
villagers and obtain a list of traditional birth attendants. This was accomplished with a diplomatic approach to village elders. chiefs. healers and rank and file villagers themselves. The next step was to interview almost all TBAs. A small percentage which had initially refused to be interviewed eventually consented. The vast majority, about 85% were interested in participating without remunerations in a training program to upgrade their skills. The TBAs were trained in groups of twelve to sixteen in a village central to the group. Because the average age of the TBAs was 62 years and transport was a decided problem, it was necessary to visit each village a day or two in advance of the training seesion as a reminder, pick up the TBAs on the day of the session, and then to return them to their villages. The content of the training program was limited and nonformal education techniques were used involving charts, models, role playing, etc. Since more than 90”/, of the group were illiterate, written texts could not be employed. The final examination was designed by the Ghanaian instructional staff and consisted of a play. each act of which portrayed one of the principal lessions of the training course. The play was presented to assembled villagers of the training cluster on the last day of the course. Having completed the training program, some of the TBAs felt they should be salaried by the Ministry of Health. Although this was clearly not the aim of the program, the Ministry did encourage TBAs to charge higher fees provided they implemented their new skills. In addition, while the TBA recruitment and training program was underway, a health education program for villagers was launched. The purpose was to share with them essential elements of the training program and to convey the message that TBAs were engaging in a program to upgrade their skills at their own expense and on their own time. The villagers were informed to look for certain features which would indicate that TBA skills had indeed improved and were encouraged to increase remuneration for services accordingly. Common to past programs where the passage of time removed the evidence of previous TBA training efforts was that there had been no follow-up, supervision, resupply of materials, or in-service training. In Ghana quite senior personnel were involved in such activities although it is now felt that this could be done by relatively more junior personnel. For example, the midwives employed in most of Ghana’s local health centers are not very busy because most women remain in their villages and look to TBAs for birth assistance. Given suitable in-service training and supervision, the health center midwife could be considered a candidate for managing much of the TBA training and supervision. The Danfa TBA training program is being gradually replicated throughout the country. In order for this to be accomplished, suitable instructions and directives had to be issued by the Ministry of Health. Nurse midwives in the health centers in whose jurisdictions TBA training courses are to be held now receive suitable inlservice training as do heads of health centers, district health officers, regional chief nursing officers and others. Eventually the curriculum of the schools which train biomedical personnel in the
first place will have to be modified to reflect the new policies already being implemented at the periphery. Budgets will have to be augmented to account for additional transportation needs. supplies for midwifery kits and record keeping functions. The need for ongoing supervision and refresher classes for TBAs who have completed training also implies the need for additional budgetry and administrative resources. The obstacles mentioned here are similar to those noted by WHO during its conference on birth attendants in Mexico City in 1979 [Ill and cannot be overcome without the maximum efficient utilization of all current Ministry of Health personnel and financial resources. Furthermore, strategies designed for nationwide replication will almost certainly have to be modified according to local circumstances. In this regard, community studies carried out by person with medical anthropologic skills would be most appropriate as a preliminary measure in the preparation of a TBA training program. Training TBAs
in the Philippines
The Philippines provide an example of a nationwide effort to train TBAs. In the post World War II era the policy of the government of the Philippines was to discourage the practice of traditional medicine. But in 1954 a government survey indicated that TBAs or hilots delivered 7580% of all babies. Unable to provide the services of modern doctors and nursemidwives, the government decided to stop discouraging the use of hilots. In fact, a large-scale pilot training program for hilots was instituted, eventually carried out by both the Ministry of Health and a private organization [ 14,153. Traditionally the highly respected hilots provided massage and assistance at delivery, administered herbal medicines, gave advice about marriage, fertility control and child rearing and to some extent engaged in medical practices. The training program that was developed for them emphasized hygienic practices, routine delivery and family planning education. More recent programs include instruction in birth registration and the distribution of contraceptive materials. Some hilots are specially selected for further training so as to become hilots aids who supervise the work of their colleagues and serve as a liaison with the health unit personnel. The hilot training program was interrupted in the early 1970s to permit comprehensive evaluation. As a result the decision was made to institutionalize the program and to train all of the estimated more than 30,000 hilots in the Philippines. Laws were changed to legalize the functioning of trained hilots and to sanction their practice of midwifery in localities where doctors and registered midwives were not available to offer their services. Finally, a program of supervision and resupply of materials has been established through the Philippines. Training TBAs in Indonrsia
The program in Indonesia represents another example of an extensive effort of a national government to link TBAs with the Health Ministry while also expanding the role of TBAs to include specific responsibilities for family planning services and maternal and child health. The number of TBAs or
Ethnomedicine
and biomedicine linking
bajis potentially to be involved is more than 75,000. They attend at least 85% of all birth in Indonesia and are highly respected in their communities. In addition to giving delivery assistance and advice on matters relating to fertility, the dukun bajis make use of herbal medicines and play a role in maintaining magico-religious customs. The first government school for traditional midwives was opened as early as 1850 but closed 25 years later. It reopened in 1910 and several others were established subsequently. In 1952 UNICEF began to sponsor training programs and to distribute midwifery kits as part of a worldwide effort to upgrade the skills of TBAs so that by the 1970s an estimated half of Indonesia’s dukun bajis had completed formal training programs. Finally, in 1973 the National Family Planning Program sought to recruit TBAs who were interested in an intensive 2-day family planning seminar so as to join subsequently in efforts to motivate the public. It was found that the dukun bajis. like TBAs throughout the world, see the provision of family planning services part of their function and were in fact already responsible for referring a small but steady stream of women to family planning centers.
dukun
CONCLUSIONS
AND
RECOMMENDATlONS
The conclusions noted here are based upon a review of the literature and discussions with primary health care workers and government officials from many developing areas. The senior author also drew upon in-depth personal experience in elaborating viable, lasting linkages between ethnomedicine and biomedicine in a manner which results in improved services to the public at a cost no greater than alternatives such as an expansion of the existing biomedicine network. Some general conclusions are as follows: 1. The cultures and belief systems of most nonWestern societies are primarily oriented to personal relationships and to the individual’s relationship to soul and spirits. Being at peace with the family, clan, village. tribe and ancestral spirits is of the utmost importance. Ethnomedicine and its practices spring directly from this system of beliefs. To destroy the traditional medical care system is equivalent to destroying a vital element of culture. Biomedicine is of great scientific value but does not address issues vital to the psychological well-being of individuals who are products of traditional cultures. 2. Therefore. the ideal appraoch to optimizing the physical and mental health of most people is an approach in which elements of ethnomedicine and biomedicine supplement and complement each other. Each group will have to understand the basic philosophy of the other. 3. There is a legacy of mutual misunderstanding and mistrust on the part of both ethnomedicine and biomedicine practitioners. Moreover. it is easier for many traditional healers to assimilate different techniques than it is for Western-trained professionals who often are in the shizophrenic position of having been steeped in traditional healing values as children,
1823
noting that respected relatives still cling to the old ways and yet following their own professional training which espouses a rejection of indigenous medicine. 4. There is a significant shortage of hard data on most aspects of the problem of integrating ethnomeditine and biomedicine. Here medical anthropologists can play an invaluable role, especially if willing to assume a task-oriented posture and work with biomedicine health sector planners [IO]. 5. A growing number of developing countries are upgrading and expanding their health planning units and developing linkages with rural health teaching units which are frequently university based. These are good points of association for medical anthropologists where effective input can be made into the biomedicine planning process directly through the Ministry of Health as well as indirectly through the educational system. 6. Political pressures are being exerted by the rural masses for enhanced social welfare services and increased real productivity. This must be done expeditiously and at minimal cost while preserving the integrity of cultures. Medical anthropologists working for the integration of biomedicine and ethnomedicine could help facilitate the understanding that would alleviate some of these pressures. 7. If health services in less developed countries are to be optimized and include efficient, effective linkage between ethnomedicine and biomedicine. some specific questions must be answered: (a) What is the understanding of and attitude towards biomedicine by leading traditional practitioners? (b) What is the understanding of and attitude toward ethnomedicine by teachers of modern Western medicine and by health service planners and managers? (c) What are possible linkage mechanisms and which ones seem most feasible? (d) How do ethnomedicine and biomedicine practitioners feel about the alternative linkage strategies? (e) What means exist for evaluating both systems’ effectiveness in rural areas? (f) What were the successes/failures and costs. of past efforts? (g) Are there and will there be sufficient numbers of traditional practitioners so as to warrant promoting collaboration with them as a way to meet the need for primary health care?
SOME
PREDICTIONS TWENTY
FOR THE
NEXT
YEARS
Recommendations and ideals notwithstanding, there is much that can be said regarding what is likely to come about as government planners and managers of health care systems examine realistically the circumstances in which they find themselves. Perhaps the three most important factors to be dealt with in seeking to expand health care services are: (1) rapidly increasing demands and needs for services; (2) the finite character of financial and other resources, which seriously limits the capabilities of modern medicine: and (3) the pervasiveness and persistence of tra-
1824
A. K. NEUMANNand P. LAURO
ditional medicine. Given these observations and accounting for current trends. one can make the following predictions : 1. The movement to recruit and train traditional birth attendants and effectively link them to the biomedicine system will gain momentum and be refined. There will be greater selectivity in the recruiting and training of TBAs and their roles will broaden. 2. As community mental health problems increase in the wake of modernization and it becomes painfully clear that Western psychiatry is ineffective, there will be a gradual, linkage with traditional spiritual healers. 3. The technical specialists, such as bonesetters, will continue to function independently as they have for ages. 4. Herbalists are such a varied group as to make generalization difficult. Where they are organized, have training schools, texts, standardized medications and professional associations, such as in India and the PRC, they will officially work in parallel with the biomedical establishment in a mutual advantageous manner. In other areas some will be effectively coopted by the biomedicine establishment either by being hired to function according to modern scientific protocol or by deciding it is economically advisable to employ Western medications and procedures. 5. Efforts to control quacks and charlatans will increase. 6. Some biomedical professionals will acknowledge the need to learn more about traditional medicine and its sociocultural, holistic approach will be better practitioners for this knowledge. However, modern medical education will continue to emphasize superspecialized curative medicine. 7. Medical anthropology as a discipline will grow in importance and prestige, will attract more biomedical professionals and will play an important role in the difficult task of bringing about effective, beneficial linkages between ethnomedicine and biomedicine. 8. The supply of medical doctors will be insufficient to meet the’growing health care needs. Attempts to induce physicians to remote rural areas in both developed and lesser developed countries will continue to meet with limited success. 9. Government efforts to recruit and train community health workers (CHWs) to provide health care will continue and will expand. Although trained in modern medical techniques, as actual members of the communities they serve, these CHWs will represent a linkage of the traditional culture and the biomedical establishment. 10. Greater efforts will be made through health education programs to increase the general level of knowledge of the masses in the areas of health, nutrition and family planning. The aim of such programs will be to promote a self-help approach and thereby reduce demands placed on already strained health care resources. 11. More practical research will be forthcoming in the area of the linkage of modern and traditional medicine. Governments will give more attention particularly to the classification and analysis of herbal and other traditional remedies while the study of the
practice of indigenous medicine will remain of interest primarily from an anthropological point of view. 12. Patterns of provision of health services will remain complex and multiple sources of care will continue to exist side by side. Indigenous practitioners will contribute to this phenomenon by modifying their practices and adding selected modern procedures and medications to their repertoires. 13. Many countries will reduce social welfare sector expenditures outright or will not increase them fast enough to compensate for inflation and population growth. As a higher priority is given to military spending, the time will come when pressure by the masses will force countries to reduce armaments in favor of programs which improve the quality of life. 14. In general, the managers of the health sector will seek to develop efficiently the full potential of limited biomedical resources. As part of this process although most will recognize that indigenous medicine is not likely to be completely displaced, linkage of the modern and the traditional will be given less attention than it deserves.
REFERENCES
1. Executive Board of the World Health Organization. Srrategies for Heulth for All bj, rhr Yeur 2000. World Health Organization. Geneva, 1979. 2. Foster G. M. and Anderson B. G. Medicnl Anthropology. Wiley. New York. 1978. 3. Lambo T. A. Traditional African cultures ahd Western medicine. In Medicine and Culture (Edited by Poynter F.N.L.). Wellcome Institute of Medicine, London, 1969. 4. Fabrega H. Ethnomedicine and medical science. Med. Anthrop. 2, 11-29, 1978. 5. Director-General of World Health Organization and Executive Director of United Nations Childrens’s Fund. Primar_v Health Care. World Health Organization, Geneva, 1978. 6. Taylor C. E. Development and the transition of global health. Med. Anthrop. 2, 59-70, 1978. 7. Eisenberg L. The search for care. In Doing Better and Feeling Worse (Edited by Knowles J. H.). W. W. Norton. New York. 1977. a. Neumann A. K. et al. Role of the indigenous medicine practitioner in two areas of India: report of a study. Sot. Sci. Med. 5. 137-149. 1971. 9. Nichter M. Patterns of resort in the use of therapy systems and their significance for health planning in South Asia. Med. Anthrop. 2. 29-58. 1978. 10. Woods C. M. Alternative curing strategies in a changing medical situation. Med. Anrhrop. 1, 25-53, 1977. 11. World Health Organization. Inter-regional consultation on traditional birth attendants. Mexico City, 1979. 12. Ministry of Health. Report qf the Cow&tee to Assess and Evaluate the Present Sratus of Ayrrrcedic System of Medicine. Government of India. Calcutta. 1959. 13. Ampofo D. A. et (II. The training of traditional birth
attendant in Ghana: Experience of the Danfa Rural Health Project. Trop. Geogrl. Med. 29. 197-203, 1977. 14. Traditional midwives and family planning. Popul. Rep. Series J, No. 22, May 1980. 15. Verderse M de L. The Traditional Birth Attendant in maternal and child health and family planning. World Health Organization, Geneva. 1974.