From Ancestors to Herbs: Innovation According to the ‘Protestant Re-formation’ of African Medicine

The institutional view

In traditional African medicine healing is believed to follow from putting things right between an array of forces that go beyond the person of the sufferer. As a leading commentator on the field puts it, “One characteristic feature of traditional medicine – wherever in Africa it is practiced – is the belief that serious illness can be caused by a supernatural agency, for example, ancestor spirit anger.” (Okpako, 2006: 239). In this view, bodily health is largely a by-product of an intermediary successfully attending to the wider metaphysical causes behind a person’s illness on their behalf.

It was only after conducting research into personal healthcare practices in South Africa (at mainly township locations in Cape Town and Johannesburg) that we learned just how far many people’s everyday health narratives diverge from this traditional model. If we as researchers went into the field sensitive to the cultural influence of specifically ‘African’ approaches to healing, we quickly learned that in urban South Africa there was little privileged status accorded to ‘traditional African medicine’ compared to other forms of available healthcare. But while it therefore had no hegemony, it remained one resource upon which people could draw.

As I said, we took a practice-led approach in our research focusing on the actions these households took (both preventatively and reactively) to safeguard their healthcare. This often began by with looking first at the medicines or treatments used. These tangible artifacts served as prompts for more detailed descriptions of their healthcare practices (as well as the institutions they interacted with). As these narratives unfolded we got access to any beliefs or ideologies concerning their healthcare situation or providers in the townships.

One of most striking things we learned was that most informants did not feel hard pressed in their health needs, but instead had whole repertoires for dealing with household health (involving medications, institutions, and practices). Within their considerable collections of medicines we usually found no less than four types: prescription drugs or remnants of these (often antibiotics or vitamins); western branded OTC medicines; Old Dutch patent medicines, and some kind of herbs or herbal-derived treatments (often located in another part of the house). This in turn gave insight into the institutions they were interacting with and what they felt about them.

The state of affairs described by much of the published commentary (Dunlop, 1975), (DeJong, 1991), (Hewson, 1998), (Gilbert and Gilbert, 2003) is one in which the majority of the non-white population have practically no access to Western-style physicians, or biomedicine, (and thus were said to depend on traditional African healers). By 2004 in township Cape Town and Johannesburg this was no longer the case. In fact “The Clinic” or free government health service emerged as the main healthcare institution that was not only within reach for our informants, but appeared to be (in marketing jargon) their ‘first port of call’. Clinics had the virtues of being a “drop-in” service and of dispensing free prescriptions on the spot. However, the highest status was reserved for “Doctors” (meaning private doctors) who required an appointment and charged a hundred rand fee for a consultation (bundled with medicine). Doctors were preferred because believed to be more efficacious. One informant explained, clinic medicine is “weaker” whereas with Doctor’s medicine “you notice an improvement in two days”. An important backup to these institutions were “Pharmacies” where prescription refills, or OTC medicines could be obtained between clinic visits along with advice; and “Supermarkets” or street stalls, where these items could be purchased when advice wasn’t needed.

Only four of the households described treatment by traditional healers: two giving favorable accounts; two rejecting any further such treatment. In contrast, almost all of the households had herbs in their medicine collections, yet there was usually no practitioner guidance or institutional support corresponding to these. It was this notional ‘gap’ which started us thinking about the transitional role of traditional African medicine.

Transitions from a Tradition

If the discipline of anthropology (and doing ethnographic research) teaches anything, it is that time, shifts in context, and different social actors play havoc with even the most solid institutions and representations. One of the great global transformations emerging from the European industrial revolution has been migration from rural hinterlands to urban centers. The history of South Africa has its own painful version of this story. The historian Robert Ross has even written that the whole rise and fall of apartheid hinged on its ability to deal with the issue of urbanization, or “attempts to control the numbers and behaviour of Africans within South Africa’s cities, and by resistance to such control” (1999:116). As part of this attempt ‘townships’ emerged toward the end of the 19^th century (becoming official policy after 1948). A township was an area on the outskirts of established cities where members of non-white groups were encouraged (or forced) to live in racially distinct zones. Since their formation townships have been the entry point absorbing most of the migration from rural areas, so even if racially prescribed, they remain extremely diverse environments composed of people and customs from across South Africa and beyond. Nine of the households we studied lived in townships, three in urban areas of equal diversity; and one of the questions their health practices helped us answer was: what happened to ‘traditional African medicine’ once it moved to the city? In our ethnographic research for Procter& Gamble we discerned four key transitions in the use of medications from the way it is ‘traditionally’ described for African medicine. We summarize these as from ancestors to herbs:

• from the power of ‘ancestor spirits’ to that of the body- People talked and understood their health in terms of bodily symptoms (pains, chills, aches, fevers) and furthermore described treatments as ways responding to the body. The cause or reason for sicknesses was blamed on; climate, heredity, diet, stress, unclean surroundings, or other people. Neither Black, nor Colored nor Indian seemed to have a supernatural disposition toward their health or ailments – even though many professed to have a religion. Even those who mentioned using traditional healers spoke of consulting them to address a problem of the body (in one case, a pain in the throat).
• from mediated ‘treatment’ by experts to direct treatment (by people of themselves and dependants)- The traditional model of African healing emphasizes an intense personal engagement by the healer with and for the ‘patient’ (as in the example above). The healer crucially intervenes both in the spiritual and natural world on the part of the ill person until their health is restored. In our urban research however, the household were very active in their own treatment, seeing their health as mainly there own responsibility. They kept considerable armories of medications to hand. The women especially could describe a wide variety of symptoms and how they would treat them without outside help. Clinics and Doctors were reserved for problems they could not self-diagnose or treat, (or for children needing careful attention). There was some resentment and a feeling that the traditional healers would not allow one to take charge of your own health.
• from taking remedies composed of opaque mixtures to identifiable herbs- In traditional African medicine herbal mixtures were specific to the person and the occasion and the way they were mixed or blended was kept secret. Often people who use herbs now know which ones work for what complaints and wish to be given them without going to a healer (possibly several times – if our account above is representative). They also seem to believe them ‘effective’ without being administered with an incantation.
• from a reliance on healers for traditional medicines to use of pharmacies, street traders and other vendors lacking ‘traditional authority’- As many people know what they should use to treat particular symptoms, this opens up ‘the market’ to other suppliers who can supply herbal medicines simply as a product – often cheaper and conveniently free of ritual.

We had observed the results of such movements in their current-state but could only speculate about how and when these transitions occurred. Looking for background beyond our own research’s scope, we found mainly timeless, ahistorical accounts like the expositors of TAM above. So we are indebted to a South African geographer Dauskardt (1990)who looked at the spatial flows of traditional medicine in South Africa over time. His most important contribution was the story of the growth of ‘urban herbalism’; how the use of African plants (gained from sources other than traditional healers) spread during the last century in South African cites.⁷ This provided some of the historical ‘facts’ needed to validate our analyses and help us realize these transitions had a trail into the past. We learned western OTC or ‘patent’ medicines became popular in the townships from the 1930’s onwards at a time when access to actual western medical doctors was rare. So, combining these trends with the known lack of ‘formal’ healthcare in poor ‘native’ areas until recently (DeJong, 1991), (Gilbert and Gilbert, 2003) we arrived at the earlier impetus for the strong self-help tendency that we had observed. And given all these factors, we believe unlike the ‘institutional’ view would have it, the mass of urban dwellers had not simply resorted to the government’s residual category of traditional African healing – but had been evolving their own DIY healthcare in a dialogue between TAM and western medicine, Dutch medicine and whatever knowledge of ‘home remedies’ they had brought from their native place or evolved there.

This self-care over time has given birth to a ‘spirit’ we discerned in the research; one of pluralism and pragmatic experimentation, as mentioned, but also a further attitude (that can be said to be a cumulative effect of the transitions above as well their encourager) of: whatever increases my sense of personal power and control is desirable, whatever doesn’t less so.

This combined with the specific transition towards people wanting to access herbs directly and not go through healer-intermediaries led us to proclaim “African medicine is undergoing a protestant reformation” in our original project document(Lodestar/P&G, 2004). And there are obvious conceptual echoes of that historical epoch. Certainly we mean it mainly as an ideal-typical analogy (following Weber (1930) but hold that this characterization matches the phenomenology of experience gained from listening to our informant’s comparing different healthcare traditions.

Recent epochal events linking the personal and political (or macro and micro) in South Africa reinforce the analogy. Just as Schama (1987) has shown how the Calvinist Dutch of the Golden Age had their creative energies unleashed once they threw off their colonial masters the Spanish; so the average South African has seen a huge increase in their real and symbolic sense of agency since the transition to popular democratic rule in 1994 (Deegan, 1999). In one of the few works to deal with this subject in South Africa in a way not predominately structural, Naidoo and Van Wyk (2003) (who are community psychologists) cite Serrano-Garcia’s (1984) description of empowerment as involving:

1. The enhancement of personal power
2. Creating awareness of alternative strategies to problem solving
3. Accessing resources in society

Naidoo and Van Wyk (2003:75)

It is possible to make a case on all three counts that a primary reliance on traditional African medicine (or traditional healers themselves) would represent a diminishment in South Africans’ experience of empowerment. First, TAM in its purist mode is very healer-led and opaque in its treatment regime, representing less agency than the self-help of DIY practices (or the pluralistic mixing of different institutions where the patient makes the choice which to use and when). Reliance on traditional healing could also represent for many South Africans a throwback to when this was their only expected source of healthcare (and they had less alternatives), also, arguably, going to clinics or private doctors feels like the attainment of a wider involvement ‘in society’ especially since it was formerly withheld. So maybe it is not surprising – given wider social and political history – that newly enfranchised, non-white, urban South Africans are not embracing TAM in its wholly traditional form, preferring to cleave off its herbalism and mingle it with other types of medicine available to them.

Critique

But it is just this kind of failure – to acknowledge the separate destiny of ‘herbalism’, from the tradition of African healing – which is typical of the literature on TAM. In this paper we had to theorize these transitions because of a considerable lacuna between our research experience and what we encountered when we tried to reflect on it. Focusing on the prevailing forms of health and healthcare in township South Africa it appeared that ‘divining’, or conferring with the ancestors, was declining in frequency (at least as a ‘healthcare’ practice) while ‘urban herbalism’ appeared widespread and on the rise.⁸ Yet most literature seemed not to acknowledge this divergence preferring to treat ‘traditional healing’ as a timeless unity (with the salutary exceptions of Ngubane (1981) and Hammond-Tooke (1989), cited by Dauskardt, (1990). This is an illusion I believe commentators on TAM have actually fostered by focusing on the ‘purest’ examples they can find. For example, Hewson also researched with a healer from the Eastern Cape of South Africa, “who practiced in a herbalist store that she co-owned with a white South African man” (1998: my emphasis) yet chose to highlight as her prime model of healer practice a woman who lived in a “traditional African compound” in Mozambique. There is only one word for this – essentialism – and it has had a prominent critique within anthropology and social theory for years. (Said, 1979), (Rosaldo, 1989) (Abu-Lughard, 1991) This tendency to treat certain chosen qualities of a cultural form as intrinsic, defining or unchanging (Sayers, 1997) has been seen as one of the weaknesses provoked by the ‘culture concept’ itself, leading Abu-Lughard to claim we should “write against culture” to uncover a more differentiated sense of the real (1991). We have already seen how (Okpako, 2006: 239)defined TAM as bound up with concepts of supernatural agency; and others (Hewson, 1998) (Gilbert and Gilbert, 2003) characterize traditional African medicine as a whole (from a cultural-ideological perspective) rather than as a set of practices that can be discretely deployed at different places and times by different actors.

Once we move beyond this essentialistic vision of TAM and place it back within history we realize its trajectory is typical of many traditions within ‘a post-traditional society’, (as described by Anthony Giddens in his notable essay on the topic (1994). He usefully connects the contextual nature of tradition with its ability to command authority, “The natural state of tradition, as it were, is deference .Traditions exist in so far as they are separated from other traditions, the ways of life of separate or alien communities” (1994:86) But a tradition becomes “disembedded” (1994:86) when it has shifted to a context “where pre-existing traditions cannot avoid contact not only with others but also with many alternative ways of life” (1994:96). Therefore, its sense of authority loosens, becoming something to be reflexively ‘chosen’ (among other alternatives) rather than simply adhered to. Township South Africa is such a post-traditional context, and in this setting you will remember our informants unanimously opted for a pluralist stance showing little deference to any of the medical ‘traditions’ they encountered; but much deftness in choosing to juggle them all. Taking Giddens’ analysis further by adding the dimension of practice, we realize there is in fact a triple disembedding that a ‘tradition’ can undergo:

1. A tradition can be disembedded from its context (as traditional African medicine has been from its historically rural setting; as emphasized by Giddens when he speaks of time-space distanciation), but equally;
2. A tradition’s practices can be disembedded from its experts, or traditional ‘guardians’ (e.g. for TAM, the growth of herbal stores and pharmacies, prepared herbs sold without input of healer), and;
3. Practices can become disembedded from any tradition at all (remedies and herbs as part of everyday life, little concern with origins or deeper explanatory principles )

From our research it appears parts of TAM have undergone all three senses of disembedding (particularly in the transition to the newer practices of urban herbalism), but these can also be used as a heuristic to evaluate any current medical tradition.

The third disembedding is especially important since it illuminates a key aspect of the self-help (or DIY ‘layer’) of urban healthcare described earlier. At this level there are really no ‘traditions’; just treatments, regimes and strategies that respond to particular conditions. In this ‘view from practice’ all medicines and remedies are pooled together into one great repertoire of competence: ginger, Dipirin, alse, Grandpa powder, aloe vera, antibiotics, comfrey, Vicks Vaporub, gum tree leaves, verstek druppels, axel grease, Med-Lemon, and camphor oil. What unites them is that they can all be called on, are all ready-to-hand within practical wisdom waiting to be mobilized, and are all seen as somehow effective if they are to remain within the repertoire.

If we have already referred to this as the 4^th tradition in African medicine, it is really more like the master; or meta-tradition that contains the others, and in so doing cannot be said to be within any tradition at all (except the catch-all of ‘folklore’ or ‘folk medicine’). I do also believe from our research that this folk practice is the most responsive and relevant form of healthcare in urban South Africa; (without it there would be many more people miserable or dead in the townships everyday) and that for the herbalism of TAM to join this repertoire does not entail that it as a tradition is ‘dying’, rather, it shows that TAM can be resilient and adaptable.

However, from this viewpoint some of the writing on TAM (DeJong, 1991), (Hewson, 1998) (Gilbert and Gilbert, 2003) (Okpako, 1999, 2006) seems to amount to scholarly re-construction; or a reification of practice extracted from current social process in order to isolate a strong and intact African tradition (that can stand alongside the indigenous medical ‘great traditions’ of China and India) for the purposes of policy-making or systematic integration into state health systems. Okpako is a particularly strong proponent of this cause, even lamenting the fact that being an oral tradition “has hindered emergence of a generally accepted theory and hence the systematic development of TAM as a self-regulating profession” (1999:482).

I am reminded at this point of a trope from the anthropologist and potent critic of essentialism, Renato Rosaldo, who suggested we would be better off thinking of culture and cultural forms as more like ‘garage sales’ than ‘art museums’ (1989) I feel like I have just sketched out how one such garage sale can work for the healthcare needs of urban South Africans, yet we are in no short supply of would-be curators.

Construction

A deeper consideration of DIY health practices makes the project they have in mind seem all the more unpromising. Namely, there is a final transition we observed but have not yet revealed: from pluralism to syncretism. Our research and analysis suggests that in township South Africa the ‘medical pluralism’ we described (different traditions or systems separately applied for different ailments or phases of them) is tipping over into a state of ‘syncretism’:

The attempt to reconcile disparate, even opposing, beliefs and to meld practices of various schools of thought. It is especially associated with the attempt to merge and analogize several originally discrete traditions…and thus assert an underlying unity (Wikipedia, my emphasis).

This means that in practice ‘Traditional African Medicine’ is all the more inseparable (and functionally fused) with other practices and traditions. We noticed such syncretism on three different levels:

1. Home remedies: There was significant frequency of homemade remedies, made by our informants that literally combined Western over-the-counter medicines with fresh ingredients or traditional herbs to make new hybrid preparations. Examples – Boiling Dispirin, a soluble aspirin, together with fresh ginger (or ginger beer) to make a fever-reducing hot drink; another made the same mixture adding tea from gum leaves. This is syncretism at its purest and most literal, like the Christian Saints in Condomblé who are venerated after the fashion of Yoruba gods.

2. Treatment regimes: Often the manner in which something was used demonstrated a local cultural ‘appropriation’ (Miller, 1991) of a product and a melding of logics.Examples – Vicks Vaporub (from P&G) was not merely used alone as soothing relief but as one crucial element in a whole regime (with other components) for “sweating out” a fever. In another example a popular headache powder was mixed with Vaseline and applied directly to the body as a poultice to soothe painful joints more (explained as more powerful relief than taken internally).

3. Medical theory: There were also signs of ‘conceptual unification’ typical of syncretism. Examples – The mother of our only known informant who was HIV+ spoke of using a traditional herbalist to get her son muti not in order “to remove impurity or disequilibrium” as in TAM (Hewson, 1998;), but, as she said, “to boost his immune system” – expecting the potency of a substance from one medical ontology to have an effect on an entity within another. In a non-syncretistic system these ontologies would be incommensurable, but is here illuminated by knowing her son was also taking the full complement of anti-retroviral for the same reason. This is how traditions of practice conflate; as different means toward the same aim – thereby pluralism begats syncretism. In other words, syncretism seems to be a kind of ‘strategy’ born out of an overwhelmingly practical orientation, rather than a confused or mystified one as commonly believed. Similarly, other informants said they used traditional remedies to combat “stress” and “psychosomatic” ailments – because that was what they had on hand.

The syncretistic mechanisms were put in place when western OTC or ‘patent medicines were disseminated widely through the culture (at a time when there was little access to western doctors in ‘native’ urban areas) and the only ‘institutions’ were traditional healers. But then as now domestic DIY healthcare was probably the mainstay and people began experimenting with the ‘new’ and the ‘old’ medicines at their disposal. From the 1930’s onwards Grandpa headache powder and Vicks Vaporub have been pluralistically used alongside traditional ‘African’ medicines and ‘home remedies; gradually interpenetrating into the hybridized ‘folk medicine’ that predominates in the townships today.

So rest assured, dear reader, if worried that nothing of ‘local’ or ‘African’ culture remained in township health practice; syncretism is not ‘westernization’, and both sides of such a pairing ‘bleed’ into one another. The strongest evidence for this is what our informants felt they needed to add to or take alongside the ‘western’ medicines they used. There was a systematic pattern here that we shared with our client; in Southern Africa medicines needed to be more experiential. It was good to know something would work (empirical criteria), but better to also feel it working (cultural criteria cum empirical evidence). And the form that the ‘evidence’ should take was highly shaped by South African culture and preferences. Soluble aspirin alone may work, but taking it as a hot drink along with the burning taste of ginger is believed to make it work much better (and therefore preferred).

Consequently, Dauskardt goes too far in speculating that Western pharmaceuticals have conquered “the consciousness of medicine” (1990:282) in urban South Africa. What they have done (in line with this paper’s focus on practice over ideology) is capture a large share of medicine’s modus operandi. Some practices of ‘Traditional ‘African Medicine’, especially its herbalism, may seem to have been re-configured in the image of Western over-the-counter medicine. (But you could equally say herbalism had ‘grafted’ onto it after it was unloosed from traditional healers by ‘internal market forces’). Whatever your choice of metaphor (military or botanical – though which has serious implications) herbs, like OTC remedies, are now something you can recognize a symptom for, conveniently buy, then administer yourself. In this one can also say that certain characteristics of western medicine dovetail with the spirit of the times and the more ‘protestant’ character of township dwelling ‘consumers’ – who in a shocking parallel to ourselves are indeed concerned with time and money. Which is not surprising given they all live in a big city, work 8, 10 ,12 or longer hours a day, commute some distance to work, and can afford little time off to be sick.

Given the current nature of urban healthcare that I have been describing throughout this paper, and the fact South Africa is now 57% urbanized and due to continue at 2.9% a year, (Unicef, 2004) we believe the ‘disembedding’ of TAM will continue. We would furthermore argue that the essentialistic construction of ‘Traditional ‘African Medicine’, in leaning heavily on its metaphysical basis and the ministrations of healers (my title-transition could almost equally have been ‘from healers to herbs’), fails to acknowledge the reality of everyday healthcare for a growing majority of the population, tying its practices to an imagined place in the rural past. Consequently, I believe TAM as a concept should be displaced in favor of an African medicine drawing more loosely on the following characteristics:

• We treat ourselves whenever we can (self-help/DIY medicine, OTC drugs, home remedies)
• We use whatever works – old or new; homemade or commercial; and mix them together (despite source or ‘tradition’ in a way characteristic of pluralism-syncretism)
• We use local ingredients for remedies whenever we can; especially. herbs “from the African soil” (as Rastas might say) or simply “things from the neighbors garden” (as one Colored family put it)
• We want treatments in which we feel the healing (other formats in addition to pills, such as; rubs, hot drinks, poultices – manifesting culturally favored sensations, e.g. burning taste, sweating out fevers)
• We draw on treatments and recipes handed down informally; from ‘the elders’, family, friends, and ‘folk knowledge’; not only ‘experts’ (healers or doctors). (The sense of authority of our medicines can thereby be said to feel ‘traditional’ – even if not located within a specific ‘tradition’).

This is what we analogize as the ‘protestant re-formation of African medicine’. It is revolutionary in breaking the misleading conceptual entailment between something being ‘African’ and therefore necessarily ‘traditional’; it accounts for one of TAM’s most vibrant constituent parts ‘urban herbalism’ where TAM cannot; it encourages an increased sense of personal power and agency in its users, making it in tune with macro forces in the culture and a good descriptive model of personal healthcare in South Africa today. Therefore, we believe this ‘protestant re-formation’ should be an effective reference for the development of over-the-counter medicines in the region.