The importance of knowing about not knowing

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<ul><li>OlbQ-7987 XI 030387.06S02000 c'opyr,gh, </li><li><p>388 MURRAY LAST </p><p>recorded in ethnographies: their purpose was. natur- ally enough. to explain a s~wzm or medicine and to unravel the complexities of know/edge--and in the past no doubt systems were really systems. So 1 will rely instead on my own data which 1 offer here merely as an example: for. let me repeat. I am acutely aware how presumptuous this excursion into not-knowing is. It would be difficult enough even in ones own medical culture, let alone in another peoples, </p><p>Lastly, I am using the term medical culture for all things medical that go on within a particular geo- graphical area. It is consequently a wider term than medical system. as will become clear from the example that follows. </p><p>EXAMPLE: THE MEDICAL CULTURE OF </p><p>THE MLUMFASHI AREA </p><p>Malumfashi (Kaduna State. Nigeria) is by Hausa standards a medium-sized district headquarters which in the 1963 census had a population of 17,ooO; the districts population was 177.ooO. A strongly Muslim. Hausa town. it nonetheless had a Christian immigrant population from more southerly states of Nigeria and a scattered pagan Hausa or Maguzawa population in the surrounding countryside. I came to Malumfashi in 1969, after some 6 years of historical research else- where in Hausaland, in order specifically to study Hausa medicine. My three years of research were completed before large-scale studies by the Medical Research Council and the World Bank-financed Fun- tua Agricultural Development Project got under way. Most of my research was conducted from a Magu- zawa house 15 miles from Malumfashi. but only after an intensive survey of a Muslim village and a hamlet had been carried out. My data are best. therefore. for the most traditional end of the spectrum that makes up Malumfashis medical culture. </p><p>At one end of the spectrum of medical practice is the set of treatments deriving from Western or hospi- tal medicine. A branch of Ahmadu Belle Universitys teaching hospital is located on the outskirts of Malumfashi town: so too, are or were Protestant and Catholic mission dispensaries. Government dispen- saries and leprosy clinics operate too in the area. as do. at a much more informal level. peddlers of pills, liniments and even injections. Though conventionally one describes hospital medicine as a coherent system and the hospital as a single homogeneous unit. in reality. the hospital is staffed by people of widely dif- ferent cultural and linguistic backgrounds and of varied technical competence: yet all these, in their private capacity, represent hospital medicine and may give advice or procure treatment after their own man- ncr. </p><p>At the other end of the spectrum is the enormous variety of treatments that is included under the label traditional. The variety reflects not only the diversity within the culture of the dominant Hausa group, but also the large immigrant population some of whom even import folk culture (for example, rosiscrucian ideas) from abroad. Between these two ends of the spectrum is Islamic medicine. relatively strongly syste- matised but which overlaps, in its herbal specifics with Western medicine, and in its concern for spirits </p><p>or jinn, with traditional cures. The core of its treat- ments is based on the use of Arabic texts, and its practitioners are expected to be Islamic scholars or students and to work within an Islamically orthodox framework. Government and universities, though pro- viding education in Islamic studies. do not speciticallq include Islamic medicine. but much of what is taught is relevant to it: furthermore, the texts of Islamic medicine in Arabic are widely available. </p><p>The historical antecedents of this medical culture are broadly as follows. During the 19th century the area became de-populated so that Malumfashi town was only re-settled less than 100 years ago. A large proportion of the present population migrated yn from adjacent areas between 1890 and 1930 and still retain something of a frontier atmosphere there. Though the early 19th century Islamic reform move- ment was the source of the local political and ideolo- gical framework which governed the new frontier community. the communitys territorial expansion was possible only under colonial rule. The carlq period (c. 1903- 1940) of colonial government also wit- nessed the burgeoning of a more strict Islamic culture throughout Hausaland. in part as a response to colo- nialism; by contrast the impact of Western culture. and Western medicine in particular. was slight. Only in the later colonial period (c. 1945 1960) and during the decade since independence, has modern medicmc become part of the areas medical culture; along with dispensaries there also came schools and all that better roads brings. The degree to which Western medicine was associated with colonialism (as. for example, in the manner described by FrantL Fanon in A Dying Colortitrlisr,l [Z]) is not clear: certamly an unflattering folklore exists. Much more important hih- torically. how,ever, has been the role of I&amp;m 111 colonising the medical culture of the area. Hy according non-Muslims an inferior status polit~callq and culturally. Islam has undermined rhe authority of traditional medicine. Maguzawa. though dicerse and often Muslim in origin. now form part of ;L rural lower class and are treated almost as a paruh group for whom the peddling of traditional pagan ritual \cr- vices is seen as an appropriate part-time occupation. Since other aspects of non-Muslim Hausa culture have been of less interest to the rest of the com- munity, many of the traditional social ceremonls\ such as initiaiion and even weddings have been \horn of particular elements or gradually altered thclr \~g- nificancc. However. the formal continuation of non- Muslim culture has been necessary in or&amp;l- to \~II- date some of the rituals of traditional medicine for the rest of the community. and. if for no other reason. the specifically non-Muslim aspect of this segment of society still persists. MeanwhIle Islamic rnedlclne. faced with the recent extension of hospital medicine to the area, has become predominantly the mcdicmr for social ills. preventing or curing unpopularlr!. warding off financial disaster. It still olltxs it UI~C range of specifics. especially for ailments that hospl- tals do not cure. but it faces consldcrablc compctltlc&gt;n in this from patent remedies of a modermsmg kind. </p><p>In short, the sequence of dominant medical slstcms within this medical culture is: </p><p>(a) A putative traditional Hauw medlcinc no\\ </p></li><li><p>The importance of knowmg about not knowing 389 </p><p>maintained, probably in a much altered form, mainly by Maguzawa [3]. </p><p>(b) An Islamic medicine which was particularly strong during the early colonial period. </p><p>(c) Hospital medicine, important in the late colonial period but now freed from its association with colo- nialism and financed by government. </p><p>HOW FAR IS TRADITIONAL MEDICINE </p><p>IN MALUMFASHI STILL A </p><p>SYSTEM? </p><p>The criteria I wish to use in assessing how far a method of medical practice is systematised or is seen by either its practitioners or its patients as a system are as follows. The top end of the scale would be occupied by a system in which: </p><p>(a) There exists a group of practitioners all of whom clearly adhere to a common. consistent body of theory and base their practice on a logic deriving from that theory. </p><p>(b) Patients recognise the existence of such a group of practitioners and such a consistent body of theory and, while they may not be able to give an account of the theory, they accept its logic as valid. </p><p>(c) The theory is held to explain and treat most illnesses that people experience. </p><p>Applying these criteria to traditional medicine in the Malumfashi area. we find: first. traditional healers form a category in M. G. Smiths terms, rather than a corporate group [4]. They have no association, no exams, no standard treatment. Indeed they compete with one another. using different curative techniques. There is in consequence no local doctor accepted by all the community and as choice of practitioner is also governed as much by kinship links as by medical reputation or convenience, a more distant healer is often consulted before the neighbourhood expert. </p><p>The various Hausa terms used, boku, mai mugoni, mai Danko (or mui BaGwri, etc.), Sarkin Mu~yu do not denote either a hierarchy of skill or an area of medical specialisation- -though they might provide a clue to the healers sex or ethnic background [S]. Tht distinction between. say, herbal remedies (from a boka) and spirit possession rituals (from a mui Dunko) is spurious, since both a hoku and a mui Danka will use both kinds of treatment. </p><p>The technicians of traditional medicine-the bar- ber- surgeon (wunzumi), the bone-setter (mudori), the midwife (unyo~omut~form a separate group; they are treated more as professionals and tend, in any case, to be Muslims. Only the first. the barber-surgeon, is for- mally recognised as a craft, with the local expert appointed as Master-Barber (Sarkin Aska or Magajin Asku) and is thus in effect licensed (e.g. to do circum- cisions). The other two professionals render strictly limited services, but nonetheless vary widely in the details of their techniques. They are not required to diagnose illnesses since they are called in only to per- form their specialised duties. </p><p>By contrast the traditional healer not only has to diagnose but also may be called upon to render a range of services like fortune-telling, supplying poison. guarding or otherwise coping with wandering </p><p>lunatics. In practical medicine, his main rivals are the individuals, to be found in almost every house, who have inherited some specific nostrum (for example, against the pain of scorpion bites), or amateur practi- tioners of spirit possession. But major problems. like mental illness, are not amenable to do-it-yourself home remedies and these. along with residual cases of medical catastrophes, are apt to end in the care of the hoku. </p><p>Nevertheless a proportion of all traditidnal healers have to take to the road and peddle their skills often among foreign communities such as the Yoruba; similarly healers from the Niger Republic tour the Malumfashi area. The value of their remedies lies in their very strangeness, in their not being part of a known system of medicine. </p><p>In short, the range of traditional healers that serve the Malumfashi area cannot be said to adhere to a single consistent theory of logic-except insofar as they are defined negatively, as not offering hospital or Islamic medicine. Nor, since traditional medicine is too diffuse to be monopolised, do healers form an exclusive group. </p><p>Second, patients and their kin do not expect their traditional doctors to have a consistent theory or form a cohesive group. Instead, they accept that the different systems and methods of medicine have only a limited validity, though people do treat traditional medicine also as a residual category, when other methods seem too dangerous or simply inadequate. This is best illustrated by a folk theory of ethno- ecology which. given the social component in illness, has considerable sociological insight. According to this theory. each ethnic community carries within itself not only its own specific illnesses but also its own cures. Thus European medicine was necessary originally only for Europeans. then later for those who have to operate in European society; now. finally. as modern medicine it has the best cures for modern illnesses caught in modern society. Similarly, Muslim medicine. though much less sinister (and less powerful). is nonetheless essential for those who have to visit or work in a Muslim community, while non- Muslim medicine can cure, for all members of the community, not just the ailments caught deep in the bush but also aberrant throw-backs like lunacy or a sinister malformation. Fulani pastoralists (who share the deep bush with Maguzawa) also have their own ailments and cures; but both groups tend to treat each others patients for some illnesses, thus transfer- ring to the other group not only the patient but also some of the blame for the illness existence. </p><p>In this ethno-ecological theory, then, medicine is being seen not so much as a medical system but as part of the necessary cultural camouflage. like clothing and food. that enables one to survive. prefer- ably unnoticed, in a diverse society. There are not alternative treatments, only appropriate ones- appropriate. that is, to the place where one happens to be. </p><p>But the theory is more complicated in practice, and has been modified over time. For example. hospitals are now recognised as at least temporarily effective against traditional illnesses, since hospitals. so care- fully fenced off and manned with guards, are no-go areas for spirits; relapses may occur, though, as soon </p></li><li><p>390 MURRAY LAST </p><p>as one leaves the gates. On the other hand, and par- ticularly in the past, one needed ones own medicine as well in order to survive a stay in a hospital-since hospitals are places of extreme danger (being one of the sources whence Europeans derived their magical power and domination over the local community), and one has to be protected from the doctors too. Implicit here is the recognition that the medical and geographical sphere in which traditional medicine is relevant is liable to shrink, and indeed has shrunk in recent times. Certain classes of spirits, for example. have died out, while other spirit-linked illnesses are confined now only to women. In short, one of the fundamental premises of traditional medicine--that spirits control illness--seems to be giving way, and if the present trend continues, only the herbal aspect of traditional medicine will survive while spirits become for some mere figures of the theatre. </p><p>Third, from what has already been said, for tra- ditional medicine to have a single comprehensive theory to account for all illness is out of the question. But it seems that even a coherent set of ideas. embed- ded in the language or implicit in peoples actions, has now disappeared. Fragments of a theory, with associ- ated medical facts, seem to survive, but it also seems impossible to make a proper historical reconstruction for any particular period, place or people; in the theorys break-up, the fragments and the facts have themselves been altered beyond the recall of mens memories. The most striking evidence for the diffi- culty in prising a coherent theory out of the language is the lack of an agreed medical vocabulary not only among patients but also among practitioners. In try- ing to construct a Hausa medical dictionary I found what several others before me have found--as a com- parison of all our vocabularies shows--that a large proportion of medical words (but especially terms for illnesses) have no standard meaning. The Ministry of Health issued a list of terms which are gradually gain- ing acceptance but so far they remain officialese and patients in the know...</p></li></ul>