Los útiles del A-TWI

In relation to the dimension of power in healing and therapy management, this thesis is concerned with: 1) a pluralistic situation where different healers are competing to control lay people, 2) an urban social context in which the therapeutic action of healers and lay people is operating, 3) the influence of the state over the practice of traditional medicine and popular management of therapy, and 4) the impact of national

and international economy on the practice of

traditional medicine and popular management of

therapy. 1 shall examine the first two issues in this

section and the last two in the next section.

While medical anthropology appears to be

increasingly concerned with the issue of contestation of plural medicines (Lindenbaum and Lock eds 1993),

there have not been many studies conducted

specifically on these issues. On the other hand, there have been a number of medical anthropological studies conducted in cities. However, not many studies have specifically focused upon the issue of urban social relationships in which theraputic action is operating. Here, 1 shall review some of the major ethnographies that look into the political dimension of social relationships and identities in relation to healing and therapeutic management in general. In this regard, five features of power order and social relationships are distinguishable in the literatures: 1) domination, 2) resistance, 3) solidarity, 4) pluralism, and 5) autonomy. At the end of this section, 1 shall comment on some of the analytical and methodological problems of these studies.

1) Domination: Medical sociologists have long

been interested in power relationships between

Turner 1987; Scambler ed. 1987; Gerhardt 1989). In recent years, sociological studies of relation between power and medical knowledge has been revitalised by Foucault's work (Foucault 1973, 1977; Turner 1986;

Armstrong 1987) . By contrast, medical anthropology has

not been concerned with the political dimension of healing and therapy management until recently. In this regard, one of the first anthropologists to emphasise the significance of the relations between power and medical knowledge is Allan Young.

Young (1982) points out that medical knowledge has an ideological dimension. In his view, medical knowledge is determined by social relationships in the sense that the actors' knowledge of their social relationships affects the kinds of knowledge that they are likely to produce and act on during the course of their therapeutic management. Conversely, medical knowledge is conducive to the reproduction of specific patterns of social control over actors.

In his case study of post-traumatic stress

disorder (PTSD), Young (1993) traces the way in which

particular medical knowledge is produced and

inculcated into both medical workers and patients in such a way as to serve the social order of a medical institute. PTSD is a recently identified psychiatric disorder. It was defined mainly in the context of diagnosis of mental disorders from which Vietnam War veterans suffer as a result of their traumatic experiences. Apart from such traumatic experiences, the symptoms of PTSD are indistinguishable from depression disorders and other anxiety disorders.

Young carried out his research at the Institute of PTSD which was established by the US government

after lobbying by veteran organisations. The

aetiological theory and treatment programmes of PTSD at the Institute have been created largely by the director of the Institute and disseminated to medical

workers and patients. The point Young makes is that

this medical knowledge serves the hierarchy of

authorities and division of labour, with the director

at the Institute at the top of the apex. The

therapists and patients sometimes resist the

Institute's treatment programme. But such resistance is either sanctioned or appropriated within the framework of medical knowledge operating at the Institute. The strength of this ideological knowledge is that both therapists and patients are encouraged and encourage themselves to keep to the treatment programme for the sake of efficacy and construction of

respectable identities.

Young's study is focused on the process by which individuals are controlled by a form of medical knowledge and therefore by the medical institute that produces this medical knowledge. In other words, this

is a scenario of domination. However, there are

studies indicating that the opposite view of medical knowledge and practice is just as possible, that is, a scenario of resistance. Here, medical knowledge and practice are viewed as means of resistance against the dominant class and groups in societies. A major contributor to this approach is I.M. Lewis.

2) Resistance: Lewis (1971) surveys various cults of affliction in the world and shows that the

practitioners and patients of cults of affliction tend to be those who are marginalised in societies - women in male dominated societies, people in a lower class or caste, ethnic minorities, homosexuals, and disabled people. In his view, cults of affliction provide the marginalised members of societies with a subtle means of protest against the dominant members. Thus, through

their affliction, 1) the marginalised get the

attention of the dominant, 2) the marginalised openly utter their aggression against the dominant by means of the words of spirits during trances, and 3) the

marginalised achieve some redistribution of the income of the dominant at healing sessions - the meeting of such a request is in fact viewed as the dominant group's shadowy recognition of their injustice. While Lewis is not so much concerned with the wider social contexts in which rituals of protest operate, there have been an increasing number of studies that situate the ritual in wider political contexts. I will examine these studies later.

3) Solidarity: A third conceptualisation of healing and aetiology in the context of political relations would be to view healing and aetiology as symbols of solidarity of groups and communities. This perspective is explored by Press (1978) in relation to

urban healers. Examining a range of ethnographies

about healers in cities, Press argues that in cities traditional healers function to minimise the trauma of

acculturation and dislocation that migrants

experience. They do this by applying familiar concepts of illness and treatment in the language of the migrants. At the same time, traditional healing also serves to maintain migrants' communal identity - here the occurrence of sickness is considered as a sanction against the neglect of certain traditional roles, and healing acts to restore such a role.

In Africa, Swantz (1990) notes that one of the

roles of the maganga among the Zaramo in Bar es Salaam

is as a preserver of the Zaramo's social and religious

patterns. The Zaramo maganga, who is one of the sole

surviving professional functionaries of traditional practice, reinforce the Zaramo world view and promote "Zaramo-ness" through their healing practice. Through diagnosis of spiritual afflictions, they also remind

urban Zaramo of the importance of their clan

membership.

Likewise, Jules-Rosette (1981) maintains that

psychological entrepreneurs who exploit the problems of urban adjustment. They achieve this by redefining these problmes as the result of non-natural causes and developing a sense of religious, moral and familial obligation among clients. In her view, healing is a transitional symbol, that is, a concrete signifier or

"bricolage" that is appropriate to both rural and

urban forms of life.

Similar arguments are made from a Marxist point

of view as well. Thus, employing the idea of

articulation of modes of production. Van Binsbergen (1981) analyses the Bituma healing ritual among the Nkoya in Lusaka. According to him, the Bituma healing ritual represents the articulation of the capitalist

mode of production with the domestic mode of

production. Nkoya people in Lusaka are in a low class and economically insecure position. Women especially are entirely dependent on men's income, unlike their village counterparts. In this context, the Bituma ritual urges men to redistribute the income they earn in the urban capitalist sector to women and to the domestic and rural sectors - it helps the domestic sector to reproduce itself. Likewise, Mullings (1984) considers traditional healing in Accra to contribute to the perpetuation of a village mode of production, that is, the maintenance of kinship, authority of the

elders and reciprocity extended from village

communities to the city. On the other hand, Mullings notes that the modes of the healing and symbols employed are individualised in the city context under

the influence of predominantly capitalist

relationships.

Thus these studies, based largely on a

structural-functionalist point of view, suggest that traditional medicine in cities can be seen as serving to solidify migrant communities, to maintain their

difficulties of adjustment in urban environments. 4) Pluralism: The above studies which I have classified under the rubric of domination, resistance and solidarity have largely been conducted among particular groups and communities such as medical

institutes, cults of affliction and migrant

communities. However, in the pursuit of therapy,

people are not necessarily solely dependent on a particular social relationship or community of which they are members. Especially, in urban contexts, people are likely to be involved in a plurality of social relationships and possess different identities. It is thus necessary to broaden the scope of research to examine the relation between the therapeutic

actions of individuals and their plural social

relationships. In this regard, while studies on this issue are not yet very numerous, there are some important works to be noted here.

Perhaps the most important study on this subject is Janzen's (1978b) study of therapeutic management among the Bakongo in lower Zaire. Janzen's detailed

case studies show that the decision-making of

healthseekers is influenced by their various social relationships (close families, patrilateral kinship, matrilateral kinship, friends, various healers and religious groups) which entail internal political relationships. To describe such social relationships, Janzen creates the term, "therapy managing groups".

The significance of this concept is to allow

researchers to broaden the focus of analysis from patient-healer dyadic relations and from a supposedly homogeneous community to diverse agents and their political relations that affect the therapy management of actors. This approach also draws our attention to the particular configuration of social relationships of healthseekers and the differential importance attached to the relationships - among the Bakongo,

kinship, especially the matrilineal relationship, is of central importance for therapeutic management.

Exploring thé medical anthropological literature in Africa, Feierman (1985) argues that in Africa, lay people generally have a very wide range of therapeutic choice, and that lay control over patients is much greater than healers' control over them - the latter merely present therapeutic options from which those in control choose. Feierman's point is, however, that lay

therapy managers' control is subject to general

authority in the domestic and community sphere, which is in turn under the influence of wider political and economic relationships in societies.

5) Autonomy: Janzen's study emphasises the jural relationships of healthseekers, that is, the way in

which individuals' decision-making is affected by social norm. Feierman, too, is concerned with the structure of authority in societies which, in his view, can be adequately understood only in the context of the total history of the societies. However, one could also focus on individuals' autonomy and their choices of social relationships and identities in relation to therapeutic management. It is conceivable that individuals seek their therapy not just to cure their affliction but to construct their identities. Such strategic use of therapies and aetiology for the construction of identities has been studied by some anthropologists.

Thus, in her Bolivian ethnography, Crandon-

Malamud (1991) describes the complex process through which the shifting identity of villagers is reflected in their appropriation of therapy and aetiology. Here, the relative decline of the social and economic

position of mestizos encourages some to seek their

social ties with Indians by appropriating Indian

therapies and aetiology, whereas relative upward

one of Crandon-Malamud's informants (a clinical doctor of Indian origin) emphasises his identity with a class category and disregards Indian healing and aetiology.

Sargent's study (1985) indicates that Bariba women in the city of Parakou in Benin prefer a hospital delivery partly because they consider a hospital delivery as a requisite for the urban woman,

that is, "civilizee", and a home delivery as an indication of a peasant mentality. However, Sargent adds that urban women have mixed values and goals such that most of them still express admiration for the virtuous women who deliver at home.

In contrast. Last's (1979) study indicates that actors can use aetiological explanations and therapies to maintain their identities in a situation where they might otherwise be identified with a social category which they do not like. Thus, in his study, Maguzawa women in Northern Nigeria try to perpetuate their

identity as women who can bear children by

increasingly attributing their various ailments to

gishiri illness and applying cutting treatment to

their vagina to cause bleeding. Women who have reached menopause have a high chance of being identified as witches in the communities where social and economic change is taking place.

Thus, in the above literature are discussed different features of power orders in relation to healing and therapeutic management. Once again, we are confronted with variation and contradictions in the features to be explained.

First of all, these differences are partially a reflection of the theoretical perspectives of these researchers and the kinds of methodology they have employed for their researches. As noted, the studies that emphasise aspects of domination, resistance and solidarity in healing and aetiology are based on relatively bounded groups and communities. The problem

with this methodology is that it often fails to acknowledge the action of individuals outside the context of the groups with which the research has been concerned. It may well be that the therapeutic actions of individuals, which appears at first glance to be controlled by the particular groups in which they are involved, turn out to be just one part of a broader range of therapeutic action through which they also try various other groups and healers. In that sense,

studies that trace the therapy management of

individuals without focusing exclusively on particular groups have an advantage.

On the other hand, it seems clear that under certain situations, the control of therapeutic action is quite durable and fixed. The point is that within the same society, the therapeutic action of some individuals is fluid, whereas that of others is fairly fixed. It is also conceivable that fixedness and

fluidity of social control vary in different

societies. It appears to me that such variation in the ordering of power within and between societies leads us to acknowledge that there exists a plurality of relatively autonomous agencies (therapists, medical institutions and therapy managing groups) with varying power within societies; the configuration of these agencies differ according to societies, and fixedness and fluidity in theraputic action also depend very much on the particular construction of actors'

identities with therapies and aetiological ideas. However, such configuration of social agencies is in turn strongly influenced by the state and the wider economy, as Feierman argues.