jiCC/v , Ui JiiH '"Hi-eS-eS P e c m ACCiiiaiUv i.L 11 University of Ghana http://ugspace.ug.edu.gh THE NAZARETH HEALING COMPLEX: A STUDY IN INTEGRATED 4PPROACH ..TO H B M H Ml y.KOFI" Gfc,OVER B '.... * .\» • • * ■ \ • • • J• • '• • • V A thesis Ipubmitted to theQDepartment of Sociology, University\ of Ghana, in partial fulfilmei/t of the requirement^ for the award of M.Phil. degre December, 1989 University of Ghana http://ugspace.ug.edu.gh DEDICATION THIS STUDY IS DEDICATED TO THE FEMALES OF MY FAMILY (AMETORWOSOR, NDA AFAFA, WORLA, AKPENE), AND THE OLD MAN - SEVATO FOR THEIR MORAL SUPPORT. ... AND OF COURSE TO CHRIS ABOTCHIE, LECTURER, DEPARTMENT OF SOCIOLOGY, LEGON, FOR INITIATING ME INTO THIS HIGHER ACADEMIC PURSUIT. University of Ghana http://ugspace.ug.edu.gh I D E C L A R A T I O N I, EVAM KOFI GLOVER, HEREBY DECLARE THAT THIS WORK IS MY ORIGINAL WORK. EXCEPT WHERE ACKNOWLEDGEMENTS ARE MADE, THE MATERIAL PRESENTED IS A RECORD OF MY OWN RESEARCH. NO PART OF THIS WORK HAS BEEN PRESENTED IN ANY FORM FOR ANY DEGREE IN ANOTHER EDUCATIONAL INSTITUTION. E. K. GLOVER PROF. P . A . TWUMASI (SU PERVISOR) University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGEMENT Although I must take ultimate responsibility for the material presented in this thesis, I wish to point out that I was not without friends. My sincere thanks go to all friends who contributed in one way or the other to the success of this work. I am grateful to my supervisor, Prof. P. A. Twumasi for his help and direction. A special mention must be made of my lecturer and friend, Kojo Amedjorteh Senah, and Drs. Peter Wondergem, (the principal investigator in the research project on "Herbal Drugs in Primary Health Care in Ghana"). They have been very kind to me by including me in the above research project. Indeed, the data for this thesis were gathered during the above mentioned research project. I wish to acknowledge with deepest appreciation their supervisory support in the field. They have been invaluable and constant critics, willing to read drafts of the thesis and to point our errors of commission and omission. My thanks to them here can only partially repay their help. In the same vein, I am indebted to the Royal Tropical Institute, Primary Health Care Unit, Amsterdam and the Netherlands Ministry for Development Co-operation, The Hague, for their indirect financial and logistical support for this thesis. II University of Ghana http://ugspace.ug.edu.gh Ill Also, I gratefully acknowledge the help given by Dr. Lynne Brydon, Department of Sociology, University of Liverpool, Marian Paape, Royal Tropical Institute, and Ampong Darkwa, Institute of African Studies, Legon. I am much appreciative of their help and interest in this work. That this study could have been conducted at all owes to the active participation and collaboration of the chiefs and people of Vane, the personnel of the Nazareth Healing Complex and the director/founder Mr. S. K. Baku. I am very grateful to them for their support and help. I also wish to thank especially Messrs. Fritz Dzradosi, the late Kadzi and Miss Gloria Bakudie; the Field Assistants for this thesis. They have been kind, and of great help to me. I am also indebted to my friends, Ibrahim Isahaku, Assor Vincent, M. 0. Sackey, Chris Abbe, Joe Whittal and Tony Amedzakey for their unfailing source of help and encouragement. My indebtedness would not be completed without the special mention of Miss Rose Awuyah for her moral support. To all these people, and to many others who have given freely of their time and thought, I am grateful. However, I wish to emphasize that I must be held fully responsible for the shortcomings of this thesis. E.K.G. University of Ghana http://ugspace.ug.edu.gh A B S T R A C T The main thrust of this study is to investigate a novel phenomenon in health care delivery at Vane, in the Volta Region of Ghana called the Nazareth Healing Complex (NHC). Designed to provide comprehensive health care at one location, the NHC combines faith, herbal and modern medical systems. The central aim of the NHC multispeciality group practice is to allow an interchange of ideas and consultation among all the health practitioners within the same facility. The assumed advantage is the greater continuity of care where referrals between different specialists are effected within the same facility, for the total health care of patients. This study seeks to discover the role of the NHC in meeting the psychological, social and physical health needs of the people. It attempts to explain the nature of the inter­ relationship between the constituent parts and to show the role-relationship between the NHC and the larger community of Vane. The Theoretical framework for the analysis was the Social Systems perspective which includes features of both rational and a fundamentalist model in the study of social change. The study adopted three methods for collecting data: participant observation, in-depth interviews and questionnaires. IV University of Ghana http://ugspace.ug.edu.gh Analyses of the records show that the utilization of the NHC facilities is rather low. Findings suggest that the people largely by-pass the NHC facilities for other health care systems in the locality. Thus it was concluded that the NHC facilities are relatively unacceptable to the people. The people hardly see it as an added value. An attempt was made to offer some sociological explanations for this situation. Factors responsible for this situation include external and internal problems facing the NHC. With reference to the external factors, available evidence suggests that the NHC was unable to compete with the already established health institutions at Vane. These health institutions include self-care resources, modern medical systems, and traditional health care resources (including faith healing, general herbalists and diviner healers) in the locality. The internal factors include; administrative problems and poor co-ordination of constituent parts. This situation led to the eventual collapse of the intersectoral referral system which was the main premise on which the NHC was built. It has therefore been established that the low acceptability of the NHC facilities on the one hand is a function of poor integration into the socio-cultural milieu of Vane. On the other hand, the failure is a function of poor interplay between the constituents of the organization. University of Ghana http://ugspace.ug.edu.gh Finally, the results of this study indicated that the diffusion of any innovation in any given community is a function of its relevance to the values, beliefs and expectations of the people. Coupled with this, the internal equilibrium of the innovating organization is also an essential determining factor in the realization of the goals and objectives of the organization. The success of the programme - among others - is positively related to these factors. The study suggests however, that there is need for further empirical research into sources of self-care services and factors which seem to make this a more convenient source of health care for the rural societies. University of Ghana http://ugspace.ug.edu.gh VI CONTENTS Declaration ............. i Acknowledgement ii Abstract ............................. iv List of Ta b l e s ........................ ix List of G r a p h s ........................ x List of Figures x University of Ghana http://ugspace.ug.edu.gh VII TABLE OF CONTENTS CHAPTER ONE: INTRODUCTION The Problem ........................................ 1 Objectives of the Study ............................. 2 Relevance of the Study ............................. 3 Theoretical Perspective ............................. 4 Background Review .................................. 7 Method ............................................. 18 Limitations of the Method ... 22 Operational Definitions ............................. 23 Structure of the Report ............................. 25 CHAPTER TWO: THE SOCIAL STRUCTURE OF VANE 27 Geography........................................ 27 The People (History) 28 Economic and Demographic Characteristics 30 Political System .................................. 32 Existing Medical Systems ............................. 33 Ideas on Health and Disease ........................ 34 Health Resources .................................. 41 Summary of Discussion ............................. 52 PAGE University of Ghana http://ugspace.ug.edu.gh VIII PAGE CHAPTER THREE: THE N.H.C. 54 History and Organization of NHC ................. 54 The Constituent Parts of NHC ... . ........... 65 The Modern Medical Sector 65 The Herbal Sector .................................. 82 The Faith Healing Sector ... 127 Summary ............................................. 150 CHAPTER FOUR: The Problems of the NHC’s Approach to Health Care Delivery 156 External Factors ................................. . 157 Internal Factors .................................. 197 The Interplay of the Constituent Parts ............. 203 Summary of Discussions ............................. 214 CHAPTER FIVE: SUMMARY AND CONCLUSION 219 Summary ...................................... ... 219 Practical Implications ............................. 234 Theoretical and Research Implications ............. 238 University of Ghana http://ugspace.ug.edu.gh Table Table Table Table Table Tabl e Table Table Table Tabl e Table LIST OF TABLES I: Morbi d.L ty , Patterns as Portrayed by illness Episode 33B !:Morbidity Patterns as Portrayed by illness Episode and data from the NHC Modern sector. 77B I: Attendance of the Modern Sector Between 1982-1988 79 I: Age/Sex Distribution of Patients ............. 80 >: Number of Patients Per Year of the Herbal Sector 84 5: Herbal Clinic Records of N.H.C.: January 1987 to March 1988 113 &. 114 Specialization of Healers According to Community 115 Response to their Services ?: Advantages of NHC Healers over (other) Traditional Healers that influenced patients in their choice of therapy 121 ): Community Survey ~ Traditional Healers Visited 125 10: Distribution of Members by Sex/Age (Faith Healing Sector) 134 11: Reasons for A s s o c i a t i n g with the Prayer Sessions o f NHC 13 9 IX PAGE University of Ghana http://ugspace.ug.edu.gh L IS T OF DIAGRAMS PAGE Fig. 1.1 The Philosophy of NHC 63 Fig. 3.1 Age distribution of patients. 119 Fig. 3.2 Proportion of Herbal Treatments in self-medication per Age/Sex groups. 120 Fig. 4.1 Sources of Treatment 158 Fig. 4.2 Sources of herbal drugs 160 Fig. 5,1 Interplay of NHC constituents 203B LIST OF MAPS Fig.l The Local, ion of Vane in the Volta Region of Ghana. 2 6 Fig. Map of Study Area - Vane showing H e a l t h f a c i l i t i e s . 4 IB University of Ghana http://ugspace.ug.edu.gh XI APPENDIX A: Disease Episode Questionnaire ............ B: Community Survey: ............ C: Other Related Projects of NHC ............ D: Educational Standing of Respondents: .. E: Occupation of Members (Faith Healing Department) ............ F: Drugs sold in the Small shops of Vane .. G: Services and job Description of Staff: NHC Modern Sector ............ BIBLIOGRAPHY ............ PAGE 241 243 247 248 248 249 251 254 University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE INTRODUCTION THE PROBLEM The study investigates a novel phenomenon in health care delivery at Vane community in the Volta Region of Ghana known as the Nazareth Healing Complex (NHC). This new approach combines faith, herbal and modern medical systems within the same facility. In this wise, the NHC is a multispeciality approach in which three healing systems are grouped together to provide a more comprehensive health care. It is purported to be an answer to the complex ill-health problems which patients usually present at different times to different therapeutic agents. According to the Christian Medical Commission; The Nazareth Healing Complex is the only attempt in any part of the world where a serious initiative had been taken and is being sustained to bring three systems (Faith, Herbal and Modern Healing systems) under one 11 roof” and in a way that offers people a choice. (Contact June 1988:1) The relevant literature indicate that, Ghanaians in search of therapeutic expertise, usually shop around. (Twumasi 1978, Fosu 1977, Hagan 1986). Seen against this backdrop, the attempt of NHC is to bridge the gap by bringing the different health agencies to the doorsteps of the people in a more comprehensive form. The central aim of the NHC multispeciality group practice is to allow free association for the communication of ideas and for consultation with other health practitioners within the same facility. The anticipated advantage is the greater continuity of care for the patient through intei— sectoral referrals. University of Ghana http://ugspace.ug.edu.gh It is the hope of the initiators of NHC that this approach would positively affect members of the society who would seek new and improved methods in their health and illness problems. This study attempts to analyse the role of NHC in meeting the health needs of the community. Needless to say, any new thing introduced into society would encounter preliminary problems. An attempt to group together three originally independent medical systems into a comprehensive system therefore would naturally involve some problems. Issues relating to the interrelationship between constituent parts of the programme, management of tensions and conflicts, and the relationship between the new system and the social structure of the recipient people, must be taken into consideration. These are some of the pertinent issues which this study attempts to investigate. Objectives of the Study What is considered of fundamental importance in the context of the thesis is the examination of the nature of the relationship between the social structure of Vane community and the NHC. It would seem urgent also to determine the nature of the interrelationship between the three constituent parts of the NHC. 2 University of Ghana http://ugspace.ug.edu.gh The following questions are framed to guide the discussions: 1. How do the NHC constituent parts work in practice? 2. What is the nature of the interrelationship between the parts? 3. To what extent does the NHC cater for the health needs of the people in the community? Relevance of the Study For a long time, Developing countries have been trying to find better means of coping with the management of the health problems of their people. The search is for a health care system that would be culturally acceptable, affordable, available and accessible to the people. The NHC programme is one of such attempts adopted by a Ghanaian Community to take care of the sick. By investigating the issues related to this programme therefore, this study breaks new grounds. As an exploratory and primary study in the direction of the search for integrated approach to health care, this research would be of help to health planners and policy-makers in the field. Evidently, international organizations such as the World Health Organization (WHO), the Christian Medical Commission (CMC) and the Intel— Church Co-ordinating Committee for Development Projects (ICCD) in the Netherlands may also benefit from the results of this study. It is hoped that, by highlighting the main issues in this new idea, this study would provide broader perspectives and deeper insights into the problems and prospects of this innovation in health care delivery. 3 University of Ghana http://ugspace.ug.edu.gh This would enable the author to generate some hypothesis for the study of social change. Theoretical Perspective This study, as has been stated earlier, examines the interrelationship between the constituent parts of the NHC, and the nature of the relationship that exists between the social structure of Vane community and the NHC. In examining the related issues the study adopts the Social Sytems perspective which includes features of both rational and a fundamentalist model in the study of social change. The concept of social change implies the impact of some influence on the social structure. From the sociological point of view, when a new idea impinges upon the social structure, it affects patterns of social interrelationships in several ways. In the shortrun, the repercussions may not be far reaching, but in the longrun, it would affect all the component parts. From this point of view therefore, the theory which would guide our discussion is that of the systems approach. The Social Systems Approach, applied to medical systems, implies regarding and respecting the multitude of factors in the social and cultural environment which are considered to have an influence on the causal explanation of health and illness (R. A. Kurtz et all. 1984:5). This focus emphasizes a fundamental interrelationship between medical systems and social structures. 4 University of Ghana http://ugspace.ug.edu.gh Social and cultural habits, values, attitudes, the world view of a people, and the state of the economy, invariably influence the development and quality of medical systems (G. Myrdal, 1968). The fact that the NHC is a novel approach to health delivery presupposes that some new element has been introduced into the culture of the given society. It is likely that more than the concept of health and ill-health are affected. To fit in something new where order already exists cannot be done without major changes within the social structure. From the Social Systems perspective, this study explores the interrelationship between the innovation and the extent to which it is integrated with the norms, health needs, values and expectations of the society it serves. What is considered to be of fundamental importance is the examination of the nature of the relationship between the social structure and the NHC. There must be a co-operative posture between the new idea and the existing social structure within which it is planted. The new idea per se certainly does not determine any social action. Its success therefore is a function of the degree to which there are supporting elements within the social milieu. Apart from its relationship with the external world, the change Agent’s own internal stability is crucial for achieving its aims and objectives. In this regard the institutional theory becomes relevant to our analysis. 5 University of Ghana http://ugspace.ug.edu.gh Central to the institutional theory is the postulate that human aims are achieved through organization. It focuses on the fashion in which organized groups select specific purposes for accomplishment and fashion specific norms for achieving those aims. Three elements become fundamental to this focus. There is the concept of purpose, for the achievement of which members co­ operate. There is the concept of an institutional group; the group of members co-operating to achieve their purpose. Then there is the concept of the institution per se, the complex cultural expectations which are shared by the members of the given institutional groups. It is a fact that all institutions include prescription about the ways in which institutional goals shall be attained by the members of the group. This includes the recruitment of personnel, the definition of conduct of personnel, job specifications and the personal interaction of members within the organization. The interrelationship between the component parts of the organization on the one hand, and the relationship between the organization and the social structure of the recipient people - on the other hand, should form a part of the institutional framework. Determination of relationship as argued by Wessen (1951) becomes essential in social change analysis because it means in practice we can get at the variation in attitudes and influence of various personnel and sectors within the NHC. Thus individuals and parts of the NHC, like in all institutional settings, stand in a series of different relationship to each other- 6 University of Ghana http://ugspace.ug.edu.gh From this perspective, the success of any institution is based on its internal cohesion or the equilibrium of the constituents of the given organization. Following these trends, this study proposes the hypothesis that, the success of the NHC will depend on the degree to which the organization is integrated into the socio-cultural milieu of the recipient people, and also on the degree to which there is internal cohesion or equilibrium between the constituent parts. Background Review The co-existence of the modern and traditional medical systems have been documented in several societies. (Twumasi 1975, Melrose 1982, Standgard 1925). In Ghana for example, the two medical systems exist simultaneously (Twumasi 1975). This means that alternative and often competing medical services are available to the people. Throughout history, these two medical systems have confronted each other- Modern medicine has often demonstrated its hostility toward traditional health care which has been termed quackery and "witchcraft". Inspite of these misconceptions, many studies have shown that the use of the traditional healer is significant in the every day life of the people of Ghana and other developing countries (Jahoda 1961, Bonsi 1973, Hagan 1986, Djukanovic etc.) 7 University of Ghana http://ugspace.ug.edu.gh Press (1969) suggests that the phenomenon of resorting to both medical systems is so complex and cannot be understood in simple terms of "pragmatism", "appropriateness" or "acculturation". One needs to examine the manner in which patients evaluate a whole host of factors, beginning with their beliefs in the efficacy of treatment offered by a variety of healers and their relationship to the healers. Thus it must be realized that health consumers take many different paths to reach the goal of "relief". This puts the situation in a slightly broader perspective than Parson’s view that the sick has an obligation to seek care from the most qualified person - the physician. The shortcomings of the Parsonian concept of the sick role has been noted in relation with the "dual systems" approach to health care in the African perspective (Twumasi 1976, Gallagher 1976). According to Hagan (1982), the fact of Ghanaians resorting to multiple health systems could be explained in terms of the cosmological perspective they hold as a society. The Ghanaian places life and health in a global frame comprising three interpenetrating sections; the subliminal, the liminal and the super!iminal worldly realm. Linked to these are the respective powers of native medicine, allopathic medicine and Faith healing. 8 University of Ghana http://ugspace.ug.edu.gh Hagan explains that these three therapeutic systems in Ghana rest on three cosmological assumptions about nature and the source of healing power. One is the materialist assumption that nature is all matter, and healing power derives from material things. This premise then asserts the efficacy of materia medica to the total exclusion of spiritual means and rejects symbolic metaphysical rituals from medical kits. (Hagan 1982). Then there is the second cosmological assumption which asserts that whatever there is, is spirit or is spiritual. On this assumption, sickness could be dealt with entirely or mainly by spiritual and ritual means. Even where the rituals for healing presupposes the use of material objects, these are only seen as symbolic of spiritual agents. The third approach seeks to integrate the realms of material things and spirit for the resources needed for restoring health. To this school of thought, the universe has two dimension - spirit and matter. This latter approach is dualistic in its perspective. At any point in the progress of a disease and with respect to any disease, material or spiritual resources and techniques would be given greater or less emphasis. 9 University of Ghana http://ugspace.ug.edu.gh Pathways to health care are thus seen as completely "open". According to Kong-Ming New, (1977) a person seeking health care may take a number of paths, of which the following represent only some; a. he may start out by seeking advice from the lay referral system and end with health care in the professional referral system along the lines which Freidson (1961) has suggested. b. he may start with advice from lay persons who then may suggest that he takes the "deviant" path to traditional healers, for either advice or care. These persons then may never enter the orbit of the professional physician. c. he may enter the"western" medical system but find little or no relief and seek the services of traditional healers. d. he may seek the services of orthodox medicine and traditional healers simultaneously (Twumasi 1975, 1988, Hagan 1982, Janzen, Melrose 1982). This endorses the idea of an integration of the two medical systems. The introduction of the concept and policy of Primary Health Care (PHC) some decades ago, has promoted the idea of the collaboration of modern medicine with traditional medicine in national health care systems. The main focus, however, has been on the Third World countries whose populations are largely rural and poor with little or no modern health care facilities. 10 University of Ghana http://ugspace.ug.edu.gh The task of providing adequate modern health care facilities for the majority of the people in Developing Countries has been very problematic. In Ghana, for instance, the funds available are grossly inadequate. The modern medical facilities are therefore more or less limited to the urban minority, neglecting a large section of the rural population (Ofosu-Amaa 1975; Ewusi 1978). Even in the few cases where modern medical facilities are provided for the rural populace, these f a c i l i t i e s a r e understaffed and under-equipped (Twumasi 1975: 81-85, MOH 1988, Twumasi 1988). Traditional medicine on the other hand is used by a significant number of people every where, and is often the only health system that the majority have recourse to when sick. The acceptance and reinforcement of traditional medical practices are logical consequences of PHC which emphasizes community participation, with people contributing their own resources and sharing responsibility for health development. Since 1978, the World Health Organization (WHO has been promoting the PHC idea in an attempt to transform the old model of urban-centred curative health care into a community-based PHC. In this respect, WHO urged Third World governments not to rely exclusively on western-type or western trained physicians in attempting to provide Health Care for all their people. They have been advised therefore to aim at "a synthesis ... between the best of modern with the best traditional medicine" (WHO 1979). 11 University of Ghana http://ugspace.ug.edu.gh Following this trend of thought, WHO started promoting international programmes on traditional medical practices which include; the retraining of traditional practitioners i.e. herbalists, bone-setters, and Traditional Birth Attendants (TBAs); the selection of essential traditional medicaments and techniques for use in PHC and the promotion and development of basic and applied research in traditional medicine (WHO, 1978). In Ghana, quite a few attempts have been made to positively encourage the collaboration of the two medical systems. Retraining of TBAs in Ghana dates back to 1970 when the Danfa Comprehensive Rural Health and Family Planning project took off. In 1975, the Ministry of Health, with the assistance of WHO, also established the Brong-Ahafo Rural Integrated Development project at Kintampo to train middle-level personnel for the proposed PHC programme. An attempt was made towards the promotion and development of basic and applied research in traditional medicine. In 1974, the Centre for Scientific Research into plant Medicine was established at Mampong. The aim was to encourage research into and the dissemination of information on herbal medicine. It is ideally meant to be a collaborative effort between the traditional healers and scientists. 1 2 University of Ghana http://ugspace.ug.edu.gh Evidence suggests that except three attempts (all in Ghana), no African country has actually attempted retraining general traditional practitioners. (Wondergem and le Grand 1986). The three examples in Ghana include attempts made under the "Primary Health Training for Indigenous Healers’ programme" (PRHETIH) 1979, in Techiman to retrain general traditional practitioners. A similar course has been set up in Dormaa Ahenkro (Fink, 1987). Also in the Nandom area, Upper-West region, experiments were carried out with the Co-operation of modern and traditional practitioners (Horst, 1985). The limitation of these programmes was that, after the retraining, the healers were left alone again to practice on their own. No continuity in the collaboration of the two medical systems was enforced after the retraining programme. General traditional healers were therefore not integrated into the modern health care system under these projects (Warren et al; 1982). It is evident therefore that, no African country has actually attempted an organized system that would forge the collaboration of both medical systems in an integrated approach towards health care - on any large scale. There is the interesting work in Aro - Nigeria, where Lambo introduced the use of traditional methods (ethno-psychiatry) to supplement modern psychiatric care. But we must say that by and large, the Region has very little practical experience of the integration of these two medical systems. 13 University of Ghana http://ugspace.ug.edu.gh In the wider world however, the best results have been achieved in Asia, where collaboration is facilitated by an organized system of indigenous medicine whose infrastructure "parallels" the national health system. (WHO, 1985, Djukanovic and Mach, 1975). The two medical systems may not necessarily be under one roof, but the collaboration is facilitated by this organized system which gives recognition to the role of the traditional healing system alongside the modern system. Expert opinions on the benefits of combined modern and traditional health care are divided, especially regarding the desirability and effectiveness of incorporating Traditional Medicine into national health systems. Many political, cultural and emotional arguments have been put forward for and against integration.* These discussions mainly concern general aspects of the relation between traditional and western medicine. They deal with the unfamiliarity of modern health personnel with traditional medical cultures and the lack of a sound scientific basis for the traditional practices. These debates however have no direct empirical background of a project which attempted the integrative model of health delivery. They are therefore rather speculative. 14 *See for example Bichman, 1979, McDonalds, 1981, Phillsbury, 1982, Velimirovic, vdGeest, 1985, Streefland, 1985, Oku Ampofo and Johnson Renauld, 1978, Twumasi,1985, Warren and Green, 1988, Green, 1988, Bannerman, 1983. University of Ghana http://ugspace.ug.edu.gh The controversies emphasize the need for a more systematic study of the phenomenon. This is where the essence of studying the Nazareth Healing Complex (NHC) becomes all the more important. The NHC in Vane, Ghana, as explained already, has been noted as the only attempt to forge the collaboration of the two medical systems (seen in three strands of faith, herbal and modern healing) under one ’roof’. However, it must be noted that, given the heritage of mutual suspicion between orthodox and traditional healers and the lack of communication and understanding about each other’s diagnostic and therapeutic methods, it is evident that something more than formalized institutional arrangements will be needed if this potential is to be fully harnessed and integrated into the overall national health service. It is in the light of this that Ojanuga (1981) asserts that the success of an integrated policy would depend on the willingness of orthodox and traditional doctors to work together, that is, how willing would the doctor be to share his position and prestige with traditional healers? This is certainly a controversial issue. However, the works of a number of social scientists in the field have given clues to some expectations. In his recent work on Professionali zation of Traditional Medicine in Zambia. Twumasi (1984) found that 66% of medical personnel expressed positive views on the question of the integration of modern and traditional healing systems. 15 University of Ghana http://ugspace.ug.edu.gh They argue that the field of modern medicine would benefit from co-operation especially in treating social and psychological illness. Again 84% of modern doctors and nurses emphasized the positive role that traditional healers can play in the Primary Health Care programme as ’Community Workers’. In an earlier study on the way magic and science work in Western Yunnan, Hsu (1355) described how traditional healers and western trained physicians had to work side by side to eradicate a cholera epidemic rampant at the time. Because the Chinese did not understand the effectiveness of western medicine, more traditional methods also had to be used. Hsu concludes that any attempt to introduce new knowledge or new techniques in a foreign setting will benefit from the realization that all communities respond to these attempts according to premises implicit in their own cultural traditions. Another classical example of how traditional healers co­ operated with western medical doctors in a refugee camp in Thailand highlights the theme of "the law of innei— necessity” and co-operation. A psychiatrist, Dr. Hiegal (1382) writes that in 1379 many Khmer fled from their villages and sought refuge in Camps in Thailand. The International Committee of the Cross (ICRC) and other humanitarian organizations had to provide for the needs of a sudden influx of people uprooted from homes, exhausted by famines, suffering, fear, sickness and the ravages of war. 16 University of Ghana http://ugspace.ug.edu.gh A number of people suffering from mental disorders were rejected by the Khmer population whose own lives were so fraught with problems on every side that they did not tolerate the "misfits". Their admission to hospitals frustrated the medical teams and disturbed the other patients. In the long run a programme co-organised by modern and traditional medicine practitioners was suggested. Refugees with a painful organic complaint attributed their affliction to supernatural causes and believed themselves possessed, behaving in a way that might appear pathological in the orthodox psychiatry nosology. Patients were first examined by an orthodox doctor or nurses and treated by a traditional practitioner. Traditional treatment and orthodox treatment operated in separate places. The traditional healer however, did not hesitate to ask the opinion of modern doctors when he feels there is a risk involved in a case. Thus there was a referral system between the two health systems. Occasionally a case was discussed and a traditional form of treatment was at times decided on under supervision. Indeed, the relevance of these examples for this study cannot be overemphasized. One salient realization in this union is "the law of necessity" which enhanced the co-operation of the two systems. Thus, this union has emphasized the premise that, the integration of the two systems into a comprehensive system of health care results from forces which pull them together and govern their participation and association without generating i nferi ori ty-superi ori ty 17 University of Ghana http://ugspace.ug.edu.gh complex. Such a union is a function of the confidence the western medical doctors put in the traditional healers and the complementary role of each of these systems towards the realization of the goal. It must be interesting therefore to find out in the case of the NHC, the response of the community to the new model of health care. The gains are quite enormous. The literature reviewed show that in the Ghanaian social structure, patients tend to shop around for health care. From the population’s point of view it must appear that the new model of NHC has created the situation in which the various health items (herbal, faith and modern health system) for which the people shop around are brought, as it were, under one "roof" to their very dooi— steps. This is in a bid to forge co-operation between these health approaches so as to cater for the total health needs of the people. Our interest therefore is to find out the role of the NHC in achieving this goal. Questions like - "what is the nature of the interrelationship between the parts of NHC, on the one hand, and the community on the other? What are some of the problems and issues emerging from these attempts?" - become pertinent issues for our analysis. Methods The field work which was carried out from January to November 1988 adopted three methods for collecting data: participant observation, in-depth interviews and questionnaires. 18 University of Ghana http://ugspace.ug.edu.gh Participant observation technique was the initial method used. During the first phase of the study, the author and his assistants spent some time participating in the society and observing trends in order to design the appropriate approach to the study. This method made it possible for us to elicit the content of social behaviour, and the general attitude of community members towards health and illness issues. Apart from participant observation, specific information was collected through semi-structured interviews. Interviews were held with key informants including, healers, health personnel at NHC, health officials at MOH - Ho -, drug sellers, opinion leaders -chiefs, elders, pastors- patients and various people within the community with whom a good personal relationship was establi shed. Questionnaires were also used to obtain most of the socio­ economic data. Field assistants, specially trained for the exercise, administered these questionnaires through conversational interviews in a community survey.* Illness episode monitoring for the collection of information on the morbidity pattern in Vane was conducted as part of the community survey. Households were the sample unit. 19 ^Copies of the different questionnaires are in Appendix A University of Ghana http://ugspace.ug.edu.gh Households are defined as all people who are fating from the same pot,. Not more than one household per house was included in the study to avoid previous knowledge of the contents of the questionnaire. Houses were considered as clusters containing several households. The methods used involved serial numbers (using chalk on the walls) of all buildings in Vane (in which people sleep). A systematic sampling procedure was then employed. We depended solely on the random numbers compiled by White el al (1 979). A sample size of 664 people from 141 households were involved in this study which is approximately 30% of the population of Vane. To av'o id the built-in limitations of household morbidity surveys, that is, relying on the memories of respondents for data on illnesses, the author tried to ensure that all illnesses which occurred wi thin the selected households were detected each day and recorded. A member of each household was asked to keep a health calendar for all household members for a period of two months. Follow-up interviews wore carried out for tni ght-ly with household members based on the information from the calendar.* *Li terHt.e school children were employed in this exercise of recording. Adult sick persons were interviewed but parents were int.erv iewetl about disenses in children below the age of 10 years. University of Ghana http://ugspace.ug.edu.gh Morbidity data and attendance statistics of the health centre of NHC were quite scanty and for only a few number of years. Morbidity data were available only from the period August 1987 to December 1987. Attendance statistics were available only for the years between 1982 and 1987. These were obtained from the figures sent to the regional office of the Ministry of Health - Ho. In the case of the herbal department of NHC, data from the record books kept by the Assistant Herbalist were used for our analysis. For comparative reasons, we have used the data collected over a period of two years - 1986 and 1987. Visits of clients who came for a second or third time for the treatment of the same diseases were excluded. The recorded data included; name, age, sex, address and ailment of clients. For practical reasons only patients living inside, or within four kilometres of Vane were interviewed. The Faith Healing Department however lacked adequate records. A research assistant therefore recorded attendance at every prayer/heal ing session for a period of two months - between July and August 1988. All the people who utilized the facility at the time were recorded. There was a high degree of consistency in the regularity with which the names recorded at the initial stages kept recurring till the end of the two months. This emphasizes that the department was more or less a sect with identifiable membership. People who turned up were recorded only once. The data collected included name, sex, occupation, educational level, year of membership and reasons for coming. A total of 35 interviews were held. 21 University of Ghana http://ugspace.ug.edu.gh Limitations of the Method The sampling unit, as explained, was that of households. One housing unit consisted of several households. The concept of household was defined as all permanent residents eating from the same pot. The impression is that a household forms a social and economic unit. However, practical difficulties were encountered in putting this concept into operation. It was difficult sometimes to tell to which household some people belonged. Their eating places were not very fixed, and they belonged by our definitions to a number of households since they ate from different "pots" e.g. father and son may eat together even though this son may be married, and therefore sometimes eats in his wife’s house. This is mainly because accommodation is a difficult problem in Vane, and the household unit is hardly the residential unit. Secondly, most family heads normally insisted on including all their children in the household, even where some of these are independent of his "pot''. To the family head, the family bond was the most important. Because of this it was quite difficult sometimes to identify people by their households. The solution was for us to cross­ check each time so that we do not have double counting problems. This was made easier mainly because the research team lived with the people and became familiar with the individual community members. 22 University of Ghana http://ugspace.ug.edu.gh Operational Definitions 1. Self-Care: The term here? means the process whereby a lay person functions on his own behalf in decision-making on health, in disease prevention, detection and Lreatment.* We discern two forms of self-care; use of pharmaceuticals and use of plant medicine (Herbs). These we refer to as self medication. Other forms of self-care, for example personal prayers, and massage are also fmportant aspects of self­ care practice, 2. Faith Healing: As used here means the use of spiritual means within the principles of the Christian religion, as healing power. This approach might, use material objects like; the cross, incense, blessed water and Florida water. These objects, however are used on account of their symbolic significance along with Christian worship and prayer. 3. Traditional herbal treatment : riy this we mean the use of therapeutic extracts from sources like plants, animals and minerals, with or without mag i co­ re? 1 i g i ous rituals, as therapeutic device. 4. Professional treatment : The term i.n this context means the use of both modern medical treatment (within formal institutions) and herbal treatment by socially recognised traditional practitioners within the. c.ommun i ty . ♦Adopted from Levin 1983. University of Ghana http://ugspace.ug.edu.gh 5 . Acceptabil :i. ty : The term here is interpreted to mean appreciation by consumers - both individuals and (.he coimnuri i l,y of t.he health services at their disposal. Acceptability can be shown in a number of ways; by statements made; by community members during community survey and patient surveys as well as the level of utilization of the services of the NHC. Under-utilization may imply rejection of the services while over-util i nation may indicate inadequacy of the services provided. 6. Integrated/holistic approach to healing: The term as used in this thesis means t.he act of bringing together the modern and the traditional healing systems in a symbiotic: relationship towards a holistic medical perspec t i ve. 24 University of Ghana http://ugspace.ug.edu.gh Structure of the Report This study comprises five chapters. The first chapter sets forth the problem, the background theoretical information, the objectives of the study, the method of study, operational definitions and the structure of the report. Chapter two deals with the social structure of the Vane community. It provides the background from which to analyze the role of the NHC and the attitude of the people towards it. In chapter three, the Nazareth Healing Comp 1 ex is discussed, its structure, philosophy and history. The chapter also deals with the dynamics of the constituent parts of the NHC - the Modern Sector, the herbal sector and the Faith Healing Departments. In Chapter four, the general problems and issues of the NHC as a project are discussed. The last chapter deals with some of the conclusions, the implications and recommendations of the study. 25 University of Ghana http://ugspace.ug.edu.gh ab Fig. 1 LOCATION OF VANE IN THE VOLTA REGION OF GHANA L E G E N D © S t u d y A r e a E3 R s g i o n a l C ap i to l o O t h e r T o w n s I n t e r n a t i o n a l B o u n d a r y ________ Reg iona l ' B o u n d a r y L01'9 0° O [ r I H / > rJ \JasikanO / / 80 KMj I University of Ghana http://ugspace.ug.edu.gh 27 CHAPTER TWO THE SOCIAL STRUCTURE OF VANE I n~t roduct i on An overview of ethnography of Vane Community is necessary for the understanding of the people and their attitude towards health and health-care. The chapter discusses the geography, a brief history, the family structure, economic activities and community participation in development. Geography Vane is an Avatime village, 25 miles north of Ho, and about 185 kms. from Accra. It is located on the elevated grounds of the central part of the Akwapem-Togo ranges which rise to about 3,000ft. at Amedzofe and a small area of lowland to the North­ West where Dzokpe and Fume villages are located. It is basically an area of forest-clad mountains intersected by a deep valley along which the villages are scattered. The mountain ranges are formidable barriers and it is not surprising to note that the people of each of the seven villages of Avatime share a sense of unity and feel that as a unit, they are different, compared with people of the other villages of the area. Vane is the traditional capital of the Avatime area. The elevation is sufficient to give much cooler climate. University of Ghana http://ugspace.ug.edu.gh A dusty road from Ho through Vane and Amedzofe linking the main Accra-Hohoe trunk road is the only motorable road in the area. In the rainy season it becomes extremely difficult to reach Vane when the road becomes inundated and gulley erosion makes it impassable. During such periods, vehicles do not come to Vane. People have to walk over eight miles to the junction at Fume or five miles to Dzolokpuita to join passenger vehicles, even in periods of emergencies when sick people are involved. The topography of the place however influences the health of the people. As will be discussed later, health problems here include bodily pains, waist problems and injuries. These are positively related to the mountainous nature of the place. The People: (History) The people of Vane claim that their forbears migrated from Ahanta in the present day Western Region of Ghana long after the main Ewe influx into the Volta Region. Linguistically, the people of Vane (Avatime) speak a language called Siyasa. According to Ford (1971), this language is characterised by a noun class system, with a degree of concordance and apparently unusual tone system. It is generally placed in the western "kwa" group of languages. However the Ewe language has become the 1ingua-franca for both native and non-natives. 28 University of Ghana http://ugspace.ug.edu.gh The arrival of Christian missionaries in the 1890s had a tremendous impact on the life of the people. Education and Christianity are greatly valued by the people and non-Christians and illiterates are usually assigned to the periphery of social 1 ife. Today, the Christian Churches in Vane include the Evangelical Presbyterian Church, the Apostles Revelation Society, and Roman Catholic Church and the Pentecostal Church. Vane has two primary schools, a middle school, one junior and one senior secondary school which serve the educational needs of some of the surrounding villages as well. Family System The key to the understanding of the Vane family system is through the patrilineal descent principle which is based on clan organisation. Clans at Vane are localised. There are eight clans - defined as a group of people who claim descent from one or several agnatic forbears who migrated from Ahanta. All the clans are also segmented into lineages. In Vane, the lineage is a localised kin group and has practical control over land and succession to various social offices for which a lineage may be designated - priesthood, royal family and land owners. The smallest group on the scale is the residential unit. A residential unit is spatially isolable in that it consists of a series of buildings. Agnatic descent therefore forms the basis for the relevant groupings in Vane village life. Of these groupings - lineage, clan, village - all have spatial correlates. 29 University of Ghana http://ugspace.ug.edu.gh Ward’s findings in 1950 show that there were a number of female-headed households in Vane. Ward did not say how many female headed dwelling units there were but our observations reveal that the phenomenon is quite common in Vane at the time of this research. Perhaps this may be due to the high rate of migration. Both Ward (1950) and Brydon (1976) have noted that, most Avatime (Vane inclusive) people live and work away from their villages for most of their working lives. Migrants however maintain permanent links with the villages and always return home to settle after retirement. Economic and Demographic Characteristics According to the census office, in 1984, Vane had a population of 1,800. Primary subsistence farming is the main economic activity of the people. However, a small proportion of farmers also engage in cash crops. The missionaries introduced cash crops such as cocoa, tea, coffee, and potatos to the area as early as the 1890s. Generally, the farmer here balances his activities in a harmoniously diversified manner, the land being his main source of livelihood. The system for farm cultivation is mixed-cropping - cassava, yam, potatoes, maize, rice, beans, plantain, banana, oranges, pears, etc. Indeed, there is both adequate rainfall and suitable climate to provide for crops. 30 University of Ghana http://ugspace.ug.edu.gh However, farming at Vane has a lot of problems. The land surface is rocky. It is relatively unsuitable for arable farming or mechanical system which would make for big scale economic venture. The people of Vane depend solely on the use of simple implements such as cutlasses and hoes for the cultivation of the land. Bush fallowing, especially the rotation of the fields is still a dominant practice even though the population pressure on the land has greatly limited the practice now. The rocky nature of the land is the limiting factor. Manual work becomes the first string. The people use pickaxes for planting and harvesting root crops. The farms are also far removed from Vane. They are mostly situated in the valleys behind the mountains. It means that the farmers have to wake up early at dawn and trek up and down the hills for some 3 miles to the farms. There are a number of other income-generating activities in Vane but these are quite few. These include teaching, corn- milling, petty trading, art and crafts. 31 University of Ghana http://ugspace.ug.edu.gh Political System The political system of Vane is evolved around kinship and lineage groupings. The people stand together, relatively autonomous and different in the eyes of the Ewe people surrounding then and certainly in their own views. Vane is territorially divided into two compact areas of habitation - known respectively as Tsadome and Osorpome in respect of the two major clans. Each is further divided into four sub-clans, thus making up the eight known clans of Vane- Avatime. The two major clans have their chiefs respectively. The Osie is the Chief of the Osorpome, but he is the Paramount Chief of Avatime Traditional area as well. The Chief of Tsadome is therefore responsible to the Osie. A well developed form of democratic procedure has been evolved for settling disputes and distributing duties in the society. Vane has evolved an almost ideal, fanatical sense of difference, of social cohesion and of intense group loyalty. These sentiments are exploited to effect social development projects eg. schools, toilet facilities, clean drinking water and the maintenance of roads - keen community participation. The spirit of self-reliance therefore has great implications for health and related issues especially in relation to environmental sanitation and other contributions towards health development. 32 University of Ghana http://ugspace.ug.edu.gh 33 Existing Medical Systems Health Conditions The Vane community is served with pipe borne water from a spring up the mountains. There are two public latrines, and two dunghills. Relatively, because of the elevation, the Vane (Avatime) community enjoys a cooler climate and low population of snakes, scorpions and mosquitos. As part of the community survey, data were collected o n morbidity patterns at Vane through a household survey. This is intended to serve as a backdrop against which the utilization of Health Care services could be assessed. The health problems mentioned included the following: malaria, pains and bodily weakness, stomach troubles and diarrhoea, cough and throat pains, ear and eye troubles, fractures and dislocations, menstrual problems, hypertension and heart problems, boils hernia, piles, asthma and mental disorders. University of Ghana http://ugspace.ug.edu.gh Table 1: MORBIDITY PATTERNS AS PORTRAYED BY ILLNESS EPISODE 33 6 DISEASE ILLNESS EPISODE : NO. : % Malaria : 40 : 32 .78 Pai ns : 46 : 37 .70 Pyrexia of unknown : 10 : 8 .20 origin other than malaria Diarrhoea : 4 . O . o 28 Cough and Colds : 4 . o. o 28 Boi Is : 4 . o. o 28 Asthma : 3 : 2 46 Skin diseases : - Ear and Eye troubles : 2 : 1 64 Fractures/Dislocations : 2 : 1 64 Other accidents : - - Barrenness/Menstrual problems : 2 : 1 64 Hypertension/Heat problems : 2 : 1 64 Complications in Pregnancy : 1 : 0 82 Anaemi a : - Mental disorder : 1 : 0. 82 Herni a : 1 : 0. 82 Pneumonia : - - Malnutrition : - - TOTAL : 122 : 100 SOURCE: Illness episode: (see Chapter 1 under methods). University of Ghana http://ugspace.ug.edu.gh Table 1. shows that generally, bodily pains/weakness and malaria/fever predominate while the incidence of diarrhoea and stomach trouble was low. The morbidity pattern shows that the major- health hazards were very much related to the environmental problems including geographioa1 hazards and working conditions; waist, leg, head pains, general bodily pains and weakness should be related to the topography. Malaria lias been of a high endemic nature. A significant proportion of cases in the sickness episode (32.8%) were of malaria. Ideas on Health and Disease As in all societies, the people of Vane have causal explanations for diseases. According to literature (Twumasi 1984, Fosu 1977, Senah 1981) cultural explanations and definitions of diseases are determining factors for the choice of therapy. Tn Vane, diseases are defined in l.erms of modern and traditional concepts. By and large however, interviews with opinion leaders irrespective of their socio-economic dispositions show that the people classify diseases .into two major types: - diseases caused by natural agents and those caused by sux>er natural agent,s - but there is a third which is not very clear - the natural/supernatural element. 34 University of Ghana http://ugspace.ug.edu.gh The contemporary world view of the people of Vane is therefore an admixture of modernized, traditional and Christian elements. By their cosmological assumptions, it is believed that illness may result from three main sources: (a) Natural elements including food, the sun, cold, dirt, blood problems etc. etc.; (b) Supernatural elements like witchcraft, ancestral spirits, personal soul, punishment from God etc; and (c) A combination of both natural and supernatural elements, especially depending on how long the natural sickness persists even after the usual remedies were applied. The reliance on any of these however depends on the individual’s social background, education, sex, religion and this in turn influences the choice of therapy. In the case of the natural elements, the belief is that the effective functioning of the human body depends, among other things, on the quality of one’s blood, and stomach conditions. The "dirt theory of disease causation" becomes paramount here. “Dirty blood" is deemed to account for many common kinds of malady. Bad blood may manifest itself in various forms of boils, infertility, menstrual disorders and piles. The blood may run short or may be in excess and these have their physiological manifestations. 35 University of Ghana http://ugspace.ug.edu.gh Excessive blood is termed hypertension and it is believed that Herbal medicine is the main solution to this problem. When blood is short, it may manifest itself in dizziness and fatigue, or bodily weakness. Herbal blood tonics are very common in Vane. In addition to these, the head and the stomach are seen as capable of accumulating dirt which causes ill-health when the body does not expel it. Retention of faecal matter is believed to be responsible for many physiological problems - headache, fever and general weakness. Herbal enema and purgatives are very common in Vane for these ailments. The head may also retain dirt in the form of mucus and phlegm. Local snuff, and herbal nasal drops are prepared as solutions. The Supernatural element relates to the belief in witchcraft and sorcery in the Vane system. Assimeng (1974) has observed that "the central focus of religious activity in traditional Ghanaian society seems to be the warding off of "honhom fi" from the affairs of men. No doubt therefore “the greater part of the set of beliefs in magic, sorcery and witchcraft which are the daily baggage in traditional Ghanaian religion are directed towards this”. (Assimeng 1974: 21). In Vane, this belief system has been grafted on and transfused into the Christian teachings about the Devil and its powers of evil. Indeed the majority of healing "testimonies" during prayer sessions at most syncretic groups are usually deliverance from such forces and most prayer sessions are devoted to “binding the devil". 36 University of Ghana http://ugspace.ug.edu.gh However, "spiritual dirt" through breach of taboos and norms may incur the displeasure of the ancestors and other spiritual agencies and create physical malaise and death. Various rites and ablutions exist for cleansing individuals and corporate groups of their "spiritual dirt”. These perceptions on the aetiology of illness are shared by a large number of the people - Christians as well. In times of health problems therefore, efforts are focused on whatever element is perceived to have precipitated the condition. Patients and healers share the same perceptions. Thus in the act of diagnosis, the healer’s authority is also shared by the client. Perhaps the views of the oldest practising traditional practitioner of Vane may give us clues to the general cosmological assumption and causal explanations for diseases and i11 ness; 37 University of Ghana http://ugspace.ug.edu.gh 38 We have different diseases but they can all be grouped under two main sources. There is the first group which we believe are naturally caused. These are day-to-day health problems; They are related to the workings of on e’s stomach, or the blood system, or just straight forward injuries on the farm, or too much of work, food, drink, sex, etc. or effects of the change of the weather; cold or hot, or eating fresh fruit and fresh "foods" early in their seasons eg. mangoes and yam. The average family elder, and most youths know some home treatments for such ailments. Indeed one may choose self medication by buying some pills at the wayside stores, use herbs at home, or go to the nurse for some injection. There is the other group of diseases that are caused by supernatural agents like sorcery, witchcraft and evil eyes. Diseases like gonorrhoea may be natural or supernatural depending on the causal agent. Gonorrhoea may be contracted through magic by a rival. In such a case the problem is a supernatural force and must be treated by traditional specialists. Another shade of this is sickness brought about as a result of "spiritual dirt". This is punishment from ancestral spirits where the people or a person breaches the taboos of the clan. He must be given a ritual-bath, and the ancestors must be appeased. These problems cannot be solved by the modern doctor... The above classification system has been observed in many societies by various Anthropological studies. Twumasi (1975, 1984) Warren (1974) Nukunya, Twumasi and Addo 1976). Fosu (1977) for example observed in his ethnographic study of the Berekuso of Ghana that there are diseases whose causes are found in nature on the one hand, and those which are caused by supernatural agents on the other- However, unlike other studies, Fosu has established the third category of the natural/supernatural causation. This however was not fully accepted by some practitioners University of Ghana http://ugspace.ug.edu.gh 39 When further explanation was sought in this specific direction, the old traditional healer had this to say: In reality only these two extremes exist. What you call the natural/supernatural category is usually a limitation on the part of most healers. The healer’s inability to discern appropriately at the first go, the primary source of the problem at hand, may be responsible for this assertion. Thus in his diagnosis he may fail to detect the exact source of the problem. He may therefore assume that it is a natural problem at the preliminary stages. It is only when the problem defies the treatment he gives that he may wake up to the reality. Nevertheless a natural case could be hijacked by spiritual agents and made worse; perhaps that is what you termed natural/supernatural. But an expert diviner sees it clearly at the very first go as a supernatural case that has become the driving force behind it. However, in the view of the lay public, Fosu’s assertion of the third category of natural/supernatural elements have been commonly acknowledged. The cultural definition of natural ailments however may not necessarily be identical with the definition of modern medicine. A cultural theory explains the prevalence of malaria for example, and this explanation is the single factor that determines how this problem is cured traditionally. University of Ghana http://ugspace.ug.edu.gh 40 In the opinion of a 70-year-old traditional healer of Vane, The Whiteman’s medicine says mosquitoes are the cause of malaria, but in Vane mosquitoes are rare and yet still malaria is endemic. Our malaria is therefore not caused by mosquitoes. Our malaria is caused by too much manual work in the fields. Excessive work under the sun, without any adequate resting may result in the blood system generating heat. Since the blood flows in the body, the heat is carried to all parts. The stomach becomes inactive when the heat is too much. The bowels are closed and constipation engender the settling of dirt in the stomach. The dirt enters the blood stream and it is the cause of the restlessness, bodily weakness, general bodily pains, fever, dizziness, and nausea which are associated with fever and malaria. No doubt, the local treatment for malaria includes purging and draining. The sick may be given enema. As will be seen later, orthodox treatment using injections is highly valued for partial treatment of malaria since it is believed to give faster relief to the fever. However the complete cure of malaria, according to the beliefs of the people, "is through the combined use of herbs and i njections”. The complementary use of herbs and injections in treating malaria becomes plausible if we consider the background cultural assumptions about the effects of both treatments on the body and the disease. There is the idea that, the hypodermic needle reaches the blood stream directly with the medicine which brings down the temperature at a relatively faster rate than swallowing medi ci n e . University of Ghana http://ugspace.ug.edu.gh No doubt, in most cases, the efficiency of a medical treatment is often judged by the willingness of the medical personnel to give injections. This, among others, is a principal reason for the near failure of the Village Health Volunteers under the Primary Health programme in the surrounding communities since they are not to give injections. Quack doctors therefore dominate the market because they satisfy the demands of the average person in these communities. In the people’s perception however, the ultimate cure for malaria must involve the removal of the dirt in the blood and the stomach, this is the role of herbal medicine in malaria treatment. Health Resources Introduction Our discussion here gives an overview of the health resources including the Basic Health Services and the Community - Based health care systems in the locality of Vane to which the people have recourse when sick. This is to serve as background to the understanding of the nature of the relationship between the original health systems of Vane and the NHC innovation which impinges on these. Basic Health Services At the time of this research, the area enjoyed a number of public basic health facilities. Most of these facilities - especially the Hospitals - were not precisely in the traditional area of our concern but if we map out where individuals are wont to go for health services, a comprehensive "Health Community" evolves. 41 University of Ghana http://ugspace.ug.edu.gh S c m - A s h 1 2 / 8 8 University of Ghana http://ugspace.ug.edu.gh The orthodox facilities included the following:- The NHC Health Centre within Vane itself, and the kpedze Health Centre (about 5mi1es from Vane) were the only Health Centres in the immediate environment. The health posts included; Liate Catholic Mission Clinic, Dzolo Clinic, Hlefi, Amedzofe and Nyagbo-sroe clinics (an average of about 6 miles from Vane). There is also one Dressing station at Dzolokpuita (5miles from Vane) and four hospitals in the area - including Anfoega and Hohoe government hospitals, and two hospitals in Ho (an average of about 20 miles from Vane). In addition to these, there are a number of private clinics in towns surrounding Vane and about 8 primary health care centres in the immediate communities. Community-Based Health Care Introduction Under this, we shall discuss the common health care services within Vane which are outside the public health system of NHC. These include unofficial dealers in pharmaceuticals, store keepers, itinerant drug sellers and traditional healers. Unofficial Sources of Pharmaceuticals The sources of pharmaceuticals in Vane are many and often involve complex relationship of familism and patronage. To a large extent, this complex situation is a function of the peculiar health needs of the people, poverty, as well as the structure of the official health care facility at their disposal. 42 University of Ghana http://ugspace.ug.edu.gh The Ministry of Health (MOH) is responsible for the supply of drugs for the Health Centre of NHC. Apart from this, as a Mission Centre, the NHC clinic also benefits from The Christian Health Association of Ghana (CHAG) supplies of drugs to complement the efforts of MOH. However, the absence of any effective drug monitoring system and the high demand for pharmaceuticals have enabled private drug sellers to make some inroads. A haphazard, uncontrolled system of drug distribution has evolved: Various small shops and a number of lay members of the society sell pharmaceutical products. As we shall see later, this has dwarfed the significance of the role of the "NHC modern sector" through self medication. In most cases, to avoid the payment of consultation fees, patients auto- diagnose and auto-prescribe. Where the latter involved injectables, these are bought from the small shops, or individual dealers, or nurses. Injections are administered by quack doctors and unofficially by nurses of the Health Centre at home for a lower fee. Injections are also administered by retired nurses and other retired personnel who illegally practice at home. Such treatments are not only cheaper than the fee paid at the clinic, but they are also more convenient to the patient since he could go to his farm at dawn and work the whole day, then consult the "Physician" at home in the night. Given this complex nexus of demand and supply, dealing in pharmaceuticals in Vane has become a lucrative business. 43 University of Ghana http://ugspace.ug.edu.gh Traditional Healers Introduction There are four main types of traditional healers in Vane. They are classified as Traditional Birth Attendants (TBAs), General herbalists, Diviners and Faith Healers We shall discuss these in turns. The Traditional Birth Attendants The Traditional Birth Attendants are the traditional midwives. They focus attention on obstetrics, assisting delivery of children and seeing to the health of mothers. Before the introduction of the maternity clinic of NHC, TBAs were the sole midwives for the people. It was a part-time family occupation, and usually considered as service to the community not necessarily for pecuniary purposes. In almost every clan or lineage, there are old experienced TBAs who deliver their own kins to replenish their stock. Thus TBAs tend to have intimate knowledge of their clients. Indeed they share a common belief system. In time of complications during delivery, this belief system becomes the means by which solutions are sought. In some cases the TBA may call for the services of a Diviner to diagnose the given problem. In other instances, she may rely solely on her knowledge of herbs and other medicaments. Various herbal preparations are used by TBAs for massage, insertions for expectant mothers and for spiritual protection of the mother and the baby. 44 University of Ghana http://ugspace.ug.edu.gh 45 TBAs are very important individuals in the rural community of Vane. They are usually elderly women who played very important roles in the nubility rites. They are the resource personnel during these rites. They treat topics relating to sexual reality, that is relationships between man and woman, sexual roles, social norms for sexual behaviour, sexually transmitted diseases, motherhood etc. They are the marriage counsellors of the community. As mothers of the community, TBAs are the authorities on traditional family planning techniques. In the words of one elderly TBA of Vane; Contrary to what the nurses think, we had ways of birth control, using our own methods of planning and use of herbs, long before they (nurses) were born. Why do they think that we are as prolific as rabbits? Traditionally, a man married several wives and spent nights with the different wives as he may wish, but it was taboo for him to "sleep" with a wife who is breastfeeding...his semen could poison the breast milk and the suckling child could d i e ....Weaning took between two to three years and most times the pregnant wife leaves the husb an d’s home for her own family (of orientation) to deliver and time enough for we a n i n g. ..Stigma was attached to a family with "weak" chi 1 d r e n ....y e s , the simple code was; have a lot of children, but donot have them too close. Gossip and "malicious pity" safe-guarded the code and we knew the periods of every month when a woman could "sleep" with a man without any fear of getting p r eg na nt ....or d o n ’t you know that a man can "withdraw himself" before he ejects the "life- giving-fluid?" ... .These are taught when girls are n u b i 1 e ....that is one purpose for the nubility rites. However, the old TBA accepted the fact that the society itself encourages the possession of large families. University of Ghana http://ugspace.ug.edu.gh Only two TBAs still exist in Vane. Social change has greatly eroded their role in the community. Though they were retrained under the Ministry of Health, the womenfolk no longer patronise their services after the NHC with a maternity wing was introduced. Nevertheless, these TBAs still play some minor roles in the society especially in the preparation and sale of blood tonics and treatment of some health problems peculiar to the female gender. Though now very much different because of the effect of Christianity, nubility rites still exist in Vane and so the role of TBAs in this field. General Practitioners (Herbalists) They are the most common of the traditional practitioners in Vane. Their approach to healing is related to the use and application of therapeutic extracts from plants, animals and minerals. They are often called herbalists since herbs are invariably the most common component of their medicaments. In Vane, herbalists include specialists in bone setting and general medicine. Most of these practitioners had undergone a long period of training under mentors (Twumasi 1975: 25). This training was done within the context and practice of magico-rel i gious rituals. Their long socialization, code of ethics and reference were the traditional beliefs and values. With the advent of Christianity, education and orthodox medical practice however, the position of these practitioners within the Vane community was threatened. Almost all these healers in Vane were influenced by social change. Most of them accepted Christianity and were baptised into the Church. 46 University of Ghana http://ugspace.ug.edu.gh Despite the effect of social change on their practices, the underlying beliefs and practices including the spiritual, intrinsic powers of herbs, ancestors, ghosts and relics, beliefs in sorcery and witchcraft; are still important aspects of their causal explanations of health and disease. They also use "the dirt theory of disease". On the other hand in Vane, there is the emerging group of healers Bonsi (1973), Jahoda (1961), and Twumasi (1984) have termed 'new- healers". These are practitioners whose underlying tenets of practice are relatively related to modern medical practice. They see herbs as therapeutic substances per se and not necessarily as having any intrinsic spiritual powers which effect healing. These neo-herbalists therefore do not use any magico- religious rituals in their practices. The Diviners The third category of traditional practitioners in Vane are the Fetish priests and Diviners. In Vane itself, only one person was known as a diviner. 3ut one other diviner was stationed at Dzogbefeme, a quarter of a mile from Vane, and two others were stationed at Dzolokpuita - some 5 kilometres from vane. There was however evidence that people from Vane patronise the services of these other diviners - perhaps because they were situated in other villages, and thus consultation could still remain relatively confidential, the anonymity of the client ensures the secrecy. 47 University of Ghana http://ugspace.ug.edu.gh The author and his team had the opportunity of accompanying the diviner of Vane on some of his rounds and healing sessions, and we were privileged to be participant observers in two consultative sessions of the two diviners at Dzolokpuita. Diviners use methods of possession, casting of bones and other ritual means to diagnose and to effect healing. They claim they are only vessels through whom the deities and spiritual agencies speak to clients. The “casting of bones" by the Diviner is a whole panorama of symbols - bits of plants, organs of animals, - bones, skulls, claws, etc. stones, cowries, palm kernel etc. are used. The Diviner fills in the hiatus by verbal interpretations of proverbs which are quite pliable. When he is satisfied with the diagnosis of the problem, the Diviner may resort to an interviewing technique to get more information. The basic theoretical tenet here is that social relationships have a telling effect on the health of a person. Enemies may cast spells to limit a person's progress, wealth and peace. Thus such tenets take into consideration social and psychological dispositions in understanding health problems. Diviners charge fees for their services, however for purposes of rituals, clients were usually asked to bring food items like palm oil, goats, sheep fowls and eggs etc. for sacri fi c e . 48 University of Ghana http://ugspace.ug.edu.gh Social change has affected these practIces considerably. In a predominantly Christian society like Vane, stigma is attached particularly to the practices of diviners. On their part however, some of the diviners regard themselves as C h r i s t i a n s since they have been baptised into I he church. The Chief Priest and Diviner of the cult in Vane for example alleged he was baptised into Lhe church in 1 94 1 ... "before being called by the gods to serve at the shrine". Until his death (during this research project), he held that he was a Christian. He explained that the Lord’s supper was the only Church sacrement that he avoided - his reason was clear: "....because T have two wives and it is taboo to the Christian Got) for one to join in "the sharing of bread" on the holy table when one has more than a w i f e . " The clients of diviners include all social categories - Christ, ians, highly educated peopl e, poor, rich, government appointees etc. Most, of these consult the oracle under the cover of night especially in t.he case of Christians, to avoid social sanctions like excommunication from the church. 49 University of Ghana http://ugspace.ug.edu.gh The Chief Priest and Diviner of Vane was one of the seven traditional practitioners attached to the NHC herbal department as consultants during the second phase of the programme.* Faith Healing Before the advent of the NHC, the notion of Faith healing as a profession - full-time or part-time - was unknown in Vane. It used to be known or spoken of in urban circles, when migrants returned home with interesting awe-inspiring experiences and stories about the sectarian churches, Christian Fellowships and Open air Crusades in the city. They have brought home news about the Bonnke crusade, the Oral Roberts; Tommy O ’del, Derek Prince etc; with supporting posters to portray their illustrations about the thousands of people who flock there from all walks of life, for worship and healing sessions. The established denominations in Vane took some time to co­ opt this new dimension of religiosity into their churches. 50 *The phases are discussed in chapter 3. University of Ghana http://ugspace.ug.edu.gh Youth wings emerged and were accommodaLed in the varoius orthodox Denominations. The Catholic Charismatic Movement, and the Presbyterian Prayer/Bible Study groups respectively were of this calLbre. Apart from these denominations, Vane has a number of syncretic groups. These churches Included the Apostolic Church of Ghana, the New Covenant Church and l.he Apostolic Revelation Society. An example of the attitude of members of most of these new movements towards health care institutions could be illustrated using the Christian Fellowship of Vane. The Christian Fellowship of Vane has been t.he most recent Christian group to emerge. It is interdenominational - thus its membership cuts across all the denominations and sectarian churches. They are a minority however, and membership is very youthful - pupils and secondary school students of the local school and training college. The Christian Fellowship is not a church. Members still belong and play salient roles within their churches of orientation. What is most important to members of the fellowship has been the central role of prayers for the sick in preference to the use of other health care facilities. They believe that the devil is real and seeks to destroy man. Sickness and general ill-health, accidents, failures in life, infertility and mishaps are tribulations imposed on man by the Devil. 5.1 University of Ghana http://ugspace.ug.edu.gh In some other cases, God may punish a sinner through disease and death. Though Fellowship members may seek professional medical care when sick, prayer or faith healing is the first string. Even then, it is the modern medical system that is acceptable. Traditional professionals are not trusted because "their practices tend to lean on deities other than the Spirit of God" SUMMARY OF DISCUSSIONS Vane community may be described, in relative terms, as a homogeneous society. Kinship and descent groupings in Vane are the basis of social, economic, religious and political organizations. In many respects, Vane is an agricultural community where the people live very close to the soil. The early contact with the missionaries in the early 1890s however, has effected social change in Vane. The introduction of modern institutions like schools and churches in the area have gone a long way to influence the world view of the people. The contemporary world view of the people of Vane is therefore an admixture of modernized, traditional and christianized elements. These perspectives are utilized in defining illness and health 1 S S U 6 S . The morbidity pattern showed that the major health hazards are related to environmental features including geographical hazards and working conditions. 52 University of Ghana http://ugspace.ug.edu.gh The health resources in the area include; public health facilities, unofficial sources of modern drugs, and traditional sources of health care. It is within this social setting with apparent Christian flavour but appreciably strong traditional beliefs and practices that the NHC as an innovation in health care delivery finds itself. It is important to note however, that the acceptability of any innovation by a people is a function of the extent to which it is integrated into the values, beliefs and expectations of the given social structure. Against this background therefore, attempts shall be made in the next chapter to analyse the role of the NHC in satisfying the health needs of the people of Vane. 53 University of Ghana http://ugspace.ug.edu.gh 54 CHAPTER 3 THE NHC INTRODUCTION In the preceding chapter the main elements in the Vane social structure - including the various social institutions, health conditions and health facilities existing before the advent of the NHC - were discussed. This chapter attempts an analytic description of the organizational strategy of the NHC, and the examination of the historical background, the aims, objectives, structures and utilization of the various constituent parts of the NHC programme. It is hoped that this exercise will enable an appreciation of the dynamics of the NHC - as an innovation in health care delivery. The History and Organization of NHC The primary preoccupation of the NHC is to satisfy the psychological, social and physical health needs of the people of Vane and surrounding communities. A central feature of the NHC social system is the high degree of division of labour and task specialization. It is a multi-speciality approach where three healing systems, herbal, modern and faith healing are grouped together in the same facility. The aim of the NHC mul ti-speci al i ty group practice is to allow association for the communication of ideas and for consultation with other health practitioners within the same faci1 i ty . University of Ghana http://ugspace.ug.edu.gh The Origin of the NHC Idea The idea for the NHC project grew out of the personal experiences of the founder and director of the project - Mr. Emmanuel Baku - a retired engineer and a faith healer. Interviews with the founder and some opinion leaders revealed that the original idea of a tripartite healing system that would merge the diverse health systems in the community stems from the founder’s social background. As a child, it was alleged that he was strongly attached to things pertaining to the mystic world. The use of spiritual forces for healing the sick fascinated him. An important aspect of life which influenced the ultimate development of his ideas and perspective has been the unique ®xperiences he gained from belonging to a family of conflicting r®ligious orientations. His father was among the first converts the Christian faith in Vane. As a result, the family rejected magico-religious practices substituting Christian principles them. On the other hand, the maternal family (of the founder) sphered strictly to the practices of the traditional religion. The maternal grandfather for example, was a famous ^viner/healer. The Christian religious outlook of his father as the pater fsmilia greatly influenced the child, but this did not rule out influence of his mother who devoted herself to the success and spiritual protection of her son, through traditional magico- r''tual practices. 55 University of Ghana http://ugspace.ug.edu.gh This conflicting value orientation enabled the child to understand the beliefs and values of each of these two religious persuasions and their implications for health related issues. Participating in the activities of both religious orientations, the founder became aware of the hypocritical attitude of some professed Christians when seeking health care. It was common place that some Christians condemned magico- religious practices in the open, but during acute and bizarre ailments they sought refuge with the founder’s maternal grandfather. According to the founder "the white man’s medicine could not penetrate such health problems... especially where no germs are involved..." To avoid excommunication from the church, most Christians consulted the fetish in the night. What gave the founder impetus towards concretising his ideas may be traced to his experiences in India and Britain. The opportunity to study engineering in India, under what was then termed the Ghana Government Independence scholarship, gave the founder the opportunity to learn from a social structure that had diverse religious orientations and strong inclinations towards metaphysical healing practices. 56 University of Ghana http://ugspace.ug.edu.gh The thoughts and teachings of Gandhi about the use of religion for social development greatly inspired the founder. Coupled with this, the very fact that he studied in both Hindu and Moslem universities in India widened his mental horizon about the attitude of other religions towards health issues. As a student, he also participated actively in the India Evangelical Students’ Association and later in the Cambridge Brotherhood of Britain. These were Christian organizations that practised faith heali ng. Mr. Baku also became aware of the diverse efforts in India at the time to improve upon the traditional medical system. He was determined therefore to follow this line which recognised some inherent capabilities in the traditional medical system. According to the founder: ...the experience that back at home people were standing in ambivalence between the two cultures and religious forces in terms of health issues... so that certain Christians went secretly in the night to the Diviner/healers, while in the day condemned these ritual and herbal drugs made me resolve to do something to save the situation... He was aware that, back in Ghana, at the time, there were very few modern medical facilities, and in the remote areas of the country especially, the people depended solely on traditional healing systems. Though this worked for the people, the traditional medical system had its own limitations especially in handling certain physical ailments like tetanus, cholera and some general infectious diseases. 57 University of Ghana http://ugspace.ug.edu.gh 58 Likewise he was aware that even though in the cities the modern medical facilities were available, to the average person with a traditional background, these facilities seemed to lack something important. Some cases of bone setting and infectious diseases defy treatment with modern medicine. Co-operation with other traditional methods of healing greatly enhances the overall success of treatment. And while the knowledge of traditional healing can be fully integrated into modern practice, the hygiene and quality of these other treatments can also be improved with attention to up-to-date medical methods" (Mr. Baku: Contact: 1988:4). In other cases where people were confronted with bizarre and anxiety-provoking situations, the average person resorted to the traditional resources for healing. The founder was aware that, the Christian Missionaries rejected the magico-religious practices of the traditional healing system, yet they were not able to make any adequate restorative substitution using the symbolic system of Christianity to invoke in their converts the same supportive traditional universe necessary for faith healing. Commenting on this, the founder said; Christianity itself has stronger spiritual powers ....... the Holy Spirit power which could be used to effect healing. But the orthodox churches were rigid and European in their outlook and therefore did not want to open up and reach out to the suffering with faith healing and the manifestation of the gifts of the Holy Spirit...... thus I came to the realization that, given the strengths and weaknesses of each of these health systems, it would be in place to evolve a new system that combines all these health systems for the benefit of the society. University of Ghana http://ugspace.ug.edu.gh Shrewdly analysing the various health institutions within his native society, and aided by his wider perspective and experience in other cultures, the founder reasoned that an ideal system in which these health systems were made to collaborate would cater fully for the total health needs of the community. It is clear that a wholesome, open-minded approach on the part of all healers can only help a suffering person more completely. In the right spirit, inherent differences among the systems are truly complementary (Mr. Baku: Contact 1388:4) After graduation, the founder returned to Ghana to work in the Ministry of Works and Housing as an Engineer. His first posting took him to Nsawam as the district Engineer. In the late 1960s, Mr. Baku became one of the founding fathers of the Nsawam Association of Healers, made up of medical doctors, herbalists and faith healers. He acted as a faith healer and the organizer of the Association. He founded similar Associations in all the subsequent stations he was transferred to. The principal objective of these Associations were to effect informal referrals between the different specialists, on the basis of trust, mutual respect and understanding. After the founder retired from active service in the Ministry of works and Housing, he returned to his native home - Vane - to settle. The sanctuary which he built in his house formed the nucleus of the three-in-one complex he had been thinking of. Thus at this stage he was operating only as a faith healer, and referring patients to traditional healers depending on the case at hand. 59 University of Ghana http://ugspace.ug.edu.gh As the number of his patients grew larger with time he thought of building a hospital complex of modern, herbal and faith healing sections. The building of this edifice started in 1974. The herbal and spiritual Healing Sections of this complex were officially opened in December 1976, whilst the modern medical section was opened in June 1977. Information on the source of funds for the complex is not very clear. However opinion leaders are of the view that the complex was put up through the founder’s own private funds and loans from the banks. Members of the Vane community however offered some communal labour by fetching water and stones at the initial stages of the project. The government of Ghana and some Non-governmental organizations including The Christian Medical Commission of the World Council of Churches (CMC), the Christian Health Association of Ghana (GHAG), and the Inter-Church Co­ ordinating Committee for Development projects (ICCO) in the Netherlands have contributed towards the provision of equipment for the project.* Today the NHC is a Christian Mission Health Institution under the auspices of the Evangelical Presbyterian Mission. According to the traditions of the Mission, Management Boards exist for all mission institutions including Health Institutions. 60 *See Appendix C for other related projects of NHC funded by external donors. University of Ghana http://ugspace.ug.edu.gh 61 The Management Board of NHC comprises representatives from: the Mission Head Office, Medical Officers from the Mission Hospital, the office of the Regional Medical Director - MOH - the Regional Secretary of State, the Regional Association of Psychic and Traditional Healers, local healers, as well as significant others from the Vane community - the Chiefs and the Church. The Board is supposed to deliberate upon issues concerning policy, and the dynamics of the project. It is supposed to meet at least once a year. The Management Committee of NHC is the locally constituted Committee. Members include lieutenants of the founder/di rector, some opinion leaders of the society, representatives of the Vane development committee, representatives of the local traditional healing system, and some individuals who show interest in the project. The management board of NHC, represented by the Management Committee at the local level, is therefore the single point of command or policy making body over all the various sectors of the NHC. The Chairman of this committee and the one directly in control of the project is the founder/director of NHC. He serves as the Co-ordinator of the project, presiding over all meetings as well as controller of the finances and personnel of all sectors. Having discussed the history of the NHC, the focus will now turn to the appreciation of the basic philosophy of the NHC model . University of Ghana http://ugspace.ug.edu.gh The Basic Philosoohv o f NHC Three structures in the same yard, house the three departments - a Modern Health Centre, a Faith Healing Centre and a Herbal Cl inic. As depicted in the diagram (fig. 1 .1 ) the basic philosophy of the NHC model stressed joint effort, and respect between the three constituent parts. The thrust of this model therefore is the interplay of the various parts within NHC towards an integrated approach to healing. The patient may enter the orbit of NHC through any of the three sectors