The infancy of Edward Shelonga Part III
an extended case study in medical and religious anthropology from the Zambia Nkoya
Wim van Binsbergen
|
The infancy of Edward Shelonga Part III an extended case study in medical and religious anthropology from the Zambia Nkoya Wim van Binsbergen |
|
to Part 0 (Abstract)
to
Part I (Problem and Method; Background)
Part
II (The extended case; Ethics)
Part
IV (References; Postscript on Cognition)
6. Interpretation of the extended case
Let
us first consider the role of cosmopolitan health agencies.
Both at the beginning and at the end of my account of
Edward’s infancy stands the Lusaka University Teaching
Hospital: in between, the protagonists move to and for between
various other cosmopolitan health agencies and Nkoya
Alternatives. When and why, therefore, do people utilize
cosmopolitan health agencies?
Obviously, accessibility
is a first condition for such utilization. In the urban situation
(cf. Shattock n.d.), urban clinics tend to be within walking
distance from the homes of the majority of the population. With
the exception of private doctors, Zambian cosmopolitan health
agencies have become non-fee-paying in the late 1960s. Therefore,
the main determinant of accessibility now lies in the time factor
(cf. Zeller 1974). Limitations of staffing and equipment usually
cause long waiting hours, which form such a common and perennial
feature of cosmopolitan medicine in Africa that patients are
prepared to accept them — provided no third party is making
an urgent demand on their time. In many cases however there is
such a third party: children waiting to be fed at home, an
employer anxious for his employee’s return to work,
one’s own business that needs attention, etc. Should the
urban clinic refer one to the central hospital, not only a
further loss of waiting time is involved, but also the distance
to be discovered often requires use of public transport, which
means further expense of time and money. Among the urban poor,
lack of transport money often means that a visit to hospital has
to be postponed.
In the rural areas the access factor weighs much more heavily.[1] Here a visit to a rural
health centre or hospital usually involves travelling over
considerable distances. In Chief Kahare’s area, motor
transport is very seldom available. The long journey and the long
waiting hours frequently necessitate an absence of several days,
which many people cannot afford (particularly young women, who
under the tight control of their senior consanguinean or affinal
kin carry the lion’s share of domestic and agricultural
tasks). Such prolonged absences require that one carries
blankets, food and kitchen utensils on the journey, money does
not affect sleeping arrangements has money to buy food on the
way. As a result, rural utilization of cosmopolitan health
services falls steeply with increasing distance, and on the
longer distances (exceeding 10-20 km) tends to show a bias
against those who are particularly busy, poor or junior.
In Edward’s case, the Lusaka data do not suggest that the
accessibility factor is very important in the urban environment.
Mary remained on the outside of cosmopolitan medicine,
irregularly went for antenatal care, gave birth at home, and did
not attend the under-five clinic[2]
(except when Edward was obviously ill) — not for reasons of
access, time or money. However, in the rural data the effect of
these factors was demonstrated by the fact that, while visiting
the distant Rural Health Centre (and a
fortiori the even more distant hospitals)
was a major decision, and one which people would not take except
in very serious cases (when it was often too late), they would
daily flock in considerable numbers to our improvised bush
clinic. Even at our clinic the impact of distance made itself
felt. Our patients were mainly from Mema valley, where Chief
Kahare’s capital is located. Even from the adjacent Mushindi
valley, where e.g. Nyamayowe village is located, markedly fewer
patients would come: and those who did come would tend to have
more serious complaints. It proved impossible to have Edward
brought in daily for eye treatment, across a distance of less
than one hour of cycling. Considerations of accessibility also
form an obvious explanation for the common phenomenon of
black-market medicine (cf. Patrick’s death) — although
we shall find additional explanations when discussing the health
role of the elders.
While largely economic factors underlie the effect of
accessibility, time and money, Edward’s case clearly brings
out the role of non-economic factors. In the literature these are
often discussed in terms of local, culturally shared modes of
conceptualizing health and disease. Authors in this connection
often speak of the force of ‘tradition’ and the
persistence of ‘traditional’ medicine, as if that would
explain anything.[3]
As we have seen, the same person (Mary) may in the course of a
short period repeatedly shift between cosmopolitan and Nkoya
health agencies; yet her ideas on health and disease remained the
same, throughout the process. why was Edward dragged to and for
between the various outlets of cosmopolitan medicine, and a
variety of local alternatives such as ancestral ritual, cults of
affliction, diviners, etc.? Why did Mary achieve overnight
mastery in hygienic bottle-feeding, yet allowed Edward to go
through a musical chairs of Nkoya treatments, which by delaying
effective clinical action nearly cost him his life? The health
concepts in her mind are not likely to explain the variability of
her actions — except perhaps for this one notion, so
fundamental in Nkoya social structure, that potential support and
remedy is never limited to one exclusive source, and that one may
safely look for alternatives if one way is blocked. But given the
options present in Edward’s health situation, what
principles governed that certain options were finally taken, and
others were not?
The typical Third World medical situation today is that of a
person surrounded by various alternative health agencies, all off
them in principle accessible (albeit not at equal costs). Given
this situation, the data suggest that such a
person’s actual pattern of utilization will to a
considerable extent result from the social process in which he is
involved in his immediate social environment.
In the years covered by my data, Muchati and Mary (and by
consequence their child Edward) did not significantly change
their class position, level of income, educational status, etc.
All these individual attributes which surveys have tried to link
up with health agency utilization, here remained constant, and
for that reason are incapable of explaining the variation in
Muchati’s and Mary’s health activities. But what did
undergo perceptible and significant changes was the pattern of
crucial relationships by which each of them was surrounded. It
is in the evolution of these relationships that their health
choices become understandable.
In these relationships, a number of major spheres can be
identified:
a. Formal-sector employment
One
such sphere was the relationship of Muchati’s family with
the families of his employers (not just us). Here Muchati was
thoroughly exposed to cosmopolitan health concepts, and obliged
to apply them at least in his professional work as a domestic
servant. He could enhance his employment security by pleasing his
employers. The latter would expect him to observe basic hygiene,
and would normally make a visit to a cosmopolitan medical agent a
condition for sick leave. Moreover, expatriate members of the
Zambian elite has become a reference group for him; he would
attempt to selectively adopt their life-style. Largely for these
reasons Muchati absorbed modern hygiene and applied them in his
personal life. As is repeatedly demonstrated in Edward’s
case, this made Muchati a strong advocate of cosmopolitan
medicine. He struggled to have Mary attend the urban clinics and
to have Edward born in hospital; he supervised Mary’s
bottle-feeding; upon departure from the village he left money for
visits to the rural cosmopolitan health agencies, etc. At our
bush clinic, in his greatly enhanced status of research
assistant, Muchati would often take the initiative of lecturing
the women and youth on elementary hygiene (use of boiled water
for drinking, etc.).
However, the impact of formal-sector employment was set off
against that of other social spheres, in shaping the health
actions of Muchati’s family.
b. Elders
While
living in town, Muchati’s and Mary’s frequent
interaction with fellow-Nkoya meant a continuous confrontation
between Nkoya medicine and cosmopolitan medicine. Nkoya medicine,
in this context, was not offered in the form of advice that one
could either take or leave. Rather, the idiom of illness and
healing provided a major context to shape interpersonal relations
within this ethnic group. propounding advice in health matters,
dreaming up new therapies for sick kinsmen, dispensing herbal
medicine and other therapies forms an integral and central part
of dealings between kinsmen and between tribesmen among the
Nkoya, in town as well in the village. Seniority and authority
imply protection and care, and the most common form in which
these are offered is a medical one. Most Nkoya adults over forty
years of age claim specialist knowledge of certain aspects of
local medicine. It is no exaggeration to claim that, today,
health action is the Nkoya elders’ main task. At the same
time it is also their major prerogative, by which they assert
their authority over their junior relatives and tribesmen at
large. This is particularly the case with the village headman.
Therefore a headman’s failure to protect his village from
illness, death and sorcery is a terrible shortcoming, which will
greatly lessen his authority in local-political and judicial
matters. On a less exalted scale, the relationship between
parents and children, and even that between husband and wife,
calls for explicit health intervention from the dominant party.
In the past, the medical dimension of the elders’ role among
the Nkoya was accompanied by very considerable power in the
marital, political and economic domain. Together, these aspects
made for a marked dominance of the old over the young. Now that
political incorporation of the national state and the penetration
of capitalism, have largely destroyed the elders; political and
economic power, mainly two domains have survived in which the
elders can expropriate the products of the labor of their
juniors: affinal relationships, and health action. In the field
of affinal relationships, recent decades have seen the evolution
of marital payments from trade goods or labor (bride services),
to high and standardized monetary bride-prices in the order of
magnitude of K80, i.e. what an unskilled laborer, if he manages
to secure employment, can earn (not: save) in about three months.[4]
In general it is the juniors who pay and the elders who receive
these payments. Thus a major inter-generational flow of
town-earned cash is maintained. In the domain of health action,
the elders’ medical services not only drive home the
juniors’ fundamental dependence on the elders no matter how
economically independent the former may have become such health
action invariably also involves the transfer of money from the
young to the old (and/or from men to women). In the case of cults
of affliction, fees of K20 are no exception. Where the symbols of
economic and political excellence have declined, the elders seek
recourse in new medical symbols to express and assert their
uncertain dominance. Not only do they deal in historical forms of
Nkoya medicine, or in such modern derivations as the cults of
affliction — they also appropriate and dispense modern
medicine obtained in dispensaries or the black market.
Patrick’s death illustrates to what tragedies this can lead.
c. Kinship and marriage
The
third major sphere in the social process surrounding
Edward’s health experience is that of kinship and marriage.
Edward’s story reflects two main processes in this respect.
First there is the development, against many odds, of a mature,
stable conjugal relationship between Mary and Muchati. And
secondly there is the increasing juxtaposition between their
respective kin groups, with Mary being more and more drawn away
from her parental kin group and into that of her husband. It is
largely from elements derived from these two processes that the
elders (taking temporary precedence over the cosmopolitan health
agencies championed by Muchati) shaped their healing activities
with relation to Edward. The elders’ health action (which
sometimes amounts to illness-provoking action), is primarily a
means to assert their kinship-political claims over juniors such
as Mary and her child Edward. Conflicting supernatural
interpretations are advanced in order to bring out the
imperfections of the rival kin group, and ritual is undertaken to
incorporate the juniors more fully into one’s own kin group.
Judged exclusively within the framework of cosmopolitan medicine,
it would seem as if the relatives cynically let the child suffer,
merely using its critical condition as a pretext to pursue their
own kinship-political interests. However, a less ethnocentric
interpretation is called for. Kinship dominates the Nkoya
community, as it is the fundamental organizational set-up by
which rural production and reproduction are organized. Bilateral
kinship creates the specific structural problem of several kin
groups competing, with virtually equal force and with uncertain
outcome, for the allegiance of junior members. this competition
is a major structural theme in Nkoya society. It makes for a very
high rate of inter-village migration, and is closely connected
with the high degree of martial instability. The competition for
juniors is further acerbated by the fact that offspring is so
very scarce due to an extremely low fertility. This seems to be
the background of the Nkoya’s obsession with illness and
death. Reproduction is a major concern in any society; it is a
centre of gravity in all societies organized around the domestic
community (Meillassoux 1975). But among the Nkoya, with their
impaired fertility coupled to a continuous emigration of young
labor power to the towns, reproduction has eclipsed most other
concerns, perhaps even production, which is at a low level
involving severe annual shortages. In this context, even a
child’s minor health complaints activate, in the
consciousness of that child’s kin, the whole predicament of
their society. A child’s death is in fact what the frantic
mourners claim it to be: an assault on the survival of their
group. Naming ritual (meant to tie the child more closely to the
kin group and its ancestors) and ritual contests (cf. the two
divinations of the causes of Edward’s illness) with other
groups that extend rival claims over the child, may not
constitute the most effective way of curing a sick child, yet
they do form a meaningful attempt to get to the roots of the
child’s condition and its paramount social significance for
the various groups that lay a claim to his membership.
d. Cosmopolitan health agencies
A
fourth major sphere in the social process shaping our
protagonists’ health behavior, is formed by the cosmopolitan
health agencies themselves.[5]
Once the problems of access have been overcome, what kind of
interaction actually takes place between patients and medical
staff at rural health centres, clinics, hospitals and private
practices? Edward’s case suggests repeatedly (cf. negligence
of Mary’s breast-feeding while Edward was in hospital; the
rural health centre lacking essential drugs; the doctor’s
attitude towards Muchati when he brought Edward in for admission;
Kafungu’s pneumonia) that this interaction is often of a
very deficient nature, both in social and in technical-medical
respects, and especially in those cases that require more than
quick and simple administration of medicaments.[6] In terms of social
relations there is often little to reinforce and consolidate a
patient’s initial attraction to cosmopolitan medicine, and
there may be much to deter him. the immense pressure of work (cf.
Leeson 1970), the cultural and linguistic barriers (cf. Conco
1971), the conflict-ridden internal structure of institutions of
cosmopolitan medicine[7]
and the difficulties involved in keeping up medical supply lines
in a hug empty country like Zambia (Hage-Noël 1974) may all be
quoted in vindication of individual health workers. However this
does not take away the fact that often health action along the
lines of cosmopolitan medicine is frustrated by the very
institutions that claim to have scientific furtherance of health
as their major aim. Cosmopolitan health agencies have a great
influence on peoples’ health behavior — but sometimes
this influence may be of a kind to encourage them to take their
health problems elsewhere.
Alternatively, Edward’s case offers sufficient examples
(Mary’s bottle-feeding; our bush clinic, my patronage in the
event of Edward’s final hospitalization) of the fact that,
given adequate social relations between Nkoya individuals and the
advocates of cosmopolitan medicine, the effect of cognitive or
kinship-political barriers to adequate health action can be
minimized. In a Central African society like that of the Nkoya,
where ‘shopping-around’ (for kinship support,
followers, medico-ritual attention within the context of Nkoya
medicine) is a fundamental structural theme, one should hardly
expect that such a powerful source of support as cosmopolitan
medicine would be ruled out for reasons of principle! Just as in
the choice of a headman or a nganga,
two major factors are important here: one’s ability to enter
into a satisfactory relationship with that agent. The manifestly
low standards of performance in both medical and social respects,
among some agents of cosmopolitan medicine, deter Nkoya patients,
no matter how much the latter are prepared to admit, at the
cognitive level, the power of cosmopolitan medicine.
Of
these four major structural domains, two (elders, kinship) belong
to the internal structure of Nkoya society, and two
(modern-sector employment, cosmopolitan health agencies) to the
wider society into which Nkoya society has become incorporated.
An important problem in analyzing the social process out of which
Edward’s case exists, is that it continuously links these
two entirely different structural settings. The theoretical and
methodological difficulties which this situation (yet so common
in the modern world) poses, have not yet been overcome (cf. Van
Binsbergen, n.d. b.). Meanwhile Muchati’s role can be
appreciated as that of one who, due to an increasingly successful
yet still very vulnerable position in the wider society, could,
slightly better than his fellow-tribesmen, afford to ignore the
claims of the internal Nkoya social structure, such as it is
expressed through the elders’ health action. At
Edward’s birth he tried to wrench the initiative from the
hands of the Nkoya women he had himself called earlier in the
evening. A year later, when Edward’s health declined, his
relatives dared enlist the services of a healer only after
Muchati had left for the town. Yet the pressures channeled
through his wife, parents, affinal kinsmen and urban tribesmen
left him little choice but to accept Edward’s extensive
exposure to Nkoya medicine. Although Muchati’s close
personal relationship with his elite employers make him somewhat
exceptional, this reluctant compliance is surely one of the main
characteristics of contemporary Nkoya youths and young adults in
relation to the elders. Of great structural significance, it
reflects the indeterminateness of the social-structural position
of modern Nkoya, who are caught between two totally different
social systems. The rudiments of their pre-capitalist rural
society can no longer fully provide an adequate material life for
them. Alternatively, in the modern capitalist urban society they
are lowly-educated newcomers with only a very insecure footing.
Ultimately such economic, social and psychological security as
they have, has therefore to come from the village. For
this reason they are forced to adhere to the social and symbolic
arrangements of the village society, including their medical
aspects.
Having thus identified some main and often conflicting spheres of
relationships that among the contemporary Nkoya intersect around
specific individuals in their pursuit of health, it is important
to realize that these relationships are not static structural
arrangements. They constitute a veritable social process.
‘Historicity’, in the sense of the seriality of evens
and the accumulation of effects along a time
axis, is the key to an understanding of the
specific health actions of individuals at a specific moment of
time. This historicity pervades Edward’s case from beginning
to end. Without the mounting tensions between Jimbando and
Nyamayowe villages (the struggle over Mary’s social and
ritual allegiance, the abortive marriage negotiations concerning
Banduwe’s son, the death of Kashimbi’s daughter, and of
Patrick, in Jimbando) it is unlikely that the struggle over
Edward would have been enacted at such an early stage, when the
child was barely one year old. It is more usual for such
struggles between affines over a child’s allegiance to begin
when the child is in his tens. Without the truly traumatic
outcome of Edward’s first hospitalization (the impairment of
Mary’s lactation), and without the repeated recent
disappointments at the ill-supplied Rural Health Centre,
Edward’s kin would also have looked to cosmopolitan
medicine, and not so exclusively to Nkoya medicine, to deal with
the decline of his health from October 1973.
This historicity is implied in the extended-case method, and
constitutes one of its great advantages. When we concentrate on
the action aspects rather than on the cognitive or cultural
aspects of health dynamics, some recurrent findings of medical
anthropology in Africa can be placed in their proper perspective.
Africans have been claimed not to make too rigid a distinction
between cosmopolitan and local medicine.[8]
Along the same lines, it is claimed that they do not consider
themselves as defaulters to one side or the other when they shop
around for health assistance. On the cognitive level these
findings are hard to explain. Hardly would one assume that
Africans fail to perceive the enormous differences between
cosmopolitan medicine and the various African systems of
medicine. But if one sees such cognitive elements as primarily
shaped, and given meaning, in a specific sequence of actual
interaction, then the fusion of the various spheres of medical
care in the social processes in which people are involved,
explains the absence of neat compartmentalization between these
spheres in their thinking and attitudes.
Such a complemental relationship between cosmopolitan medicine
and local alternatives as my analysis suggests, lies not
primarily in the fact that they are so very different (or so very
similar to each other, for that matter), but in the fact that
both are involved in the same social field.
The social process, within the various spheres that in mutual
rivalry determine it, takes people now to cosmopolitan medicine,
now to local healers, kin therapy, or self-medication. This is a
rather horizontal view, which looks at cosmopolitan medicine as
one among many alternatives, neither incomparably superior to
Nkoya medicine, nor rigidly separated from the latter by
impassable cultural or social boundaries.
This raises the much debated issue of the functional
complementality of cosmopolitan medicine and local alternatives.[9]
Do people refer to local alternatives, mainly for emotional
relief and social redress, whereas they refer to cosmopolitan
medicine mainly for sheer somatic treatment? Complex as the issue
is, I have a feeling that this kind of reasoning erroneously
projects into the participants’ minds the distinctions and
evaluations common among members of North Atlantic society, and a
fortiori among our doctors. Could the latter
afford to admit that local, non-cosmopolitan medicine is
anything more than just emotionally and
socially relevant, in other words can they admit that it
primarily entails medical
actions fellow-doctors, however exotic? As I have tried to
demonstrate, the oscillation between cosmopolitan medicine and
Nkoya medicine in Edward’s case was primarily the outcome of
the evolving struggle between various major foci in the social
process of the people involved. it was not as if at one stage
emotional or social concerns or needs began to prevail over the
desire for somatic cure, and that therefore
cosmopolitan medicine had to yield to healing ritual etc.
Non-cosmopolitan medicine does not have the monopoly of social
and emotional aspects. Would not the following aspects of
cosmopolitan medicine upon closer analysis reveal major parallels
with the symbolic and social content of African medicine: the
period of seclusion that Mary underwent at the escorts’
shelter while her child was in hospital; the fixed routine of
daily rounds through the wards; the rigidly defined role
expectations in the interaction between patient and staff. Just
as local healing ritual may reveal crucial aspects of the village
society,[10]
the patients enforced submission to anonymous structures is
eminently significant in a urban capitalist society dominated by
formal bureaucratic organizations both within and outside the
medical sphere. Thus, the absence of sociability in the sphere of
cosmopolitan medicine, may be just as much of a socially relevant
fact, as the unmistakable ‘social’ element in local
African medicine. Hitherto, perhaps, social scientists interested
in health action have too readily accepted our doctors’ own
definition of the cosmopolitan medical situation, thus taking for
granted what most needs elucidated (cf. Loudon 1976: 33f).
Does my analysis imply, then that medico-anthropological analysis
is to lose itself entirely in the tracing of petty families
histories, without any prospect of producing structural insights
that can be generalized and thus applied in public-health policy?[11] Such a view would ignore
the lessons I have tried to derive from Edward’s case.
However complex, and however unpredictable in details, yet the
social process that surrounds individuals in their pursuit of
health shows a systematic pattern such as explained throughout my
argument, and summarized in my introduction. In this pattern
cosmopolitan health agencies play an integral but often far from
ideal part. The better this pattern is understood, the nearer
Third-World cosmopolitan medicine may come to the realization of
its lofty ideals, and to the justification of the comfortable
social privileges of its professionals.[12]
7. Conclusion
When
I presented an earlier and admittedly less balanced version of
this paper to an audience of Third-World physicians, their main
reaction was one of disbelief and irritation. Was not the
implication of my argument that even if the accessibility factor
was taken care of, yet people like the Nkoya would not, and could
not, embrace cosmopolitan medicine overnight and whole heartedly?
The reaction of the audience was: ‘So much of unique and
unquestionable value that was as agents of cosmopolitan medicine
come to offer them — and you are telling us that they may
have reasons for rejecting it?!’ It is not with impunity
that one can present a more relative view of cosmopolitan
medicine; nor it is easy to explain anthropological data and
insights in a manner that makes sense to medical professionals.
Edward’s case suggest how complex the situation really is,
and how difficult to alter. Nkoya, both in town and in the
village do consult cosmopolitan health agencies. As elsewhere,
this utilization increases with increased accessibility. The
Nkoya are not deaf to the persuasions of non-Nkoya outsiders, or
of enlightened fellow-Nkoya, who advocate cosmopolitan medicine.
Rather complex hygienic routines, such as bottle-feeding, may be
mastered within an amazingly short time, and adequately performed
provided the logistics of the situation allow this. Cultural
notions play a relatively limited role in this set-up, and
certainly do not create insurmountable barriers against
cosmopolitan medicine. Yet two main factors militate against
these people becoming exclusively
committed to cosmopolitan medicine. First, their own medicine is
so central in their social process (both in the village and in
town), that they cannot afford, as yet, to do away with it. Their
structure of authority, kinship, competition between kin groups
over scarce members, largely revolves on it. And secondly, the
version of cosmopolitan medicine offered to them is of
perceptibly inadequate standards.
These standards can only be improved if more fund become
available and if medical
performance is re-assessed and continually evaluated against the
social, political, ideological and ethical priorities of the
local community, of the national state which administers
cosmopolitan medicine, and of the world community at large.
Ultimately this means a political process in which the elitist
and consumptive tendencies inherent in the cosmopolitan medical
professions, and the de-humanizing tendencies inherent to all
modern formal organizations including medical ones, are radically
checked in favor of the people’s interest (medical and
otherwise) at the grass-roots level.[13]
Humanitarian compassion alone is not like to bring about such a
change — it has to be brought about by the organized demands
of the people themselves. Thus the evolution of public health
becomes an aspect of a much more general class struggle.
Alternatively, the centrality of Nkoya medicine in their society
is not likely to decline unless a profound transformation takes
place in their political and economic situation within the wider
society. Nkoya society is not really disappearing. It lives on in
a greatly modified form as a handmaiden of urban capitalist
structures, nursing future laborers and sheltering discarded
laborers. Even in this neo-traditional form can Nkoya society
only survive if its basic social and ritual institutions,
including Nkoya medicine, remain more or less intact. Nkoya
medicine underpins the elders’ authority, articulates group
processes especially at their most dramatic stages, and provides
a mechanism of redistribution through which some meager revenues
of labor sold in the capitalist sector can be channeled back into
Nkoya rural society.
Other forms to legitimate authority, and other mechanisms of
redistribution, are conceivable, and their substitution in the
place of Nkoya medicine might pave the way for fuller adoption of
cosmopolitan medicine. However, such cultural engineering is
reminiscent of the naïve, a-political manipulation advocated by
the old-fashioned schools of applied anthropology (e.g. Foster
1962; Erasmus 1961). It is deceptive, as it only deals with
surface phenomena and does not confront the problem at its roots:
the reality of exploitative incorporation, within the ‘mode
of reproduction of cheap labor’. If this reality could be
overcome through the class struggle of the Nkoya and other
Central African peasants and urban poor, Nkoya society would be
transformed (both internally and as regards its place in the
world system), and Nkoya medicine would no longer need to serve
the functions which now make it indispensable.[14]
[1]King
1966: section 2: 6 and 2: 9; Fendall 1965; Sharpston 1971; Stein
1971: 100.
[2]Stein
reports (1971: 127) that only 9% of the under-five population is
brought to clinics, while re-attendance averages only 3.4. visits
per child. Mary’s health action in this respect is therefore
fairly representative in the Zambian context; understanding of
her choice of alternatives is likely to have wide applicability.
However, Nur et al. (1976) quote much higher figures for the
Lusaka municipal township of Matero.
[3]For
a general criticism of the notion that ‘tradition’ or
‘culture could serve as an explanatory in the study of
health action, cf. Lieban (1973: 1058) and Erasmus (1961).
[4]Reference
is to recent urban immigrants in Lusaka in the early 1970s.
[5]It
is remarkable that, as late as 1962, patients’ secondary
reactions to health institutions etc. had to be discovered as a
forgotten factor in the utilization of cosmopolitan medicine and
its alternatives; cf. Von Mering 1962; Polgar 1962.
[6]The
same point is made by Leeson 1970: 10f; for a Nigerian parallel,
cf. Ademuwagun 1973: 72f.
[7]Cf.
Craemer and Fox 1968; Jayaraman 1969; Frankenberg and Leeson
1974.
[8]Frankenberg
& Leeson 1974: 261; Ademuwagun 1973: 73f.
[9]Gonzalez
1966; Lieban 1973: 1056f; concerning Zambia, e.g. Quintanilla, as
quoted in Grollig & Haley 1976: 450.
[10]Turner 1957, 1967c, 1968; however, cf. Van
Binsbergen 1976b.
[11]Let it be understood that I do not consider such
extended-case analysis as an alternative to sophisticated
quantitative analysis. Far from being incompatible, such
quantitative analysis should follow at a later stage, once the
fundamental determinants of health agency utilization have been
identified qualitatively. Current quantitative studies in this
field, however, have seldom reached this stage, and often remain
crude, ‘fact-finding’ exercises, prone to produce
artifacts by solely considering the speech reactions of
individuals while ignoring the social processes in which they are
involved.
[12]Meanwhile it must be clear that the structural
conditions surrounding the interplay between cosmopolitan and
local medicine, an analysed here for the Nkoya case, are very
specific; the preliminary Nkoya findings are not likely to apply
to other societies, with different internal structures and with
different forms of incorporation in the modern economic and
political world system.
[13]Cf. Frankenberg and Leeson 1974 for similar
views.
[14]I wish to direct my readers’ attention to
two important publications which appeared too late to be included
in my argument: Spring Hansen 1978 and Janzen 1978. Janzen’s
is by far the richest and most comprehensive study yet available
on the interplay between medical systems in Central Africa. In
this last-minute footnote I could hardly do justice to these
works.
to Part 0
(Abstract)
to
Part I (Problem and Method; Background)
Part
II (The extended case; Ethics)
Part
IV (References; Postscript on Cognition)
| page last modified: 20-04-13 12:31:42 |  |
|