What are Langwicks research methods?

Articulate(d) Bodies: Traditional Medicine in a Tanzanian Hospital

Author(s): Stacey A. Langwick

Source: American Ethnologist , Aug., 2008, Vol. 35, No. 3 (Aug., 2008), pp. 428-439

Published by: Wiley on behalf of the American Anthropological Association

Stable URL: https://www.jstor.org/stable/27667501

JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of content in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new forms of scholarship. For more information about JSTOR, please contact [email protected] Your use of the JSTOR archive indicates your acceptance of the Terms & Conditions of Use, available at https://about.jstor.org/terms

American Anthropological Association and Wiley are collaborating with JSTOR to digitize, preserve and extend access to American Ethnologist

This content downloaded from ������������131.252.67.104 on Tue, 01 Nov 2022 19:39:56 UTC�������������

All use subject to https://about.jstor.org/terms

STACEY A. LANGWICK

Cornell University

Articulate (d) bodies: Traditional medicine in a Tanzanian hospital

ABSTRACT Hospital practitioners in East Africa see traditional

and modern medicine interrupt and interfere with

one another on hospital grounds everyday. In

response, nurses and nurse's aides have developed

innovative ways of assembling diverse therapies and

the knowledges, practices, desires, and medicines of

which they consist. Through their care and

coordination, nurses and nurse's aides forge complex

bodies within the therapeutic interruptions and

interferences they face in their clinical work.

[traditional medicine, biomedicine, body, ontology,

Tanzania, Africa]

owhere in Tanzania is modern medicine seen as a sufficient re

N source to care for all health concerns and complaints. Not only patients but also biom?dical practitioners and government bu reaucrats recognize that biomedicine is only one element in a broader therapeutic ecology. In striving to meet health de

velopment goals, the Tanzanian ministry of health, with the support of the World Health Organization (WHO), the World Bank, and other mem bers of the international community, has formally invested in the sci entific development of traditional medicine since the 1970s and in the professionalization of traditional healers since the 1980s. The elabora tion of traditional medicine through such laboratory investigations and bureaucratic management is filling out the category of knowledge and practice first evoked through colonial encounters and prohibitions.1 This genealogy begins to suggest the particularities of the pluralism shaping of ficial postcolonial efforts to delineate and modernize a field of traditional medicine. To enable medical science to assess, evaluate, and deploy them, so-called traditional treatments and practitioners must be conceived of as resources for (and therefore distinct from) their biom?dical counterparts. The (in)commensurabilities evoked in this vision facilitate the transforma

tion of traditional medicines into pharmaceuticals and the reduction of healers to outreach workers referring clients to the clinic but not adminis tering treatments themselves (Adams 2002; Janes 1999). This institutionally articulated medical pluralism and the forms of integration it promotes dif fer, however, from the more pragmatic relationship between modern and traditional medicine enacted in the clinic.2

The clinic directs attention toward practice, highlighting the fundamen tally interventionist nature of medical care. Clinical staff, as well as pa tients and kin, strive to attend to affliction, pain, debility, and misfortune; they strive to act. The urgencies and inadequacies of biomedicine in Africa shape the conditions under which interventions can be imagined and care carried out. Others have written of the ways that biomedicine crafts a space of emergency in which individual bare life marks the success of care

AMERICAN ETHNOLOGIST, Vol. 35, No. 3, pp. 428-439, ISSN 0094-0496, online ISSN 1548-1425. ? 2008 by the American Anthropological Association. All rights reserved. DOI: 10.1111/J.1548-1425.2008.00044.X

This content downloaded from ������������131.252.67.104 on Tue, 01 Nov 2022 19:39:56 UTC�������������

All use subject to https://about.jstor.org/terms

Articulate(d) bodies American Ethnologist

(Nguyen 2007; Redfield 2005). Yet many clinics in Africa are not consistently equipped with even the most well-known technologies and medicines for facilitating basic medical care. In Tanzania, nurses and nurse's aides evoke traditional

medicine in their attempts to mediate this double bind.3 In this article, I argue that biomedicine's inability to address the very crises that constitute it as a necessity is leading to the formulation of new realities and new bodies at the in tersection of traditional and modern medicine.

Although ideas of distinct medical systems remain im portant to institutionalized projects of integration, fewer and fewer anthropologists invest analytically in the in dependence of traditional and modern medicine or the hierarchies that their separation enables.4 In arguing for the changing nature of that which is called "traditional," accounting for the sophisticated, shifting positioning of healers, and chronicling the emergence of new fields of knowledge, anthropologists have complicated many of the modernist agreements that have shaped studies of med ical pluralism. Accounts of healers' engagements with

medical technologies (e.g., using syringes, reading patients' diagnostic tests, and combining their medicines with phar maceuticals) and with biom?dical concepts (e.g., address ing biom?dical disease entities and arguing for the scien tific validity of their medicines) challenge the self-evidence of boundaries between traditional and modern medicine.

We have not, however, trained our attention as directly on the ways in which postcolonial biomedicine is be ing simultaneously refigured by the interruptions of tra ditional medicine.5 I am interested not only in the ways that healers innovate in the face of biomedicine's interrup tions (Langwick 2001) but also in the ways that biom?dical practitioners innovate in the face of traditional medicine's interruptions.

Hospital practitioners in Tanzania witness traditional and modern medicine interfering with one another daily on hospital grounds.6 The realities of affliction, discomfort, debility, and relief present themselves through the intersec tion of diverse forms of healing practice. Focusing on nurses and nurse's aides in one district hospital in Tanzania, I de scribe some of the ways that biom?dical and nonbiomedi cal therapies are coordinated in the service of treatment.7 As Annemarie Mol (2002) has demonstrated, biom?dical prac titioners strive to enact bodies that are coherent for a mo

ment, long enough for therapeutic transformation or relief; or if one reflects on the root of the Kiswahili word kupona, to cure, then biom?dical practitioners strive to enact bodies that cohere long enough to be cooled. Tanzanian medical

worlds compel the coordination not only of the tests in the lab, the images from the X-ray room, and the intake history collected in the doctor's office but also of the body (or bod ies) of traditional medicine. Nurses and nurse's aides are ar

ticulating new bodily assemblages; that is, they are joining together versions of bodies to allow for movement, for inter

vention into the complex life of pain, debility, and suffering in Tanzania. The very multiplicity of such bodies enables

ways of acting within the therapeutic interruptions and in terferences faced by clinical staff in their work. These newly articulated and articulate bodies have a temporal dimen sion, as do all objects in practice.8 They emerge in an effort to generate action, not to populate the world indefinitely. They cohere to direct attention as long as the care that they facilitate is considered useful. The institutionalized forms of

integration imagined in health development programs dif fer epistemologically and ontologically from the more prag matic relationship between traditional and modern reme dies, healers, and knowledge in the clinic.

The work of the clinic seems to compel the cultivation of skills to discern afflictions or aspects of affliction that might be best treated by one form of therapy or another. To address the demands and the complaints that are made at the intersection of a variety of powerful ways of think ing about, articulating, and acting on the body, nurses and nurse's aides in Tanzania cannot not afford to think of tra

ditional and modern medicine separately.9 In response to this reality, they are developing ways of coordinating di verse therapies and the knowledges, practices, images, de sires, and medicines of which they consist. Nursing care comes to render bodies compatible with both traditional and modern treatments. To explore the complexity of heal ing in Tanzania, my account below focuses on (some of) the spaces in which therapies intersect with each other, forming therapeutic assemblages as health practitioners coordinate

medicines, knowledge, well-being, and comfort.

Hospital T

The examples I present of different therapeutic trajectories interrupting, interfering, and transforming one another are derived from research I conducted in a district hospital in Tanzania, which I refer to from this point on as "Hospital T." This hospital was built in the mid-1960s, after Tan ganyikan independence, and assumed the responsibilities of an earlier Anglican mission hospital in the area. Histori cally, the state has underfunded this district hospital, even as it has tasked it with serving a particularly large catch ment area in a relatively resource-poor region of the coun try. Although differences between clinical care in Hospital T and in other hospitals (whether in other parts of the coun try or the world) cannot be attributed solely to economic asymmetries, the practical challenges of running an under staffed, underfunded hospital with undertrained personnel are salient. In the context of my argument here, they are most important in situating the significance of the work of lower-level clinic staff in the therapeutic care available at Hospital T.

Since 1998, when I first became familiar with its staff

and work, this hospital has supported one to three doctors.

42B

This content downloaded from ������������131.252.67.104 on Tue, 01 Nov 2022 19:39:56 UTC�������������

All use subject to https://about.jstor.org/terms

American Ethnologist Volume 35 Number 3 August 2008

Because it is located in a part of the country in which few elite, educated Tanzanians want to live, the government has found it difficult to keep a Tanzanian doctor in the hos pital for more than a year. Since the mid-1980s, one or two of the physicians have been young German doctors working for the German development organization GTZ. With one notable exception, these doctors have tended to learn only rudimentary Kiswahili and have not learned any of the local languages. As a result, nurses and nurse's aides field patients' questions about medicines and ad dress their anxieties about care. They are also the staff most frequently confronted with mediating traditional medicine and biomedicine in the clinic.

In 2003, the district nursing officer at Hospital T, bur dened by the overwhelming task at hand, calculated the difference between the staff needed to meet the demands

placed on the hospital and the staff that he was able to maintain. He concluded that from 2000 to 2002 the hospi tal was only staffed at 42 percent of the level that would have been required to adequately serve the demand. The percentage of trained nursing staff in 2000, 2001, and 2002 tended to be less than 50 percent of what the hospital needed.10 More specifically, the district nursing officer cal culated that the hospital was operating with 52.4 percent of the needed public-health nurses and MCH aides, 43 percent of the needed registered nurses and nursing officers, and 36 percent of the needed "enrolled" nursing staff, which in cludes nurse-midwives. Hospital T has continued to func tion by hiring more lower-level (less well-trained) staff. In fact, the district nursing officer calculated that this district had 194 percent of the number of medical attendants it needed. Medical attendants can be hired who have no train

ing at all. In the past, they handled jobs such as sweep ing, cleaning, washing sheets, and making beds. In the cur rent staffing crisis, however, medical attendants have come to dispense medicine, give blood transfusions, and tend to

wounds. In light of their expanded responsibilities, most of the medical attendants in Hospital T have taken a one-year training course that teaches the principles of basic first aid and patient care.

Although these numbers speak to the specific condi tions of Hospital T, they are in no way unique. In the past 15 to 20 years, clinical staffs in Tanzania have struggled to provide quality biom?dical care under increasingly aus tere conditions. In the mid-1980s, Tanzania began to imple

ment an IMF structural adjustment program that required, as such programs have in many countries, the reduction of state expenditures on social services. Because a social ist minister of health remained in office until 1991, how

ever, the full effect of the fiscal adjustments on health was delayed. Although private practices opened slowly through the 1980s, government clinics did not introduce fee-for service or what are often called "cost-sharing" measures un til the 1990s.

One Tanzanian NGO has referred to the cumulative ef

fect and resulting conditions of these neoliberal reforms as "brutalization," a term used to depict their impact on both nurses and patients.11 Under current conditions, nurses are unable to manage their clinics with the attention and care their professional commitments demand, and patients suf fer these inadequacies when good intentions are a poor substitute for the treatments that they desire. Neoliberal reforms have had profound implications for hospitals and clinics in Tanzania, affecting the quality and sufficiency of staffing, the conditions of the clinic, and the availability of medicines (Lugalla 1995; Richey 2003). Faced with these harsh realities and the frustrations of not being able to of fer ideal care, nurses in Hospital T seem to evoke traditional

medicine in an effort to address the immediate needs of

their patients. I became intrigued by nurses' engagement with tradi

tional medicine after hearing healers' periodic claims that nurses in Hospital T had referred certain patients to them. I began to formally investigate the issue by conducting in depth interviews with all of the nursing staff in Hospital T.12 Between interviews, I would often remain in the wards and continue conversations with the nurses and nurse's

aides who were on duty, watching them work. Examining the mediation of traditional medicine within biomedicine

drew me into the unofficial and private interactions that nurses and nurse's aides have with patients and with each other. My formal interviews and informal conversations with nurses and nurse's aides in Tanzania probed not only their encounters with traditional medicines but also the

veiled references, euphemisms, and silences that enabled the presence of traditional medicine in the hospital. Al though I conducted the majority of the fieldwork presented in this article in 2003,1 have worked in the area of Tanzania

in which Hospital T is located much longer. Between 1998 and 2000,1 conducted research both in Hospital T and with traditional healers in the area in an effort to understand the

therapeutic landscape. In fact, when I began hospital inter views in 2003 I was already known to some of the nursing staff by a diminutive form of the name of the healer with whom I work most closely.

My ongoing work with healers, as well as my commit ment to and knowledge of this area, underlies the nursing staffs willingness to confide in me and reveal the unofficial, sometimes clandestine, interactions that characterize tradi

tional medicine in the hospital. These activities range from referring a patient to a traditional healer to facilitating the use of traditional medicines in a hospital ward. In addition, nurses and nurse's aides described patterns of communi cation and innuendo.13 Their generosity and trust reveal a more fluid, flexible, and evolving picture of the relationship between modern and traditional medicine than has typi cally been portrayed in African hospitals. Here I not only discuss the existence of healers in the hospital and of their

430

This content downloaded from ������������131.252.67.104 on Tue, 01 Nov 2022 19:39:56 UTC�������������

All use subject to https://about.jstor.org/terms

Articulate(d) Bodies American Ethnologist

medicine in the bodies of patients that arrive there but I also attempt to account for the intangible conditions through which biomedicine implicates traditional medicine and, in the process, hails new complex bodies.

For the nurses and nurse's aides in Hospital T, the new sensitivities and practices of discernment through which they assemble the bodies of patients are not academic ex ercises. Neither are they in any simple sense driven by "in terests" or "beliefs." Rather, nurses are skeptical of heal ers. Ideological agendas shape the ways in which the nurs ing staff is implicated in the articulation of so-called tradi tional maladies, but nursing practice is itself not straight forwardly ideological. Stacy Leigh Pigg (1996) argues that articulations of one's belief in or thoughts on traditional medicine are ways of positioning one's self. The skepti cism, even condescension, of clinical staff toward tradi tional medicine is shaped by their training, their position as "professionals," and their position in the complicated class structures of postcolonial modernities (e.g., as peo ple earning salaries in an area where many if not most are subsistence farmers). Medical staff's claims about belief or statements about usefulness to a U.S. researcher, friend, or

colleague are gestures within the deeply fraught landscape of modernity. Nurses and nurse's aides craft themselves as modern subjects, as cosmopolitan, as legitimate embodi ments of the state and exemplary forms of its citizenry. De spite their investment in boundaries between traditional and modern medicine, nursing staff come to discern more and less "dangerous" medicines, to assess "traditional mal adies," to mediate the encounters between traditional and

modern medicines, and to articulate new complex objects that refuse to be reduced to either the biom?dical or the

traditional. Political, economic, and clinical conditions, as

well as the diverse relationships that call on nurses in their everyday lives, compel them to coordinate the new com plex objects of care that I describe below, that is, to generate more articulate bodies.

Personal negotiations

Twenty-three of the 26 nurses and aides I interviewed de scribed using traditional medicine at least once in their lives. The chief nursing officer swore by an herbal treat

ment that he argued saved him from having to pull one of his teeth. Eighteen members of the nursing staff said that they had gone with or helped relatives and friends seeking out traditional treatments; eight either claimed that they had never taken or accompanied someone to a traditional treatment or they avoided the question. These differences in personal experience played a role in nurses' and nurse's aides' own sensitivity to the use of traditional medicine in Hospital T. Almost all of them suggested that at least 50 percent of patients had used or were using traditional medicines. Only one nurse claimed that the use of tradi

tional medicine was infrequent (wachache tu), and three suggested that it might be as high as 80 percent.

The personal experiences of nurses reveal some of the more complicated ways that traditional medicine exists in the hospital. After all, the nursing staff consists of people

who are also mothers and fathers, spouses, relatives, and neighbors. One of the nurses in Hospital T lived across a small dirt road from a healer with whom I have worked for

years. This healer and her kin would call on their neigh bor with nursing experience (and vice versa) for assistance. When the healer's granddaughter screamed late one night with labor pains, the nurse came running across the road to help. In addition, the healer regularly collected the leaves of a tree in the front of the nurse's compound to make a medicine for a common eye ailment. Their individual ex periences with healers and medicines shaped how clinical staff in Hospital T imagined the relationship between mod ern and traditional medicine.

Nurses born in the immediate area were more fluent

in traditional medicines than nurses who were transplants from other parts of the country. The nurse who claimed to have seen the fewest instances of traditional medicine

(despite working in the maternity ward, which has a his tory of some of the most controversial and tragic inter actions between pharmaceutical and herbal treatments)? who was, in other words, the least sensitive to the use of traditional medicine in the hospital?was originally from Zambia. Explicating the relationship of hospital medicines to other forms of treatment was a way for nurses from the area to position themselves in the broader community and specify their own stakes in Makonde, Makua, or Yao sub jectivities. Although religious affiliation appeared to influ ence the use of traditional medicines and their meanings, it seemed less significant than familiarity with local medici nal traditions in determining nurses' sensitivities to the use of traditional medicines in the hospital. Nurses from the area, whether Christian or Muslim, tended to know heal ers as neighbors and not infrequently to be connected to them through extended kin networks. These connections shaped their knowledge about and sympathies for tradi tional medicine even more than religion or rank.

Through the use of traditional medicine, nurses and nurse's aides often developed a personal philosophy about the kinds of traditional medicines that might be effective.

Many nurses would only use dawa za kukinga, protective medicines. Some claimed that their only use of traditional medicine was to wear a protective medical "bracelet" that they made themselves from ingredients bought at the mar ket for their young children. Others did not "have faith" in medicine that was written or tied on to the body or buried in front of the door of a house; rather, they only believed in things that one drank, bathed in, or rubbed into the skin (kuchanga). Still others expressed concern about drinking

medicines. They feared that the dosage might be too strong.

431

This content downloaded from ������������131.252.67.104 on Tue, 01 Nov 2022 19:39:56 UTC�������������

All use subject to https://about.jstor.org/terms

American Ethnologist Volume 35 Number 3 August 2008

These women only used medicine that they could bathe in or rub on. Still others refused medicine that was rubbed

on or tied on because, then, others would know that they were using traditional medicine. Some believed that tradi tional medicine was useful for particular sorts of afflictions but not others. Many claimed that traditional treatments for infertility or hernias were more efficacious than hospi tal treatments. Faith in herbal remedies for malaria or in

testinal worms varied more widely. For still others, faith or belief in the efficacy of traditional medicines was irrelevant. Their use was represented as a product of family obligations and pressures. The uncertainty about traditional medicines, and the sorts of differences that were held as salient be

tween traditional medicines, shaped the advice nurses gave to patients and the tolerance they had for particular kinds of treatments smuggled into the hospital.

Personal experience and professional experience bled together in nurses' narratives about traditional medicine. As Mama Zenabu recounted her struggle to conceive and the various therapies she employed, she also described the "many, very many, too many" women admitted to Hospital T who used similar medicines. The impact of personal experience on professional work was, at times, as simple as the recognition and tolerance of traditional medicines in the clinic. Yet such stories also resonated

with the more broadly generative capacities of affliction in Africa. In this area of Tanzania, as in other places across the continent, some are called to become heal ers through affliction. Their own healing depends on their submission to this calling. Their struggle for survival en dows them with new relationships, new capacities, and new demands. When individual nurses grow more sensi tive to certain forms of affliction and to a range of possible therapies because of their own experience, their expertise confounds any straightforward description of skill or know how. Through the excesses of their own engagements, these nurses highlight the friction between the forms of knowl edge and expertise that inhere in profession and those that inhere in callings.

Discerning affliction, mediating movement

Whether nurses claim that any sort of traditional medicine is efficacious or beneficial, their work with patients who use these medicines requires that they engage with them. The

medicinal use of plant, animal, and mineral substances af fects the afflictions that are presented in Hospital T and, therefore, the routine practices of staff in the search for effective treatment. All of the nurses and nurse's aides

gave examples of traditional medicines that caused medical problems. One of the most common examples concerned herbal medicines that increased contractions during labor. Several nurses had witnessed women, their babies, or both

die as a result of a ruptured uterus and massive hemor

rhaging. The MCH clinic had made a concerted effort in previous years to discourage pregnant women from us ing herbal treatments. Nurses leading workshops to train traditional birth attendants (TBAs) still campaign strongly against them using any medicine for any reason. In addi tion to medical problems they attributed directly to the use of traditional medicines, hospital staff regularly complained that patients arrived in critical condition, sometimes "too late" to be cured, because they went to see a tradit

Collepals.com Plagiarism Free Papers

Are you looking for custom essay writing service or even dissertation writing services? Just request for our write my paper service, and we'll match you with the best essay writer in your subject! With an exceptional team of professional academic experts in a wide range of subjects, we can guarantee you an unrivaled quality of custom-written papers.

Get ZERO PLAGIARISM, HUMAN WRITTEN ESSAYS

Why Hire Collepals.com writers to do your paper?

Quality- We are experienced and have access to ample research materials.

We write plagiarism Free Content

Confidential- We never share or sell your personal information to third parties.

Support-Chat with us today! We are always waiting to answer all your questions.