Healing systems in Africa, Health problem in Africa

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Tropical Medicine and International Health

volume 2 no 9 pp 903–911 september 1997

Is there a role for traditional medicine in basic health services in Africa? A plea for a community perspective

Sjaak van der Geest

Medical Anthropology Unit, University of Amsterdam, The Netherlands

Summary Traditional medicine in Africa is contrasted with biomedicine. Most traditional medical theories have a social and religious character and emphasize prevention and holistic features. Traditional

medical practices are usually characterized by the healer’s personal involvement, by secrecy and a

reward system. Biomedical theory and practice show an almost opposite picture: asocial,

irreligious, curative and organ-directed; professional detachment, public knowledge and – until

recently – ‘free of charge’. It is suggested that local communities do not expect that basic health

care will improve when traditional healers become integrated into the service. They ask instead for

improvement of basic health care itself: more services with better access, more dedication and

respect from doctors and nurses, more medicines and personnel. Fieldwork needs to be done at the

community level to arrive at a better understanding and assessment of the community’s opinion

concerning a possible role of traditional medicine in basic health care.

keywords traditional medicine, basic health care, primary health care, cooperation, quality of care, community perspective, Africa

correspondence Sjaak van der Geest, Medical Anthropology Unit, University of Amsterdam, Oudezijds Achterburgwal 185, 1012 DK Amsterdam, The Netherlands

Introduction

The quality of modern health care services in Africa is

increasingly being criticized in recent literature (Hours

1985; Van der Geest et al. 1990; Gilson 1992; Gilson

et al. 1994; Booth et al. 1995). The consequences of

structural adjustment are strongly felt in the diminishing

budgets for health care. At the microlevel, the attitude

and behaviour of health personnel towards patients have

been singled out as problematic. Compared to local

traditional healers, health workers in the basic health

services are often found to show little concern and

respect for patients. The question could be raised

whether integration of traditional healers in basic health

care would help to improve its quality.

Since 1978 the WHO has been calling for more

cooperation, even integration, of traditional medicine

and biomedicine. The role of traditional medicine was

viewed as an integral part of primary health care with its

basic philosophy of self-reliance. Obviously, traditional

healers and traditional self-care were considered a form

of self-reliance.

The idea was inspiring and breathed the spirit of

optimism of those days. However, national governments

and their ministries of health, controlled by biomedical

practitioners, were less enthusiastic. They did pay lip

service to the WHO suggestion, created token

departments of traditional medicine, but did not give the

idea much chance to materialize. Green (1996) provides

a useful overview of government policies, ranging from

banning traditional medicine to programs for

integrating it into the regular national health service, but

most policies existed merely on paper to please

international donors. I shall return to this intentional

misunderstanding later on when discussing the

multilevel perspective. In the meantime the WHO itself

has – almost silently – changed its position and placed

traditional medicine in the Division of Drug

Tropical Medicine and International Health volume 2 no 9 pp 903–911 september 1997

S. van der Geest Traditional medicine in basic health services in Africa

Management and Policies where it is dying a slow death

(Ventevogel 1996).

By now we have a library of publications advocating

or rejecting the idea of integrating traditional and

biomedical services. Most authors who have contributed

to that discussion base their argument on their own

assessment of the complementarity or incompatibility of

the two – or more – medical traditions (for overviews

see Bichmann 1995; Green 1996; Ventevogel 1996). Some

have interviewed local healers and/or biomedical

practitioners about their views on a possible

cooperation. Overall, however, their conclusions reflect

their own logic. Amazingly, the question whether local

communities favour an integration of traditional and

modern medicine has hardly been raised, let alone

investigated by medical anthropologists. This article is a

plea for such research and at the same time carries the

cautious suggestion that local communities may be less

enthusiastic about the idea of integration than some of

its advocators assume.

African medical traditions

It has become a tradition in Africa to refer to medical

practitioners outside the realm of biomedicine as

‘traditional healers’. In the same vein, their practice and

knowledge is called traditional medicine. The term is

misleading, embarrassing and naive. It is misleading

because it suggests that there is a more or less

homogeneous body of medical thought and practice

which can be put together under one name. Such a body

does not exist, however. If one examines the type of

medical practitioners who are designated traditional,

one will find an extreme diversity both in theories and

practices. The only thing these practitioners have in

common – like alternative practitioners in Europe and

North America – is that they are non-biomedical. That

is why the term is embarrassing. Lumping together

everything which is not ‘ours’ and treating it as if it

were one type is a school example of ethnocentric

ignorance. Finally, the term is naive because it suggests

that ‘our’ medical system is not traditional, meaning

handed over, from generation to generation. Clearly,

biomedicine is being handed over all the time, in

medical schools, in hospitals, in books and articles,

through conferences and the media. Biomedicine

therefore is as traditional as any other medical

tradition.

Another misunderstanding is brought about by the

term ‘medical system’, which suggests a coherent whole

of beliefs and practices. Anthropologists, however, have

shown that medical ideas and practices do not always

harmoniously fit together. There is often confusion,

ignorance and contradiction in what people think and

do around health and illness. To a Western-trained

scientist the statements and activities of traditional

healers and their clients may seem outright illogical and

unsystematic.

Having said this, I will nevertheless – with some

embarrassment – try to make a few general observations

about African traditional medicine. African medicine

consists primarily of self-help. For various reasons, self-

care and self-medication are far more widely practised

in African families than, for example, in my own

society, the Netherlands. Self-care is not only something

of people’s own choice, it often is bare necessity due to

poverty or lack of good medical facilities (Van der Geest

& Hardon 1990). Home remedies and popular

knowledge of herbs and other therapeutic substances

take up the greater – and perhaps the better – part of

African medicine. Its efficacy is publicly discussed and,

for that reason, open to critique and adjustment.

Popular knowledge therefore is a most valuable part of

the medical tradition. It needs to be safeguarded and

strengthened if we want to enhance people’s ability to

cope with health problems and to improve the quality of

health care.

It is more difficult to speak in such general terms

about the specialists in African medicine, the traditional

healers. To risk overlooking their cultural diversity and

to simplify the complexity of their medical practice, I

shall discuss four more or less characteristic features of

their medical theories and three features of their style of

practice.

Most African medical theories have a social character.

The description and explanation of illness is often

phrased in terms of social interaction, in particular

between members of one kinship group. The origin of

illness, its treatment and prevention is linked to the

quality of human relationships. Jealousy, hatred and

moral wrong-doing are associated with physical and

mental dysphoria. Ancestors and witches are believed to

play a crucial role in bringing about illness and other

misfortune. Disorder in the community leads to disorder

in the health condition of its members. An illness of one

family member therefore is seen as an illness of the

Tropical Medicine and International Health volume 2 no 9 pp 903–911 september 1997

S. van der Geest Traditional medicine in basic health services in Africa

entire family. Finding a solution to the problem is the

responsibility of the group to which the sick person

belongs.

The second feature is the religious dimension of

medical reasoning. Religion permeates every aspect of

human existence, including health and disease. Medical

problems are often interpreted in religious terms and,

conversely, religious rituals are nearly always linked to

the maintenance or restoration of well-being in the

community. Many medical practitioners are also

religious specialists. Healing the body while neglecting

the deeper religious grounds of the problem is senseless.

African medicine’s third characteristic will be a

surprise to most readers: its orientation to prevention.

There is a popular western prejudice that Africans do

not worry about the future and are little interested in

preventive medicine. It is one of the most stubborn

misconceptions about Africa circulating in the rest of

the world. Prevention, however, is central in people’s

everyday life and follows logically from their

preoccupation with religious and social values. As we

have seen, traditional healers concentrate on the deeper

origins of illness and insist that something should be

done about them to avoid a repetition of the misfortune.

They provide their patients with moral and social

guidelines to prevent them from catching the same

illness again. The preventive character of traditional

medicine is, however, hardly recognized by outsiders

who do not believe in the social and religious roots of

illness and consider the healers’ suggestions irrelevant to

health and illness.

The fourth characteristic of medical theories in the

African tradition is that health and illness are more

comprehensive concepts than in the Western tradition.

As a matter of fact, ‘health’ cannot be adequately

translated in many African languages. Indigenous terms

closest to it comprise a much wider semantic field. They

refer to the general quality of life including the

conditions of animals and plants, the entire physical and

social environment. ‘Well-being’ or even ‘happiness’

seem better English terms to capture the meaning of

traditional African medical concepts. As a consequence,

the English term ‘medicine’ is also a misnomer, but

interestingly the term has been indigenised in many

African languages and now entails much more than

restoring bodily health. Medicine is any substance that

can bring about a change, anywhere, anyhow.

Medicines heal a sickness, catch a thief, help someone to

pass an exam, make a business prosper, kill an enemy

and win someone’s love (Keller 1978; Whyte 1988). In

the explanatory model of many African healers there is

no neatly demarcated field of physical health. Their

medical perspective is holistic in the most holistic sense

of the word. Interestingly, their vision is not so different

from the idealistic and much criticized WHO definition

of health: a state of physical, mental and social well-

being.

Three prominent, more or less general features of the

practice of traditional medicine in Africa are the healers’

emotional commitment in the therapeutic process, the

secrecy surrounding their practice and the healers’

reward.

Several students of traditional medicine have

described the deep personal involvement of African

healers in the treatment of patients. Therapeutic sessions

lasting more than an hour, and continuing over a period

of several months are common. The style of treatment

also indicates the healer’s concern. Patients are

frequently touched and their social and mental problems

extensively discussed, often in the presence of their

relatives.

Many traditional healers consider their medical

knowledge as personal property which they protect by

keeping it secret. Only a few select people are allowed to

know their secret, for example an apprentice who has

paid for his training or a relative who is destined to

succeed the healer in the future. The secrecy may be

medically legitimized: if the secrecy around a treatment

is broken, the treatment loses its efficacy (Cohen 1969;

Buckley 1985; Pearce 1986, 1989; Van Sargent 1986,

Wall 1988). The secrecy also has consequences for the

healer-patient relationship. The patient knows nothing

and must totally surrender to the healer (Buckley 1985;

Wall 1988).

A final characteristic, contrary to some popular

beliefs, is that traditional healers are rewarded for their

service. Their personal involvement does not imply that

their work remains unrewarded. The social context of

the therapeutic act requires reciprocity. In most cases

the positive outcome of a treatment needs a response

from the patient or his relatives. Paying for received

treatment is a sign of respect and appreciation. No

payment implies no obligation, no appreciation, no

relationship (Van der Geest 1992). If no reward is given,

the patient runs the risk of falling sick again. Like the

concept of secrecy, the reward too has been built into

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S. van der Geest Traditional medicine in basic health services in Africa

medical theory. The payment contributes to the efficacy

of the treatment.

The imported tradition

The imported biomedical system is in many respects the

opposite of the above described indigenous tradition.

The religious dimension is totally absent and the social

dimension only plays a marginal role. In European

history, biomedicine made its great advances after it had

isolated the human body from its wider context and was

able to concentrate on technical failures of the body-

machine. Its great achievements were in the field of

curative medicine while prevention received far less

attention. Biomedicine has an uneasy relationship with

all medical traditions which hold a more holistic view of

human health and disease; the African traditions being a

case in point.

It is no wonder that also in its practice biomedicine

strongly contrasts with the African way. In the first

place, biomedical doctors or nurses usually do not want

to get personally involved in the problems of their

patients but prefer to keep some distance.

Anthropologists who compared biomedical with other

practitioners observed that the latter devoted much

more time to their patients than the former and that they

were closer to their patients in their choice of words and

in their behaviour.

Knowledge in biomedical science and practice is,

almost by definition, public. Doctors openly discuss

their practice with colleagues and advice is frequently

exchanged among them. Progress in biomedical science

is made possible through conferences and publications

in which scientists make their discoveries known to the

world.

The contrast in the reward system is perhaps less

prominent, but until recently, biomedicine in

government institutions was – at least nominally – free

of charge in a large number of African countries. The

absence of any form of remuneration usually confirmed

the absence of a personal relationship between doctors

(and nurses) and their patients.

This brief contrasting picture is, however, incomplete

and over-schematic. It describes the imported system in

abstracto. In the actual situation of African

communities, biomedical knowledge and practice are

often indigenised and adjusted to local needs and

expectations. Self-help, for example, continues to be

practised in hospitals and clinics. Relatives bring herbs,

pharmaceuticals and other popular remedies to patients

in hospitals who use them alongside the professional

treatment they receive.

Visiting biomedical institutions one may discover that

the religious factor has entered biomedicine. Hospitals

have become favourite places for religious activities. The

experience of pain and suffering invites metaphysical

questions among patients and their relatives. During my

own admission to a Ghanaian government hospital,

some years ago, I encountered more preachers than

doctors and nurses.

A similar observation can be made with regard to the

social factor. Relatives of patients are conspicuously

present in hospitals and health centres. They occupy

themselves with numerous chores such as feeding and

bathing patients and going out to buy medicines for

them. It would be difficult for hospitals and health

centres to function without the assistance of those

relatives. It is true that the social factor has not entered

the doctor’s aetiology and diagnosis, as is the case in the

traditional setting, but social relationships do play a

crucial role in the therapeutic activities in biomedical

institutions. As far as the other two characteristics are

concerned, the emphasis on curative and organ-

orientated medicine, the indigenization and

transformation of biomedicine is less prominent.

The impersonal and unconcerned attitude of

biomedical doctors and nurses to their patients may

apply to the majority of cases, but there are significant

exceptions. When there is a family or other relationship

between health worker and patient, one may witness a

totally different therapeutic encounter. The health

worker will show concern and affection and spend a lot

of time with the patient (Gilson et al. 1994).

The openess of the doctor to colleagues and patients

may be far less than one would expect from a

biomedically trained person. Especially to patients,

doctors (and nurses) are taciturn and secretive. Nothing

is explained to them. The image of the all-knowing but

secretive traditional healer is transposed to the

biomedical physician. The patient just trusts him

because he is the doctor.

Finally, the claim that government medical services

are (were) free of charge is in many cases a myth. They

were only free in theory, in the official political rhetoric.

In actual practice, patients had to pay a sum of money

to establish a relationship with the doctor or the nurse

Tropical Medicine and International Health volume 2 no 9 pp 903–911 september 1997

S. van der Geest Traditional medicine in basic health services in Africa

to oblige him/her in order to get the treatment and

medicines they desired ( Van der Geest 1982). The

traditional concept of reciprocity was informally – and

illegally – reintroduced into biomedical settings.

Payment was not necessary if the doctor/nurse and

patient were in some way related. In those cases,

payment was superfluous, since another form of

reciprocity already existed. In most countries therefore

the cost recovery introduced by the Bamako Initiative is

a confirmation of an existing practice rather than an

innovation.

Arguments for cooperation between traditional medicine and biomedicine

The problems and frustrations encountered in the

modern health care system seem to call for a

rapprochement between biomedicine and traditional

medicine. Health planners and social scientists have

provided several reasons why cooperation between the

two traditions should be considered an option to

alleviate the present problems in health care.

The first reason is the shortage of personnel in the

biomedical sector. Training traditional healers as

community health workers would be a quick and

inexpensive way to fill some of the gaps in biomedical

services. The second argument refers to the mainly rural

character of the logistical problems in government

health care. Doctors and nurses are reluctant to settle in

rural areas and even community health workers

disappear after some time to try their luck in an urban

environment (Van der Geest et al. 1990). Traditional

healers are far less inclined to leave their rural

community. They usually are farmers, tied to the land.

Moreover they depend on the local flora and/or on local

deities for their medical practice. For most of them a life

in the city, where they will lose the prestige they enjoy in

the home community, is not attractive. To train and

install them as community health workers therefore

seems a wise policy decision to improve the accessibility

of basic health care in rural places.

A plea for cooperation with traditional healers is

also in accordance with the Primary Health Care

(PHC) philosophy of self-reliance. Where possible,

dependence on external services should be replaced by

reliance on local resources. Traditional healers are part

of the available local resources and suit the PHC

concept.

The cultural affinity between traditional healers and

their patients is a fourth reason to support greater

involvement of healers in the health care system. The

fact that healers and patients share ideas about the

origin, meaning and preferable treatment of illness

enhances the efficacy of treatment. The lack of such a

cultural affinity between biomedical practitioners and

their patients is often blamed for the limited compliance

by patients and the frustrations of doctors and nurses.

The last reason for biomedicine to make overtures

towards traditional medicine lies in the assumed unique

value of the latter. The belief that African traditions

contain valuable insights and therapeutic techniques

which are unknown in the biomedical tradition is

considered by many a sufficient grounds for closer

cooperation which hopefully leads to mutual

enrichment.

These five arguments in favour of cooperation

between the two traditions mainly reflect the outsider’s

perspective. They may make sense from the points of

view of policy makers, idealists and social scientists, but

what do people in rural communities think about this

option? Would it be attractive to them if traditional

healers were included in the basic health services?

Would a dose of traditional medicine enhance the

quality of health care to them? These questions are not

easily answered because little is known about

community perspectives on traditional medicine.

A multilevel perspective

Health policy is usually conceived and pushed by

discussions on the level of national ministries and supra-

national organizations, where the interests and ideas of

the local population hardly get through. Moreover,

health planners are often not prepared to listen to

community demands. They are convinced that people in

the villages do not know what is good for them or come

with impossible requests. Nevertheless, suggestions for

the improvement of health care which have been

produced by high-level policy makers are often

presented as plans reflecting the interests of the people

directly affected by them.

What is needed is a research strategy for the study and

comparison of health care ideas at different levels of

social organization. The multilevel perspective provides

such a tool to gain an understanding of the contrasting

and conflicting views between people at different social

Tropical Medicine and International Health volume 2 no 9 pp 903–911 september 1997

S. van der Geest Traditional medicine in basic health services in Africa

levels. It brings into focus possible conflicting interests

at different levels. Opposite interests give shape to

conflicting ideas about health care and health care

policy. The same words may be used but with very

different meanings. Language thus becomes a

camouflage of conflicting ideas and interests. The

appreciation of traditional medicine is a good example.

Different opinions are probably hiding behind general

statements pledging support for the inclusion of

traditional medicine in the regular health care system. In

the Alma-Ata document collaboration with traditional

medical practitioners was recommended in the

following terms:

Traditional medical practitioners and birth

attendants are found in most societies. They are

often part of the local community, culture and

traditions, and continue to have high social

standing in many places, exerting considerable

influence on local health practices. With the

support of the formal health system, these

indigenous practitioners can become important

allies in organizing efforts to improve the health of

the community. Some communities may select them

as community health workers. It is therefore well

worthwhile exploring the possibilities of engaging

them in primary health care and of training them

accordingly (WHO/UNICEF 1978).

In addition, the WHO (1978) devoted a report to the

integration of Western and traditional medicine.

Optimism about possible cooperation between

representatives of different medical cultures also

predominated in a collection of articles Bannerman et al.

(1983) published under the auspices of the WHO.

Although some scepticism about traditional medicine

still exists, the idea seems to prevail at the international

level that additional training and involvement of

traditional practitioners can partly fill the shortage of

personnel in PHC or at least ease it and that such

practitioners will make valuable community health

workers. Their close relationship with fellow-villagers is

seen as a guarantee of good communication.

At the national level lip service is often paid to the

above-cited passage in the WHO document. Promotion

of traditional medicine frequently serves the purpose of

national and cultural self-awareness. In practice,

however, there is hardly any example of real

collaboration and exchange between modern and

traditional medicine in the framework of PHC. Health

workers within the biomedical system are generally

opposed to the idea of collaboration, whereas

traditional practitioners are often more responsive. The

latter expect an increase in prestige and income through

their association with the official health care system

(Green 1988; World Band 1994; Ventevogel 1996).

As yet, little is known about the reaction of local

population groups to the incorporation of traditional

medicine into PHC. While they have long been

accustomed to Western and traditional medicine being

used side-by-side, they are likely to see themselves

fobbed off with second rate provisions when traditional

practitioners are mobilized as community health

workers (Green 1988).

Community perspective

How do ordinary people perceive traditional medicine

and would they favour some kind of integration of

traditional medicine into basic health services? I have

already pointed out that hardly any research has been

done on this question. The only example of such

research which comes to mind is a twin project in Ghana

and Thailand (Le Grand & Wondergem 1990). Most

researchers deal with the opinions of policy makers,

medical doctors and traditional healers.

The first and most appropriate answer to the above

question is of course that we need proper field research

at the community level. Bearing in mind the caveats

expressed at the beginning of this essay, we should

reckon with considerable differences in community

perspectives in different African societies. African

medical traditions vary enormously and so will people’s

appreciation of them.

I can only speculate about community perspectives,

based on rather subjective impressions and experiences

in various African countries (particularly Ghana,

Cameroon, Mali and Zambia) and on reading – mostly

between the lines – a large number of publications and

unpublished reports.

The first impression is that on the whole people do

not favour a mix of biomedical and traditional services.

It has been frequently observed that people have divided

their health problems between biomedical and

traditional practitioners. In their view, some complaints

can only be treated in the hospital or health centre and

other ones only by the local healers. Integrating the two

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S. van der Geest Traditional medicine in basic health services in Africa

traditions would not help them. As a matter of fact they

have already made some kind of integration in their

heads. They know where to go for what kind of health

problem. The medical situation in Africa is indeed

essentially pluralistic. Moreover, and quite rightly, they

would suspect that they are being cheated with cheaper

and – as they call it – ‘second rate’ health care if

traditional practitioners would become their basic

health workers. In the present situation, they have access

to traditional medicine whenever they want it and they

probably prefer to keep it that way.

People do want better quality of care from

biomedical doctors and nurses: more concern and

respect. Anthropological research in biomedical

institutions in Africa is practically nonexistent.

Anthropologists, usually of western origin, were after

the exotic (diviners, witchdoctors, herbalists and

traditional midwives) and neglected what was familiar

to them (hospitals, clinics, doctors and nurses).

Overviews of the functioning of hospitals and health

centres in Africa, including the recent Better health in

Africa by the World Bank (1994) only discuss problems

of cost-effectiveness and limited accessibility. What is

widely known, though hardly mentioned in written

sources, is that the quality of care in Africa leaves much

to be desired. Doctors and nurses are frequently accused

of not respecting patients and lacking concern.

Paradoxically, that negative judgement does not

prevent people from frequenting biomedical

institutions. They are well aware of their technical

efficacy. Patients who make use of basic health services

want their own ideas and home remedies to be taken

seriously. They ask for good medicines in sufficient

supply. They want the services to be more accessible to

them. One could perhaps say that they ask for some of

the qualities of traditional healers in their biomedical

practitioners, but that does not mean that they want

traditional healers to replace them. The biomedical

tradition has become an integral part of local

community life and people do not want to lose it. They

rather ask for more of it: more and better medicines,

more health workers, more facilities.

It is significant that people in Ghana and Thailand

were not very enthusiastic about the idea of introducing

traditional herbs into modern health facilities. To them,

herbs were out of place in the setting of a health centre

(Le Grand & Wondergem 1990). The authors, however,

recommend the promotion of herbal medicine by

biomedical workers. They argue that integrating herbs

into basic health care would be far preferable to the

integration of traditional healers. As we have seen

before, herbs which are commonly and widely used have

to some extent proved their efficacy. It is uncertain,

however, that the practices of secretive healers are

equally effective.

Some healers claim that the therapeutic efficacy of a

plant does not lie in the plant itself, but that they give

the plant its medicinal power through a ritual act such

as a prayer or a blessing. Yoruba healers in Nigeria, for

instance, awake the power of a plant by incantations.

The incantation is not directed to the patient (who

cannot understand it) but to the medicine (Buckley

1985). Without the magical formula the medicine would

not work. Similarly, in Burundi, for 80% of herbs used

by specialist healers, the efficacy is added to the herb by

the healer. The healers emphasize that it does not matter

which herb they use; the only thing which counts is that

they make it into a medicine (Baerts & Lehmann 1993).

How they do this is a well-kept secret. Mallart Guimera

(1977), who did research in South Cameroon, discovered

a disquieting lack of consensus among healers as to

which herb was effective against which medical

problem. Their completely different perspectives on

efficacy would make their cooperation with biomedical

practitioners extremely problematic.

Moreover, the motives of healers who do join the

public health care system are sometimes opposed to

those of health planners. Green (1988) reports that a

survey among healers in Swaziland showed that:

… if they were to choose which aspects of Western

medicine they could learn about, they would

choose X-ray technology, blood transfusions and

injections of antibiotics.

Healers hope to raise their social prestige and

increase their income by learning the ‘mysteries of

modern medical science’ and sharing the prestige and

income of biomedical practitioners. It is no wonder that

many of their biomedical colleagues have their

reservations:

A plan to develop healers as promotors and

distributors of packaged oral rehydration salts was

defeated by physicians and health officials who felt

traditional healers could not be trusted with

modern medicine. (Green 1988)

Tropical Medicine and International Health volume 2 no 9 pp 903–911 september 1997

S. van der Geest Traditional medicine in basic health services in Africa

Conclusion

My – admittedly hypothetical – impression is that most

communities do not expect improvements in basic

health care when traditional healers become integrated

into the service. They ask instead for improvement of

basic health care itself: more, and more accessible

services, more dedication and respect from doctors and

nurses, more medicines and personnel. Medicines used

in traditional self-care also deserve more attention from

policy makers.

Most importantly, fieldwork needs to research at the

community level to arrive at a better understanding and

assessment of the community’s opinion concerning a

possible role of traditional medicine in basic health care.

Suggestions to integrate traditional medicine into basic

health care are insufficiently founded on the views and

preferences of those who would be most directly

involved in such a policy. Pleas for the integration of

traditional and modern medicine seem to be mostly

inspired by romantic – and simplistic – ideas concerning

traditional medicine or by economy motives. Medical

anthropologists should assess the rationality and

feasibility of such recommendations by studying the

views of people in the community.

Acknowledgements

Parts of this paper were used in a keynote address at the

European Conference of Tropical Medicine in

Hamburg, October 1995.

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