Indigenous and biomedical concepts of disease: A complementary approach to HIV/AIDS prevention in Mozambique (AT)
Written by Agnes Raschauer
Text reference: Kotanyi, Sophie (2005): Zur Relevanz indigener Konzepte von Krankheit und Ansteckung für eine wirksamere HIV/Aids-Prävention im soziokulturellen Kontext von Mosambik. (translation: Relevance of Indigenous Concepts of Disease and Contamination in the Socio-cultural Context for an Effective HIV/AIDS Prevention in Mozambique.) Curare Zeitschrift für Ethnomedizin und transkulturelle Psychiatrie, 28:2+3: p247-264.
Introduction: HIV/AIDS prevention’s limited success
In this article focusing on HIV/AIDS prevention in Mozambique and Sub-Saharan Africa, Sophie Kotanyi argues that the limited success of prevention efforts can be attributed to the fact that they rest heavily on a biomedical approach while neglecting indigenous concepts of disease and contamination. In her view, HIV/AIDS needs to be conceived as a sociocultural matter with prevention practices taking into account local ways of viewing the world and forging social relationships. Building on research the author conducted in different regions of Mozambique, she investigates how indigenous concepts and practices might be integrated into HIV/AIDS prevention in order to strengthen its impact.
It is not a new idea that the design of medical practices and social intervention need to embrace a local population’s values, ideas and way of living in order to be accepted by that population. For the practices to resonate, they in some way have to fit with or at least engage with existing beliefs. Yet, HIV/AIDS prevention in Mozambique and Sub-Saharan Africa seldom incorporates local concepts and belief systems into their practices. Starting from this observation Kotanyi sets out to analyse how indigenous concepts of disease may inform HIV/AIDS prevention. She interrogates not only how prevention efforts are being undermined by indigenous concepts, but also how these concepts might facilitate prevention practices.
Biomedical notions of prevention vs. traditional healing concepts?
To date, prevention rests heavily on a biomedical notion of infectious diseases and how they are being transmitted. Biomedicine refers to a vision of medicine prevalent in the Western hemisphere, where health care systems are commonly based on this approach. According to a biomedical model, knowledge of health and disease is gained through natural sciences and scientific practices, stressing the importance of biological processes treating bodily conditions understood as diseases. It is linked to specific assumptions about what constitutes health / a healthy body and which factors are deemed relevant for diagnosis and cure. While physical and biochemical processes are given priority, social context and individual experiences are largely neglected.
Traditional healing concepts on the other hand are based on the specifics of local culture. They emerge from beliefs, historical practices and modes of social organisation. Commonly, they follow a holistic approach – fundamentally different from the practice of categorising within biomedicine. “Traditional” means that ideas and concepts have been passed down from previous generations, mostly in an oral fashion. Thus, traditional healing concepts are not fixed, but change over time, in the course of being passed down from one generation to another, but also in the course of on-going social practice. In this way, they are not old, obsolete practices, but ideas that have descended and are moulded to current life.
Kotanyi argues that there is a general lack of cooperation between biomedical experts and experts of indigenous medicine in Mozambique and many countries in Sub-Saharan Africa. Traditional medicine had been criminalised in Mozambique in the past, which is no longer the case now. Yet state authorities remain hesitant to accept traditional healing as a medical practice. According to the author, it is generally not the traditional healers who resist cooperation, but representatives of the state, who expect the healers to dissent rather than engage with them. Concepts of health, disease and healing are tied to questions of power.
In some African countries efforts have been made to include traditional healers in prevention measures. Yet the attempts produced little success, since members of the biomedical system or state actors tried to incorporate indigenous methods of healing by trying to fit them into the biomedical model. Thereby, they were secondary to the rationale of biomedical prevention and their specific character was lost.
Kotanyi proposed a complementary approach to HIV/AIDS prevention instead. Based on George Devereux’ concept of complementarity (1972) indigenous and biomedical explanations are viewed as two different dimensions of the phenomenon of health / disease, each following a distinct rationality. Notwithstanding the fact that patients can hold on to biomedical ideas, they can hold on to indigenous ideas at the same time. Approaching these two models in a complementary way means assessing each according to its own logic and not from the standpoint of the respective other. Held to the standards of biomedicine, indigenous concepts will always seem deficient and vice versa. According to the concept of complementarity, both approaches shall be explored in keeping with their own rationale. Since biomedicine and indigenous concepts aim at different things, they are not to be fused, but can supplement each other.
In this way, both approaches shall be paralleled, since each is able to shed light on specific elements of HIV/AIDS prevention. Paralleling biomedicine and indigenous concepts help to arrive at a fuller, more nuanced picture. As a consequence, prevention strategies that are developed based on a complementary approach might prove better suited for the local contexts they are targeting.
For example, using healing plants is an element of indigenous healing practices. Being treated with healing plants can aid a patient with many HIV/AIDS related symptoms, such as herpes, loss of appetite or diarrhoea. Moreover, ritual procedures which are associated with healing practices might produce further beneficial effects. These treatments can happen complementary to biomedical procedures. In the best case, traditional healers and biomedical experts communicate and agree on a course of action so as to maximise beneficial effects and avoid negative interactions.
Disease and healing in Mozambique and Sub-Saharan Africa are largely infused by indigenous medical concepts. Only a small proportion of the peoples in Sub-Saharan Africa adhere to the notion that disease is caused by biological processes. Most aetiologies prioritise social reasons. These aetiologies play a vital part in how locals deal with HIV/AIDS prevention measures.
Within indigenous healing the meaning of a disease is key. In order to uncover this meaning, one has to assess when, where and why an ailment came about. Disease is usually interpreted as a disorder in the sick person’s social relations – either between the living and the dead or among the living. The analysis of disease aims at reconstructing the sick person’s social relationships to find the reason for sickness within these relationships. Among the indigenous concepts Kotanyi researched, there are four main causes for disease: 1) ancestors (deceased), 2) ghosts, 3) witchcraft and 4) disease that was sent from God or happened “just so”. According to the author, each explanation can be relevant for HIV/AIDS prevention. In the following remarks we will focus first on the example of ancestors (deceased) and then on the example of witchcraft to discuss how these concepts might be paralleled with biomedical prevention practices.
Disease befalls when one’s relationship with dead ancestors is disrupted; harmony between the living and the dead being key for happiness and health. The relationship can be disrupted, if the bereaved do not adequately perform the important burial and bereaving rituals. Disease might also be attributed to ancestors when the breaking of a taboo is suspected. For example, after losing a spouse, a widow/widower is expected to conduct traditional purification rituals, since each death brings about a form of social contamination to the bereaved. In order to transform this contaminated state of being, the bereaved need to conduct purification rituals. Not conducting these rituals means breaking a taboo, which is thought to cause disease. Ancestors are also said to react to the breaking of sexual taboos. Since ancestors are considered moral authorities and may influence behaviour, HIV/AIDS prevention should focus on how beliefs surrounding ancestors could serve to benefit prevention strategies.
Another reason why it is important to engage with indigenous concepts of ancestors is that symptoms associated with an HIV/AIDS infection are often times not interpreted as such, but as consequences stemming from breaking a taboo. Combining biomedical expertise with expertise of traditional healers might lead to an earlier identification of HIV infection: symptoms pointing to the breaking of a taboo might also be pointing to HIV/AIDS.
Moreover, some indigenous purification rituals that are to be performed after the passing of a spouse involve a ritual sexual act in order to cleanse the widowed person of social contamination caused by death. From a biomedical standpoint these rituals carry a high risk of spreading HIV/AIDS. In some regions, these rituals are being transformed to minimise the potential of infection, i.e. by abstaining from coitus. If there is no dialogue between experts of indigenous medicine and biomedical experts, people might be faced with having to decide between remaining in a socially contaminated position or engaging in high-risk sexual behaviour.
A second concept that could prove relevant for communicating and devising prevention measures is witchcraft. Witchcraft refers to relations among the living that have taken a negative turn. In Mozambique it encompasses all types of evil thoughts and intentions people have, but also unintentional harmful behaviour, for example caused by envy. Since humans pass on the deadly disease HIV/AIDS to other humans, it can be perceived as result of witchcraft. Kotanyi cites one example of a nurse in Paris, who is originally from Congo, living with HIV. Even though the nurse subscribed to biomedical explanations of HIV/AIDS, it was most important to her to uncover if there were evidence of witchcraft in her family. She did not want to die being considered a witch. Following indigenous concepts, a dead witch is not able to pass from dead person to ancestor, which in turn means not being able to safeguard the living family members. This example not only shows that people may hold on to different types of aetiologies at the same time, which may seem conflicting, but are meaningful to them. It also points to the potential of engaging with concepts of witchcraft for HIV/AIDS prevention. Sick persons will receive much more community support, if they are thought to be a victims of witchcraft and not witches themselves.
Kotanyi argues that it is largely the inconsistency between socially held ideas and beliefs and the rationale of HIV/AIDS prevention that hinders its impact. Especially, since the differences are not being addressed. While HIV/AIDS prevention follows biomedical notions of infection, contamination as it is understood by many people living in Mozambique and Sub-Saharan Africa is a highly social concept.
Conclusion: How HIV/AIDS prevention can benefit from paralleling biomedical and indigenous strategies
In order to arrive at more successful prevention strategies, Kotanyi engaged with indigenous concepts of disease prevalent in Mozambique and Sub-Saharan Africa. Her findings point to the fact that contamination, disease and healing are dimensions of social life, which are not dealt with individually, but by engaging with one’s community and its core beliefs. Thus, prevention needs to systematically involve local communities, communicate in local languages and employ common forms of disseminating information. Brochures, for example, are no adequate way of communicating in highly oral cultures, which put a prime on metaphors, story-telling, song and dance.
Additionally, Kotanyi explains that it makes a lot more sense to address social notions of contamination instead of solely taking into account biological causes for HIV/AIDS infection. Whenever indigenous concepts serve to facilitate infection, they should be discussed with traditional healers, experts on indigenous medicine, and local authorities, in order to adapt them accordingly. Whenever concepts lend themselves to fostering prevention, they should be incorporated into prevention strategies. Thereby, it is important not to subordinate these concepts to biomedical rationale, but to parallel them with existing biomedical prevention strategies.
Thus, people involved in prevention efforts need to engage with indigenous concepts in order to make prevention more effective. By respecting differing aetiologies, HIV/AIDS prevention could increase its impact.