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an extended case from the Zambian Nkoya

[ part 2 ]

Wim van Binsbergen



Let us first consider the role of cosmopolitan health agencies.

      Both at the beginning and at the end of my account of Edward's infancy stands the Lusaka University Teaching Hospital: in between, the protagonists move to and for between various other cosmopolitan health agencies and Nkoya Alternatives. When and why, therefore, do people utilize cosmopolitan health agencies?

      Obviously, accessibility is a first condition for such utilization. In the urban situation (cf. Shattock n.d.), urban clinics tend to be within walking distance from the homes of the majority of the population. With the exception of private doctors, Zambian cosmopolitan health agencies have become non-fee-paying in the late 1960s. Therefore, the main determinant of accessibility now lies in the time factor (cf. Zeller 1974). Limitations of staffing and equipment usually cause long waiting hours, which form such a common and perennial feature of cosmopolitan medicine in Africa that patients are prepared to accept them - provided no third party is making an urgent demand on their time. In many cases however there is such a third party: children waiting to be fed at home, an employer anxious for his employee's return to work, one's own business that needs attention, etc. Should the urban clinic refer one to the central hospital, not only a further loss of waiting time is involved, but also the distance to be discovered often requires use of public transport, which means further expense of time and money. Among the urban poor, lack of transport money often means that a visit to hospital has to be postponed.

      In the rural areas the access factor weighs much more heavily.30 Here a visit to a rural health centre or hospital usually involves travelling over considerable distances. In Chief Kahare's area, motor transport is very seldom available. The long journey and the long waiting hours frequently necessitate an absence of several days, which many people cannot afford (particularly young women, who under the tight control of their senior consanguinean or affinal kin carry the lion's share of domestic and agricultural tasks). Such prolonged absences require that one carries blankets, food and kitchen utensils on the journey, money does not affect sleeping arrangements has money to buy food on the way. As a result, rural utilization of cosmopolitan health services falls steeply with increasing distance, and on the longer distances (exceeding 10-20 km) tends to show a bias against those who are particularly busy, poor or junior.

      In Edward's case, the Lusaka data do not suggest that the accessibility factor is very important in the urban environment. Mary remained on the outside of cosmopolitan medicine, irregularly went for antenatal care, gave birth at home, and did not attend the under-five clinic31 (except when Edward was obviously ill) - not for reasons of access, time or money. However, in the rural data the effect of these factors was demonstrated by the fact that, while visiting the distant Rural Health Centre (and a fortiori the even more distant hospitals) was a major decision, and one which people would not take except in very serious cases (when it was often too late), they would daily flock in considerable numbers to our improvised bush clinic. Even at our clinic the impact of distance made itself felt. Our patients were mainly from Mema valley, where Chief Kahare's capital is located. Even from the adjacent Mushindi valley, where e.g. Nyamayowe village is located, markedly fewer patients would come: and those who did come would tend to have more serious complaints. It proved impossible to have Edward brought in daily for eye treatment, across a distance of less than one hour of cycling. Considerations of accessibility also form an obvious explanation for the common phenomenon of black-market medicine (cf. Patrick's death) - although we shall find additional explanations when discussing the health role of the elders.

      While largely economic factors underlie the effect of accessibility, time and money, Edward's case clearly brings out the role of non-economic factors. In the literature these are often discussed in terms of local, culturally shared modes of conceptualizing health and disease. Authors in this connection often speak of the force of 'tradition' and the persistence of 'traditional' medicine, as if that would explain anything.32

      As we have seen, the same person (Mary) may in the course of a short period repeatedly shift between cosmopolitan and Nkoya health agencies; yet her ideas on health and disease remained the same, throughout the process. why was Edward dragged to and for between the various outlets of cosmopolitan medicine, and a variety of local alternatives such as ancestral ritual, cults of affliction, diviners, etc.? Why did Mary achieve overnight mastery in hygienic bottle-feeding, yet allowed Edward to go through a musical chairs of Nkoya treatments, which by delaying effective clinical action nearly cost him his life? The health concepts in her mind are not likely to explain the variability of her actions - except perhaps for this one notion, so fundamental in Nkoya social structure, that potential support and remedy is never limited to one exclusive source, and that one may safely look for alternatives if one way is blocked. But given the options present in Edward's health situation, what principles governed that certain options were finally taken, and others were not?

      The typical Third World medical situation today is that of a person surrounded by various alternative health agencies, all off them in principle accessible (albeit not at equal costs). Given this situation, the data suggest that such a person's actual pattern of utilization will to a considerable extent result from the social process in which he is involved in his immediate social environment. In the years covered by my data, Muchati and Mary (and by consequence their child Edward) did not significantly change their class position, level of income, educational status, etc. All these individual attributes which surveys have tried to link up with health agency utilization, here remained constant, and for that reason are incapable of explaining the variation in Muchati's and Mary's health activities. But what did undergo perceptible and significant changes was the pattern of crucial relationships by which each of them was surrounded. It is in the evolution of these relationships that their health choices become understandable.

      In these relationships, a number of major spheres can be identified:

a. Formal-sector employment

One such sphere was the relationship of Muchati's family with the families of his employers (not just us). Here Muchati was thoroughly exposed to cosmopolitan health concepts, and obliged to apply them at least in his professional work as a domestic servant. He could enhance his employment security by pleasing his employers. The latter would expect him to observe basic hygiene, and would normally make a visit to a cosmopolitan medical agent a condition for sick leave. Moreover, expatriate members of the Zambian elite has become a reference group for him; he would attempt to selectively adopt their life-style. Largely for these reasons Muchati absorbed modern hygiene and applied them in his personal life. As is repeatedly demonstrated in Edward's case, this made Muchati a strong advocate of cosmopolitan medicine. He struggled to have Mary attend the urban clinics and to have Edward born in hospital; he supervised Mary's bottle-feeding; upon departure from the village he left money for visits to the rural cosmopolitan health agencies, etc. At our bush clinic, in his greatly enhanced status of research assistant, Muchati would often take the initiative of lecturing the women and youth on elementary hygiene (use of boiled water for drinking, etc.).

      However, the impact of formal-sector employment was set off against that of other social spheres, in shaping the health actions of Muchati's family.

b. Elders

While living in town, Muchati's and Mary's frequent interaction with fellow-Nkoya meant a continuous confrontation between Nkoya medicine and cosmopolitan medicine. Nkoya medicine, in this context, was not offered in the form of advice that one could either take or leave. Rather, the idiom of illness and healing provided a major context to shape interpersonal relations within this ethnic group. propounding advice in health matters, dreaming up new therapies for sick kinsmen, dispensing herbal medicine and other therapies forms an integral and central part of dealings between kinsmen and between tribesmen among the Nkoya, in town as well in the village. Seniority and authority imply protection and care, and the most common form in which these are offered is a medical one. Most Nkoya adults over forty years of age claim specialist knowledge of certain aspects of local medicine. It is no exaggeration to claim that, today, health action is the Nkoya elders' main task. At the same time it is also their major prerogative, by which they assert their authority over their junior relatives and tribesmen at large. This is particularly the case with the village headman. Therefore a headman's failure to protect his village from illness, death and sorcery is a terrible shortcoming, which will greatly lessen his authority in local-political and judicial matters. On a less exalted scale, the relationship between parents and children, and even that between husband and wife, calls for explicit health intervention from the dominant party.

      In the past, the medical dimension of the elders' role among the Nkoya was accompanied by very considerable power in the marital, political and economic domain. Together, these aspects made for a marked dominance of the old over the young. Now that political incorporation of the national state and the penetration of capitalism, have largely destroyed the elders; political and economic power, mainly two domains have survived in which the elders can expropriate the products of the labor of their juniors: affinal relationships, and health action. In the field of affinal relationships, recent decades have seen the evolution of marital payments from trade goods or labor (bride services), to high and standardized monetary bride-prices in the order of magnitude of K80, i.e. what an unskilled laborer, if he manages to secure employment, can earn (not: save) in about three months.33 In general it is the juniors who pay and the elders who receive these payments. Thus a major inter-generational flow of town-earned cash is maintained. In the domain of health action, the elders' medical services not only drive home the juniors' fundamental dependence on the elders no matter how economically independent the former may have become such health action invariably also involves the transfer of money from the young to the old (and/or from men to women). In the case of cults of affliction, fees of K20 are no exception. Where the symbols of economic and political excellence have declined, the elders seek recourse in new medical symbols to express and assert their uncertain dominance. Not only do they deal in historical forms of Nkoya medicine, or in such modern derivations as the cults of affliction - they also appropriate and dispense modern medicine obtained in dispensaries or the black market. Patrick's death illustrates to what tragedies this can lead.

c. Kinship and marriage

The third major sphere in the social process surrounding Edward's health experience is that of kinship and marriage. Edward's story reflects two main processes in this respect. First there is the development, against many odds, of a mature, stable conjugal relationship between Mary and Muchati. And secondly there is the increasing juxtaposition between their respective kin groups, with Mary being more and more drawn away from her parental kin group and into that of her husband. It is largely from elements derived from these two processes that the elders (taking temporary precedence over the cosmopolitan health agencies championed by Muchati) shaped their healing activities with relation to Edward. The elders' health action (which sometimes amounts to illness-provoking action), is primarily a means to assert their kinship-political claims over juniors such as Mary and her child Edward. Conflicting supernatural interpretations are advanced in order to bring out the imperfections of the rival kin group, and ritual is undertaken to incorporate the juniors more fully into one's own kin group.

      Judged exclusively within the framework of cosmopolitan medicine, it would seem as if the relatives cynically let the child suffer, merely using its critical condition as a pretext to pursue their own kinship-political interests. However, a less ethnocentric interpretation is called for. Kinship dominates the Nkoya community, as it is the fundamental organizational set-up by which rural production and reproduction are organized. Bilateral kinship creates the specific structural problem of several kin groups competing, with virtually equal force and with uncertain outcome, for the allegiance of junior members. this competition is a major structural theme in Nkoya society. It makes for a very high rate of inter-village migration, and is closely connected with the high degree of martial instability. The competition for juniors is further acerbated by the fact that offspring is so very scarce due to an extremely low fertility. This seems to be the background of the Nkoya's obsession with illness and death. Reproduction is a major concern in any society; it is a centre of gravity in all societies organized around the domestic community (Meillassoux 1975). But among the Nkoya, with their impaired fertility coupled to a continuous emigration of young labor power to the towns, reproduction has eclipsed most other concerns, perhaps even production, which is at a low level involving severe annual shortages. In this context, even a child's minor health complaints activate, in the consciousness of that child's kin, the whole predicament of their society. A child's death is in fact what the frantic mourners claim it to be: an assault on the survival of their group. Naming ritual (meant to tie the child more closely to the kin group and its ancestors) and ritual contests (cf. the two divinations of the causes of Edward's illness) with other groups that extend rival claims over the child, may not constitute the most effective way of curing a sick child, yet they do form a meaningful attempt to get to the roots of the child's condition and its paramount social significance for the various groups that lay a claim to his membership.

d. Cosmopolitan health agencies

A fourth major sphere in the social process shaping our protagonists' health behavior, is formed by the cosmopolitan health agencies themselves.34 Once the problems of access have been overcome, what kind of interaction actually takes place between patients and medical staff at rural health centres, clinics, hospitals and private practices? Edward's case suggests repeatedly (cf. negligence of Mary's breast-feeding while Edward was in hospital; the rural health centre lacking essential drugs; the doctor's attitude towards Muchati when he brought Edward in for admission; Kafungu's pneumonia) that this interaction is often of a very deficient nature, both in social and in technical-medical respects, and especially in those cases that require more than quick and simple administration of medicaments.35 In terms of social relations there is often little to reinforce and consolidate a patient's initial attraction to cosmopolitan medicine, and there may be much to deter him. the immense pressure of work (cf. Leeson 1970), the cultural and linguistic barriers (cf. Conco 1971), the conflict-ridden internal structure of institutions of cosmopolitan medicine36 and the difficulties involved in keeping up medical supply lines in a hug empty country like Zambia (Hage-Noël 1974) may all be quoted in vindication of individual health workers. However this does not take away the fact that often health action along the lines of cosmopolitan medicine is frustrated by the very institutions that claim to have scientific furtherance of health as their major aim. Cosmopolitan health agencies have a great influence on peoples' health behavior - but sometimes this influence may be of a kind to encourage them to take their health problems elsewhere.

      Alternatively, Edward's case offers sufficient examples (Mary's bottle-feeding; our bush clinic, my patronage in the event of Edward's final hospitalization) of the fact that, given adequate social relations between Nkoya individuals and the advocates of cosmopolitan medicine, the effect of cognitive or kinship-political barriers to adequate health action can be minimized. In a Central African society like that of the Nkoya, where 'shopping-around' (for kinship support, followers, medico-ritual attention within the context of Nkoya medicine) is a fundamental structural theme, one should hardly expect that such a powerful source of support as cosmopolitan medicine would be ruled out for reasons of principle! Just as in the choice of a headman or a nganga, two major factors are important here: one's ability to enter into a satisfactory relationship with that agent. The manifestly low standards of performance in both medical and social respects, among some agents of cosmopolitan medicine, deter Nkoya patients, no matter how much the latter are prepared to admit, at the cognitive level, the power of cosmopolitan medicine.

Of these four major structural domains, two (elders, kinship) belong to the internal structure of Nkoya society, and two (modern-sector employment, cosmopolitan health agencies) to the wider society into which Nkoya society has become incorporated. An important problem in analyzing the social process out of which Edward's case exists, is that it continuously links these two entirely different structural settings. The theoretical and methodological difficulties which this situation (yet so common in the modern world) poses, have not yet been overcome (cf. Van Binsbergen, n.d. b.). Meanwhile Muchati's role can be appreciated as that of one who, due to an increasingly successful yet still very vulnerable position in the wider society, could, slightly better than his fellow-tribesmen, afford to ignore the claims of the internal Nkoya social structure, such as it is expressed through the elders' health action. At Edward's birth he tried to wrench the initiative from the hands of the Nkoya women he had himself called earlier in the evening. A year later, when Edward's health declined, his relatives dared enlist the services of a healer only after Muchati had left for the town. Yet the pressures channeled through his wife, parents, affinal kinsmen and urban tribesmen left him little choice but to accept Edward's extensive exposure to Nkoya medicine. Although Muchati's close personal relationship with his elite employers make him somewhat exceptional, this reluctant compliance is surely one of the main characteristics of contemporary Nkoya youths and young adults in relation to the elders. Of great structural significance, it reflects the indeterminateness of the social-structural position of modern Nkoya, who are caught between two totally different social systems. The rudiments of their pre-capitalist rural society can no longer fully provide an adequate material life for them. Alternatively, in the modern capitalist urban society they are lowly-educated newcomers with only a very insecure footing. Ultimately such economic, social and psychological security as they have, has therefore to come from the village. For this reason they are forced to adhere to the social and symbolic arrangements of the village society, including their medical aspects.

      Having thus identified some main and often conflicting spheres of relationships that among the contemporary Nkoya intersect around specific individuals in their pursuit of health, it is important to realize that these relationships are not static structural arrangements. They constitute a veritable social process. 'Historicity', in the sense of the seriality of evens and the accumulation of effects along a time axis, is the key to an understanding of the specific health actions of individuals at a specific moment of time. This historicity pervades Edward's case from beginning to end. Without the mounting tensions between Jimbando and Nyamayowe villages (the struggle over Mary's social and ritual allegiance, the abortive marriage negotiations concerning Banduwe's son, the death of Kashimbi's daughter, and of Patrick, in Jimbando) it is unlikely that the struggle over Edward would have been enacted at such an early stage, when the child was barely one year old. It is more usual for such struggles between affines over a child's allegiance to begin when the child is in his tens. Without the truly traumatic outcome of Edward's first hospitalization (the impairment of Mary's lactation), and without the repeated recent disappointments at the ill-supplied Rural Health Centre, Edward's kin would also have looked to cosmopolitan medicine, and not so exclusively to Nkoya medicine, to deal with the decline of his health from October 1973.

      This historicity is implied in the extended-case method, and constitutes one of its great advantages. When we concentrate on the action aspects rather than on the cognitive or cultural aspects of health dynamics, some recurrent findings of medical anthropology in Africa can be placed in their proper perspective.

      Africans have been claimed not to make too rigid a distinction between cosmopolitan and local medicine.37 Along the same lines, it is claimed that they do not consider themselves as defaulters to one side or the other when they shop around for health assistance. On the cognitive level these findings are hard to explain. Hardly would one assume that Africans fail to perceive the enormous differences between cosmopolitan medicine and the various African systems of medicine. But if one sees such cognitive elements as primarily shaped, and given meaning, in a specific sequence of actual interaction, then the fusion of the various spheres of medical care in the social processes in which people are involved, explains the absence of neat compartmentalization between these spheres in their thinking and attitudes.

      Such a complemental relationship between cosmopolitan medicine and local alternatives as my analysis suggests, lies not primarily in the fact that they are so very different (or so very similar to each other, for that matter), but in the fact that both are involved in the same social field. The social process, within the various spheres that in mutual rivalry determine it, takes people now to cosmopolitan medicine, now to local healers, kin therapy, or self-medication. This is a rather horizontal view, which looks at cosmopolitan medicine as one among many alternatives, neither incomparably superior to Nkoya medicine, nor rigidly separated from the latter by impassable cultural or social boundaries.

      This raises the much debated issue of the functional complementality of cosmopolitan medicine and local alternatives.38 Do people refer to local alternatives, mainly for emotional relief and social redress, whereas they refer to cosmopolitan medicine mainly for sheer somatic treatment? Complex as the issue is, I have a feeling that this kind of reasoning erroneously projects into the participants' minds the distinctions and evaluations common among members of North Atlantic society, and a fortiori among our doctors. Could the latter afford to admit that local, non-cosmopolitan medicine is anything more than just emotionally and socially relevant, in other words can they admit that it primarily entails medical actions fellow-doctors, however exotic? As I have tried to demonstrate, the oscillation between cosmopolitan medicine and Nkoya medicine in Edward's case was primarily the outcome of the evolving struggle between various major foci in the social process of the people involved. it was not as if at one stage emotional or social concerns or needs began to prevail over the desire for somatic cure, and that therefore cosmopolitan medicine had to yield to healing ritual etc.

      Non-cosmopolitan medicine does not have the monopoly of social and emotional aspects. Would not the following aspects of cosmopolitan medicine upon closer analysis reveal major parallels with the symbolic and social content of African medicine: the period of seclusion that Mary underwent at the escorts' shelter while her child was in hospital; the fixed routine of daily rounds through the wards; the rigidly defined role expectations in the interaction between patient and staff. Just as local healing ritual may reveal crucial aspects of the village society,39 the patients enforced submission to anonymous structures is eminently significant in a urban capitalist society dominated by formal bureaucratic organizations both within and outside the medical sphere. Thus, the absence of sociability in the sphere of cosmopolitan medicine, may be just as much of a socially relevant fact, as the unmistakable 'social' element in local African medicine. Hitherto, perhaps, social scientists interested in health action have too readily accepted our doctors' own definition of the cosmopolitan medical situation, thus taking for granted what most needs elucidated (cf. Loudon 1976: 33f).

      Does my analysis imply, then that medico-anthropological analysis is to lose itself entirely in the tracing of petty families histories, without any prospect of producing structural insights that can be generalized and thus applied in public-health policy?40 Such a view would ignore the lessons I have tried to derive from Edward's case. However complex, and however unpredictable in details, yet the social process that surrounds individuals in their pursuit of health shows a systematic pattern such as explained throughout my argument, and summarized in my introduction. In this pattern cosmopolitan health agencies play an integral but often far from ideal part. The better this pattern is understood, the nearer Third-World cosmopolitan medicine may come to the realization of its lofty ideals, and to the justification of the comfortable social privileges of its professionals.41


When I presented an earlier and admittedly less balanced version of this paper to an audience of Third-World physicians, their main reaction was one of disbelief and irritation. Was not the implication of my argument that even if the accessibility factor was taken care of, yet people like the Nkoya would not, and could not, embrace cosmopolitan medicine overnight and whole heartedly? The reaction of the audience was: 'So much of unique and unquestionable value that was as agents of cosmopolitan medicine come to offer them - and you are telling us that they may have reasons for rejecting it?!' It is not with impunity that one can present a more relative view of cosmopolitan medicine; nor it is easy to explain anthropological data and insights in a manner that makes sense to medical professionals.

      Edward's case suggest how complex the situation really is, and how difficult to alter. Nkoya, both in town and in the village do consult cosmopolitan health agencies. As elsewhere, this utilization increases with increased accessibility. The Nkoya are not deaf to the persuasions of non-Nkoya outsiders, or of enlightened fellow-Nkoya, who advocate cosmopolitan medicine. Rather complex hygienic routines, such as bottle-feeding, may be mastered within an amazingly short time, and adequately performed provided the logistics of the situation allow this. Cultural notions play a relatively limited role in this set-up, and certainly do not create insurmountable barriers against cosmopolitan medicine. Yet two main factors militate against these people becoming exclusively committed to cosmopolitan medicine. First, their own medicine is so central in their social process (both in the village and in town), that they cannot afford, as yet, to do away with it. Their structure of authority, kinship, competition between kin groups over scarce members, largely revolves on it. And secondly, the version of cosmopolitan medicine offered to them is of perceptibly inadequate standards.

      These standards can only be improved if more fund become available and if medical performance is re-assessed and continually evaluated against the social, political, ideological and ethical priorities of the local community, of the national state which administers cosmopolitan medicine, and of the world community at large. Ultimately this means a political process in which the elitist and consumptive tendencies inherent in the cosmopolitan medical professions, and the de-humanizing tendencies inherent to all modern formal organizations including medical ones, are radically checked in favor of the people's interest (medical and otherwise) at the grass-roots level.42 Humanitarian compassion alone is not like to bring about such a change - it has to be brought about by the organized demands of the people themselves. Thus the evolution of public health becomes an aspect of a much more general class struggle.

      Alternatively, the centrality of Nkoya medicine in their society is not likely to decline unless a profound transformation takes place in their political and economic situation within the wider society. Nkoya society is not really disappearing. It lives on in a greatly modified form as a handmaiden of urban capitalist structures, nursing future laborers and sheltering discarded laborers. Even in this neo-traditional form can Nkoya society only survive if its basic social and ritual institutions, including Nkoya medicine, remain more or less intact. Nkoya medicine underpins the elders' authority, articulates group processes especially at their most dramatic stages, and provides a mechanism of redistribution through which some meager revenues of labor sold in the capitalist sector can be channeled back into Nkoya rural society.

      Other forms to legitimate authority, and other mechanisms of redistribution, are conceivable, and their substitution in the place of Nkoya medicine might pave the way for fuller adoption of cosmopolitan medicine. However, such cultural engineering is reminiscent of the naïve, a-political manipulation advocated by the old-fashioned schools of applied anthropology (e.g. Foster 1962; Erasmus 1961). It is deceptive, as it only deals with surface phenomena and does not confront the problem at its roots: the reality of exploitative incorporation, within the 'mode of reproduction of cheap labor'. If this reality could be overcome through the class struggle of the Nkoya and other Central African peasants and urban poor, Nkoya society would be transformed (both internally and as regards its place in the world system), and Nkoya medicine would no longer need to serve the functions which now make it indispensable.43



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1978  Faith and participation in traditional versus cosmopolitan medical systems in Northwestern Zambia. Paper presented at the Twenty-first Annual Meeting, African Studies Association, Baltimore.

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(c) Copyright: Wim M.J. van Binsbergen, 1979



Wim M.J. van Binsbergen

In his introduction, Van der Geest point at what he claims to be a major weakness in my contribution: the fact that I have ignored the role of cognition as a determinant of the selection of specialist healers. I am grateful for this opportunity to explain my position more fully.

When, like in the contemporary Nkoya situation, patients and their sponsors are confronted with a plurality of medical systems, the problem of which specialist healer they select, when, and why, is of obvious theoretical and practical interest. Many medical anthropologists44 have dealt with this selection problem as follows. Participants are said to impose their cultural classifications upon the diseases they suffer from. These classifications interpret the nature of each disease, and imply the specialist agent (if any) capable of curing it. Where cosmopolitan health care is available along with forms of indigenous medicine, people allegedly tend to classify some diseases as 'suitable for hospital treatment', and others as 'to treated by non-cosmopolitan healers'. In my own analysis I did largely ignore this cognitive approach, and instead interpreted the participants' switching forward and backward between cosmopolitan and other healers as the outcome of a sustained, complex social process - a process which had little to do with the specific nature of the diseases involved, and which could be understood retrospectively but could hardly be predicted.

The data as presented in my paper provide support for my view that among the Nkoya there is no one-to-one relationship between certain somatic (or mental) symptoms, and the choice in favor of cosmopolitan or non-cosmopolitan medicine. In the case of Edward, the same few symptoms (coughing, fever, emaciation, lack of appetite, inflamed eyes, retarded motoric development) , which recurred over a period of 11/2 years, were subject to a shifting labeling process. Sometimes his relatives imposed cognitive categories such as shipelo (an unborn child's attack on his immediately preceding sibling), lizina (illness springing from a name which the bearer's ancestors do not approve of), or mpashi (illness caused by an ancestor who is angry because of a violation of kinship obligations between living kinsmen). I suggested how in each instance the particular labeling could be understood as the result of the ongoing social process in which the boy and his relatives were involved; and I described this process in detail. When the labels mentioned were applied, the boy's condition was not considered amenable to cosmopolitan treatment, and local, ritual cures were pursued instead. At other times the relatives accepted the possibility that the very same somatic symptoms, in the same boy, might be within the realm of cosmopolitan medicine. They took the boy to hospitals and clinics, where such cosmopolitan diagnostic categories as pneumonia, malnutrition and conjunctivitis were pronounced, without the relatives opposing these diagnoses or rejecting the modern treatment that was indicated.

Edward's case does not stand on its own. Our field-work involved us deeply in the health problems of our Nkoya informants. Not only did we collect people's statements on illnesses, their categories, and explanations - in many cases we also examined the patients and tried to treat them. Malaria, gastro-enteritis, respiratory tuberculosis, bilharzia, hookworm and various forms of conjunctivitis are among the most frequent diseases in Chief Kahare's area. The attendant somatic symptoms are (with the exception of hookworm), fairly unmistakable, and as easy to discuss in the Nkoya language as they are in English. However, when it came to labeling a particular combination of symptoms with a Nkoya category diagnostic labels to the same set of symptoms. Moreover, these labels had again widely different implications as to the alleged illness-causing agent, and as to the healer to be selected. Similarly, the same diagnostic labels, such as wulozi, 'sorcery'; mashika,'cold'; and mulutu, '(hot) body', were used to describe such different disease patterns as malaria, gastro-enteritis, and respiratory tuberculosis. This finding is rather at variance with Symon's (1968) description of the medical system or the Nkoya and neighboring groups: without any semantic analysis or methodological discussion, Symon's crude listing or local disease names and treatments suggests a one-to-one relationship between local diagnostic terms and those of cosmopolitan medicine.

In essence, however, Nkoya diagnostic categories form an idiom to discuss, in a more or less coded and symbolic for, the social relationships surrounding the patient. For instance, if these relationships are currently in a state of intense conflict, and if in the patient's social environment there is a strong interest, among one faction or another, to bring this conflict in the open and force the issue, then the diagnosis of wulozi ('sorcery') is likely to be made by that faction. (For a case in point, cf. Van Binsbergen 1977b: 50f) Rival factions thus implicitly accused of evil practices, or this parties who have an interest in playing down the conflict, will instead propound alternative diagnostic labels: e.g. bituma (a spirit affliction unrelated to human aggression; cf. Van Binsbergen 1977a); wulweli ya Nyambi ('illness sent by God', i.e. regardless of human deeds); wulweli wa Bamukuwa ('Europeans' illness', i.e. amenable to cosmopolitan treatment); etc. Typically, the various parties involved try, through display of formal authority, gossip, and rumors, to influence the patient, sponsors, and public opinion in general, so as to have their own interpretation of the disease prevail. This struggle is in itself part of the social process in which the patient, and the surrounding parties, are involved, and its outcome depends on their relative strength. Once the patient and his sponsors have accepted one diagnostic category as the most applicable one, they thereby commit themselves to a particular type of healer45 until further developments take place in the social process, necessitating a new interpretation of the same patient's complaints. Edward's case provides illuminating examples of this.

      Thus it would seem as if, in the Nkoya case, the cognitive approach cannot in itself throw light upon the selection problem. There is no denial that Nkoya medicine, like any other medical system in the world, is also a cognitive system; and I should have described this system more systematically and in greater detail. This cognitive system, with all its obscure symbolic implications, sets the boundaries within which Nkoya health action can take shape, and defines basic fears as well as the possibilities for mutual identification within the community and across the urban-rural divide. For this reason cognition constitutes one of the pivotal elements of Nkoya society. But between the cognitive system, and actual health action, stands the ongoing social process, which determines which elements in this cognitive system will be selected for action. Where medico-anthropological studies have so far ignored the social process, I still feel justified in concentrating on it.



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(c) Copyright: Wim M.J. van Binsbergen, 1979



30King 1966: section 2: 6 and 2: 9; Fendall 1965; Sharpston 1971; Stein 1971: 100.

31Stein reports (1971: 127) that only 9% of the under-five population is brought to clinics, while re-attendance averages only 3.4. visits per child. Mary's health action in this respect is therefore fairly representative in the Zambian context; understanding of her choice of alternatives is likely to have wide applicability. However, Nur et al. (1976) quote much higher figures for the Lusaka municipal township of Matero.

32For a general criticism of the notion that 'tradition' or 'culture could serve as an explanatory in the study of health action, cf. Lieban (1973: 1058) and Erasmus (1961).

33Reference is to recent urban immigrants in Lusaka in the early 1970s.

34It is remarkable that, as late as 1962, patients' secondary reactions to health institutions etc. had to be discovered as a forgotten factor in the utilization of cosmopolitan medicine and its alternatives; cf. Von Mering 1962; Polgar 1962.

35The same point is made by Leeson 1970: 10f; for a Nigerian parallel, cf. Ademuwagun 1973: 72f.

36Cf. Craemer and Fox 1968; Jayaraman 1969; Frankenberg and Leeson 1974.

37Frankenberg & Leeson 1974: 261; Ademuwagun 1973: 73f.

38Gonzalez 1966; Lieban 1973: 1056f; concerning Zambia, e.g. Quintanilla, as quoted in Grollig & Haley 1976: 450.

39Turner 1957, 1967c, 1968; however, cf. Van Binsbergen 1976b.

40Let it be understood that I do not consider such extended-case analysis as an alternative to sophisticated quantitative analysis. Far from being incompatible, such quantitative analysis should follow at a later stage, once the fundamental determinants of health agency utilization have been identified qualitatively. Current quantitative studies in this field, however, have seldom reached this stage, and often remain crude, 'fact-finding' exercises, prone to produce artifacts by solely considering the speech reactions of individuals while ignoring the social processes in which they are involved.

41Meanwhile it must be clear that the structural conditions surrounding the interplay between cosmopolitan and local medicine, an analysed here for the Nkoya case, are very specific; the preliminary Nkoya findings are not likely to apply to other societies, with different internal structures and with different forms of incorporation in the modern economic and political world system.

42Cf. Frankenberg and Leeson 1974 for similar views.

43I wish to direct my readers' attention to two important publications which appeared too late to be included in my argument: Spring Hansen 1978 and Janzen 1978. Janzen's is by far the richest and most comprehensive study yet available on the interplay between medical systems in Central Africa. In this last-minute footnote I could hardly do justice to these works.

44Cf. Lieban 1973: 1056 f. and references cited there. Lieban is however rather critical of the accepted views.

45My emphasis is on the cognition of the patients and their sponsors; the specialist healers each use a diagnostic system that tends to be more technical, elaborate, idiosyncratic, and orientated towards somatic symptoms, than are the laymen's diagnostic categories on which the patients and sponsors base their choice of healers in the first place.


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