Zambezia (1989), XVI (i).MEDICINES AND SYMBOLS*M. F. C. BOURDILLONDepartment of Sociology, University of ZimbabweTHERE ARE DISAGREEMENTS about the status and efficacy of indigenous1African medicines. On the one hand, traditional healers are undoubtedlysuccessful in helping people to overcome a variety of illnesses. On the other,people often assume that indigenous medicines are inferior to modern Westernmedicines.I have recently discussed the logic of magic: I argued that, in magic, peopleconfuse the logic of communication with the logic of material efficacy.2 Someapproaches to indigenous medicine provide a practical application of theargument.Indigenous African medicine is a complex field, not susceptible to any singleexplanation, and the field is changing to meet the needs of modern Africa. Thiscan be seen particularly in various attempts to give professional status topractitioners of indigenous medicine,3 which in turn involves some control overstandards and ultimately over training. Frequently we find an emphasis onindigenous herbal medicines in both the teaching and research of professionalassociations. In 1969, Professor Akisanya, a biochemist, called for research intoindigenous African medicines, to be tested according to modern scientificprinciples, in order to utilize indigenous knowledge in modern healing practice.4This call has been repeated by other scholars in Africa.To some extent at least, indigenous medicine adopts a cognitive model akin tothat of modern science, and demands to be judged by standards comparable tothose of modern science. If Foucault is right in arguing that empirical thinking inmodern medicine is partly a result of the social and physical environment inwhich it is practised,3 indigenous African medicine will presumably adapt in a* I acknowledge helpful comments on this paper from Pamela Reynolds and from participantsin seminars in Manchester and Adelaide.1 I use the term 'indigenous' rather than the more common term traditional' in order to drawattention to the fact that we do not know what changes have taken place in the indigenous healingtradition in the recent past When identifying healers working in the indigenous system, I refer tothem as traditional healers'.2 M. F. C. Bourdfllon, 'Magic, communication and efficacy", Zambezia (1988),XV, 27-41. Myargument is close to that of J. Skorupslti, Symbol and Theory (Cambridge, Cambridge Univ. Press,1976), esp. 125-59.3 See M. Last and G. L. Chavunduka (eds.), The ProfessionaUsation of African Medicine(Manchester, Manchester Univ. Press, 1986).4 A. Akisanya, New Wines in Old Bottles (Lagos, Univ. of Lagos, inaugural lecture, 1969).5 M. Foucault, The Birth of the Clinic: An Archaeology of Medical Perception, trans. A. M.Sheridan Smith (New York, Pantheon, 1973 [Originally published as Naissance de la Ctinique(Paris, Presses universitaires de France, 1963)]).2930 MEDICINES AND SYMBOLSparallel way. Is there any reason to propose a logical distinction betweenindigenous medical knowledge and that of modern doctors? To begin to answerthis question, we need to take a closer look at indigenous healing practices. Myfocus will be on Zimbabwe, and the Shona peoples in particular, but thearguments have a wider application.INDIGENOUS SHONA HEALINGMost traditional healers in Shona society claim to be guided in their art by ahelping spirit who takes possession of the healer from time to time, when,according to Shona belief, it is the spirit who speaks through the body of the hostIn keeping with this belief, it is rare for a traditional healer to admit to having beentaught by another healer. Rather, traditional healers attribute their knowledge ofindigenous medicines to the influence of their spirits, who reveal cures in dreams,or guide the healers in the veld to appropriate plants. Sometimes, the cures arerevealed to the healer through the dreams of their patients (often themselvespotential healers). Accounts of the histories of particular healers emphasize thepower of the healing spirits imposing themselves on apparently reluctant hosts.Practice does not, however, exactly correspond with the ideology that thepower of healers comes simply from their spirits. A traditional healer usuallycomes from a family containing one or more established healers. The prospectivehealer is usually chosen by a senior relative, an established healer, who starts toteach the child about indigenous herbs from early childhood onwards. The childis likely to act as an assistant to the relative even, as the child moves into his or herteens, to the extent of treating patients in the absence of, though under thedirection of, the healer. Such training requires the willing co-operation of thechild.6A knowledge of herbs has always been important in indigenous medicine.Practitioners build up their reputations and clienteles partly on the knowledge of avariety of herbs. Learning about herbs is an important part of the informaltraining of aspiring practitioners.Professional associations which have been developing in recent times place aneven greater emphasis on herbalism.7 The Zimbabwe National TraditionalHealers Association (ZINATHA), the largest and the officially-recognizedassociation in the country, established two schools at which students were taughtthe use of plants and other medicines (together with hygiene and simple book,keeping), and also co-ordinates research on plants. After completing the one-yearcourse in medicines, students served a three-year apprenticeship in one of the6 See P. Reynolds, 'The training of traditional healers in Mashonaland', in Last and Chavunduk,(eds.), The Professionalisation ofAfrican Medicine, 165-87.7 Chavunduka and Last, 'Conclusion: African medical professions today', ibid., 262-5.M.F.C. BOURDILLON 31clinics run by the Association, but spirit mediumship (the dominant technique oftraditional healers in Zimbabwe) was never taught.8 In other countries, too, wefind traditional healers' associations paying more direct attention to research andtraining in herbalism than to other aspects of indigenous healing techniques.Professor Chavunduka and Dr Last attribute this trend to a number of factors.Herbalists were less organized than healers in cults, and so had more to gain fromthe formation of associations. Herbalism fits in better with a move towardsempiricism induced by the modern educational system. Herbalism is more easilysubject to scientific investigation. There is the further point that herbalism is moretangible than other aspects of indigenous healing and, therefore, is more easilytaught, examined and controlled. We have seen a similar trend in Westernmedicine, in which training takes place largely in terms of chemical or surgicalintervention in teaching hospitals: such an environment minimizes attention tosocial and environmental factors in health, and does little to prepare generalpractitioners for much of their work, which comprises dealing with people'spersonal and social problems. The medical profession has been aware ofproblems in the training system for thirty years at least, but has been unable toovercome them: knowledge of chemistry and anatomy can be objectively taughtand examined, but it is not so easy to teach and assess objectively a bedsidemanner and an ability to help with social problems. Perhaps traditional healers'associations were falling into the same trap of focusing on what is easiest tocontrol. It is, perhaps, significant that the schools of ZINATHA ceased to functionon account of financial problems and problems over the structure and thecurricula of the training programme.Whatever the situation in traditional associations, a knowledge of herbs hasalways been important in traditional medicine. The long training of aspiringpractitioners in the use of herbs has resulted in a considerable body of indigenousknowledge about herbs and their uses. A study of herbal medicines used by 250traditional healers from all over Zimbabwe revealed that more than 500 differentspecies were in use, comprising about ten per cent of flowering plant and fernspecies in Zimbabwe, and about half of the species which have vernacularnames.9 From standard published works, 234 of these medicinal plants are alsoused for medicinal purposes in other countries in Africa, though only 60 plants areused to treat the same kinds of comp'aints in different countries. The few that areused to treat the same complaints in different countries are used to treat othercomplaints as well.10Ł G. L. Chavunduka, 'ZINATHA: The organisation of traditional medicine in Zimbabwe', ibid.,37 8. The schools and clinics had a short life, and were no longer functioning by the end of 1988.9 M. Gelfand el al., The Traditional Medical Practitioner in Zimbabwe: His Principles ofPractice and Pharmacopoeia (Gweru, Mambo Press, 1985), 76.10 Ibid., 240.32 MEDICINES AND SYMBOLSProfessor Chavunduka emphasizes the common usage of a number of plants,and concludes from the data that traditional healers have built up a significantbody of medicinal knowledge which could supplement the drugs used byWestern medicine, especially in view of the difficulty in obtaining the latter onaccount of the problems of hard currency that the country faces.11 The task ofcomparing usage across countries is difficult, bearing in mind the variations inflora and, more particularly, the sparsity of information publicly available. Thefact that there is common usage of a number of drugs does indeed support theview that the properties of at least some herbs are worth investigating from ascientific point of viewThe variety of uses of herbs, however, is more striking than the similarity ofuses. Gelfand etaL found 168 plants which were prescribed for certain complaintsin Zimbabwe, but which were prescribed for different complaints in othercountries.12 Even when plants are used for the same problems in differentcountries, they are used for other problems as well. To take one example, Gelfandel al list Swartzia madagascariensis as being used in Zimbabwe, Zambia andZaire for treating diarrhoea and headaches: in Zimbabwe the root is commonlyand widely used for treating diarrhoea, and the root and pod are commonly usedfor treating convulsions; on rare occasions the root is used for infertility in womenand oedema; the pod is commonly used for syphilis and occasionally for woundsand headache; the fruit is commonly used as an emetic and as a fish poison, andoccasionally for abdominal pains and cataract; the bark is occasionally used forearache.13 Many herbs are used to treat a wide variety of complaints even withinZimbabwe. The medicinal uses of a single substance varies widely, and thissuggests that any concept of chemical treatment is peripheral to most ofindigenous medical practice.Even when the same drug is used for treating similar symptoms in differentcountries, this does not exclude a common perception of symbolic rather thanchemical properties. To take the example of S. madagascariensis again, V. W.Turner states that among the Ndembu of Zam bia the roots of this tree are used totreat stomach illness in children (fitting in with the common usage justmentioned), and gives the Ndembu healer's explanation: Kapwipu (S. madagas-cariensis) medicine is used because it is a hard tree. Hardness (ku-kola) representshealth and strength.14 This explanation has little to do with the chemicalproperties of the root.11 G. L. Chavunduka, 'African Traditional Medicine and Modern Science' (Harare, Univ ofZimbabwe, Symposium on Development of Drugs and Modem Medicines, 6 Aug. 1988, as renonniat length in the Sunday Mail, 7 Aug. 1988).1J Gelfand etal.The Traditional Medical Practitioner in Zimbabwe, 240.» Ibid., 154-5, 286.'* V. W. Turner, 'Lunda medicine', in his Forest of Symbols: Aspects of Ndembu Ritual (IthanCornell Univ. Press, 1967), 316. ^M.F.C. BOURDILLON 33Turner gives a list of medicines used in certain rites of affliction among theNdembu.15 It includes roots and leaves from a strong, tough tree to impart virilityand strength; a tree with a slippery surface, related to the way children haveslipped away from the woman being treated, and the need to make diseases slipaway; the bark and leaves of a tree, whose name derives from the word to reveal,and whose many small fruits make small animals appear to the hunter; roots andleaves from a tree with strong thorns to catch a child; and others. Some plants areused because their names associate them with the condition being treated or thedesired effects of treatment. Other medicines fit in with the symbolism of hotnessand coolness, and elsewhere Turner says that many medicines fit in with thetripartite Ndembu colour symbolism, chosen because they are, or they come fromsomething that is, white or red or black.16 He lists indigenous explanations ofherbs used, which often refer to their bitter or hot taste. Other medicines are usedbecause the plants, or sometimes animals, in some way characterize thesymptoms of the patient. All the senses, sight, hearing, taste, smell and touch, areemployed in the analogies between the medicines used and the disease or thedesired effects. Some plants and objects used medicinally also appear in culticrituals. Turner explains the use of Ndembu medicines in terms of their symbolicsignificance, rather than because of any chemical property, although he doespoint out that since Ndembu healers try many medicines it is likely that somebecome established because they are observed to bring relief. As E. H.Ackerknecht has pointed out, the knowledge and use of some medicines that arephysically efficacious does not make the system of medicine a scientific one.17 Theknowledge of herbs, and of the symbolic system in which they are used, may bedetailed and require much learning; but it does not necessarily involve aknowledge of drugs.We are in the realm of what is often called sympathetic or homeopathicmagic: the medicines have qualities which the healer would like to transfer to thepatient. Although attempts to transfer qualities (such as heat or perhaps evendisease) by contagion or consumption can in principle be quite empirical, thewhole context of Ndembu medicine shows that the dominant associations are atthe cognitive and symbolic level. As in much magic, it is a response to fear of whatcannot be controlled empirically: people express their wishes and hopes with thecognitive associations they can control.18Unfortunately, there is little published work on attempts to obtain andelucidate the symbolic reasons behind the use of indigenous medicines in13 V. W. Turner, The Ritual Process (London, Routledge and Kegan Paul, 1969), 24-7." Turner, 'Lunda medicine', 303-5.17 E. H. Ackerknecht, Medicine and Ethnology: Selected Essays, ed. H. H. Walser and H. M.Koebing (Baltimore, Johns Hopkins Press, 1971), 135-61.18 I have argued this more fully in 'Magic, communication and efficacy'.34 MEDICINES AND SYMBOLSZimbabwe. The vast collection of herbal remedies by Gelfand et al. gives nodetails of texture, colour or smell of the plants used, neither does it give anyindication of other symbolic usages of the plants. No attempt was made to obtaina symbolic exegesis of the use of herbs from the practitioners themselves. Indeed,there is some doubt about the usefulness of a collection such as this, in whichherbs are taken out of the healing context, affecting both their symbolic value andtheir possible chemical value when used in conjuction with other herbs. Anyonewho has seen the huge dominant baobab trees in the woodlands of the lower-altitude areas of Zimbabwe will readily see a sympathetic symbolism in the use ofthe bark of this tree 'to secure respect, prestige and security in one's job', or thebark and fruit 'to fatten babies'; the trees are also used for important land shrinesin some areas. Nevertheless, as Turner points out, we should be wary ofattributing a logic without reference to the explanations of people within theculture concerned.We can notice again the point tnat many plants are used for a wide variety of;omplaints in different countries, and even by different healers in Shona country: thisfurther suggests that treatment is determined largely by a variety of local, and evenindividualistic, systems of symbolic logic rather than by universal physical properties.There is the further point that traditional healers often learn about medicinesthrough dreams. One reason for dreaming about a herbal treatment may be asubconscious working on past training and experiences. The ability to call on pastexperiences in this way, and the reliance of healers on this skill, could in principle bedeveloped in a tradition that is not able to rely on written textbooks. But besides acausative association that one may have come across, dreams call on a variety ofassociations and experiences. Psychoanalysis has shown us that what appears indreams has a logic, usually through some kind of symbolic association. Medicines thatcome from dreams are more likely to be susceptible to the kind of symbolic analysispresented by Turner than the biochemical analysis suggested by Akisanya.Turner points out that the use of medicines has to be understood in the context ofthe Ndembu cosmology of hidden powers which have to be exorcised or controlled.The medicines themselves have such powers, and it is the healer's task to rouse thepowers within the medicines to perform their healing functions. This is clearly not theefficacy of chemical drugs.Elsewhere, Turner points out that many healing rituals refer to conflict within thecommunity. It is now generally accepted in modern Western medicine thatpsychological and social factors are significant both in the incidence of disease and inthe healing process. Turner points to the skill of traditional healers in pinpointingareas of tension, and in organizing rituals to overcome tensions and restore some kindof order and harmony in the community."" V. W. Turner, 'A Ndembu doctor in practice', in his Forest of Symbols, 359-93.M.F.C. BOURDILLON 35Bacteria and viruses may be immune to complex symbolic systems, but people arenot. In so far as an important part of the traditional healer's role is to influence theattitudes of his clients, especially their attitudes towards one another, involving themin symbolic gestures and rituals may well be the most effective way to do this. At theindividual level, a patient's attitude may affect the ability of his own body to fight thebacteria and viruses, which are consequently indirectly affected by the use of symbols.INDIGENOUS AND WESTERN MEDICINEA variety of recent studies have pointed to the limits of modern medicine on the onehand, and the very real efficacy of indigenous practices on the other.20 Nevertheless,what we have seen so far suggests fundamental differences between the two systems.It will be useful to look at some typologies of the differences.In the early part of this century, it was customary for administrators, missionariesand others to dismiss indigenous healing practice as superstition and the practitionersas charlatans. To such people, the difference between indigenous and modernmedicine is the difference between superstition and science. At worst such views weresimply ethnocentric. Although such views have rightly been dismissed in theanthropological tradition, two points need to be considered. Firstly, these ethno-centric perceptions were given some apparent credibility by the use of deception onthe part of traditional practitioners. Secondly, traditional practitioners have occasion-ally harmed their patients by administering toxic substances.To take the first point, a common example in Southern and Eastern Africa iswhen a healer produces a worm or other object which he claims to have been thecause of sickness, and to have sucked this object out of the body of the patient, usuallyinto a horn or similar vessel placed against some part of the patient's body. That suchpractice involves deception is clear from Evans-Pritchard's account of a Zandehealer's reluctant teaching of such tricks to the anthropologist's Zande assistant, andthe assistant's dismay in discovering that the practice simply depended on sleight ofhand.21Levi-Strauss produced an interesting account of how an indigenous healer (in thiscase in North America) might at first be disillusioned about the deceptive aspects ofthe healing art, but might nevertheless continue to practise in the genuine belief that heoffered some relief to his patients which they could get from nowhere else, and that hispractice was less fraudulent than that of other healers.22 It is no longer tenable todismiss indigenous medicine as fraudulent. At best such a notion arises from a failureto see the necessary distinction in perceptions between the practitioner who20 See, for example, A. L. Strauss, Where Medicine Fails (New Brunswick, Transaction Books,1979).21 E. E. Evans-Pritchard, Witchcraft, Oracles and Magic among the A zande (Oxford, ClarendonPress, 1937), 229-39.22 C. Levi-Strauss, Structural Anthropology, trans. C. Jacobson and B. G. Schoepi (London,Penguin, 1968), 175-82.36 MEDICINES AND SYMBOLSmanipulates symbols and the subject who is affected by the symbols: such distinctionscan be used unethically as in much advertising or by a quack,23 but the implied'deception' can, and often is, used to benefit the subject (as in the use of a placebo).A modern general practitioner who prescribes for material gain a drug that is notnecessary would be considered as behaving unethically. But the same deed may beacceptable when the benefit of the patient is the motive. One doctor described to mehow she prescribed a harmless but unnecessary drug to a patient who had problems athome which he clearly wished to discuss with her on a regular basis: it is sociallyacceptable to visit the doctor to have a prescription renewed, but not to discuss one'srelations with one's spouse!The point I am making is simply that the use of deception in certain situations bytraditional healers to achieve their effects does not necessarily mean that these healersare charlatans.On the administration of toxic substances, a number of cases of harmfulresults of the use of poisonous herbs by traditional healers have come beforeWestern medical practitioners for remedy.24 We could simply dismiss theseincidents post factum as incompetence on the part of the individual practitionersinvolved: indeed, we have no comparative statistics on harm done by professionalhealers in either the modern or the older African tradition Š and there are thosesceptics like Ivan Illich who regard modern medicine as doing more harm thangood in society.25 The question of error and testing is more complicated than this;the point at this stage is that the existence of error does not itself condemn a systemwhich has many beneficial results.While the limits of modern medicine and the efficacy of traditional healingare widely accepted in academic circles, there remains a popular characterizationof the two systems which associates the modern Western system with science andprogress, while indigenous systems are associated with ignorance and backward-ness. We notice that champions of indigenous medical knowledge, such asChavunduka and Akisanya, want scholars in the modern scientific tradition toexamine the herbs, to isolate the active ingredients and to verify the most effectiveform of dosage. It is true that Chavunduka wants scientists to do this mainly inorder to restore confidence in indigenous medicines, which he assures us havebeen fully researched by indigenous healers and are effective. Nevertheless, theneed to restore confidence suggests that many people have more confidence in the23 Malinowski was right to see something common in the logic of quackery and advertising onthe one hand and the logic of Trobriand magic on the other: see B. Malinowski. Coral Gardens andTheir Magic (London, Allen and Unwin, 1935), 237-8. But there is reason to believe that thetraditional healer, unlike the advertiser and the quack, usually himself believes in what he is doing24 See Gelfand el al. The Traditional Medical Practitioner in Zimbabwe, 294-5.2! See I. Illich, Limits to Medicine: Medical Nemesis: The Expropriation of Health (Harmonds-worth, Penguin, 1977).MFC. BOURDILLON 37ability of modern science to assess the chemical effectiveness of drugs than theyhave in traditional healers. Is this simply a result of cultural imperialism? Or isthere some basis to common people's beliefs?Turner suggests that indigenous medicine treats symptoms only, whereasWestern medicine treats disease.26 The idea is that a traditional medicalpractitioner might try to treat a headache or a fever, whereas Western medicinewill aim to find out what in the body of the person is causing the headache or thefever and treat that. On the other hand, one could equally argue that Westernmedicine stops with the physical body, whereas indigenous medicine aims todiscover and to treat whatever in the social environment makes the individualliable to succumb to disease. D. I. Ben-Tovim, in a study in Botswana, cites apsychiatric patient as saying, 'The Tswana doctor tells me why I am ill. Yourmedicine cures the illness as it affects the body.' Ben-Tovim interprets this as aview that Western medicine suppresses the symptoms of disease, but indigenousmedicine offers answers to 'why' in terms of indigenous beliefs.27There is a problem over what counts as symptom and what counts as disease.Frequently the term 'disease' is used to apply precisely to a disorder as definedphysiologically by Western medicine. If such a definition is accepted, it is neithersurprising nor informative to state that Western medicine treats disease, and othersystems treat something else.Botswana has been relatively successful at organizing a primary health caresystem in which traditional healers have a role to play. They are involved in thelocal-level health committees, and even Western doctors are appreciative of thecontributions that traditional practitioners can and do make at this level. But thereis frequently a breakdown in communication when particular diseases arediscussed. Traditional heajers may frequently adopt the name of a disease fromWestern medicine, say, 'bilharzia' or 'AIDS', but the perception and definition ofthe problem that they call by that name has little to do with the cognitive system ofWestern medicine. Conversely, some complaints treated by traditional healershave no clear English translation.28Even when traditional healers talk about diseases in terms of observablephysical symptoms, and claim to treat them accordingly, we find that, in practice,diseases are defined and treatment is applied according to other factors. It has longbeen established that diviners using dice use the throws freely as a peg on which tohang their commentaries on the social situation which they are considering.2926 See Turner, 'Lunda medicine'. 305.27 D. I. Ben-Tovim, Development Psychiatry: Mental Health and Primary Health Care inBotswana (London, Tavistock, 1987), 17928 See Gelfand el at.. The Truditional Medical Practitioner in Zimbabwe, 77.29 See R Werbner, 'The superabundance of understanding: Kalanga rhetoric and domesticdivination', American A nthr opologisti 1973), LXXV, 1414 40. and MFC. Bourdillon, TheShonaPeoples (Gweru, Mambo Press, 3rd edn., 1987), 154 6.38 MEDICINES AND SYMBOLSSimilarly, healers freely interpret symptoms in the light of social problems andconflicts, irrespective of how particular symptoms are paradigmatically associ-ated with specific problems: people may say that backache is typically a symptomof witchcraft, but, depending on circumstances, a particular case may be regardedas a sign from the ancestors or simply the advent of old age.Traditional healers normally look at a problem in its total social andpsychological context: the 'disease' as defined by Western medicine is simply thesymptom of the problem. The detailed knowledge of anatomy and physiologywhich provides the parameters of a Western definition is, where it exists at all,peripheral to the indigenous cognitive system.The problem is perceived, defined and treated differently in each system. Thedistinction in Western medicine between disease and symptom is applicable onlyto the Western system and is meaningless in the context of the indigenous system.A third way in which I have heard the difference between the two systemscharacterized is that indigenous African medicine (at least in the region underconsideration) has no coherent theory of the body. Again, this notion hassuperficial plausibility when one compares the detailed anatomical knowledge onwhich modern medicine is based with the very limited knowledge of anatomy oftraditional healers. But again there are problems when one examines the notionmore closely, problems that relate to the whole debate about modes of thought.One problem arises over what might constitute theory in a non-literatetradition. Although many, if not most, traditional healers are now literate, theirknowledge and training have been acquired in a tradition that has until recentlyhad no writing, and which still does not rely on writing. Indeed, a fairly commonfeature in accounts of young persons being chosen by a healing spirit is mentaldisturbance involving neglect of school work, or even running away fromschool.30 One does not expect to find in such a non-literate tradition a systematicenquiry and exposition of the logical basis for practical decisions. This does notnegate the possibility of a logical basis which does in fact systematize practicaldecisions. Can one talk meaningfully about implicit theory?Some non-Western medical traditions do have their own theories of the body,Islamic medicine, for example, or many of the Eastern traditions. Such theoriesare built up in written literature, even if many or even most of the healers are infact illiterate. But it is not clear that the existence of such theory is useful indifferentiating indigenous and modern medicine in Southern Africa.Take, for example, Kapferer's recent outline of'exorcist theory' in Sri Lanka30 It is dear from the role of spirit mediums in tne liberation war in Zimbabwe leading up toIndependence in 1980 that spirit mediumship was an effective symbol of opposition to Whiteculture; see M. F. C. Bourdillon, 'Religious symbols and political change', Zambezia (1984 5), XII,39-54, and D. Lan, Guns and Rain: Guerrillas and Spirit Mediums in Zimbabwe (HararejZimbabwe Publishing House, 1985).MFC. BOURDILLON 39in terms of three fundamental humours: wind, blood/bile, and phlegm.31 Theseshould be in balance in a healthy person. Diseases, emotional states and afflictingdemons are understood in terms of how they affect this balance, and treatmentproceeds accordingly. Here we find an established theory of the body, on whichtreatment is based. Nevertheless, there is an overlap in the symptoms attributed tothe different humours, and in the effects of various spirits. The understanding andtreatment of illnesses within such a system seems closer to the understanding ofaffliction in terms of spiritual powers that we find in traditional Shona medicinethan it is to modern medicine. It is the specific biochemical theory of the body,which was only recently developed, rather than the existence of theory as such,which distinguishes modern medicine from other traditions. It could be arguedthat such biochemical theory provides, in any case, only a limited understandingof disease.Turner emphasizes the importance of spiritual powers and witchcraft asbelieved causes of disease in contrasting the Ndembu healing system with that ofWestern medicine. He argues that the Ndembu do not know of natural causes forserious diseases and resort to divination rather than diagnosis.32 This is probablyoverstated; but the valid point remains that when a disease is serious enough tothreaten life, or persists beyond normal expectations, it demands some kind ofsupernatural explanation.33 The aim of healers is to make the invisible appear, andthen to tame it, through the use of symbols.34 The polysemic symbols used in turnrelate to the fundamental values and ethics of Ndembu society, which are broughtinto play into such everyday matters as curing a headache-35Turner is somewhat dismissive of the efficacy of indigenous medicines,though he does concede that they might help in mild psychosomatic illnesses. Heattributes the continued resort to indigenous medicine to its intimate linking withthe whole Ndembu cognitive system: to question the efficacy of indigenoushealing would be to question the whole Ndembu world view. He also points tothe fact that most ailments are self-curing, and may appear to be cured byindigenous treatment (or, we might add, equally by modern treatment). He arguesthat there is a danger of assuming that the Ndembu are able to cope with a poorhealth situation through their indigenous medicine, whereas improved diet andbetter hygiene, together with more modern preventive medicine and morewidespread hospital facilities, are urgently required.31 B. Kapferer, A Celebration of Demons (Bloomington, Indiana Univ. Press, 1983), 49-52.32 Turner, 'A Ndembu doctor in practice', 360.33 See Chavunduka's category of'abnormal illness' among the Shona, requiring explanation andtreatment in terms of spirits or witchcraft, G. L. Chavunduka, Traditional Healers and the ShonaPatient (Gweru, Mambo Press, 1978), 12.34 Turner, 'Lunda medicine', 353.35 Ibid., 356.40 MEDICINES AND SYMBOLSNow, more than twenty years after Turner wrote, we are inclined to be lessconfident about modern medicine and less dismissive of indigenous practices.Nevertheless, Turner was probably right in his assessment that improved diet andhygiene comprise important health needs for the Ndembu, although mentalproblems due to dislocation and other problems of contemporary life possiblyrequire equal help from the traditional system. Turner was also right in pointing toa basic logic of Ndembu medicine which is radically different from that of modernmedicine. Modern medicine is concerned with the inanimate world of nature.Ndembu medicine is concerned with personal relations and personal causes ofillness, both of which can be manipulated through the use of symbols. Whereindigenous medicine does provide physical treatment of disease, this is secondaryto the main thrust and logic of the healer's practice.To say that chemical treatment is secondary is not to deny that it is real. Workby Professor Chavunduka and Dr P. Reynolds suggests that physical properties ofdrugs used by traditional healers in Shona society are widely known and utilizedin indigenous healing. Moreover, a number of herbs are invariably mixed in anymedicine. Some healers explicitly test new medicines, often on themselves, beforeadministering them to their patients.Nevertheless, the testing in the traditional system is not as public and welldeveloped as it is in the Western system, with its systematic use of controls andcomplicated statistical tests. It is true that sometimes new drugs are put on to themarket without adequate testing, but such incidents are in breach of the normsthat have been established. In contrast, when a traditional healer dreams up a newmedicine, any testing of this will be simply on his own initiative. The amount oftesting a healer can do on himself is very limited.If we are to look at the logic of a system of knowledge, it is important to lookat the generation and incorporation of new ideas. Old ideas are generally acceptedon authority and learnt in any system: most human knowledge is in facthabitual.36 T-he scientific tradition has developed techniques, which may notalways be properly applied, for testing new ideas and expanding the body ofavailable knowledge: the way in which new ideas are incorporated intoindigenous medical knowledge needs to be examined. Here there is a problem inthat there have been no studies over time to provide data on the incorporation ofnew ideas into the traditional indigenous healing system, although there has beensome recent work on the use of Western medicine by traditional indigenoushealers.37 Nevertheless, the contrasting emphasis on revelations by spirits in36 My argument is more fully expressed in 'Magic, communication and efficacy'. I do not agreewith the characterization of traditional medicine as only habitual, by Ackerknecht, Medicine andEthnology, 156.37 See C. Peltzer, Some Contributions of Traditional Healing towards Psychosocial Health inMalawi'(Frankfurt, Verlag fur Psychologic 1987).M.F.C. BOURDILLON 41dreams on the one side, and on observation and systematic testing on the other,suggests two different cognitive systems.This is not to suggest that the traditional system is inferior because it is notscientific. There are differences between the two systems, but any correctcharacterization of these differences must allow for the advantages andshortcomings of each.TWO TYPES OF EFFICACYIn the healing process, there are two distinct types of efficacy.38 One is theinanimate physical efficacy of chemical or surgical treatment. Secondly, there isthe efficacy of communication, communication to patients and their associates ofappropriate attitudes for the healing process to take place.Communication of factual knowledge (what Sperber calls encyclopaedicknowledge39) is often obscured by the polysemic nature of elaborate symbols,which rarely have a very precise meaning. But the communication of attitudes isenhanced by the use of symbols which often derive their power from repeated usein a variety of contexts, and which have an effect on the psychology of individuals.This second type of efficacy is used in modern medicine in the use of placebos.A combination of the two types is frequently used in modern psychiatrictreatment, and in some other traditions comm unicative treatment is reinforced bythe use of psychoactive drugs.40 But generally in the modern system, medicalpractitioners are aware of which type of efficacy they are trying to manipulate.The testing of drugs and treatments has controls, precisely to enable scientists todistinguish between the two types of effects. And it is clear that, apart from inpsychiatry, it is the physical efficacy of various treatments that is emphasized inmodern medicine.In the indigenous system, some medicines are administered because of theirknown physical properties. Others are chosen because of some symbolicassociation, and their use based on the logic of communication rather than that ofphysical causality. The emphasis on dreams and revelations in indigenousmedicine, together with the ways in which herbs are used, suggests that thistradition pays more attention to symbolic efficacy. Such symbolic usage maycomprise a realistic attempt to control the disposition of the healer's clients; or insome cases it may comprise 'magic', trying to control the material world throughsymbolic associations." The two types of efficacy correspond roughly to the two types of medicine discussed by H.Ngubane, Body and Mind in Zulu Medicine (London, Tavistock, 1977), 109. My suggestion is thatparticular medicines may involve one or other type of efficacy, or both, in different circumstances.39 D. Sperber, Rethinking Symbolism (Cambridge, Cambridge Univ. Press, 1974).40 See D. H. Efron, B. Holmstedt and N. S. Kline (eds.), Ethnopharmacologic Search forPsychoactive Drugs (Washington DC, US Govt. Printing Office, Public Health Service Publication1645, 1967).42 MEDICINES AND SYMBOLSFailure to differentiate between the logic of communication and the logic ofphysical efficacy is a cognitive error, resulting in what can conveniently be calledmagic. The use of symbolic medicines as if they were physical drugs is magic.Turner argues that in Ndembu medicine no attempt is made to distinguishbetween the different types of effects that medicines may have, and that symbolicmedicines are mixed indiscriminately with herbal drugs. Against this one mightargue that, although no explicit distinction is made between the two types ofefficacy, indigenous healers use both types of logic effectively; consequently, thereis no reason to assume that traditional healers are unable to make the distinction,even though the distinction does not appear explicitly in their body of knowledge.Elsewhere, traditional healers are explicitly aware of the two types of medication,although they deliberately confuse the two as far as their patients are concerned,41since their status depends on a certain mystification of their techniques. The fact,however, that the distinction is not explicit in traditional expositions of theirpractice means that errors are likely to occur from time to time.Perhaps the greater confusion is in the minds of academics rather than in thoseof the healers. Perhaps biochemists interested in possible chemically-activeingredients of traditional medicines need to learn something of anthropology inorder to see in what circumstances and combinations the medicines are supposedto work. Indeed, the precise combinations of herbs may be important for anunderstanding of their chemical efficacy.As I mentioned at the beginning of this article, Foucault has argued that theperspective of modern medicine has evolved in response to the situations in whichit is practised. The role of medics as advisers and counsellors increased with thedecline of the standing of priests. An emphasis on environmental factors in health,together with state control of large city hospitals, turned the attention of medicineto diseases rather than to patients, and to what can be seen and examined. Patientsbegan to be taken out of their home environment, and to be treated as cases inhospitals. At the same time the state began to take a greater interest in the trainingand practice of medicine. The emphasis in medicine consequently turned awayfrom invisible forces to the details of what can be seen.42If his insight is correct, we should expect to see indigenous African medicinemoving in a parallel direction as the society in which it is practised changes.People move from rural communities, in which everyone knows everyone andhealers can be chosen according to personal reputations, into large urbanpopulations, in which relationships, including those with healers, are simple andfunctional rather than complex and personal. Accordingly, the impersonal statetakes control over many institutions, including those surrounding health.41 Personal communication from T. Allen, from his recent field research in Ethiopia.42 Foucault, The Birth of the Clinic.M.F.C. BOURDILLON 43Indigenous healers find that they are having to treat patients without havingdetailed knowledge of their social backgrounds. The numbers of patients are suchthat healing becomes a full-time occupation, and 'clinics' are set up for the moreefficient processing of patients. The confidence of the public is furthered bymembership of formal organizations, and perhaps by formal training. The powerof the healers must now depend more on the power of their medicines.Does this turn indigenous medicine into becoming a primitive and inferiorform of modern medicine? One could argue this case, claiming that it remains incommon use largely because it is more accessible in terms of cost, both in training(allowing for a greater number of practitioners charging little for their services)and in the materials it uses. On the other hand social institutions do not changesuddenly and absolutely. There is still much demand for the traditional role of theindigenous healers in the rural areas. The resurgence of alternative medicines inWestern countries shows that Western medicine is unlikely ever to fulfil allpeople's health needs even in industrialized urban areas.CONCLUSIONI have wandered away from my original subject. Where does all this leave thestatus of the indigenous medicines used by traditional practitioners? Let mesummarize my conclusions.There are two kinds of logic involved in healing practice. There is the logic ofcommunication, affecting people's attitudes through symbolic associations; andthere is the logic of physical cause and effect. Both forms are utilized in bothmodern and indigenous medicine, though with very differing emphases.The explicit use of subconscious associations through dreaming, and the totalimmersion of indigenous medicine in indigenous culture, give traditionalpractitioners skills in manipulating social and psychological states with whichmodern practitioners in Africa are unable to compete.Some indigenous African medicines may well have chemically-effectiveingredients which are worth researching. Useful drugs in the past have beenobtained from similar traditions. Nevertheless, academics involved in suchresearch should be aware that many medicines are symbolic rather than physicalin their efficacy. Academics who assume that all herbs, or even the majority ofherbs, are to be treated as equivalent to Western drugs are making the error ofmagic.Although indigenous knowledge includes chemical drugs, the way in whichthe body of indigenous knowledge is built up, and the way in which new ideas areinitially assessed, is more appropriate to symbolic medicines than to chemicaldrugs. In the field of chemical drugs, the modern scientific tradition is clearlysuperior, with its more developed theories of the chemistry of the body, and its44 MEDICINES AND SYMBOLSmore explicit testing techniques (even if they are not always used by thepharmaceutical industry). In this field, indigenous knowledge is rightly sub-ordinated to Western medicine.The question arises as to the possibility of the professionalization ofindigenous practice, at least according to the modern model. It seems likely thatthis can be fully achieved only at the cost of reducing the emphasis oncommunication and the social side of healing. The most effective part ofindigenous healing is hard to teach and examine and control.