Traditional psychiatric practices in Africa

Abstract

Many leaders in Africa bemoan the disappearance of African culture, including the use of traditional medicines, and there have been numerous calls for recognition of their value and for the integration of these treatments into orthodox medicine. This is especially so with regard to psychiatric disorders. The literature on psychiatric practice in Africa contains very few references to herbal treatments, however, and more is to be learnt about the use of herbs as adjuvants in the solution of psychosocial problems from the anthropological literature. At a conference held in the University of Ife in 1974, psychiatric disorders were not included in a list of nine conditions (e.g. cancer) in which it was recommended that herbal treatments be further investigated.

Questions of definition

The term ‘traditional medicine’ covers diverse health practices, approaches, knowledge and beliefs, as well as medicines that incorporate plant, animal and/or mineral substances, spiritual therapies, manual techniques and exercises (World Health Organization, 2002). Herbal treatments cannot be described separately and it should be noted that many ‘traditional medicines’ consist of mixtures containing, in addition to those listed, modern pharmaceutical products. I will use the terms ‘traditional medicines’ and ‘herbal medicines’ interchangeably. Traditional healers are called isangoma in South Africa, ng’anga in Zambia and ngengang in Cameroon, and many other variants, but all these names have a common origin.

African herbal medicine is rightly classed with complementary and alternative medicine, and also with systems such as Chinese medicine, Ayurveda and Unani, which have strong, coherent traditions. On the other hand, most traditional healers in Africa have relied largely upon verbal traditions and apprenticeships. Last (1990) has pointed out that traditional healers (especially of the ‘sacred’ kind, who also use herbal medicines) are too diffuse a group, and their knowledge and practices too rooted in local contexts, to be effectively standardised. This is not to say that traditional healers’ associations do not exist in many African countries, and in some their members regularly meet for the exchange of information and views. Because of a lack of formal training, it is not surprising that disagreements arise between healers, even regarding the names of the shrubs or trees being used. In a meeting with traditional healers which I attended, we had to resort to members of the Forestry Department (who were well informed) to try to resolve disputes in identifying specimens.

Types of herbal medicine

Chavunduka (1994) has presented a list of herbal preparations classified largely according to their use. He starts with simple herbal medicines which can be used by anyone, such as those used for headache, the common cold, nose bleeds or diarrhoea. Other herbs with medicinal properties must be administered by a skilled practitioner, such as those for more complex medical conditions or medicines used for severe symptoms, which must be administered according to a special ritual. In his list, Chavunduka includes the following uses:

• prophylactic purposes – for example to ensure that a baby develops a good set of teeth, or to prevent convulsions, or as contraceptives, or to discourage unwanted behaviours

• as a way of enforcing law and morality – for example to bring harm to a woman committing adultery when she uses a bed in which medicine has been placed, or to detect crime (sometimes in the form of trial by ordeal).

Herbs are also used to bring luck, in potions with the purpose of injuring someone, to assist in a change of lifestyle (for example for heavy drinkers) and to change animal behaviour (for example to make guard dogs fiercer). Thus herbs have many uses besides their purely medical ones, and this is consistent with views on their function.

Most traditional healers are willing to admit that the proximate cause of the symptoms and signs of illness are physical, but they will look at the cause of the disease not in terms of any pathological process but in terms of intent, which may arise within a person or some supernatural agent.

What herbal medicines are thought to do

Most traditional healers are willing to admit that the proximate cause of the symptoms and signs of illness are physical, but they will look at the cause of the disease not in terms of any pathological process but in terms of intent, which may arise within a person or some supernatural agent. Since it cannot be known how a person or supernatural agent manifests this intent, whether hostile or good (for example to protect against harm), there are no descriptions of how the medicines work. An explanation for an illness may be given as ‘The spirit of your grandfather is displeased and has removed his protection’. Because a supernatural agent is involved here, who must presumably be communicated with via a ritual, herbs alone are unlikely to be effective unless they are administered or used according to a set of very strict rules.

Boyer (2002) has conceptualised this in terms of misfortune (including illness) as social integration. He writes: ‘the particular ways in which they [those explaining misfortune] represent these situations is framed by their social interaction inference systems’, for instance evil spirits being seen as enforcers of unfair deals and witches as cheats. Contact must be made with these entities and it must be believed that they are subject to influence. Often these social explanations involve problems in personal relationships which, if looked at in a clinical setting, will be seen to be important factors in psychiatric disorders. Boyer links this conceptualisation to the existence of local specialists who are recognised as being different from other people; medicines will not be effective unless they are administered by those who have the knowledge and authority to use them. Boyer makes reference to local knowledge and locally recognised expertise, using locally known herbs. While it is evident that the clients using herbs will have no knowledge of how a medicine actually works, they will be expected to accept that they must be administered in a particular way.

Other herbs with medicinal properties must be administered by a skilled practitioner, such as those for more complex medical conditions or medicines used for severe symptoms, which must be administered according to a special ritual.

While in rural areas the traditional healer tends to use the approach described above, there are also many herbalists, who may be defined as people who study, collect, sell, or administer herbs or plants as medicines for the treatment of diseases in human beings. Many such herbalists are found in markets in major cities and towns, and their herbs are sold with no stipulation of the details of their use in terms of ritual and so on. And there is another difference: buyers usually purchase single herbs, whereas the traditional healer may well provide a medicine which contains a mixture of herbs, or may use different herbs during various phases of a ritual.

Is use of herbal remedies decreasing in Africa?

There can be no doubt that Africans take a very pragmatic approach and they will seek the medicines they know to work – but much depends upon the criteria for success. For example, cessation of fits may have to be accompanied by propitiation of angry ancestors.

We can surmise that people living in rural areas and some living in towns will use common folk remedies. The extent to which people have access to orthodox medicine must inevitably be a factor in the degree to which they do so, besides the question of personal preference. Crude estimates of numbers are misleading. There are too few trained health workers in many rural areas of Africa. Comparisons are often made between the numbers of traditional healers (mostly estimates with no stated defining criteria) and the paucity of doctors, when, in fact, most basic health care is provided by clinical officers and nurses, who are far more numerous.

There are few estimates of the proportion of populations consulting traditional healers and there is little reliable information on preferences. In an on-going study of epilepsy and stigma in Zambia, in which church leaders (pastors and priests) were interviewed, 92% of the 149 respondents stated that they would seek orthodox medicines and 34% stated that they would use a traditional therapy; 32% of those advocating orthodox medicine would also seek traditional medicine. Of the 68 who stated that a member of their extended family had suffered from epilepsy, 42% stated that they would use traditional therapy. There can be no doubt that Africans take a very pragmatic approach and they will seek the medicines they know to work – but much depends upon the criteria for success. For example, cessation of fits may have to be accompanied by propitiation of angry ancestors.

It has been remarked that few herbs appear to have any great potency, especially those which may be directly purchased. Seeking out herbs which are effective when mixtures are being used and when the constituents of mixtures may vary from healer to healer makes the task even more formidable.

The place of herbs in modern medicine in Africa

It is often recommended that the use of traditional means of therapy, including herbs, be integrated into modern healthcare systems. There are various ways in which this could be done, and these are not necessarily mutually exclusive. One is to seek out promising herbs and to have them made available, either as traditionally prescribed or after processing into recognised pharmaceutical products. But the number of herbs used by healers is very large – 54 medicinal herbs used by one healer in Congo, for example (Janzen, 1978). It has been remarked that few herbs appear to have any great potency, especially those which may be directly purchased. Seeking out herbs which are effective when mixtures are being used and when the constituents of mixtures may vary from healer to healer makes the task even more formidable.

It is frequently stated that health professionals should work directly with traditional healers in the detection of potent medicines. I have said little of the rituals used by healers because of their complexity (see Janzen, 1978, for example) and their extreme variability in terms of choice of herb, so this would seem to be an impractical recommendation. The authors of a study from South Africa (Behr & Allwood, 1995) stated, after allowing a healer to examine and recommend her own therapy for four of their patients: ‘Although there are probably advantages to unifying traditional and Western psychiatric care, we may have to conclude … that the two systems are best left to function independently’. Gureje & Alem (2000) state that when policy makers have talked about the need to integrate traditional healthcare into orthodox service delivery, the modus operandi of this integration has not been well articulated. They state that a policy of integration ought to have as one of its primary goals an examination of the nature of traditional practices, and that proof of efficacy and safety need to be available before any pharmacologically active compound (including herbs) can be used. This is endorsed by the World Health Organization (2002), which sets out a checklist of criteria that include: ‘establishing safety monitoring of herbal medicines and the establishment of national standards, and technical guidelines and methodology, for evaluating safety, efficacy and quality of traditional medicines’.

Conclusion

The literature is insufficient to allow any general or comparative survey of the use of herbal medicines in managing mental illness in Africa. Mental health workers ought to try to gain some understanding of local beliefs surrounding the use of traditional medicine, including the use of herbal medicines. But caution must be used in engaging in more active collaboration in their use without applying the accepted international standards regarding efficacy and safety as are applied to modern pharmaceuticals.