Traditional medicine in Africa: an ethnography in Huye District Rwanda

Traditional Medicine in Africa: An Ethnography in Huye District, Rwanda
Ph.D. Student: HABINEZA Jean Paul
Main Supervisor: Professor Benjamin RUBBERS (University of Liege)
Co-Supervisor: Professor François MASABO (University of Rwanda)
Draft Date: 29th January 2018
Abstract
This is a Ph.D. research project on challenges and various trends undergone by Traditional Medicine (TM) in Rwanda, especially in Huye District. The primary objective of the research is to explore therapy-seeking processes by TM clients and the meaning of sickness and health as cultural constructions in Rwanda. Moreover, this research will be acquainted with traditional healers in the everyday lives of Rwandese to understand the meaning of being a traditional healer in contemporary Rwanda. The research project explores the dialectic relationship between TM and divergent powers that include social, political, economic and religious scopes. An inclusion of a theoretical framework will be useful in to explore the underlying ideologies within this research. Structural-functionalism, Interactionism and The Critical Theory supplement this research by understanding its root cause before offering the solutions. Finally, a comprehensive methodology involving both quantitative and qualitative approaches works toward understanding the data collection process in this study.
Keywords: Traditional Medicine, Medical Anthropology, Rwanda
Table of Contents
TOC o “1-3” h z u Background of the project PAGEREF _Toc514592265 h 4Literature review PAGEREF _Toc514592266 h 5Problem statement: PAGEREF _Toc514592267 h 7Research Objectives PAGEREF _Toc514592268 h 9Traditional practitioner, a socio-cultural role PAGEREF _Toc514592269 h 9Integration of traditional practitioners in the healthcare system PAGEREF _Toc514592270 h 10Men of powers and powers of men PAGEREF _Toc514592271 h 11Political powers: PAGEREF _Toc514592272 h 11The religious powers: PAGEREF _Toc514592273 h 11The financial, economic powers: PAGEREF _Toc514592274 h 12Therapeutic powers: PAGEREF _Toc514592275 h 13Theoretical framework PAGEREF _Toc514592276 h 13Structural-functionalism: PAGEREF _Toc514592277 h 13Interactionism: PAGEREF _Toc514592278 h 13Critical theory: PAGEREF _Toc514592279 h 14Methodology PAGEREF _Toc514592280 h 16Exploratory approach PAGEREF _Toc514592281 h 16Critical approach PAGEREF _Toc514592282 h 17Ethics Statement PAGEREF _Toc514592283 h 18Area of research PAGEREF _Toc514592284 h 18Qualitative Data Collection PAGEREF _Toc514592285 h 18Quantitative Data Collection PAGEREF _Toc514592286 h 19Data Analysis PAGEREF _Toc514592287 h 20References PAGEREF _Toc514592288 h 21
Background of the ProjectFor almost forty years, since the Alma-Ata Declaration (1978), the World Health Organization (WHO), has been promoting non-exclusive healthcare systems through Primary Health Care (PHC).

It has been advocating for another solution to health problems of third world countries, particularly in Sub-Saharan Africa. Failure of previous policies, low efficiency of an expensive hospital medicine, sometimes dysfunctional, has been arguments to promote a new strategy based on primary health care (Dozon, 1987). Therefore, it was emphasized that the success of PHC would depend on population participation in solving their health problems. Furthermore, the organization recommended inclusion of Traditional Medicine with a possible involvement of “healers” in PHC implementation (WHO et al., 1978).
From the above-mentioned declaration, Rwanda opened a centre, “Centre Pharmacopoeia” for a possible exploitation of traditional medicine; which later on became the Centre for Research in Phytomedicines and Life Sciences, to investigate the botany and agronomy of the flora used in Rwandan herbal medicine (Karangwa & All, 2002). Furthermore, the centre beginning came along with the creation of traditional healers associations across the country. In addition, Rwanda adopted a primary health care approach based on the principles of Alma Ata declaration, recognized as one of the vision 2020 strategic plan pillars launched in 2000 and intended to rapidly transform Rwanda from a low-income agrarian economy to a knowledge-based middle-income society by the year 2020 (Rwanda., 2000).
Nevertheless, in 2008, the World Health Organization reported that some countries in the African region including Rwanda, have stagnated or even lost ground. These countries were blamed for the slow progress and the disappointing advances in access to primary health care (WHO, 2008). Despite the above-mentioned report(s) in Rwanda, there is room for improving persistent challenges and trends linked to the integration of Traditional Medicine in the global and local Health Care system.
Literature ReviewMany studies worldwide have shown interest in traditional practitioners. To be precise, there is a focus on the collection of their knowledge and methods to cure different diseases. Only a few of them focused on traditional practitioners themselves as they were linked to the collaboration with biomedicine practitioners. One of them was made by Kofi Busia Ossy MJ Kasilo, and it focuses on collaboration between traditional health practitioners and conventional health practitioners as illustrated by some country experiences. They reminded several calls that have been made by WHO on governments to take responsibility for the health of their people and to formulate national policies, regulations, and standards. It is part of comprehensive national health programmes that ensure appropriate, safe and effective use of traditional medicine (Busia & Kasilo, 2010). The authors underlined a serious issue that linked decades of disregard of traditional medicine practices and products, which has created mistrust between the two sectors hampering all the efforts being made to promote this potentially useful partnership (Busia & Kasilo, 2010). Apart from theoretical models of collaboration, grounded studies were made to explore perceptions of service users and providers of current interactions between the two systems of care and ways in which collaboration could be improved, and revealed that in general, western biomedical trained practitioners were less interested in such arrangements (Campbell-Hall et al., 2010).
Furthermore, some authors think that even when bio-medical agree on the program in collaboration with traditional practitioners, even if they call it a valorization program, it actually involves a reduction or rejection of anything that does not look like Western medicine (Dozon, 1987). There are, however, cases where it is impossible to do without it particularly in African countries that appreciate the efforts of midwives. Dozon pointed out that, on the other hand, there remains the paradox that it is in countries where the vitality of traditional medicines is evident that this “will” of valorization is growing, and advise to rethink health policies from an endogenous development perspective (Dozon, 1987).
Another issue pointed out by some researchers like Didier and Eric Fassin; is that those bio-medical driven models of collaboration fed a certain quest for new sources for legitimating purposes. They analyzed the issue in three following points:
1) Healers who are the most inclined to search for official recognition are also those who have the weakest traditional legitimacy
2) Actors who claim for official recognition of healers reinforce at the same time their own legitimacy
And
3) These new principles of legitimacy necessitate authorities for legitimating situated outside the scientific world (Fassin & Fassin, 1988).
In brief, the state health programmes of collaboration are well intended but lack anthropological consultation.
Problem Statement:There is a gap in knowledge about indigenous healers in Africa in general and Rwanda in particular. In addition to that, the few publications available focused on ethnopharmacology, paying less attention to traditional practitioners themselves as drugs and medicines are administered by people to other people in particular social contexts and particular social environments. Therefore, some interrogations invite to research systematically on the subject, for example, a dichotomy between the biomedical and the traditional medicine, and the popularity of the later as it is mentioned by Karangwa: “it was demonstrated that, at any given moment, the Rwandan health care system was unable to deal with the overall medical situation in the country. In addition, approximately 80 percent of the population consulted trad-practitioners rather than medical doctors” (Karangwa & All, 2002:128). Therefore, this raises questions on social determinants of use of traditional medicine at such high rate with such popularity. It also examines the reasons that drive people to traditional practitioners rather than conventional doctors.
Another concern is about the legal environment in regards to Traditional Medicine. The World Health Organization worldwide review stated that Rwanda does not have a clear integration framework for traditional practitioners in the broader health care system, neither official legislative/regulatory texts governing the practice of traditional medicine, nor a licensing process for traditional health practitioners, or procedures for the official approval of traditional medical practices and remedies (WHO & Others, 2001). In fact, there are two laws concerning Healthcare in Rwanda, which are the law concerning the Art of Healing (Rwanda, 1998) and the law relating to the pharmacy (Rwanda, 1999). Both laws mention in their text that they do not govern traditional medicine that is supposed to be governed by a special law; because such a law does not yet exist. From that gap in the legal framework, emerge different questions on the daily practice of traditional medicine in Rwanda, either individually or in associations. There is another gap in knowledge: even if there are many studies and publications on traditional medicine in Rwanda, some are descriptive, and others are specialized on pharmacopoeia while others on clinical psychology (Rutembesa, 2004; Rwangabo, 1993; Muganga, Angenot, Tits, & Frederich, 2010; Mukazayire et al., 2011). From that gap, there is a need to go beyond and make an anthropological study to identify different illnesses and sicknesses, which are more subjective and social aspects of different sufferings and how they are treated in the Rwandan context (Augé & Herzlich, 1983; Zempléni, 1985; Zempléni & i Guimerà, 1986).
In fact, as stipulated by some researchers like Singer and Baer; Health and sickness do not take place in a social vacuum; they are a result of different socio-political forces in action. Consequently, there is a need to assess how sickness and health are experienced by people in their social networks and how health-related beliefs and practices fit and are shaped by encompassing social and cultural systems and environmental contexts (Singer and Baer, 2011). In addition to that, it is of paramount importance to emphasize that; those above-mentioned forces may shape the lives of those men and women involved in healing their fellows; traditional practitioners. In brief, the researcher intends to focus on traditional practitioners, to understand why their practice remains popular, and how they view their practice in such unclear legal environment.
Research ObjectivesIt is believed that health and diseases healing are the panaceas of biomedical sciences, but social sciences have a lot to contribute in, especially anthropology, by helping to understand how people (Bio-medical doctors or traditional healers) cope with health issues in their societies. Death and sickness are total social facts according to Marcel Mauss as he defined this in a simple sentence, “Social total facts impact all men of a given society, in all dimensions of their lives in all points of view, for all the time” (Mauss, 2000). It is true for all people in the world including Rwanda, where sickness is continually subject to different discourses, discussions and social representations, the reason is that every biological process will involve some socio-cultural implications on sleeping, feeding, defecating, reproducing, being sick, dying, feeling pain, which is common even to animals, but will have socio-cultural aspects only for human beings. Those cultural aspects linked to health and sickness are managed by men and women invested with special roles of keeping, repairing, and protecting their fellow well-being.
Traditional Practitioner, a Socio-cultural RoleThe researcher shall try to understand from traditional practitioners, how they situate themselves in the society, and the roles they play in the healthcare system. As two authors, Evans Pritchard and Marc Angé suggest putting back the actors’ discourses in the rationality of their culture (Evans-Pritchard, 1937; Augé, 1984). They worked on aetiologies, which are causes of sicknesses, causes which sometimes for western people seem irrational because linked to beliefs in witchcraft or simply religion. Therefore, in this study, the researcher shall pay a particular attention to traditional practitioners’ discourses.
Integration of Traditional Practitioners in the Healthcare SystemForging a new and comprehensive healthcare system, integrating traditional practitioners practice has been suggested by the World Health Organization conference in Alma Ata (WHO et al., 1978). That declaration was received with enthusiasm in Africa including Rwanda but many of the first attempts failed after few years, and according to some authors, the causes of that failure remain controversial (Dozon, 1987). Therefore, the researcher should analyze the traces and remains of such a project, by approaching and getting the opinions of the key informants and decision makers on that matter concerning integrating traditional healers in health care system.
In addition to that, there is a need to assess the traditional practitioners’ real contribution to the society, exploring if they offer a complement to biomedicine fight against diseases for a better people healthcare. The World Health Organization defined health in its broader sense in its 1948 constitution reviewed in 2006 as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity” (WHO et al., 2006). Therefore, the researcher shall explore beyond bio-medical fight of diseases, as it was stipulated by some medical anthropologists like Kleinman, that it is rare that a single therapist come to the end of all troubles (Kleinman, 1980), that is why there is a need for an objective exploration of other silenced or ignored affections treated by traditional practitioners. Consulting a bio-medical doctor or a traditional practitioner is first to seek relief from one’s illness and one’s suffering; a kind of “quest for therapy,” according to J. Janzen’s expression (1982). In brief, the research needs to identify various therapists and their respective contribution to the Rwandan health care and may study attentively why their integration in one comprehensive healthcare system is still difficult while needed.
Men of Powers and Powers of MenIn fact, every time sickness and death occur, a set of institutions enter in action; political, religious, economic institutions, along with health policies and different actors with different powers. Healthcare may be an arena in which these powers confront, oppose, or complete each other. In this research, there is an analysis of those dialectic relations only vis-a-vis traditional practitioners in Huye district.
Political powers:Health has always been a political matter, and politics feeds on its relations with those administrators, doctors or healers, involved in the healthcare field (Fassin, 1992). In fact, to understand the stakes of such powers, it will be necessary to focus on the workings and intricacies of a local political organization; Umudugudu refers to the smallest administrative unit in Rwanda (comprising on average 50–150 households). In rural areas, umudugudu is usually translated as “village.”(Sundberg, 2014) The Umudugudu’s responsible manages the daily lives of numerous people. He/ she manages so many things, like conflicts between people, make sure they comply with the countries policies (Vaccination, sanitation, etc.), it will be important to observe how traditional healers deal with the local political, administrative authorities in regards to health and traditional medicine implications in the daily life of the umudugu.
The religious powers:It is necessary to examine the religious aspects of health and sickness for Rwandans. In fact, 90% are Christian believers, who are in many ways opposed to traditional medicine, as a pagan practice, and related to pagan spirits, but recognizing that they can be healed by Holy Spirit, which leads to the first confrontation on a spiritual healing. The other spiritual confrontation is even on the beliefs aspect on healing people, As Byron GOOD said that there is a close relationship between science, including medicine, and religious fundamentalism that turns on our part of the concept “belief” (Good, 1993). In this research, it will be explored the cohabitation of healers and different religious authorities with resulting confrontations influencing the healers to work.
The financial, economic powers:
Another important power to explore is financial economic. Contrary to the saying that health has no price and healers assertions that they treat free, healing is paid and has always been paid, by suffering, by sacrifice, by alms, donations healers, for the purchase of medicines (Fassin, 1992). In this regard, the economic aspect influences so much in health care. The success in “mutuelle de santé” in Rwanda, the phyto-drugs availability, industrial production, commercialization, and different and health exploitation for different healers’ self-enrichment in Rwanda. This study will explore different relationships fed by financial, economic interest in the healthcare system, with a particular attention to traditional medicine.
Therapeutic powers:
The last but not least power is obviously the therapeutic one. The research will try to shade light on different rivalries on the capacity of healing, rivalries on the means and ways of healing, rivalries of the different sources of knowledge, all of that linked to the harsh quest of recognition and legitimating of traditional medicine healers, with consequences on performances and quality of services
Theoretical FrameworkStructural-functionalism:
In this theory, the researcher makes an exploration of how traditional practitioners fit and serve in accordance with other components of the society. The functionalism theory explains that society has to work and function correctly to ensure its own serenity as every element of the society has a purpose of ensuring that correct functioning. Therefore, when an individual endorses the role of a practitioner, he/she must face social norms and the social group in which he/she belongs will judge her/him as deviant or otherwise. By using the same Structural-functionalist theory, Talcott Parson discovered that medical norms serve as social control tools (Varul, 2010). Here, the researcher will verify if such norms exist with traditional practitioners and are in articulation with the Rwandese society. There are cultural, socio-economic and political motivations that create and perpetuate the traditional medicine. Some communities resort to African traditional medicine as it is easier to consume and works faster than the Westernized medicines (King, 2017). According to their mindset, the idea(s) that Western medicine requires an individual to have consumed food for the drugs’ effectiveness shows weakness in them (King, 2017). Although there are two or three critics on this theory, it is very systematic as it only adopts the institutional point of view and shows less interest on individual people discourses. For this reason, however, there is the need for another theory to analyze interpersonal relations between traditional practitioners and their clients.
Interactionism:
The perspective of symbolic interactionism presupposes that: “social order is the product of an ongoing process of social interaction and communication. Of central importance is the process by which shared meanings, behavioral expectations, and reflected appraisals are built up in inter-action and applied to behavior. These shared meanings attach to positions in society and thus link individual conduct to the organization of groups and to social structure. Social structure-the patterned regularities in society is an ongoing process, built up by social interactions; moreover, social structure, in turn, constrains the form and direction of these interactions by structuring communication patterns, interests, and opportunities” (Matsueda, 1992). The researcher will try to apply this theory to get deeper insights from interpersonal consultations with traditional practitioners.
Eliott Freidson analyzes similar interactions in bio-medical environments, which were interested in the patient as well as the physician. He rejected the thesis that an act may be deviant in itself rather, asserted that an act might be judged deviant depending on the other people’s point of view (Freidson, 1988). Talcott Parson explained that there is control from the physician since the sick individuals are categorized as deviant beings. Freidson, on the contrary, said that the social control of the physician creates the deviance of the patient and attributes that to him/her. In brief, the deviance is in the eyes of the person who is seeing it hence, the medical doctor or the trad-practitioner would decide who will stay at the hospital, who will go home, who is able to work or not and who is able to continue playing his/her role in the society or not. As explored, the practitioners create the sick due to the vulnerability of the latter (Freidson, 1988). These practitioners are in control of their patients’ lives; thus, they surpass their role(s) in auguring rebellion and deviance in the patients.
Critical theory:Roland Gori and Marie Josée Del Volgo went beyond the social control and talked about a totalitarian health care. They accused it of going beyond the medical acts by a dilatation of the healthcare system to social problems. When patients talk about suffering, he/she talks about something beyond a physical suffering; although the physicians, from their training, understand only facts that are linked to the body and consequently follow decisions that physicians impose on the patient. Expectedly, the trad-med clients are prone to the dismissal of the modernized medicine(s). Their difference in dispensation and effects makes it possible for these clients to pick the African traditional medicine over the modernized ones. They believe these decisions are inoffensive although they may be socially dangerous (Gori & Del Volgo, 2004). Roland Gori and Marie Josée Del Volgo sound extremists but none can ignore their contribution in raising awareness about an excessive medicalization of social problems. It is a concept taken and extended beyond by other authors like Baxerres (2012), and Farmer (2005), hence the so-called traditional medicine harvests with those tired clients of the official healthcare are in search of a more understanding less coercive solution, creating a dichotomized healthcare system with a problematic integration.
MethodologyFrom 2017-2020, the researcher shall conduct ethnography on traditional healers in Huye District, southern Rwanda. Through a mixed method approach with focus groups, interviews with key informants, concerned with traditional healers and observations on the later in their daily life, on their workplaces and their homes in order to understand what latter challenges they undergo. The analysis of data from those sessions shall undergo an inductive analysis.
Exploratory approachThe first approach is exploratory; this shall help to understand how people in contemporary Rwanda, label, describe and experience illness and how healing systems offer meaningful responses to individual and community suffering. The main point is that; these systems of healing are meaningful to people whose lives are engrossed with unexplainable episodes of suffering. The provision of meaning offers psychological support to the afflicted and may enhance healing through what Western science calls the placebo effect, or meaning effect a positive result from a healing method due to a symbolic or otherwise non-material factor (Moerman, 2002). The researcher will do an ethnographic study on TM healers (Abavuzi ba gihanga: Tradi-practitioners, Abapfumu: augury-sorcerer, …) observing them in their daily life, in their families and friends and others social relations, to find out how TM knowledge is produced and transmitted, capturing other insights about how they envision themselves in the society, and how they value their contribution.
Therefore, In the first instance, the researcher will meet key informants (AGA President, Officer in charge of TM in Ministry of Health, Directors in Health Centers, Doctors) qualified as experts, or decision makers and opinion leaders related to traditional medicine in Rwanda. and then after, the researcher will collect different available documentation on TM in Rwanda (Reports, newspapers, statistics…). In the second instance, the researcher shall carry out, deep interviews with TM clients, from different health centres (one of them is a TM health center, another one is of modern medicine, but geographically close one to another) on their therapeutic journeys.
Critical approachThe second approach to be used is critical medical anthropology which focuses on the analysis of how structural factors such as the global political economy, social inequality affect prevailing health system (Baxerres, 2010; Baxerres and Le Hesran, 2006; Farmer, 2005). It points to the process of medicalisation, or labelling a particular issue or problem as medical and requiring medical treatment when, in fact, its causes are structural.
Ethics StatementThe study protocol was approved by the University of Rwanda, College of Arts and Social sciences, research commission. The forms of consent have to be administered to each and every participant, and consent in written form (by signature or fingerprint) has to be obtained from each participant.
Area of researchHuye District, in Southern Province of Rwanda, since January 2017-2019, clusters of data collection is designed according to the 6 rural sectors for focus group discussions and TM clients survey. The main site is in Ngoma an urban sector; where the Mamba TM health Centre is located qualified as the main field site for ethnographic data collection, near the University Teaching Hospital (CHUB), a university campus, a research institution (NIRDA) with interest in pharmacopeia and a close collaboration with traditional healers.
Qualitative Data CollectionThe researcher shall use ethnography as a first-hand research on TM healers grouped in cooperative (Duharanirubuzima Mamba) working in TM health Centre. According to Julian Murchison, “Ethnography allows the researcher to examine how people’s actions compare to what they say about their actions in ideal situations and their thoughts or opinions on particular topics. In many cases, actions and behaviour in particular situations differ significantly from those observed or predicted by other research strategies.” And “Ethnography also allows the researcher to observe and to experience events, behavior, interactions, and conversations that are the manifestations of society and culture in action.”Murchison (2010) In fact, we shall get in-depth insights, from “being there” with traditional practices, their vision on their practice and their interpretation of their situation.
The researcher shall conduct a maximum of 100 in-depth interviews with self -described traditional healers or TM peddlers, healthcare advisors key informants involved in Top healthcare management, involved in TM licensing processing. We shall conduct a minimum of seven Focus Group Discussions (FGDs) composed of TM healers in every sector. We shall use purposive sampling for recruitment of the important informants that include mature adults from the holistic populace paying a particular attention to gender representatively.
Quantitative Data CollectionWe shall develop a structured survey questionnaire for testing different characteristics affiliated with TM use and practices of the Huye District general populace. To ensure that the survey questionnaire is locally significant (content validity), we shall conduct sessions of piloting during the FGDs and in-depth interviews. In an iterative process that will involve various adjustments to the questionnaire as [new] themes and ideas, emerging throughout the sessions, and numerous survey items and responses will directly be included based on the inferences of these qualitative sessions. The Cells are the most basic government units of administration in Rwanda, and within each Cell, a cluster site will be realized using geographic points that are randomly generated using Arc Global Information Systems (ArcGIS),v10.2.2.
Data AnalysisWe shall conduct a thematic analysis of the qualitative data by applying an inductive approach to the framework method. The qualitative coding, analytic memos, and corresponding matrices will be stored and analyzed using NViVO v.11.4.1 (QRS International). Additionally, quantitative data will be analyzed using SPS’s. 21 Continuous variables are reported as median (inter-quartile range). In conclusion, after every part of this project a paper may be tailored for publication, the first one will be on a literature review, the second on therapeutic itineraries, the last on social-political interaction vis-a-vis TM in Rwanda, and then after they will constitute the body of the Ph.D. thesis, to be presented.
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