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The utilization of traditional medicine— A Malaysian example
THE UTILIZATION OF TRADITIONAL A MALAYSIAN EXAMPLE H. K. Ross
Abstract-This Malay
MEDICINE-
HEGGENHOUGEN
Institute, London School of Hygiene and Tropical Medicine, London
paper documents
healer, or km&.
interviews with IO0 people who had cOme to cons&t a traditional
Many people use several types of health care resmrces Traditional and
cosmopofitan systems are not perceived as antagonjstjc: a fiomr& wilf often refer patients to cosmopolitan practitioners and wiII reinforce compliance with cosmopoiitan treatment regimens. ~~smopo~~tan medicine’s inattention to the affective aspects of heating-its concentration on disease rather &an illness-is an important reason why Malaysians are refuctant to use cosmopolitan services, and is anr reason why the homoh is consulted for physical as well as for psychological complaints.
INTRODWCI’ION
miss a thing, and they are appreciative when the now and again directs a joke to the whole “audience”. The atmosphere is casual. familial, and respectful. Tok Guru explained his powers to me in a humbfe manner: “There is nothing to say, it is simple? there is nothing complicated, it just happens-the power comes from Allah, it is Allah who heals”. More precisely, he claims to be an instrument of Allah’s messenger, Malaikat. He first demonstrated healing powers during the second World War when other means were not available and he cured a friend by blessing the water which he was given to drink. He reads the Taba and Yasin sections of the Koran daily, an activity that is commonly believed to cultivate intuitive healing power. We interviewed one hundred people who attended Tok Guru’s sessions These interviews document healing practices that are widespread in Malaysia. Compared to Mesoamerica or some parts of Africa, relativeiy little has been published on the ethno~aph~ of healing practices in Malaysia. As is often the case in developing countries, modern minded Malaysians refer to these practices as a remnant of traditional culture that survives only among a few ignorant and superstitious country folk. In fact, they involve both urban .and rural people with many degrees of knowledge and sophistication bond
In a small town at the edge of Malaysia’s richest rice land, not far from the backlands where the mountains begin, there lives a frail rehgious man, a Waji (one who has made the p~~~rna~ to Mecca) to whom people flock, sometimes more than a hundred in a day, In search of relief From aihnents or solutions to other prablems. More than 70 years old, this man is one of the best known boomohs (traditional Malay healer) in the state of Kedah in northwestern Peninsular Malaysia. People refer to him as Tok Guru (Master). Farmers and businessmen, housewives and police officers, teachers and students come to him from the surrounding area and from afar. They come with physical and mental complaints, with ailments caused by witchcraft, or simply for luck. Most carry a battIe of water and bundles of Sir.4 or betel leaves, and often aho* they carry betel nuts. According to an imported Javanese belief, these items are the royalty of ah medicines, Tok Guru consults people while seated at a small table in the shade under his house. Many people come to him after other therapies have failed, or to complement another form of treatment, or to safeguard a cure already achieved. Others consult Tok Guru before they use other resources. His manner resembles that of an ideal psychiatrist [I] ar trusted family doctor [2) in our society. His presence is extraordinary. He appears authoritative, and at the same time he jokes with patients, gently chiding and advising them. He blesses the water and the Sireh offerings they bring, reads Koran& verses and performs jm@ (incantation). He may blow or spit a blessing in a child’s face, and he may recount a recipe for an herbal tea. 1:once saw him whisper an incantatian while placing his right foot on a baby’s face. The father later testified that the unsightly blemish that Tok Guru touched with his big toe was reduced by’this therapy, yet it had been treated unsuccessfully by a succession of cosmopolitan medical specialists. Patients sit among the stilts of the house-the women to the back and the men at the sides-talking and occasionally looking toward the curer’s table. Seemingfy uninterested in the action there, they never
Procedures
We used a list of open-ended questions to interview people waiting to see Tok Guru. The interviews were conducted over a two month period in 1977. We attempted to interview recently arrived people so that no one would be detained after receiving treatment, but this was not always possible. The interviews were conducted by Abdul Rashid bin Abdul Razak and Mahani binte Mahmud. Each interviewee was assured confidentiality. Participation was voluntary, and those who participated were instructed not to answer questions they did not want to answer. The interviewers tried to detect responses which indicated a person was trying to please them by giving answers they thought the interviewer would approve. rather than answering in a manner that expressed
H.
40
K. HEGGESHOLGEN
Table I, Occupation of interviewees Farmer Business person Student Housewife Teacher Military/Police Other No answer
Table 2. Type of complaints or problems presented 50%
IlO’ I&g IlO’ 42 4% 5% 4%
their own beliefs. In this event the person was encouraged to express himself fully. On the whole, we were impressed by the openness of the responses, yet 63% of the respondents did not wish to reveal their level of schooling. This indicates a degree of reserve with the interviewers, who represented people with a slightly higher level of education. RESULTS AND
DlSCUSSlON
Of the 65 males and 35 females interviewed, 40 were patients, five were friends of patients and 55 were relatives of patients (usually a parent or spouse). Only one of the interviewees was Chinese and one Indian, the rest were Malay. Thirteen of the patients were less than 10 years old, 27 were between 10 and 20 years old, and 53% were under 30 years of age. As can be seen from Table 1, one-half of those interviewed identified themselves as farmers and 54 identified the head of their household as farmers. In all, 71 interviewees identified themselves as rural dwellers and 29 stated they lived in urban areas. However their definition of urban is subjective so the latter figure could be inflated, although a number of people did come from Alor Star, the state capital and from as far away as Kuala Lumpur. the national qapital. The composition of the households of patients corresponded with that of the country as a whole: 53% of the households had 1, 2 or no children and 24% had 3 or 4 children. (This is actually a lower average than indicated in the 1970 census report for the state of Kedah [3].) For 60% of those interviewed, total income for all working members in a household was M $200 or less a month; only two households had monthly incames of more than M $1000. It can be seen that the majority of the interviewees belonged to households poorer than average. though not necessarily poorer than an average rural Malaysian. The incomes are on a par with the income range of a decade ago when 64.6% of all Malaysian households had an income of less than M $200 per month [4].
Help with-
‘<, of respondents
Study/interview/exams Physical problems (including psychosomatic complaints) Traditional illness categories (including charms) Psychological complaints No response
Rural Clinic Private Physician Hospital Drug store Other bomoh Police
Patients having tried one other resource only (N = 25)
Patients having tried several other resources (N = 18)
4 5 9
5 8 I5
I
I
5
I3
I
I -‘O0 x0,, I” 0
In 1977, it was estimated. however. that households with incomes of less than M $300 per month were at the poverty level but that 507; of the population was at this level [5]. Interviewees were generally sedentary. 40’1, having lived in the same place for 20 or more years and 30% for I&20 years, although 297; had lived in other states of other districts before moving to their present dwellings. Table 2 indicates the type of complaints for which the homoh’s help was sought. 60 patients had visited the homoh before. 405, for the same complaint. Two patients who were returning with the same complaint stated that the problem had worsened, four that it had remained the same and the majority that improvement was evident. Of those who had been to the homoh previously for a different problem, 31 stated that they had been helped, compared to five who felt they were not and two who were uncertain. 25 patients had also tried one other type of health resource for the present problem. an additional 18 had been to more than one resource. as indicated by Table 3. The majority of these patients (33) who had sought other help earlier felt they had not been helped by these other resources, five felt they had been helped, three were not certain; and two declined to answer. The majority of the patients (87) had been recommended to the homoh by friends (53), neighbors (16) or relatives (18) and others stated simply that they “knew the homoh”. 72% stated they knew someone who had been helped by the bomoh and almost half of these indicated that the problem involved was the same for which they now sought help. 54 respondents claimed that the bomoh and the hospital (cosmopolitan medicine) provided different but complementary types of treatment. Patients said that one system was preferred over another depending on the kind of illness. 17% felt the bomoh gave “better care” in general and had more concern for the patient
Table 3. Other health resources used for the same problem by patients (N = 43)
Resource
42” 370;
The utilization
OC traditional
41
medicine NunWr
Numba of intarveiwaas O-IO
5
min 1-1
Q
IO-10 min I-1
=! 2
minf
30-45
minr1
I
Motorcycle
I
Bus
5
TOW
B Z. S
45-60minIl I-it
cl
Bike
0
s2
20-30
of !ntervewees
Walk
Car
min 71
2-3
hrf]
Fig. 2. Mode of transportation
3hr+r] 15
V
Fig. 1. Time spent in travelling to see Bomoh.
than hospitals or clinics but six felt it best first to go to the clinic or hospital for an ailment and only to consult the bomohif that did not work. Figures 1 and 2 indicate the time spent travelling to see the bomoh and the mode of transportation used. Figure 3 indicates the length of time the patients felt they had had the problem. Of the 56 who answered the question regarding payments, six paid the ~~~ more, 33 paid less and 15 paid the same as they said they wouid pay eisewhere (see Table 4). The vast majority (92%) stated that they felt (or were colrvinced they would feel) better for having seen Tok Guru. The reason most often stated for this was that he made patients confident that the problem could be solved, a feeling linked to the belief that Tok Guru as a religious man had the power of Allah working through him. 28% stated that the reason for their confidence (and for feeling better) was that Tok Guru’s treatment had worked before, either for them personally or for someone they knew. Most of the interviewees who had previously used another source of help came for a physical problem, The majority (86%) of those with physical problems had already been elsewhere. whereas only 12% of those who came for help with exams, study or inter-
used to reach the Bomoh.
views had tried another source of help for that problem. About half of those with psychological problems or traditional, spirit-based illnesses had been elsewhere, but there were few such patients so that these figures were not significant. The farmers, constituting 50% of those interviewed, seemed to make greater use of Tok Guru’s services for physical problems than those of other occupations; 467; of the farmers but only 28% of all the others came for physical complaints. Only 39% of the farmers had been elsewhere for their problems, whereas 50% of the others had sought other help. Converseiy 73% bf the farmers had been to Tok Guru previously (for the same and/or different problems) whereas only 570/, of the others had had previous contact. As a group, the farmers live closer to Tok Guru than the others, a factor that might have influenced the difference. Of those who gave a pragmatic reason for going to Tok Guru, 72% were farmers and 28% nonfarmers. (Those who indicated they felt better after coming to Tok Guru because they had been cured previously, or because they knew of others who had been cured, were considered to have come for pragmatic reasons ,as opposed to those who were indefinite about why they felt better saying simpty: “he gives me hope”, or “I have faith in him”.) There is little difference between farmers and the others in the length of time they feel they have suffered their complaint.
Dumtion of problem
No response
1-1
A few days i-1 c
I week
1-1
I=
2 weeks 1-3
2 (4
weeks 1-l
I:
2 months
yaors 3~5
yecrs
1-1
0
years 1[7 25clO monlhscj a10 yeors 1
51% 1/
1
I
I
I
I
,
5
IO
I5
20
2?
Number of pottents
Fig. 3. Length of time the patient had had problem.
J
, 30
42
H. K. HECGENHOUGEN Table 4. Indicated payment to the bomok No. of patients
Amount I. 2. 3. 4. 5. 6. 7.
Nothing Don’t know “What one wants (probably M$ I)“* 50e One ringgit (Mf I) Two ringgit (MS 2) Three ringgit (M$3) More than 5 ringgit (MS 5)
8. l
2 2 23 6
21
17
I 1
USlE 1 equals 2.20 ringgits (MS 2.20).
Income, educational level (when indicated) and age (except for exam/study problems) were not indicative of the type of problem for which help was sought. 49% of the women and only 39% of the men consulted Tok Guru for study/interview problems. This ratio was reversed for physical complaints: 41% of the men but only 31% of the women had physical complaints. The duration of the problem or illness could be directly correlated to how many health resources had been used: 49% of the multiple users had had the problem for 2 months or more but only 27% of the patients who had only consulted Tok Guru had had the problem more than 2 months (Table 5). These data may be influenced by the large number of people who come for study/exams problems. However, it is not necessarily true that the concern about an exam or doing well in school is a short lived, periodic preoccupation.
areas, and I have observed bomohs in Kuala Lumpur who see more than 100 patients a day. Tok Guru may not cure all the patients who come to him, but he assists a great number of them. Those who had been to see him previously felt that they had been helped. The majority of those who had been
elsewhere had come to Tok Guru because they felt they had not been helped. This confirms observations by Reading [6] and Osman [7] that “Feeling well is as important.. as being well”. The importance of how a patient feels about a health resource is illus-
trated by cases I, III and IV in the Appendix. Tok Guru may (directly or indirectly) cure specific diseases. in addition to making the patientsfeel better. but in some cases a different kind of treatment might be preferable. Tok Guru frequently tells a patient that. although he might assist in healing certain aspects of the problem, the hospital would be the best place to cure other aspects of the illness. Despite the limited attention cosmopolitan medicine pays to the affective side of healing, it is by now fully recognized that this aspect is of great importance [6,8,9]. As a healer, Tok Guru encourages a positive feeling and religious faith, which are of curative value for psychological and for physical ailments. Research on the placebo effect and mind/body interactions explores the nature of these therapeutic processes [9:10]. Hartog noted that in Malaysia “new crises” such as school exams, the stress of some urban and professional jobs and the trauma girls suffer when they go away to school, are not dealt with by traditional institutions which provide a crises intervention system [ 111. Tok Guru handles these crises in significant proportion of his consultations. A new book by Pelletier [12] is one of numerous recent works that points to the limitations of the biomedical
DISCUSSION
Except for ethnicity, there seems to be no significant way in which those making use of the services of this bomoh can be distinguished from the rest of the population of Kedah-the home of most of the patients. Although 71% of those interviewed described themselves as rural, other bornohs are not consulted primarily by rural dwellers. Nor are bomohs a health resource used only by the most “traditional,” or ‘isolated, segments of the population. A considerable portion of the patients not only lived in urban areas but they had also lived in a number of districts. Other studies have reported the practice of homohs in urban
approach
to medical
practice:
“It is increasingly unlikely that any pharmacological panacea will resolve the fundamental issue of illness and health. Both the benefits and limitations of surgical and chemotherapeutic intervention should be acknowledged.. Researchers and clinicians now need to investigate the means of reducing stress rather than concentrate most of the effort on the disorder that is the end result” (p. 35) [12]. 92% of the people in our study indicated that they felt, or would feel, better after seeing Tok Guru. Since 86% of those with physical problems had already used other health resources (primarily cosmopolitan medicine), seeing a bomoh did not involve denying the value of cosmopolitan medicine. An illness thought to have natural causes may later be attributed to a
Table 5. Health resources used and duration of problem
Having only visited Duration of problem I month l-2 months 2 months No answer
Total
Having used other health resources (N = 43)
Tok Guru for this problem (N = 45)
I2 (28%) 7 (16%) 21 (49%) 3 (7%) 43 (10%)
22 (49%) I i (24%) 12(27%) 45 (100%)
No Response (N = 12)
The utilization of traditional medicine spirit/charm, or to a breach of udut (customs). The use of cosmopolitan medicine in this case would be
followed by resort to a bornoh. Our interviews showed that most people expect rapid, almost miraculous cures from cosmopolitan medicine. If this does not occur, they may assume that the treatment was inferior and that another cosmopolitan practitioner should be consulted or that cosmopolitan medicine is inappropriate. In the latter case the illness is reinterpreted. Table 5 indicates that patients who had had problems for a long period also consulted a wider variety of health resources.
-Survey
REFERENCES
made at the
October. 1977. 703-710, 1977. 7. Mohd. Taib Osman. The Bomoh and the practice of Malay medicine. S. E. Asian Rev. 1, 1, 16, 1976. 8. Kleinman A. et al. Culture, illness, and care-clinical
9.
Il.
Fuller T. E. The Mind Game. Witchdocrors and Psp chiarrisrs. Bantan Books. New York, 1972. David J. A. Medical practice and tribal communities. In Health artd Disease in Tribal Societies (Edited by Elliott K.). Ciba Foundation Symposium 49-New Series. Elsevier. North Holland, 1977. Jabatan Perangkaan Malaysia. 1970 Population and Housing Census. Malaysia: Volume I-General Housing Tables. Part X. Kedah. Kuala Lumpur, August. 1972. Jabatan Perangkaan Malaysia. Socioeconomic Sample
Kuala
6. Reading A. Illness and disease. Med. C/in. N. Am. 61,
use
Acknowledgements-I want to express my appreciation to Abdul Rashid bin Abdul Razak and Mahani binte Mahmud for assisting with the research referred to in this article, to Margaret Lim for assisting with the preparation of the manuscript, and to colleagues at UC-ICMR and the Division of Rural Health, Institute for Medical Research, Kuala Lumpur, for their comments. I also wish to thank Dr George de Witt, Director, Institute for Medical Research, for his support and permission to publish this article. Special thanks goes to Tok Guru Haji Aziz and to the people who so kindly agreed to be interviewed. This work was supported by grant AI-10051 (UCICMR) to the Department of Epidemiology .and International Health, School of Medicine, University of California. San Francisco. from the National Institute of Allergy and Infectious Diseases, National Institutes of Health, U.S. Public Health Service.
1967-68.
National Seminar on the Sociul and Ecological Impact and Problems of Development. Penang, Malaysia, 4-5
10.
of traditional healers is a common phenomenon in Malaysia. This study shows that those who consult these practitioners are representing the population at large. Their complaints are not primarily traditional (charms, spirit-possession, hysteria, etc.) but are physical and psychological (including anxiety due to such events as exams, study and interviews). The people who consult traditional Malay healers also use cosmopolitan health services. The longer an ailment persists, the higher the probability that people will attribute it to a supernatural cause, and thus make a bomoh the most appropriate healer to consult. Our interviews support the hypothesis that a large proporfion of the population believe that cosmopolitan medicine is a partial healing system that neglects the socio-psychological and spiritual aspects of healing. Patients stated that the bomoh was particularly adept at making people “feel better”. Feeling is pivotal in deciding which health resource to use.
of Households-Malaysia
Lumpur, June 1974. 5. Mohd. Nor b. Abd. Ghani. Remarks
CONCLUSIONS The
43
12.
lessons from anthropologic and cross cultural research. Ann. intern. Med. 88, 251, 1978. Kiev A. Magic, Faith & Healing. Free Press, Glencoe. New York, 1964. Moerman D. E. Anthropology of symbolic healing. Curr. Anthrop. 20 (1). 59. 1979. Hartog J. The intervention system for mental and social deviants in Malaysia. Sot. Sci. Med. 6, 21 I, 1972. Pelletier K. R. Mind as Healer, Mind as Slayer. Delta. New York. 1977. APPENDIX
Case I
A 27-year-old farmer travelled 30min by car to see Tok Guru. He complained of frequent tiredness, difficulty in breathing, restlessness during the evening and what he called “spasmodic asthma”. He believed the problem originated from doing too much heavy work in his rice field which gave rise to a headache, and subsequently to his present symptoms which began “a few days ago”. There are two adults and two children in his household, and the household has a monthly income of less than M$200. He had never been to Tok Guru before but had heard from his uncle that Tok Guru could cure this type of complaint. Hd had previously been to a rural health clinic as well as to a hospital and at both places he had received medicines but was not cured. The patient, came with his brother-in-law. They brought Sireh leaves, betel nuts and a bottle of clean water. He believed that Tok Guru could discern the cause of the ailment by looking at these items and that the primary means of curing came through blessing the water. He believed that Tok Guru receives guidance and healing power from Allah through a messenger or Khadam (servant). He claimed he had confidence in, and felt good about seeing the Tok Guru because his brother-in-law had been cured of the same problem. The brother-in-law indicated strong dissatisfaction with the treatment received at the hospital because (1) the patients have to wait for many hours before receiving treatment, (2) he felt the patients were not properly examined by a doctor and (3) the patients became frustrated because they had no chance to explain the problem. Because of these failures “the hospital did not provide the right prescriptions”, and the patient had not gained relief. It was “much easier to consult with Tok Guru and to express the problem”. “Tok Guru listened and showed sympathy”, and was therefore able to provide an effecti,ve cure. Case II The patient was a 22;year-old man employed as a “hostel steward” and living at the outskirts of the state capital of Alor Star. He travelled 20min by bus
44
H. K. HEGGEXHOUGEN
to Tok Guru. He came alone. He had always lived at his current address. a household that currently contained five people. His complaint was “difficulty in breathing” which he “suspected to be TB”. He had had symptoms for 10 months. He not only believed that his ailment was the result of “long hours of work in the padi fields” and “lack of rest” but that it might also be due to the fact that he “often attended Koran reading competitions and weddings” making others jealous, wanting to charm him. He had not been to the homoh previously but for his current ailment he had gone to a rural clinic, to a hospital and to a private physician. He was advised by the government clinic to receive treatment there on a regular basis. He felt that he was helped by the clinic treatment, but he visited Tok Guru to make sure that he was not charmed. He knew people who had chest pains and had been advised by a doctor to have surgery, but who had rejected this advice and had been cured by the homoh. He also knew of a baby that had difficulty urinating and was unsuccessfully treated by doctors but “successfully treated by Tok Guru”. He felt that the difference between “hospital medicine and bomoh medicine” was that the hospital “diagnoses with modern medicine” and the bomoh “relies on the blessings of Allah”. He believes, however, that this Tok Guru is different from other bomohs because he does not go into trance and is not associated with any hantus (spirits). He is an exemplary muslim who believes in the verses of the Koran. Tok Guru told the patient that he was not charmed but that he might possibly have tuberculosis. (He told the patient, after examining his hands and tongue, that those who have, or might have tuberculosis have a whitish tongue or have a white spot on their tongue.) Tok Guru told him not to worry and strongly advised him to continue the treatment from the clinic. Case III The patient was a 20-year-old woman with a “hole in the heart”. The person we interviewed was a teacher and a friend of the woman’s father. The father and the interviewee came with the patient and her mother to seek Tok Guru’s help. They travelled almost 2 hr by car from their home in a rural village in the state of Perlis. Apparently the patient had the problem since childhood but only started complaining about it during the past several years. The friend had been to the bomoh previously in order to get a winning lottery number, but the bomoh refused to be concerned about such things and did not attempt to help him. The patient had been to the hospital several times for the problem, but the father was seeking Tok Guru’s help so that his daughter wouldn’t “be dejected”. He hoped that “through the blessing of the water” she would no longer be afraid that she would die. The father had been told by the hospital doctor that the patient had little chance of surviving and that further treatment was useless. The interviewee felt that the hospital might have given inadequate treatment to the patient, and was critical of the fact that the patient had been left with no hope.
The father felt better after going to the homoh because Tok Guru had a reputation as a religious man who receives power to heal from Allah. The father hoped his daughter would recover. and expected that she would also be hopeful. The interviewee stated that most village people were quite reluctant to go to the hospital because of the “rough and ungentle way they were treated by the nurses and doctors” which “sometime made them feel worse than did the illness for which they had come”. The teacher felt that “it is their feelings that should be taken care of first rather than the illness (disease)“. He felt that the lack of attention to “human feeling” was the reason many Malays go directly to the homoh or go to the homoh even though they have been to the hospital. because the homoh can “ease out their worry”.
Case II/ A 21-year-old air force officer with a high school education travelled alone 45 min by bus from the state capital to Alor Star to see Tok Guru about reducing his nervousness and fear of flying. He had consulted Tok Guru earlier about an examination which he passed “because of the bomoh’s help”. He had not gone elsewhere for help with his present problem. He felt that the difference between “hospital medicine” and the homoh was that the former operated on a “scientific basis” and the latter within a spiritual realm. He felt that the bomoh received special powers from his ancestors and through his pilgrimage to Mecca. The patient said he had faith in Tok Guru’s prayer on his behalf-and “felt good” as a result of seeing Tok Guru. Case V The patient was a 3 l-year-old married teacher, with no children and an income of around MS600 a month. He spent close to an hour coming alone by car from his home in one of the larger towns of Kedah. He came to see Tok Guru because his house had been burgled twice, but he was particularly concerned that someone might be trying to charm him. During each burglary one of his old shirts had been stolen. Although the thief had taken a number of things, he had not taken the newer clothes, but only an old sports shirt that the patient feared was being used to charm him. He had been to Tok Guru before and he also had a friend who was “receiving protection against harm” from the Tok Guru after someone robbed him three times, each time stealing an old shirt and his wife’s bras. He felt that by incantations and “blessing of the water” the bomoh could help him. The teacher told about a convict who escaped from a police station. The officer in charge came to Tok Guru for assistance and was told that Tok Guru would try to “darken the convict’s vision” so that he would feel badly about escaping and would give himself up within 3 days time, “which is exactly what happened”.
Abstract-This Malay
MEDICINE-
HEGGENHOUGEN
Institute, London School of Hygiene and Tropical Medicine, London
paper documents
healer, or km&.
interviews with IO0 people who had cOme to cons&t a traditional
Many people use several types of health care resmrces Traditional and
cosmopofitan systems are not perceived as antagonjstjc: a fiomr& wilf often refer patients to cosmopolitan practitioners and wiII reinforce compliance with cosmopoiitan treatment regimens. ~~smopo~~tan medicine’s inattention to the affective aspects of heating-its concentration on disease rather &an illness-is an important reason why Malaysians are refuctant to use cosmopolitan services, and is anr reason why the homoh is consulted for physical as well as for psychological complaints.
INTRODWCI’ION
miss a thing, and they are appreciative when the now and again directs a joke to the whole “audience”. The atmosphere is casual. familial, and respectful. Tok Guru explained his powers to me in a humbfe manner: “There is nothing to say, it is simple? there is nothing complicated, it just happens-the power comes from Allah, it is Allah who heals”. More precisely, he claims to be an instrument of Allah’s messenger, Malaikat. He first demonstrated healing powers during the second World War when other means were not available and he cured a friend by blessing the water which he was given to drink. He reads the Taba and Yasin sections of the Koran daily, an activity that is commonly believed to cultivate intuitive healing power. We interviewed one hundred people who attended Tok Guru’s sessions These interviews document healing practices that are widespread in Malaysia. Compared to Mesoamerica or some parts of Africa, relativeiy little has been published on the ethno~aph~ of healing practices in Malaysia. As is often the case in developing countries, modern minded Malaysians refer to these practices as a remnant of traditional culture that survives only among a few ignorant and superstitious country folk. In fact, they involve both urban .and rural people with many degrees of knowledge and sophistication bond
In a small town at the edge of Malaysia’s richest rice land, not far from the backlands where the mountains begin, there lives a frail rehgious man, a Waji (one who has made the p~~~rna~ to Mecca) to whom people flock, sometimes more than a hundred in a day, In search of relief From aihnents or solutions to other prablems. More than 70 years old, this man is one of the best known boomohs (traditional Malay healer) in the state of Kedah in northwestern Peninsular Malaysia. People refer to him as Tok Guru (Master). Farmers and businessmen, housewives and police officers, teachers and students come to him from the surrounding area and from afar. They come with physical and mental complaints, with ailments caused by witchcraft, or simply for luck. Most carry a battIe of water and bundles of Sir.4 or betel leaves, and often aho* they carry betel nuts. According to an imported Javanese belief, these items are the royalty of ah medicines, Tok Guru consults people while seated at a small table in the shade under his house. Many people come to him after other therapies have failed, or to complement another form of treatment, or to safeguard a cure already achieved. Others consult Tok Guru before they use other resources. His manner resembles that of an ideal psychiatrist [I] ar trusted family doctor [2) in our society. His presence is extraordinary. He appears authoritative, and at the same time he jokes with patients, gently chiding and advising them. He blesses the water and the Sireh offerings they bring, reads Koran& verses and performs jm@ (incantation). He may blow or spit a blessing in a child’s face, and he may recount a recipe for an herbal tea. 1:once saw him whisper an incantatian while placing his right foot on a baby’s face. The father later testified that the unsightly blemish that Tok Guru touched with his big toe was reduced by’this therapy, yet it had been treated unsuccessfully by a succession of cosmopolitan medical specialists. Patients sit among the stilts of the house-the women to the back and the men at the sides-talking and occasionally looking toward the curer’s table. Seemingfy uninterested in the action there, they never
Procedures
We used a list of open-ended questions to interview people waiting to see Tok Guru. The interviews were conducted over a two month period in 1977. We attempted to interview recently arrived people so that no one would be detained after receiving treatment, but this was not always possible. The interviews were conducted by Abdul Rashid bin Abdul Razak and Mahani binte Mahmud. Each interviewee was assured confidentiality. Participation was voluntary, and those who participated were instructed not to answer questions they did not want to answer. The interviewers tried to detect responses which indicated a person was trying to please them by giving answers they thought the interviewer would approve. rather than answering in a manner that expressed
H.
40
K. HEGGESHOLGEN
Table I, Occupation of interviewees Farmer Business person Student Housewife Teacher Military/Police Other No answer
Table 2. Type of complaints or problems presented 50%
IlO’ I&g IlO’ 42 4% 5% 4%
their own beliefs. In this event the person was encouraged to express himself fully. On the whole, we were impressed by the openness of the responses, yet 63% of the respondents did not wish to reveal their level of schooling. This indicates a degree of reserve with the interviewers, who represented people with a slightly higher level of education. RESULTS AND
DlSCUSSlON
Of the 65 males and 35 females interviewed, 40 were patients, five were friends of patients and 55 were relatives of patients (usually a parent or spouse). Only one of the interviewees was Chinese and one Indian, the rest were Malay. Thirteen of the patients were less than 10 years old, 27 were between 10 and 20 years old, and 53% were under 30 years of age. As can be seen from Table 1, one-half of those interviewed identified themselves as farmers and 54 identified the head of their household as farmers. In all, 71 interviewees identified themselves as rural dwellers and 29 stated they lived in urban areas. However their definition of urban is subjective so the latter figure could be inflated, although a number of people did come from Alor Star, the state capital and from as far away as Kuala Lumpur. the national qapital. The composition of the households of patients corresponded with that of the country as a whole: 53% of the households had 1, 2 or no children and 24% had 3 or 4 children. (This is actually a lower average than indicated in the 1970 census report for the state of Kedah [3].) For 60% of those interviewed, total income for all working members in a household was M $200 or less a month; only two households had monthly incames of more than M $1000. It can be seen that the majority of the interviewees belonged to households poorer than average. though not necessarily poorer than an average rural Malaysian. The incomes are on a par with the income range of a decade ago when 64.6% of all Malaysian households had an income of less than M $200 per month [4].
Help with-
‘<, of respondents
Study/interview/exams Physical problems (including psychosomatic complaints) Traditional illness categories (including charms) Psychological complaints No response
Rural Clinic Private Physician Hospital Drug store Other bomoh Police
Patients having tried one other resource only (N = 25)
Patients having tried several other resources (N = 18)
4 5 9
5 8 I5
I
I
5
I3
I
I -‘O0 x0,, I” 0
In 1977, it was estimated. however. that households with incomes of less than M $300 per month were at the poverty level but that 507; of the population was at this level [5]. Interviewees were generally sedentary. 40’1, having lived in the same place for 20 or more years and 30% for I&20 years, although 297; had lived in other states of other districts before moving to their present dwellings. Table 2 indicates the type of complaints for which the homoh’s help was sought. 60 patients had visited the homoh before. 405, for the same complaint. Two patients who were returning with the same complaint stated that the problem had worsened, four that it had remained the same and the majority that improvement was evident. Of those who had been to the homoh previously for a different problem, 31 stated that they had been helped, compared to five who felt they were not and two who were uncertain. 25 patients had also tried one other type of health resource for the present problem. an additional 18 had been to more than one resource. as indicated by Table 3. The majority of these patients (33) who had sought other help earlier felt they had not been helped by these other resources, five felt they had been helped, three were not certain; and two declined to answer. The majority of the patients (87) had been recommended to the homoh by friends (53), neighbors (16) or relatives (18) and others stated simply that they “knew the homoh”. 72% stated they knew someone who had been helped by the bomoh and almost half of these indicated that the problem involved was the same for which they now sought help. 54 respondents claimed that the bomoh and the hospital (cosmopolitan medicine) provided different but complementary types of treatment. Patients said that one system was preferred over another depending on the kind of illness. 17% felt the bomoh gave “better care” in general and had more concern for the patient
Table 3. Other health resources used for the same problem by patients (N = 43)
Resource
42” 370;
The utilization
OC traditional
41
medicine NunWr
Numba of intarveiwaas O-IO
5
min 1-1
Q
IO-10 min I-1
=! 2
minf
30-45
minr1
I
Motorcycle
I
Bus
5
TOW
B Z. S
45-60minIl I-it
cl
Bike
0
s2
20-30
of !ntervewees
Walk
Car
min 71
2-3
hrf]
Fig. 2. Mode of transportation
3hr+r] 15
V
Fig. 1. Time spent in travelling to see Bomoh.
than hospitals or clinics but six felt it best first to go to the clinic or hospital for an ailment and only to consult the bomohif that did not work. Figures 1 and 2 indicate the time spent travelling to see the bomoh and the mode of transportation used. Figure 3 indicates the length of time the patients felt they had had the problem. Of the 56 who answered the question regarding payments, six paid the ~~~ more, 33 paid less and 15 paid the same as they said they wouid pay eisewhere (see Table 4). The vast majority (92%) stated that they felt (or were colrvinced they would feel) better for having seen Tok Guru. The reason most often stated for this was that he made patients confident that the problem could be solved, a feeling linked to the belief that Tok Guru as a religious man had the power of Allah working through him. 28% stated that the reason for their confidence (and for feeling better) was that Tok Guru’s treatment had worked before, either for them personally or for someone they knew. Most of the interviewees who had previously used another source of help came for a physical problem, The majority (86%) of those with physical problems had already been elsewhere. whereas only 12% of those who came for help with exams, study or inter-
used to reach the Bomoh.
views had tried another source of help for that problem. About half of those with psychological problems or traditional, spirit-based illnesses had been elsewhere, but there were few such patients so that these figures were not significant. The farmers, constituting 50% of those interviewed, seemed to make greater use of Tok Guru’s services for physical problems than those of other occupations; 467; of the farmers but only 28% of all the others came for physical complaints. Only 39% of the farmers had been elsewhere for their problems, whereas 50% of the others had sought other help. Converseiy 73% bf the farmers had been to Tok Guru previously (for the same and/or different problems) whereas only 570/, of the others had had previous contact. As a group, the farmers live closer to Tok Guru than the others, a factor that might have influenced the difference. Of those who gave a pragmatic reason for going to Tok Guru, 72% were farmers and 28% nonfarmers. (Those who indicated they felt better after coming to Tok Guru because they had been cured previously, or because they knew of others who had been cured, were considered to have come for pragmatic reasons ,as opposed to those who were indefinite about why they felt better saying simpty: “he gives me hope”, or “I have faith in him”.) There is little difference between farmers and the others in the length of time they feel they have suffered their complaint.
Dumtion of problem
No response
1-1
A few days i-1 c
I week
1-1
I=
2 weeks 1-3
2 (4
weeks 1-l
I:
2 months
yaors 3~5
yecrs
1-1
0
years 1[7 25clO monlhscj a10 yeors 1
51% 1/
1
I
I
I
I
,
5
IO
I5
20
2?
Number of pottents
Fig. 3. Length of time the patient had had problem.
J
, 30
42
H. K. HECGENHOUGEN Table 4. Indicated payment to the bomok No. of patients
Amount I. 2. 3. 4. 5. 6. 7.
Nothing Don’t know “What one wants (probably M$ I)“* 50e One ringgit (Mf I) Two ringgit (MS 2) Three ringgit (M$3) More than 5 ringgit (MS 5)
8. l
2 2 23 6
21
17
I 1
USlE 1 equals 2.20 ringgits (MS 2.20).
Income, educational level (when indicated) and age (except for exam/study problems) were not indicative of the type of problem for which help was sought. 49% of the women and only 39% of the men consulted Tok Guru for study/interview problems. This ratio was reversed for physical complaints: 41% of the men but only 31% of the women had physical complaints. The duration of the problem or illness could be directly correlated to how many health resources had been used: 49% of the multiple users had had the problem for 2 months or more but only 27% of the patients who had only consulted Tok Guru had had the problem more than 2 months (Table 5). These data may be influenced by the large number of people who come for study/exams problems. However, it is not necessarily true that the concern about an exam or doing well in school is a short lived, periodic preoccupation.
areas, and I have observed bomohs in Kuala Lumpur who see more than 100 patients a day. Tok Guru may not cure all the patients who come to him, but he assists a great number of them. Those who had been to see him previously felt that they had been helped. The majority of those who had been
elsewhere had come to Tok Guru because they felt they had not been helped. This confirms observations by Reading [6] and Osman [7] that “Feeling well is as important.. as being well”. The importance of how a patient feels about a health resource is illus-
trated by cases I, III and IV in the Appendix. Tok Guru may (directly or indirectly) cure specific diseases. in addition to making the patientsfeel better. but in some cases a different kind of treatment might be preferable. Tok Guru frequently tells a patient that. although he might assist in healing certain aspects of the problem, the hospital would be the best place to cure other aspects of the illness. Despite the limited attention cosmopolitan medicine pays to the affective side of healing, it is by now fully recognized that this aspect is of great importance [6,8,9]. As a healer, Tok Guru encourages a positive feeling and religious faith, which are of curative value for psychological and for physical ailments. Research on the placebo effect and mind/body interactions explores the nature of these therapeutic processes [9:10]. Hartog noted that in Malaysia “new crises” such as school exams, the stress of some urban and professional jobs and the trauma girls suffer when they go away to school, are not dealt with by traditional institutions which provide a crises intervention system [ 111. Tok Guru handles these crises in significant proportion of his consultations. A new book by Pelletier [12] is one of numerous recent works that points to the limitations of the biomedical
DISCUSSION
Except for ethnicity, there seems to be no significant way in which those making use of the services of this bomoh can be distinguished from the rest of the population of Kedah-the home of most of the patients. Although 71% of those interviewed described themselves as rural, other bornohs are not consulted primarily by rural dwellers. Nor are bomohs a health resource used only by the most “traditional,” or ‘isolated, segments of the population. A considerable portion of the patients not only lived in urban areas but they had also lived in a number of districts. Other studies have reported the practice of homohs in urban
approach
to medical
practice:
“It is increasingly unlikely that any pharmacological panacea will resolve the fundamental issue of illness and health. Both the benefits and limitations of surgical and chemotherapeutic intervention should be acknowledged.. Researchers and clinicians now need to investigate the means of reducing stress rather than concentrate most of the effort on the disorder that is the end result” (p. 35) [12]. 92% of the people in our study indicated that they felt, or would feel, better after seeing Tok Guru. Since 86% of those with physical problems had already used other health resources (primarily cosmopolitan medicine), seeing a bomoh did not involve denying the value of cosmopolitan medicine. An illness thought to have natural causes may later be attributed to a
Table 5. Health resources used and duration of problem
Having only visited Duration of problem I month l-2 months 2 months No answer
Total
Having used other health resources (N = 43)
Tok Guru for this problem (N = 45)
I2 (28%) 7 (16%) 21 (49%) 3 (7%) 43 (10%)
22 (49%) I i (24%) 12(27%) 45 (100%)
No Response (N = 12)
The utilization of traditional medicine spirit/charm, or to a breach of udut (customs). The use of cosmopolitan medicine in this case would be
followed by resort to a bornoh. Our interviews showed that most people expect rapid, almost miraculous cures from cosmopolitan medicine. If this does not occur, they may assume that the treatment was inferior and that another cosmopolitan practitioner should be consulted or that cosmopolitan medicine is inappropriate. In the latter case the illness is reinterpreted. Table 5 indicates that patients who had had problems for a long period also consulted a wider variety of health resources.
-Survey
REFERENCES
made at the
October. 1977. 703-710, 1977. 7. Mohd. Taib Osman. The Bomoh and the practice of Malay medicine. S. E. Asian Rev. 1, 1, 16, 1976. 8. Kleinman A. et al. Culture, illness, and care-clinical
9.
Il.
Fuller T. E. The Mind Game. Witchdocrors and Psp chiarrisrs. Bantan Books. New York, 1972. David J. A. Medical practice and tribal communities. In Health artd Disease in Tribal Societies (Edited by Elliott K.). Ciba Foundation Symposium 49-New Series. Elsevier. North Holland, 1977. Jabatan Perangkaan Malaysia. 1970 Population and Housing Census. Malaysia: Volume I-General Housing Tables. Part X. Kedah. Kuala Lumpur, August. 1972. Jabatan Perangkaan Malaysia. Socioeconomic Sample
Kuala
6. Reading A. Illness and disease. Med. C/in. N. Am. 61,
use
Acknowledgements-I want to express my appreciation to Abdul Rashid bin Abdul Razak and Mahani binte Mahmud for assisting with the research referred to in this article, to Margaret Lim for assisting with the preparation of the manuscript, and to colleagues at UC-ICMR and the Division of Rural Health, Institute for Medical Research, Kuala Lumpur, for their comments. I also wish to thank Dr George de Witt, Director, Institute for Medical Research, for his support and permission to publish this article. Special thanks goes to Tok Guru Haji Aziz and to the people who so kindly agreed to be interviewed. This work was supported by grant AI-10051 (UCICMR) to the Department of Epidemiology .and International Health, School of Medicine, University of California. San Francisco. from the National Institute of Allergy and Infectious Diseases, National Institutes of Health, U.S. Public Health Service.
1967-68.
National Seminar on the Sociul and Ecological Impact and Problems of Development. Penang, Malaysia, 4-5
10.
of traditional healers is a common phenomenon in Malaysia. This study shows that those who consult these practitioners are representing the population at large. Their complaints are not primarily traditional (charms, spirit-possession, hysteria, etc.) but are physical and psychological (including anxiety due to such events as exams, study and interviews). The people who consult traditional Malay healers also use cosmopolitan health services. The longer an ailment persists, the higher the probability that people will attribute it to a supernatural cause, and thus make a bomoh the most appropriate healer to consult. Our interviews support the hypothesis that a large proporfion of the population believe that cosmopolitan medicine is a partial healing system that neglects the socio-psychological and spiritual aspects of healing. Patients stated that the bomoh was particularly adept at making people “feel better”. Feeling is pivotal in deciding which health resource to use.
of Households-Malaysia
Lumpur, June 1974. 5. Mohd. Nor b. Abd. Ghani. Remarks
CONCLUSIONS The
43
12.
lessons from anthropologic and cross cultural research. Ann. intern. Med. 88, 251, 1978. Kiev A. Magic, Faith & Healing. Free Press, Glencoe. New York, 1964. Moerman D. E. Anthropology of symbolic healing. Curr. Anthrop. 20 (1). 59. 1979. Hartog J. The intervention system for mental and social deviants in Malaysia. Sot. Sci. Med. 6, 21 I, 1972. Pelletier K. R. Mind as Healer, Mind as Slayer. Delta. New York. 1977. APPENDIX
Case I
A 27-year-old farmer travelled 30min by car to see Tok Guru. He complained of frequent tiredness, difficulty in breathing, restlessness during the evening and what he called “spasmodic asthma”. He believed the problem originated from doing too much heavy work in his rice field which gave rise to a headache, and subsequently to his present symptoms which began “a few days ago”. There are two adults and two children in his household, and the household has a monthly income of less than M$200. He had never been to Tok Guru before but had heard from his uncle that Tok Guru could cure this type of complaint. Hd had previously been to a rural health clinic as well as to a hospital and at both places he had received medicines but was not cured. The patient, came with his brother-in-law. They brought Sireh leaves, betel nuts and a bottle of clean water. He believed that Tok Guru could discern the cause of the ailment by looking at these items and that the primary means of curing came through blessing the water. He believed that Tok Guru receives guidance and healing power from Allah through a messenger or Khadam (servant). He claimed he had confidence in, and felt good about seeing the Tok Guru because his brother-in-law had been cured of the same problem. The brother-in-law indicated strong dissatisfaction with the treatment received at the hospital because (1) the patients have to wait for many hours before receiving treatment, (2) he felt the patients were not properly examined by a doctor and (3) the patients became frustrated because they had no chance to explain the problem. Because of these failures “the hospital did not provide the right prescriptions”, and the patient had not gained relief. It was “much easier to consult with Tok Guru and to express the problem”. “Tok Guru listened and showed sympathy”, and was therefore able to provide an effecti,ve cure. Case II The patient was a 22;year-old man employed as a “hostel steward” and living at the outskirts of the state capital of Alor Star. He travelled 20min by bus
44
H. K. HEGGEXHOUGEN
to Tok Guru. He came alone. He had always lived at his current address. a household that currently contained five people. His complaint was “difficulty in breathing” which he “suspected to be TB”. He had had symptoms for 10 months. He not only believed that his ailment was the result of “long hours of work in the padi fields” and “lack of rest” but that it might also be due to the fact that he “often attended Koran reading competitions and weddings” making others jealous, wanting to charm him. He had not been to the homoh previously but for his current ailment he had gone to a rural clinic, to a hospital and to a private physician. He was advised by the government clinic to receive treatment there on a regular basis. He felt that he was helped by the clinic treatment, but he visited Tok Guru to make sure that he was not charmed. He knew people who had chest pains and had been advised by a doctor to have surgery, but who had rejected this advice and had been cured by the homoh. He also knew of a baby that had difficulty urinating and was unsuccessfully treated by doctors but “successfully treated by Tok Guru”. He felt that the difference between “hospital medicine and bomoh medicine” was that the hospital “diagnoses with modern medicine” and the bomoh “relies on the blessings of Allah”. He believes, however, that this Tok Guru is different from other bomohs because he does not go into trance and is not associated with any hantus (spirits). He is an exemplary muslim who believes in the verses of the Koran. Tok Guru told the patient that he was not charmed but that he might possibly have tuberculosis. (He told the patient, after examining his hands and tongue, that those who have, or might have tuberculosis have a whitish tongue or have a white spot on their tongue.) Tok Guru told him not to worry and strongly advised him to continue the treatment from the clinic. Case III The patient was a 20-year-old woman with a “hole in the heart”. The person we interviewed was a teacher and a friend of the woman’s father. The father and the interviewee came with the patient and her mother to seek Tok Guru’s help. They travelled almost 2 hr by car from their home in a rural village in the state of Perlis. Apparently the patient had the problem since childhood but only started complaining about it during the past several years. The friend had been to the bomoh previously in order to get a winning lottery number, but the bomoh refused to be concerned about such things and did not attempt to help him. The patient had been to the hospital several times for the problem, but the father was seeking Tok Guru’s help so that his daughter wouldn’t “be dejected”. He hoped that “through the blessing of the water” she would no longer be afraid that she would die. The father had been told by the hospital doctor that the patient had little chance of surviving and that further treatment was useless. The interviewee felt that the hospital might have given inadequate treatment to the patient, and was critical of the fact that the patient had been left with no hope.
The father felt better after going to the homoh because Tok Guru had a reputation as a religious man who receives power to heal from Allah. The father hoped his daughter would recover. and expected that she would also be hopeful. The interviewee stated that most village people were quite reluctant to go to the hospital because of the “rough and ungentle way they were treated by the nurses and doctors” which “sometime made them feel worse than did the illness for which they had come”. The teacher felt that “it is their feelings that should be taken care of first rather than the illness (disease)“. He felt that the lack of attention to “human feeling” was the reason many Malays go directly to the homoh or go to the homoh even though they have been to the hospital. because the homoh can “ease out their worry”.
Case II/ A 21-year-old air force officer with a high school education travelled alone 45 min by bus from the state capital to Alor Star to see Tok Guru about reducing his nervousness and fear of flying. He had consulted Tok Guru earlier about an examination which he passed “because of the bomoh’s help”. He had not gone elsewhere for help with his present problem. He felt that the difference between “hospital medicine” and the homoh was that the former operated on a “scientific basis” and the latter within a spiritual realm. He felt that the bomoh received special powers from his ancestors and through his pilgrimage to Mecca. The patient said he had faith in Tok Guru’s prayer on his behalf-and “felt good” as a result of seeing Tok Guru. Case V The patient was a 3 l-year-old married teacher, with no children and an income of around MS600 a month. He spent close to an hour coming alone by car from his home in one of the larger towns of Kedah. He came to see Tok Guru because his house had been burgled twice, but he was particularly concerned that someone might be trying to charm him. During each burglary one of his old shirts had been stolen. Although the thief had taken a number of things, he had not taken the newer clothes, but only an old sports shirt that the patient feared was being used to charm him. He had been to Tok Guru before and he also had a friend who was “receiving protection against harm” from the Tok Guru after someone robbed him three times, each time stealing an old shirt and his wife’s bras. He felt that by incantations and “blessing of the water” the bomoh could help him. The teacher told about a convict who escaped from a police station. The officer in charge came to Tok Guru for assistance and was told that Tok Guru would try to “darken the convict’s vision” so that he would feel badly about escaping and would give himself up within 3 days time, “which is exactly what happened”.