Global Health Policy Toward Traditional Healers: A 21st Century Update

Kathy Oths, author

Kathy Oths, author

Introduction

Much has occurred in the world of traditional medicine since the World Health Organization first appealed for the integration of Bio- and traditional medicines at Alma Ata in 1978. In the interim, while most efforts to include traditional healers’ services in hospitals and clinics foundered on the basis of distrust and unshared epistemology, paradoxically, worldwide interest in ‘alternative’ medicine only continued to grow.

An unfortunate result is that while the prestige of some traditional medicines heightened, and bioprospecting “integrated” traditional knowledge in pursuit of profits, concern about the survival of folk healers themselves subsided. Climate change, poverty, hypermobility, and globalization, among other factors, have led many young persons with healing potential to choose other career paths, or if they do enter healing fields, to choose professional paths that relocate them to urban areas far from the places of greatest need. Thus, one wonders whether folk healers will survive past the next generation, and what role governments and agencies might play in assuring that they do.

Background

The WHO’s Alma Ata Declaration stated “the need for urgent action …to protect and promote the health of all the people of the world.“ Article VII-7 reads: Primary health care relies, at local…levels, on health workers, including physicians, nurses …as well as traditional practitioners as needed, suitably trained socially and technically to work as a health team …”   While the WHO continues to encourage and support traditional healers, these same healers are officially outlawed in some countries, such as Peru, where I work, though there have been efforts to legalize them and standardize their practice (WHO 2001, 2005).

Since Alma Ata

Don Felipe

Don Felipe

Complicating the picture is the rise of “CAM” or “Complementary and Alternative Medicine,” which is a term even scholars find confusing. Is traditional medicine a subset of CAM, or vice versa? Is a practice traditional in its primary cultural context and CAM if it is exported? While there are no easy answers, WHO would agree with the latter (2001). Great Tradition/Professional medicines such as Ayurvedic, Chiropractic, Traditional Chinese Medicine, etc., are larger, well-organized, and better funded than the small folk traditions found in local contexts, such as midwifery, herbalism, shamanism, and bonesetting (Kleinman, 1980), and thus are given more attention by physicians willing to operate holistic, integrated clinics (Keshet & Popper-Giveon 2013), and by WHO and other regulating bodies. Opinions of professional healers carry more weight when policy is shaped. Yet while in Latin America no Great Traditions exist, socialist-leaning governments in several countries have been at the forefront of sincere, respectful efforts to truly integrate traditional practitioners with biomedicine (Peru is not one of these, despite sincere efforts by CENSI). A recent example is Bolivia, where one finds notable efforts to refashion state health care delivery to accommodate traditional medicine in a spirit of interculturalidad (Johnson 2010).

Loss of Traditional Healers

In the late 1980s in Chugurpampa, Peru, a highland hamlet in the northern Andes of La Libertad, morbidity and mortality were low, in no small part due to a plethora of biomedical and traditional healers (Oths 1998). Since then, drastic environmental changes, such as drought, deluge, unseasonable temperatures, and invasive flora & fauna, have substantially reduced agricultural yields. The ensuing diaspora—one third of the population has fled to the coast for survival—has left the region with few healers, as people are subsistence farmers first and healers as a secondary occupation. Young adults do not have the economic nor residential stability to apprentice to existing healers.

pathway model

Bonesetter Conference, Julcan, Peru – 2013

Don Felipe Llaro, 80, is the last remaining healer in Chugurpampa and one of the region’s few bonesetters. (He is also a midwife, herbalist, and soul caller.)

  • A National Committee on Traditional, Alternative and Complementary Medicine operates out of a prestigious medical school in Lima. Its membership includes hundreds of physicians, healers, and others. They regularly hold conferences with much fanfare about reconnecting with their illustrious Incan past.
  • I accepted the Committee’s invitation to lecture about Don Felipe—twice—and given their insistence on meeting Don Felipe, I arranged a small 2-day conference on their behalf. They clamored to meet him and asked that I bring him to Lima, not considerate of the fact that he is elderly, unfamiliar with urban life, and would be outside of the cultural context in which he best functions. Not being an abstract thinker, he shows and teaches only in the act of working on an injured client.
  • In 2013 we hosted an “intercultural” conference in the rural highland Hospital of Julcan, the district capital near Chugurpampa, to showcase his talents and to promote apprenticeship to him while he still can teach. It was a success, drawing doctors, academics, healers, and others from around Peru, as well as local injured peasants who came for the free treatment they would get as demonstration patients. However, while a dozen D.s from Lima registered, in the end not a single one showed up. (Free room and board was provided to all.)
  • We achieved our goals—honor Don Felipe, re-acquaint local medical personnel with his practice, film the event, and identify an apprentice – his own granddaughter. However, who ultimately chose to attend the event, as opposed to who did not, speaks volumes.

    Treating a woman with a back injury from being thrown from her horse.

    Treating a woman with a back injury from being thrown from her horse.

Upshot

Romanticized notions of a glorious medical heritage collide with the reality of the healers—usually impoverished—who struggle to carry on their traditions. If the self-professed M.D. salvagers of traditional medicine are of no utility, the task of preserving traditional knowledge becomes that much harder. Bolivia’s WHO-assisted government initiatives to privilege traditional medicine in its state-run health care system, while not entirely successful—and with opposition from biomedicine and USAID-–provide an illustration of potential new approaches. Treating folk knowledge as valuable though folk healers as dispensable is not a viable long term strategy.

The Last Bonesetter, an ethnographic film of Don Felipe and the conference, will be shown at SfAA in Vancouver in March and at other future venues.


Biocultural Systematics is written by members of the University of Alabama Biocultural Medical Anthropology program. Kathy Oths, a professor in the department, has worked in the highlands of Peru off and on for over 30 years.

An Epidemiologic Anthropology: Considerations when Employing Mixed Methods

Anthropology versus Epidemiology

Author, Kathryn Oths
Author, Kathryn Oths

Anthropologists and epidemiologists have contributed vital knowledge to understanding public health problems such as low birth weight, reemerging disease, mental health, and more. Lively and enduring dialogue on the potential for collaboration between the disciplines was sparked in the ‘80s by Janes et al.’s (1986) Anthropology and Epidemiology and True’s (1990) chapter “Epidemiology and medical anthropology.”  The discourse continues to the present, well-summarized in the works of Dein and Bhui (2013), Hersch-Martínez (2013), Inhorn (1995), and Trostle (2005).

In contrast to early literature, later writing—from both camps—implies that what anthropology most offers epidemiology is its qualitative sensibility (e.g., Ragone and Willis 2000; Scammell 2010). While clearly one of anthropology’s great strengths, sensitivity to qualitative dimensions is not all we have to offer. Rigorous, contextualized mixed-methodology is more likely to be persuasive to other disciplines than mere entrained awareness (Prussing 2014). In fact, by incorporating epi techniques into anthropological designs, we can employ a holistic paradigm on our own—what Inhorn calls synthetic or wearing both hats. (The reverse, training health professionals in anthropology, has also been suggested [O’Mara et al. 2015]).

Kathy's epi anth model
Kathryn’s Epi Anth Model

Anthropological orientations in health research might be glossed as follows: Anthropologists of Suffering record the pain and distress of a people, striving to understand meaning surrounding health problems. Anthropologists of Sickness, in addition to searching for meaning, use structured surveys emerging from ethnographic observation to systematically ferret out factors contributing to dis-ease and illness. The first approach interrogates the meaning of critical life events, while the second investigates how socially and culturally constructed meanings themselves shape risk of morbidity and mortality. As Trostle and Sommerfeld (1996) state, “data can be used to create emotional responses in the reader, or to explain relationships.” Both approaches are vital and mutually enhancing, but less has been written about the latter.

For example, most anthropologists of reproduction interpret the clinical interactions that oppress and mystify women’s knowledge and autonomy, as well as women’s resistance to these controlling forces. They study the technologizing of natural processes and the hegemony of biomedical over self-knowledge. This research is an important corrective to years of neglect of reproductive work (Rapp 2001). The focus of others, including myself, has been more outcome-driven, a systematic explanatory study of the conditions not of clinical but rather daily lifelike workplace organization and intimate relationshipsthat shape women and babies’ health (Oths et al. 2001; Dunn & Oths 2004).

A Word on Publishing

While epidemiology and anthropology share the common goal of improving human health, each field has its own prerogatives. Those who blend qualitative and quantitative methods in the pursuit of an Epidemiological Anthropology of Sickness may face problems getting published in the public health literature. I’ll make three points regarding disciplinary differences of opinion on the accurate specification of analytic models:

   1. Anthropological methods are not self-explanatory. 

Anthropological methods essential to getting results are detailed, iterative, and not necessarily self-explanatory. However, there is no space to discuss these vital tools in standard public health journal articles. Be forewarned: Public health expects very brief methods sections!

   2. What’s reliable to others may not be valid to us.

Other fields are more strict than ours in insisting that survey items be tested for reliability before use. Reliability, or insuring that an instrument gives the same results with repeated use, is a good thing. However, a scale, once published, should not be changed. (A survey instrument you construct yourself? Even more suspect.) Yet without local contextualization, an instrument’s validityactually measuring what said instrument claims to measure—may be compromised. This is a constant issue when we employ scales that have been normed to populations other than the one we will survey. For epidemiologists, patterns of association are of greater concern than measurement issues. Categories they work with are believed to be fixed in nature, race being a prime example. For us, they are anything but fixed. Anthropologists insist on emic construct validity of categories—categories should make sense in the cultures we’re measuring them in. Rule of thumb: Take care of validity, and reliability will follow.

Rule of thumb: Take care of the validity, and reliability will follow.

   3. We lack authority to critique normative methods.

Some journals, such as American Journal of Public Health (AJPH), recommend use of specific statistics, such as logistic rather than ordinary least squares regression. They insist every dependent outcome variable be broken into two discrete categories instead of having the generally continuous, tough-to-define, but more precise character of real life. However, they don’t insist on power analyses, which determine if a given study’s sample size is sufficient to make a statistical test valid.  An example from my birth weight study illustrates this: None of six previous studies using a model developed by Karasek found a direct association between job strain and birth outcomes. Four had low power for their logistic regression, which may have resulted in undetected effects. And instead of using the full range of values—500 to 4500 grams for birth weight—logistic regression uses only ‘low’ or ‘normal’ as outcomes, which results in a loss of variability and, thus, information. We would’ve needed twice the sample size in our study to achieve sufficient power using logistic regression. When my colleagues and I demonstrated that least squares regression detects an effect while logistic regression does not, the editor of AJPH was not impressed.

Why the one model fits all assumption regardless of whether it’s the best one? It fits with naturalized categories, like disease and race, which are seen as binary oppositions: yes/no, black/white.  This implicit model of the world is simply too rigid for anthropological sensibilities (Dressler, Oths, and Gravlee 2005). Newsflash: The world isn’t always best modeled by dichotomies.

In summary, when we strive to measure more accurately, we may meet with resistance from the gatekeepers of public health journals. Perhaps my outline of some common pitfalls of writing for an interdisciplinary audience will help reduce the frustration of others who attempt the same.

This was originally posted in Anthropology News‘ August 2015 “Knowledge Exchange.”

A New Look at an Old Method: Ethnography as Essential to Good Work, or How Doing Should Start with Being

The inaugural meeting of the University of Alabama Department of Anthropology Journal Club was held Friday January 18th at 2:00 p.m. Attendees were grad students Tina Thomas, Becky Read-Wahidi, Anjelica Callery, Achsah Dorsey, and Greg Batchelder; undergrads Brittany Brooks, Samantha Sloan, and professors Kathryn Oths, Dick Diehl, and Ian Brown.

With me (Kathy Oths) moderating, a lively discussion ensued regarding a recent piece in Social Science and Medicine (SSM), On sitting and doing: Ethnography as action in global health by Stacy Pigg [99:27-134(2013)], the previous editor of Medical Anthropology. She relates scenes from her fieldwork among International Health (now Global Health) and NGO personnel who were attempting to introduce HIV/AIDS prevention education in Nepal in the late 1990s. As she sat and listened ‘between the cracks’, it emerged that a word-play exercise that encouraged participants to shout out ‘sex’ words was antithetical to a Nepalese aversion to discussing sex (much less with strangers!). While the health workers realized this, they felt obligated to carry out the mandates of the program’s international funders. A classic case of vertical programming. Or, since it ‘worked’ (really?) in Uganda, it should work everywhere. By means of much listening and many intense discussions with perceptive nationals, Pigg adroitly led her colleagues in developing a slightly altered exercise that used word about sexual relations instead of sex. Aid workers were thrilled, and across several months met and pre-tested the new exercise. It was a smashing success with the intended audience, and they self-published educational brochures using the concept, yet the higher up administrators were too wedded to the received wisdom of the international programs to pay any heed. While the revised exercise failed to be implemented, it succeeded in identifying a better way to reach a population. Many years later, Nepalese health workers were still talking about the wisdom of their strategy.

Somewhat surprisingly, SSM devoted an entire issue to ethnography, a topic that seldom receives attention anymore—especially in the medical social sciences literature—perhaps because it seems the method is uncomplicated and all that needs to be said about it has already been. I chose the Pigg article for its reminder that all good scientific work starts with reflection, observation, listening, being, mindfulness–the lesson being, “just sit there, don’t do anything (at least to start with).” The insight and hypothesis-generation that sitting and listening can engender is qualitative, and at one and the same time the crucial first stage of any systematic, scientific endeavor. I am concerned that mixed-method training in biocultural medical anthropology, while the best and most comprehensive approach (IOHO here at UA), can tend to focus on the clearly essential ‘hard stuff’—statistics, computer programs (such as SPSS, Anthropac, GIS, ATLAS.ti, UCINET…), lab analysis, measurement tools (anthropometry, cortisol, blood pressure….) and sometimes slight the ‘soft stuff’ like participant-observation, leaving it to chance. This emphasis is entirely understandable, as most of the complex tools are best learned in a classroom setting, whereas the art of fieldwork seems more idiosyncratic. This division in training is not at all unlike the case with medical education, where technological competence wins out over the art of care, even though both are vital to effective therapy (see Good and Good “Learning Medicine” in Knowledge, Power, and Practice, 1993).

I also noted that Pigg’s zen-like approach generalizes to all the anthropological work we do, such as data collection and writing (and as Dr. B noted, to everything we do in life, really). It is essential when doing ethnography to drop one’s expectations of what is the ‘right’ answer. We can unconsciously convince ourselves beforehand what it is we will ‘hear’ from an attachment to our hypothesis, e.g., we could subtly be thinking “because a girl is rural, has a single mom, goes to a poor high school, therefore…” and be expectant of a response before it emerges, thus causing us to filter what the girl really is saying. The article resonated with Tina’s dissertation fieldwork experiences. She noted that the African-American girls she is studying in Tuscaloosa regarding their perception of HIV risk “take me to places with their comments” and bring up unexpected connections, such as the 2011 tornado. Tina cautioned that “we can lose context if we focus too narrowly.” Becky notes that we should be keenly aware of “what are our goals versus those of our informants.” From Achsah’s reading of the text, she perceived that “aid workers accept that the answers will be different from one culture group to another, but maybe not that the way to ask needs to be different also,” that one needs to re-do the whole process. Dr. B, an archaeologist, could easily generalize the article’s lesson to his cemeteries class in which on the first day he has his students “just walk around and observe” to soak it all in and generate ideas. Invariably, the student who immediately starts writing does not do well and becomes frustrated, as they focus too intently on the details to see the larger patterns. Greg was impressed and grateful that the author had written about the importance of ethnography. “By doing ethnography, we can focus on ‘insider meanings’ instead of imposing our agendas and ‘mining’ for data which supports our hypotheses. Through ethnography, we allow ourselves to be open and attend to aspects of culture which we may not have been prepared for or looking for.” For further reading Greg recommended Writing Ethnographic Fieldnotes, by Robert M. Emerson et al., to which Kathy added Learning How to Ask, by Charles Briggs

A special thanks to Tina Thomas for organizing the series, and to Sarah Szurek (PhD Alabama), Post-Doc at the University of Florida, for providing us a model of how the UF journal club functions. We’re looking forward to the next meeting!