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Articulate(d) Bodies: Traditional Medicine in a Tanzanian Hospital

Author(s): Stacey A. Langwick

Source: American Ethnologist , Aug., 2008, Vol. 35, No. 3 (Aug., 2008), pp. 428-439

Published by: Wiley on behalf of the American Anthropological Association

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STACEY A. LANGWICK

Cornell University

Articulate (d) bodies: Traditional medicine in a Tanzanian hospital

ABSTRACT Hospital practitioners in East Africa see traditional

and modern medicine interrupt and interfere with

one another on hospital grounds everyday. In

response, nurses and nurse's aides have developed

innovative ways of assembling diverse therapies and

the knowledges, practices, desires, and medicines of

which they consist. Through their care and

coordination, nurses and nurse's aides forge complex

bodies within the therapeutic interruptions and

interferences they face in their clinical work.

[traditional medicine, biomedicine, body, ontology,

Tanzania, Africa]

owhere in Tanzania is modern medicine seen as a sufficient re

N source to care for all health concerns and complaints. Not only patients but also biom?dical practitioners and government bu reaucrats recognize that biomedicine is only one element in a broader therapeutic ecology. In striving to meet health de

velopment goals, the Tanzanian ministry of health, with the support of the World Health Organization (WHO), the World Bank, and other mem bers of the international community, has formally invested in the sci entific development of traditional medicine since the 1970s and in the professionalization of traditional healers since the 1980s. The elabora tion of traditional medicine through such laboratory investigations and bureaucratic management is filling out the category of knowledge and practice first evoked through colonial encounters and prohibitions.1 This genealogy begins to suggest the particularities of the pluralism shaping of ficial postcolonial efforts to delineate and modernize a field of traditional medicine. To enable medical science to assess, evaluate, and deploy them, so-called traditional treatments and practitioners must be conceived of as resources for (and therefore distinct from) their biom?dical counterparts. The (in)commensurabilities evoked in this vision facilitate the transforma

tion of traditional medicines into pharmaceuticals and the reduction of healers to outreach workers referring clients to the clinic but not adminis tering treatments themselves (Adams 2002; Janes 1999). This institutionally articulated medical pluralism and the forms of integration it promotes dif fer, however, from the more pragmatic relationship between modern and traditional medicine enacted in the clinic.2

The clinic directs attention toward practice, highlighting the fundamen tally interventionist nature of medical care. Clinical staff, as well as pa tients and kin, strive to attend to affliction, pain, debility, and misfortune; they strive to act. The urgencies and inadequacies of biomedicine in Africa shape the conditions under which interventions can be imagined and care carried out. Others have written of the ways that biomedicine crafts a space of emergency in which individual bare life marks the success of care

AMERICAN ETHNOLOGIST, Vol. 35, No. 3, pp. 428-439, ISSN 0094-0496, online ISSN 1548-1425. ? 2008 by the American Anthropological Association. All rights reserved. DOI: 10.1111/J.1548-1425.2008.00044.X

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Articulate(d) bodies American Ethnologist

(Nguyen 2007; Redfield 2005). Yet many clinics in Africa are not consistently equipped with even the most well-known technologies and medicines for facilitating basic medical care. In Tanzania, nurses and nurse's aides evoke traditional

medicine in their attempts to mediate this double bind.3 In this article, I argue that biomedicine's inability to address the very crises that constitute it as a necessity is leading to the formulation of new realities and new bodies at the in tersection of traditional and modern medicine.

Although ideas of distinct medical systems remain im portant to institutionalized projects of integration, fewer and fewer anthropologists invest analytically in the in dependence of traditional and modern medicine or the hierarchies that their separation enables.4 In arguing for the changing nature of that which is called "traditional," accounting for the sophisticated, shifting positioning of healers, and chronicling the emergence of new fields of knowledge, anthropologists have complicated many of the modernist agreements that have shaped studies of med ical pluralism. Accounts of healers' engagements with

medical technologies (e.g., using syringes, reading patients' diagnostic tests, and combining their medicines with phar maceuticals) and with biom?dical concepts (e.g., address ing biom?dical disease entities and arguing for the scien tific validity of their medicines) challenge the self-evidence of boundaries between traditional and modern medicine.

We have not, however, trained our attention as directly on the ways in which postcolonial biomedicine is be ing simultaneously refigured by the interruptions of tra ditional medicine.5 I am interested not only in the ways that healers innovate in the face of biomedicine's interrup tions (Langwick 2001) but also in the ways that biom?dical practitioners innovate in the face of traditional medicine's interruptions.

Hospital practitioners in Tanzania witness traditional and modern medicine interfering with one another daily on hospital grounds.6 The realities of affliction, discomfort, debility, and relief present themselves through the intersec tion of diverse forms of healing practice. Focusing on nurses and nurse's aides in one district hospital in Tanzania, I de scribe some of the ways that biom?dical and nonbiomedi cal therapies are coordinated in the service of treatment.7 As Annemarie Mol (2002) has demonstrated, biom?dical prac titioners strive to enact bodies that are coherent for a mo

ment, long enough for therapeutic transformation or relief; or if one reflects on the root of the Kiswahili word kupona, to cure, then biom?dical practitioners strive to enact bodies that cohere long enough to be cooled. Tanzanian medical

worlds compel the coordination not only of the tests in the lab, the images from the X-ray room, and the intake history collected in the doctor's office but also of the body (or bod ies) of traditional medicine. Nurses and nurse's aides are ar

ticulating new bodily assemblages; that is, they are joining together versions of bodies to allow for movement, for inter

vention into the complex life of pain, debility, and suffering in Tanzania. The very multiplicity of such bodies enables

ways of acting within the therapeutic interruptions and in terferences faced by clinical staff in their work. These newly articulated and articulate bodies have a temporal dimen sion, as do all objects in practice.8 They emerge in an effort to generate action, not to populate the world indefinitely. They cohere to direct attention as long as the care that they facilitate is considered useful. The institutionalized forms of

integration imagined in health development programs dif fer epistemologically and ontologically from the more prag matic relationship between traditional and modern reme dies, healers, and knowledge in the clinic.

The work of the clinic seems to compel the cultivation of skills to discern afflictions or aspects of affliction that might be best treated by one form of therapy or another. To address the demands and the complaints that are made at the intersection of a variety of powerful ways of think ing about, articulating, and acting on the body, nurses and nurse's aides in Tanzania cannot not afford to think of tra

ditional and modern medicine separately.9 In response to this reality, they are developing ways of coordinating di verse therapies and the knowledges, practices, images, de sires, and medicines of which they consist. Nursing care comes to render bodies compatible with both traditional and modern treatments. To explore the complexity of heal ing in Tanzania, my account below focuses on (some of) the spaces in which therapies intersect with each other, forming therapeutic assemblages as health practitioners coordinate

medicines, knowledge, well-being, and comfort.

Hospital T

The examples I present of different therapeutic trajectories interrupting, interfering, and transforming one another are derived from research I conducted in a district hospital in Tanzania, which I refer to from this point on as "Hospital T." This hospital was built in the mid-1960s, after Tan ganyikan independence, and assumed the responsibilities of an earlier Anglican mission hospital in the area. Histori cally, the state has underfunded this district hospital, even as it has tasked it with serving a particularly large catch ment area in a relatively resource-poor region of the coun try. Although differences between clinical care in Hospital T and in other hospitals (whether in other parts of the coun try or the world) cannot be attributed solely to economic asymmetries, the practical challenges of running an under staffed, underfunded hospital with undertrained personnel are salient. In the context of my argument here, they are most important in situating the significance of the work of lower-level clinic staff in the therapeutic care available at Hospital T.

Since 1998, when I first became familiar with its staff

and work, this hospital has supported one to three doctors.

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American Ethnologist Volume 35 Number 3 August 2008

Because it is located in a part of the country in which few elite, educated Tanzanians want to live, the government has found it difficult to keep a Tanzanian doctor in the hos pital for more than a year. Since the mid-1980s, one or two of the physicians have been young German doctors working for the German development organization GTZ. With one notable exception, these doctors have tended to learn only rudimentary Kiswahili and have not learned any of the local languages. As a result, nurses and nurse's aides field patients' questions about medicines and ad dress their anxieties about care. They are also the staff most frequently confronted with mediating traditional medicine and biomedicine in the clinic.

In 2003, the district nursing officer at Hospital T, bur dened by the overwhelming task at hand, calculated the difference between the staff needed to meet the demands

placed on the hospital and the staff that he was able to maintain. He concluded that from 2000 to 2002 the hospi tal was only staffed at 42 percent of the level that would have been required to adequately serve the demand. The percentage of trained nursing staff in 2000, 2001, and 2002 tended to be less than 50 percent of what the hospital needed.10 More specifically, the district nursing officer cal culated that the hospital was operating with 52.4 percent of the needed public-health nurses and MCH aides, 43 percent of the needed registered nurses and nursing officers, and 36 percent of the needed "enrolled" nursing staff, which in cludes nurse-midwives. Hospital T has continued to func tion by hiring more lower-level (less well-trained) staff. In fact, the district nursing officer calculated that this district had 194 percent of the number of medical attendants it needed. Medical attendants can be hired who have no train

ing at all. In the past, they handled jobs such as sweep ing, cleaning, washing sheets, and making beds. In the cur rent staffing crisis, however, medical attendants have come to dispense medicine, give blood transfusions, and tend to

wounds. In light of their expanded responsibilities, most of the medical attendants in Hospital T have taken a one-year training course that teaches the principles of basic first aid and patient care.

Although these numbers speak to the specific condi tions of Hospital T, they are in no way unique. In the past 15 to 20 years, clinical staffs in Tanzania have struggled to provide quality biom?dical care under increasingly aus tere conditions. In the mid-1980s, Tanzania began to imple

ment an IMF structural adjustment program that required, as such programs have in many countries, the reduction of state expenditures on social services. Because a social ist minister of health remained in office until 1991, how

ever, the full effect of the fiscal adjustments on health was delayed. Although private practices opened slowly through the 1980s, government clinics did not introduce fee-for service or what are often called "cost-sharing" measures un til the 1990s.

One Tanzanian NGO has referred to the cumulative ef

fect and resulting conditions of these neoliberal reforms as "brutalization," a term used to depict their impact on both nurses and patients.11 Under current conditions, nurses are unable to manage their clinics with the attention and care their professional commitments demand, and patients suf fer these inadequacies when good intentions are a poor substitute for the treatments that they desire. Neoliberal reforms have had profound implications for hospitals and clinics in Tanzania, affecting the quality and sufficiency of staffing, the conditions of the clinic, and the availability of medicines (Lugalla 1995; Richey 2003). Faced with these harsh realities and the frustrations of not being able to of fer ideal care, nurses in Hospital T seem to evoke traditional

medicine in an effort to address the immediate needs of

their patients. I became intrigued by nurses' engagement with tradi

tional medicine after hearing healers' periodic claims that nurses in Hospital T had referred certain patients to them. I began to formally investigate the issue by conducting in depth interviews with all of the nursing staff in Hospital T.12 Between interviews, I would often remain in the wards and continue conversations with the nurses and nurse's

aides who were on duty, watching them work. Examining the mediation of traditional medicine within biomedicine

drew me into the unofficial and private interactions that nurses and nurse's aides have with patients and with each other. My formal interviews and informal conversations with nurses and nurse's aides in Tanzania probed not only their encounters with traditional medicines but also the

veiled references, euphemisms, and silences that enabled the presence of traditional medicine in the hospital. Al though I conducted the majority of the fieldwork presented in this article in 2003,1 have worked in the area of Tanzania

in which Hospital T is located much longer. Between 1998 and 2000,1 conducted research both in Hospital T and with traditional healers in the area in an effort to understand the

therapeutic landscape. In fact, when I began hospital inter views in 2003 I was already known to some of the nursing staff by a diminutive form of the name of the healer with whom I work most closely.

My ongoing work with healers, as well as my commit ment to and knowledge of this area, underlies the nursing staffs willingness to confide in me and reveal the unofficial, sometimes clandestine, interactions that characterize tradi

tional medicine in the hospital. These activities range from referring a patient to a traditional healer to facilitating the use of traditional medicines in a hospital ward. In addition, nurses and nurse's aides described patterns of communi cation and innuendo.13 Their generosity and trust reveal a more fluid, flexible, and evolving picture of the relationship between modern and traditional medicine than has typi cally been portrayed in African hospitals. Here I not only discuss the existence of healers in the hospital and of their

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Articulate(d) Bodies American Ethnologist

medicine in the bodies of patients that arrive there but I also attempt to account for the intangible conditions through which biomedicine implicates traditional medicine and, in the process, hails new complex bodies.

For the nurses and nurse's aides in Hospital T, the new sensitivities and practices of discernment through which they assemble the bodies of patients are not academic ex ercises. Neither are they in any simple sense driven by "in terests" or "beliefs." Rather, nurses are skeptical of heal ers. Ideological agendas shape the ways in which the nurs ing staff is implicated in the articulation of so-called tradi tional maladies, but nursing practice is itself not straight forwardly ideological. Stacy Leigh Pigg (1996) argues that articulations of one's belief in or thoughts on traditional medicine are ways of positioning one's self. The skepti cism, even condescension, of clinical staff toward tradi tional medicine is shaped by their training, their position as "professionals," and their position in the complicated class structures of postcolonial modernities (e.g., as peo ple earning salaries in an area where many if not most are subsistence farmers). Medical staff's claims about belief or statements about usefulness to a U.S. researcher, friend, or

colleague are gestures within the deeply fraught landscape of modernity. Nurses and nurse's aides craft themselves as modern subjects, as cosmopolitan, as legitimate embodi ments of the state and exemplary forms of its citizenry. De spite their investment in boundaries between traditional and modern medicine, nursing staff come to discern more and less "dangerous" medicines, to assess "traditional mal adies," to mediate the encounters between traditional and

modern medicines, and to articulate new complex objects that refuse to be reduced to either the biom?dical or the

traditional. Political, economic, and clinical conditions, as

well as the diverse relationships that call on nurses in their everyday lives, compel them to coordinate the new com plex objects of care that I describe below, that is, to generate more articulate bodies.

Personal negotiations

Twenty-three of the 26 nurses and aides I interviewed de scribed using traditional medicine at least once in their lives. The chief nursing officer swore by an herbal treat

ment that he argued saved him from having to pull one of his teeth. Eighteen members of the nursing staff said that they had gone with or helped relatives and friends seeking out traditional treatments; eight either claimed that they had never taken or accompanied someone to a traditional treatment or they avoided the question. These differences in personal experience played a role in nurses' and nurse's aides' own sensitivity to the use of traditional medicine in Hospital T. Almost all of them suggested that at least 50 percent of patients had used or were using traditional medicines. Only one nurse claimed that the use of tradi

tional medicine was infrequent (wachache tu), and three suggested that it might be as high as 80 percent.

The personal experiences of nurses reveal some of the more complicated ways that traditional medicine exists in the hospital. After all, the nursing staff consists of people

who are also mothers and fathers, spouses, relatives, and neighbors. One of the nurses in Hospital T lived across a small dirt road from a healer with whom I have worked for

years. This healer and her kin would call on their neigh bor with nursing experience (and vice versa) for assistance. When the healer's granddaughter screamed late one night with labor pains, the nurse came running across the road to help. In addition, the healer regularly collected the leaves of a tree in the front of the nurse's compound to make a medicine for a common eye ailment. Their individual ex periences with healers and medicines shaped how clinical staff in Hospital T imagined the relationship between mod ern and traditional medicine.

Nurses born in the immediate area were more fluent

in traditional medicines than nurses who were transplants from other parts of the country. The nurse who claimed to have seen the fewest instances of traditional medicine

(despite working in the maternity ward, which has a his tory of some of the most controversial and tragic inter actions between pharmaceutical and herbal treatments)? who was, in other words, the least sensitive to the use of traditional medicine in the hospital?was originally from Zambia. Explicating the relationship of hospital medicines to other forms of treatment was a way for nurses from the area to position themselves in the broader community and specify their own stakes in Makonde, Makua, or Yao sub jectivities. Although religious affiliation appeared to influ ence the use of traditional medicines and their meanings, it seemed less significant than familiarity with local medici nal traditions in determining nurses' sensitivities to the use of traditional medicines in the hospital. Nurses from the area, whether Christian or Muslim, tended to know heal ers as neighbors and not infrequently to be connected to them through extended kin networks. These connections shaped their knowledge about and sympathies for tradi tional medicine even more than religion or rank.

Through the use of traditional medicine, nurses and nurse's aides often developed a personal philosophy about the kinds of traditional medicines that might be effective.

Many nurses would only use dawa za kukinga, protective medicines. Some claimed that their only use of traditional medicine was to wear a protective medical "bracelet" that they made themselves from ingredients bought at the mar ket for their young children. Others did not "have faith" in medicine that was written or tied on to the body or buried in front of the door of a house; rather, they only believed in things that one drank, bathed in, or rubbed into the skin (kuchanga). Still others expressed concern about drinking

medicines. They feared that the dosage might be too strong.

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American Ethnologist Volume 35 Number 3 August 2008

These women only used medicine that they could bathe in or rub on. Still others refused medicine that was rubbed

on or tied on because, then, others would know that they were using traditional medicine. Some believed that tradi tional medicine was useful for particular sorts of afflictions but not others. Many claimed that traditional treatments for infertility or hernias were more efficacious than hospi tal treatments. Faith in herbal remedies for malaria or in

testinal worms varied more widely. For still others, faith or belief in the efficacy of traditional medicines was irrelevant. Their use was represented as a product of family obligations and pressures. The uncertainty about traditional medicines, and the sorts of differences that were held as salient be

tween traditional medicines, shaped the advice nurses gave to patients and the tolerance they had for particular kinds of treatments smuggled into the hospital.

Personal experience and professional experience bled together in nurses' narratives about traditional medicine. As Mama Zenabu recounted her struggle to conceive and the various therapies she employed, she also described the "many, very many, too many" women admitted to Hospital T who used similar medicines. The impact of personal experience on professional work was, at times, as simple as the recognition and tolerance of traditional medicines in the clinic. Yet such stories also resonated

with the more broadly generative capacities of affliction in Africa. In this area of Tanzania, as in other places across the continent, some are called to become heal ers through affliction. Their own healing depends on their submission to this calling. Their struggle for survival en dows them with new relationships, new capacities, and new demands. When individual nurses grow more sensi tive to certain forms of affliction and to a range of possible therapies because of their own experience, their expertise confounds any straightforward description of skill or know how. Through the excesses of their own engagements, these nurses highlight the friction between the forms of knowl edge and expertise that inhere in profession and those that inhere in callings.

Discerning affliction, mediating movement

Whether nurses claim that any sort of traditional medicine is efficacious or beneficial, their work with patients who use these medicines requires that they engage with them. The

medicinal use of plant, animal, and mineral substances af fects the afflictions that are presented in Hospital T and, therefore, the routine practices of staff in the search for effective treatment. All of the nurses and nurse's aides

gave examples of traditional medicines that caused medical problems. One of the most common examples concerned herbal medicines that increased contractions during labor. Several nurses had witnessed women, their babies, or both

die as a result of a ruptured uterus and massive hemor

rhaging. The MCH clinic had made a concerted effort in previous years to discourage pregnant women from us ing herbal treatments. Nurses leading workshops to train traditional birth attendants (TBAs) still campaign strongly against them using any medicine for any reason. In addi tion to medical problems they attributed directly to the use of traditional medicines, hospital staff regularly complained that patients arrived in critical condition, sometimes "too late" to be cured, because they went to see a traditional healer before coming to the hospital (Langwick 2007).

Such public-health concerns have been addressed else where, but what is more often left unexamined is the way traditional medicine comes to shape routine practices in the clinic. For example, many nurses articulated the im portance of changing the treatment protocol for children with high malarial fevers who had been to see a traditional healer before coming to the hospital. Hospital personnel ar gued that the herbal medicines given to children afflicted by degedege, or convulsions, "cannot mix" with quinine. In 2003, national protocols made quinine the first response for malaria patients in critical condition. Although nurses widely agreed that "traditional medicine and quinine are like poison" (H22, also HI l),14 they did not necessarily agree on what was to be done. They negotiated solutions on a case-by-case basis, which ranged from waiting for the tra ditional medicine to "finish its work" to easing this waiting with a glucose drip (H6), reducing the fever with paraceta mol (H22), or stopping the convulsions with diazapam (H2).

The potentially fatal combination of quinine and herbal medicines to treat degedege?a common malady in which a devilish spirit plays with a person?often emerged in nurses' narratives as an example of the consequences of failing to collect information on a patient's use of tradi tional medicines. One of the most striking effects of tradi tional medicine on routine hospital practice is the time and effort made by nurses to extract medical histories from pa tients that include their recent use of traditional medicines.

All nurses, even if to slightly varying degrees, were sensitive to the signs that a new patient admitted to the hospital had come from seeing a traditional healer. These indicators in cluded the time reported between the onset of the malady and the patient's arrival at the clinic, leaves visible inside the nose, bubbles coming from the mouth, traces of leaves on the body from medicinal baths, lines or smears of black or white substances on the body, the color and consistency of vomit or feces, and small marks on the body from razor blade nicks. Nurses scrutinized patients' bodies for signs that could be used to open conversations about broader treatment histories and for evidence that could be used to

judge the truth or falsity of patients' treatment narratives.

Whereas attending to the possibility of herbal drug re actions and collecting more inclusive therapeutic histories are fairly uncontroversial changes in clinical practice, the ways in which nurses and nurse's aides mediate the use of

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Articulate(d) Bodies American Ethnologist

traditional medicine through their willingness to discharge patients from the hospital are both more subtle and more revealing. One nurse's aide, Mama Zawadi, was explicit on this point. As we spoke about the different ways patients

weave together modern and traditional medicines, I asked if she ever offered advice to those in the hospital. She replied,

Indeed, I can give a patient advice. Take, for exam ple, a child who has been admitted here and after a month has failed to recover. The doctor changed the medicine this week, and he changed the medicine the week before. I will advise the caretaker to request a dis charge in order to go home and take the child to a tra ditional healer. There are other children who have con

tracted maladies of swelling [magonjwa y a uvimbe]. This swelling is not something that is [known] here in the hospital, however, traditional healers, they can [ad dress it]. Their medicines can help a great deal. [H26]15

Pharmaceuticals move from being a curative technol ogy to being a diagnostic technology. In the process, Mama Zawadi comes to discern afflictions that are better treated

by traditional healers. Mama Saidi echoed Mama Zawadi when she told me that sometimes caretakers "may request that their patient be discharged... [and at other times], my nursing colleagues can say to their patient, 'Maybe if you go to a traditional healer you can get better.' " To leave the hospital before being cured, the patient or the patient's kin must request what is officially called a "discharge with out the doctor's consent." This bureaucratic technicality shrouds the nursing staffs mediation of traditional treat

ments in the signature of a patient's family member on the discharge form. Mama Tatu recounted another such incident:

One patient was in ward 2 [the men's ward] in the first month. He had been treated many times before Jan uary. He was hurting. He threw up a lot. His feet hurt until he failed to walk, yet he was being treated. I ad vised him that having used a great deal of modern medicine, he should try traditional medicine. Therefore he decided to go to a traditional healer. I do not know where, but he has healed and he teaches over there in [a nearby primary school]. He had gotten completely

desperate. He had been crying. After going there [to the traditional healer], he got medicine to close below [i.e., to rub on his feet]. He has been healed. [H14]16

When the clinical staff felt that their resources had been

exhausted, the process of granting a discharge without the doctor's consent provided a space to discuss the use of tra ditional medicine.

In the face of known chronic diseases such as HIV/AIDS, the inefficacy of treatments available through Hospital T may not have been as thoroughly tested. As Mama Aisha recounts,

There was one patient who had been admitted... he coughed a lot. He got thinner. He thought he had TB.

When he came here he was admitted to ward number 4. When they tested him they discovered that he was HIV positive. Basi [here in the sense of "well, that was it"], when they saw this they said, "Now this patient will get this medicine then he will return home."... He got the medicine for TB and they told him to return home, saying: "There is no need to drink this medicine in the hospital, it is better to return home. If you return home go to another healer. This is perhaps another illness, perhaps the mashetani [devilish spirits]. Therefore it is best to go to a traditional healer, they have treated

mashetani." [HI8, similar to H12]

In this ad hoc, unofficial, and more or less clandestine

practice of referring patients from the hospital to traditional healers, the strengths and weaknesses of various therapies were defined and redefined. The hospital was an active site of negotiation for both biom?dical and nonbiomedical af flictions. The lack of antiretroviral drugs in Hospital T drove nurses to make bodies afflicted by HIV compatible with bodies afflicted by mashetani.

Most nurses, however, did not describe such explicit incidents. Rather, a more subtle conversation ensued. Pa tients would request a discharge, saying that they wanted to go to another hospital or that they had run out of money and their relatives could not afford to pay for them to stay in the ward any longer. Sometimes, nurses would attempt to foil these requests or to talk people out of removing their relative from the hospital. Some nurses claimed that they would respond to some requests by telling patients how dangerous using traditional medicine or mixing it with biomedicine was. At other times, nurses would confirm that

the hospital had failed, that all medicines had been tried. Or they might reinforce the choice to see a traditional healer, by telling the family that they should not worry, that they could always bring the patient back to the hospital later if necessary. Much was unspoken in these conversations as the nursing staff refigured the boundary between compli ance and noncompliance.

Not all advice comes from nurses themselves. Inside

the hospital, patients and patients' caretakers share con cerns and experiences during the long hours they are preparing food and washing clothes. Talk emerges between kin and their sick relatives and among those who have come to care for their ill. There were animated and enthusiastic

discussions in the bandas (thatched-roofed, open-walled shelters) set aside for kin to cook for their relatives and under the larger trees that provide shade to rest. Only a very few private wards existed in Hospital T. In the regular wards, patients' beds were lined up in long rows about four feet apart. There, patients watched each other's progress, commiserated, and advised. For instance, when on duty in ward 4, Mama Sofia witnessed an exchange between a

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American Ethnologist Volume 35 Number 3 August 2008

pregnant woman who had just been admitted to the hos pital with signs of an impending miscarriage and a fellow patient in traction because of a broken leg. The woman in traction turned to her new neighbor, who had been pre scribed strict bed rest, and told her that she would lose her pregnancy if she did not go to see a certain healer. Mama Sofia's interest was piqued. She had struggled with her own pregnancy. By her own admission, she followed this woman's case closely. The pregnant woman sought out the recommended healer and used her medicines. Her bleed

ing stopped, and she carried the pregnancy to term. She returned to the hospital having given birth to a healthy child. Mama Sofia did not hesitate to attribute this success

ful pregnancy to the traditional medicines the woman used, saying that all biomedicine had to offer the woman was "complete bed rest." "Traditional medicine," Mama Sofia concluded, "works fast."

Traditional medicines shape both the ailments com ing into the hospital and the routine procedures of hospital staff, but some nurses and nurse's aides suggested that they are sensitive to distinctions between afflictions best treated

by traditional medicine and those best treated by modern medicine. These cultivated forms of discernment, together with the failure of biom?dical therapies to stimulate im provement or the diagnosis of a chronic or fatal disease, have led some nurses and nurse's aides to selectively refer patients to traditional healers. This underground practice of referral reveals the hospital as an active site at which the attributes, potentials, and objects of traditional medicine are elaborated through their engagement with biomedicine and hospital staff.

In the examples I have given so far, the physical spaces of traditional and modern medicine remain distinct. This

architecture of separation has been an important part of forging the contemporary category of traditional medicine (Langwick 2006, in press). Despite this work, however, tradi tional medicines and healers are also found in Hospital T.

Hospital medicine

Not everyone waited until leaving the clinic before seeking traditional treatments. Some used traditional medicines in

side the clinic. As Mama Juma describes,

Many can [use traditional medicine in the clinic]. During visiting hours, they leave, go to a traditional healer's, and return. Others they can escape?going outside and returning [before their absence has been detected]. You cannot know [what patients are doing]. They tell you, "I am going to the entrance over there to buy bananas." [She laughs.] They get [traditional

medicine], such as those that you smear on, and then they return. They apply the medicines inside here, right here. [H20]

Patients or their "therapy management group" (Janzen 1978) secure medicines for use in the hospital.

In the process of describing the ways in which tra ditional medicine is negotiated inside biomedicine, I do not seek to romanticize traditional medicine but only to describe the landscape in which therapies are differenti ated, ordered, and coordinated. Indeed, the use of herbal medicines in the clinic is not always a happy irony or a creative therapeutic convergence. At times, this more fluid form of "integration" has proven fatal. Mama Shida, a nurse's aide, gave the following example:

In this ward, there was one mama who brought her child. We treated this child. When we gave him another treatment he became completely unconscious. She did not understand [why this happened]. If we treated this child by using a drip... [and] after we had inserted it in him, she gave him traditional treatment in there, inside [the drip line]. I saw the signs of a person having come

with his medicine. It happened at a time when they thought I did not see. They used water to extract the

medicine [wakachuja]. This act of extraction was what I discovered. It was necessary to move closer to them.

When I moved closer, I inquired [and] they showed me [what they had done]. [H25]

The mother of this child gave him an herbal medicine intravenously. The child died. Mama Shida attributes the child's death to the mixing of traditional and modern medicine.17

Most often, traditional medicines used in the clinic were administered in secret. Hospital staff found only clues of their use. Mama Tatu refers to the use of traditional

medicine in the clinic as "stealing away."18 Other nurses confirm that some patients use medicines of traditional healers inside Hospital T. They put the medicine in a bot tle, making it look like drinking water (H24), or a thermos, disguising it as tea (H20) or porridge (H6), or they hide it in the cupboard (H19). One of the nurses who works in the TB

ward admitted to regularly finding medicine hidden in the beds.

Although nurses and nurse's aides were concerned with overdoses and drug interactions, their critique of the use of traditional medicine in the hospital differentiates between kinds of treatment. Medicinal bundles wrapped in black cloth are found tied onto almost every child's left wrist. In addition, most children who are admitted to Hospital T

wear amulets protecting them from devilish spirits, such as those that cause convulsions. These medicines were

never removed in Hospital T. Mama Zawadi also argued that no nurse would refuse the use of kombe in Hospital T. Kombe is a medicine made by writing in red saffron ink, usually on a white plate. The writing?an effect of spir its, ancestral shades, mashetani, or Mungu (God) working through a healer?is first read as a diagnosis of the patient's

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Articulate(d) Bodies American Ethnologist

ailments.19 Then, water is added to the plate and the result ing pink solution (sometimes, but not always, with the addi tion of herbs) is drunk, rubbed on, or bathed in. Those using kombe "are here," says Mama Zawadi.

You will run in to them, some are here in the chil dren's ward. They admitted their children and we have given them medicine. You find that they ask a nurse about bringing this medicine, kombe, [into Hospital T]. They say, "I want to combine [kombe and modern medicine]." This is done discreetly. We tell them that this medicine it is not poison. This medicine is good.

We tell them go and bring it. They continue using the medicine. I have seen children, many who proceed well. [H26]

Nurses and nurse's aides (as well as patients and their families or more extended therapy management groups) play a role in mediating traditional and modern medicine. At times, this role involves elaborating some forms of non biomedical care through clinical practice. Such instances suggest the possibility of new kinds of bodily assemblage in the clinic. Nurses, then, are not (only) gatekeepers enforc ing the boundary between those practices deemed mod ern and those deemed traditional. Rather, in practice, they sometimes also articulate new objects of knowledge, inter vention, and care.

As Mama Zawadi asserted, no nurse in Hospital T would deny kombe to a patient. This therapeutic technique has Islamic roots, although not all kombe is prepared by a Muslim shehe, or teacher. Women healers who have not had

access to Qu'ranic teaching, who do not speak Arabic, and who often are not literate, also prepare kombe. The power of this genre of medicine differs depending on whether the writings are verses from the Qu'ran, Arabic geomancy ta bles taken from popular Middle Eastern texts, or the em bodiment of conversations with devils, ancestral shades, or other nonhumans. Some nurses speak of the effect of kombe as "psychological," and they interpret it as a local manifestation of the "placebo effect." Others talk of God, of Allah, of a divine healing necessary to an undivided body and soul. Still others talk of mashetani, devilish actors, af

flicting patients or of witchcraft that makes it impossible for the pharmaceutical medicine distributed by the hospital to

work.

Articulate (d) bodies

Bodies in Tanzanian hospitals are sites of assemblage. They are coordinated as nurses seek to elicit histories of patients' use of traditional medicine during intakes, as standards of care are shaped by bodies full of traditional medicines, as healers on hospital grounds suggest traditional treatments for patients who are admitted, as afflictions resist biom?d ical regimes, and as nurses cultivate the skill to discern

which patients might benefit most from alternative forms of therapy and which traditional medicines might be used in the clinic. In these instances, there is a momentary syn thesis between versions of the body that emerge from dif ferent assessments, examinations, and treatments. To con

sider this point further I turn to one last example. When the son of Mama Ramadhani, one of the nurses,

fell suddenly and severely ill, she took him directly to Hospital T. As Mama Ramadhani sat in the ward next to her two-year-old child in critical condition, she began to won der if he was affected by mateso, or witchcraft. She told me her story like this:

He was very sick. He had blood in his diarrhea. Because he was losing blood, he became anemic, and his body started to fill up, to swell. [While we were in the ward] one mama came there. She told me that mashetani had climbed on my child. She cried. I was told this. She cried. This mama, the traditional healer, did not say anything else. She left. The next morning, as we were sitting on the verandah [of the clinic], one baba [lit. father] came, and he told me that I should take the child to a traditional healer in a certain section of town.

He explained to me where the healer was located. He argued that someone had played with this child [by pointing out that] we gave [the child] blood one day, and next day there was no blood and it is necessary to give him blood again. Indeed, [my son's condition]

was getting worse. The child had lost two [pint] bot tles of blood. For this reason, my mother and I left. We carried the clothes of the child. We went to this baba's

[house] to divine [kupiga ramli\. He said that it was fine [to have brought the child's clothes, rather than the child himself]. Later [however] it became necessary to bring my son. He was in the ward. Before the doctors passed through the ward on their rounds, we left with him. We took him to the healer. When we went there, the healer had to remove things. She removed things,

meaning... she made small surface level cuts at the feet... you could see that there was something sticking out of [my son's] tongue... after a little cut with the ra zor, she closed this section and then he breastfed spit ting out two things. There were ball bearings... [and] a

mdudu, a louse... he had mateso, he did not fall, he did not do anything, but he had mateso of the foot, after this, after returning to the ward, we continued to im prove, until we returned home, until today. [H12]20

During her son's illness, Mama Ramadhani continued to work as a nurse in the hospital. In the process of seeking treatment for her son, she consulted her colleagues and the doctors at the hospital. At least one other nurse advised her to follow the healer who presented herself outside the ward.

Mama Ramadhani's experience demonstrates how the hos pital serves as a site for the negotiation of afflictions and medicines, rather than as a separate sphere of therapeutic practice. A healer approached her while she was in hospital.

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American Ethnologist Volume 35 Number 3 August 2008

A diviner working with this healer also came to the hospi tal, and he gave her directions. She consulted another nurse,

who permitted her to take the child out of the hospital be tween the doctor's rounds. But I propose that this experi ence also illustrates something more.

The failure of the blood transfusions to "increase" the

child's blood served as a symptom of mateso, or witchcraft. A body with a sorcerer's mischief (wadudu) could not ac cept the pharmaceutical prescribed by the visiting German doctors. Her son's body required both traditional and mod ern medicines. He did not have separate afflictions or af flictions with distinctly traditional and biom?dical causes as much as his affliction struck a complexly configured body. Treatment for his acute condition required articulation of multiple spheres, the effects of which had to be carefully coordinated. Mama Ramadhani did not return to the hos

pital because the traditional treatment did not work; she re turned because the biom?dical treatment could only work after the sorcerer's mischief was removed. The treatment of

one body and one affliction required moving between ther apeutic spaces. Healers on the hospital grounds. Nurses in the healer's home. This is not merely a process of moving back and forth between therapeutic options in the desper ate hope that one might work. I suggest, as well, that Mama Ramadhani's experience cannot be best explained as a pro cess of diagnosis by trial and error. She did not seek out mul tiple treatments for her son to deduce his affliction through the elimination of ineffective treatments. Here the body was

multiple. Traditional and modern medicines required coor dination in the service of effective treatment.

Nursing neoliberal traditions

The relationship between traditional and modern medicine enacted through nurses' and nurse's aides' pragmatic at tention to patients is quite different from the institution alized forms of pluralism supported by national and in ternational programs. Nursing staffs in the clinic deal less

with broad distinctions between traditional and modern

medicine than with the immediate and contingent vari ables of patient history and status. In so doing, they may suggest that a patient see a traditional healer or use a par ticular kind of traditional medicine; they may facilitate the patient's temporary departure from the ward between doc tors' rounds; and they may turn a blind eye when herbal

medicines are used in the clinic. Nurses and nurse's aides in

Hospital T are cultivating new ways of discerning affliction and coordinating treatment. This process is tenuous, in that it is not institutionalized; rather, it occurs between nurses in informal conversations and between nurses and their pa tients, kin, neighbors, and friends. These forms of discern

ment are emerging in response to contemporary clinical conditions, demands for care, and institutional pressures.

The bodily assemblages that nurses and nurse's aides are enacting are historical. Or, more precisely, they are now be coming necessary in response to particular economic and political changes.

The acts of distinguishing and ordering traditional and modern therapies are, of course, not new. Both mission ary and colonial doctors and nurses confronted a diverse range of healing practices when biomedicine expanded into Africa. These encounters were complicated; they motivated scattered instances of incorporation (e.g., healers drawn into early outpost dispensaries as dressers or assistants,

midwives trained by nursing sisters, hospitals and dispen saries sprinkled with holy water to prevent witchcraft and sorcery). John Iliffe (1998) has argued that, since the early expansion of biomedicine in colonial Tanganyika, medical practitioners have encountered local healing practices in the bodies of patients filled with and reacting to organic

medicines and in the expectations of patients and their families. Yet, today, there is a new urgency to the coordina tion of traditional and modern medicine.

As medicine moved from the purview of missions and colonial powers to the responsibility of national govern ments, national health care systems were required to meet the needs of all citizens. In fact, both clinical care and public health became moral imperatives for a modern citi zenry. In Tanzania, through the 1970s and early 1980s, Pres ident Julius Nyerere aimed to build and maintain a dispen sary within ten kilometers of every person in the country. Staffing this expanding biom?dical network was a problem from the beginning, however. Acknowledging that many newly independent nations faced such labor shortfalls, the WHO, during the 1978 Alma-Ata conference, proposed con ceptualizing traditional healers as a resource. Healers in developing countries could be harnessed, the WHO sug gested, to help resolve the labor shortage as health care de livery systems moved from the limited colonial and mis sion care to the broad-based, public care of independent national governments. The WHO also encouraged devel oping countries to utilize traditional healers in their ef forts to meet international health development goals, such as Health for All by the Year 2000. Throughout the social ist period (1964-85) in Tanzania, however, most efforts to institutionalize traditional medicine focused on the sci

entific investigation of plant, animal, or mineral products and the registration of self-identified traditional healers. In other words, it depended on the expertise of scientists and bureaucrats. Since the late 1980s, neoliberal reforms have

placed new pressures on clinical staff and have driven the development of novel forms of nursing expertise.

Accepting the conditions of the IMF has meant adopt ing various structural adjustment programs that have re quired instituting medical cost-sharing measures and other policies that challenge health care provision.21 As the

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ArticuLate(d) Bodies American Ethnologist

demands of global economic governance erode the state's ability and commitment to providing health care for all, the ministries of health in Tanzania and other African coun tries have turned to traditional healers and traditional birth attendants with renewed interest. Nurses are central to

these efforts. They explicitly coordinate healers' care with that of the hospital, through training workshops around is sues such as attending home births and caring for peo ple with HIV/AIDS. The institutional salience of traditional medicine and healers is eliciting new configurations of care. To attend to this historical shift, I argue, anthropo logical analysis needs to move from examining the coex istence of multiple bodies ("medical pluralism") to exam ining the production of the "body multiple" (Mol 2002) across diverse spaces of care and through broad therapeutic ecologies.

Although boundaries between traditional and modern medicine have never been clear, the passion and will that drove investments in the purification of these two modes and that generated them as intelligibly distinct analytic cat egories is fading. Bodily uncertainty is now implicated in the contemporary political and social insecurities of "third

world" capitalism (Livingston 2005). The modernist du alisms sedimented in the gates of the hospital and the prejudices of the nurses are being overwhelmed by the demands of everyday practice. Nurses are compelled to coordinate traditional medicine not only with but also within biomedicine. The implications of this change are both subjective and ontological. In contrast to Steven Feier man's (2000) description of the movement between ther apeutic experts as a process of "diagnosis by addition"? experienced as a spiraling out, a movement from one or an other starting point toward a conclusion?such movement is now experienced as a process of discerning the ways in

which inequities, emergencies, and alterities are deeply im plicated within one another. Everyday efforts at compari son are being replaced by everyday efforts at articulation. In the economic and administrative milieu that marks ne oliberal Tanzania, movement coordinates different versions

of bodies and afflictions, allowing them to be read through one another.

Nurses are at the heart of this change, as they dom inate the administration of hospitals in Africa, taking the brunt of the weight imposed by the constraints of current economic regimes while simultaneously facing obligations to patients, neighbors, and kin. These obligations compel an object of attention and care that can hold together the ground on which the nurse and the nurse's aide know them selves to be caretakers. Called on to attend to those entering the hospital for relief or transformation, nurses forge bodily assemblages that allow them to respond, to act, and to care within the constraints and desires, the compulsions and re pulsions, and the interruptions and interferences of clinical work.

Notes Acknowledgments. The bulk of the fieldwork on which this arti

cle is based was supported by research funds from the University of Florida. Earlier versions of this article were presented at confer ences on "Rethinking Inequalities and Differences in Medicine" at Vanderbilt University and on "Mediated Bodies" at Maastricht Uni versity (Netherlands) as well as for the colloquium series in the Sci ence and Technology Studies Department at Cornell University and the Social Studies of Medicine Department at McGill University. I thank my colleagues in all four of these venues for their engage

ment and critique. In particular, Timothy Choy, Nancy Rose Hunt, Annemarie Mol, Rachel Prentice, and Babette Mueller-Rockstroh challenged me in important ways to think more deeply about these issues. I also appreciate the comments of Sjaakvan der Geest and his students, who read an earlier version of this article in their semi nar. Furthermore, the two anonymous AE reviewers offered invalu able feedback and clarity.

1. Referring to "traditional" and "modern" medicine is a histori cally fraught proposition. "Traditional" medicine emerged in rela tion to the spread of biomedicine in eastern Africa. It has served as a catchall category indexing forms of healing, kinds of affliction, and types of experts that were not officially included in mission ary or colonial health care. Traditional medicine, then, is all that is not modern medicine, or biomedicine. This initial collapsing of diverse healing practices into the category of traditional medicine undoubtedly did violence to forms of difference that were salient in colonial Tanganyika, but today references to traditional medicine are widespread. As the category has gained epistemic and bureau cratic weight over time, healers themselves have come to organize around their common commitment to and practice of traditional

medicine. The contemporary life of the phrase traditional medicine dos not make such references any less fraught, but it does make them important sites of inquiry.

2. Sjaak van der Geest has promoted the anthropological study of hospitals, what he calls "hospital ethnography," to highlight how biom?dical practice differs cross-culturally. See, for example, the special journal issue on hospital ethnography edited by van der Geest and Kaja Finkler (2004).

3. By elucidating the generative capacities of double binds, Kim Fortun (2001) initiates an important discussion about the forging of communities, experts, and objects of knowledge within the com plex asymmetries of postcolonial life.

4. This account builds on recent studies that complicate medical pluralism, rejecting too-neat, too-clean, and often ahistorical de scriptions of discrete medical systems between which patients or their kin choose (Poole 1994). For example, see Adams 2001; Cohen 1998; Farquhar 1994, 2002; Langford 2002; Lock 1993; Pigg 1997, 2001; Scheid 2002; and Zhan 2001.

5. Perhaps such interruptions are particularly visible in Tanza nia. References to traditional and modern medicine in Kiswahili

connote varied forms of the "traditional" (asili, jadi, and kienyeji) as dynamic and shifting, whereas the "modern" (kisasa) connotes the historically flat space of the "now." In contrast to the presentist no tion of "modern medicine" (dawa za kisasa), each of the Kiswahili phrases referring to traditional medicine (dawa za asili, dawa za jadi, and dawa za kienyeji) connotes a differently generated tempo rality. Asili carries with it a sense of that from which things derive, an origin. It is invoked to describe a base, basis, or foundational elements. In this context, asili is a denominator in mathematics. In contrast, jadi evokes a sense of ancestry, genealogy, descent, and lineage. Jadi has some resonance with mila, or custom. Jadi speaks most eloquently to the multifarious hybridity of any ob ject as it moves through generations. The third term glossed in En glish as traditional is the place-oriented kienyeji. Kienyeji implies

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American Ethnologist Volume 35 Number 3 August 2008

locality?tradition in the sense of that which has come to distin guish and define an area. Sometimes, when kienyeji is used in ref erence to healers or medicines, it sits a little sourly in the speaker's mouth. Tone or context can tinge it with the flavor of primitiveness or backwardness, connotations that make anthropologists cringe. Yet, to others, this place-based character, and the density of con nections that it captures, is not a problem but a strength. None of these terms (necessarily) define an unchanging past; rather, they evoke a sense of movement. Kienyeji implies the growth of, and growth out of, a place. Jadi captures development through generations. Asili suggests derivation?transformation from one state to another. These three expressions of "tradition" are about traveling. This travel is not limited to the slippery displacements of scientific universals. There are in these words many ways to travel.

6. Others have referred to such interferences. See, in particular, Semali 1982:33, 41, 63 and Good 2004:32, 49 n. 18.

7. In this article, my references to "nurse's aides" are to employ ees hired as maternal and child health (MCH) aides and medical attendants.

8. The anthropological literature on medicine, particularly by scholars working on Ayurveda and Chinese Medicine, offers differ ent resolutions to the problem of accounting for the ways in which bodies are constituted and cared for as assemblages. lean Langford (2002) refers to "fluent bodies" that emerge within the context of postcoloniality and its ambivalences, Judith Farquhar (2002) un settles the string of dichotomies attached to distinctions between traditional and modern medicine by writing of "historical bodies." Volker Scheid (2002) approaches his description of contemporary Chinese Medicine through a notion of "synthesis," which is par ticularly compelling if one mulls over Hegel's version of synthesis as a new idea that resolves conflict between the initial proposition (for the nurses in my account, biomedicine) and the antithesis (for the nurses, traditional medicine). Ayurveda and Chinese Medicine, however, have been entangled with nationalist projects and pro pelled by state investment in ways that contrast sharply with the situation in Africa. For this reason, I draw most explicitly here on the notion of "articulation" that has been elaborated by science studies scholars, who emphasize its dual meaning?to make intel ligible and to join. loining?as an elbow might join different parts of the arm?captures both the residual distinction through a spa tial metaphor (there must be something on either side of the joint) and the sense that something whole is at stake.

9. Contemporary studies of nursing in Africa, including this one, owe a great deal to Nancy Rose Hunt's work (1999) on nurses as "middles," that is, as figures who mediate alterity within the clinic and within the patient as well as coordinate the different foci of concern that arise in African hospitals.

10. During this period, the nursing staff consisted primarily of women. The district nursing officer and one other senior registered nurse were men.

11. I thank Marjorie Mbilinyi, the head of the analysis, research, and publications (ARP) section of the Tanzania Gender Network ing Programme (TGNP), for sharing her summaries of these larger TGNP discussions with me during our conversations in February 2008. For analysis of neoliberal reforms in health and other sectors in Tanzania, see Chachage and Mbilinyi 2003.

12.1 conducted interviews, ranging from one to two hours, with 26 members of Hospital T's nursing staff. These 26 nurses, MCH aides, and medical attendants included all staff members who were scheduled in the regular nursing rotations between April and July 2003. Through the interviews, I collected three main kinds of infor mation: (1) staff members' personal medical histories as well as the histories of those relatives they helped to seek treatment; (2) their

professional history, including specifics about their training; and (3) their role in mediating decisions about and use of traditional

medicines. 13. For reasons of confidentiality, I have changed the names of

and any details that easily identify my interlocutors. 14. These numbered notations refer to the confidential code

assigned to each tape-recorded interview with clinical staff in Hospital T.

15. Conversations occurred primarily in Kiswahili but included some words or phrases in local languages. All translations are my own.

16. Kufunga, to close, is a Kiswahili verb often used to refer to workings of medicine.

17. It is interesting to note that stories of herbal treatments ad ministered through nasal-gastric tubes circulated among healers and patients. In the stories I heard healers tell, the afflicted per son always recovered as a result of the treatment. I found it difficult to assess how often medicine was administered through feeding tubes as well as the resulting survival rate; however, the iconic nature of tubes and drip lines in marking the intersection of tra ditional and modern medicine was clear.

18. Mama Tatu stated that

they are here inside because they steal away. They go and pick up traditional medicines and return to the ward with, for ex ample, an [herbal] ointment. They hide and smear it on the patients when the nurse is gone. When we discover this we ask them why the patient is white, they say, "I don't know." Medici nal baths [however] we cannot detect because it resembles the [plain] water for bathing.

19. The Bantu word Mungu has acquired layers of meaning through encounter. Today both Christians and Muslims use it to re fer to God or Allah, but J. A. R. Wembah-Rashid (1974) argues that, in southern Tanzania, it is also an older term referring to the place to which offerings and sacrifices ascended. 20. In her account of her son's illness and his therapeutic

itinerary, Mama Ramadhani states that the healer who told her about the mashetani cried. Such crying is sometimes seen when healers are "diagnosing" an affliction. As a manifestation of the healer's communication with ancestral shades, spirits, and other nonhuman agents, it is cited as a sign of legitimacy.

21. Users fees have also made it more difficult for people to af ford biom?dical care. Some scholars have speculated that such fees will "push" people to use traditional healers. Although healers do require compensation, Susanna Hausmann Muela and colleagues (2000) have written convincingly on the different kinds of resources that may be mobilized for traditional versus hospital care.

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accepted January 25, 2008 final version submitted January 24, 2008

StaceyA. Langwick Department of Anthropology 260 McGraw Hall Cornell University Ithaca, NY 14853

sal54@cornell.edu slangwick@gmail. com

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