Traditional medicine in contemporary Ghana: A public policy analysis

~ Pergamon

Soc. Sci. Med. Vol. 45, No. 7, pp. 1065--1074, 1997

PII: S0277-9536(97)00034-8

~" 1997 ElsevierScience Ltd. All rights reserved Printed in Great Britain 0277-9536/97 $17.00 + 0.00

T R A D I T I O N A L M E D I C I N E IN C O N T E M P O R A R Y G H A N A : A P U B L I C POLICY ANALYSIS K O M L A TSEY Menzies School of Health Research, P.O. Box 8569, Alice Springs, NT 0871, Australia Abstract--Discourses on the future of traditional medicine in Africa and other indigenous societies often assume government recognition and integration into the formal health care systems. There is very little attempt, however, to understand the contexts in which the knowledge and practice of traditional medicine are currently reproduced, let alone the social, economic and cultural factors that determine consumer choices. Based on the participant observation combined with in-depth interview method, a longitudinal study was designed to determine the longer term trends in the reproduction of the knowledge and practice of traditional medicine in contemporary Ghana. This preliminary report covers: socio-economic conditions of the typical village practitioner; their belief systems and how that affects practise orientation; and perceptions as to whether traditional medicine could be taught and practised as part of the formal health care sector. This paper highlights some of the key issues which policymakers may wish to explore with regard to the future of traditional medicine in Ghana and other African countries. These include: the role of "spiritually based" traditional practitioners in the provision of care, especially for people with mental health and other psychosocial problems; professional relationships between the biomedically trained and the traditional practitioner, particularly with regards to policies aimed at integrating traditional medicine into the formal health sector; equity of access, given that efforts to "'control" the quality of herbal preparations through biomedical research can dramatically alter costs, thereby undermining ease of access normally associated with traditional medicine; a need to re-examine underlining reasons for the current popularity of traditional medicine in Ghana and other African countries, given the fact that the introduction of user pay services may be forcing the poor to sometimes turn to obsolete therapeutic practices in the name of "traditional medicine": and potential public health benefits accruing from better understanding of traditional African notions of illness causation and preventative health. ,~i' 1997 Elsevier Science Ltd Key words--traditional medicine, knowledge reproduction, health care systems, unequal access, public

policy, Ghana

INTRODUCTION This is a preliminary report on what is intended to be a longitudinal analysis of trends in the reproduction of the knowledge and practice of traditional medicine in contemporary Ghana. The objective of the study is to find out how traditional medicinal knowledge is currently reproduced or transmitted from one generation to another and the social contexts within which the practice occurs. The rationale is to (1) ascertain the extent to which knowledge about traditional medicine could be taught as part of Western-based medical or health curricula, and (2) explore some of the implications of current policies in Africa aimed at incorporating traditional medicine into the formal health care sectors for millions of African village healers. The study is partly motivated by the recent worldwide resurgence of interest in traditional medicine and indigenous knowledge systems in general and the almost taken for granted assumption that the future of the trade is dependent on government recognition and incorporation into the formal health sectors (WHO, 1978; Jingfeng, 1987; Launs, 1989;

Chavanduka. 1994; Chi, 1994; Rubens et al., 1995; Freeman and Motsei, 1992; Upvall, 1992). In Ghana, as in most African countries, the rising cost of Western medicine means that individuals and, to a lesser extent, governments are increasingly turning to traditional medicine as an affordable alternative (Short and Tsey, 1992). In Ghana, even the most casual observer would be struck by the amount of time and energy that the media (both the government-owned and private), academic seminars and conferences, and Ministry of Health policy documents and reports devote to discussions and debates about the future of traditional medicine. Traditional medicine is also being actively promoted by the World Health Organisation and other international agencies throughout the Third World (WHO, 1978; Leslie, 1980; Jingfeng, 1987; Launs, 1989; Chavanduka, 1994). For indigenous people in developed countries such as Aboriginal Australians and the Maori in New Zealand, resurgence of interest in traditional medicine is part of the anti-colonial struggle and pride in cultural identity (Brady, 1995). A fundamental assumption underpinning the discourses on traditional medicine in Ghana and elsewhere is the view that the trade should be

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taught and practised as part of formal health care sectors (Tamakloe, 1995; Sarpong, 1995; Neequaye, 1995). Thus, following the examples of other African countries, such as Zimbabwe, Ghana is about to introduce a postgraduate diploma course in traditional medicine at its premier medical school at Korle Bu to formally train doctors and other health professionals in traditional medicine. While discourses on the future of traditional medicine in Ghana increasingly assume integration into the formal health care systems to be a fait accompli, very little attempt is being made to understand the social contexts in which knowledge about traditional medicine is passed on from one generation to another in contemporary Ghana, especially at the village level where three-quarters of the population still live, and the possible impacts that such policies might have upon the lives of the countless of ordinary village practitioners whose main source of monetary (as distinct from subsistence) income remains traditional medicine. This study hopes to explore the nature and contexts of the reproduction of traditional medicinal knowledge and practices in Botoku, a small village in the southeastern part of Ghana, with the aim of generating some of the much needed baseline data for informed policy-making about the future of traditional medicine in Ghana, and possibly in other indigenous societies. STUDY CONTEXT

Between December 1994 and February 1995, I carried out the first stage of the study. I had originally arranged to interview all 16 members of the Botoku Branch of the Traditional Healers Association, though I only managed to interview 12. Membership of the association which is loosely defined to include community- and/or self-identified healers does not, however, reflect the actual number of practitioners in the community. I was told that many people are reluctant to join partly because of the membership fee requirement and partly too because of the fear of government control and regulation. The selection of Botoku for the study location was purely pragmatic. I grew up in Botoku myself where most of my relatives still live. My knowledge of the place included knowing virtually all the local practitioners (some of whom are related to me). Being part of the community, I was able to conduct a fairly intensive study on a topic as complex as traditional medicine within a relatively short period and at minimal cost. I was aware that being part of the community could have its own draw backs as well, such as respondents giving me answers they think I would like to hear or being more sensitive about discussing particular local issues with me. On the other hand, being part of the community also gave me the opportunity to cross-check evidence

from a much wider source, including unsolicited ones. Indeed, the very possibility of a researcher with local knowledge and familial connections being able to cross-check evidence in this way could have the effect of minimising the tendency among respondents to withhold information. The study was designed to take account of these and other issues. The approach was participant observation combined with indepth, often multiple, interviews. I conducted and recorded all the interviews in Ewe. The verbatim responses were then translated into English prior to contextual analysis. Two responses were randomly selected and translated back to the relevant respondents by an independent linguist. The aim was to ensure the reliability of the translations. The participant observation included, for example, close monitoring of individual practices of three of the respondents over one-week periods, making sure that I witnessed and documented all consultations, treatment decisions, fees and other forms of charges, and the whole context within which traditional medicinal practice occurred including the role of trainees. I found little evidence to suggest that being part of the community posed any major difficulties for the study. On the contrary, many participants were rather enthusiastic to talk to me and to show me diverse aspects of their work. Several of them admitted to me independently that they were pleasantly surprised at my interest in their work, had enjoyed talking about it, and would like me to continue the documentation for the benefit of future generations. I also talked with policy-makers at the Ministry of Health; visited the Centre for Scientific Research into Herbal Medicine, the leading institute researching into traditional medicine in Ghana; as well as took advantage of an unplanned interaction with the hospital system when a client of one of my informants had to be evacuated to the regional hospital at Ho to obtain further insights into the topic. What follows are some of the preliminary findings of the study. BACKGROUND

Botoku is a small village some 200 km northeast of Accra near Kpandu in the Volta Region of Ghana which supplements subsistence farming and fishing with trade. One-third of its approximately 2000 members live and work outside the village. Nonetheless, these "non-resident" citizens remain attached to the village throughout their lives and their remains will eventually be buried on village grounds when they die. The "non-residents" are made up of professionals, public servants, traders, migrant labourers and the urban unemployed. Traditional village obligations including funerals, festivals and community development initiatives meant that the average "non-resident" is most likely to return to the village every four to eight weeks. Although a remote community, Botoku '~residents"

Traditional medicine in contemporary Ghana are thus generally abreast with ideas and developments emanating from the urban centres. This is typical of most Ghanaian villages (Tsey et al., 1995). The tradition of community development in Botoku has given rise to a parallel power structure at the village level. On the one hand, hereditary traditional chieftaincy administers issues relating to customs and traditions. On the other hand, the "non-resident'" dominated Development Association, a non-remunerated elective body, is responsible for "modernising" the village. Despite occasional tensions, the two bodies complement each other; the chiefs and elders provide the necessary authority and legitimacy to enforce decisions made by the association. Since Ghana's independence from the British in 1957, the development association has successfully undertaken a range of projects including: two day care nurseries, two primary schools and a junior secondary school; a 12 km dirt road linking the village with the A c c r a - K p a n d u road; a hand pump water system; and a clinic staffed by two community nurses. As in most rural communities in Ghana, these facilities were all built with communal labour provided by "residents", material support from government, and levies and financial donations from "non-residents" (Tsey, 1980; Tsey et al., 1995). A significant proportion of the "resident" citizens also spend a great deal of their time on farms and fishing hamlets located some 6-10 km away from the village in the Volta basin to the west, and along the river Dayi which lies to the east of the village. As the only form of transport linking these hamlets to the village is by foot, access to health care, especially emergency care (both traditional and from the clinic), for such remote dwellers could be extremely difficult. While motor transport is available from the village to Kpandu, a distance of 35 km. where the nearest hospital with a resident doctor is available, the costs to the patient in terms of transport, drugs and, indeed, the whole logistics of such a trip could be daunting for many "residents". PRELIMINARY FINDINGS

Six of the practitioners I interviewed were men while the other six were women. Their age ranged from the mid 30s to the mid 70s with the median age being the mid 50s. O f the 12 people interviewed, four could read and write and these, incidentally, include the youngest and the oldest. N o n e of the informants considered or practised traditional healing as a full-time occupation, though the amount of time individuals devoted to their practice varied widely. These ranged from the equivalent of two to four days per week, including weekends. All the practitioners were engaged in some amount of farming and/or trade to supplement income from traditional healing. Overall, gender is not a

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significant determinant of one's ability to practise traditional medicine. There are three avenues to becoming a practitioner. The first is through informal learning from a close family member. All informants had acquired knowledge of a range of common therapies by the time of puberty which is still the case for most children in the village today. Stories such as "whenever my father sees a plant in the bush he will ask mc 'do you know the name' and if I said no then he will call the name and tell me how it is used.., he will repeat this on several occasions just to make sure I keep it in my head" are common. Of the 12 informants, three became practitioners in their own right through this type of informal learning only. The second route is through formal apprenticeship under an established practitioner. Four respondents served formal internships one time or the other before becoming independent practitioners. This process usually involved taking trips to the bush to learn to recognise plants and their uses; preparation of herbs and other concoctions; and treatment and "looking after" patients. Trainees pay a set amount as well as other payments in the form of drinks, fowls or sheep to the trainer on graduation. Of the four who became practitioners after serving apprenticeships, two were taught by family members while the other two learnt from "strangers". The third avenue is through spiritual "calling". Five informants said they became practitioners through "'calling" and that their diagnoses and treatment processes are all determined by the supernatural. While there is more than one avenue to becoming a practitioner, the categorisation of practitioners on the bases of whether their trade is "spiritually based" or "non-spiritually based" provides a more useful analytical tool for understanding the world view and practice orientation of the individual practitioner. In terms of reasons given by the informants for entering their trades (motivation), all five who said they had a "call" also maintain that the "call" was the motivating factor and that without it they would not be practising. Without exception they all provided vivid accounts of how they became healers. One person said: ...healing is in the family...but mine is spirit possession. In the beginning it was like "adava" (madness)... I saw things and I was violent when people tried to talk to me. One day I had a visitor, a strange person, l cannot give you any more description about how this person looks... It will be like showing our nakedness in public. The visitor gave me a calabash and some cowry shells and said they (the deities) would like me to be their steward to heal and help people... They gave me detailed directions about how to communicate with them and they gave me the names of people in the village who will supply me with the items to start my work; ...is one of those people you can ask him. After that they came for me and took me into the forest several times, sometimes I stayed for three to seven days without food and they showed me all the plants that I can use to treat people.., even now as soon as the person comes with a problem the first thing 1 do is

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to call them (the deities) to find out what is wrong before we can do anything... The music makes them respond quicker By contrast the seven "non-spiritually based" informants tend to offer more "worldly" or what one can term "rational" explanations with regards to their decisions to become practitioners. Three people said that they learnt their trades as patients undergoing treatment and, on recovery, decided to become practitioners themselves so that others could benefit from their knowledge while the reasons given by the other four included a mixture of family tradition and/or economic imperatives. One of them explained: ...both my mother and father were herbalists and I started learning from them when 1 was in primary school... My father was a civil servant but he also practised herbal medicine... His medicines were popular everywhere he worked... When I finished school I wanted to go to technical college but my parents did not have money to send me so they advised me to learn this trade... They said that I could make a living out of it. But I was keen to go to the technical school so I worked as a labourer and looked after myself... I did electrical. When I finished I realised there were no jobs so I came back home... We didn't even have electricity in the village and here I was saying that I was an electrician (he laughs)... I started a small farm and also treated a few people for asthma and other things, not seriously... One day your father (this researcher's) called me and said to me "everybody is talking about your medicines... It is in the family...why don't you consider taking it seriously while you wait for the electricity to come to the village" (laughs again)... We are still waiting for the electricity...now I am happy with this work and I make enough to live... It is important to note that both the "spiritually based" and the "non-spiritually based" practitioners use herbs, roots and other animal products for treatment; the main difference between the two types of practitioners is the belief systems. The "non-spiritually based" practitioner tends to look upon their healing plants for what they are, increasingly like the biomedical approach. The "spiritually based" practitioner, on the other hand, believes that you cannot treat the illness without adequately dealing with the "spiritual" factors which ultimately account for all illnesses and other human misfortunes (Geest, 1991: Ngokwey, 1994; Bierlich, 1995). O f course, this distinction is not entirely cut and dry. Even for the "non-spiritually based" practitioner, there is a tendency to look beyond the physical treatment of illness by stipulating, for example, a number of requirements such as abstaining from particular types of food, alcohol, or sex during and/or after treatment. Moreover, the "nonspiritually based" practitioner also believes that there is generally a spiritual explanation for most illnesses. A related issue is the range and diversity of "spiritually based" practitioners. The evidence from Botoku suggests at least three categories of "spiritually based" practitioners. These include: those who claim to work with bo, ama, or dzo (i.e.

supernatural prowess deriving from the ability to manipulate the spirit world, both benevolent and malevolent, to one's own end); togbewo (i.e. those whose spirituality derive from the ancestors); and kristo or those working through a variety of christian traditions. For the purpose of our analysis, however, the two broad categories of "spiritually based" versus "non-spiritually based" will apply. In the absence of systematic interviews with trainees, it is difficult at this point to determine trends in the contexts of traditional medicinal knowledge reproduction and practice from one generation to another. All respondents have trained someone who became a practitioner, and at the time of the interviews, eight practitioners had trainees, the number of trainees per practitioner ranging from one to six. It is significant to note, however, that the few trainees I talked to gave remarkably similar reasons as their trainers for learning to become healers: " I ' m learning as a patient so when I'm well I can help others suffering from koko (piles) and other problems"; "it is in the family"; and "I can make a living this way". These trainees will be followed in the longitudinal analysis to determine the longer term trends in the reproduction of traditional medicinal knowledge. Generally a practitioner started as an itinerant healer, embarking on regular trips of up to three to four weeks at a time to sell herbal concoctions and to treat people. After a proven track record through this process, "word of m o u t h " takes over so that the practitioner now becomes more settled at one place. F r o m then onwards, it is the task of the client to seek out the practitioner, the latter only taking ad hoc trips to attend to special cases. Although the road to becoming an independent practitioner could thus be tough, the results could also be rewarding: it is difficult work, going from one town to another and staying with people you don't know but once they get to know your medicine they tell people and they all come to you...if you don't do it this way the only people who will come to you will be your families in this village... It is difficult to take money from your families. A practitioner normally treated a range of illnesses. All the informants said they treated asra, a term used loosely among the Ewe to describe a variety of fevers, jaundice and malarial attacks. Epilepsy, boils, pile, asthma, menstrual pain, snake bites and infertility were the other conditions frequently mentioned. Others less frequently mentioned were: hypertension, a variety of mental and psychological disorders; spirit possession; and tukpoe, a mystical gun believed by the Ewe to be capable of causing bodily pains which can only be cured by mysteriously removing physical objects such as pebbles, metals and animal bones from the victim's body. There was a tendency towards specialisation with most participants mentioning one or two illnesses as their main specialities. It is

Traditional medicine in contemporary Ghana significant to note that none of the "non-spiritually based" practitioners specialised or treated any type of mental or psychosocial related illnesses, these areas being generally acknowledged as the "preserve" of the "spiritually based" practitioner. Only one person, specialising in asthma, said he treated "'cough" and "chest pain". Diarrhoea was not mentioned at all. The absence of water and airborne related illnesses such as diarrhoea or respiratory infections from the lists of illnesses treated aroused my curiosity because, as in other parts of the country, these illnesses are common. Further investigation revealed an interesting aspect of the community's perception of traditional medicine vish-vis Western-type health care. Two respondents felt that mothers generally preferred to take their children to the clinic for diarrhoea while another said "the cough mixture from the clinic works faster". In fact, the one asthma specialist who treated "cough" and "chest pain" also admitted that he sometimes prescribed "cough mixture" to supplement the herbal treatment. (In Ghana, like most Third World countries, drugs, including classified ones, are all freely available across the counter without doctors' prescriptions.) A community nurse, while confirming diarrhoea, malaria and respiratory infections to be the most frequent problems seen in the local clinic said, "they know what problems to bring to us...the only thing is that some of them wait for too long before coming". Among the informants, notions of illness causation spans both the physical and the spiritual domains. One person said asthma was caused by "too much crying as a child" while another person felt that the common West African practice of carrying babies on the back could cause asthma, especially if strenuous tasks were performed when the baby was still young. Asthma among adults could be caused by "damage to the lung as a result of dangerous work". Infertility among women was caused by alele (Ewe) or anidani (Akan), "a living thing in the w o m b . . . c a n be natural or caused by witches... The medicine can make the woman 'born' it like a baby is born; after this the woman can have a baby". Adava or madness is caused by evil spirits which "make the brain hot and overworking". Marijuana, too, can cause mental illness, especially among the youth. While there is interest in illness causation, the task of the practitioner is not always to diagnose: "the patient says exactly what is wrong.., our task is to cure" and sometimes treatment is believed to be possible even when there is no physiological explanation for an illness: "even if we don't know why a particular part of the body is causing pain we can still cure". For some, diagnosis and treatments are all spiritually determined: " . . . a s soon as the person comes with a problem the first thing I do is to call them (deities) to find out what is wrong before we can do anything..." Or "if

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Modzidede (to find out from the deities the cause of an illness) is required they (deities) charge two bottles akpeteshie (a type of local gin) and four cowry shells which we take outside the village to pour libation before we can start..." But for others, too, if diagnosis is impossible, the patient is advised to try the hospital: "if I don't know what is wrong with the person then I tell the family to try the hospital". On average a practitioner saw between three and five "new" cases per week. This does not, however, imply that for the rest of the week the practitioner was free to do other things. On the contrary, once treatment commence the client remained under the "care" of the practitioner even long after active treatment is complete, a period which can take up to one to two years. This meant that at any given time a practitioner had several clients attached to them, clients being classified either as under "'treatment" or under "care" depending on their conditions. At the time of the interview, the combined number of people under "treatment" and "'care" per practitioner ranged from 10 to 30. This could make the life of some practitioners busy as some of them have clients distributed over a 300 km radius (which in Ghana is not at all easy to cover due to transportation difficulties). Another important factor about traditional medicinal practice in the village relates to "residential'" care. Only three practitioners offered "residential" care for their clients. This normally involves the patient and the carer(s) moving in to live as part of the practitioner's extended family. One of these "residential" facilities had seven clients, another had five while the third one had three. Two important points need to be made about these residential facilities. The first one is that all three facilities are provided by "'spiritually based" practices. None of the "non-spiritually based" practitioners had a residential facility. But even more importantly is the fact that a large proportion of the "residential" care patients are mental health and other psychosocial cases. As noted, treatment of these types of illnesses is generally regarded by the community as the preserve of the "spiritually based" practitioner. It is also interesting to note that mental health and psychosocial problems are probably some of the conditions that the Ghanaian Western-type health care system is least equipped to address. Over the years, many informants have seen the types and methods of payments for traditional medicinal care change. "It used to be token payments and the person comes to "thank you" after recovery". But changes in the cost of living, coupled with introduction of licence fees meant that practitioners are increasingly demanding monetary payments for their services--though, significantly, capacity to pay remains an important element in the fee structures. Thus, "for asthma, I can charge from CI0,000 to C50,000 (CI000 = U.S.$1 at the time of research in

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1994) depending on how much the person can pay" and "there are different charges for different people depending on circumstances". For "spiritually based" practices the charges tend to be a combination of monetary and other forms of payments in kind: "For Atamkaka (to take an oath) the charge is two bottles of spirits; kola nuts, four when the person is a woman and three for a man; and C5000" and " . . . i t costs two bottles of spirits; two fowls and C3000 for Gudede (to undo a taboo). Nukaka (divination) is one bottle spirits, kola nuts and C1500". Generally, though, the patient is required to make only a small down payment prior to commencement of treatment, the bulk of the charges being paid during treatment and upon recovery from the illness. The highest income per week reported by a practitioner was C16,000 and the lowest was C5000, the median self reported income being C11,000. The average wage in Ghana at the time of this research in 1994 was about C70,000 per month or about C17,000 per week which means that only the highest income village practitioner is able to earn anything near the national average wage. It is true that income from traditional medicine normally supplements small scale farming and trade. Nonetheless, given the relatively high costs of many essential imports in Ghana, such as petroleum products for lanterns and transportation, clothes, educational materials and Western-type health care, all of which consume a high proportion of the monetary income of the rural dweller, the material condition of the average village practitioner is far from rosy. There is a general perception of traditional medicine as a trade from which to "make a living". All practitioners, both "spiritually" and "non-spiritually based" agree on this point. Thus, with regards to the future of their practise, issues such as "reputation", "doing the right thing by clients", "good health and strength", "to earn enough to look after my family" and "respect and recognition for our work" were some of the most frequently mentioned by the respondents. More concrete plans include: " . . . t o make an extension to this living place so my clients can be comfortable", "I need shelter on my own compound where I can keep an eye on the people I am looking after", "we need the government to help us" and "on every trip I make about C20,000...if the government gives me a small loan l can pay b a c k . . . " The view that government was not doing enough to support traditional medicine was a widely held one. As one person cynically explained: "we have an association but the only 'benefit' we get is to pay licence fees to the government" while another lamented, " . . . t h e government has set aside occasions to honour farmers, fishermen, teachers, traders . . . b u t there is no recognition for us". With regard to whether traditional medicine could be taught in a formal curriculum, "non-spiri-

tually based" practitioners generally believed that their trades could be taught at college because the most important requirement was to be able to recognise and know the uses of plants, though several of them still had some reservations. Comments such as "this is the way we have always learnt" and "I am not sure hospital people can do it our way" were common. By contrast, all the "spiritually based" practitioners were emphatic that it was neither possible to teach nor practise their trade within the formal health care sector: "mine is through 'calling' and without it you cannot be a healer" and "never, never, they don't go together". Again, it is interesting to note that "spiritually based" medicinal practice is the aspect of traditional medicine in Ghana that has so far failed to receive any systematic attention in government initiatives aimed at incorporating traditional practices into the formal health sector. What l have tried to do so far is to describe the contexts of traditional medicinal practice in one small community in Ghana including, the profile of the practitioners, motivation and avenues to becoming a practitioner, the belief systems of practitioners and how that affects practise orientation. Other issues raised include types of diseases treated, perceptions about efficacy of traditional medicine vis-dvis Western-type health care with regards to particular illnesses, notions of illness causation, income from medicinal practice and perceptions about whether traditional medicine could be taught and practised within the formal health sector. The rest of the paper consists of three case studies analysing in a much greater detail some of the issues raised. The aim is to locate the study within the wider Ghanaian public health policy context.

Case stud), 1: "scientific" research into herbal medicine in Ghana The Centre for Scientific Research into Herbal Medicine is located at Mampong, less than an hour's drive east of Accra. This large research facility, housed in a one-story complex in the serene environment of the Akwapim range, started in 1972 through the private initiative of a dedicated Ghanaian biomedical scientist, Dr Oku Ampofo. Two years of intensive lobbying led to the Ghana Government officially taking over and making the Centre a publicly funded institution for research into herbal medicine. Members of the governing council of the Centre now include representatives from the Ghana Medical School, Korle Bu and School of Pharmacy in Kumasi, traditional herbal practitioners, doctors and people with special interests in herbal medicine while the staff are made up of medical practitioners, biochemists, botanists and other research scientists. All employees are Ghanaian. As the name itself suggests, the Centre's activities have focused primarily on "biochemical

Traditional medicine in contemporary Ghana and pharmacological analysis of medicinal plants" with the aim of establishing treatment efficacy. Identification of medicinal plants started from the late 1970 s when leading herbalists throughout the country were approached for samples, an exercise which yielded a total of 730 plant samples now preserved in the Centre's herbarium. So far efficacy for 30% of these plants have been established through trials on guinea pigs, mice and on humans, according to the Centre's director, Professor Tackie. The Centre runs a busy clinic with three doctors seeing over 100 patients a day. Both Western and herbal treatments are available in the clinic and patients have the opportunity to opt for either of them or a combination of the two, depending on interest and capacity to pay. The Centre is located next door to the Tetteh Quarshie Memorial Hospital a hospital named after the Ghanaian migrant labourer believed to have introduced cocoa to Ghana from the Atlantic Ocean island of Fernando Po in the 1870 s. The two institutions maintain a close working relationship including a two-way referral system. The Centre also maintains a ward at the hospital next door where patients on herbal treatment are admitted and monitored. The Centre specialises in lifestyle diseases, especially hypertension, diabetes and arthritis. Malaria and premenstrual pain are also specialities. Medicinal farms have been developed throughout the country including a five-acre plot immediately adjacent to the Centre itself. Although there is a growing interest from European and North American drug companies in the activities of the Centre the official policy so far has been one of caution. This is a very good illustration of an attempt to "modernise'" and incorporate traditional herbal knowledge and treatment into the formal health sector. Several points can be made about this case study though we shall limit ourselves only to three. Firstly, there seems to have been very little contact with traditional herbalists once the original samples were collected. Whilst lack of resources may hinder any genuine attempts to collaborate on an even footing, it is also true that the social context of the Centre's activities is simply beyond the world view of the traditional herbalist. Clearly, there is a danger of the Western trained Ghanaian biomedical scientist appropriating intellectual property from the herbalist without a corresponding benefit to the latter in the form of results from clinical trials or financial returns accruing from possible commercial exploitation of medicinal plants. It is possible to argue that herbal medicine ought to be seen as a "public good". Whilst this may be true of the large majority of folk treatments, the fact remains that renowned herbalists have traditionally guarded their knowledge and skills in great secrecy. Be that as it may, issues relating to professional relationships and intellectual property rights remain legitimate concerns which any attempts to integrate traditional

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medicine into the formal sector would have to address. Another problem about incorporating herbal medicine into the formal health system is the tendency for the product to become more expensive. In the case of the Centre for Scientific Research into Herbal Medicine, attempts to control the quality of herbal preparations through clinical trials and other biomedical research meant that the costs of the final products have risen well beyond the means of many ordinary people, thereby undermining easc of access normally associated with traditional medicine. Clearly, it is important that the poor does not become doubly disadvantaged in terms of lack access to Western-type care as well as traditional medicine administered by the formal health system. Thirdly, there is a noticeable similarity in the activities of the Centre and those of the "non-spiritually based" village practitioners. They both focus on "herbal" treatment of physical illnesses. Indeed, the evidence from Ghana suggests that attempts to incorporate traditional medicine into the formal sector has so far been limited to "non-spiritual based" type practices. The "spiritually based" practices simply do not seem to have a role or are perceived not to be able to sit comfortably within the essentially "rational" environment of the formal health care sector. But as we have noted in the case of mental health and other psychosocial problems, it is precisely the "spiritually based" practitioner which alone provides the majority of Ghanaians with a much needed specialist service in this area. Several examples of these types of indigenous mental health treatment facilities exist across the country. Clearly, the role of "spiritually based" type traditional medicine, especially with regards to addressing psychosocial related illnesses, is an area that requires more exploration and informed policy initiatives. Case study 2." "the), only come as a last resort when everything has failed them... I don't blame them, it is the astronomical costs of drugs that is preventing them" The second case study relates to an indirect interaction I had with the hospital system when a client of one of the practitioners I was studying had to be evacuated to the hospital. The case involved a 20year-old young man who was being treated for a boil on the buttock. The boil was diagnosed to be dzudoe, euphemistically referred to by the Ewe as hemakee, meaning "the one that knife does not touch". Herbal treatment is the only traditionally known remedy and there are usually scores of different treatment regimens in every village. Many dzudzoe sufferers are believed to have died in the hands of "ignorant" doctors who attempted incision on dzudzoe and so hospital treatment is generally frowned upon.

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It had been exactly eight days since the boil developed. Since then the young man had swollen from the waist downwards and was unable to eat for nearly seven days. Half the body was completely paralysed. Apart from the herbal treatment he was receiving, a member of an African charismatic church had also been praying for the patient in the evenings. This latter person had also prescribed antibiotics and vitamins for him. He was looking very dehydrated, weak and had lost a lot of weight. Every single discussion regarding the young man's condition that I had listened to automatically assumed that hospital treatment was strictly out of the question. I was therefore greatly surprised when on the way back from one of our early morning visits to the patient my respondent asked me whether I could do him a favour by taking the young man to hospital in my friend's car which I had been using that week. Nevertheless, I willingly agreed and a few hours later I arrived at the Ho Hospital with the patient and the carers. We hardly arrived at the hospital when the cultural conflict between herbal and hospital medicine came into a sharp focus. The nurse taking the blood pressure and temperature decided that the herbal medication on the body had to be washed away before the patient could see the doctor otherwise "the doctor will just send you away"--only reluctantly allowing us to see the doctor upon my intervention. Whilst the doctor did not "send us away" he was certainly scornful of the tendency among patients to seek hospital treatment only as a last resort, though he also admitted that relatively high cost of treatment was to blame. As the doctor retorted in frustration, "they only come to the hospital as a last resort when everything has failed them", adding that "I don't blame them, it is the astronomical costs of drugs that is preventing them". In Ghana the direct cost to the consumer of Western-type health care can be high. Under a cost sharing arrangement the government is responsible for hospital infrastructure and the costs of medical and nursing services whilst the patient pays for drugs, food and other consumables. In the case of this young man, the total bill for a two-week admission at the hospital amounted to C70,000 or the equivalent of US$70 which is roughly the average monthly wage in Ghana. A senior nursing sister in charge of the ward said to me, "we provide nothing but we demand that you have everything, and we insist on it". Clearly, only a few people in Ghana could afford Western-type health care. This point was brought home to me vividly when several days after the young man had returned from the hospital my respondent decided to explain to me the reasons he recommended hospital treatment for a boil which everybody had apparently agreed was dzudzoe. He said that as a practitioner he was often aware of when to recommend alternative therapy but generally refrained from doing so unless he was

sufficiently convinced that the patient's family had the means to access the options being recommended. The rationale, he further explained, is twofold. One was to prevent people feeling guilty that they could have done something better for the sick person when in actual fact they simply do not have the means to do so. The second was to provide a therapeutic sense of hope for the patient and the family "even to the last end". In this particular case, the practitioner was prepared to invoke the Ewe construction of dzudzoe, a "non-hospital illness", as a means of reassuring the patient and the family in the absence of the material means to access hospital care. What this case study shows is that in Ghana both patients and traditional medicinal practitioners are generally aware of the various health care options available and would normally make rational choices about the type of care to access in particular situations if given the opportunity. As the village practitioner who treated chest pain and cough said: "the cough mixture works better". This is a positive attitude which a healthy public policy ought to promote. As the community nurse had also commented about attendance at the village clinic, "they know what problems to bring to us... the only thing is that some of them wait for too long before coming". In response to my query why some people waited for "too long" before coming to the clinic, the nurse said: "some people think it is just a small thing and it will go away; for others too it is the money.., it used to be free but now they have to pay for all the medicines". Clearly, one of the problems about current user pay services in Ghana is the tendency to force the poor to hold on to some therapeutic traditions that they might otherwise have considered obsolete. Case study 3." busu mebla eta haft va gbome o, meaning "'a bad spirit does not forewarn o f its arrival"

The final case study relates to beliefs about illness causation. As noted, both the "spiritually" and the "non-spiritually based" practitioner generally believe that there is ultimately a spiritual explanation for every human misfortune including illness. So strong was this belief that the individual was almost portrayed as a hapless victim in the hands of jealous neighbours and malevolent spirits--a phenomenon that has been widely documented elsewhere in Africa (Geest, 1991: Ngokwey, 1994; Bierlich, 1995). A notion of illness causation that appeared to leave no scope for individual and/or community responsibility naturally aroused my curiosity. Further investigation into the subject provides an interesting insight into what one can call traditional Ewe ideas of preventative health. Belief in spiritual causation of illness, many respondents cautioned, should not imply that the individual or the community is a mere puppet in the hands of the gods. On

Traditional medicine in contemporary Ghana the contrary, the very existence of jealous neighbours and malevolent spirits literally hovering round our physical domain, ready to take advantage of any signs of slackness or human failings on our part, imposes a special responsibility on us as individuals and communities to be constantly on the guard so that our actions do not play into the hands of the spirit world. What this means is that there are two levels of responsibility for every human misfortune including illness. One is the "spiritual" over which the individual has no control. The other is the "human". The essence of the human responsibility is the fact that the individual and/or group should as much as possible avoid taking unnecessary risks because of the belief that risky behaviour is an essential element in the ability of the spirit world to cause havoc. This dualism of illness causation and responsibility, according to some informants, explains, for example, why the Ewe proverb describing an alcoholic person, wo de zo rome he, "they (bad spirits) have put (palm wine) pot into the stomach" is often followed by another proverb: busu mebla ta haft va gbome o, meaning "a bad spirit does not forewarn of its arrival". In the first proverb, responsibility for being an alcoholic rests not with the victim but with the spiritual realm which the victim has no control over. The rationale for this proverb is to draw sympathy and support for the victim who cannot be hold responsible for their situation. In the second proverb, responsibility for the human condition (in this case for being an alcoholic) rests not with the spiritual realm but with the individual. Given that the human domain is full of jealous neighbours and malevolent spirits waiting to cause havoc the individual has a responsibility to ensure that their actions do not play into the hands of these forces. The rationale for the second proverb is to caution against unnecessary risk-taking because of the belief that the spirit world is unable to cause havoc unless humans are foolish enough to let their actions play into the hands of the latter. The belief that the spirit world often cannot act unless given the opportunity by humans, according to some informants, explains why public drunkenness, except in the case of funerals and other ceremonies, is so much frowned upon among the Ewe. In short, despite the ability of malevolent spirits to cause the individual misfortune including illness this can only happen if the individual or the community creates the necessary conditions (in this case publicly experimenting with alcohol abuse) which allows the spirits to act. Clearly, a good understanding of traditional African notions of individual and/or community responsibility for illness causation among policy-makers and health care workers is relevant to developing appropriate preventative public health strategies.

1073 CONCLUSION

In this preliminary study, I have attempted to explore the social context of traditional medicine in a small village in Ghana as a background to a much broader longitudinal analysis of trends in reproduction of traditional medicinal knowledge and practise in Ghana. The aim is to provide a much needed baseline information that would inform health policy-making in Ghana and elsewhere. As a preliminary study, I have deliberately refrained from making my conclusions prescriptive. This conclusion is therefore limited to drawing attention to a number of key issues which policymakers may wish to explore with regard to the future of traditional medicine. One is the role of "spiritually based" traditional practitioners in the provision of care, especially for people with mental health and other psychosocial problems. This is particularly pertinent in view of the inability of allopathic medicine or the formal health care system in Ghana to deal effectively with mental health related illnesses. The second is legal and ethical issues relating to the relationships between the biomedical trained and the traditional practitioner, particularly with regards to policies aimed at integrating traditional medicine into the formal health sector. In the case of research into herbal medicine in Ghana we have seen how the evidence points to an unequal relationship between the biomedical scientist and traditional practitioner. This is in a "mono-racial" society, so to speak. Thus the issue assumes an entirely different dimension in interracial contexts as in the case of societies such as Australia where the biomedical trained is normally White and the traditional healer is Black. Thirdly, in trying to "modernise" herbal medicine through imported biomedical science there is a tendency for the product to become more expensive and thereby undermining ease of access often associated with traditional medicine. The fourth one relates to the way traditional practitioners perceive their work as a "trade" from which to "make a living". According to the government's own figures there are currently one registered traditional practitioner for every 400 people. The equivalent ratio for doctors is 1:12,000. Clearly, in Ghana, traditional medicine is as buoyant as ever. Thus policy-makers may wish to consider supporting these traditional practitioners in their own domains rather than maintaining the current efforts to incorporate them into the formal sector. In this regard, it is important that policy-makers recognise the professional autonomy traditionally enjoyed by practitioners of both allopathic and traditional medicine in Africa and the potential for "cooperation" (between the two systems) rather than "incorporation" of one into the other--a phenomenon that was long ackowledged by

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Twumasi (1972) and others (Warren, 1971) in their pioneering analyses o f traditional medicine in G h a n a and other West African societies. Fifthly, there is a need to re-examine some of the underlining reasons for the current popularity of traditional medicine in G h a n a and other African countries. Factors such as "new ageism" and struggles to assert cultural identity m a y be the driving force behind the growing interests in traditional medicine in some parts of the world. In the case of Africa, the introduction of user pay services appeared to have accentuated historical inequalities in access to Western-type health care (Tsey and Short, 1995), thereby forcing the poor, in some cases, to hold on to obsolete practices in the n a m e of "'traditional medicine". The evidence suggests the need to question some of the uncritical p r o m o t i o n of traditional medicine by some African governments and international agencies as an alternative to Western-type health care. Finally, analysis of Ewe ideas a b o u t illness causation provides interesting insights into what one can call traditional African notions of preventative health. A good u n d e r s t a n d i n g of these traditional preventative issues by policy-makers and Westerntype health care workers could have e n o r m o u s public health benefits.

Acknowledgements--The support and encouragement provided by traditional healers interviewed for the study are warmly acknowledged. I also acknowledge the following friends and colleagues for their comments and advise on various aspects of the study: Felix Ameka, Annekathrin Schmid-Hergeth, David Scrimgeour, Antonia Bagshawe, and Stephanie Short, as well as Edward Koku, for his research assistance.

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