On Knowing and Not Knowing in the Anthropology of Medicine

Roland Littlewood

• Publisher: Routledge
• Year: 2016
• Print ISBN:
  9781598742756
• eBook ISBN:
  9781315423319
• Topic: Social Sciences
• Subtopic: Anthropology
• Index: Social Sciences

Social scientific studies of medicine typically assume that systems of medical knowledge are uniform and consistent. But while anthropologists have long rejected the notion that cultures are discrete, bounded, and rule-drive entities, medical anthropology has been slower to develop alternative approaches to understanding cultures of health. This provocative volume considers the theoretical, methodological, and ethnographic implications of the fact that medical knowledge is frequently dynamic, incoherent, and contradictory, and that and our understanding of it is necessarily incomplete and partial. In diverse settings from indigenous cultures to Western medical industries, contributors consider such issues as how to define the boundaries of "medical" knowledge versus other kinds of knowledge; how to understand overlapping and shifting medical discourses; the medical profession's need for anthropologists to produce "explanatory models"; the limits of the Western scientific method and the potential for methodological pluralism; constraints on fieldwork including violence and structural factors limiting access; and the subjectivity and interests of the researcher. On Knowing and Not Knowing in the Anthropology of Medicine will stimulate innovative thinking and productive debate for practitioners, researchers, and students in the social science of health and medicine.

1

The Importance of Knowing about not Knowing

MURRAY LAST

Introduction

I wish to raise the question of how much people know, and care to know, about their own medical culture and how much a practitioner needs to know in order to practice medicine.¹ If the answer to both questions is “very little,” then the concept of “medical system” will need to be reexamined, as will the notion of pluralism. In this essay I suggest that under certain conditions not knowing or not caring to know can become institutionalized as part of a medical culture and that it is inadequate, then, simply to claim there is still at work an unconscious system embedded, for example, in the language.

The reluctance in ethnography to record what people do not know is understandable; it is hard enough to record what they do know. On a superficial level every investigator has received the answer “don’t know” and has been unsure whether the answer was the truth or simply a snub. Many anthropologists have relied on one “best” informant if for no other reason than that this person “knew” and could express this knowledge. Without such an informant models are apt to be constructed like a jigsaw from information collected piecemeal from the less knowledgeable; the process is embellished sometimes by the label “cross-checking.” In an earlier paper,² I have argued that medical information in particular is liable to be layered, and as an outsider one may seep through into the inner layers of knowledge; yet the deeper one goes, the less certain is that knowledge. Furthermore, the researcher is always open to having a “leg pulled,” particularly as the process of inquiry is often either richly comic or deeply aggravating to others. None of this should surprise us, accustomed as we are in our own societies to the uneven, often bizarre distribution of knowledge, although I am astonished at our subsequent claims to know something as recondite as another medical culture. To discuss, then, the extent of not knowing is presumptuous in the extreme; nonetheless to ignore the existence of not knowing in medicine only negates our very claim to know another medical culture.

My other concern in this essay is the problem of alternative systems. Instead of treating them as isolates or even as competing equals, I rank them in a hierarchy of organization and access to government funds. For it is clear that the different methods of treatment vary widely in the extent to which they are systematized and recognized as a system by practitioners and patients. In short, the problem I suggest is one of inequality and the effect this has had on traditional medicine and its relationship to other methods of medicine.

The connection between not knowing and/or not caring to know and a hierarchy of medical systems lies in my argument that the medical system at the bottom of the hierarchy can become desystematized and that one striking symptom of this is a widespread attitude, to be found among patients and to a lesser extent among practitioners, of “don’t know,” “don’t want to know.” In our own societies lay disinterest in the intricacies of medicine is commonplace, but the public recognizes that there is a system. What I am suggesting here is that under certain conditions traditional medicine is not recognized even as a system, yet it can still be practiced widely and be patronized by the public.

To convince the skeptical reader I have to show first that there is a hierarchy of medical systems; second, that there is such a thing as a “nonsystem”; third (and hardest of all), that not knowing and not caring to know are genuine attitudes of mind and that they are very important to the medical culture. Negative evidence, which might reveal a nonsystem and extensive not knowing, is not commonly recorded in ethnographies; their purpose was, naturally enough, to explain a system of medicine and to unravel the complexities of knowledge—and in the past, no doubt, systems were really systems. I am using the term “medical culture” for all things medical that go on within a particular geographical area. It is consequently a term wider than “medical system,” as will become clear from the example that follows.

The Medical Culture of the Malumfashi Area

Malumfashi (then Kaduna, now Katsina State, Nigeria) is by Hausa standards a medium sized district headquarters that in the 1963 census had a population of 17,000; the district’s population was 177,000. A strongly Muslim Hausa town, it nonetheless had a Christian immigrant population from more southerly states of Nigeria and a scattered “pagan” Hausa or “Maguzawa” population in the surrounding countryside. I came to Malumfashi in 1969, after some six years of historical research elsewhere in Hausaland, in order specifically to study Hausa medicine. My three years of research were completed before large scale studies by the Medical Research Council and the World Bank–financed Funtua Agricultural Development Project got under way. Most of my research was conducted from a Maguzawa farmhouse fifteen miles from Malumfashi, but only after an intensive survey of a Muslim village and a pastoralist Fulani hamlet had been carried out. My data are best, therefore, for the most traditional end of the spectrum that makes up Malumfashi’s medical culture.

At one end of the spectrum of medical practice is the set of treatments deriving from “Western” or hospital medicine. A branch of Ahmadu Bello University’s teaching hospital is located on the outskirts of Malumfashi town; so too are or were Protestant and Catholic mission dispensaries. Government dispensaries and leprosy clinics also operate in the area, as do—at a much more informal level—peddlers of pills, liniments, and even injections. Although conventionally one describes hospital medicine as a coherent system and the hospital as a single homogeneous unit, in reality the hospital is staffed by people of widely different cultural and linguistic backgrounds and of varied technical competence; yet all these, in their private capacity, represent hospital medicine and may give advice or procure treatment after their own manner.³

At the other end of the spectrum is the enormous variety of treatments that is included under the label “traditional.” The variety reflects not only the diversity within the culture of the dominant Hausa group, but also the large immigrant population, some of whom even import folk culture (for example, Rosicrucian ideas) from abroad. Between these two ends of the spectrum is Islamic medicine, relatively strongly systematized but over-lapping in its herbal specifics with “Western” medicine and in its concern for spirits or jinn with traditional cures. The core of its treatments is based on the use of Arabic texts, and its practitioners are expected to be Islamic scholars or students and to work within an Islamically orthodox framework. Government and universities, although providing education in Islamic studies, do not specifically include Islamic medicine, but much of what is taught is relevant to it; furthermore, the texts of Islamic medicine in Arabic are widely available.

The historical antecedents of this medical culture are broadly as follows. During the nineteenth century the area became depopulated by almost annual warfare; hence, Malumfashi town was only resettled less than a hundred years ago. A large proportion of the present population migrated in from adjacent areas between 1890 and 1930 and the town still retains something of a frontier atmosphere. Although the early nineteenth century Islamic reform movement was the source of the local political and ideological framework that governed the new frontier community, the community’s territorial expansion was possible only under colonial rule. The early period (ca. 1903–1940) of colonial government also witnessed the burgeoning of a more strict Islamic culture throughout Hausaland, in part as a response to colonialism; by contrast the impact of Western culture, and Western medicine in particular, was slight. Only in the later colonial period (ca. 1945–1960) and during the decade since independence in 1960 has modern medicine become part of the area’s medical culture; along with dispensaries there also came schools and all that better roads bring. The degree to which Western medicine was associated with colonialism (as, for example, in the manner described by Frantz Fanon⁴) is not clear; certainly an unflattering folklore exists. Much more important historically, however, has been the role of Islam in “colonizing” the medical culture of the area. By according non-Muslims an inferior status politically and culturally, Islam has undermined the authority of traditional medicine. Maguzawa, although diverse and often Muslim in origin, now form part of a rural lower class and are treated almost as a pariah group for whom the peddling of traditional pagan ritual services is seen as an appropriate part time occupation. Since other aspects of non-Muslim Hausa culture have been of less interest to the rest of the community, many of the traditional social ceremonies such as initiation and even weddings have been shorn of particular elements or gradually altered their significance. However, the formal continuation of non Muslim culture has been necessary in order to validate some of the rituals of traditional medicine for the rest of the community, and if for no other reason the specifically non Muslim aspect of this segment of society still persists. Meanwhile Islamic medicine, faced with the recent extension of hospital medicine to the area, has become predominantly the medicine for social ills, preventing or curing unpopularity, warding off financial disaster. It still offers a wide range of specifics, especially for ailments that hospitals do not cure, but it faces considerable competition in this from patent remedies of a modernizing kind.

In short, the sequence of dominant medical systems within this medical culture is:

1. a putative traditional Hausa medicine⁵ now maintained, probably in a much altered form, mainly by Maguzawa

2. an Islamic medicine that was particularly strong during the early colonial period, and

3. hospital medicine, important in the late colonial period but now freed from its association with colonialism and financed by government.

Is Traditional Medicine in Malumfashi Still a “System”?

The criteria I wish to use in assessing how far a method of medical practice is systematized, or is seen by either its practitioners or its patients as a system, are as follows. The top end of the scale would be occupied by a system in which:

1. There exists a group of practitioners, all of whom clearly adhere to a common, consistent body of theory and base their practice on a logic deriving from that theory.

2. Patients recognize the existence of such a group of practitioners and such a consistent body of theory and, while they may not be able to give an account of the theory, they accept its logic as valid.

3. The theory is held to explain and treat most illnesses that people experience.

Applying these criteria to traditional medicine in the Malumfashi area, we find, first, traditional healers form a category in M. G. Smith’s terms,⁶ rather than a corporate group. They have no association, no examinations, no standard treatment. Indeed they compete with one another, using different curative techniques. There is in consequence no “local doctor” accepted by all the community, and as choice of practitioner is also governed as much by kinship links as by medical reputation or convenience, a more distant healer is often consulted before the neighborhood expert.

The various Hausa terms used—boka, mai magani, mai Danko (or mai BaGwari, etc.), Sarkin Mayyu—do not denote either a hierarchy of skill or an area of medical specialization, although they might provide a clue to the healer’s sex or ethnic background.⁷ The distinction between, say, herbal remedies (from a boka) and spirit possession rituals (from a mai Danko) is spurious, since both a boka and a mai Danko will use both kinds of treatment.

The technicians of traditional medicine—the barber surgeon (wanzami), the bonesetter (madori), the midwife (ungozoma)—form a separate group; they are treated more as professionals and, in any case, tend to be Muslims. Only the first, the barber surgeon, is formally recognized as a craftsman with the local expert appointed as Master Barber (Sarkin Aska or Magajin Aska) and is thus in effect licensed (e.g., to perform circumcisions). The other two professionals render strictly limited services but nonetheless vary widely in the details of their techniques. They are not required to diagnose illnesses since they are called in only to perform their specialized duties.

By contrast, the traditional healer not only has to diagnose but also may be called upon to render a range of services such as fortune telling, supplying poison, and guarding or otherwise coping with wandering lunatics. In practical medicine, the practitioner’s main rivals are the individuals, to be found in almost every house, who have inherited some specific nostrum (for example, against the pain of scorpion bites) or amateur practitioners of spirit possession. But major problems, like mental illness, are not amenable to do-it-yourself home remedies, and these, along with residual cases of medical catastrophes, are apt to end in the care of the boka. Nevertheless, a proportion of all traditional healers has to take to the road and peddle their skills often among “foreign” communities such as the Yoruba; similarly, healers from the Niger Republic tour the Malumfashi area. The value of their remedies lies in their very strangeness, in their not being part of a known system of medicine.

In short, the range of traditional healers that serves the Malumfashi area cannot be said to adhere to a single consistent theory of logic, except insofar as they are defined negatively, as not offering hospital or Islamic medicine. Nor, since traditional medicine is too diffuse to be monopolized, do healers form an exclusive group.

Second, patients and their kin do not expect their traditional doctors to have a consistent theory or form a cohesive group. Instead they accept that the different systems and methods of medicine have only a limited validity, although people do treat traditional medicine also as a residual category when other methods seem too dangerous or simply inadequate. This is best illustrated by a folk theory of ethno-ecology that, given the social component in illness, has considerable sociological insight. According to this theory, each ethnic community carries within itself not only its own specific illnesses but also its own cures. Thus European medicine was necessary originally only for Europeans, then later for those who had to operate in European society; now, finally, as “modern medicine” it has the best cures for modern illnesses caught in modern society. Similarly, Muslim medicine, although much less sinister (and less powerful), is nonetheless essential for those who have to visit or work in a Muslim community, while non-Muslim medicine can cure, for all members of the community, not just the ailments caught deep in the bush but also aberrant “throwbacks” such as lunacy or a sinister malformation. Fulani pastoralists (who share the deep bush with Maguzawa) also have their own ailments and cures, but both groups tend to treat each other’s patients for some illnesses, thus transferring to the other group not only the patient but also some of the blame for the existence of the illness.

In this ethno-ecological theory, then, medicine is being seen not so much as a medical system but as part of the necessary cultural camouflage, like clothing and food, that enables one to survive, preferably unnoticed, in a diverse society. There are no “alternative” treatments, only appropriate ones—appropriate, that is, to the place where one happens to be.

However, the theory is more complicated in practice and has been modified over time. For example, hospitals are now recognized as at least temporarily effective against traditional illnesses since hospitals, so carefully fenced off and manned with guards, are “no-go areas” for spirits; relapses may occur, though, as soon as one leaves the gates. In contrast, and particularly in the past, one needed one’s own medicine as well in order to survive a stay in a hospital, since hospitals are places of extreme danger (being one of the sources whence Europeans derived their magical power and domination over the local community), and one must be protected from the doctors, too. Implicit here is the recognition that the medical and geographic sphere in which traditional medicine is relevant is liable to shrink, and indeed has shrunk in recent times. Certain classes of spirits, for example, have died out, while other spirit-linked illnesses are now confined to women. In short, one of the fundamental premises of traditional medicine—that spirits control illness—seems to be giving way, and if the present trend continues, only the herbal aspect of traditional medicine will survive while spirits become for some mere figures of the theater.

Third, from what has already been said, for traditional medicine to have a single comprehensive theory to account for all illness is out of the question. But it seems that even a coherent set of ideas, embedded in the language or implicit in people’s actions, has now disappeared. Fragments of a theory, with associated medical “facts,” seem to survive, but it also seems impossible to make a proper historical reconstruction for any particular period, place, or people; in the theory’s breakup, the fragments and the “facts” have themselves been altered beyond the recall of people’s memories. The most striking evidence for the difficulty in prizing a coherent theory out of the language is the lack of an agreed medical vocabulary not only among patients but also among practitioners. In trying to construct a Hausa medical dictionary I found what several others before me have found—as a comparison of all our vocabularies shows—that a large proportion of medical words (but especially terms for illnesses) have no standard meaning. The Ministry of Health issued a list of terms t...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Introduction: Not Knowing about Medicine
• 1. The Importance of Knowing about not Knowing
• 2. Coconuts and Syphilis: An Essay in Overinterpretation
• 3. On “Medical System” and Questions in Fieldwork
• 4. Explanatory Models and Oversystematization in Medical Anthropology
• 5. The Ambivalence of Integrative Medicine
• 6. Not Knowing about Defecation
• 7. Christianity, Tradition, AIDS, and Pornography: Knowing Sex in Western Kenya
• 8. Feeling and Borderlinking in Yaka Healing Arts
• 9. On Knowing and not Knowing in Latvian Psychiatric Consultations
• 10. Farewell to Fieldwork? Constraints in Anthropological Research in Violent Situations
• 11. Neutralizing the Young: The South African Truth and Reconciliation Commission and Youth
• 12. In Touch without Touching: Islam and Healing
• About the Contributors
• Index