Raising the Dust Chapter Reflections

Chapter Eight: Footprints, Pathways and Pedals.

Part III: Referral Pathways

Last month I described how the Mulanje traditional healers move around in the local community for the purposes of harvesting. I explained that they harvest from various environments, both local and further afield and into neighbouring areas. Not only do these activities ensure a regular supply of traditional medicines, it sets up a network of associations that extends their influence. It is clear then that the movement of traditional medicine does not go one way; it flows back and forth in many different directions. Practitioners develop new associations when they travel to outside areas and sometimes people come back to the Mountain for consultations. For example, participants reported that once they had established good reputations, it was common for patients to travel to Mulanje Mountain for follow up consultations from a range of local, national and even international locations. As they move around, the participants in my study become connected to different people in different places through their practices, and once they have established reputations outside of the area, the scope of their knowledge and skills extends accordingly. In exploring these connections, we are able to review the patterns of referral that define, not only African Traditional medicine, as practiced in the South of Malawi, but the patterns of referral that tend to be characteristic of medical systems anywhere where there is a dual medical outlook in a country – as there is in Australia today.

Most people have some knowledge and practice skills in traditional medicine, mainly how to use herbs. Just like in Australia where most of us have some idea of herbs and healthy household practices (like good kitchen nutrition), a lot of common illness ‒ like colds and common viruses ‒ will be managed with the household, within the family. Women tend to have more household healing knowledge in my study area, as is often the case, especially were women’s roles are more clearly socially defined. Often women will manage the household’s illnesses and this includes making the decision of whether an illness can be managed in the home or needs referral, either to a traditional healer or bio-medical service provider, like a hospital, western style doctor or medical clinic. As we saw in my Chapter Six reflections, this system of referral is quite pronounced in the case of traditional birth attendance where women seek either the services of their traditional healer ‒ usually someone who is known to assist women in giving birth ‒ or they go to their nearest hospital. Even with this common event, there is a network of referral relationships that surrounds the care of women when they are giving birth in my area of study.

For example, I described how, even when a traditional healer has delivered healthy baby by traditional birth attendant methods, often she will send the mother and baby to the hospital for a check-up and for follow up vaccinations. The referral process does not seem to be going the other way in managing births but hospitals and western style doctors tend to refer patients who are having fertility issues to traditional healers, as they are known for their success in treating what may be seen in allopathic practice as “psychological” causes. (Traditional healers tend to see infertility issues more as having more of a spiritual cause).

The other area where there is a strong referral pathway between the bio-medical model and traditional medical practices is in the area of mental health, and in this case there is better collaboration between the two models of health. Once again this is because western bio-medicine tends to see mental illness as having a psychological cause. With western bio-medicine being more focussed on treating the physical aspects of health, collaborating with traditional healers is seen as a benefit. As noted in my reflections on Chapter Seven, not only is there is strong referral system between traditional healers and bio-medical practitioners in terms of treating patients, there is also greater collaboration between these stakeholders when it comes to networking and sharing information.

As we know, holistic healers and other indigenous and complimentary healers treat the mind/body and spiritual aspect of health and wellbeing. They also focus on health promotion and health prevention ie; the benefits of exercise, the need for clean water and fresh air, the need for a varied and nutritious diet and the need for positive and healthy relationships. The role of the traditional healer is thus to foster a range of relationships that support the health needs of their community, and then to make and receive referrals within this network. The stronger the networks, the deeper and more embedded the practice becomes within the wider community.

As with holistic health practices all over the world, in my area of study reputations are generally spread through word of mouth recommendations. For instance, one of my participant’s patients came from Blantyre ‒ the city closest to Mulanje ‒ yet another one came from an area a 670 kilometres drive to the north as well as someone who came from neighbouring Mozambique towards the east. Another participant said that her skills are invariably advertised by those who she has treated successfully. When they recover other people ask them;

where did you feel alright”? and they reply with, “I went to the spiritual
such, such is ***[i] , she [is] living at Mulanje”.

Another participant’s patients came to her from different places around the mountain, also hearing about her skills through word of mouth ‒ as well as the recommendations of other traditional healers. She said people came to her from “anywhere” because: “when they go to the doctor, a sing’anga, they tell them, you must go to see ***. **** knows that [spiritual] medicine.”  As they were talking I realised that my participants do not wait for patients to come to them and in many respects they are always ‘on call’ to those who are unwell.

Some of my research participants treat people locally and others extend their services beyond the border of Malawi to neighbouring places like Zambia and Malawi and even to South Africa. It was once again interesting to note the different perceptions of what might be seen as “near” or “far”. It really did depend on how a particular traditional healer’s practice has been set up and the scale of the services that they provide. Once again, we can draw parallels here between my interview participant’s practices and holistic and complimentary health practices everywhere else. We all tend to use the resources and knowledge that we have at our disposal at any particular time, then expanding on these.

Since ethno‒medical care is preventative, it often requires follow up treatments. Patients often return to their treating practitioner a number of times or they may send relatives on their behalf. In these cases, the treating practitioner makes up a new supply of medicine and ‒ particularly in cases where patients come from distant places ‒ instructs either the patient (or their relative) on how to administer the medicine and this increases both knowledge and continuity of care. A participant explained that where a patient does not respond to his initial treatment, he goes back to the forest and gathers a different selection of herbs, changing the patient’s treatment. Alternatively, patients are referred to another healer or to a hospital. Just as we have health care treatment plans here in Australia, these treatment plans are a negotiation between himself, the patient and the patient’s family.

One interview participant explained that when patients come for consultations from distant places, she cannot always treat them in the same way she cares for her local patients. Her local patients are treated and then sent home but she feels obliged to allow patients who have travelled from distant places to stay in her home until they get better. She said that these patients were “forced” to sleep at her house, she did not say they were ‘invited’ and she said it in such a way as to suggest that it was a necessary, yet not optimal arrangement. My interview participant explained that her patient would remain at her house when she goes into the forest to gather herbs for them. The practice of accommodating patients at home was expressed as an imposition on the traditional healer ‒ not the patient ‒ because it is customary for the healer to maximise the patient’s comfort at their own expense. Some traditional healers sleep outside to accommodate a patient’s health care needs. Another participant reported that when patient’s come to see him from Mozambique, he sleeps outside and makes sure his patients are comfortable inside his home. He too stated that he has to “force” himself to do this and hence needed a “shelter”.

Tsey (1997[ii]) notes that in some African countries traditional healers reserve residential care for patients with mental health symptoms and other complex ‘psychosocial conditions, often accommodating patients, carers and other members of their extended family. Tsey explains that this is because biomedical health care is “least equipped” (1997:1069) to treat these kinds of health issues, which often have a spiritual cause and thus require ongoing care. Furthermore, it is common practice for traditional healers to be treating a number of different patients simultaneously ‒ often with a broad range of mental, physical, spiritual and relational health issues in traditional healing contexts.

Another distinctive feature of ethnomedical practice that emerged from the interviews was consultation by proxy. Unlike in biomedical health assessments, participants in the interviews explained that they are able to treat a patient based on information given by their relatives, without viewing the patient. (This would clearly contravene our standards of privacy!)  Sending a relative with information on a family member’s condition achieves a number of things. Most obviously, it alleviates the need for the sick person to travel. It also reinforces the relational aspect of health because, by taking an active role in supporting another, a person acquires a better understanding of their relative’s illness.

This is of relevance to all holistic and complimentary health care practitioners as we recognise the ability to facilitate healing from a distance. This is even more relevant to us now as we face lockdown and other social distances measures in the current COVID 19 pandemic. We know we can still direct our healing energies to people from a distance, we know we can provide holistic counselling and Reiki and an extensive range of other healing modalities from a distance and are doing this now through our lap tops and our phones. We can also provide information, education and support. Once again we are brought back to the family, the kitchen, our friends, our colleagues before we look further outwards towards our therapists and other practitioners in the community and then incorporating the bio-medical health services that we might need. We can see the parallels between the referral practices in a place like Mulanje and where I live in Australia today.

Patients can sometimes return to a traditional healer, not only for further treatment, but because they are happy with their treatment outcome. One participant said she once treated a child from a place that is about 70kms away who had “a big brain.” (I learned that this is how epilepsy is conceptualised by her and traditional healers in my area of study). She had been recommended to the child’s parents and when the child got better, they travelled back to Nessa to thank her, in this case with 25 kilograms of rice. Others confirmed that patients do sometimes return at times to thank them and sometimes even pay them “a small, a little money”. Even when the patient recovers, movement continues.

So as we can see, the way in which illness is conceptualised often determines the ways in health care is accessed and the referral pathways people take in managing their health. Traditional healers are like holistic and complimentary health care practitioners in most other places, they do not practice in isolation and instead they are part of a widely differentiated system of health care. Even where there are two dominant systems of health care provided in a country, our health and wellbeing is determined by how well we are able to meet our physical, mental (psychological), emotional and spiritual needs. It is thus a complex, changing, growing, flowing pathway that is best negotiated with a wide range of options and opportunities. I believe that optimal health can only be met when we have choice. The more (affordable) choice we have, the healthier we will all be.

[i] For the purposes of these articles, I have kept the identity of my participants anonymous

[ii] Tsey, K. (1997). Traditional Medicine in Contemporary Ghana: A Public Policy Analysis. Social Sciences and Medicine, 45(7), 1065-1074.