THE INFANCY OF
EDWARD SHELONGA
an extended
case from the Zambian Nkoya
[ part 2 ]
Wim van Binsbergen
6.
INTERPRETATION OF THE EXTENDED CASE
Let us first
consider the role of cosmopolitan health agencies.
Both at the beginning and at the end of my account of Edward's
infancy stands the Lusaka University Teaching Hospital: in
between, the protagonists move to and for between various other
cosmopolitan health agencies and Nkoya Alternatives. When and
why, therefore, do people utilize cosmopolitan health agencies?
Obviously, accessibility is a first condition for such
utilization. In the urban situation (cf. Shattock n.d.), urban
clinics tend to be within walking distance from the homes of the
majority of the population. With the exception of private
doctors, Zambian cosmopolitan health agencies have become
non-fee-paying in the late 1960s. Therefore, the main determinant
of accessibility now lies in the time factor (cf. Zeller 1974).
Limitations of staffing and equipment usually cause long waiting
hours, which form such a common and perennial feature of
cosmopolitan medicine in Africa that patients are prepared to
accept them - provided no third party is making an urgent demand
on their time. In many cases however there is such a third party:
children waiting to be fed at home, an employer anxious for his
employee's return to work, one's own business that needs
attention, etc. Should the urban clinic refer one to the central
hospital, not only a further loss of waiting time is involved,
but also the distance to be discovered often requires use of
public transport, which means further expense of time and money.
Among the urban poor, lack of transport money often means that a
visit to hospital has to be postponed.
In the rural areas the access factor weighs much more heavily.30
Here a visit to a rural health centre or hospital usually
involves travelling over considerable distances. In Chief
Kahare's area, motor transport is very seldom available. The long
journey and the long waiting hours frequently necessitate an
absence of several days, which many people cannot afford
(particularly young women, who under the tight control of their
senior consanguinean or affinal kin carry the lion's share of
domestic and agricultural tasks). Such prolonged absences require
that one carries blankets, food and kitchen utensils on the
journey, money does not affect sleeping arrangements has money to
buy food on the way. As a result, rural utilization of
cosmopolitan health services falls steeply with increasing
distance, and on the longer distances (exceeding 10-20 km) tends
to show a bias against those who are particularly busy, poor or
junior.
In Edward's case, the Lusaka data do not suggest that the
accessibility factor is very important in the urban environment.
Mary remained on the outside of cosmopolitan medicine,
irregularly went for antenatal care, gave birth at home, and did
not attend the under-five clinic31 (except when Edward was
obviously ill) - not for reasons of access, time or money.
However, in the rural data the effect of these factors was
demonstrated by the fact that, while visiting the distant Rural
Health Centre (and a fortiori the even more distant hospitals)
was a major decision, and one which people would not take except
in very serious cases (when it was often too late), they would
daily flock in considerable numbers to our improvised bush
clinic. Even at our clinic the impact of distance made itself
felt. Our patients were mainly from Mema valley, where Chief
Kahare's capital is located. Even from the adjacent Mushindi
valley, where e.g. Nyamayowe village is located, markedly fewer
patients would come: and those who did come would tend to have
more serious complaints. It proved impossible to have Edward
brought in daily for eye treatment, across a distance of less
than one hour of cycling. Considerations of accessibility also
form an obvious explanation for the common phenomenon of
black-market medicine (cf. Patrick's death) - although we shall
find additional explanations when discussing the health role of
the elders.
While largely economic factors underlie the effect of
accessibility, time and money, Edward's case clearly brings out
the role of non-economic factors. In the literature these are
often discussed in terms of local, culturally shared modes of
conceptualizing health and disease. Authors in this connection
often speak of the force of 'tradition' and the persistence of
'traditional' medicine, as if that would explain anything.32
As we have seen, the same person (Mary) may in the course of a
short period repeatedly shift between cosmopolitan and Nkoya
health agencies; yet her ideas on health and disease remained the
same, throughout the process. why was Edward dragged to and for
between the various outlets of cosmopolitan medicine, and a
variety of local alternatives such as ancestral ritual, cults of
affliction, diviners, etc.? Why did Mary achieve overnight
mastery in hygienic bottle-feeding, yet allowed Edward to go
through a musical chairs of Nkoya treatments, which by delaying
effective clinical action nearly cost him his life? The health
concepts in her mind are not likely to explain the variability of
her actions - except perhaps for this one notion, so fundamental
in Nkoya social structure, that potential support and remedy is
never limited to one exclusive source, and that one may safely
look for alternatives if one way is blocked. But given the
options present in Edward's health situation, what principles
governed that certain options were finally taken, and others were
not?
The typical Third World medical situation today is that of a
person surrounded by various alternative health agencies, all off
them in principle accessible (albeit not at equal costs). Given
this situation, the data suggest that such a person's actual
pattern of utilization will to a considerable extent result from
the social process in which he is involved in his immediate
social environment. In the years covered by my data, Muchati and
Mary (and by consequence their child Edward) did not
significantly change their class position, level of income,
educational status, etc. All these individual attributes which
surveys have tried to link up with health agency utilization,
here remained constant, and for that reason are incapable of
explaining the variation in Muchati's and Mary's health
activities. But what did undergo perceptible and significant
changes was the pattern of crucial relationships by which each of
them was surrounded. It is in the evolution of these
relationships that their health choices become understandable.
In these relationships, a number of major spheres can be
identified:
a.
Formal-sector employment
One such
sphere was the relationship of Muchati's family with the families
of his employers (not just us). Here Muchati was thoroughly
exposed to cosmopolitan health concepts, and obliged to apply
them at least in his professional work as a domestic servant. He
could enhance his employment security by pleasing his employers.
The latter would expect him to observe basic hygiene, and would
normally make a visit to a cosmopolitan medical agent a condition
for sick leave. Moreover, expatriate members of the Zambian elite
has become a reference group for him; he would attempt to
selectively adopt their life-style. Largely for these reasons
Muchati absorbed modern hygiene and applied them in his personal
life. As is repeatedly demonstrated in Edward's case, this made
Muchati a strong advocate of cosmopolitan medicine. He struggled
to have Mary attend the urban clinics and to have Edward born in
hospital; he supervised Mary's bottle-feeding; upon departure
from the village he left money for visits to the rural
cosmopolitan health agencies, etc. At our bush clinic, in his
greatly enhanced status of research assistant, Muchati would
often take the initiative of lecturing the women and youth on
elementary hygiene (use of boiled water for drinking, etc.).
However, the impact of formal-sector employment was set off
against that of other social spheres, in shaping the health
actions of Muchati's family.
b. Elders
While living
in town, Muchati's and Mary's frequent interaction with
fellow-Nkoya meant a continuous confrontation between Nkoya
medicine and cosmopolitan medicine. Nkoya medicine, in this
context, was not offered in the form of advice that one could
either take or leave. Rather, the idiom of illness and healing
provided a major context to shape interpersonal relations within
this ethnic group. propounding advice in health matters, dreaming
up new therapies for sick kinsmen, dispensing herbal medicine and
other therapies forms an integral and central part of dealings
between kinsmen and between tribesmen among the Nkoya, in town as
well in the village. Seniority and authority imply protection and
care, and the most common form in which these are offered is a
medical one. Most Nkoya adults over forty years of age claim
specialist knowledge of certain aspects of local medicine. It is
no exaggeration to claim that, today, health action is the Nkoya
elders' main task. At the same time it is also their major
prerogative, by which they assert their authority over their
junior relatives and tribesmen at large. This is particularly the
case with the village headman. Therefore a headman's failure to
protect his village from illness, death and sorcery is a terrible
shortcoming, which will greatly lessen his authority in
local-political and judicial matters. On a less exalted scale,
the relationship between parents and children, and even that
between husband and wife, calls for explicit health intervention
from the dominant party.
In the past, the medical dimension of the elders' role among the
Nkoya was accompanied by very considerable power in the marital,
political and economic domain. Together, these aspects made for a
marked dominance of the old over the young. Now that political
incorporation of the national state and the penetration of
capitalism, have largely destroyed the elders; political and
economic power, mainly two domains have survived in which the
elders can expropriate the products of the labor of their
juniors: affinal relationships, and health action. In the field
of affinal relationships, recent decades have seen the evolution
of marital payments from trade goods or labor (bride services),
to high and standardized monetary bride-prices in the order of
magnitude of K80, i.e. what an unskilled laborer, if he manages
to secure employment, can earn (not: save) in about three
months.33 In general it is the juniors who pay and the elders who
receive these payments. Thus a major inter-generational flow of
town-earned cash is maintained. In the domain of health action,
the elders' medical services not only drive home the juniors'
fundamental dependence on the elders no matter how economically
independent the former may have become such health action
invariably also involves the transfer of money from the young to
the old (and/or from men to women). In the case of cults of
affliction, fees of K20 are no exception. Where the symbols of
economic and political excellence have declined, the elders seek
recourse in new medical symbols to express and assert their
uncertain dominance. Not only do they deal in historical forms of
Nkoya medicine, or in such modern derivations as the cults of
affliction - they also appropriate and dispense modern medicine
obtained in dispensaries or the black market. Patrick's death
illustrates to what tragedies this can lead.
c. Kinship and
marriage
The third
major sphere in the social process surrounding Edward's health
experience is that of kinship and marriage. Edward's story
reflects two main processes in this respect. First there is the
development, against many odds, of a mature, stable conjugal
relationship between Mary and Muchati. And secondly there is the
increasing juxtaposition between their respective kin groups,
with Mary being more and more drawn away from her parental kin
group and into that of her husband. It is largely from elements
derived from these two processes that the elders (taking
temporary precedence over the cosmopolitan health agencies
championed by Muchati) shaped their healing activities with
relation to Edward. The elders' health action (which sometimes
amounts to illness-provoking action), is primarily a means to
assert their kinship-political claims over juniors such as Mary
and her child Edward. Conflicting supernatural interpretations
are advanced in order to bring out the imperfections of the rival
kin group, and ritual is undertaken to incorporate the juniors
more fully into one's own kin group.
Judged exclusively within the framework of cosmopolitan medicine,
it would seem as if the relatives cynically let the child suffer,
merely using its critical condition as a pretext to pursue their
own kinship-political interests. However, a less ethnocentric
interpretation is called for. Kinship dominates the Nkoya
community, as it is the fundamental organizational set-up by
which rural production and reproduction are organized. Bilateral
kinship creates the specific structural problem of several kin
groups competing, with virtually equal force and with uncertain
outcome, for the allegiance of junior members. this competition
is a major structural theme in Nkoya society. It makes for a very
high rate of inter-village migration, and is closely connected
with the high degree of martial instability. The competition for
juniors is further acerbated by the fact that offspring is so
very scarce due to an extremely low fertility. This seems to be
the background of the Nkoya's obsession with illness and death.
Reproduction is a major concern in any society; it is a centre of
gravity in all societies organized around the domestic community
(Meillassoux 1975). But among the Nkoya, with their impaired
fertility coupled to a continuous emigration of young labor power
to the towns, reproduction has eclipsed most other concerns,
perhaps even production, which is at a low level involving severe
annual shortages. In this context, even a child's minor health
complaints activate, in the consciousness of that child's kin,
the whole predicament of their society. A child's death is in
fact what the frantic mourners claim it to be: an assault on the
survival of their group. Naming ritual (meant to tie the child
more closely to the kin group and its ancestors) and ritual
contests (cf. the two divinations of the causes of Edward's
illness) with other groups that extend rival claims over the
child, may not constitute the most effective way of curing a sick
child, yet they do form a meaningful attempt to get to the roots
of the child's condition and its paramount social significance
for the various groups that lay a claim to his membership.
d.
Cosmopolitan health agencies
A fourth major
sphere in the social process shaping our protagonists' health
behavior, is formed by the cosmopolitan health agencies
themselves.34 Once the problems of access have been overcome,
what kind of interaction actually takes place between patients
and medical staff at rural health centres, clinics, hospitals and
private practices? Edward's case suggests repeatedly (cf.
negligence of Mary's breast-feeding while Edward was in hospital;
the rural health centre lacking essential drugs; the doctor's
attitude towards Muchati when he brought Edward in for admission;
Kafungu's pneumonia) that this interaction is often of a very
deficient nature, both in social and in technical-medical
respects, and especially in those cases that require more than
quick and simple administration of medicaments.35 In terms of
social relations there is often little to reinforce and
consolidate a patient's initial attraction to cosmopolitan
medicine, and there may be much to deter him. the immense
pressure of work (cf. Leeson 1970), the cultural and linguistic
barriers (cf. Conco 1971), the conflict-ridden internal structure
of institutions of cosmopolitan medicine36 and the difficulties
involved in keeping up medical supply lines in a hug empty
country like Zambia (Hage-Noël 1974) may all be quoted in
vindication of individual health workers. However this does not
take away the fact that often health action along the lines of
cosmopolitan medicine is frustrated by the very institutions that
claim to have scientific furtherance of health as their major
aim. Cosmopolitan health agencies have a great influence on
peoples' health behavior - but sometimes this influence may be of
a kind to encourage them to take their health problems elsewhere.
Alternatively, Edward's case offers sufficient examples (Mary's
bottle-feeding; our bush clinic, my patronage in the event of
Edward's final hospitalization) of the fact that, given adequate
social relations between Nkoya individuals and the advocates of
cosmopolitan medicine, the effect of cognitive or
kinship-political barriers to adequate health action can be
minimized. In a Central African society like that of the Nkoya,
where 'shopping-around' (for kinship support, followers,
medico-ritual attention within the context of Nkoya medicine) is
a fundamental structural theme, one should hardly expect that
such a powerful source of support as cosmopolitan medicine would
be ruled out for reasons of principle! Just as in the choice of a
headman or a nganga, two major factors are important here: one's
ability to enter into a satisfactory relationship with that
agent. The manifestly low standards of performance in both
medical and social respects, among some agents of cosmopolitan
medicine, deter Nkoya patients, no matter how much the latter are
prepared to admit, at the cognitive level, the power of
cosmopolitan medicine.
Of these four
major structural domains, two (elders, kinship) belong to the
internal structure of Nkoya society, and two (modern-sector
employment, cosmopolitan health agencies) to the wider society
into which Nkoya society has become incorporated. An important
problem in analyzing the social process out of which Edward's
case exists, is that it continuously links these two entirely
different structural settings. The theoretical and methodological
difficulties which this situation (yet so common in the modern
world) poses, have not yet been overcome (cf. Van Binsbergen,
n.d. b.). Meanwhile Muchati's role can be appreciated as that of
one who, due to an increasingly successful yet still very
vulnerable position in the wider society, could, slightly better
than his fellow-tribesmen, afford to ignore the claims of the
internal Nkoya social structure, such as it is expressed through
the elders' health action. At Edward's birth he tried to wrench
the initiative from the hands of the Nkoya women he had himself
called earlier in the evening. A year later, when Edward's health
declined, his relatives dared enlist the services of a healer
only after Muchati had left for the town. Yet the pressures
channeled through his wife, parents, affinal kinsmen and urban
tribesmen left him little choice but to accept Edward's extensive
exposure to Nkoya medicine. Although Muchati's close personal
relationship with his elite employers make him somewhat
exceptional, this reluctant compliance is surely one of the main
characteristics of contemporary Nkoya youths and young adults in
relation to the elders. Of great structural significance, it
reflects the indeterminateness of the social-structural position
of modern Nkoya, who are caught between two totally different
social systems. The rudiments of their pre-capitalist rural
society can no longer fully provide an adequate material life for
them. Alternatively, in the modern capitalist urban society they
are lowly-educated newcomers with only a very insecure footing.
Ultimately such economic, social and psychological security as
they have, has therefore to come from the village. For this
reason they are forced to adhere to the social and symbolic
arrangements of the village society, including their medical
aspects.
Having thus identified some main and often conflicting spheres of
relationships that among the contemporary Nkoya intersect around
specific individuals in their pursuit of health, it is important
to realize that these relationships are not static structural
arrangements. They constitute a veritable social process.
'Historicity', in the sense of the seriality of evens and the
accumulation of effects along a time axis, is the key to an
understanding of the specific health actions of individuals at a
specific moment of time. This historicity pervades Edward's case
from beginning to end. Without the mounting tensions between
Jimbando and Nyamayowe villages (the struggle over Mary's social
and ritual allegiance, the abortive marriage negotiations
concerning Banduwe's son, the death of Kashimbi's daughter, and
of Patrick, in Jimbando) it is unlikely that the struggle over
Edward would have been enacted at such an early stage, when the
child was barely one year old. It is more usual for such
struggles between affines over a child's allegiance to begin when
the child is in his tens. Without the truly traumatic outcome of
Edward's first hospitalization (the impairment of Mary's
lactation), and without the repeated recent disappointments at
the ill-supplied Rural Health Centre, Edward's kin would also
have looked to cosmopolitan medicine, and not so exclusively to
Nkoya medicine, to deal with the decline of his health from
October 1973.
This historicity is implied in the extended-case method, and
constitutes one of its great advantages. When we concentrate on
the action aspects rather than on the cognitive or cultural
aspects of health dynamics, some recurrent findings of medical
anthropology in Africa can be placed in their proper perspective.
Africans have been claimed not to make too rigid a distinction
between cosmopolitan and local medicine.37 Along the same lines,
it is claimed that they do not consider themselves as defaulters
to one side or the other when they shop around for health
assistance. On the cognitive level these findings are hard to
explain. Hardly would one assume that Africans fail to perceive
the enormous differences between cosmopolitan medicine and the
various African systems of medicine. But if one sees such
cognitive elements as primarily shaped, and given meaning, in a
specific sequence of actual interaction, then the fusion of the
various spheres of medical care in the social processes in which
people are involved, explains the absence of neat
compartmentalization between these spheres in their thinking and
attitudes.
Such a complemental relationship between cosmopolitan medicine
and local alternatives as my analysis suggests, lies not
primarily in the fact that they are so very different (or so very
similar to each other, for that matter), but in the fact that
both are involved in the same social field. The social process,
within the various spheres that in mutual rivalry determine it,
takes people now to cosmopolitan medicine, now to local healers,
kin therapy, or self-medication. This is a rather horizontal
view, which looks at cosmopolitan medicine as one among many
alternatives, neither incomparably superior to Nkoya medicine,
nor rigidly separated from the latter by impassable cultural or
social boundaries.
This raises the much debated issue of the functional
complementality of cosmopolitan medicine and local
alternatives.38 Do people refer to local alternatives, mainly for
emotional relief and social redress, whereas they refer to
cosmopolitan medicine mainly for sheer somatic treatment? Complex
as the issue is, I have a feeling that this kind of reasoning
erroneously projects into the participants' minds the
distinctions and evaluations common among members of North
Atlantic society, and a fortiori among our doctors. Could the
latter afford to admit that local, non-cosmopolitan medicine is
anything more than just emotionally and socially relevant, in
other words can they admit that it primarily entails medical
actions fellow-doctors, however exotic? As I have tried to
demonstrate, the oscillation between cosmopolitan medicine and
Nkoya medicine in Edward's case was primarily the outcome of the
evolving struggle between various major foci in the social
process of the people involved. it was not as if at one stage
emotional or social concerns or needs began to prevail over the
desire for somatic cure, and that therefore cosmopolitan medicine
had to yield to healing ritual etc.
Non-cosmopolitan medicine does not have the monopoly of social
and emotional aspects. Would not the following aspects of
cosmopolitan medicine upon closer analysis reveal major parallels
with the symbolic and social content of African medicine: the
period of seclusion that Mary underwent at the escorts' shelter
while her child was in hospital; the fixed routine of daily
rounds through the wards; the rigidly defined role expectations
in the interaction between patient and staff. Just as local
healing ritual may reveal crucial aspects of the village
society,39 the patients enforced submission to anonymous
structures is eminently significant in a urban capitalist society
dominated by formal bureaucratic organizations both within and
outside the medical sphere. Thus, the absence of sociability in
the sphere of cosmopolitan medicine, may be just as much of a
socially relevant fact, as the unmistakable 'social' element in
local African medicine. Hitherto, perhaps, social scientists
interested in health action have too readily accepted our
doctors' own definition of the cosmopolitan medical situation,
thus taking for granted what most needs elucidated (cf. Loudon
1976: 33f).
Does my analysis imply, then that medico-anthropological analysis
is to lose itself entirely in the tracing of petty families
histories, without any prospect of producing structural insights
that can be generalized and thus applied in public-health
policy?40 Such a view would ignore the lessons I have tried to
derive from Edward's case. However complex, and however
unpredictable in details, yet the social process that surrounds
individuals in their pursuit of health shows a systematic pattern
such as explained throughout my argument, and summarized in my
introduction. In this pattern cosmopolitan health agencies play
an integral but often far from ideal part. The better this
pattern is understood, the nearer Third-World cosmopolitan
medicine may come to the realization of its lofty ideals, and to
the justification of the comfortable social privileges of its
professionals.41
7. CONCLUSION
When I
presented an earlier and admittedly less balanced version of this
paper to an audience of Third-World physicians, their main
reaction was one of disbelief and irritation. Was not the
implication of my argument that even if the accessibility factor
was taken care of, yet people like the Nkoya would not, and could
not, embrace cosmopolitan medicine overnight and whole heartedly?
The reaction of the audience was: 'So much of unique and
unquestionable value that was as agents of cosmopolitan medicine
come to offer them - and you are telling us that they may have
reasons for rejecting it?!' It is not with impunity that one can
present a more relative view of cosmopolitan medicine; nor it is
easy to explain anthropological data and insights in a manner
that makes sense to medical professionals.
Edward's case suggest how complex the situation really is, and
how difficult to alter. Nkoya, both in town and in the village do
consult cosmopolitan health agencies. As elsewhere, this
utilization increases with increased accessibility. The Nkoya are
not deaf to the persuasions of non-Nkoya outsiders, or of
enlightened fellow-Nkoya, who advocate cosmopolitan medicine.
Rather complex hygienic routines, such as bottle-feeding, may be
mastered within an amazingly short time, and adequately performed
provided the logistics of the situation allow this. Cultural
notions play a relatively limited role in this set-up, and
certainly do not create insurmountable barriers against
cosmopolitan medicine. Yet two main factors militate against
these people becoming exclusively committed to cosmopolitan
medicine. First, their own medicine is so central in their social
process (both in the village and in town), that they cannot
afford, as yet, to do away with it. Their structure of authority,
kinship, competition between kin groups over scarce members,
largely revolves on it. And secondly, the version of cosmopolitan
medicine offered to them is of perceptibly inadequate standards.
These standards can only be improved if more fund become
available and if medical performance is re-assessed and
continually evaluated against the social, political, ideological
and ethical priorities of the local community, of the national
state which administers cosmopolitan medicine, and of the world
community at large. Ultimately this means a political process in
which the elitist and consumptive tendencies inherent in the
cosmopolitan medical professions, and the de-humanizing
tendencies inherent to all modern formal organizations including
medical ones, are radically checked in favor of the people's
interest (medical and otherwise) at the grass-roots level.42
Humanitarian compassion alone is not like to bring about such a
change - it has to be brought about by the organized demands of
the people themselves. Thus the evolution of public health
becomes an aspect of a much more general class struggle.
Alternatively, the centrality of Nkoya medicine in their society
is not likely to decline unless a profound transformation takes
place in their political and economic situation within the wider
society. Nkoya society is not really disappearing. It lives on in
a greatly modified form as a handmaiden of urban capitalist
structures, nursing future laborers and sheltering discarded
laborers. Even in this neo-traditional form can Nkoya society
only survive if its basic social and ritual institutions,
including Nkoya medicine, remain more or less intact. Nkoya
medicine underpins the elders' authority, articulates group
processes especially at their most dramatic stages, and provides
a mechanism of redistribution through which some meager revenues
of labor sold in the capitalist sector can be channeled back into
Nkoya rural society.
Other forms to legitimate authority, and other mechanisms of
redistribution, are conceivable, and their substitution in the
place of Nkoya medicine might pave the way for fuller adoption of
cosmopolitan medicine. However, such cultural engineering is
reminiscent of the naïve, a-political manipulation advocated by
the old-fashioned schools of applied anthropology (e.g. Foster
1962; Erasmus 1961). It is deceptive, as it only deals with
surface phenomena and does not confront the problem at its roots:
the reality of exploitative incorporation, within the 'mode of
reproduction of cheap labor'. If this reality could be overcome
through the class struggle of the Nkoya and other Central African
peasants and urban poor, Nkoya society would be transformed (both
internally and as regards its place in the world system), and
Nkoya medicine would no longer need to serve the functions which
now make it indispensable.43
REFERENCES
Ademuwagun,
Z.A.
1974-75
The meeting point of orthodox health personnel and traditional
healers/midwives in Nigeria: The pattern of utilization of health
services in Ibarapa division. In Harrison and Dunlop 1974-75:
55-77.
Apthorpe, R.J.
1968a (ed.)
Rhodes-Livingstone Communication Number Fifteen. Lusaka:
Rhodes-Livingstone Institute (1959) 1968.
1968b
Introduction. In Apthorpe 1968a: i-vii.
Barnes, H.F.
1949 The
birth of a Ngoni child. Man 49, 118:87-9
Beattie, J.
and J. Middleton
1969 (eds.)
Spirit mediumship and society in Africa. London: Routledge and
Kegan Paul.
Blankhart,
D.M.
n.d. Report
on a visit to Zambia 1 May - 13 July 1966. Amsterdam: Royal
Tropical Institute. Mimeo.
Boswell, D.M.
1965
Escorts of hospital patients: A preliminary report on a social
survey undertaken at Lusaka Central Hospital from July-August
1964. Rhodes-Livingstone Communication no. 29 Lusaka:
Rhodes-Livingstone Institute.
Central
Statistical Office
1975 Inter-regional
variations in fertility in Zambia. Lusaka: Government Printer.
Clay, G.
1946
History of the Mankoya district. Rhodes-Livingstone Communication
No. 4. Lusaka: Rhodes-Livingstone Institute.
Colson, E.
1969 Spirit
possession among the Tonga of Zambia. In Beattie and Middleton
1969: 69-103.
1977 A
continuing dialogue: Prophets and local shrines among the Tonga
of Zambia. In Werbner 1977: 119-39.
Conco, W.Z.
1971
Problems of communications and traditional practice of medicine
in Africa. In La Recherche multidisciplinaire appliquée dans le
Tiers Monde, Développements et Civilisations 45-46: 151-65.
Craemer, W. de
, and R.C. Fox
1968 The
emerging physician: A sociological approach to the development of
a Congolese medical profession. Stanford: Hoover Institution
Studies, 19.
Davies, D.H.
1971 (ed.)
Zambia in Maps. London: University of London Press.
De Jonge, K.
1974
Fertility: a dependent variable. Kroniek van Afrika 1974/1:
61-71.
De Kadt, E.,
and G. Williams
1974 (eds.)
Sociology and development. London: Tavistock.
Epstein, A.L.
1967 (ed.)
The craft of social anthropology. Manchester: Manchester
University Press.
1969 The
network and urban social organization. In Mitchell 1969: 77-116.
Erasmus, C.J.
1961 Man
takes control. Minneapolis: University of Minnesota Press.
Evans, A.J.
1950 The
Ila V.D. campaign Rhodes-Livingstone Journal/Human Problems in
British Central Africa 9: 40-47.
Fendall,
N.R.E.
1965
Medical planning and the training of personnel in Kenya. Journal
of Tropical Medicine and Hygiene 68: 12f.
Foster, G.M.
1962
Traditional cultures and the impact of technological change. New
York: Harper and Row.
Frankenberg,
R.
1969 Man,
society and health: Towards the definition of the role of
sociology in the development of Zambian medicine. African Social
Research 8: 573-87.
Frankenberg,
R. and J. Leeson
1974 The
sociology of health dilemmas in the post-colonial world:
Intermediate technology and medical care in Zambia, Zaïre and
China. In De Kadt and Williams 1974: 255-78.
1976
Disease, illness and sickness: Social aspects of the choice of
healers in a Lusaka suburb. In London 1976: 223-58.
Gerold-Scheepers,
T., and W.M.J. van Binsbergen
1978
Marxist and non-marxist approaches to migration in tropical
Africa. In Van Binsbergen and Meilink 1978: 21-35.
Gilges, W.
164
Some African poison plants and medicines in Northern Rhodesia.
Occassional Paper No.11. Livingstone: Rhodes-Livingstone Museum.
2nd edition.
Gonzalez, N.S.
1966 Health
behavior in cross-cultural perspective: A Guatemalan example.
Human Organization 25:122-5
Grollig, F.X.,
and H.B. Haley
1976 (eds.)
Medical anthropology The Hague/Paris: Mouton.
Hage-Noël,
G.L.M.-A.
1974
Farmaceutische mijmeringen in en over Zambia. Pharmaceutisch
weekblad 109, 49: 1202-3.
Harrison,
I.E., and D.W. Dunlop
1974-75
(eds.). Traditional healers: Use and non-use in health care
delivery. Rural Africana 26.
Honigmann,
J.J.
1973 (ed.)
Handbook of social and cultural anthropology. Chicago: Rand
McNally College Publishing Company.
Illich, I.
1977 Limits
to medicine. Medical nemesis: the expropriation of health.
Harmondsworth: Pelican Books.
Imasiku, H.L.
1976 Annual
Report 1976, Public Health Services. Kaoma district: Department
of Health Mimeo.
Imperato, P.J.
1974-75
Traditional medical practitioners among the Bambara of Mali and
their role in the modern health care delivery system. In Harrison
and Dunlop 1974-75:41-53.
Janzen, J.M.
1975 The
dynamics of therapy in the lower Zaire. In Williams 1975:441-63.
1978 The
quest for therapy in lower Zaire. Berkeley, etc.: University of
California Press.
Jayaraman, R.
1970 The
professional medical assistant in Zambia: A study of the social
background and occupation role of medical assistants in the
Lusaka teaching hospital. Paper read at the East Africa Social
Sciences Conference, Dar es Salaam.
King, M.
1966
Medical care in developing countries. Nairobi: Oxford University
Press.
Leeson, J.
1969 Paths
to medical care in Lusaka, Zambia: Some preliminary findings.
African Urban Notes 4, 2:8-19.
1970
Traditional medicine: Still plenty to offer. Africa Report 15(7),
Oct. 1970: 24-5.
1972 Lusaka
children and their mothers. Medical Journal of Zambia 6:173f.
Leeson, J.,
and R. Frankenberg
1977 The
patients of traditional doctors in Lusaka. African Social
Research 23:217-233.
Le Nobel,
C.J.P.
1969
Maternity care in a Zambian district. Amsterdam: Jacob van
Campen.
Lieban, R.W.
1973
Medical anthropology. In Honigmann 1973: 1031-72.
Loudon, J.B.
1976a
Introduction. In Loudon 1976b: 1-48.
1976b
(ed.) Social anthropology and medicine. A.S.A. Monography 13.
London:Academic Press.
Maclean,
C.M.U.
1971
Hospital or healers: An attitude survey in Ibadan. Human
Organization 25:131-9.
McCulloch, M.
1951 The
southern Lunda and related peoples. Ethnographic Survey of
Africa. London: International African Institute.
Marwick, M.
1965
Sorcery in its social setting. Manchester: Manchester University
Press.
Meillassoux,
C.
1975
Femmes, greniers et capitaux. Paris: Maspero.
Mitchell, J.C.
1969 (ed.)
Social networks in urban situations: Analyses of personal
relationships in Central African towns. Manchester: Manchester
University Press.
Kaoma Rural
Council
n.d.
Minutes of the general meetings 1965-77. Kaoma. Mimeo
Munday, M.C.
1945 A
problem in sanitation: Lala childbirth. NADA 22: 50-2.
National Food
and Nutrition Programme, Zambia
1974
Nutrition Status Survey. Rome: UNDP.
Newson, Dr.
1932 Report
on investigation of disease Mumbwa-Kasempa July-August 1932,
Enclosure in file ZA1/9/28/21/1. Zambia National Archives,
Lusaka. Typescript.
Northern
Rhodesia
1930 Blue
Book for the year ended 31st December 1929. Livingstone:
Government Printer.
1955
African Affairs Annual Report 1954. Lusaka: Government Printer.
1956 Native
Affairs Annual Report 1955. Lusaka: Government Printer.
Nur, A.M.,
J.R. Wray and J.W. Kibukamusoke
1976 Health
survey of Mwaziona and Matero in the city of Lusaka
Medical Journal of Zambia 10, 2:34-41.
Ohadike, P.O.,
and H. Tesfaghiorghis
1975 The
population of Zambia. n.p.: CICRED series.
Polgar, S.
1962 Health
and human behavior: Areas of interest common to the social and
medical sciences. Current Anthropology 3: 159:205.
Raphael, D.
1976
Warning: The milk in this package may be lethal for your infant.
In Grollig and Haley 1976:129-36.
Republic of
Zambia, Ministry of Health
1969 Annual
Report for the Year 1967. Lusaka: Government Printer.
1972 Annual
Report for the Year 1968. Lusaka: Government Printer.
1976 Annual
Report for the Year 1972. Lusaka: Government Printer.
Roberts, S.A.
1977 (ed.)
Law and the family in Africa. Paris/The Hague: Mouton.
Schoffeleers,
J.M.
n.d. (ed.)
Guardians of the Land: Essays on Central African Territorial
cults. Gwelo: Mambo Press (in press).
Schültz, J.
1976 Land
use in Zambia. Part I: The basically traditional land-use systems
and their regions. München: Weltforum Verlag.
Sharpston,
M.J.
1971-72
Uneven geographical distribution of medical care: A Ghanaian case
study. Journal of Development Studies 8:205-22.
Shattock, F.M.
n.d. The
provision of primary health care in a developing country: Lusaka,
with special reference to the Teaching Hospital Filter Clinic and
the Matero Clinic Complex. Department of Community Health,
University of Zambia, n.p. (Lusaka, c. 1974). Mimeo.
Spring Hansen,
A.
1971
Fertility, marriage and ritual participation among the Luvale of
North-Western Province, Zambia. Seminar paper, Institute for
African Studies, University of Zambia, Lusaka. Mimeo.
1978 Faith
and participation in traditional versus cosmopolitan medical
systems in Northwestern Zambia. Paper presented at the
Twenty-first Annual Meeting, African Studies Association,
Baltimore.
Stefaniszyn,
D.
1964 Social
and ritual life of the Ambo of Northern Rhodesia. London:
International African Institute.
Stein, L.
1971
Medical facilities: Health and the prevention of disease. In
Davies 1971: 100-3, 127.
Symon, S.A.
1968 Notes
on the preparation and use of African medicine in the Mankoya
district Northern Rhodesia. In Apthorpe 1968: 21-77.
Turner, V.W.
1957 Schism
and continuity in an African society: A study of Ndembu village
life. Manchester: Manchester University Press.
1961 Ndembu
divination: Its symbolism and techniques. Rhodes-Livingstone
Paper no. 31. Manchester: Manchester University Press.
1962
Chihamba: The White Spirit. Rhodes-Livingstone Paper No. 33.
Manchester University Press.
1967a Lunda
medicine and the treatment of disease. In Turner 1967c: 299-358.
1967b A Ndembu
doctor in practice. In Turner 1967c: 359-93.
1967c The
forest of symbols. Ithaca: Cornell University Press.
1968 The
drums of affliction. Oxford: Clarendon Press.
Van
Binsbergen, W.M.J.
1975
Ethnicity as a dependent variable: The Nkoya ethnic identity and
inter-ethnic relations in Zambia. Paper read at the 34th Annual
Meeting, Society of Applied Anthropology, Amsterdam.
1976a The
dynamics of religious change in Western Zambia. Ufahamu 6, 3:
69-87.
1976b
Ritual, class and urban-rural relations: Elements for a Zambian
case study. Cultures et Développement 8,2:195-218.
1977a
Regional and non-regional cults of affliction in Western Zambia.
In Werbner 1977: 141-75.
1977b Law in
the context of Nkoya society. In Roberts 1977: 39-68.
1978a A simple
statistical method to disguise published quantitative data in
order to protect ethnographic privacy. African Studies Centre,
Leiden, Typescript.
1978b Class
formation and the penetration of capitalism in a Zambian rural
district. Paper read at the Seminar on class formation and social
stratification in Africa. Leiden, African Studies Centre.
n.d.(a)
Explorations in the history and sociology of territorial cults in
Zambia. In Schoffeleers n.d.
n.d. (b)
Ritual, class and urban-rural relations: The Nkoya of Zambia.
Forthcoming.
Van
Binsbergen, W.M.J. and H.A. Meilink
1978 (eds.)
Migration and the transformation of modern African society.
African Perspectives 1978/1. Leiden: African Studies Centre.
Van Velsen, J.
1964 The
politics of kinship: A study in social manipulation among the
Lakeside Tonga. Manchester: Manchester University Press.
1967 The
extended-case method and situational analysis. In Epstein 1967:
129-49.
Von Mering, O.
1962
Comment. In Polgar 1962:187-8.
Werbner, R.P.
1977 (ed.)
Regional cults. ASA Monograph 16. London: Academic Press.
Williams, T.R.
1975 (ed.)
Psychological Anthropology. The Hague: Mouton.
Zeller, D.L.
1974-75
Traditional and western medicine in Buganda: Coexistence and
complement. In Harrison and Dunlop 1974-75:91-103.
(c) Copyright:
Wim M.J. van Binsbergen, 1979
POSTCRIPT: THE
ROLE OF COGNITION
Wim M.J. van
Binsbergen
In his
introduction, Van der Geest point at what he claims to be a major
weakness in my contribution: the fact that I have ignored the
role of cognition as a determinant of the selection of specialist
healers. I am grateful for this opportunity to explain my
position more fully.
When, like in
the contemporary Nkoya situation, patients and their sponsors are
confronted with a plurality of medical systems, the problem of
which specialist healer they select, when, and why, is of obvious
theoretical and practical interest. Many medical
anthropologists44 have dealt with this selection problem as
follows. Participants are said to impose their cultural
classifications upon the diseases they suffer from. These
classifications interpret the nature of each disease, and imply
the specialist agent (if any) capable of curing it. Where
cosmopolitan health care is available along with forms of
indigenous medicine, people allegedly tend to classify some
diseases as 'suitable for hospital treatment', and others as 'to
treated by non-cosmopolitan healers'. In my own analysis I did
largely ignore this cognitive approach, and instead interpreted
the participants' switching forward and backward between
cosmopolitan and other healers as the outcome of a sustained,
complex social process - a process which had little to do with
the specific nature of the diseases involved, and which could be
understood retrospectively but could hardly be predicted.
The data as
presented in my paper provide support for my view that among the
Nkoya there is no one-to-one relationship between certain somatic
(or mental) symptoms, and the choice in favor of cosmopolitan or
non-cosmopolitan medicine. In the case of Edward, the same few
symptoms (coughing, fever, emaciation, lack of appetite, inflamed
eyes, retarded motoric development) , which recurred over a
period of 11/2 years, were subject to a shifting labeling
process. Sometimes his relatives imposed cognitive categories
such as shipelo (an unborn child's attack on his immediately
preceding sibling), lizina (illness springing from a name which
the bearer's ancestors do not approve of), or mpashi (illness
caused by an ancestor who is angry because of a violation of
kinship obligations between living kinsmen). I suggested how in
each instance the particular labeling could be understood as the
result of the ongoing social process in which the boy and his
relatives were involved; and I described this process in detail.
When the labels mentioned were applied, the boy's condition was
not considered amenable to cosmopolitan treatment, and local,
ritual cures were pursued instead. At other times the relatives
accepted the possibility that the very same somatic symptoms, in
the same boy, might be within the realm of cosmopolitan medicine.
They took the boy to hospitals and clinics, where such
cosmopolitan diagnostic categories as pneumonia, malnutrition and
conjunctivitis were pronounced, without the relatives opposing
these diagnoses or rejecting the modern treatment that was
indicated.
Edward's case
does not stand on its own. Our field-work involved us deeply in
the health problems of our Nkoya informants. Not only did we
collect people's statements on illnesses, their categories, and
explanations - in many cases we also examined the patients and
tried to treat them. Malaria, gastro-enteritis, respiratory
tuberculosis, bilharzia, hookworm and various forms of
conjunctivitis are among the most frequent diseases in Chief
Kahare's area. The attendant somatic symptoms are (with the
exception of hookworm), fairly unmistakable, and as easy to
discuss in the Nkoya language as they are in English. However,
when it came to labeling a particular combination of symptoms
with a Nkoya category diagnostic labels to the same set of
symptoms. Moreover, these labels had again widely different
implications as to the alleged illness-causing agent, and as to
the healer to be selected. Similarly, the same diagnostic labels,
such as wulozi, 'sorcery'; mashika,'cold'; and mulutu, '(hot)
body', were used to describe such different disease patterns as
malaria, gastro-enteritis, and respiratory tuberculosis. This
finding is rather at variance with Symon's (1968) description of
the medical system or the Nkoya and neighboring groups: without
any semantic analysis or methodological discussion, Symon's crude
listing or local disease names and treatments suggests a
one-to-one relationship between local diagnostic terms and those
of cosmopolitan medicine.
In essence,
however, Nkoya diagnostic categories form an idiom to discuss, in
a more or less coded and symbolic for, the social relationships
surrounding the patient. For instance, if these relationships are
currently in a state of intense conflict, and if in the patient's
social environment there is a strong interest, among one faction
or another, to bring this conflict in the open and force the
issue, then the diagnosis of wulozi ('sorcery') is likely to be
made by that faction. (For a case in point, cf. Van Binsbergen
1977b: 50f) Rival factions thus implicitly accused of evil
practices, or this parties who have an interest in playing down
the conflict, will instead propound alternative diagnostic
labels: e.g. bituma (a spirit affliction unrelated to human
aggression; cf. Van Binsbergen 1977a); wulweli ya Nyambi
('illness sent by God', i.e. regardless of human deeds); wulweli
wa Bamukuwa ('Europeans' illness', i.e. amenable to cosmopolitan
treatment); etc. Typically, the various parties involved try,
through display of formal authority, gossip, and rumors, to
influence the patient, sponsors, and public opinion in general,
so as to have their own interpretation of the disease prevail.
This struggle is in itself part of the social process in which
the patient, and the surrounding parties, are involved, and its
outcome depends on their relative strength. Once the patient and
his sponsors have accepted one diagnostic category as the most
applicable one, they thereby commit themselves to a particular
type of healer45 until further developments take place in the
social process, necessitating a new interpretation of the same
patient's complaints. Edward's case provides illuminating
examples of this.
Thus it would seem as if, in the Nkoya case, the cognitive
approach cannot in itself throw light upon the selection problem.
There is no denial that Nkoya medicine, like any other medical
system in the world, is also a cognitive system; and I should
have described this system more systematically and in greater
detail. This cognitive system, with all its obscure symbolic
implications, sets the boundaries within which Nkoya health
action can take shape, and defines basic fears as well as the
possibilities for mutual identification within the community and
across the urban-rural divide. For this reason cognition
constitutes one of the pivotal elements of Nkoya society. But
between the cognitive system, and actual health action, stands
the ongoing social process, which determines which elements in
this cognitive system will be selected for action. Where
medico-anthropological studies have so far ignored the social
process, I still feel justified in concentrating on it.
REFERENCES
Apthorpe, R.J.
(ed.)
1968
Rhodes-Livingstone Communication no. 15 Lusaka:
Rhodes-Livingstone Institute (1959).
Honigmann,
J.J. (ed.)
1973
Handbook of Social and Cultural Anthropology Chicago: Rand
McNally College Publishing Company.
Lieban, R.W.
1973
Medical Anthropology. In Honigmann 1973: 1031-72.
Roberts, S.A.
(ed.)
1977 Law
and the Family in Africa. Paris/The Hague: Mouton.
Symon, S.A.
1968 Notes
on the Preparation and Use of African Medicine in the Mankoya
District, Northern Rhodesia. in Apthorpe 1968: 21-77.
Van
Binsbergen, W.M.J.
1977a
Regional and non-religious Cults of Affliction in Western Zambia.
In Werbner 1977: 141-75.
1977b Law in
the Context of Nkoya Society. In Roberts 1977: 39-68.
Werbner, R.P.
(ed.)
1977
Regional Cults. ASA Monograph 16. London: Academic Press.
(c) Copyright:
Wim M.J. van Binsbergen, 1979
NOTES TO PART
II
30King 1966:
section 2: 6 and 2: 9; Fendall 1965; Sharpston 1971; Stein 1971:
100.
31Stein
reports (1971: 127) that only 9% of the under-five population is
brought to clinics, while re-attendance averages only 3.4. visits
per child. Mary's health action in this respect is therefore
fairly representative in the Zambian context; understanding of
her choice of alternatives is likely to have wide applicability.
However, Nur et al. (1976) quote much higher figures for the
Lusaka municipal township of Matero.
32For a
general criticism of the notion that 'tradition' or 'culture
could serve as an explanatory in the study of health action, cf.
Lieban (1973: 1058) and Erasmus (1961).
33Reference is
to recent urban immigrants in Lusaka in the early 1970s.
34It is
remarkable that, as late as 1962, patients' secondary reactions
to health institutions etc. had to be discovered as a forgotten
factor in the utilization of cosmopolitan medicine and its
alternatives; cf. Von Mering 1962; Polgar 1962.
35The same
point is made by Leeson 1970: 10f; for a Nigerian parallel, cf.
Ademuwagun 1973: 72f.
36Cf. Craemer
and Fox 1968; Jayaraman 1969; Frankenberg and Leeson 1974.
37Frankenberg
& Leeson 1974: 261; Ademuwagun 1973: 73f.
38Gonzalez
1966; Lieban 1973: 1056f; concerning Zambia, e.g. Quintanilla, as
quoted in Grollig & Haley 1976: 450.
39Turner 1957,
1967c, 1968; however, cf. Van Binsbergen 1976b.
40Let it be
understood that I do not consider such extended-case analysis as
an alternative to sophisticated quantitative analysis. Far from
being incompatible, such quantitative analysis should follow at a
later stage, once the fundamental determinants of health agency
utilization have been identified qualitatively. Current
quantitative studies in this field, however, have seldom reached
this stage, and often remain crude, 'fact-finding' exercises,
prone to produce artifacts by solely considering the speech
reactions of individuals while ignoring the social processes in
which they are involved.
41Meanwhile it
must be clear that the structural conditions surrounding the
interplay between cosmopolitan and local medicine, an analysed
here for the Nkoya case, are very specific; the preliminary Nkoya
findings are not likely to apply to other societies, with
different internal structures and with different forms of
incorporation in the modern economic and political world system.
42Cf.
Frankenberg and Leeson 1974 for similar views.
43I wish to
direct my readers' attention to two important publications which
appeared too late to be included in my argument: Spring Hansen
1978 and Janzen 1978. Janzen's is by far the richest and most
comprehensive study yet available on the interplay between
medical systems in Central Africa. In this last-minute footnote I
could hardly do justice to these works.
44Cf. Lieban
1973: 1056 f. and references cited there. Lieban is however
rather critical of the accepted views.
45My emphasis
is on the cognition of the patients and their sponsors; the
specialist healers each use a diagnostic system that tends to be
more technical, elaborate, idiosyncratic, and orientated towards
somatic symptoms, than are the laymen's diagnostic categories on
which the patients and sponsors base their choice of healers in
the first place.
page last modified: 05-02-01 20:58:29 | |