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Integrating western orthodox and indigenous medicine
Sot. SCI. Med. Vol.
0277-9536/82/l
16. pp. 1611 IO 1617, 1982
XI 61 I-07K13.00/0
Per@tmon Press Ltd
Printed in Great Britain
INTEGRATING WESTERN ORTHODOX INDIGENOUS MEDICINE* PROFESSIONAL
INTERESTS AND ATTITUDES AMONG TRAINED NIGERIAN PHYSICIANS
AND
UNIVERSITY-
TOLA OLU PEARCE Department
of Sociology/Anthropology,
University of Ife. lie-lfe, Nigeria
Abstract-The problem of integrating the two major medical systems in Africa can be approached from many sides. This paper focuses on the attitudes of Western-trained practitioners. They are seen as a major force to be reckoned with in any serious attempt at cooperation or corporation. Nevertheless, substantive information in this area remains minimal. In the light of the well documented history of the struggle for control of the medical field by University-trained physicians in the West, and Freidson’s discussions on professional dominance’ the author theorized that the issue of integration in Nigeria would stir professional anxieties. The Western-trained physicians can be expected to object to serious moves-to integrate the two systems. Given this approach, it was hypothesized that. (1) Western-trained medical doctors will not like attempts to be integrated with indigenous healers (personnel) into a unified medical system. (2) Of the various aspects of the indigenous system. they will be interested in the quantifiable as compared to the nonquantifiable. One hundred and three self administered questionnaires were analysed. These were obtained in February 1978 from members of the Nigerian Medical Association attending a conference in Ibadan. The results supported the first hypothesis. For although two-thirds of the respondents said they favoured integration in general. when pressed, such suggestions as the development of ‘joint clinics’ were rejected by a significant majority and the ‘separate development of each system favoured. The second hypothesis was not however supported. There was ample evidence of interest in the less tangible, as yet not quantifiable aspects of the medical practices of indigenous practitioners.
INTRODUCTION The prospects for integrating the two major medical systems in various African countries has been a much debated topic since the 1970s. Both radical and the more conservative scholars have written in favour of integration, although their proposals for programmes often differ. Nevertheless, the reasons given in support of integration have become familiar. The case for integration has been made by various scholars. Some point to the lack of coverage of the Western type of services. The cost of reproducing the type of facilities available in the urban areas, throughout a nation, is seen as an impossible task. It is believed that the less expensive indigenous facilities could be merged with the hospital system of Western practitioners to produce a nationwide network of services. It has been argued that the indigenous medical practices are not discontinuous with regard to the culture and beliefs of the general population. Use could be made of the knowledge that the local practitioners have of the psychology and values of the people. Thus Ademuwagun writes “Since most professional health workers have limited knowledge of the cultural factors likely to promote or inhibit health, they would do well to consider working in partnership with native doctors” [I]. There is the additional aspect of the present re*Paper originally presented at 7th International Conference of Social Science and Medicine, June 1981.
ality of the public’s utilization patterns. Several authors have demonstrated that people use both services freely even when Western-style services are available (e.g. in the urban setting) [2-4]. Finally, there is growing interest in the ‘ecological approach of indigenous workers. The fact that many diseases are psychosomatic, and that the psychological dimension of illness is important in effective therapy has increased the appreciation of the social analysis approach associated with indigenous healers. It is assumed that for teamwork to be established in the future, research to upgrade and develop the best that exists within the indigenous system is necessary. At the present time, a country such as Nigeria is just debating the issue. There is as yet no official programme of integration, although research into the active components of local medicines has been going on for some time in such places as the universities of Ife and Ibadan. With regard to those scholars who are sceptical about the role of indigenous healing, Gould upon retiring from a visit to China, made it clear that he was opposed to attempts at sustaining and increasing the influence of traditional medicine. He argued that in China, “Men trained in Western Medicine are being forced to accept or adopt ancient magics.. Herbal medicine is a mixture of empiricism and superstition: acupuncture is unspoiled magic” [S]. He insisted that it is impossible to integrate the two systems. In Nigeria. Asuni (a psychistrist) has pointed out that
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TOLA OLU PEARCE
many practitioners feel that not enough is known about indigenous practice to attempt integration programmes. He remains unimpressed with the amount of knowledge Yoruba healers have exhibited in the fields of surgery, opthalmology, neurology and pathology. From his own studies of indigenous healers. he feels that traditional healing will have many problems in adjusting to the changing social scene. He concludes that most Western-trained doctors are indifferent to indigenous ones and that in fact it is the latter who are at a disadvantage, fear competition and may be weary of cooperation [6,7]. Any programme for integration requires the cooperation of four distinct groups in any nation. These are: (1) the indigenous practitioners; (2) the westerntrained practitioners; (3) governmental agencies/ policy making bodies: (4) and the consumers. Most of the research conducted on this topic has focused on the role of government policy making bodies or the informal utilization patterns of different segments of the general population [S-l 11. There is yet little substantive information on the desires and aspirations of either of the two groups of practitioners. For example, information on the attitudes of Western-trained physicians are largely available through the comments of scholars (physicians/non-physicians) in their general discussions on the problem of intergration. In a 1969 article advocating integration, Ademuwagun stated that “At present fear and suspicion of the native doctor exists among Western trained health professionals because the traditional medicine men do not possess scientific knowledge and skills” [12]. This fear and suspicion may be rooted in the indigenous healer’s claims of access to supernatural forces as can be concluded from the statements of the Assistant Director of Medical Services and Training in Nigeria in a recent paper. With respect to the services of indigenous practitioners, Dr Cole (a physician) noted that “A series of incantations and ritual performances unintelligible to the patient and whose significance is lost even to the most eminent practitioner cannot but be truly mumbo jumbo when the effects if any, are being ascribed to supernatural powers whereas in fact they can be reproduced by definite processes in orthodox medicine” [ 133. The aim of the present piece of research therefore, is to pursue the issue of the attitudes and aspirations of Western-trained physicians in Nigeria beyond the level of impressions. What do the members of this group feel about working with their indigenous counterparts? To what extent have they made use (informally) of indigenous therapeutic practices? In what areas do they believe that Western models or practices can learn from the other system? These are some of the specific interests of the author. As stated earlier, the cooperation of this group of professionals is crucial for any programme of integration. In discussing the U.S.A. example of integrating new personnel into the medical system, Freidson has argued that “ in the present scheme of things no effective and widespread program using such workers (i.e. midwives, medical assistants, medical corpsmen) is possible without the active cooperation of the dominant profession. If the profession does not trust them, or if it resents or fears them, it will not refer patients to them nor will it graciously receive patients referred
from them. Given the strategic position of the profession in health services. mere administrative fiat establishing the right of other occupations to supply health services is not enough to assure integrated and coordinated care. Optimal forms of coordination of health services require that physicians be positively interested in working with other personnel” [14]. The author believes that this maybe as true for indigenous practitioners in Nigeria, as. say. for the medical corpsmen in the U.S.A. INTEGRATION
IN UIGERIA
Nigeria is sometimes cited as one of the African nations in which attempts at integration have been successful. In 1975 Twumasi noted that “China. as well as Nigeria was credited with the capacity to fuse two ideas, indigenous and foreign medical systems. to suit their cultural needs” [IS]. As is well known. it was the Aro experiment begun in 1954 by Professor Lambo near Abeokuta. that brought Nigeria to the world’s attention. The experiment was based on two major ideas. Of less interest to us here. was that community-based treatment system was needed in psychiatry. Patients were required to live in villages around Abeokuta. and their kinfolk accompanied to assist with their care. The second idea entailed the notion that collaboration with indigenous healers would be highly therapeutic. Under the supervision of the clinical staff, these practitioners helped in the dayto-day treatment procedures. A few were allowed to do “some psychotherapy on their own with psychoneurotic patients” [16]. The initial success of this experiment encouraged others to collaborate with indigenous psychiatrists [ 17. 181. Nevertheless, it has been noted that in Aro today. the treatment pattern no longer involves ‘traditional healers’ [ 191. It is often noted that the local practitioners were never full partners in the venture and as one author recently revealed, interviews with Dr Lambo in the 1960s showed that he did not “advocate extensive training for traditional healers.. He and other physicians with whom we talked opposed setting up institutes of traditional medicine along the lines of those established in mainland China and in India” [20]. Nevertheless, Lambo is generally cited as one of those in favour of some form of collaboration. Since the 1960s the issue of integration has remained problematic in Nigeria. Numerous indigenous medical associations have been inaugurated and have promptly disintegrated. Some of the more successful have been the Nigerian Association of Medical Herbalists, the Nigerian Union of Medical Herbal Practitioners, the Nigerian Association of Traditional Medical Practitioners. By and large, the official attitude towards integration until very recently has been one of informal recognition of the work of local healers. Individual practitioners are licensed by the above type of associations. However. no official restructuring of either system occurred to develop an integrated system. The Basic Health Service Scheme developed as part of the National Development Plan (1975) to improve medical coverage sought to train three new categories of health workers. These are the community health officer, assistant and aide. Nothing was said in the plan about integration. With the return of civilian government in 1979, there has been
Integrating Western orthodox and indigenous medicine interest in the issue of collaboration. Besides the research into the chemical components of African plants and local herbal mixtures referred to earlier, seminars and conferences have been supported by a variety of organizations and governmental bodies. For example in April 1979. the Federal Ministry of Health organized a seminar on ‘Traditional Medicine’. After the 2-day conference several recommendations were adopted. It was suggested among other things. that a Traditional Medical Conference of Nigeria (TMCN) should be set up to help control the practice of indigenous medicine and set up a syllabus for training practitioners. Other recommendations included the creation of wards in hospitals for the practice of indigenous medicine alongside Western medicine. the creation of a National Research Institute, and the inclusion of ‘registered’ herbalists on the Committee on Traditional Medicine in the Federal Ministry of Health. To enhance training and research on indigenous medicine, traditional medical centers have been set up in some states (e.g. Lagos, Bendel, Imo, Anambra. Plateau). It is hoped that indigenous birth attendants. .opticians, psychiatrists, and gynaecologists can be produced from these centers. Some indigenous healers have been in the foreground with regard to the agitation for integration. For example, there is Dr J. Lambo (relative of the psychiatrist). President of the Lagos State Branch of Nigeria Association for Trado-medicalism and government adviser on indigenous medicine. He advocates the substitution of herbal medication for the synthetic drugs introduced by the West. He believes the latter are dangerous and that Westerntrained physicians should work with herbalists to develop herbal remedies [21]. In a paper presented at the 7th International Conference on Social Science and Medicine, Odebiyi argued that there is interest in integration among indigenous health practitioners in Nigeria [22]. There have been many statements issued by indigenous healers to the press in recent years that support Odebiyi’s findings. Nevertheless, one is also aware that some practitioners are ambivalent towards integration. There is the fear of losing control of their own practices if integration becomes a serious proposition. These views were succinctly expressed by Mr Apata during the inauguration of The General African Medical Herbal Association (date of inauguration not given). He argued that the organization intended to develop “medical-herbalism and native system of Therapeutics as a profession in order to avoid total absorption with medical section (sic) in the Ministry of Health. So that the medical herbalism and native system of Therapeutics should be under the control and supervision of its practitioners” [23]. Thus the problem of establishing control over indigenous medical practices is well recognized by the healers themselves. From the point of view of Western-trained doctors, the issue of integration would also be expected to stir up anxieties over control. competition and other problems affecting their professional interests. LITERATURE
REVIEH
Indigenous medical practice has many dimensions. Therefore. Western-trained doctors are obviously
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reacting to a number of different factors when asked to comment on the possibility of integration. While some may react favourably to herbal medicine and suggest their use to patients, others may be distressed by what is viewed as the ‘nonscientific’ or religious dimension of indigenous practices. Still, others may feel that specific acts of mechanical intervention such as cupping, methods of surgery or blood letting leave much to be desired. Research on these questions is still scanty. Simpson interviewed 24 medical doctors from the various medical institutions in Ibadan in 1964. Although the results were not reported in a systematic manner, certain attitudes could be gleaned from the material. Theories of causation are either tolerated for the sake of the patient (as when patients are told to go and make the necessary sacrifices after treatment) or rejected. For example one physician held “that one is not justified in being dogmatic when a patient is under stress. Instead, he listens to the complaints and doesn’t try to convince the patient that his explanation of his disease is wrong. When the crisis is over, he tries gradually to wean the patient ‘away from traditional beliefs” [24]. Some physicians feel that the increase in migrant population and the heterogeneity of our cities will decrease the effectiveness of indigenous healers, since much of their success depends on the ability to ‘handle the patient’. Also, patients come from afar and hold different beliefs, the efficacy of indigenous methods are expected to diminish. The overall impression is one of tolerance but not serious acceptance. A more systematic piece of work has been reported by Imperato as a result of studies conducted among the Bambara of Mali between 1967 and 1974. Material collected among 16 physicians revealed that 78% of them would be willing to cooperate with herbalists. However, none of these university trained doctors wished to work with other types of indigenous healers such as the diviners (Basitiqui). spirit mediums (Soma) or Koranic teachers (Moriba) [25]. Imperato’s findings indicate that physicians gravitate towards what they consider to be the quantifiable, rationalizable aspects of indigenous practice. Herbs. animal parts, and mineral elements are readily amenable to scientific tests. No doubt locally discovered drugs have in the past been incorporated into the Western medical system without altering its premises, structure or requiring the use of indigenous personnel. However, other dimensions of indigenous medicine (also upheld by herbal practitioners) are likely to be viewed by the university doctors as dependent on the esoteric (and questionable) knowledge of specific personnel whose activities are suspect. Thus serious cooperation with local practitioners might raise anxieties concerning control over what are acceptable medical activities, as will be argued below. THEORETICAL
FRAMEWORK
Although the university-trained physician is the undisputed head of the Western medical team today, this has not always been the case. Various scholars have documented the struggle for dominance with the medical division of labour [2628]. Throughout the fifteenth. sixteenth and seventeenth centuries in Europe for example, physicans struggled against or
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aligned with either surgeons of the long robe (i.e. master surgeons) or surgeons of the short robe (the Barber-surgeons) in attempts to enhance their own position and gain control over certain medical activities. At other times the fight was against the apothecaries (the original drug merchants) whose skills they needed to control in order to deliver services adequately. Bonesetters, midwives and other groups were seen as threats at different times. Within the twentieth century osteopaths, chiropracters, and various groups of paramedical workers are agitating for improved positions within the health occupational ladder. In the U.S.A., physicians insist on controlling the activities of the budding group of physician extenders by making sure the latter are legally under them. If the issue of integrating Western-style and indigenous medicine is viewed from this perspective, one can argue that the University-trained physicians will view integration as competition from yet another group of health workers seeking control over certain types of medical activities. The right to define what is medical knowledge for example would be seriously challenged by practitioners of the indigenous system. With respect to acceptable sources of medical knowledge, the Western medical system has distanced itself from some of the theoretical premises upheld by indigenous practitioners. Physicians (and other scientific researchers) control what is to be accepted as medical theories of disease causation and proper medical activities. Freidson has stated the problem in the following way. There is the issue of where “knowledge comes from, how it gets established as recognized knowledge, and how its development and utilization become organized evaluated and controlled. . . . Those engaged in the process of creating, communicating and applying knowledge are identified and identify themselves with recognizable, increasingly organized occupational groups” [29]. It is likely that this group of professionals would rather not share this area of control with any other group. However, the local practitioners remain highly respected individuals within their own system and they believe steadfastly in the preternatural and supernatural causes of illness and the type of preventive and therapeutic measures that have been developed to handle illness among their people. The author would suggest that on this issue they have the majority of the population in agreement with them. Nevertheless. they are frequently charged with being ‘unscientific’ in their theories and activities. Many Western-trained doctors believe indigenous healers need not be taken seriously. Recently, the Secretary-General of the Nigerian Medical Association (NMA) was taken to task for insisting that “herbal practitioners (i.e. traditional healers) had nothing serious to offer the nation” [30]. Scientific training teaches physicians to look at the world, the body and illness in a particular way. The emphasis is on gathering ‘objective’ facts from the observable world with the use of well developed techniques. Such facts must be reproducible and the knowledge gained is considered tentative until more accurate information is developed. ‘Knowledge’ that cannot be disproven is unacceptable, which brings under suspicion many of the claims of indigenous healers. The focus of science is on observable. natural pheomena. and facts gath-
ered through the senses. Increasingly. there have been criticisms levied against science and its limitations. These include the charge that it is only one way (and a narrow one) of understanding nature or life [31]. Jones, has also suggested that both the techniques developed to gather ‘objective’ facts. and the very facts (or content of science) are significantly influenced by more fundamental. cultural/human factors such as world-views. He outlines four worldview indicies that can affect methods of understanding the world and the type of knowledge developed. These include static/dynamic. continuity/discreteness. abstract/concrete and immediacy. mediation biases. For example, an important aspect of the western scientific method-the use of ‘variables’-requires a discreteness-bias. Peopie with a continuity-bias see things as organically related and would oppose the idea of removing things from their network (context) and using them as variables. Thus. “not only does a difference in world-view account for fundamentally different conceptions of what explanation consists in. it also accounts for differing conceptions of what seems to be in need of explanation” [32]. Another problem is that. given the many accomplishments of science, it may increasingly be used ideologically to intimidate, thus allowing its practitioners to retain certain privileges. such as remaining dominant. It is well recognized that much of Western medicine is not scientific [33], but it is doubtful that the doctors would want to have their established practices challenged. The claim to science thus protects. Again. Western medicine is only gradually becoming engulfed by science. Science did not begin within the medical profession. To open its dooos to indigenous medicine would be threatening and the fear of loosing some of the prestige gained through science is no doubt present. In Africa, the Western system of medical care was introduced as part of the colonial administration. It enjoyed much legal. financial and political protection from the colonial government. Maximum prestige and power has continued with the national administrations. Given the above arguments. it is therefore assumed that the wish to minimize competition from an’increasingly vocal group of workers and safeguard dominance within the medical system results in the following.
(1) H_!Jpothesis I Western-trained medical doctors will not like attempts to be integrated with indigenous healers (personnel) into unified medical system. (2) Hl’pothesis
II
Of the various aspects of the indigenous system, they will be interested in the quantifiable as compared to the unquantifiable dimensions. METHODOLOGY
Many problems were anticipated with respect to data collection. A directory of physicians was unavailable for sampling purposes. The author was also advised against mailing questionnaires since the postal system is unreliable and physicians would be unlikely to take the time from their busy schedules to respond. Given these problems. the author decided to
Integrating Western orthodox and indigenous medicine take advantage of a Nigerian Medical Association (NMA) meeting announced for February 1978, to be held at Ibadan. Doctors from three southern states (Oyo, Ogun, Ondo) were expected to attend. Both salaried and private practitioners were expected at the meeting. At the start of the meeting 200 questionnaires were distributed to all seated in the hall. Each questionnaire contained both open-ended and closed questions. On each of the closed questions the respondent was given a choice of five alternatives. For example, the physicians were given the following item: It is better to encourage traditional medicine to develop its own potential fully, and not insist on creating one integrated medical system in Nigeria. 1. Agree strongly
0
2. Agree
0
3. Undecided
0 0
4. Disagree 5. Disagree
strongly
0
An example of an open-ended item was: Would you please indicate whether you personally use ideas and methods from the other type of medicine, and which methods these are. The questionnaires were selfadministered and anonymity was maintained. The schedules were handed in after the meeting. Altogether, 103 schedules were returned. Chi-square and percentages were used in analysing the data. FINDINGS
With respect to the demographic characteristics of the physicians, 94 were male and 9 female. Approximately two-thirds (61.17,) were between the ages of 26 and 35 and only 9.7q, between 46 and 55. None admitted to being above the age of 55. As expected, the majority were specialists (82.3?,). with only 18 (17.69;) who designated themselves as general practitioners. worked in UniAltogether, 7 1.5”” of the respondents versity/teaching hospitals and other 16.60/;; in government hospitals. Only 6 (5.89~) respondents were in private practice. A few others (5 respondents) worked in the Ministries or for International Organizations where they were no doubt involved in planning activities. Twelve specialities were represented in the sample. with surgery (20.2”;). medicine (14.1Yg), pediatrics (10.14,) and obstetrics/gynecology (7:;) topping the list. Unfortunately psychiatry was not indicated on any questionnaire. Of the 100 responding to the question on length of practice, almost half (469;) indicated they had been on the job between one month and five years. Another 361, had been working for 610 years. Only 2”” had more than 21 years of experience. With respect to the first hypothesis. the physicians were asked to indicate whether or not they felt the two systems should work towards integration. This was a very general question and 63 (61.19;) physicians gave positive responses. Of these 15 felt strongly about the need for integration. There were a total of 32 (31.0”,) doctors who rejected the idea. with 12 strongly opposing it. Eight (7.7”“) remained undecided. With almost two-thirds of the sample agreeing that integration was acceptable. it would appear that
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Table 1. Attitudes towards integration and the use of joint clinics Work towards integration (Yes) (Undecided/No)
Build joint clinics (i’es) (Undecided/No) 23 7
35 30
58 37
30
65
95
x2 = 5.08; d.f. = 1; P < 0.05: NA = 8. the first hypothesis should be rejected. Nevertheless, the actual prospect of working with indigeneous personnel is another matter (see Hypothesis I). To elicit this information other items were included in the schedule. Physicians were asked whether they would work along side local healers in joint clinics (item 18) (an item suggesting equality in status) or whether the indigenous healers should be trained to ‘treat minor diseases at the grassroots level’ (item 14) (suggesting junior partnership). Of the 95 who responded to the item on joint clinics, 54.7% did not believe it was a good idea. Another 13.6% remained undecided. Thus a total of 68.3% were unable to give a positive response. From Table 1. it is obvious that a relationship does exist between wanting integration and joint clinics (P < 0.05). Of interest also is the apparent ambivalence of many physicians. Fifty-eight respondents favoured integration, but almost two-thirds (60.3%) of these would not encourage the development of joint clinics (i.e. working alongside local healers). Joint clinics are often advocated as a practical step towards integration (as in China), yet this would apear not to be an attractive proposition to these respondents. The respondents were further asked if Nigeria needed a new group of medical workers to treat the minor/common diseases. Sixty-seven believed the nation did. Of these 61 (91.0%) preferred that these health workers be ‘a new group of orthodox workers’. Only four opted for the training of ‘traditional practitioners’. Two respondents did not answer the question. From these responses, it is quite clear that the physicians would prefer to work with those of their own kind. Finally,‘102 responded to the question on the separate development of the two medical systems. Of these, 63.77; felt that separate development was a good idea. These findings indicate that the initial positive response to the suggestion of integration camouflages ambivalent feelings or reservations. The more specific questions on joint clinics and the inclusion of indigenous healers on the lower runs of the occupational ladder met with resistance. Thus whether or not the theories and methods of indigenous medicine are researched or developed it would appear that many physicians may not want to work with indigenous personnel. In the light of these results, we would suggest that the first hypothesis be accepted. The second hypothesis sought to discover the aspects of indigenous medicine in which the physicians were either interested or held in high esteem. The respondents were asked: “What are the main areas in which Western orthodox medicine can learn
1616 Table
TOLA OLU PEARCE
2. Areas of indigenous medicine from physicians felt they could learn
which
the
Number of mentions 1. 2. 3. 4. 5. 6. 7.
Psychiatry/mental health practices Herbal/pharmaceutical remedies Orthopedicsihonesetting Supernatural healing The psychological impact on the patient Community health practices Others (e.g. cancer research, gynecological research 8. Minimal/None
26 31 4 9 5 2 4 5
from traditional medicine?” The doctors were expected to enumerate the quantifiable aspects of local practices (i.e. massage, diet, herbalism, bonesetting etc.). With the emphasis on ‘science’ in Western medicine, there should be little interest in . such features as rituals, or supernatural powers. They were expected to dwell on the measurable effect of herbal and mechanical processes and not on what is often seen as mysticism in indigenous practices. Also, with respect to their own professional interests, an emphasis on these quantifiable aspects (focus on ‘science’) would ensure that knowledge developed in the feature would be judged according to the rules by which they excelled. The responses could be grouped into eight categories (Table 2). Some physicians gave multiple responses and each was coded separately. There were 34 respondents who did not respond to this question. As expected, many physicians are interested in herbal remedies. This is one of the most quantifiable dimensions of local practice. Nevertheless, there was almost an equal amount of interest in psychiatry. This appeared not to be a mere interest in psychiatric drugs as many respondents who indicated an interest in herbal remedies also mentioned psychiatry. Much of traditional psychiatry draws on a system of supernatural beliefs and embodies much ritual performance. The author believes there is an interest in understanding why these appear to be effective. Although mentioned far fewer times, the third and fourth largest categories also deal with the more intangible aspects of local medicine. Examples of interest in supernatural dimensions are “the power of incantations”, beliefs”, and “fighting “magic”, “certain traditional witches”. It can be argued that the fifth (psycho impact) and first (psychiatry) can be collapsed. although the former appears to focus more specifically on the doctor-patient relationship dimension. Finally, there were 5 respondents who feelt there was really nothing to be learnt from local practices. Of the 81 positive mentions, 40 could be said to focus on the less tangible as yet non-quantifiable aspects of medical practice. The author would thus suggest that the second hypothesis be rejected. DISCUSSION
Since the early 1970s there has been a growing interest in the official role of indigenous healers in non-European medical systems. Organizations such
as the W.H.O. have suggested the retraining of traditional practitioners to serve as primary health workers [34], so that the network of hospitals and medical centre can function more efficiently as secondary and tertiary units. The Chinese attempt at integration has also caught the attention of many scholars. In Nigeria. although the government does not yet have any official programme for integration, there has been pressure from consumers. intellectuals and some indigenous practitioners to ‘do something about the role of indigenous medicine’. The author was thus interested in the attitudes of Universitytrained doctors towards the issue of integration. since their cooperation is needed in any official programme. In a study conducted in 1978 on 103 doctors. results showed that although the physicians indicated an interest in integration. when confronted with possible methods of working with indigenous personnel, they showed reluctance to accepting them. It was also discovered that many doctors felt that Western orthodox medicine could learn something from the non-quantifiable aspects of local practices. The wish to learn more about these areas of indigenous practice while hesitating to absorb its practitioners brings to the foreground the problem of control and competition. In the history of the development of the profession there have been many attempts to absorb or control relevant material from other groups (e.g. granny midwives) who are seen as threats to their dominance over medical practice. When doctors feel that any group is encroaching on their turf, attempts will be made to control the competition. Judging from the results of the present study, the fears expressed in the statement below are not imaginary There is a certain amount of apprehension among indigenous healers “borne out of fear of modern scientists taking control of African medicine and absorbing Herbalism as a profession, and wipe (sic) out its practitioners in the field of medical profession” [35]. Finally, it was also interesting to see that few (only 4) physicians gave a positive response to the following item: “Would you please indicate whether you per.sonu/lv use ideas and methods from the other type of medicine”. The four respondents answered as follows: “psychotherapy”, “Herbs and Roots for the treatment of infantile of impotency” and “psyeczema”. “in treatment chiatry”. The paucity of responses to this item again suggests that at present physicians do not interact readily with individual practitioners of the indigenous system. This piece of research would indicate that active and widespread participation in any official integration programme would be resisted. REFERENCES
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Integrating
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orthodox
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medicine
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tine. Paper presented at Seminar en Traditional Medicine, Lagos. 1979. Odebiyi A. Integrating traditional and orthodox medicine in Nigeria: the traditional healers’ perception. Paper presented at Social Science and Medicine Conference, Leeuwenhorst, 1981. Apata L. General African Medical Herbal Association, p. 8 Ile-Ife. n.d. Simpson G. op. cit., p. 156. Imperato P. Traditional medical practitioners among the Bambara of Mali and their role in the modern health care delivery system. In African Therapeutic Systems. op. cit., p. 202. Berlant J. Profession and Monopoly University of California Press, Berkeley, 1975. Bullough V. and Bullough B. A brief history of medical practice. In Medical Men and Their Work (Edited by Freidson E. and Lorber J.), ppl. 86102. Aldine, Chicago, 1972. Garrison F. History of Medicine. W. B. Saunders, Philadelphia, 1929. Friedson E. The Professions and Their Prospects. p. 28. Sage, London. 1971. Sodipe R. Medical union put to task. Daily Sketch (Nigeria) p. 3. 18 February. Ibadan. Blume S. Toward a Political Sociology of Science. The Free Press. New York, 1974. Jones W. World views and asian medical systems: some suggestions for further study. In Asian Medical Systems (Edited by Leslie C.), p.- 390. University of California Press. Berkelev. 1976. Freidson E. Profession of-Medicine Dodd, Mead & Co. New York, 1972. Director-General W.H.O. and Executive Director of U.N. Children’s Fund. Primary Health Care W.H.O.. Geneva. 1978. Apata L. op. cit.. p. 12.
0277-9536/82/l
16. pp. 1611 IO 1617, 1982
XI 61 I-07K13.00/0
Per@tmon Press Ltd
Printed in Great Britain
INTEGRATING WESTERN ORTHODOX INDIGENOUS MEDICINE* PROFESSIONAL
INTERESTS AND ATTITUDES AMONG TRAINED NIGERIAN PHYSICIANS
AND
UNIVERSITY-
TOLA OLU PEARCE Department
of Sociology/Anthropology,
University of Ife. lie-lfe, Nigeria
Abstract-The problem of integrating the two major medical systems in Africa can be approached from many sides. This paper focuses on the attitudes of Western-trained practitioners. They are seen as a major force to be reckoned with in any serious attempt at cooperation or corporation. Nevertheless, substantive information in this area remains minimal. In the light of the well documented history of the struggle for control of the medical field by University-trained physicians in the West, and Freidson’s discussions on professional dominance’ the author theorized that the issue of integration in Nigeria would stir professional anxieties. The Western-trained physicians can be expected to object to serious moves-to integrate the two systems. Given this approach, it was hypothesized that. (1) Western-trained medical doctors will not like attempts to be integrated with indigenous healers (personnel) into a unified medical system. (2) Of the various aspects of the indigenous system. they will be interested in the quantifiable as compared to the nonquantifiable. One hundred and three self administered questionnaires were analysed. These were obtained in February 1978 from members of the Nigerian Medical Association attending a conference in Ibadan. The results supported the first hypothesis. For although two-thirds of the respondents said they favoured integration in general. when pressed, such suggestions as the development of ‘joint clinics’ were rejected by a significant majority and the ‘separate development of each system favoured. The second hypothesis was not however supported. There was ample evidence of interest in the less tangible, as yet not quantifiable aspects of the medical practices of indigenous practitioners.
INTRODUCTION The prospects for integrating the two major medical systems in various African countries has been a much debated topic since the 1970s. Both radical and the more conservative scholars have written in favour of integration, although their proposals for programmes often differ. Nevertheless, the reasons given in support of integration have become familiar. The case for integration has been made by various scholars. Some point to the lack of coverage of the Western type of services. The cost of reproducing the type of facilities available in the urban areas, throughout a nation, is seen as an impossible task. It is believed that the less expensive indigenous facilities could be merged with the hospital system of Western practitioners to produce a nationwide network of services. It has been argued that the indigenous medical practices are not discontinuous with regard to the culture and beliefs of the general population. Use could be made of the knowledge that the local practitioners have of the psychology and values of the people. Thus Ademuwagun writes “Since most professional health workers have limited knowledge of the cultural factors likely to promote or inhibit health, they would do well to consider working in partnership with native doctors” [I]. There is the additional aspect of the present re*Paper originally presented at 7th International Conference of Social Science and Medicine, June 1981.
ality of the public’s utilization patterns. Several authors have demonstrated that people use both services freely even when Western-style services are available (e.g. in the urban setting) [2-4]. Finally, there is growing interest in the ‘ecological approach of indigenous workers. The fact that many diseases are psychosomatic, and that the psychological dimension of illness is important in effective therapy has increased the appreciation of the social analysis approach associated with indigenous healers. It is assumed that for teamwork to be established in the future, research to upgrade and develop the best that exists within the indigenous system is necessary. At the present time, a country such as Nigeria is just debating the issue. There is as yet no official programme of integration, although research into the active components of local medicines has been going on for some time in such places as the universities of Ife and Ibadan. With regard to those scholars who are sceptical about the role of indigenous healing, Gould upon retiring from a visit to China, made it clear that he was opposed to attempts at sustaining and increasing the influence of traditional medicine. He argued that in China, “Men trained in Western Medicine are being forced to accept or adopt ancient magics.. Herbal medicine is a mixture of empiricism and superstition: acupuncture is unspoiled magic” [S]. He insisted that it is impossible to integrate the two systems. In Nigeria. Asuni (a psychistrist) has pointed out that
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TOLA OLU PEARCE
many practitioners feel that not enough is known about indigenous practice to attempt integration programmes. He remains unimpressed with the amount of knowledge Yoruba healers have exhibited in the fields of surgery, opthalmology, neurology and pathology. From his own studies of indigenous healers. he feels that traditional healing will have many problems in adjusting to the changing social scene. He concludes that most Western-trained doctors are indifferent to indigenous ones and that in fact it is the latter who are at a disadvantage, fear competition and may be weary of cooperation [6,7]. Any programme for integration requires the cooperation of four distinct groups in any nation. These are: (1) the indigenous practitioners; (2) the westerntrained practitioners; (3) governmental agencies/ policy making bodies: (4) and the consumers. Most of the research conducted on this topic has focused on the role of government policy making bodies or the informal utilization patterns of different segments of the general population [S-l 11. There is yet little substantive information on the desires and aspirations of either of the two groups of practitioners. For example, information on the attitudes of Western-trained physicians are largely available through the comments of scholars (physicians/non-physicians) in their general discussions on the problem of intergration. In a 1969 article advocating integration, Ademuwagun stated that “At present fear and suspicion of the native doctor exists among Western trained health professionals because the traditional medicine men do not possess scientific knowledge and skills” [12]. This fear and suspicion may be rooted in the indigenous healer’s claims of access to supernatural forces as can be concluded from the statements of the Assistant Director of Medical Services and Training in Nigeria in a recent paper. With respect to the services of indigenous practitioners, Dr Cole (a physician) noted that “A series of incantations and ritual performances unintelligible to the patient and whose significance is lost even to the most eminent practitioner cannot but be truly mumbo jumbo when the effects if any, are being ascribed to supernatural powers whereas in fact they can be reproduced by definite processes in orthodox medicine” [ 133. The aim of the present piece of research therefore, is to pursue the issue of the attitudes and aspirations of Western-trained physicians in Nigeria beyond the level of impressions. What do the members of this group feel about working with their indigenous counterparts? To what extent have they made use (informally) of indigenous therapeutic practices? In what areas do they believe that Western models or practices can learn from the other system? These are some of the specific interests of the author. As stated earlier, the cooperation of this group of professionals is crucial for any programme of integration. In discussing the U.S.A. example of integrating new personnel into the medical system, Freidson has argued that “ in the present scheme of things no effective and widespread program using such workers (i.e. midwives, medical assistants, medical corpsmen) is possible without the active cooperation of the dominant profession. If the profession does not trust them, or if it resents or fears them, it will not refer patients to them nor will it graciously receive patients referred
from them. Given the strategic position of the profession in health services. mere administrative fiat establishing the right of other occupations to supply health services is not enough to assure integrated and coordinated care. Optimal forms of coordination of health services require that physicians be positively interested in working with other personnel” [14]. The author believes that this maybe as true for indigenous practitioners in Nigeria, as. say. for the medical corpsmen in the U.S.A. INTEGRATION
IN UIGERIA
Nigeria is sometimes cited as one of the African nations in which attempts at integration have been successful. In 1975 Twumasi noted that “China. as well as Nigeria was credited with the capacity to fuse two ideas, indigenous and foreign medical systems. to suit their cultural needs” [IS]. As is well known. it was the Aro experiment begun in 1954 by Professor Lambo near Abeokuta. that brought Nigeria to the world’s attention. The experiment was based on two major ideas. Of less interest to us here. was that community-based treatment system was needed in psychiatry. Patients were required to live in villages around Abeokuta. and their kinfolk accompanied to assist with their care. The second idea entailed the notion that collaboration with indigenous healers would be highly therapeutic. Under the supervision of the clinical staff, these practitioners helped in the dayto-day treatment procedures. A few were allowed to do “some psychotherapy on their own with psychoneurotic patients” [16]. The initial success of this experiment encouraged others to collaborate with indigenous psychiatrists [ 17. 181. Nevertheless, it has been noted that in Aro today. the treatment pattern no longer involves ‘traditional healers’ [ 191. It is often noted that the local practitioners were never full partners in the venture and as one author recently revealed, interviews with Dr Lambo in the 1960s showed that he did not “advocate extensive training for traditional healers.. He and other physicians with whom we talked opposed setting up institutes of traditional medicine along the lines of those established in mainland China and in India” [20]. Nevertheless, Lambo is generally cited as one of those in favour of some form of collaboration. Since the 1960s the issue of integration has remained problematic in Nigeria. Numerous indigenous medical associations have been inaugurated and have promptly disintegrated. Some of the more successful have been the Nigerian Association of Medical Herbalists, the Nigerian Union of Medical Herbal Practitioners, the Nigerian Association of Traditional Medical Practitioners. By and large, the official attitude towards integration until very recently has been one of informal recognition of the work of local healers. Individual practitioners are licensed by the above type of associations. However. no official restructuring of either system occurred to develop an integrated system. The Basic Health Service Scheme developed as part of the National Development Plan (1975) to improve medical coverage sought to train three new categories of health workers. These are the community health officer, assistant and aide. Nothing was said in the plan about integration. With the return of civilian government in 1979, there has been
Integrating Western orthodox and indigenous medicine interest in the issue of collaboration. Besides the research into the chemical components of African plants and local herbal mixtures referred to earlier, seminars and conferences have been supported by a variety of organizations and governmental bodies. For example in April 1979. the Federal Ministry of Health organized a seminar on ‘Traditional Medicine’. After the 2-day conference several recommendations were adopted. It was suggested among other things. that a Traditional Medical Conference of Nigeria (TMCN) should be set up to help control the practice of indigenous medicine and set up a syllabus for training practitioners. Other recommendations included the creation of wards in hospitals for the practice of indigenous medicine alongside Western medicine. the creation of a National Research Institute, and the inclusion of ‘registered’ herbalists on the Committee on Traditional Medicine in the Federal Ministry of Health. To enhance training and research on indigenous medicine, traditional medical centers have been set up in some states (e.g. Lagos, Bendel, Imo, Anambra. Plateau). It is hoped that indigenous birth attendants. .opticians, psychiatrists, and gynaecologists can be produced from these centers. Some indigenous healers have been in the foreground with regard to the agitation for integration. For example, there is Dr J. Lambo (relative of the psychiatrist). President of the Lagos State Branch of Nigeria Association for Trado-medicalism and government adviser on indigenous medicine. He advocates the substitution of herbal medication for the synthetic drugs introduced by the West. He believes the latter are dangerous and that Westerntrained physicians should work with herbalists to develop herbal remedies [21]. In a paper presented at the 7th International Conference on Social Science and Medicine, Odebiyi argued that there is interest in integration among indigenous health practitioners in Nigeria [22]. There have been many statements issued by indigenous healers to the press in recent years that support Odebiyi’s findings. Nevertheless, one is also aware that some practitioners are ambivalent towards integration. There is the fear of losing control of their own practices if integration becomes a serious proposition. These views were succinctly expressed by Mr Apata during the inauguration of The General African Medical Herbal Association (date of inauguration not given). He argued that the organization intended to develop “medical-herbalism and native system of Therapeutics as a profession in order to avoid total absorption with medical section (sic) in the Ministry of Health. So that the medical herbalism and native system of Therapeutics should be under the control and supervision of its practitioners” [23]. Thus the problem of establishing control over indigenous medical practices is well recognized by the healers themselves. From the point of view of Western-trained doctors, the issue of integration would also be expected to stir up anxieties over control. competition and other problems affecting their professional interests. LITERATURE
REVIEH
Indigenous medical practice has many dimensions. Therefore. Western-trained doctors are obviously
1613
reacting to a number of different factors when asked to comment on the possibility of integration. While some may react favourably to herbal medicine and suggest their use to patients, others may be distressed by what is viewed as the ‘nonscientific’ or religious dimension of indigenous practices. Still, others may feel that specific acts of mechanical intervention such as cupping, methods of surgery or blood letting leave much to be desired. Research on these questions is still scanty. Simpson interviewed 24 medical doctors from the various medical institutions in Ibadan in 1964. Although the results were not reported in a systematic manner, certain attitudes could be gleaned from the material. Theories of causation are either tolerated for the sake of the patient (as when patients are told to go and make the necessary sacrifices after treatment) or rejected. For example one physician held “that one is not justified in being dogmatic when a patient is under stress. Instead, he listens to the complaints and doesn’t try to convince the patient that his explanation of his disease is wrong. When the crisis is over, he tries gradually to wean the patient ‘away from traditional beliefs” [24]. Some physicians feel that the increase in migrant population and the heterogeneity of our cities will decrease the effectiveness of indigenous healers, since much of their success depends on the ability to ‘handle the patient’. Also, patients come from afar and hold different beliefs, the efficacy of indigenous methods are expected to diminish. The overall impression is one of tolerance but not serious acceptance. A more systematic piece of work has been reported by Imperato as a result of studies conducted among the Bambara of Mali between 1967 and 1974. Material collected among 16 physicians revealed that 78% of them would be willing to cooperate with herbalists. However, none of these university trained doctors wished to work with other types of indigenous healers such as the diviners (Basitiqui). spirit mediums (Soma) or Koranic teachers (Moriba) [25]. Imperato’s findings indicate that physicians gravitate towards what they consider to be the quantifiable, rationalizable aspects of indigenous practice. Herbs. animal parts, and mineral elements are readily amenable to scientific tests. No doubt locally discovered drugs have in the past been incorporated into the Western medical system without altering its premises, structure or requiring the use of indigenous personnel. However, other dimensions of indigenous medicine (also upheld by herbal practitioners) are likely to be viewed by the university doctors as dependent on the esoteric (and questionable) knowledge of specific personnel whose activities are suspect. Thus serious cooperation with local practitioners might raise anxieties concerning control over what are acceptable medical activities, as will be argued below. THEORETICAL
FRAMEWORK
Although the university-trained physician is the undisputed head of the Western medical team today, this has not always been the case. Various scholars have documented the struggle for dominance with the medical division of labour [2628]. Throughout the fifteenth. sixteenth and seventeenth centuries in Europe for example, physicans struggled against or
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TOLA OLU PEARCE
aligned with either surgeons of the long robe (i.e. master surgeons) or surgeons of the short robe (the Barber-surgeons) in attempts to enhance their own position and gain control over certain medical activities. At other times the fight was against the apothecaries (the original drug merchants) whose skills they needed to control in order to deliver services adequately. Bonesetters, midwives and other groups were seen as threats at different times. Within the twentieth century osteopaths, chiropracters, and various groups of paramedical workers are agitating for improved positions within the health occupational ladder. In the U.S.A., physicians insist on controlling the activities of the budding group of physician extenders by making sure the latter are legally under them. If the issue of integrating Western-style and indigenous medicine is viewed from this perspective, one can argue that the University-trained physicians will view integration as competition from yet another group of health workers seeking control over certain types of medical activities. The right to define what is medical knowledge for example would be seriously challenged by practitioners of the indigenous system. With respect to acceptable sources of medical knowledge, the Western medical system has distanced itself from some of the theoretical premises upheld by indigenous practitioners. Physicians (and other scientific researchers) control what is to be accepted as medical theories of disease causation and proper medical activities. Freidson has stated the problem in the following way. There is the issue of where “knowledge comes from, how it gets established as recognized knowledge, and how its development and utilization become organized evaluated and controlled. . . . Those engaged in the process of creating, communicating and applying knowledge are identified and identify themselves with recognizable, increasingly organized occupational groups” [29]. It is likely that this group of professionals would rather not share this area of control with any other group. However, the local practitioners remain highly respected individuals within their own system and they believe steadfastly in the preternatural and supernatural causes of illness and the type of preventive and therapeutic measures that have been developed to handle illness among their people. The author would suggest that on this issue they have the majority of the population in agreement with them. Nevertheless. they are frequently charged with being ‘unscientific’ in their theories and activities. Many Western-trained doctors believe indigenous healers need not be taken seriously. Recently, the Secretary-General of the Nigerian Medical Association (NMA) was taken to task for insisting that “herbal practitioners (i.e. traditional healers) had nothing serious to offer the nation” [30]. Scientific training teaches physicians to look at the world, the body and illness in a particular way. The emphasis is on gathering ‘objective’ facts from the observable world with the use of well developed techniques. Such facts must be reproducible and the knowledge gained is considered tentative until more accurate information is developed. ‘Knowledge’ that cannot be disproven is unacceptable, which brings under suspicion many of the claims of indigenous healers. The focus of science is on observable. natural pheomena. and facts gath-
ered through the senses. Increasingly. there have been criticisms levied against science and its limitations. These include the charge that it is only one way (and a narrow one) of understanding nature or life [31]. Jones, has also suggested that both the techniques developed to gather ‘objective’ facts. and the very facts (or content of science) are significantly influenced by more fundamental. cultural/human factors such as world-views. He outlines four worldview indicies that can affect methods of understanding the world and the type of knowledge developed. These include static/dynamic. continuity/discreteness. abstract/concrete and immediacy. mediation biases. For example, an important aspect of the western scientific method-the use of ‘variables’-requires a discreteness-bias. Peopie with a continuity-bias see things as organically related and would oppose the idea of removing things from their network (context) and using them as variables. Thus. “not only does a difference in world-view account for fundamentally different conceptions of what explanation consists in. it also accounts for differing conceptions of what seems to be in need of explanation” [32]. Another problem is that. given the many accomplishments of science, it may increasingly be used ideologically to intimidate, thus allowing its practitioners to retain certain privileges. such as remaining dominant. It is well recognized that much of Western medicine is not scientific [33], but it is doubtful that the doctors would want to have their established practices challenged. The claim to science thus protects. Again. Western medicine is only gradually becoming engulfed by science. Science did not begin within the medical profession. To open its dooos to indigenous medicine would be threatening and the fear of loosing some of the prestige gained through science is no doubt present. In Africa, the Western system of medical care was introduced as part of the colonial administration. It enjoyed much legal. financial and political protection from the colonial government. Maximum prestige and power has continued with the national administrations. Given the above arguments. it is therefore assumed that the wish to minimize competition from an’increasingly vocal group of workers and safeguard dominance within the medical system results in the following.
(1) H_!Jpothesis I Western-trained medical doctors will not like attempts to be integrated with indigenous healers (personnel) into unified medical system. (2) Hl’pothesis
II
Of the various aspects of the indigenous system, they will be interested in the quantifiable as compared to the unquantifiable dimensions. METHODOLOGY
Many problems were anticipated with respect to data collection. A directory of physicians was unavailable for sampling purposes. The author was also advised against mailing questionnaires since the postal system is unreliable and physicians would be unlikely to take the time from their busy schedules to respond. Given these problems. the author decided to
Integrating Western orthodox and indigenous medicine take advantage of a Nigerian Medical Association (NMA) meeting announced for February 1978, to be held at Ibadan. Doctors from three southern states (Oyo, Ogun, Ondo) were expected to attend. Both salaried and private practitioners were expected at the meeting. At the start of the meeting 200 questionnaires were distributed to all seated in the hall. Each questionnaire contained both open-ended and closed questions. On each of the closed questions the respondent was given a choice of five alternatives. For example, the physicians were given the following item: It is better to encourage traditional medicine to develop its own potential fully, and not insist on creating one integrated medical system in Nigeria. 1. Agree strongly
0
2. Agree
0
3. Undecided
0 0
4. Disagree 5. Disagree
strongly
0
An example of an open-ended item was: Would you please indicate whether you personally use ideas and methods from the other type of medicine, and which methods these are. The questionnaires were selfadministered and anonymity was maintained. The schedules were handed in after the meeting. Altogether, 103 schedules were returned. Chi-square and percentages were used in analysing the data. FINDINGS
With respect to the demographic characteristics of the physicians, 94 were male and 9 female. Approximately two-thirds (61.17,) were between the ages of 26 and 35 and only 9.7q, between 46 and 55. None admitted to being above the age of 55. As expected, the majority were specialists (82.3?,). with only 18 (17.69;) who designated themselves as general practitioners. worked in UniAltogether, 7 1.5”” of the respondents versity/teaching hospitals and other 16.60/;; in government hospitals. Only 6 (5.89~) respondents were in private practice. A few others (5 respondents) worked in the Ministries or for International Organizations where they were no doubt involved in planning activities. Twelve specialities were represented in the sample. with surgery (20.2”;). medicine (14.1Yg), pediatrics (10.14,) and obstetrics/gynecology (7:;) topping the list. Unfortunately psychiatry was not indicated on any questionnaire. Of the 100 responding to the question on length of practice, almost half (469;) indicated they had been on the job between one month and five years. Another 361, had been working for 610 years. Only 2”” had more than 21 years of experience. With respect to the first hypothesis. the physicians were asked to indicate whether or not they felt the two systems should work towards integration. This was a very general question and 63 (61.19;) physicians gave positive responses. Of these 15 felt strongly about the need for integration. There were a total of 32 (31.0”,) doctors who rejected the idea. with 12 strongly opposing it. Eight (7.7”“) remained undecided. With almost two-thirds of the sample agreeing that integration was acceptable. it would appear that
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Table 1. Attitudes towards integration and the use of joint clinics Work towards integration (Yes) (Undecided/No)
Build joint clinics (i’es) (Undecided/No) 23 7
35 30
58 37
30
65
95
x2 = 5.08; d.f. = 1; P < 0.05: NA = 8. the first hypothesis should be rejected. Nevertheless, the actual prospect of working with indigeneous personnel is another matter (see Hypothesis I). To elicit this information other items were included in the schedule. Physicians were asked whether they would work along side local healers in joint clinics (item 18) (an item suggesting equality in status) or whether the indigenous healers should be trained to ‘treat minor diseases at the grassroots level’ (item 14) (suggesting junior partnership). Of the 95 who responded to the item on joint clinics, 54.7% did not believe it was a good idea. Another 13.6% remained undecided. Thus a total of 68.3% were unable to give a positive response. From Table 1. it is obvious that a relationship does exist between wanting integration and joint clinics (P < 0.05). Of interest also is the apparent ambivalence of many physicians. Fifty-eight respondents favoured integration, but almost two-thirds (60.3%) of these would not encourage the development of joint clinics (i.e. working alongside local healers). Joint clinics are often advocated as a practical step towards integration (as in China), yet this would apear not to be an attractive proposition to these respondents. The respondents were further asked if Nigeria needed a new group of medical workers to treat the minor/common diseases. Sixty-seven believed the nation did. Of these 61 (91.0%) preferred that these health workers be ‘a new group of orthodox workers’. Only four opted for the training of ‘traditional practitioners’. Two respondents did not answer the question. From these responses, it is quite clear that the physicians would prefer to work with those of their own kind. Finally,‘102 responded to the question on the separate development of the two medical systems. Of these, 63.77; felt that separate development was a good idea. These findings indicate that the initial positive response to the suggestion of integration camouflages ambivalent feelings or reservations. The more specific questions on joint clinics and the inclusion of indigenous healers on the lower runs of the occupational ladder met with resistance. Thus whether or not the theories and methods of indigenous medicine are researched or developed it would appear that many physicians may not want to work with indigenous personnel. In the light of these results, we would suggest that the first hypothesis be accepted. The second hypothesis sought to discover the aspects of indigenous medicine in which the physicians were either interested or held in high esteem. The respondents were asked: “What are the main areas in which Western orthodox medicine can learn
1616 Table
TOLA OLU PEARCE
2. Areas of indigenous medicine from physicians felt they could learn
which
the
Number of mentions 1. 2. 3. 4. 5. 6. 7.
Psychiatry/mental health practices Herbal/pharmaceutical remedies Orthopedicsihonesetting Supernatural healing The psychological impact on the patient Community health practices Others (e.g. cancer research, gynecological research 8. Minimal/None
26 31 4 9 5 2 4 5
from traditional medicine?” The doctors were expected to enumerate the quantifiable aspects of local practices (i.e. massage, diet, herbalism, bonesetting etc.). With the emphasis on ‘science’ in Western medicine, there should be little interest in . such features as rituals, or supernatural powers. They were expected to dwell on the measurable effect of herbal and mechanical processes and not on what is often seen as mysticism in indigenous practices. Also, with respect to their own professional interests, an emphasis on these quantifiable aspects (focus on ‘science’) would ensure that knowledge developed in the feature would be judged according to the rules by which they excelled. The responses could be grouped into eight categories (Table 2). Some physicians gave multiple responses and each was coded separately. There were 34 respondents who did not respond to this question. As expected, many physicians are interested in herbal remedies. This is one of the most quantifiable dimensions of local practice. Nevertheless, there was almost an equal amount of interest in psychiatry. This appeared not to be a mere interest in psychiatric drugs as many respondents who indicated an interest in herbal remedies also mentioned psychiatry. Much of traditional psychiatry draws on a system of supernatural beliefs and embodies much ritual performance. The author believes there is an interest in understanding why these appear to be effective. Although mentioned far fewer times, the third and fourth largest categories also deal with the more intangible aspects of local medicine. Examples of interest in supernatural dimensions are “the power of incantations”, beliefs”, and “fighting “magic”, “certain traditional witches”. It can be argued that the fifth (psycho impact) and first (psychiatry) can be collapsed. although the former appears to focus more specifically on the doctor-patient relationship dimension. Finally, there were 5 respondents who feelt there was really nothing to be learnt from local practices. Of the 81 positive mentions, 40 could be said to focus on the less tangible as yet non-quantifiable aspects of medical practice. The author would thus suggest that the second hypothesis be rejected. DISCUSSION
Since the early 1970s there has been a growing interest in the official role of indigenous healers in non-European medical systems. Organizations such
as the W.H.O. have suggested the retraining of traditional practitioners to serve as primary health workers [34], so that the network of hospitals and medical centre can function more efficiently as secondary and tertiary units. The Chinese attempt at integration has also caught the attention of many scholars. In Nigeria. although the government does not yet have any official programme for integration, there has been pressure from consumers. intellectuals and some indigenous practitioners to ‘do something about the role of indigenous medicine’. The author was thus interested in the attitudes of Universitytrained doctors towards the issue of integration. since their cooperation is needed in any official programme. In a study conducted in 1978 on 103 doctors. results showed that although the physicians indicated an interest in integration. when confronted with possible methods of working with indigenous personnel, they showed reluctance to accepting them. It was also discovered that many doctors felt that Western orthodox medicine could learn something from the non-quantifiable aspects of local practices. The wish to learn more about these areas of indigenous practice while hesitating to absorb its practitioners brings to the foreground the problem of control and competition. In the history of the development of the profession there have been many attempts to absorb or control relevant material from other groups (e.g. granny midwives) who are seen as threats to their dominance over medical practice. When doctors feel that any group is encroaching on their turf, attempts will be made to control the competition. Judging from the results of the present study, the fears expressed in the statement below are not imaginary There is a certain amount of apprehension among indigenous healers “borne out of fear of modern scientists taking control of African medicine and absorbing Herbalism as a profession, and wipe (sic) out its practitioners in the field of medical profession” [35]. Finally, it was also interesting to see that few (only 4) physicians gave a positive response to the following item: “Would you please indicate whether you per.sonu/lv use ideas and methods from the other type of medicine”. The four respondents answered as follows: “psychotherapy”, “Herbs and Roots for the treatment of infantile of impotency” and “psyeczema”. “in treatment chiatry”. The paucity of responses to this item again suggests that at present physicians do not interact readily with individual practitioners of the indigenous system. This piece of research would indicate that active and widespread participation in any official integration programme would be resisted. REFERENCES
Ademuwagun
Z. The relevance
of Yoruba medicine men in public health practice in Nigeria. In African Thrrtrpeutics .Systcnr.~ (Edited by Ademuwagun Z.), p, 155. Crossroads Press. Waltham. MA 1979. Maclean U. Maqictrl Medicine: A Niqrhn Cuw Study. Penguin Books. New York. 1971. Odebiyi A. Socio-economic status. illness behaviour and attttudes towards disease etiology in Ibadan. Niger. Brhut. Sci. Q. 3, 172, 1980. Ademuwagun Z. The challenge of the co-existence of orthodox and traditional medicine in Nigeria. In .4fricm Thertrprutic~ Systems op. c,if. p. 165.
Integrating
Western
orthodox
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