Traditional medicine in The Gambia

Susan Campbell

While work ing in a rural hospital in The Gambia, I realized that some of my colleagues viewed tradit ional healers wi th some degree of scepticism. Some felt that i t led to a delay in patients seeking t reatment and, at times, could lead to death from herbal intoxication.

However, despite the unscientific, and at t imes harmful, t reatments i t remains a popular choice of health care that is cultural ly acceptable and readily available in the rural communities.

So important are culture and ethnici ty to health outcomes that, even if structural constraints are removed in the health sector, desired results are unlikely to be achieved unless the cultures of communit ies are taken into consideration by health policymakers and planners and providers of health care. Indeed, increased at tent ion to these issues by policymakers increases the chances of success in implementing policy. If this is done, providers wil l be less likely to display an ambivalence towards the use of tradit ional medicine and users wil l be less likely to vacillate between modern and tradit ional medicine (World Bank 1995).

With an increase in chronic diseases (and new diseases such as AIDS) wi th no known cure, i t seems that this valuable resource should be tapped safely and more effectively, wi th support and supervision, to improve the chances of health for all by the year 2000.

Susan Campbell BSc(Hons), RGN, Clinical Nurse Tutor (VSO) Bansang, The Gambia

Currently studying for MPH

SOCIO-CULTURAL BACKGROUND

The Gambia is a small country in West Africa with a population of around 1 million (Ministry of Trade, Industry and Employment 1992). It is surrounded on three sides by Senegal and to the west by the Atlantic Ocean. The climate is typically Sahelian with a long dry season from October to June. The population comprises a number of ethnic groups and the predominant religion, Islam, accounts for 95% of the country's religion. Culturally, The Gambia is a polygamous, male-dominated society where women have little decision-making power and are valued for their fertility. Traditional beliefs including early marriage, female circumcision and scarification are very strong, particularly in the rural areas. More than 70% of the population is engaged in subsistence farming and the GNP/capita is US$350 (UNDP 1996), making it one of the poorest countries in Africa.

HEALTH CARE

The health system has an emphasis on primary health care (PHC) and, since the WHO conference in

Alma-Ata, the government has made deliberate poli- cies to control hospital expenditures and protect a village-based PHC strategy. Village Development Committees (VDCs) manage the village health pro- grammes and select and support their own Village Health Workers (VHWs) and Traditional Birth Attendants (TBAs). The Bamako Initiative, a struc- tural adjustment cost-recovery policy, instructed by the International Monetary Fund, has been com- menced in certain areas.

Presently, there is 1 physician per 10000 people and very few doctors in the rural areas. The infant mortality rate is 131/1000 (UNDP 1996) with the leading causes of death being diarrhoea, malaria, acute respiratory infections and malnutrition.

There is one government hospital in the rural area which was built in 1938 during the colonial period and has 120 beds. Patients who are referred to the hospital from health centres often have a long uncomfortable journey on foot or by horse cart ambulance. The nurses based here also have various problems such as low pay, shortage of staff and equipment, and a postings system that separates many of them from their families and the amenities of urban life. They also often find themselves taking on the role of the doctor.

Complementary Therapies in Nursing & Midwifery (I 997) 3, 103-105 �9 1997 Pearson Professional Ltd

104 Complementary Therapies in Nursing & Midwifery

In The Gambia, illness is thought to be caused by

many different factors such as evil spirits or witchcraft.

TRADIT IONAL MEDICINE

Traditional medicine also exists and is said to cater for the health needs of 80% of the African population (Bannerman 1993). Here, traditional medicine means the ancient and culture-bound health care practices which existed before the application of science to health matters. In The Gambia, it is an informal train- ing where the knowledge is passed from father to son. The practice is usually inseparable from religion and the traditional healer can draw on his knowledge of magic, physical disorders and major syndromes and proceed to assemble what amounts to a case his- tory that will culminate in his diagnosis. His task does not end there as he still has to dispense his own prescription, whether for remedies or for therapeutic rites. The religious healers, known as marabouts, are highly-respected members of the community.

In The Gambia, illness is thought to be caused by many different factors such as evil spirits or witchcraft. It can have a personal responsibility and is often seen as a punishment, e.g. after a quarrel with a neighbour, a curse or spirit could be sent to cause worry or ill-health. Treatment by traditional healers is in keeping with this and includes the wearing of jujus*, drinking of herbs, bathing in roots and leaves, and giving out charity or local treatments (such as applying certain leaves to cuts on the limbs).

THE USE OF TRADIT IONAL MEDICINE

For a long time it has been recognized that there is a great potential for traditional medicine to contribute to primary health care in developing countries. It remains a popular choice of health care that is cul- turally acceptable and the vast numbers of formally

and non-formally trained practitioners of traditional medicine live and work in remote communities, making them more aware of the patients' circum- stances and able to treat patients in relation to their environment. Western medicine has a problem in reaching a significant coverage of the population.

Another advantage of the traditional healer is that the patient can pay for treatment with a gift, e.g. a chicken or a goat, instead of with cash.

Many patients are aware that Western medicine is not something that is bad but external factors, such as the expense or the long distances needed to travel to reach the nearest facility, hinder its usage.

INCORPORATION OF TRADIT IONAL A N D O R T H O D O X MEDICINE

An enormous advantage could exist if modem and traditional approaches can be combined, particularly in cases of chronic physical illness, or of mental disorders requiring psychotropic drugs. It would guarantee proper medical intervention, e.g. on an out- patient basis, and a psychologically more comfortable hospital environment within the traditional setting. It would also be considerably cheaper (Parry 1984).

Most traditional healers regard a visit from a hos- pital doctor as a boost to their prestige and would be open to collaboration. Traditional healers do attend hospitals for treatment themselves, e.g. I have nursed traditional healers after cataract operations. Traditional healers have also requested that I give them a stethoscope to enable them to improve their diagnostic skills! During hospital visiting hours, tra- ditional healers visit their patients through posing as relatives, and continue to carry out their treatments. It is never known who is attributed with making the patient better.

* A juju is a passage from the Holy Koran written on a piece of paper by a tradi- tional healer. It is then folded and sewn into a leather pouch (about 2 cm x 3 cm) and usually worn round the waist, arm or neck. The passages are appropriate to the person's needs, e.g. to prevent the person from attack in war, or from evil spirits or ill- health. Fig. I Rural children, some wear ing jujus.

Traditional medicine in The Gambia 105

...healing practices relying on, e.g. faith, magnetism and

exorcism, are

by no means extinct in the industrialized world.

Fig. 2 Typical rural scene of children out gathering wood.

DISADVANTAGES OF TRADITIONAL HEALERS

Opponents of traditional healers emphasize that its practices are rapidly dying out. They consider any form of collaboration dangerous and contrary to all attempts at health education. This is because it implies recognition of traditional practices as almost

equal to those of modern medical doctors. The oppo- nents may also claim that healers are often shrewd exploiters to whom income and prestige count more than the welfare of their clients.

Opponents often forget that healing practices

relying on, e.g. faith, magnetism and exorcism, are by no means extinct in the industrialized world.

Disadvantages of traditional healers are also cited by patients. Some are aware that treatment given can be toxic and it is not uncommon to have deaths from

herbal intoxication. It is also recognized that there are many false healers.

Nurses are often cynical about the local healers but will still attend for some ailments such as

headache. They seem to be most acceptable in con- ditions where behavioural, emotional or spiritual factors play a major role and where scientific meth-

ods have not produced noticeable improvements. WHO have identified five areas of concern in

Traditional Medical Programmes, including clini- cal and scientific investigations into the various

treatments used. They also want to encourage the inclusion of safe policies on traditional medicine in National Programmes (WHO 1996).

RECOMMENDATIONS

Traditional medicine is presently under the control

of the Department of Forestry, but it needs to be linked up in some way to the official system in order to obtain a more equitable and wider health-care coverage. Through educational activities with the

healers, and provision of a place in the PHC team that corresponds to their skills and abilities, com- munication could be improved and the best mix of traditional and Western healers could be achieved.

REFERENCES

Bannerman R H 1993 Traditional Medicine and Health Care Coverage. WHO, Geneva

Ministry of Trade, Industry and Employment 1992 National Population Policy for Socioeconomic Development. The Gambia

Parry E H O 1984 Principles of Medicine in Africa. Oxford University Press, UK

UNDP 1996 Human Development Report. Oxford University Press, UK

WHO 1996 WHO Policy and Activities in the field of Traditional Medicine. Geneva

World Bank 1995 Better Health in Africa. World Bank, Washington