Social science & medicine. Part B, Medical anthropology最新文献

Most medical ethnographies in Africa have focused on notions and taxonomies of disease, their causes and the therapies available to treat them. This ‘negative’ pathology-oriented perspective misses, or underplays, important although often unlabelled practices and ideas of hygiene, adaptation to the environment, normative health, and the conscious maintenance of health ideals, all of which are increasingly important in planning health programs based on popular support and rooted in cultural values. It is argued in the paper that medical anthropology needs to consider, as a single domain, both disease and health, both taxonomies of disease and of health, and the study of this expanded domain. In order to more adequately identify and analyze such an expanded domain, the paper reviews numerous ethnographic works on medicine and health in Africa—including Heinz on the !Ko, Evans-Pritchard on the Azande. Buxton on the Mandari, Ngubane on the Nyuswa-Zulu, and Janzen on the Kongo—exploring their potential for understanding alternative logics in therapeutics and for explaining sources of change in medical and health thought.

This article is an attempt to find the systematic bases of therapeutic organization in north-eastern Tanzania, based on recent research in Galambo, Lushoto District. The whole of Tanzania suffered a long period of very low investment in either health care or public health during the colonial period. During that time the costs of reproduction of labor were borne in the countryside, mostly by women and children. Neglect by the colonial powers left a sphere of rural autonomy in medical matters, in which a number of therapeutic systems and sets of ideas fourished side by side, with no one therapeutic tradition establishing an effective monopoly. How then is a socially approved course of therapy determined?

One possible answer to this question—based on shared world-view and shared assumptions about the causes of illness—is rejected. Evidence shows clearly that individuals disagree fundamentally on theories of illness causation. Radical scepticism concerning the validity of spirit-causation of illness, and of sorcery-explanation, is common.

The boundaries of the system are shaped by the power of the government and (among those who are Christians) the authority of the church. The government has decided that cholera and tuberculosis must be treated within the biomedical tradition. The chruch tries unsuccessfully to limit its adherents to the use of hospital medicines or simple herbal therapies.

The system as it works in actual practice is shaped by two principles. First, treatment is diagnosis. The only way to know with certainty the cause of a particular illness is to treat that cause and see if the condition improves. In many circumstances therapies are tried primarily to advance the process of diagnosis. Some treatments are structured so that only a part of the treatment need be tried initially, for diagnostic purposes, with the rest completed if the initial results are positive. The second principle is that the range of therapies is determined by the range of therapy managers. Therapeutic options supported by a relative or neighbor of the patient are almost never rejected, even if the patient or other therapy managers disagree with the assessment or therapeutic theory. Because of this each individual whose illness continues over a period of time tends to be treated by a wide range of practitioners.

Recent historical writing has cast medical missions in Africa as handmaidens of colonialism. The present paper offers a revisionist medical history of one medical mission effort—that of the Universities Mission to Central Africa (U.M.C.A.)—which was explicitly opposed to colonial capitalism and such policies of industrial medicine as the coercion of laborers, but which shared with other missions a paternalistic civilizing mission and Christian evangelization. This combination of scientific rationality and Christian evangelicalism provide the basis for a ‘theory’ of mission medicine, in terms of which it can be asked whether, and to what extent, missions—here the U.M.C.A.—succeeded in their goals. A series of tests confront the Masasi U.M.C.A. medical position, to illustrate mission medical history, including: (1) the early colonial epidemics (1880–1926) which largely overwhelm mission medicine, with the exception of success in treating Yaws; (2) the role of the jamaa lay kin therapy managing group's interference with the mission's self-defined role in diagnosis and treatment; (3) the practice of alternative therapies within the African Christian community; (4) medical modernization and the formation of a cadre of African medical people; (5) initiation rites and efforts of mission personnel to improve circumcision hygienic conditions without disrupting the rites; (6) the challenge of spiritual healing and the rise of African prophetic healing. Although the U.M.C.A. is considered to have failed to maintain its objectives in each of these tests, and ultimately to have abandoned its early ‘theories’, it survives in Tanzania as a government-sanctioned presence with a role in contemporary rural health care, utilizing very different goals from those originally espoused.

This paper analyses the structure of Cokwe medical knowledge in the context of the occurrence of illness. Their knowledge of illness and medicine grows out of several centuries of contact with neighboring peoples, and, most recently, with Europeans. The paper makes four main points. First, that Cokwe classification of disease can best be understood as based upon a series of principles by which diseases are identified. Second, that the ascription of causation is more important in the choice of treatment than in the diagnosis of disease. Third, that causal explanations change when illnesses are unresponsive to treatment. And fourth, that one can best understand the importance of the various categories of medical knowledge when those categories are placed within specific episodes of illness.

The sick of Kinshasa, capital city of Zaire, have at their disposal an array of both official hospital and traditional medicine options. However, because of the rapid post-independence population influx to the city, increasing the population from 400,000 to over 2 million inhabitants since 1960, and only a 50% increase in hospital and biomedical facilities in that time, as well as the continued preference for some African treatments, these latter remain an important health care resource in the city. Nearly half of the city's population is from the immediate Lower Zaire area, thus the Kongo medical system is the prevalent overall medical culture in terms of recourse to treatment. The Kongo medical culture is multidimensional in its range of diagnoses, preventions, or elimination of disequilibriums of a physical, mental or social character. Etiological categories are based upon a distinction between normal and abnormal causes. Therapies range from the physiological to the psychological. This Kongo medicopsychotherapeutic culture is carried out by several levels and types of practitioners, including profane herbalists, nurses and doctors with varying degrees of formal training in the use of biochemical drugs (of fluctuating availability because of economic uncertainty), and clairvoyant psychotherapies by a series of practitioners who deal with afflictions caused by ancestors, witchcraft, and other spirits including those of ‘medicines’. These clairvoyant practitioners often practice on a one-to-one basis with clients, but there are also group therapeutic rites—e.g. Zebola, Bilumbu, Mpombo, Mizuka—and spiritual healing churches led by Christian prophets. This broad-ranging medical culture in an urban setting reflects the diversity of the society and a wide range of responses to problems.

In this paper a short introduction is given to the general topic of health and health related indicators, emphasizing the need and the difficulty to construct indicators which are appropriate for specific situations and specific questions.

The non-existence of vital statistics in most Third World rural areas is then discussed, with comment on some solutions proposed to generate health indicators from defective data.

It is argued that the problem becomes more urgent with the growing attention for primary health care programmes. A new indicator is then introduced, called the Survival Index, which is basically the relation between gravidity number and number of children alive. This indicator is illustrated with some preliminary data.

The possible uses and restrictions are discussed and indications are given for further research needed for development of this indicator or related types.

This brief report of an ongoing official effort to coordinate medical pluralism speaks directly to the issues of this section: the application of cultural analysis to medical practice and planning.

Health sector planning is here analyzed in terms of three forms of social legitimacy put forward by Max Weber: rational-legal, traditional and charismatic. Health care planning which is completely legitimated by rational-legal means in bureaucratic institutions usually leaves populations at the periphery of the system ill-provisioned, especially in societies such as many in Africa in which productive resources are in the rural countryside. A proposal is offered for the integration of legal-rational health care organization with traditional health care such that both sectors serve best for that which they are qualified, although not at the expense of the other.