Introduction to Ethnomedicine: Examples from Yemen

by Beth Kangas

Yemen Update 35 (1994):22-27)

[This article is based on a talk for Peace Corps Pre-Service Training, Ta'izz, Yemen, July 27, 1993.]

Medical anthropology looks at cultural conceptions of the body, health and illness. It also focuses on health behavior as a way to learn about social values and social relations. Medical anthropology research has much to contribute to projects being designed to improve health service delivery and health education. Health projects often proceed upon the assumption that “if we teach people `correct' health beliefs and behaviors, they will adapt their behaviors and become healthier." Numerous studies (e.g., Jordan 1989; Mull and Mull 1988; Nichter 1985) have found that new knowledge does not necessarily translate into behavior change. The desire to empower people with knowledge is laudable. However, failure to recognize local knowledge and relations of power and authority leads to a lack of appreciation of contingencies which affect health behavior.

In the summer of 1993, with the assistance of a fellowship from the American Institute for Yemeni Studies, I conducted medical anthropology research at the outpatient clinics of Al-Thawra Hospital in Sanaa. The high turnover of patients at the clinics, with doctors having only two or three minutes per patient, provided an excellent opportunity to survey the implications of health conditions in Yemen. In this paper, I will discuss the social and cultural context of health care seeking as a means of illustrating: 1) the importance of health beliefs and practices; 2)variability among patients; and 3) social relations of health care seeking. Specifically, I will focus on the following three arenas of “knowledge": a) ethno physiology, b) etiologies, and c) treatments and healers; as well as the following three arenas concerning “variability among patients": a) the household production of health, b) the therapy management group, and c) moral identity. My intention is not to provide an exhaustive account of illnesses and treatments, nor a detailed description of Yemeni society. Rather, I offer a series of examples to illustrate the social context of health and illness, of which biomedicine forms a part. It is my hope that the concepts presented here will be useful as "tools" to others attempting to learn more about Yemeni society, especially those planning health and development intervention.

KNOWLEDGE

Ethno physiology

Ethno physiology considers people’s understandings of how their bodies function. These understandings influence health practices, symptom evaluation, and health-care seeking. That people's perceptions of the workings of their bodies may differ from the physiology of medicine can be seen in the following exchange. After a doctor in the Orthopedic Clinic of the hospital listened to an older woman describe her upper back pain, he turned to me to say, "Sometimes we can't understand their complaint. She's saying that while eating, she gets a pain in her back. I don’t believe her. She feels as if her back is open like a window."

Local perceptions of how the body works underlie women's concern that an IUD will cause headaches and are evident when they speak of the placenta coming out of a woman’s mouth. Such ideas are associated with the perception that the area between the abdominal region and the head is hollow, so that anything inserted in the vagina can travel to the head. Notions of ethno physiology also underlie women's ideas about menstrual blood and conception. In her research in the Hujariya, Cynthia Myntti(1985:168) describes the belief among women she studied that menstrual blood and vaginal fluids should be eliminated regularly from the body lest they cause physical disorders. This popularized version of the Galenic-Islamic tradition also exists among Iranian women, who are encouraged to have babies early in marriage because until women have given birth, their body is in a less healthy state since it is polluted with excess menstrual blood (Good 1980). Women believe that the contraceptive pill causes polluted blood to remain in the body and so are reluctant to use it (See also Morsy 1980 for Egypt).

In addition, women's willingness to use the pill is affected by their understandings of conception. Common to the Middle East is a "monogenetic" notion of procreation (Delaney1991). Here, the man provides the seed, while the woman provides “the vessel in which the seed grows" (Good 1980:149).1 Thus, says Good, a woman is greatly concerned about the condition and health of her uterus or "vessel." Women are again encouraged to have babies early in marriage, as the condition of the uterus in a younger woman is believed to be better. Because of the popular focus on the uteruses the female's contribution to reproduction, women are concerned about the effects of the contraceptive pill on the uterus. They fear that its use may result in the drying of the uterus and a loss of fertility (Good 1980:152).

The above examples illustrate the importance of research on ethno physiology to an understanding of women’s reproductive health.

Etiologies

Research on explanations of illness causality sheds light on health care behavior. In Yemen, in addition to biomedical explanations, illnesses are attributed to the sun, jinn[spirits], a bad scare [fij'a, Swagman 1989],or the evil eye, among others. Perceived causes of illness affect people’s attempts to explain bodily occurrences in clinics. For instance, a girl in the Dermatology Clinic had a white mark on the back of her neck. The doctor told me that her mother was concerned that this ailment was very serious and would spread; she saw it as a punishment from God. Another instance is of a young woman in the Neurology Clinic who complained of headaches. She said that the headaches began after someone had told her about a car accident outside, which had given her a fright (fij'a).

Examinations of etiologies entail an exploration of folk epidemiology, factors which lead to vulnerability and susceptibility, as well as what can be done to avoid the risks. For example, direct sunlight is avoided as a cause of illness, especially for children ( Myntti 1985). Accordingly, a man crossing the street in front of the hospital shielded his baby and called out to the crowd, "Ash-shams, ash-shams (the sun, the sun)" to clear a path to remove the baby from the sun.

A closer examination of one cause of illness, the evil eye, will highlight how local notions of etiologies may influence health projects. The evil eye (hasad oral-'ayn) results from an envious or covetous gaze. Due to fear of the evil eye, pregnancies may be kept secret, as pregnancy is a vulnerable transitory state. Infertile women are often seen as a source of the evil eye. In addition, mothers may be reluctant to weigh babies or chart their growth as this might provoke envy of a desired condition. Toddlers may be left dirty so as not to draw attention to their beauty, which would make them susceptible to the evil eye.

The evil eye can provide a satisfying explanation for otherwise inexplicable events, such as in the following illustration. A woman told me about her sister who had long hair and was beautiful. On the day of her own wedding, the sister danced, swinging her loose hair in the Hodeida style. Ever since that day, for the past twenty years, she has suffered from a headache and her hair has been falling out. The woman said that her sister’s condition was the result of hasad from one woman at the wedding. She does not know who it was, but said that the only cure is to wait for the inflicting woman to die.

The evil eye can also affirm that one has desirable skills or characteristics and therefore provides comfort when facing mishaps. Illustrations of this include a young man in the Dermatology Clinic who complained of blotches around his eyes for the past four months. He attributed his condition to hasad. Some girls, he explained, had said how handsome he was, and then the blotches appeared. Another instance is of a woman in the Ophthalmology Clinic who told how she had given herself and another woman an injection as she lives faraway where there are no doctors. She said that the other women present were surprised by her ability to give an injection, which caused the medicine to splash in her eye.

Multiple explanations for illnesses have survival value in that they are reassuring and help people cope with misfortune. Health projects planning to displace local explanations for illness by strictly biomedical interpretations need to consider the social relations of illness attribution. Comfort may be replaced by blame, as the following example suggests. One woman had accused a neighbor man of being the cause of her baby's illness. She told me that the man was jealous of her husband for having so many children(eighteen to the other man's seven). While a biomedical explanation for the baby's illness might lay blame on her for bad mothering, perceptions of blame elsewhere helped her cope. Health projects should offer people ways to improve their health while respecting their dignity. Projects should be cautious not to blame the very people they are trying to assist.

Treatments and Healers

Signs that patients have used "traditional"(i.e. non-biomedical) treatments and healers are evident in outpatient clinics. For example, some patients have strings or scarves tied around their abdomen or ankles to alleviate pain, others have scars or scabs from cauterizing, still others mention treatments of cupping or blood-letting. In the Orthopedic Clinic, several patients I interviewed had been first to a tbib 'Arabia("Arab doctor," traditional bone setter in this case) to have their bones set. Unfortunately, in many of these orthopedic cases, the treatment proved iatrogenic. For example, when the gauze was wrapped too tightly, it cut off blood circulation which lead to a gangrenous arm that then needed amputating.

Self-medication from pharmacies is popular in Yemen (Myntti 1988). Especially popular are vitamin tonics(muqawiy¡t, which are related to "strength"). People may also visit private clinics specializing in first-aid, injections, IVs, and circumcision. Herbal remedies are also used, such as by the man who told me that he changed to an herbal remedy after prescribed medication had upset his stomach. In addition, receiving a diagnostic test or x-ray is sometimes viewed as a treatment in itself. Diagnostic analyses have become quite fashionable, as the following example describes. A doctor pointed out the case of an old woman from a rural area who has high blood pressure. One of her two elderly male companions asked for her to have a kambuter (from “computer") test (a CT scan). Although the test was unrelated to her condition, the technology (al jih¡z al jadid) was new and desired, familiar to people from rural areas as well.

It is important to realize that people maybe trying a variety of treatments and healers in their search for acure. Thus, they are not necessarily choosing one medical "system “over another; they are looking from something that works. A case study will help illustrate this search for a cure.

A one-and-a-half-year-old boy was in the Pediatrics Ward for repeated convulsions similar to epilepsy. His mother, who estimated her own age to be nineteen, was staying in the hospital with him. He was her only child. The boy was four months old, his mother said, when the first convulsion occurred. She and her husband were afraid, of course. They tore off the baby's clothes and put water on his face. Afterwards, they took him to a neurologist at the hospital who said that nothing could be done for him as he was young and the medicine would be too strong for him. The doctor told them to take the baby back home and wait until he’s bigger.

A second fit occurred five days later. With the advice of a neighbor, they went to a shaikh, a religious healer. The shaikh read from the Quran and cut off the neck of a chicken. He rubbed the blood on the baby until it dried. The shaikh told the mother to bring olive oil to him. He read Quranic verses over the oil. He told her that when a fit occurs, she should rub the oil on the baby.

Another fit occurred. The mother rubbed the oil on the baby, but there was no effect. She went back to the shaikh. He told her to remove any pictures off the walls of their house. Fits came several times again. She again returned to the shaikh. He told her to take the baby to a doctor or hospital.

They returned to the neurologist when the baby was eight months old. He suggested tests and medicine. He said he could not diagnose the condition exactly but to use the medicine. She used it for a month and a half while the fits continued. The doctor then changed medicines several times without any benefit.

Finally, the boy was admitted to the hospital for investigation and treatment. The one-and-a-half-year-old boy and his mother had been in the hospital for three weeks. The day I met them, a doctor had said they might have to go out of the country for treatment as it was not available in Yemen. The boy was still having fits &emdash; four to twelve a day.

This case of convulsions contains interesting parallels between the shaikh and the doctor. Neither knows what is causing the fits nor exactly how to cure the condition. Both try a variety of treatments, not only to stop the convulsions but also possibly to tell them something about the unclear causes. In both situations, the health practitioner confronts an unknown, which highlights the rather mysterious process of illness and healing.

The search for a cure is a process of alternating doubt of, hope for, and commitment to remedies and healers. Medical practitioners should recognize that patients visiting them are at different points in this search for a cure. Patients may be involved in a multiplicity of treatments, sequentially or concurrently. The visit to the doctor, therefore, may be one attempt of several, such as with the mother who brought her daughter to the Pediatrics Clinic. She carried medication with her, which she had purchased from a pharmacy the night before. Since the medicine had proven ineffective (during the far fewer than 24hours that had passed since trying the medicine), she was in the clinic the next morning looking for another remedy. What we do not know and what needs to be researched further are people’s expectations for treatments and the length of time that they are willing to suspend their doubt or sustain their hope as they await a result.

VARIABILITY AMONGPATIENTS

In the preceding sections on "ethno physiology" (people's understandings of how the body functions), "etiologies" (people's explanations as to the causes of illnesses), and "treatments and healers" (what people do to relieve discomfort), I have discussed local knowledge, which may be unfamiliar to those trained predominantly in clinical medicine. I have done so in order to encourage further exploration of health beliefs and practices.

In the next sections, I will discuss variability among patients, affected by household dynamics. I do so in order to emphasize that a person is not an isolated unit. This reminder is necessary since health projects often target individual members of a household, such as mothers or children, while seeming to forget that individuals rarely act alone regarding their health behavior. A person's access to health care, for instance, is often dependent on his or her status and position within a household. For this discussion, I will introduce the concept "household production of health."

Household Production of Health

The concept of "the household production of health" (Berman, et al. 1989) recognizes that a person's access to and use of various forms of treatment are connected to his or her social power in relation to other household members. Here, a “household" is examined rather than a "family," as a household may be easier to define. A household in Yemen may include, for example, other relatives living in the house, a divorced relative (e.g., the husband’s sister), children from a previous marriage, co-wives, or an absent father. A study of "the nuclear family" or "the extended family," or even "the family," would not explicitly account for these members. Studies of the "household production of health" examine how household members cooperate and compete for resources in order to restore, maintain, and promote health. Such analyses, therefore, highlight the variability in autonomy, status, power, and access to resources existing among household members. Household dynamics and their effect on health behavior can be seen in the following discussions of: 1) resources and responsibilities, and 2)statuses.

Resources and Responsibilities

A range of medical conditions could affect members of a household, including headaches, diarrhea, anemia, diabetes, hernias, goiters, cancer, as well as traumas like car accidents, falls, shootings or stab wounds. With each condition comes shifts in resources and responsibilities as members cope with both the unexpected and chronic situations. Caretakers attend to the patient through examinations, diagnoses, and treatments. Household responsibilities are adjusted accordingly.

Several of the adjustments that may be involved when dealing with illness can be seen in the case of a girl who was in the Pediatrics Ward with a lung condition. Her mother was staying in the room with her. They had been in the hospital almost a month. The father was staying in a nearby hotel. The remaining three daughters and three sons were at home in the village. The oldest daughter, twelve years old, was now responsible for things at home, including cooking and taking care of the animals.

A second example demonstrates the caretaker’s role, which may be overlooked when focusing only on the patient. A twelve-year-old boy was in the hospital for renal failure. His mother was busy in their house four hours away, so his slightly older sister was staying with him. While food is provided by the hospital, the sister brought fruit and bottled water from outside. She also read to her brother from the Quran and other books.

As the above examples indicate, a medical condition necessitates a variety of changes in a household. Indeed, the full extent of the resources and responsibilities which need to be negotiated may not be recognized by outside observers. These include fees for medications, analyses and examinations, transportation costs, arrangements for accompaniment, and the loss of a worker and more likely of two workers either in wages or housework. All of these factors, and no doubt more, can influence health-care seeking decisions.

A consideration of the impact of a medical condition to the household helps explain why patients may come to the hospital too late for treatment. Looking at just one of the aspects involved, that of transportation, demonstrates barriers to seeking medical assistance. Transportation arrangements could involve complicated logistics, like with the one woman who was from a village where to go to Sanaa, one has to walk for two hours to the road and then take a car for five hours. If someone is ill, she must be carried for the two hours. As one doctor explained, since many people cannot readily afford transportation to the hospital, they wait until they determine that the condition is severe enough to require the disruptions. People may try local treatments first before going to the capital.

Illustrations of traumas that had occurred quite a bit prior to the patient's visit include a ten-year-old girl who had been burned along the right side of her body three months earlier; a girl with a clouded retina where a needle had struck her eye a year and a half ago; a woman from a village who fractured her ankle one month earlier when a zebu cow stepped on it; and a twelve-year-old boy who fell from a tree a month ago.

When patients do reach the hospital, however, they may be criticized for having waited too long for treatment. Rather than criticizing patients for not seeking medical care sooner, we should consider the impediments to seeking that care and the arrangements that need to made in order to visit the hospital. Such arrangements are also required for people who live in Sanaa, of course, such as with the one woman waiting at the door of the gynecological clinic who said that she had left her four children behind a locked door to come to the clinic.

Status and Its Influence on HealthCare

As mentioned, a member's access to healthcare is often influenced by his or her position within the household. One member may receive immediate treatment or the more prestigious treatments, while another member may receive care only if the symptoms are prolonged or may receive less prestigious treatments, such as home remedies. Among the characteristics influencing a person’s status within the household are his or her age, gender, generation, marital status, and work status. Because of the variation in roles and responsibilities within a household, medical conditions of various members affect the household differently. The effect may be as great as with the elderly man who expressed his worry to the doctor that he had six daughters, was afraid he was going to die, and then who would support them?

Since members' statuses within the household vary as does the impact of their illness, then their access to treatments also differs. For instance, a woman brought her baby to the Pediatrics Clinic for his diarrhea. She showed the doctor the six different kinds of medicine she had for him. I remarked on the large quantity of medicines. She explained that while she has daughters, this is her only son. It appeared that she was trying everything to make him well. Biomedical practitioners focusing on a trauma or disease might overlook the household negotiations involved in a patient's access to medical care, as resources and responsibilities need to be shifted and the person's status and roles are considered.

Furthermore, a person's position within the household not only influences his or her access to medical care, but also influences his or her sick role behavior. Thus, a high status individual or wage earner like the father/husband or maybe the mother-in-law may receive concern and medical attention over a cough, whereas a lower-status individual, a daughter-in-law or middle son perhaps, may have to really moan in order to appear sick enough to receive attention. Therefore, listening not only to what patients are saying but how they are saying it may provide insight into household dynamics.

Therapy Management Group

As many of the illustrations throughout this paper have shown, a patient rarely acts alone in deciding the course of his or her treatment. Other people are also influential in making health care decisions. In addition to household members, a patient’s “therapy management group" (Janzen 1987) may include friends, neighbors, and medical practitioners. Studies of the therapy management group examine who is involved in health care decisions, who gives advice and what kind, who makes the final decisions, and who judges the effectiveness of the treatment. Research on therapy management groups in Yemen should consider the influence of women’s gatherings on therapy decisions. These regular afternoon visits that take place in many parts of Yemen with neighboring women, friends, or relatives may be a forum for discussing illnesses and health behavior.

Moral Identity

A person's moral identity is affected by others' perceptions of her illness and health care seeking. Much of illness discourse is engaged in to create the impression that the speaker is a good person. In telling a story, the speaker decides how to present herself. She gains a sense of personal control over herself definition, as well as her life. For example, narrating the search for a cure may provide an ideal way to show that a mother did all she could for her sick child given her economic and social constraints (Early 1985, 1982). She may also recount how she outwitted a physician or government health service. The use of such narratives in Yemeni society deserves further research.

CONCLUSION

In this paper, I have presented observations from a clinical setting to draw the reader's attention to the cultural context of the illness experience and the social relations of health care seeking. I have presented medical anthropology concepts which enhance our understanding of these phenomena. Highlighted have been ethno physiology and etiologies, ideas about how the body functions and what causes illness. Additionally, I have drawn attention to health care seeking process decisions about what an illness is (and isn't), what treatments should be tried, and an evaluation of their efficacy. In a discussion of the household production of health, I pointed out that different patients, depending on their position within a household, have differing entitlements which translate into differing abilities to make and follow through on health care decisions. The concept of a therapy management group was introduced to draw attention to the many actors involved in decisions about treatments which may be outside the household as a structural unit. Finally, I have encouraged analysis of illness discourse, how and why people talk about illnesses and treatments, the stories they tell, and the audiences involved.

References cited

Anees, M.A.
1989 Islam and Biological Futures: Ethics, Gender and Technology. London: Mansell.

Berman, P., Kendall C. and K. Bhattacharyya
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1. Quoting Musallam (1983). Delaney (1991:48) finds that Musallam does not "persuasively document" that the Islamic attitude towards sexual generation is that the father and mother are equal contributors. Monogenesis, where men are believed to be the creators of children, may be the more widespread view. It has appeared in works on Turkey (Delaney 1991),Iran (Good 1980), Morocco (Crapanzano 1973:48-49), and Egypt (Inhorn(1994).

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