UNIVERSITY OF IBADAN LIBRARY
READINGS IN MEDICAL
SOCIOLOGY
Edited by:
E.A.OKE
&
B.E.OWUMI
UNIVERSITY OF IBADAN LIBRARY
© E.A. Oke and B.E. Owumi, 1996.
All rights reserved. No part of this publication may be reproduced
or transmitted, in any form or by means, without permission.
First Published, 1996.
ISBN 97S-027-1IS-X
Published by
Resource Development and Management Services (RDMS)
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Opposite U.1. Post Office,
Agbowo, U. 1.,
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Printed and Produced by
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ABOUT THE BOOK
The text is a collection of .high quality writings from various
scholars and practitioners of medical sociology \ anthropology and
related disciplines. Although not all written by medical sociologists
, anthropologists, the writings focus on current ideas, concepts and
issues in the discipline.
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CONTRIBUTORS
Agbonlahor F.I. Ph.D. (Ibadan), Department of Sociology, Edo State
University, Ekpoma.
Aina J.O. Ph.D., FNACN, Department of Nursing, University of Ibadan.
Ajuwon Ademola B.Sc., M.P.H. (Ibadan), Department of Preventive &
Social Medicine (African Regional Health Education Centre),
University of Ibadan.
Asuzu M.C. M.B.B.S. (Ibadan), D.O.H., Macmastor, F.M.C.P.H (Nig.),
Department of Preventive & Social Medicine, University of Ibadan.
lsamah. A.N. Ph.D. (Ibadan), Department of Sociology, University of
Ibadan.
Isiugo-Abanihe U. Ph.D. (Penn.), Department of Sociology, University of
Ibadan.
Jegede A.S. Ph.D. (Ibadan), Department of Sociology, University ofIbadan.
Nabofa M.Y. Ph.D.(lbadan), Department of Religious Studies, University of
Ibadan.
Oke E.A. Ph.D. (Kentucky), Department of Sociology, University of Ibadan.
Olutayo A.O. Ph.D. (Ibadan), Department of Sociology, University of
Ibadan.
Osunwole S.A. Ph.D. (lbadan), Institute of African Studies, University of
Ibadan.
Owumi RE. Ph.D. (Ibadan), Department of Sociology, University of
Ibadan.
Shokunbi W. A. M.B., B.S., (Ibadan), F.M.C. Path. Nigeria. Department of
Hematology, University College Hospital, Ibadan.
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PREFACE
Reading in Medical Sociology is a collection of group of 'essays,
articles and research findings focusing on current ideas and issues in the
discipline, The collection represents the work of medical sociologists and
scholars in related discipline. The articles are wide-ranging in terms of
coverage, approach and content, they raise a whole host of issues which
are of particular interest to the discipline.
The need for the book arises because of lack of adequate and
suitable reading materials particularly, local materials, for students
specializing in Medical Sociology/Anthropology and also for general
readers interested in the area. We have designed the book as a
supplementary reading, it is an excellent collection which covers the
major sub themes in Medical Sociology/Anthropology.
We are grateful to our students, past and present in th~
Department of Sociology and Nursing, University of Ibadan; The Federal
Centre for Teachers of Health Sciences, University Teaching Hospital
(UCH) Ibadan. We have also been "guest" Lecturers at the West African
College of Physicians Revision Course for Primary Part One and Part
Two, Department of Preventive and Socio Medicine, U.C.H. The ideas
and enthusiasm of these students have been very challenging and have
provided an impetto for assembling the materials.
We are indebted to Dr. Dele Jegede, Department of Sociology,
for arranging for the production and providing technical advice.
We appreciate all the contributions of our colleagues. We also
acknowledge the contributions of the Head of the Department of
Sociology, Dr. Justin Labinjoh. Finally, we wish to express our
profound love and gratitude to our wives Mrs.Lola Oke and Mrs. Angela
Owumi for their moral support and encouragement.
E. Adewale Oke and Bernard E. Owumi
Department of Sociology, University of Ibadan, Ibadan.
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CONTENTS
Page
About the Book I
Contributors ii
Preface iii
Chapter 1 Introduction
The Emergence of Medical Sociology
Adewale Oke
Chapter 2 Adaptation of Anthropological
Methodologies to the Health-Care
Delivery Programmes
Adewale Oke 15
Chapter 3 Comparative HealthCare
Delivery System.
Festus Agbolanhor 33
Chapter 4 Social Epidemiology
Ayodele Samuel Jegede 52
Chapter 5 Age and Aging Process in Nigeria
A. O. Olutayo 72
Chapter 6 Women and the Risk of HIV Infection
in Nigeria: Implications for
Prevention andControl Programmes.
Ademola Johnson Ajuwon
Wuraola Shokunbi 85
. Chapter 7 Women and Family Planning Practice
in Nigeria
Uche C. Isiuo-Abanihe 104
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Chapter"8 Organisation and Management of
Health Services and Facilities
Austin, Isaman 131
Chapter 9 Professions, Hierarchy and
Management Within the Health
Community. A Doctors View
M.C. Asuzu 151
Chapter 10 Professions, Hierarchy and
Management Within the Health
Community. A Nurse's View.
J.O. Aina 166
Chapter 11 Biocultural Adaptation
E. Adewale Oke 178
Chapter 12 Society and Health: Social
Patterns of Illness and Medical. Care
B..E. Owumi 196
Chapter 13 Disease Diagnosis and Etiology
as a System of Thought
S.A. Osunwole 209
Chapter 14 Traditional Practitioners
(Healers & Healing Practices
B.E. Owumi 223
Chapter 15 Faith/Spiritual Healers as
Alternative Therapeutics
Successes and Failures
M.Y. Nabofa 234
Index 267
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Chapter One
lNTRODUCTION
THE EMERGENCE OF MEDICAL SOCIOLOGY
E.A Adewale Oke. Department of Sociology,
University of Ibadan, Ibadan.
lNTRODUCTION
Medical Sociology is a sub-discipline of sociology. It arose
from developments in both Sociology and Medicine. This led to an
appreciation and articulation of interests in the discipline in the
middle of the 20th century. There were two main antecedents.
these are (1) Sociological- developments and (2) Developments in
Medicine.
SOCIOLOGICAL DEVELOPMENTS
The developments in Sociology could be found with
reference to (I) subject matter (2) Theoretical concerns and (3)
Research Methods (Twaddle, 1982).
Subject Matter
Initially, the subject matter was mostly demography, specif-
ically the long standing tradition of fertility, mortality an morbidity
studies which can be traced back into the 1600s with the work of
Graunt in London an Petty in Dublin, to the work of contemporary
scholars throughout the world.
Death rates have been analysed as indicators of the health
of population as well as being componerss of population composi-
tion and change. Today, considerable sophistication has been
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developed with respect to measurement and a high level of refine-
ment and conventionality with respect to definition of key
concepts.
Theoretical Developments
A massive theoretical development has created a fertile
ground for the development of medical sociology. Twaddle (1982)
identified six of them, these are:
Spencer's Organic Tradition: This provided a common conceptual
ground with medicine by conceptualizing societies as organisms.
Through this idea, Spencer contributed the concept of System in
which wholes are seen as more than the sum of their parts and
changes in one part are seen as affecting each of the other parts.
The Debunking Tradition: This was articulated by Berger (1963)
as -inherent in sociology. Research, 1966) as inherent in sociology.
Research findings have challenged the traditional beliefs of some
segment of the society "as a self conscious motif, this has led to
the punturing of the myths generated by and for the most powerful
prestigious groups". For instance such groups as physicians and
corporations have received special attention.
Durkheim'~ Study of Suicide: The study gave a centra attention to
what later emerged as the discipline of psychiatry. In fact,
Durkheirn could be regarded as the founder of medical sociology.
The Concept of Cultural Lag Developed by the Chicago School:
in most of the associated studies, medical care was used as a case
example. Prominent among these studies were the work or
sydenstricker's (1930) study of health services to the poor and
Moore's (1927) study of the relationship between social change
and the development of medical services.
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The Lynds' Study of Middletown: The studies were carried out in
1929 and 1937. The were regarded as major empirical studies of
social class. The emphasis was on the influence of class on
American village life. The studies revealed social class differences
in the health practices and the treatment of disease.
Talcot Parson's Theoretical Development of Professions and
Clients: This was the most important development. Talcot Parsons
(1951) argued that as the businessmen emerged as a dominant
figure in the transition to capitalism, the professional was also
becoming a dominant occupation.
He further suggested that the professions differed from
business in that they took a collective position toward the
interaction with clients while the businessmen took a competitive
one. This analysis centered attention on the physician as a
prototype professional and the patient as a prototype professional
and the patient as a prototype client, thus conceptualizing sickness
as a form of deviant behaviour which he placed as an important
element in the existing sociological study of social control,
analyzable in comparison with crime and law.
Methodological Development
The survey was the most important methodological development.
notable Lazarsfeld's creation of the panel design, the scaling
techniques provided a basis for collaboration between sociology
and medicine.
Developments in Medicine
The developments in medicine can be divided into two broad
categories, these are: (I) Theoretical crisis associated with the
collapse of the explanatory power of the germ theory of disease
and (2) The changes in the organisation of medical services.
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Theoretical Crisis
The theoretical crisis had been developing slowly for many years.
The following are.some of the elements:
1. The germ theory as noted by Dubos (1959). is an ideology
that makes an implicit claim that all disease is ultimately'
conquerable. Dubos observed that germs are a necessary,
but not sufficient cause of some diseases.
They do not cause diseases unless other environmental
conditions present. The narrowing of focus away from
social and environmental concerns would not work and
such factors needed to be taken into account.
2. The development of psychiatry within medicine was based
on demonstration that some physical cause. Further,
psychic factors were implicated in all disease and all
disease has psychological component. Coupled with
recognition of the importance or socia! environment for the
development of personality system (Erikson, 1959;
Parsons, 1964). It became difficult to treat any illness a
simple physical pnoblern.
3. Social Epidemiology has demonstrated that disease remains
socially patterned. Based on social surveys and vital
records, it has been shown that the overall success of
medicine in reducing the level of disease is' negligible and
possibly negative as rates of chronic disease seem to be
rising. Further, the high correlation of many causes of
death with social characteristics and with each other has led
some epidemiologists to abandon the concept of disease as
irrelevant (Syrne, 1996).
4. Finally. health surveys have not only contributed a
technique of research to medical interests, but also they
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have repeatedly demonstrated the continuing relevance of
social structures for the patterning of disease and the
uti Iization of heath care resources.
At the very least, a multi causal mode of disease seems to
be needed. While micro-organic life continues to be relevant. it is
clear that a germ theory of disease is not. In the search of
alternatives, the social sciences seem to be promising area.
Changes in the Organisation of Services
the development of the modern medical school contributed
to a chain reaction including the following:
1. Placing medical schools in universities and requiring a core
in. the basic sciences improved the level of medical
knowledge.
2. As a result of improvements in knowledge, diagnosis and
treatment became more intricate, requiring more efforts in
each case.
3. Medicine responded to these pressures like any other
historical system as followsr-
(a) It increased the scale of its organisation by moving
practice out of the home of the patients into the
clinic and hospital. The trend toward bureaucratiza-
tion was increased by the need to share expensive
new techniques developed in part in an attempt to
find labour-saving means of coping with demand.
(b) Physicians began to specialise. From the perspective
of the patient, this constitutes fragmentation of
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service. The patient is often faced with the need to
see several physicians to treat difficult problems.
Medicine is less well coordinated and takes more
sophistication on the part of the patients.
4. The increase reliance on high technology, the greater
labour intensiveness of medicine as a result of
bureaucratization and technological elaboration, the
increased unit costs of special ised as compared with
generally trained physicians, all combined to drive up
medical costs. These trends have a number of implications:
(a) There were pressures to make the system more
efficient for clients.
(b) There was a need for cost controls and better
organisational forms to improve coordination.
(c) There was a need to provide a more humane mode
of delivering service.
The central emerging issues facing medicine were those that
had long been core concerns of sociology. Issues such as social
organisation, interaction and alienation. As we have mentioned, the
developments in sociology made the field ripe for developing a
focus of medicine. In articulation of these interests, medical
sociology emerged in the 1950s and became an established
special ity by 1960.
The Three Dimensions of Medical Sociology
The basic premise that led to the development of medical
sociology is the assumption that understanding of health problems
and the mobil isation of effective response to these problems could
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be found through medicine.
This assumption was clearly demonstrated during the period
following the second world war. Medicine had firmly established
its credentials as an effective source of treatment of disease. As
Twaddle put it, "physician - centered scientific healing was where
the action was", that was where sociological attention was
directed.
We can identify three but inexclusive dimensions of this
development, these are:
(1) Sociology in Medicine;
(2) Sociology of Medicine; and
(3) Sociology of Health.
Some scholars particularly Robert Strauss (1957) identified
only the first two dimensions which he labelled "The dual focus of
Medical Sociology". He saw the third dimension as a new trend
in sociology or what Twaddle Sub-categories as "Toward a
Sociology of Health". Today, Sociology of Health has emerged as
an integral part of medical sociology.
Sociology In Medicine
Sociology in Medicine refers to the applied aspects of
medical sociology. In extreme form, it refers to sociological work
that provides technical skills for the solution of medical problems
or of problems in health care delivery without regard for
contribution to sociological theory.
The work of those primarily concerned with the prevention
and treatment ·of disease, the allocation of resources, and similar
problems fell into this category. The basic stance of people with
this orientation is to treat sociology as an adjunct of medical
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practice, a supporting discipline to medicine. The problems
defined for investigation tend to come from the concerns of
physicians.
The goals of sociology in medicine have been to improve
diagnosis and treatment. This has meant getting involved in
medical education and in medical settings particularly hospitals.
This approach has contributed much to medical education, social
epidemiology and our knowledge of utilization and compliance.
Sociology of Medicine
Sociology of Medicine on the other hand refers to the basic
research of medical sociology. As with education, religion, the
family and the economy, medicine is a social institution worthy of
sociological study in its own right. A~ with other social
institutions, the study of medicine generates insights into the
properties of social relationships and social organisation.
The goal of this approach is to learn about societies rather
than to understand disease processes or otherwise contribute to
medical ends. The fundamental stance of the sociology of medi-
cine is hence that medical practice is a social institution that can
serve as an avenue for understanding society.
The goals of sociology of medicine therefore are to improve
the state of knowledge relative to social structures and processes.
Such things as complex organisation, the biological parameters of
human behaviours, social norms and identities, status changes,
roles, interaction, and deviance. These can be studied in medical
setting.
These settings make explicit some of the criteria and
assumptions that are left largely implicit in other settings. For
example, the evaluation of human beings on non-technical grounds
is more explicit among physicians than among school teachers.
The unique concerns of medicine and medical settings highlight
questions that are generic to the discipline.
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Sociology of Health .
Modern medical sociologists have directed much effort in
e the direction of sociology of health. This is a result of some
changes in the issues facing health services. Scholars in this
direction are now divorcing from the traditional perspective and
medico-centric perspective to one that takes medicine as one
element associated with the health of both individuals and
populations, the relevance and salience of which needs to be
empirically established.
While both sociology in health and sociology of health or
what may be referred to as traditional medical sociology. were
essentially modelled on biological and sociopsychological para-
digms, the sociology of health is based on social structure and
humanistic paradigms.
The main change of emphasis has been from a positivist
emphasis on the organism and physiological foibles. and on the
human personality, social roles and deviance towards an emphasis
on social structures in which human beings are enmeshed and the
problems ofcoping with these structures.
Traditional medical sociology was centrally concerned with
disease, illness and sickness. The sociology of health is taking a
broadened perspective on all kinds of events and structures that
Iimit freedom of choice and/or reduce personal effectiveness. In
traditional medical sociology, the key healing roles were located
within medical institutions. For sociology in medicine for instance,
attention was given primarily to the physician and secondarily to
the patient, who was seen most often as a passive recipient of
services.
Sociology of medicine paid some attention to other health
occupations, mostly nursing, but primarily from the perspective of
the relationships between physicians and nurses. For the sociology
of health however, all of the traditional healing roles have a lower
profile. For instance, emphasis is on politician who can legislate
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changes with major implications for health: powerful groups in the
economy who have interests that may be detrimental to or
supportive of health concerns.
Sociology of health is moving toward a different conception
of the main means of healing which focuses attention on social
change, environmental control. smoking, nutrition and exercise.
The objective is to promote well-being. reduce mortal ity
and morbidity in population. There is also a change in the kinds of
organisation - this is central to the field. The shift is away from
the hospital. clinic, and self-care centre, which were most
important to traditional medical sociology, toward legislation,
schools, public recreational settings and more informal settings.
Medical Sociology and Medical/health Profession
Although medical sociology is closely related to other
sciences, nevertheless, it has a unique relationship with medi-
cal/health profession. It provides an adequate cultural and social
context for interpreting and solving health problems (Oke , 1991).
Otite (1987) had earlier expressed similar view, he noticed that the
phenomenon of health is both a medical and a socio-behavioural
concept, just as medicine itself is a natural as well as a socio-
behavioural science.
He suggested a comprehensive view of health that combines
both physical and socio-cultural dimensions that is capable of
providing adequate explanation of health phenomenon.
The relationship between socio-curtural factors and the use
or non-use of health services has long been demonstrated by
scholars. Otti (1991) emphasized that this depends not only on the
presence or absence of disease, or of health care institutions "but
also on the feelings of acceptance or rejection of health services
offered by professionals. She further observed, "Such acceptance
or rejection may arise from the nature of people's perception of
the usefulness of the health care delivery, which is essentially a
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socio-cultural phenomenon". In short, there is an association of
personal characteristics and/or socio-cultural factors with the use
of medical services. (Oke, 1982).
The implication is quite obvious, medical sociologists and
medical/health professionals alike should recognise the fact that
both health and illness are intricately woven together with the way
man lives (Otti, 1991). Disease or illness is a manifestation of
social and physical context in which an individual lives. This view
is well articulated by Otti referred to above. She observes "The
individual patient lives in a social environment in which various
factors contribute to or even almost entirely on their own product
disease conditions".
It is apparent from the above that there is a need to
recognise'medical sociological knowledge and skills and fully
utilise the expertise of the practitioners by the health professionals
in our society .1R~levant c~ourses in Sociology should be taught to
our medical students by S¢cjologists along side with other students
taking such courses, so that by the time they (medical students)
become fully qualified and become professionals, they will have an
appreciation and understanding of socio-cultural phenomena that
have bearing on health and health related practices. For similar
reason. medical sociology students should also have some exposure
to biomedical science.
In addition. medical sociologists must always remember
that medical professionals operate in terms of a sub-culture and are
apt to be disturbed as anyone else when basic tenets of their sub-
culture are challenged (Oke, 1991). The sociologist must maintain
his professional posture. but he must be willing to learn and
adjust. He must try to keep communication lines open and
remember that medical professionals as well as other professionals
have specified goals they wish to reach. These can be
accommodated in a multi-disciplinary venture. this will promote
advancement of science for the betterment of mankind.
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In this' text, we have brought together a diverse collection
of high quality writings from various scholars and practitioners of
medical sociology and related disciplines. Although, not all written
by medical sociologists, the writings focus on current ideas,
concepts and issues in the discipline.
No attempt is made to categorise each chapter or groups of
chapters into a distinctive dimension as this will be mere
superficial. In reality all the three dimensions identified above are
mostly for analytical purposes and can be represented, and is often
represented in a single research project especially now that multi-
disciplinary approach is the vogue for health and health related
projects and programmes.
Nevertheless, the reader will appreciate the orientation of
each scholar as reflected in his contribution and thus a better
understanding of the readings and an appreciation of the dynamics
of medical sociology.
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REFERENCES
Berger, P. (1963) Invitation to Sociology. Garden City.
New York. Double day
Dubos, R. (1959) Mirage of Health. Garden City.
New York. Double day
Erikson, E. (1959) Identity and the Life Cycle. New York:
International University Press Psychological Issues.
Lynd, R. and Lyod H. (1929) Middle Town. New York. Harcourt,
Brace and World.
Lynd, R. and Lynd, H. (1937) Middle town In Transition: A
Studyin Cultural Conflicts. New York Harcourt, Brace and
World.
Moore, H. (1927). American Medicine and the People's Health.
New York. Appleton
Oke, Adewale (1982) "Social Epidemiology" in Nigeria
Perspectives on Medical Sociology. Third World Societies.
No. 19,43 - 57.
Oke, E. Adewale (1991) "Anthropology in Medical Curriculum":
Ogere. Paper presented at The Nigerian Association of
Colleges of Medicine Workshop on the Integration of the
Social Sciences into the Under-graduate Medical Training
in Nigeria.
Otite, Onigu (1987) "The Impact and Integration of Behavioural
Sciences in the Education of Health Care Professionals."
Soc.Sci. Med. Vol. 25 No.6.
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Otti. Paulie N. (1991) "Sociology, Medicine and Primary Health
Care Approach: Converging Frontiers of Interest". Ogere
Paper Presented at the Nigerian Association of Colleges of
Medicine Workshop of the Integration of the Social
Sciences into the Under-graduate Medical Training in
Nigeria.
Parsons, T. (1951) The Social System. Glencoe, Ill. Free Press.
Parsons, T. (1964) Social Structure and Personal ity. New York.
Free Press.
Sydenstricker E. (1930) Hagarstown Morbidity Studies.
Washington D.C. U.S. Government Printing Office.
Twaddle, Andrew C. (1982). "From Medical Sociology to. the
Sociology of .Health: Some Changing Concerns in the
Sociological Study of Sickness and Treatment". In Medical
\ Sociology. The State of The Art. Eds. Tom Bottomore,Stefan Nowak, and Magdalena Sokolowska. London Sage
Publication.
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Chapter Two
ADAPTATION OF ANTHROPOLOGICAL
METHODOLOGIES
TO THE HEALTH CARE DELIVERY PROGRAMMES
E. Adewale Oke
Department of Sociology
University of Ibadan, Ibadan.
INTRODUCTION
Application of anthropological data, theories and methods.
to action programmes had long been recognized and appreciated by
health professionals and health workers. The sub-discipline of
znthropology, referred to as "Applied Anthropology" has played
a remarkable role in this direction. The most important
contribution of applied anthropologists to action related
programmes is an unusually broad and flexible research
methodology based on a holistic view of society and culture
(Foster, 1969).
The traditional approaches of anthropology, particulari y the
"System approach" that is, the concept of whole systems underlies
the anthropological method. The anthropologist habitually thinks
of data and problems in the context of large units. This may be
social, cultural, economic or more likely a combination of this.
The emphasis on systems was not a mere accident, it
developed from within the discipline itself, it is an inevitable
outgrowth of the early definition of the anthropologist's primary
task. Foster (Ibid) puts it vividly.
The task was to study and record the primitive
societies of the world before they vanished. The
assignment was total - find out everything there was
to be known about the people studied.
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The underlying problems were assumed to be historical and
the goal was to describe and reconstruct as far as possible the
histories of non-literate peoples.
The interests then have been theoretical rather than practical
and most time and effort were devoted to university teaching and
university based-research.
But as far back as the first part of this century, there was
a need to shift attention to solving practical problems, more so,
anthropology's claim to status as a social science has now been
established as such, applied anthropologists are most concerned
with processes of social change and cultural change particularly as
they bear upon planned improvements in the fields of agriculture,
health and medical services, educational systems, social welfare
programmes and community development as a whole.
It is .also obvious that the traditional approaches are too
expensive and time consuming. Programme planers do not often
have the patience or the funds to finance such research. At times.
anthologists have been called upon to give quick advice on specific
problems based on their years of experience with cultures and
programmes. Scrimshaw (1992) however observes:
Often the practical questions asked by programme
planners and health care providers could be
answered with information derived from examine
the existing anthropological and rural sociological
literature and suggesting common sense solutions or
by a few days or weeks of exploratory observation
and interviewing. This work and the methods used
was unlikely to be shared with the originating
profession since it did not constitute formal
research.
The need then arises for formalizing anthropological
methodologies aimed at action programmes, in this case, health
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related programmes.
Such methodologies have been well documented and applied
to various health programmes or community development projects
(Oyejide, Oke, Oladepo, 1988: Oke and Yoder, 1989: Oni,
Shumann,Oke, 1991: Oyejide, Oke, Oladepo, 1991: Yoder, Oke,
Yanka, 1993: Oke, .oladepo, Oyejide, 1991: Wilson, Shale,
Parker, 1992: Iyun, Oke, 1993: etc) , The main focus of this
chapter is to illustrate with a few recent studies, drawing heavily
on African materials, the application of anthropological
-: methodologies to health delivery programmes.
SELECTED STUDIES
The studies selected for discussion here are mostly for easy
illustrations. They include:
1. A Longitudinal Observational Study of Diarrhoeal disease
Risk Factors in a Rural Nigerian Community, Oluyole
Local Government Area (LGA) .
.2. Maternal Education, Maternal Behaviours and Risk Factors
for Diarrhoeal Disease in Children in Urban Nigeria and
3. Rapid Assessment Procedure in the Early Planning for
Control of Paediatric Acute Respiratory Infections:
Lesotho.
A Longitudinal Observational Study of Diarrhoeal Disease
Risk Factors in a Rural Nigerian Community, Oluyole LGA
(Oyejide, Oke and Oladepo, 1988).
The study was a multi-disciplinary project. The approach,
•. involved a combination of three research methods, these are:
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(a) Ethnography
(b) Diarrhoeal surveillance and
(c) Structured observation in homes. It was conducted in rural
villages of Oluyole LGA of Oyo State.
The Principal Investigators (PIS) include Dr. C. O.
Oyejide, a medical doctor from Department of Preventive and-
Social Medicine, University of Ibadan, Dr. E. A. Oke, an
anthropologist from Department of Sociology, University of
Ibadan, and Dr. O. Oladepo, a Health Educator from Department
of Preventive and Social Medicine of the same University.
Although the PIS worked together as a team throughout all the
phases of the study, my main concern here is on the ethnography
being a major contribution of anthropology to the project.
The overall objectives of the study were to determine the
incidence rates and severity of diarrhoeal disease among under -
five children in the community arid to identify environrr ental and
behavioural risk factors for diarrhoeal disease with the ultimate
aim of utilizing the information for planning an intervention study
aimed at reducing diarrheal morbidity in this community.
The primary objective of the ethnographic study was to
elicit information on knowledge, attitudes, beliefs and practices
(KABP) of mothers about diarrhoeal etiology and method of
prevention. The study also aimed to obtain information on a list of
common childhood diseases in the community, to identify the
symptoms, causes, and treatment options for these diseases. In
addition, it was aimed to obtain information about childhood
feeding especially during episodes of diarrhoea. This information
is indispensable for the preparation and implementation of an
anticipated intervention programme.
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Research Method
The study was conducted in four villages clusters of
Oluyole LGA (Jago, Badeku, Ajia and Ojoku) between June and
December, 1988 by the research team including a trained
ethnographer with a M.Sc. degree in sociology and M.P.H degree
candidate. The ethnographer resided permanently in the community
throughout the duration of the study. It should be noted that the
ethnographer and the PIS belong to the same ethnic group
(Yoruba) of the community.
The study was based on indepth interviews. The main
target groups for the interview were the mothers of under-five
children and village key informants. This was on the assumption
that the mothers (or care-takers) of young children were mostly
responsible for taking the initial decisions about diagnosis and
treatment of their' children although the investigators were also
aware of the fact that the men often made the final decisions.
The second target made up of community leaders were the
key informants. Their views, uuerances and behaviours were
considered, to a great extent, a reflection of community ideas,
habits, beliefs and values. These individuals are sources of
information that have ceased to exist or have been modified by the
time the ethnographer arrived on the scene. Thus the information
obtained from such key informants is vital.
Community Level Data
The community level data was collected on the following:
1. Geographical conditions
2. Demographic distribution
3. Health services availability and utilization
, . 4. Sources of water supply
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5. Methods of human waste disposal
6. Methods of refuse disposal
7. Women's work/child-care practices
8. Religious beliefs
9. Utensils used for cooking and eating and those specified for
children.
10. Inventory of utensils used for water storage
11. Animals kept in the house.
Household Level Data
The household level data included:
1. General childhood diseases
2. Childhood diarrhoeal
3. The last diarrhoeal episode
4. Feeding and weaning practices
5. Feeding during diarrhoeal episodes
6. Hand washing practices
The ethnography lasted for about one month in each village
cluster. A total of 151 persons participated in the interviews. The
preliminary information gathered from the ethnography helped
considerably in the formation of questions or guide-lines for both
the structured observation and the diarrhoeal surveillance
(Ethnography, in this study, is regarded as an integral part of the
baseline study. The baseline study as it is then is a combination of
a more intensive and extensive ethnographic study, structured
observation and diarrhoeal surveillance).
Once the preliminary investigation in the first village
chaster was analyzed and the instrument for a more intensive and
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extensive ethnographic study, the structure observation and the
diarrheal surveillance were prepared, the investigations were
conducted simultaneously. The three set of field workers (the
ethnographer; the field workers responsible for the diarrheal
surveillance and structure observation; and the staff nurse and the
nursing sister in charge of the min-c1inic) met daily and exchange
notes. The information from each component served as
complementary, cases were referred to appropriate field worker for
thorough investigation or treatment.
Aside from treatment of cases referred to the clinic for
instance, the staff nurse and the nursing sister assisted in validating
the surveillance data. Day-to-day supervision of the data collection
was done by the. ethnographer (also designated as the supervisor);
and by the PIS during each of the weekly visits. At the end of each
day, th'e supervisorcollected the observation forms completed for
the day and checked them. Every Friday, there was a meeting of
r- all the field staff with the ,PIS where activities in the previous week
were discussed. Almost all the field workers are indigenes of the
community and resided there (including the staff nurse) throughout
the period of the study.
The result of the ethnographic study showed that the
.1;., villagers were familiar with the symptoms of diarrhoeal and were
able to distinguish various types. However. they were ignorant
about the causes and about preventive measures. This finding is
not peculiar to Oluyole LGA alone but is common through most
rural areas in Nigeria. The fear of certain diseases such as cholera
(Onigbameji) and tetanus (Giri), that is, the fear of mentioning was
rampant. It was believed that mere mentioning of the name will
cause the disease.
The fact that teething diarrhoeal was not considered to be
a disease but a normal apart of growing up is a cause for concern
as it was, many of these village children would have frequent
episodes of teething diarrhoea which would contribute to
malnutrition and the mother would not be aware of the association.
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A reonentation needs to be done to make the mothers aware of the
potential danger of teething diarrhoea as a potential contributor to
malnutrition. For a more comprehensive discussion on the
methodology and the findings, interested readers are referred to the
source.
Maternal Education, Maternal Behaviours and Risk Factors
for Diarrhoeal Disease in children in Urban Nigeria
(Oni,Schumann and Oke,1988).
The study was conducted in Ilorin, an urban centre in
Nigeria. The P. I. was Dr. Gbolahan Oni of the Department of
Epidemiology and Community Health, University of Ilorin, the Co
P. I. was Dr. Debra Schumann, Department of Anthropology,
Case Western Reserve University, Cleveland, Ohio, U.S.A.,
Dr. Ezekiel A. Oke of the Department of Sociology, University of
Ibadan was the Anthropological Consultant/Advisor in addition to
his role as a Co P. I.
The study examined the relationship between maternal
education, maternal behaviours and risk factors for diarrhoeal
disease in children in an urban Yoruba population in Kwara State.
It was suggested that generally, the effect of mother's education on
child mortality is far greater than paternal education (Cochrene et,
aI, 1980) although the investigators were aware that father's
education may also be equally important in explaining differentials
in child mortality.
RESEARCH METHOD
The research was divided into three stages. The first stage
was a household survey carried out between October, 1988 and
December, 1988. The primary purpose of the survey was to
ascertain family and household composition, maternal and paternal
education and occupation as well as household amenities.
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A list of mother-child units was developed upon completion
of the survey for the following four strata based upon maternal and
socio-economic status:
1. No maternal education/low socio-economic status.
2. Maternal primary education/low socio-economic status.
3. No maternal education/medium socio-economic status.
4. Maternal primary education/medium socio-economic status.
The second stage involved a 12 months diarrhoeal disease
surveillance among 240 mother-child units stratified by maternal
education and socio-economic status. The diarrhoeal disease
surveillance was carried out between February, 1989 and January
1990 by 14 trained fieldworkers. Trained surveillance workers
visited each child home twice weekly recording the occurrence of
diarrhoea and treatment given. The workers arrived at each home
as early as 6.30a.m and remained until about 5p.m.
The third stage involved an ethnographic study and
structured observation of behaviours associated with diarrhoeal
disease. The ethnographic design emphasized an intensive key
. " informant interviewing to provide detailed information and
descriptions of childhood management practices at different phases
of the disease.
The interviews were conducted by Dr. Oke and a female
ethnographer (B.Sc. Sociology, University of IIorin) and Dr.
Sohumann between August 1 and August 15. 1989 in ten study
households in Alanamu ward. The preliminary ethnography
included community observation (focusing especially on
environmental sanitation), household observation and an interview
using a study guide with the mother of the index child focusing on:
1. Health services availability and utilization
2. Mother and child daily schedule
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-------
3. Child care and family domestic task allocation
4. Water collection storage and use
5. Methods of human waste and refuse disposal
6. Meal preparation
7. Treatment of diarrhoea
8. Feeding and weaning practices (including feeding during
diarrhoea).
After the ethnographic study, research instrument for
structured observation was developed. This involved.' mostly
observational studies of behavioural risk factors associated with
diarrhoeal disease. The objective was to identify diarrhoeal disease
transmission behaivours which increase the risk of diarrhoeal
disease incidence and which may be helpful in developing an
intervention strategy.
As in the previous case, at the end of each day's work, the
research team went through the field-notes, cases that needed
further investigation/observation were referred to appropriate
fieldworker or investigator. Seriously sick children, discovered
during the course of the study were referred immediately to
Alanamu Basic Health Clinic (Operated through the State Ministry
of Health) for prompt treatment.
The preliminary findings from the ethnography reveal that:
(a) Diarrhoea is perceived as a major childhood disease in the
community. The informants were knowledgeable of the
symptoms but did not recognize causation and prevention,
(b) Teething diarrhoea is perceived as normal and self-
regulating. As such, virtually nothing is done in terms of
treatment unless the problem persists or is getting worse.
Because it is considered to be a normal part of the child's
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development, informants perceive that it is not possible to
prevent the child from acquiring it.
It is apparent from these findings that health education
efforts should specifically target mothers' perception of teething
diarrhoea. There is also. the necessity for use of oral rehydration
solution as well as addressing the causation of diarrhoeal disease.
Specific efforts towards improved environmental sanitation,
excreta, and refuse are needed in the poorest areas of our urban
centres. Diarrhoea should not be viewed in isolation, there is a
need to provide a comprehensive health programme to improve the
health status of the community. There is also a need to raise the
confidence of the community in the effectiveness of modern health
care del ivery .
(Rapid Assessment Procedures in the Early Planning for
Contr"ol of Paediatric Acute Respiratory Infections: Lesotho
(Wilson, Shale and Parker, 1989).
A. two-phase anthropological study was designed to obtain
community baseline data on acute respiratory infections (API) in
Lesotho. The phase one of the study is of a particular interest to
us in this chapter. The PIS included Dr. Ruth Wilson, a medical
anthropologist at the Centres for Diseases Control, Atlanta,
Georgia, U.S.A. Dr. Mamochaki Shale, Department of Sociology
and Anthropology, National University of Lesotho, Rama,
Lesotho, and Dr. Kathleen Parker, a Health Education specialist,
Centre for Disease Control, Atlanta, Georgia, U.S.A.
The primary purpose of the phase one was to determine if
there was a specific comprehension of ARI among village health
workers and among care-takers of children under five years of age
in Lesotho.
The study also aimed at an assessment of. rapid
anthropological methods in the collection of social and cultural
25
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data ·on ARI' (Wilson, Shaler and .Parker,:. :1992). Rapid
Anthropological procedures are generally usee to determine local
terms, categories and treatment practices associated with a
particular ilLness..
" !lq bluorle zrro' . j
Research-Method f. zi Jl£ nr .seo.rnsrb
. Two study-sites were. selected by he Lesotho Ministr.)' of
Health based on accessibility and thepresence of an' active will age
worker programme ..Theplan was' to interview 20 ·.;~24care-takers
of small children .(to,::! 12 per 'health catchment) and 'two groups of
village health workers'{S.> 6 per vilrage).. J" } n' '"' '
, • ! A preliminary interview guide, was, designed-by he PIS
through discussions with the staff from the Ministry of Health, this
was pretested in thee field setting, then revised and a final
instrument emerged which included .the following 'five caiegeries:
, ., . .1 .' {. '
1. Illness terms related to ge-neral childhood illness. -
. f .i .••••..•
2. Categories of se~v"e.rity for elicited illness terms.3: ~ •.Illness teLr'insassociated with breathing difficulty.
" ,f .,)~ . ~ t), t ,; " ~
4. Narratives of ARI - related-illness'iexplain how Basi21thl:.i
define, diagnose- and respond to. A'R episodes in :young,
.children. ,'--_- G ";:J
'1 ~ . 4'. • 1 • ~ 1 • r,' n h I ~ .• ~'.. .' y T
5. Suggestions for' appropriate health, education' interventions.
1 I ~ ••..•
2:1 ~ , ,- , _, j I J j. (. • ,
. The research te~ ,was .made ~p. of lh!ee _PIS and tw~
interviewers. The interviewers .were selected from a-Iist of
applicants ,who had ~i~ilar field '~xperje~~~ 'a~n~could read and
write English and -Lesotho" languag~s. .When p.oss!l}lp._., . the
interviewers were accompanied by a village health worker assigned;
to the selected village. He assisted by helpjng the researchers gain
.' .• r .
entrance to the community and permisJ~9n --;tol,co_nquGt.,the.
26
UNIVERSITY OF IBADAN LIBRARY
interviews through meeting with the village chiefs. 1
A small purposive sample was selected from ...i.dentified
households. The sample represented different socioeeconomic
groups in the community. In most cases, the village-chief or health
worker helped -in the selection of the information. .Data were
collected using participant. observation, observations and informal
and formal interviews withrindividuals-and groups.
Observations of thehousehold surroundings were the basis
for deciding socio-economic status. Other variables considered
included demographic: and. "distance .from -a health centre. The
selection of small purposive sample requires that researchers who
are knowledgeable of the 'culture-make quick-decisions after asking
a few direct questions from the informants.
The study was completed in three weeks, five days for
logistics of the-field 'Work, twelve days fori data. collection in the!
field, and two/days for w.riting aidraftreport. .A'final report was
submitted to the Ministry one month latern The study reveals that
home-treatments, traditibnal and religions leaders-play-a part along
with over-the-counter medicine.chealth providers. and; modern
medicines in caring for young children with ARI. These findings
would help in the preparation 'ofresearch instrument for phase two
of the study. _ .; .> }. ,) r':-- D:-"
~ ~1 J
J s an 10 t'uoi/lf ( J ':'1r..
CON<2LUSION I J '~?"1 1£:JlgO!OqO' J T' I
r , r r= - J
The above studies are excellent illustrations of conscious
efforts by anthropologists-either as individuals .or in collaboration
with other scientists to adapt the traditional approaches in order to
p,~<?viqepeeqed informatieTl nd. 'solutions to health care related
problerrus). In most cases.' such information .. was 'I sed for
preparing and implementing comprehensive health care
prograrnmes j- I~ I)c,')l.t! !'jJ.!J'j' > 'J.I) ::. 11'. i;
•• ~T 1;' J" •••• on ~flt nr ~.nu)llI'JC','I!O l:lrl "'0 ~H! '!I ~d.i:Jfjl:.
rl 1 .l"',' '.)ri1 ririw V,iP.1il'''Y' /1!!'~ nn!) >,;J!>qij\!,"q JII
UNIVERSITY OF IBADAN LIBRARY
There are certain prominent features common to all the
three studies:
(1) The need to collaborate with medical scientists or health
professionals and cooperate with government agencies, non-
governmental organizations (NGOs) and other health
provider organizations in order to provide a comprehensive
health programme without compromising the fundamental
tenet of anthropology as a scientific discipline.
(2) The need to make anthropology more relevant to modern
human needs, that is, human species as a whole, rather
than concentrating on archaic cultures or the so called
primitive societies.
(3) A realization that in a modern complex world, there is a
need to focus a research project to specific or manageable
aspects of human behaviour(s) aimed at providing
information/solution to a pressing or anticipated problem(s)
rather than all facets of social life.
A common criticism of anthropological studies is that the
field-work is too slow, too rigid and takes a long time to complete.
Modern anthropologists are conscious of this and have learned that
the speed of conducting anthropological research can be enhanced
(Wilson, Shale, and Park op cit) by:
(1) Focusing the scope of the research problem.
(2) Cooperating with a multidisciplinary research team that can
answer technical questions rapidly,
(3) Working with a country national social scientist with
expertise in his or her own culture in the host country who
are participating and fully cooperative with the research
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UNIVERSITY OF IBADAN LIBRARY
activity and
(4) Having the managerial support of a resident project staff
member.
For anthropology to remain relevant and sensitive to human
needs, to continue to be the science of man, men of all periods and
his work, it is apparent that the traditional methodologies must be
modified, we must strengthen the capability to collaborate with
multidisplinary research teams, cooperate with health care delivery
agencies and organizations without undermining the identity of the
discipline.
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REFERENCES
Cochrene; ~S1l' ,tLj!n9~OtThe Socio-economic Determinants of
Mortality: The Cross National Evidence in The Effects of
Education on Health by Coohrane et. al. World Bank Staff
nsrr r ,Working Paper No. 45, Washington D. C.
1 -): 1 I J..j.' '. -, ~J f;r _
Foster.. George, [M, n969} Applied Anthropology Boston, Little,
,. Br-own 'and Company.
,.. .
'" 1.:;'-
Iyun.i B, p., .Oke.~.E. A._ (1992) "Community and Ecological
Factors Impending Use of ORT in Riverine Areas of Ondo
State" Ibadan Department of Geography, University of
Ibadan. - .
Oke, E. Adewale, Yoder, P. S (1989) "Know ledges and Practices
Related to Diarrhoeal and Oral Rehydration in Niger State
Nigeria: 3rd African Conference on DiarrhQeilI Disease
(AFCODD Proceedings. 118 - 124.
Oke, E. A., Oladepo, O. Oyejide. C. O. (1991) "Community
Participation in a Longitudinal Observational Study of
Diarrhoeal Disease Risk Factors: Perception and Coping
Measures" West African Journal of Archaeology Vol. 21,
187 - 195.
Oni G. A. Schumann, D. a. Oke, E. A. (1988)' "Maternal
Education, Maternal Behaviours, and Risk Factors for
Diarrhoeal Disease in Children in Urban Nigeria" Ilorin,
Department of Epidemiology and Community Health,
University of Ilorin.
UNIVERSITY OF IBADAN LIBRARY
:jf,:;"!~.~'h(199l;D) iaerhoeal Disease 'Mobility, Risk Faotors and
.10 'Ir .Treatments in a Low.Socio-economic Area in Ilorin, Kwara
'State, Nigeria. Journal Diarrhoeal Dis; Res. ·Sept.'9 (31).
Oyejide, C. O. Oke. E. A., Oladepo, O. (1988) "A Longitudinal
Observational Study of Diarrhoeal Disease Risk Factors in
Rural Nigerian Villages" Ibadan, Dept. of Preventive and
Social Medicine, College of Medicine, University of
Ibadan.
............... (1991) "Diarrhoeal Among Rural Children:
Experience in Oluyole Local Government Area of Oyo
State, Nigeria". Journal of Community Medicine and
Primary Health Care Vol. 4, 13 - 21.
Scrimshaw, Susan, C. M. (1992) "Adaptation of Anthropological
Methodologies to Rapid Assessment of Nutrition and
Primary Health Care" , in RAP, Rapid Assessment
Procedures: Qualitative Methodologies for Planning and
Evaluation of Health Related Programmes Eds. Nevin, S.
Scrimshaw and Gary R. Gleason Boston. International
Nutrition Foundation for Developing Countries (INFDC).
Wilson, Ruth, Shale, Mamochaki, Parker, Kath-leen A (1992)
"Rapid Assessment procedures in the Early Planning for
Control of Paediatric Acute Respiratory Infections:
Lesotho, 1989" In RAP, Rapid Assessment Procedures:
Qualitative Methodologies for Planning and Evaluation of
Health Related Programmes Op. cit.
Yoder, P. Stanley, Oke, E. Adewale. Yanka, Bihini (1993).
"Ethnomedical Research for Development Purposes:
Examples from Nigeria and Zaire" in Note from the Field
in Communication for child survival ed. Relata E. Seidel.'
UNIVERSITY OF IBADAN LIBRARY
a
Washington D. C. United States Agency for International
Development, Bureau, for Research and Development,
Office of Health.
.-
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CHAPTER THREE
COMPARATIVE HEALTH CARE DELIVERY SYSTEM.
Festus Agbolanhor. Edo State University, Ekpoma.
'-----T-H--E GOAL OF HEALTH CARE DELIVERY
The theme of this chapter reminds me of a joke told by one
of my lecturers sometime ago. It had to do with a debate organized
to mark the independent anniversary of Nigeria in the early
seventies. Featuring were three international students on exchange
programme. Each participant was given ten minutes to address the
issue of health care coverage and funding in his own country.
The first speaker was an American. He described the opera-
tion of health care delivery services in his country as a derivative
of market focus. He spoke about Laissez-faire arguing that
America's health care policy is in line with its principle of liberal
derrrocracy. He maintained that health care is a private matter for
the most part and that a number of private insurance firms exist to
provide coverage. He summed up by saying that his country's
health care delivery was the best in the world because it was
considerably funded and that the introduction of medicare and
medicaid policies by the American congress guaranteed coverage
from birth to death.
The second speaker, a Briton, rendered an equally moving
account. He acknowledged that his country is a capitalist society
and that like the first speaker, they too believe in market forces.
However, because his country realizes that a healthy nation is
contingent on healthy citizenry, it has devised a plan whereby
everybody in the population can be adequately catered for. He
called this plan, National health service scheme. He spoke about
the organization of this scheme, talked about modes of payment as
capitation, and at other times General practitioners whom he
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sometimes referred to as Family doctors. He rounded up by
claiming that Britain's health care delivery services is the best in
the entire universe because it was the most adequately funded and
that coverage was from craddle to grave.
The third speaker spoke with equal zeal- He was of Russian
origin. He spoke articulately and tried to convince his audience
that Socialist Russia's health care delivery system is the best. He
disagreed with the first speaker arguing that America's health
model engenders the exploitation of man by man. He talked about
social classes and key terms like bourgeois, proletariat were used
quite freely. He did not believe that British health care can
guarantee much, considering that people were still at liberty to
shop health care outside the National health service. He concluded
by saying that Russia's health model is the best in the entire globe
because it is socialized and promises coverage from-the rising of
the sun to the setting.
A hallmark of the above discussion by these boisterous
speakers is that each of them eventually underscored the fact that
health care delivery service are closely tied to the policy economy
of operating nation and the noble objective of health care delivery
services. In its Alma-ata Heaith Declaration, the World Health
Organization (The WHO) (1978), reaffirmed this when it observed
that:
Health which is a state of complete
physical, mental and social well-
being, and not merely the absence of
disease or infirmity, is a fundamental
human right and that the attainment
of the highest possible level of health
is a most important world-wide
social goal whose realization requires
the action of many other social and
economic sectors in addition to the
health sector. .',
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~ -As we shall soon find out, the practice of health care
delivery by nations is principally concerned with the realization of
the WHO's objectives. However, the modalities for achieving this
is shaped by a number of actors: among which are the climatic
conditions, the amount of funds available for health services and
the political idealogy or will of a country. Let us now examine the
operations of each of these factors in some details.
DETEl{MINANTS OF THE NATURE AND SCOPE OF
HEALTH CARE DELIVERY SYSTEMS
Climatic Condition: The pattern of medical care or health care
delivery of a country can be determined by the types of diseases
that are prevalent in such countries. For example, some countries
are situated in the temperate regions of the world, while others are
located in the tropics. It is known that some diseases that are
." spread by vectors need warm climate to thrive. Examples of such
diseases are cholera, blackwater, lassa fever, yaws, worm
infestations, yellow fever, schistosomiasis, trypanosomiasis,
malaria and onchocerciasis. Since the vectors which causes these
diseases hardly survive in the temperate regions of the world, they
are usually not transmitted there. The implication of this for health
care delivery systems, is that for effective control, countries that
are located in the tropical axis of the world, should ideally develop
a health. care system which emphasize preventive measures.
Funds: The amount of resources a nation has or is willing to
devote to health care, directly influence the pattern of health care
delivery of such nation. In the past, all nations were poor and
diseases like plague, tuberculosis, cholera, rabies, small pox,
measles, leprosy, kwashiorkor and others which have their roots
in poverty were quite prevalent. However, as a result of industrial
revolution, most Euro-American societies have been able to raise
the standards of living of their people and to reduce or virtually
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eliminate poverty induced diseases to the part of non-existent (Jolly
and King, 1975),
In contrast, most developing nations of today are still very
poor. There is shortage of everything needed for effective health
care delivery. Aside from shortage of physicians, lack of adequate
funds, the hiring and training of all other categories of health
workers, there are no drugs, available facilities are breaking down
from lack of maintenance and the sites are littered with abandoned
projects. Worse still, the people themselves are poor and this
further limits access to health care. Health services financing has
to compete with other needs of a nation. In the end, aver has to
determine exactly how much to spend on health services, Where
this amount is small, it invariably follows that not much can be
achieved.
Political Ideology/Political Will: This variable finds expression in
the operations of health care delivery services. The nertinent -•..
questions here are: should health care delivery services be funded
by individuals or the state? What category of people should be
covered by a particular health programme? Although this may not
be a conscious policy, we find that whatever health caresystem is
adopted by a particular country is not completely divorced of its
political ideology. As indicated by the American, the United States
health policy is highly influenced by laissez-faire. Efforts to
socialize medical care is usually blocked by medical practitioners
who contend that it will be grossly unfair to adopt such measures
in a society which believes so much in market forces.
Arguably, health care organization can be placed on a
continuum. At one extreme, are liberal democracies and capitalist
societies like America where the sense of individual is so strong.
In the United States, health care funding is mostly in the hands of
individuals who reserve the right to shop wherever they like.
Under such arrangement, the poor is usually at the mercy -of the
private insurance companies which exist to cover diverse range or
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health services as the most sophisticated or quality care is reserved
for the highest bidders (Erinosho, 1982).
Liberal democracies like Britain, Sweden and Japan are in
at die middle of the continuum. In these countries, the
governments even while acknowledging the strong sense of
individuals have established national insurance schemes that have
gone a long way to ensuring a reasonable health status for their
citizenry. Lastly, countries like Russia, China, Cuba and other
socialist/communists societies can be located at the end of the
continuum. These countries emphasize the state rather than
individuals. It is believed that the state is more than the summation
of the individuals that make it up. Accordingly, the state owns and
directly interferes in the running of health services. Private
practice, and private insurance companies are not tolerate. The
remaining part of this chapter will be devoted to the organization
of orthodox medicine and its operations in selected countries.
The Organization of Orthodox Medicine
Units of Health Care:- It is common to hear people refer to
hospital as the corner stone of orthodox medicine. In practice, the
units of orthodox medicine can be classified as follows.-
(1) Village aide;
(2) Aid camp;
(3) Dispensary;
(4) Health centre;
(5) Hospital; and
(6) Teaching hospital.
Let us take a closer look at each one.
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UNIVERSITY OF IBADAN LIBRARY
Village Aide:- This. is usually a person who -has some knowledge
of modern medicine. He resides in the community where he works
and usually acts as the local representative of health services at this
quasi . level. Such a person can be a Traditional birth attendant.
who can be given some training in sanitary practices like cutting
their nails and washing their hands before delivering a baby. They
are also taught the act of sterilizing equipment and can be given a
delivery kit containing a pair of scissors, and a few medicaments.
Some village aides are part-time workers. As an agent of modern
health care, a village aide is regularly visited by mobile 'teams
from the dispensary, health centre or hospital, (depending on; the
supervisory body) and instructed on how to address health matters
in the locality. His basic function is to educate the people OIr health
practices (Jolly and King, 1975).
Aid Post.sThis is-usually an agreed place ofmeeting. Itcould be
a market square, village square or town hall. Such places are
normally arranged in advance between the health workers and a
targets population. An aide can be sent to inform the people either
through . local .chieftain or any' medium that a, particular health
activity - inoculation, public health education, and the like ''':will
take place. At such times, the team arrives and the business' of-the
day is conducted. <'
Dispensary:- Like the previous two categories, a dispensary is
normally located in the rural areas. It is often a small structure and
is run by a medical assistant, a nurse and/or a midwif~. Treatment
at a dispensary is mostly on an out-patient basi's. 'However, there
is small provision for in-patients. In addition, dispensary.personnel
are also expected to spread knowledge of healthy practices in the
area where they work. '.' "
Health Centre:- The latter can tie differentiated from a dispensary
by the scope of its activities. A health centre may be headed by a
38
UNIVERSITY OF IBADAN LIBRARY
medical doctor, or a medical assistant. However, which ever one
is adopted usually depends 'on the official policy of a nation and
the amount of manpower available. Fendall (1975) classifies the
services rendered by a health centre into two, namely: personal
and community. .' .' '" ' "
~ 1-.> ~
t:' sr .Personal Services
t;<->UL G_en~ralcurative outpatients services
-·imi· Maternity care
Oi' "Family planning
-a o '; i
The care of under-fives - immunization
J I < The care of school children
,~G. co~suitativeclinics' <~.f
! .;,;. ,"" , ! ,. ? 1 ,fje,.)
fijlSiv ; ~linics for special diseases, eg,: Tuberculosis.and, i 2~Ar;r!
bne , :Malnutrition
·"n'·Dental care .,
o t r .Mental c¥e ~I) 'j!,}L,
21 q Home visiting :-'·1 B JR hr N ll' 5'}! ~ '},
10 V E Case work) . ~ilJ1Erf r! ionn r! ,~Gf,r ':
1',1'; C .,).i'. J J'-'i. " ':l"~ l ' .,:.> rhiEf;' ,,{h
Limited fn-p
< '!lUP"H ,I'N 1 fj1 7;!"tie~nt . \' 15.1(! If.
1n~mlJiC"n5 t)~1·l.):1"'\1.·. J
ommumty Se~~~ces
::r'f.:J -it'" ; ',r. ~n " T 'I 'fl
erto•rr ,H"Iegalth ecfucation ( , .D~ <->l'W,Y' 'tl', 1';~""', ,'1")1
101 ni -n~evjmproMe..mentojftexcreta disposal
iud J'I'Phe' s~perV-isroiidr'ho~sing'conditions" r"'l
01 l~£')! ~I·.j f"'h 'L1.b~·).~ 'J," J x . ',' , .•.. j J "!'N 7.,
rzorn Jh~r.x~~~1~~i:H?Pitff,9P~:-~sha$npd.smarket- [, Ii /,~ 1."
UNIVERSITY OF IBADAN LIBRARY
· Campaigns against communicable diseases
The collection of statistics.
Hospital and Teaching Hospital: Hospitals can be classified based
on size, number of beds, admission rate and the number of
outpatient cases seen. A more remarkable distinction however, is
that based on specialization and technical sophistication. Hospitals
are usually manned by physicians, a good number of whom are
general practitioners. Together they carry out the functions listed
against the health centre. On the other hand, Teaching hospitals
are quite sophisticated. They are run by consultants and professors.
They are expected to cater for patients who have special cases or
ailments which need the attention of specialists.
It is often the case, to restructure these units of care into
three tiers. In such arrangement, a village aide, aid post,
dispensary and health centre will become the point where a patient
makes the first contact with a health care system (Primary healtf
care). Hospitals will represent the second level (Advisory) 'and
Teaching hospitals the third tier (Specialized treatment) (Ency,
Britannica, 1990).
The relationship amongst these levels is ideally that of
referral. A village aide or work at a rendezvous aid camp is
expected to refer cases that cannot be handled to a dispensary or
health centres. Similarly, health centres are supposed to refer
special cases to hospitals and only cases that will require
specialized treatment and/or use of very sophisticated equipment
that will be referred to a Teaching hospital.
This means that as one moves from Primary health care
(PHC) to the third tier, health workers encountered get more
specialized. This is not to say that doctors cannot work in for
example, a dispensary, they can in the country can find them, but
as with other resources, manpower is scarce and this leads to
increase rationalization regarding optimum utilization. In most
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UNIVERSITY OF IBADAN LIBRARY
developing nations; PHC is usually an area for auxiliary workers.
The assumption underlying a referral system is that all units are
available in all localities and that patients.actually move from one
to the other. In practice, one finds that among other things, the
amount of money an individual is prepared to commit to health
care vis a vis the degree of freedom permitted in health shopping,
the politics of resources do ont always make it feasible or even
necessary to move from one unit to the other. In places like
Nigeria, there is no clear-cut patter of utilization. A patient who
began a course of treatment at the Teaching hospital may later be
moved to the house of a traditional healer or may decide that to
cut down on cost, it will be better to ask an auxiliary health
worker in his vicinity to complete the course of treatment.
A PARADIGM FOR CLASSIFYING WORLD'S HEALTH
SYSTEMS AND HEALTH CARE DELIVERY SERVICES IN
SELECTED CONTEMPORARY SOCIETIES
Field (1973) suggests four 'ideal types' of medical system,
namely: (1) The pluralistic health system; (2) The health insurance vi
system; (3) The health service system; and (4) The socialized
health system. This section outlines Field's contribution and
examines a contemporary medical system 'erected' on such
touchstone.
The Pluralistic Health System: In this system, a number of
medical systems and/or institutional schemes exist contemporane-
ously for the provision of health services. A number of systems of
ownership of health facilities can be identified in a plural society.
The first of these is ownership by the public, This means that the
facilities that are provided are owned by the government .
.Depending on the tier of government in a country, this could be
national, regional/state, or municipal/local government. In such
organization, the government provides health services and
41
UNIVERSITY OF IBADAN LIBRARY
remunerates all cadre of health workers. A second form of
ownership is private proprietary. This means that a member of the
society can own aclinic or a hospital and can provide services on
a fee-for-service basis to members of the public. A third form of
ownership is voluntary organizations. These bodies are usually
motivated by humanitarian reasons. They do not exist to make
profit. Examples of this will be Missionary owned facilities. A
fourth form of ownership under a plural health care system is co-
operative or Group practice. An example of this will be where a
labour union sets up a hospital to cater for the interest of its
members, or where two or more doctors team up to establish and
run a health care centre.
Two examples of nations whose health care system can be
designated as plural are the United State of America and Nigeria.
HEALTH CARE DELIVERY IN THE UNITED STATES
The provision of health care in the United States is basi-
cally in the hands of private enterprises, which exist to provide
coverage for a range of health needs. Accordingly, a good number
of American doctors are in private practice. Two forms of practice
can be distinguished. These are solo and group practice. A
Physician in solo practice works alone. He may be a general
practitioner or a specialist in one body system. In group practice,
a number of physicians come together for the purposes of
providing health care. Similarly, it is possible to distinguish three
forms of group practice. The first is general practice group, where
a number of general practitioners team up, the second is a uni- .r
specialty or single-specialty groups which cater for one body
system and multi-specialty groups in which a number of physicians
specializing in different areas corriestogether.
Two modes of payment can be i,dentified.. The first is called .
fee-for-service. This is the practice whereby health consumers pay
directly for the services they get. In'the second form which
....:-;;.7
42
,I
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UNIVERSITY OF IBADAN LIBRARY
involves paying advance (prepaid), patients and/or his agents pay
an agreed sum (fix rate) every month for a full range of medical
coverage. Prepaid arrangements are also of two' types. The first
type is called Health maintenance organization (HMO). This type
of arrangement combines prepayment with services. Usually, a
number of physicians specializing in various aspects of health
come together or form a group practice which collects monthly fee
from member of the public (subscribers) in advance with the
promise that they will be catered for when ill. The second mode
of prepayment involves private health insurance coverage. Here,
a person pays a specific amount annually (premium) to a health
insurance firm for coverage of all or some of the medical expenses
that might arise as a result of ill-health. Again, ownership of
insurance companies also range from solo, through partnership,
limited liability companies to non-profit ones like Blue cross and
Blue shield.
About 80 per cent of Americans are covered by one form
of insurance or the other. Generally, insurance companies do not
pay all medical bills incurred at any particular time. Consequently,
individuals still have to find at least a third portion of the money
themselves (Ency. Americana, 1990).
By the middle of this century, it became clear that certain
categories of people lack health access of any kind, either because
they are too old to work or too poor to afford the cost of health
care. After series of debate and protests b powerful lobby groups
like American Medical Association (AMA), the American congress
finally passed a bill providing for a public owned Medicare and
Medicaid programmes.
Medicare programme is actually a Federal health-insurance
programme which provides coverage for the aged - defined as
individuals over 65 years of age and the disabled. Medicaid on the
other hand, is a Federal-state sponsored programme designed to
help the poor and the medically indigent.
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UNIVERSITY OF IBADAN LIBRARY
HEALTH CARE DELIVERY SERVICES IN NIGERIA
Nigeria has two medical systems. These are orthodox and
. traditional medicine. Orthodox medicine or modern medicine as it
sometimes called, is the only officially recognized practice.
However, due to a multiplicity of factors, traditional healing has
continued to remain the people's medicine. Some of these factors
have to do with the phenomenon of the definition of disease and
the fact that orthodox medicine is simply not available to two
._ thirds of Nigeria's teaming population who reside in the rural
. " areas. Patronage or utilization of healers services are usually at the
. discretion of patients or his therapy managers (usually kinsmen).
:Traditional doctors are not allowed to issue excuse duty certificate
'. to their patients. No official policy exists regarding the practice of
.... traditional medicine.
The implication of this is that health care delivery relates
.. .•only to' orthodox medicine. Nigeria's approach follows the three
tiers of PHC, Hospitals, and Teaching hospitals. There is no
-, provision for village-aide in Nigeria, but aid camps and other
forms of rendezvous are fairly regular, especially in the rural
.: .areas. This means that aid camps, dispensaries and health centres
are the first point of contact with health services. These facilities
are financed_bythe local governments and are manned by medical
•
-t assistants and other cadre of paramedical staff. It is possible to see
hospitals financed by local governments, but they are few,
.compared to the number of local government in the country.
Hospitals are more the domain of the states. They are usually
located in the capital and other cities. Similarly, Teaching hospitals
are almost the sole responsibility of Federal government.
There is no specific pattern of utilization, but orthodox
medicine is usually thought to be the best form of treatment for
natural ailments, while traditional healing is considered most
appropriate for prolonged ailments or illnesses'which are diagnosed
to be of preternatural origins. Oke (1995) finds that such
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UNIVERSITY OF IBADAN LIBRARY
conception cuts across all segments of the society, while the
pattern of dual utilization described by Asuni (1979) adequately
captures the illness behaviour. Aside from public health facilities,
a lot of physicians are in private practice. It is possible to classify
private practices into solo and group practices, but the latter is
quite few. No form of prepaid arrangement exists. This means that
there is no health insurance of any kind. The closest arrangement '\
to this is found where governments and certain companies cater for
their employees, their spouse and a maximum of four children.
Physicians in such practice usually send their health care bills on
monthly or quarterly basis. Other than these, all forms of practice
- both public and private - operate on a fee-for-service basis. As
in America, utilization of orthodox services does not take
cognizance of tiers of health care. People utilize tier or system
depending on the definition of disease. Health care delivery
services in Tanzania, Ghana, Kenya and a number of developing
nations follow the same basic structure outlined above.
The Health Insurance System- Except for Great Britain, -rnost
other countries of Western Europe and Japan practice this system
of health care delivery services. Health structures in these parts
bears resemblance to those obtainable in pluralistic societies.
However, unlike the case in the latter societies, most financial
transfers, either to institutions or physicians are made by third
party agencies - which could mean the government or private
groups. In these countries, the role of insurance companies are
limited to that of collecting premium - dues, taxes, contributions -
from a population needing coverage and ensuring that such monies
are disbursed either directly to those responsible for providing the
services or to the patients as part or total reimbursement for their
medical care expenses. The health care delivery services of Japan
is proto-typical of this model.
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UNIVERSITY OF IBADAN LIBRARY
HEALTH CARE DELIVERY SERVICES IN JAPAN
In Japan, two major types of health insurance scheme exist.
These are the National Health Insurance and Employee
Programmes. Japan National health insurance scheme came into
force in 1961. This programme covers all Japanese residents who
are not in the labour force. The employee health insurance scheme
on the other hand, covers everybody working in any establishment
or organization that employs an upward of five people.
The government takes direct charge of administering all
insurance schemes and sees to it that equity is achieved in terms
of coverage and benefits. In a limited cases however, the
government nominates or mandates health insurance firms to
manage employee schemes. Funding for the latter scheme is
sourced by equal contribution from both employers and employees,
while the national programme is funded directly from the treasury.
As the case with most insurance schemes, the National health
insurance does not cover an entire medical or hospital expenses.
Patients still have to look elsewhere or subscribe to a private
health insurance to make up the shortfall. Health structures in
Japan bears close resemblance to the pluralistic system. The three
tiers of operations are discernible. Doctors can either work for the
Ministry of health or in private practice. They can be in lone
practice (solo) or work in group.
The Health Service System
In this category most physicians are either in private
practice or work in government hospitals as consultants. Health
structures follow the 'same three tiers discussed earlier. One
hallmark of this system, is that almost all health facilities are
owned by the state (national government). The maximum number
of patients a physician registered with the scheme can see in
regulated by the government. Physicians are paid directly from the
46
UNIVERSITY OF IBADAN LIBRARY
state treasury. Such payments usually very, depending on whether
or not a physician is in private or public service. The physicians
in the latter service are usually paid salaries. Those on contract for
the government either get salaries, or they can charge by the times
they see a patient (sessional fees. Another way is by capitation.
This is a form of block payment which taken cognizance of the
number of patients seen rather than number of times seen. The
British National Health Service is an archetype of this third model.
HEALTH CARE DELIVERY IN BRITAIN
In Britain, most medical facilities are owned and operated
by the state (national government). The National Health Service
Act of 1948 provided for everyone in the population. Medical
attention is free. Residents are expected to register with the general
practitioners (family. doctors) of their choice. The ceiling of
doctor-patient ratio is pegged. Specialists in this system usually
work in the hospitals or a salary.
The National health service programme is funded by the
government from taxes. Doctors are paid capitation (fixed rate)
based on the number of patients that are registered with them.
Physicians can choose to register with The National health service
or be independent of it. In reality, almost all physicians register
with the scheme. Wealthy citizens or those dissatisfied with the
services of their family doctor, are at liberty to see other doctors
of their choice. However, they are expected to bear the medical
expenses. Again, the structure of health care also follows the three
tiers discussed earlier.
The Socialized Health System
In a socialized system, all facilities are owned and managed
by the state. As in Britain, the state is responsible for fixing the
number of patients a doctor can see. Such patients are usually
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UNIVERSITY OF IBADAN LIBRARY
r
selected on a geographic or occupational basis. Physicians and
paramedical staff in a socialized system are regarded as state
employees and are paid salaries directly from the state's treasury.
The health care systems of Eastern Europe and Russia are classical
examples of socialized medicine.
HEALTH CARE DELIVERY IN RUSSIA
As typical or socialized medicine, health care delivery in
Russia is operated by the government. Physicians and other
paramedical staff are paid salaries from the treasury. Health care
is comprehensive and free. Again, heath care delivery follows the
three tiers mentioned earlier. However, emphasis is placed on
preventive care. A lot of polyclinics or outpatient units exists to
cater for the health needs of people.
Polyclinics are staffed by teams or physicians, a good
number of whom are specialists. Health care in the more remote
areas are largely in the hands of auxiliary workers. In.large cities,
polyclinics are organized for children, adults and for special
purposes like looking after one aspect of the body system. In
contrast, small towns usually have 'one multipurpose polyclinic.
Unless in extreme cases and that is after due process, patients are
not at liberty to change their physicians. Similarly, physicians have
no choice over the schedule of duty that is allocated to them.
SUMMARY
This chapter is concerned with comparative health care
delivery services. We have pointed out how health care delivery
services can be influenced by ideological considerations. We have
identified the goal of health planning and suggested that the nature
and scope of a health care delivery services is affected by a
number of factors, among which are the climatic conditions of a
country, the amount of funds available for health services and the
48
UNIVERSITY OF IBADAN LIBRARY
political leaning of nation. Lastly. we examined a number of
medical systems using Field's scheme In all. one basic fact stands
out: the goal of health planning remains that of equalizing health
access and achieving a reasonably high health status for all
citizenry.
SELECTED REFERENCES
ASUNI, T. (1979) "The dilemma of Traditional Healing with
special reference to Nigeria". Social Science and Medicine,
I3B.
CHILIVUMBO, A.B. (1976) Social basis of illness: a search for
therapeutic meaning. In: Grolling, 1.S. and Haley, H.B.
(eds), Medical Anthropology, Paris, Monson.
ERINOSHO; O.A. (1982), (ed.), "Nigerian Per-spectives on
Medical Sociology" Studies in Third World Societies.
(1990), "Financing health services in a depressed economy"
The International Hospital Federation, 25 (3).
FENDALL, R. (1975). The health centre, In King, M (ed),
Medical care in developing countries--. London, Oxford
University Press.
FIELD, M.G. (1973) "The concept of the "health system" at the
Macrosociological level. Social Science and Medicine.
Vol. 7.
HELMAN, C. (1985) Culture. he<Jlthand illness. Britol, John
Wright.
49
UNIVERSITY OF IBADAN LIBRARY
, , 'i..; ~~;,~.
KING, M, AND JOLLY, R:"(l9-J5) The Organization of Health
Services In: King-M. fed) Op.cit.
LEININGER, R.N. (1974) Health care dimensions, Philadelphia,
F.A. Davis Company.
MECHANIC D. (1968) Medical sociology, New York,
Free Press.
NDETI K. (1976) The relevance of African Traditional Medicine
in modern training and practice. In: Grolling, J.S. and
Haley, H.B. (ed.) Op.cit.
OATMAN, E.F. (ed.) (1978) Medical care in the United States.
New York, The H.W. Wilson Company.
OKB-, Adewale (1995) Traditional health services: an lm:.:~stigation
of the providers and the level and pattern of !ltiIization
among the Yoruba, Ibadan Sociological Series, No.1,
Sociology Department, University of Ibadan.
OYEBOLA, 0.0.0. (1980) "Traditional medicine and its
pracntioners among the Yoruba of Nigeria: 4
classification". Social science and medicine.
RAPPAPORT, H. ET AL. (1979) "An analysis of contemporary
East Africa fold psychotherapy" BritishJournal of Medical
Psychology.
SABLDSKY. A. (1990). Medicine. In The Encyclopedia
Americans, International Edition, Vol. 18.
TWUMASI, P.A. (1975) Medical system in Ghana, Ghana
Publishing Corporation.
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UNIVERSITY OF IBADAN LIBRARY
WORLD HEALTH ORGANIZATION (1978) "The Promotion and
Development of Traditional Medicine" Technical Report
~.622.
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Chapter Four
SOCIAL EPIDEMIOWGY
Ayodele Samuel Jegede,
Department of Sociology, University of Ibadan,
Ibadan.
INTRODUCTION
The definition of epidemiology as academic discipline has
been controversial over the years. Scholars have defined
epidemiology in various ways. But the most important thing is that
society from the existence of man has been bedeviled by one
disease epidemic' or the other. Therefore, the word 'epidemic' is
not just mere abstraction but it is a social fact which has its root
in the Greek, words 'epi' meaning 'on' and 'demos' rieaning
'people' (Evans 1979). The modern science of epidemiology
originated with John Snow's identification of a particular source of
drinking water as the cause of the 1849 cholera epidemic in
London.
Although epidemiology which is simply being defined as
the study of prevalence and dynamics of stages of health in human
population (Frerichs and Neutra, 1978) is primarily based on
biological theory at the cellular level it is now drawing more on
sociological theory. As a result epidemiology has been conceptual-
ized as a social phenomenon thereby reflecting more on social and
cultural factors of incidence, prevalence, distribution and
determinants of states of health and disease in human group and
population. Therefore, social epidemiology is the study of disease
process, its occurrence in population groups, those socio-cultural
factors that affect their incidence, prevalence, distribution and host
responses; as well as their dynamic state.. in the understanding of
disease prevention and control in human population. This is the
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UNIVERSITY OF IBADAN LIBRARY
basic goal of social epidemiology as academic discipline. It helps
to understand the role of socio-cultural factors in state of .health
and disease in population groups, and how these can be Influenced
to provide solutions.
This chapter discusses social epidemiology by looking at
various perspectives in social epidemiology such as sources of data
collection, approaches and the use of epidemiological data.
PERSPECTIVES IN SOCIAL EPIDEMIOLOGY
Many social science theories have contributed immensely
to the understanding of disease. For instance, the theory of roles
in disease has been used to designate social science model.
Labelling theory has also been used to explain mental illnesses
(Becker, 1963). For instance, secial science models of health were
developed by various scholars like Talcolt Parsons' (1951 a and b)
work on sick role model, Becker's (1974) theory of Health Belief
Model (HEM), Mabogunje's (1974) urbanization theory, Erinoso
(1978) Oke's (1982) model of socio-cultural variables, Jegede's
(1994) work on the social concept of health and illness analysis,
and epidemiology transition model by Omran (1971) etc.
Hipocrates had argued that disease may result from the
imbalance of the four humus of the body that is, blue bile, yellow
bile, blood and phlegm. He said, for people to be healthy there
must be balance between the four bodily humus. This may differ
from culture to culture and may also depend on ecological diversi-
ties.
After this model came the germ theory of disease. The
model states that diseases are caused by certain agents. It explains
how people can be infected by bacteria or viruses, the host
responses and manifestation on the part of the victim. The model
suggests treatment by eliminating the bacteria and viruses by the
use of medicines. The theory developed by Pasture in response to
health problems of his time dominated medical thought for a long
53
UNIVERSITY OF IBADAN LIBRARY
time and was major break through in biomedical research. After
sometime this theory depleted because it became clear that it could
not account for wholistic perception of disease causation. As a
result multicausal perspective of disease as against monocausal
model gained ground. Both social and physical environments are.
considered necessary for incidence and prevalence of disease
(Hollingshead, 1961). Far instance, recent survey of Yellaw Fever
in Delta State of Nigeria shaw that Yellow Fever is mare prevalent
in the upland area of the state where there are thick forests and
high population density than in the-.riverine area (Jegede and
Onoja, 1994). Also, Mozden (1966) has found that there is relation-
ship between environment and incidence of cancer.
Social perspective of epiderniology explains that human
activities .are relevant to, health analysis. Human interaction
process, behaviour, attitude, belief and practices contribute to,
incidence, distribution, prevalence and dynamics of diseases in
human population groups. Changes in pattern of social
organization like moving from one place to, the ather as the case
is with refugees. They are always exposed to, health hazards. For
instance, water borne diseases like cholera and diarrhoeal, and
infectious diseases are associated with refugee camps. High
incidence of cholera was reported from the Oru Camp of the
Liberian refuses in Nigeria in 1991. Also" the recent civil.war in
Ruwanda left many of the citizens dead in the refugee can}'ps in the
neighbouring countries, Erinoso (1978) and Oke (1982) studies
among the Yoruba people of Nigeria found that the type of food
eaten have health implications far the people. Far instance, certain
food items that are required far certain category of peoplemay be
forbidden: while same harmful ones may be approved. Also,
Odebiyi (1989) noted this nutritional factor in her study of healing
processes in Ile-Ife.
Sociologists have used social structure, class, network
system. environment, social status, socio-cultural practices, and
urbanization to, analy~.e health.
UNIVERSITY OF IBADAN LIBRARY
Within a social system a patten of relationship exists
between individuals and groups. Such relationship may lead to
certain health hazards. For instance, sexually transmitted diseases
like gonorrhea and acquired immuno-deficient syndrome (AIDS)
have been associated with indiscriminate sexual intercourse. It has
been argued that the onset of AIDS has generated interest in sexual
:-'b~haviour both before and outside marriage in an attempt to
identify the quantity and characteristics of men and women at risk
of contractin~iD.s,. especially through heterosexual activity, and
. ::n.·f v...TV
to understand (Hffetences between the sexual behaviour of different
groups (Isiugo~Abanihe 1993f-;~Orubuloyeet. al. 1992, 1993). In a
recent study, Isiugo-Abanihe '(1994):tound that about 54 per cent
of men and 39 per Reni Of ~ •o.men have had extra-marital relations.
This has implication for ·incid~iice;. distribution and prevalence of
AIDS in Nigeria. ' ...•.__ - ,~.. , .
These models tend to explain disease ~(rom various
perspectives other than the germ theory. This shc)\vSi\hat disease
diagnosis may not be monocausal rather multicausal.; Certain
'"'t. .•••. ~
diseases have more than one causes. Even many illnesses maynot '
be as a result of any germ but due to break down of the social
process. For instance, stress may be' caused by failure in an aspect
of life, divorce, bereavement, disappointment, loss of jobs etc.
Social epidemiology makes it possible to analyse health in the light
of social-cultural factors that may influence illness and
profer adequate solution or therapy. To do this we will have to
discuss health research in epidemiology.
SOURCES OF DATA COLLECTION IN SOCIAL
EPIDEMIOLOGY
v Social epidemiology uses various sources of data in its
operations. It has.. peen argued that !social epidemiology is a
discipline involving.diverse disciplines. of the social sciences like
demography, econo~tcs:' political .science, sociology an'd
:1.-t
55 '.~'. i .' ~, "" r ~ ',\,.
UNIVERSITY OF IBADAN LIBRARY
I
.• geography. All these have tended to employ one type of method or
the other to explain epidemiological investigation of particular
s disease. The sources of data range from census. data, ministry or
Institutional data, vital registration, hospital data, business data,
personal data-documents and biographies to international sources.
Census is an enumeration of the entire population at an
interval of periods either quininally (every ten years) or more as
may be determined by individual country. In census data an
attempt is made to gather information on sex, age, occupation,
marital status and other varied demographic sources that may
i form the knowledge of a researcher. In using this type of data
the demographer or the epidemiologist who is involved in the
study tend to relate the prevalence of a particular disease to the age
categories within the population. It can also be used to determine
the ratio of health workers such as nurses and doctors to the entire
population. For instance, the on-going development of Preventive
Health Care (PHC) in Nigeria is based on the 1963 census data.
Odebiyi and Edington (l976).used 1962/63 census to analyse the
Occurrence of cancer in Ibadan.
Census data as good as it is has its limitations. Census data
are primarily collected for administrative purpose and therefore it
becomes very limited in use for epidemiological studies because all
the information needed. in health analysis may not be available.
Secondly, it is politically biased since allocation of resources is
usually based on population while election is a game of numbers
(Odumosu, et. al. 1995). Also in most cases census data are
inflated. This was the case with the 1973 census in Nigeria.
Because census takes place periodically usually every ten years it
becomes difficult to base health analysis on it.
The ministries and research institutions collect data for use
in administrative matters. This include patient biodata, drug supply
personnel etc. This type of information is useful for epidemiologi-
cal studies. This particular source of data has some setbacks in its
effective utilization. Since ministries send out questionnaires and
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information card to collect information from outside, it becomes
.! apparent that most of them are not returned. For instance, the
cancer registry unit of the University College Hospital (UCH),
Ibadan between 1962 and 1963 sent ut cards to private hospitals as
well as public hospitals to gather information on the incidence of
cancer in Nigeria, but most of the cards were not returned.
Vital statistics or registration of vital events like births,
deaths, marriage etc. is another source of data. In some countries
like the U.S.A -, Britain and Sweden, it is a law that such events
as births, deaths etc. must be registered at a specific centre
approved by the government. It could be an administrative unit or
on town basis, Usually chiefs and local teachers, assembly pastors
and health care centres are used for this type of data gathering in
Nigeria though not very effective. Although this is a good method
of gathering information, it has the problem of proper implementa-
tion. For instance, National Demographic Health Survey (NDHS)
for Nigeria revealed that many of the births in Nigeria were
delivered by traditional birth attendants (TBAs), friends and
relatives, (NDHS, 1990), and therefore, this kind of deliveries
may not be registered. This shows that only a negligible proportion
of births, for instance, were registered. Secondly, the law guiding
registration of vital events are not effectively enforced. The local
chiefs and teachers normally used for the assignment in the rural
areas where majority of the people (about 65 per cent) reside in
Nigeria are weak and could not enforce the law.
Hospitals records. When a patient reports in the hospital it
is a routine to collect his/her biodata information usually referred
to in medical parlance as 'Clack'. In case of any incidence such as
death the doctor takes down certain information concerning the
victim or deceased. This information tends to say some things
about him/her. Although the physician acting within his
professional ethics may not be concerned about such things that the
epidemiologist might be interested in. For instance, Odebiyi and
Pearce (1976) in their study of congenital malformation found that
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the data collected by the doctors in the hospital was not sufficient
enough to explain the cause and distribution of the disease.
Business data is another source of epidemiological data.
The geographers in collaboration with the town planners may
del ineate a city for study. The problem with this type of data is
that they are primarily collected for spe
. .cific purposes and not for
epidemiological use, per se, but can only be twisted to suit one's
purpose.
Personal data or biography can be used for epidemiological
analysis. This is useful because it unveils information concerning
the owner of the document. But it is not very reliable because it is
not kept for epidemiological purpose, one can only make
inferences from it. It is also subjective and the definition of
concepts may create a barrier for the interpretation of such
document.
International source of data like the United Nations
Organisation's (UNO's) documents, atlas and so on are very useful
in epidemiological analysis. They provide information that are
necessary for comparative analysis and cross-cultural studies.
Although they are good sources of data they cannot be relied upon
because the information provided may not be good enough for
epidemiological studies of a particular place at a point in time.
This is because they are usually too large to handle.
Although these have been considered as sources of data,
epidemiologist must go to the field to collect primary data in order
to perform their job effectively. Some of the data from the
sources above may not provide the required answers to
epidemiological questions. Even where they tend to provide
answers such information may not be reliable, even they may be
completely obsolete as the case is with the 1963 census data. In
order to provide valid and reliable data, epidemiologist use
primary data.
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APPROACHES OF SOCIAL EPIDEMIOLOGICAL STUDIES
Epidemiological studies involve certain dimensions if they
are to be adequately carried out. These are cause; diagnosis,
symptom, treatment, prevention and rehabilitation. It also includes
the origin, nature and solution of health problem, and nutrition that
contribute or can contribute to it. Availability of data is
paramount to such research. Since epidemiology deals with
incidence, distribution and prevalence of diseases data on custom
of the people and health facilities will be very useful. Relocation
of facilities and evaluation of their effectiveness in relation to the
population will be helpful for the assessment of the adequacy of
such facilities. Information on age composition and distribution
will help health planners in planning and implementation of health
programmes. The number of children will help whether to train
more peadiatricians or not. The result of hypothetical test will
determine the type of intervention programme needed to solve any
particular health problem (Grundy and Reinke, 1973).
Epidemiological hypothesis will normally reflect the cause
and effect relationships between two variable. Several other
intervening variables may determine whether or not such
relationship exist. The first stage is that whether a statistical
association exists between the two categories, and also whether
there is correlation. For instance, drinking of water from the
stream and the incidence of diarrhoea among a certain population
group. Epidemiologist will first establish whether there is
relationship between water and the disease. Then they will examine
the association between the variables. The contribution of
epidemiology to the assessment of relationship is the provision of
information whether an association exists between cause and effect.
Several methods can be used to obtain data and test hypotheses.
Social Epidemiological studies can either be qualitative or
quantitative or both. Most epidemiological studies today employ
qualitative methods as a short cut to provide rapid assessment
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Y
measure for any epidemic. Methods used include focus group
discussion (FGD), indepth interview, observation (participant or
non-participant), and semi-structured interview. While quantitative
methods include structured interview, non-experimental studies,
cohort studies, case control study, retrospective study, prospective
study, cross-sectional and longitudinal studies and the Cornell
medical index method. All these methods attempt to understand the
relationship between disease prevalence and causal factors.
Focus Group Discussion: This is a method of interview that
involves a group of people with similar socio-demographic charac-
teristics. Participants are usually arranged in a circular form which
provides opportunity for participants to sit face to face.
Participants range from 6 to 12 per session. There is usually a
study guide to which participants respond freely. There is no
restriction as to answers because it is an avenue for people to
speak up their mind about the theme of discussion. It is usually
administered by a facilitator or moderator and recorder or note-
taker. Also, responses are recorded on magnetic tapes. A typical
FGD is usually conducted under conducive atmosphere while the
facilitator makes sure that no participant is dominating the
discussion, as well as guide against the problem of digression from
the these of discussion. This method is useful for rapid assessments
in social epidemiology to gather information for intervention and
evaluation programmes during epidemics. A typical FGD lasts
between 30 minutes and 1 hour.
Indepth Interview: This is a method used to obtain information
from individuals in the society in which the respondent is allowed
to talk freely about the topic under discussion. Responses are
probed further by the interviewer who normally records the
responses. Sometimes the interviewer may seek the consent of the
informant to record the interview. There is usually a study guide
for the interview. This method is also useful for rapid assessment
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in social epidemiology to gather information for intervention and
evaluation programmes during epidemics. Questions for this type
of interview should not be too long and must be clear.
Observation Method: There are two types of observation. These
are: participant observation and non-participant observation. In
participant observation researcher gets himself involved in the
activities of the group under study. He takes note of his
observations and record them at the end of an activity. On the
other hand non-participant observer does not take active part in the
activity of the group under study. He merely observes as an
outsider and records his observations.
Structured Interview: This is a method of interview in which
respondents have options of choosing from preceded answers. It is
restrictive and usually can be self-administered. It can be mailed
to respondents or through telephone, fax or administered by an
interviewer especially while dealing with ilIiterates. This method
is usually useful for longitudinal studies because of the time
involved in it administration and analysis.
Semi-Structured Interview: This is a combinationof both qualita-
tive and quantitative approach. Here some questions may be
preceded while some may be left open. This can be self
administered for ilIiterates while the interviewer can administer it
to the illiterates. It stands between indepthinterview and structured
interview. It is also useful for rapid assessment during epidemics.
A social-epidemiologist is not restricted to these methods.
Today social epidemiologist use other methods that are explained
below. -
Experimental Studies: This provides a way of testing cause and
effect hypotheses by deliberate application of certain variables or
holding them constant. This provides information about occurrence
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or lack of occurrence of certain factor as contributing to the
disease ep isode.
Non-Experimental Studies: This is a way of gathering facts to
test hypotheses without necessarily performing experiment. The
epidemiologist want to identify the natural circumstances that
cannot be put into experiment. For instance, human experience is
used to test the hypotheses that cigarette smoking causes lung
cancer. This is done by categorising study groups into smoking
and non-smoking categories and examine the groups with history
or causes of lung cancer by quantifying them and find their ratio
before drawing conclusion.
Cohort Studies: Here the investigator selects the study population
consisting of two categories of people who are exposed to a
particular health hazard and those who are not exposed. He will
then observe these groups for a specified period of time in order
to determine how many of them are exposed to and how many are
not exposed to such health hazards. By doing this he will be able
to determine the group which is prone to illness. He will have to
compare the proportion of cases between groups. This helps to
know the rate in each group.
Case Control Study: This is an alternative study method. In an
epidemic environment a study population of sick people and
healthy people are selected. The investigator will observe the
frequency at which people are exposed to causal factors. He will
examine the proportion of people wyo are sick and are exposed to
the causal factors. He will compare this with those who are not ill
but are exposed. Although in an study of this type the study groups
are selected from the affected and unaffected categories, they
represent unknown proportion of the case study population since
the number of controls included is determined by the available
number of cases.
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Choosing the Research Study: Cohort studies provide the most
adequate and easiest method. They are economical when the
disease under consideration appears more frequently. It is
uneconomical when disease under consideration is not frequent.
Very large cohorts are required to obtain firm estimates.
The case control approach is more preferable. A limitation
of the case control study is that information on the supposed 'case
must be retained either in the memory ·of each person or written
down until the person can be identified as having disease.
A case study is usually more advantageous in terms of time
and resources, it is usually frequently undertaken first to determine
the cause and effect and that may explain the occurrence of an
association between the two categories. Cohort study can be
undertaken later, to confirm the degree of the association of
occurrence. While retrospective study collect data on past events
prospective study collect data to forecast future events or
occurrences.
Cross-Sectional and Longitudinal Studies: Epidemiological study
can be ascertained where the event relates to two points in time or
a point in time. In longitudinal study, the observation will relate
to two points in time. Most cohort and case control studies are
longitudinal in nature.
In cross-sectional study reference is made to a particular
point in time. Although it is more and easier and economical, it is
limited to studies that are permanent or relatively permanent of
individual so that the relationship of the individual status to the
cause has the probability of reflecting his/her status as at the time
of disease episode.
The Cornell Medical Index: This IS a 'symptom-list'
questionnaire. It is used together information about different
categories of people or population. It provides crude health-illness
profile of a particular group or community. This method has been
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criticised for its limitation in cross-cultural studies. According to
Oke (1982), it is very difficult to use in non-literate societies for
which it is not designed. He argued, for instance, that the index
designed for Dade County in Florida, United States, is not suitable
for any rural community in Nigeria.
MEASUREMENT APPROACHES IN SOCIAL
EPIDEMIOLOGY
In examining the relationship between health and
environment there is needs to take certain measurements. For
example, in order to describe health problems in communities
frequency distribution need so be constructed. That is we count the
number of occurrences of each phenomenon, proportion and
percentages are used to explain raw data in order to understand the
distribution and compare variables and categories. For instance, in
two communities with different population sizes say community A
with 10,000 people and community B with 20,000 people and
reported cases of Tuberculosis of 9,000 and 19,000 respectively.
In analysing the two communities one may be tempted to say that
community B has more TB problem than community A. It is a
problem to conclude from data on the face value. Measurement
shows that incidence of TB is almost the same because the
proportion or percentages of the population is the same pattern.
Therefore, in epidemiological studies percentage and proportion
are used because raw data is difficult to comprehend explanation
in this case:
9,000 19,000
10,000 (A) and 20,000 (B)
For example Oduntan gives an idea of cases of anaemia in
children aged 6-15 admitted to the University College Hospital
(UCH) Ibadan in 1965.
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==============================
ANAEMIA FREQUENCY PROPORTION PERCENTAGE.
====================================
Sickle Cell (HB.SS) 42 0.575 57.5
Sickle Cell (HB.SS) 8 0.109 11.0
Megaloblastic Anaemia 3 0.041 4.1
Haemolytic Anaemia 2 0.027 2.7
Iron Deficiency Anaemia 1 0.014 1.4
Unspecified Cases 17 0.232 23.2
================~===================
TOTAL 73 1.00 100
=======================~=============
Source: Oduntan, S.O. (1973) Pattern of Disease and Anaemia in Nigeria
Children of School Age. The Journal of Tropical Medicine and Hygiene, Vol.
76: No.2: 28-35. From the table above, the data show that sickle cell is the
most frequent type of anaemia with 57.5 per cent and the least is iron deficiency
with 1Aper cent.
.For comparison it is important to know the prevalence, proportion and
the percentage. We also calculate the rates and ratios in order to compare the
incidence of diseases between communities when comparing communities of
different sizes than there is the need to calculate the rate A = 50, B = 100. A
has different size from B. To be able to understand the distribution there IS need
to calculate rates and ratios.
According to MacMahon and Pugh (1970) "a rate is the frequency of
a disease or characteristic expressed per unit of size and time of the population
of group in which it is observed". The population of a group that is being
observed is generally referred-to as the population at risk. For example in two
communities A and B with population of 300,000 and 1,000,000 respectively,
there are 500 and 1,000 TB cases respectively.
Cases of TB 500
Community A
Population 300,000
Cases of TB 1,000
Community B
Population 1,000,000
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In the two communities above rate is case divided by population size.
This is frequency per unit size and time. Rate is the number of cases in a given
community divided by population at risk or population in the community.
Therefore the rates for the two communities are as follows:-
A 1/600 or 0.0016%
B 1/1000 or 0.0001 %
Tuberculosis rate is higher in Community A although the frequency is
higher in Community B going by the raw data the problem is in A than B.
Therefore, the chance of contracting TB in community A is higher than B.
Ratio: This indicates the number of affected persons as a proportion of the
number of unaffected persons in a particular population. For instance, from the
example given above, we will subtract the affected cases from the total
population and divide the number of cases by the number of unaffected
population. That is: in Community A 300,000 - 500 = ~99,500 and Community
B 1,000,000 - 1,000 = 999,000. The ratios are:
500 Affected population
A
299,500 Unaffected Population
5/2.995
1,000 Affected population
B
999,000 Unaffected Population
1/999.
The social epidemiologist are also interested in the incidence and
prevalence of diseases or state of health of the population.
Incidence: The incidence of a disease is the number of new cases which occur
within a particular period of time among certain category or population group.
The usual period of calculation is one year.
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Prevalence: This denotes a .total number of .cases at any given time. It refers
to the existing cases at a given point in time e.g. January to June of a particular
year.
Period Prevalence: This is a number of prevalence observed over a period of
time usually three months.
USE OF SOCIAL EPIDEMIOLOGICAL DATA
The usefulness of social epidemiology cannot be over-emphasized.
Social epidemiological data provides a comprehensive clinical outlook and/or
disease history in a social group or population. The data are used for planning
health programmes. Erinoso (1982) has argued that no human society can
adequately plan for its needs in the field of health unless there are epidemiologi-
cal data. He also argued that epidemiological data are to the health planners as
demographic data are to a nation. It provides information for the development
and expansion of health facilities. including the training of health workers.
Social epidemiology helps to understand the influence of social and cultural
factors on the health of the population. As a result, these socio-cultural factors
are taking into consideration in prevention and control of diseases as well as
health planning and implementation. .
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Adegbola, C. (1987) The Impact of Urbanization and Industrialization on
Health Conditions. The Case of Nigeria" .World Health Statistics Q. 40.
74-83.
Balogun, S.K. (1994) Psychological Well being of Vesico Vaginal Fistula (VVF)
Victims in Nigeria. A paper presented at the XIIIth World Congress of
Sociology, Bielefeld, Germany, 18 -23 July.
Becker, H. (1963) Outsiders: Studies in the Sociology of Deviance. Free Pres,
NY.
Bolton, J.M.(1972) " Food Taboos among the Orang Ash in Western Malaysia:
A potential nutritional hazard". America Journal of Clinical Nutrition.
25,789 -799.
Durheim, E. (1951) Suicide, New York, Frees Press.
Ebrahim, G.J. (1979) Care of the New Born in Devetoping Countries.
MacMillan, New York p.2l.
Erinoso, O.A. (1978) Notes on concepts of disease and illness: The case of the
Yoruba in Nigeria. Nigeria Journal of Economic and So£ial Studies
Vol. 18, No.3.
---------""(1982 ) Medical Sociology in Perspective in Nigeria Perspectives on
Medical Sociology. Studies in Third World Societies, 19:1- 15.
Evans, A. (1979) "Re Definitions of Epidemiology" American Journal of
Epidemiology, 109 No.3, 379.
Freriches, R. R. and Neutra, R. (1978) 'Re Definitions of Epidemiology"
American Journal of Epidemiology, 108 No.74-75.
Grundy, F. and Reinke, W. A (1973) Health Practice Research and Formalized
Managerial Methods. Public Health Papers 51,World Health
Organization, Geneva.
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Hollingshead, A.B (1961) Some issues in the epidemiology of schizophrenia,
American Sociology Review. 26: 5-13
Isiugo-Abanihe, U.C. (1993) Sexual behaviour and exposure to risk of AIDS in
Nigeria. Faculty lecture delivered at the University of Ibadan, Faculty
of Social Sciences, Dec. 22,
............ (1994) "External relations and perceptions of HIV/AIDS in Nigeria"
Journal of Health Transition Review. Vol. 4, No.2, October 111-125.
Jegede A: S. (1994) "Aisan as a Social Term in Nigerian Perception of Illness".
An Award winning Paper for the 2nd World Wide competition for
Young Sociologists presented at the Pre-XIIIth World Congress
Colloqum, Orlinghauzen, Bielefed, Germany, 9-23 July.
Jegede A. S. and Onoja, A (1994) Knowledge, Attitudes, Beliefs and Practices
Related to Yellow Fever in Delta State of Nigeria. Monograph of Study
Supported by the National Task Force on the Eradication of Yellow
Fever in Nigeria, Federal Ministry of Health, Lagos.
Langford, C.M. and P.Storey (1992) "Influensa in Sri-Lanka, 1918 - 1919: the
impact of a new disease in a pre - modem Third World Setting".
Health Transition Review Vol. 2 Suppl. Issue, 97 - 123.
Mabogunje ,A. (1974) Urbanisation Problem in Africa "Urbanization. National
Development and National Planning in Africa (ed) El Shakhs S. &
Obudho N.Y.Praeger, 13 - 26.
MachMahon, and Pugh, T. (1970) Epidemiology. Boston, Little Brown and
Company.
Mckay, D.A. (1971) Food Illness and Folk Medicine. Ecol. Fd. Nutrition
I, 67 - 72.
Mozden, P.l. (1966) "Neoplasm" in 1.S. Myers An Orientation to Chronic
Disease and Disability, New York: The Macmillan Company.
National Demographic and Health Survey(1990) Federal office of Statistics,
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Odebiyi, A.I. (1980) Socio - economic status. illness behaviour attitudes towards
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of Traditional Healers in lIe - Ife, Nigeria" Social Science and
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Odebiyi, A.I. and Edington. (1976) Cancer and Ageing in Ibadan: A
Sociological Analysis. Social Science and Medicine Vol.lO: 477 - 481.
Oduntan, S.O. (1973) Pattern of Disease Anaemia in Nigeria Children of School
Age. The Journal of Tropical Medicine and Hygiene. Vo1.76: No.2:
28 - 35.
Odumosu, Oi.Robert, F.O.N. and Jegede, A.S.(1996) Regional Differentials
and The Implementations of the National Policy on Population. Pretest
Survey Report of the NISER Study in Sustainable Development in
Nigeria (NISISDIN),1
Ofodile, F.A. (1980) "QUotedin Odebiyi(1989) Food Taboos in Maternal and
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Oke, Adewale (1995) Traditional health services: An investigation of providers
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Omran, A.R.(1971) " The epidemiologic transition: A theory of epidemiology
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Otubuloye, 1.0. , J.C. Caldwell and P. Caldwell (1991) "Diffusion and Focus
in Sexual Networking: Identifying Partners and Partner's Partners."
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................. (1993) The role of high-risk occupations in the spread of AIDS:
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Family Planning Perspectives 19:43-48.
Parsons, T. (195la) Illness and the role of the Physician: A Sociological
perspective. American Journal of Orthopsychiatry. 21:454-60
.................. (1951b) Social Structures and dynamic process: the case of
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processes in social systems.Taristock, London.
Simeon, E. (1990) ART Swaziland Pneumonia Study: July - August,1989,
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Wilson et. al. Working papers: Diagnosis and management of ARI by
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Wilson, C. S.(1973) "Food taboos of child birth and nutrition.Ecol. Fd. Nutr.
2, 267-274.
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Chapter Five
AGE AND AGING PROCESS IN NIGERIA
. A.O Olutayo,
Department of Sociology, University of Ibadan,
Ibadan.
INTRODUCTION
Age has always constituted a very important variable for ensuring order
in African, societies, of which Nigeria is a part. However the tendency that this
phenomenons will continue to be relevant to the social structure IS slim.
This is because 'Europeans', conquest and colonial rule, have fora long
time set the agenda for development in Africa. African values have been under
pressure not only from Christianity, but also from imported paradigms of
development such as Europeanization, Westernization, Modernization, and now
democracy'. (J. F. Ade Ajayi, n.d.: 41). Thus recent breeds of African know
more of European ways of life than of themselves. They are what someone has
referred to as 'White men in black skin'. The few who care about African
culture do not seem to know the philosophies informing it.
Interestingly, the Europeans and Americans being emulated now care
about age and aging. Though for different reasons. The various publications
arising from government concerns on the youth and the elderly were responses
from social problems emanating from their social structure. Thus, for instance,
the falling birth rate in the American society in the 1960s led to the concern for
the aged. It led to a new demographic structure such as that elderly became
politically and economically significant. In the words of Lammers (1983: 1):
The falling birthrate beginning in the early 1960s, coupled
with increases in life expectancy, makes this demographic shift
inevitable. The number of older persons with the personal
resources and political skills needed to participate in the
political process is growing, and elected officials are becoming
increasingly sensitive to their voting strength. This suggests
the likelihood of greater political influence for the aging. (my
emphasis).
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Consequently, the various political parties' policies have been shifting
in emphasis to the aged. The educational institutions have responded by directing
attention from the youth to the aged.
In Nigeria, like in most Africa societies, the modernization process is
directing attention towards the establishment of European and American social
structures. It is not surprising, therefore, that some of these developing nations
have started to think of establishing 'Old Peoples Homes'. This is in spite of the
fact that the traditional social structures have not completely broken down.
There have been enough studies on the youth even though African populations
are youthful. Even the aged, now constituting the retirees, in the urban centres
and those in the rural areas who constitute about 70 per cent, male and female
are not being cared for.
Traditional African Social Structures, as earlier stated, had their own
peculiar arrangements such that both the youth and the elderly were taken care
of towards the maintenance of social order. We shall now turn to a consideration
of some of these.
Age in Traditional Nigeria
The principle of extended family is central to an understanding of the
kinship system in Africa. In fact, the concept of extended family was developed
from studies of African societies (Aldous, 1965: 109). Central to this principle
is age. It is in relation to age that social anthropologists identify the position of
different members of the extended family.
The polygynous extended family is commonly practised in West African
societies (Oke, 1984). The head of he family is the oldest man in he extended
family tree and is treated with awe and reverence, He had the last say in almost
all affairs. Due to his age, he is assumed to have a wealth of experience about
the environment. Thus he decides and advises his wives and children s .the
accepted ways of life. He is only one of die many elders in the community all
of whom belong to the same age-group and therefore act in the same way.
In almost all African societies, age-group or age-set associations are
used to assign duties as well as to control and discipline members. This is
possible because age-sets cut across lineages. The age-groups are assigned duties
such as maintenance of order in markets; clearing of bushes/roads; defense and-
so on. Especially in non-centralized societies like the Igbo in Eastern Nigeria,
the age-groups was the only formalized group. The questions of war and peace
were decided by the senior age grade along with members of titled societies. It
is also from this age-grade that personalities to provide leadersbip, during wars
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and other external danger, emerge. Junior age-grade provide social services such
as sanitation and related services. There were also lower age-groups responsible
for music, play and so on. Members ot the society move through these age-
grades as an important socialization agent.
Even in centralized societies where sophisticated administrative systems
had been established apart from age-grades and lineages, age-grades still helped
to facilitate, effective participation of the members in decision-making process.
For instance recruiting people into the army and the determination of location
in normal formations are done through the age-grades. Among the Egba, the
youths often assist as 'scouts' during war to locate enemies. In short:
age-set associations were an important mechanism for fostering group feeling
across lineage loyalties and affinities, and for mobilizing community according
to age in the traditional societies in Africa. The age-set associations were thus
a major factor making for change in traditional societies (Ade Ajayi Op. cit)
It has ben pointed out that age-grades or age-groups are
different from age-sets. Age-grades are, like 'status-positions', 'stages through
which a person passes between birth and death'. Age-groups have also been
differentiated from age-sets (Huntingford, 1960: 216). Tbe later is seen as a
loose unit unlike the former. Age-groups are a corporate entity the members of
which are not only conscious of their unit and of their distinctiveness from both
older and younger groups ... but they often act as a single body. Tbey recognize
common rights and obligations and acknowledge their own selected leader's
(Gulliver 1963: 25). The transition is often made through circumcision for boys
or through engagement in physical fighting from age 13 - 16 (Nadel, 1960) and
clitoridectomy ceremonies for girls as among the Okpe. Physiological
development of the breast for women, especially between ages 10 - 14 years,
also mark an important transition stage. At about the age of 14, the girl
undergoes the clitoridectomy ceremonies as means of initiation (for details see
Owumi, 1993) and circumcision for boys. This age grade is for those who
undertake the production and the fighting for men as well as 'active'
participation in societal affairs by the women (for Okpe society see Otite, 1972).
From about the age of 14 years up to 40 or 45 years can be categorized as the
working-group. Aside from this age categories the other two major categories,
below and after, also contribute significantly to the survival of the system. For
instance the elders often constitute members of the secret societies as among the
Ogboni in Egba Kingdom (Lloyd, 1962).
The young children often run errands for their parents at home and on
the farm. As earlier mentioned, the elders are a repose of knowledge and
experience from whom the working or economically active groups depend for
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advise concerning not only how to behave but even the work they do. Ade Ajayi
(Op. tit: 41 42). 'The societies looked forward to the ancestors (i.e. the dead
and the aged); their interest in looking backward was to protect their heritage
in the interest of generations yet unborn, the kind of interest that is now being
fostered in the West with the newly found concern for the environment'.
Ironically, the present trend in African societies particular, Nigeria is
that of neglect of the future due to the very practice of European values. It is as
if these societies want to first get to the crisis stage, as is being witnessed in
developed nations. For now however, there is still a hope if only attempt are
made to revive relevant values which can assist in maintaining order in the so
called developing societies. The present situation from which a recourse needs
to be made is what we now turn to.
Age and Aging in Modern Nigeria
According to the United Nations Economic Commission for Africa
(1994), the African populations, unlike the developed nations, are youthful.
This, it is argued, is a result of recent history of high fertility and decrease in
child mortality. The percentages of children aged under 15 years ranged from
41.2 percent in the North African subregion to 47.4 per cent in the
East/Southern Africans sub-region in 1989 and above 40 per cent in the
countries of West Africa in 1990. Nigeria had 47.4 per cent of its population
aged under 15 years in 1990 while Kenya had 50 per cent; Botswana 49.4,
Rwanda 49; the United Republic of Tanzania 49.2, Zambia 49.7, and Zimbabwe
44.9 percent. Countries with low fertility rate had lower percentage under age
15 years. Such countries include Egypt 39.4, Morocco 40.5, Tunisia 30.8
Gabon 32.4 per cent. Generally, the member States of Economic Commission
for Africa had the weighted percentage of 45 percent in 1990.
The working age group i.e. 15 - 64 percentage are also very high in
Africa. The percentages vary from 51 in the West African (Nigeria has 49 per
cent) sub-region to 55 in the North African sub-region. This implies that the
total dependency ratio is quite high for Africa (99 per cent in 1989) as compared
to the developed world (50 per cent also in 1989). This also implies that the
percentage population in the 65 + age group is also less for member states of the
Economic Commission for Africa as compared to those in the developed world. -
In other words, the problem of an aged population is not as precarious as in the
developed nations. Consequently, more attention needs to be directed to the
population below age 65 + in Africa than ill the developed world.
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In fact, one may hypothesize that increasing wave of violence and even
political instability in Africa is a result of the age composition. It would be
recalled that such violent tendencies pervaded the economies of the developed
world in the eighteenth century as witnessed in what became known as industrial
revolution. By he nineteenth and early twentieth centuries in Europe, and
America, so many studies were carried out focusing on the youth. By the mid-
twentieth century,
attention was being re-directed to the elderly in the developed nation for reasons
earlier adumbrated.
It should be pointed out that it was during these revolutionary periods
that sociology emerged as a discipline to study the disorder pervading these
social structures. So many theories were developed during tbis period wbile
anthropology was being used to study the seeming orderliness - which was
perceived as stable (1) societies - in Africa. It was not until the early twentieth
century that sociology was being applied to the study of African societies since
changes were being witnessed in its social structure attributed to contact with
Europeans. African societies were perceived as having no bistories and the
sociological theories, earlier developed for Europe was applied to these
societies. (Roxborough, 1979). As these theories change in their application to
the developed nations, the same was still being lifted wholly to African studies.
This is not surprising since the application of 'scientific' methods to the social
sciences requires a generalizing frame work. Unfortunately, the histories and
experiences of different societies have continued to render the results from
empirical researches invalid. In spite of this, the reproduction of foreign values
has persisted. Consequently, virtually no relevant solution has been proffered for
the instability in Africa. The age structure may be a relevant indices of analysis
of this problem.
Ideally, as in the Westernized system being practised in Africa, the
concept of milestone is central to the study of age and ageing. Milestone
according to Kimmel (1980: p. 5), is 'an event that stand out in a person's
memory or future plans as a significant, age-related turning point, or marker,
this 'maker' is relevant only to the socio-cultural milieux. Even 'biology' or the
physiological changes reflect cultural constructions of societal dictates. For
instance the years of puberty which follow birth and childhood is marked by
menstruation for women. What follows as societal expectation in traditional
societies, including British society even in the early nineteenth century, was
marriage. These societies designated women's 'nature' as being characterized
by marriage, pregnancy, childbirth, nursing and child care. These were
inventions of a cultural time and place. 'T-hey were also ideological control,
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whose social functions included the restriction of the social and economic
activity of their women. These models of the female life cycle were social
stereotypes which defined what was acceptable and unacceptable in terms of
gender' (Jalland and Hooper, 1986).
These stereotypes, among others, became well established during the
colonial period. Consequently, a child is expected, rather that still being backed
by the mother, at the age of three starts a day care/nursery school (often
earlier). By the age of six he/she begins elementary school. At about age
fourteen, puberty sets in and. instead of traditionally celebrated rites of passage
marking the end of childhood and initiation into the beginning of adulthood
requiring production and fighting activities, the youth is not socially relevant in
the modem social structure. This is also the beginning of adolescence during
which the child enters into youth culture but which is largely undefined in the
modem African setting. In fact, very few attempts are being made to understand
the youths of Africa at this stage of development. The general feeling is that a
child who partakes ip this sub-culture is a deviant - a product of improper up-
bringing rather that):crucial stage in life during which the effect of peer pressure
and influence is far more than parental influence on the youth. In fact, military
despotism has become the norm rather than excepting (Vogt, M. 1992). Most
parents become intolerant of their adolescents who, in turn, result into
identifying more with their peer groups. This is moreso since parental historical
experience of societal expectations of children is totally different form the
children's. Hence, the 'generation gap' creates a fundamental transformation
from the shared experiences affecting the attitudes, values and the world view
of parents and Children. (Kenniston, 1971); Kimmel, 1980).
The children are tom between two-worlds-that of their parents and that
of their peers. The latter has grown in influence since the socialization of the
youth is now done by new agencies outside the nuclear/extended family
structure. The educational, religious, economic and even the political institutions
present values which are often contradictory to that which the family gives. For
instance the freedom/independence which the child is exposed at about the age
of sixteen in the University is far different from what exists in the family. The
'official' means of communication even in secondary school is, also, often
different from that in the home. Most importantly the physiological awareness
of the child often leads to social awareness which the parents have not been able
to cope with successfully. Since the peer groups associate with themselves more-
than their parents, the boys often engage 'in gangsterism while the female would
have engaged in sex (Demographic and Health Survey (1992) and now even
engage in prostitution (Olutayo, 1994). This is in spite of the fact that
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adolescents are categorized as an extended period of moratorium between
childhood and adulthood (Kimmel, 1980). Unlike in the traditional societies, the
adolescents are treated more as cfiildren than adults in modem societies, (Bilton,
1981). Furthermore, the christian tradition of morality also reinforce (d) beliefs
among adults about the
discomfort of talking about sexuality with adolescents' (UNECA, 1994).
At the age of 18, the society confers social and legal rights and
privileges on the child. Such privileges include voting rights, driver's license
and criminal trial as an adult. In Nigeria, and most African countries, most
children enter into the University and is often the first time of leaving home and
a sudden incase of self-reliance. For some, the age signals, full participation in
the adult role of the society. The rate of school drop-out is quite high in Nigeria,
for example, of about 71 per cent of female children aged 15 - 19 years in rural
areas in 1990, (calculated from Population References Bureau 1992) not less
than 60 per cent would have dropped out after primary school, given the fact
that only 34 percent of 29 percent in the same age category in urban area had
secondary school education. For the very few who enter the University, full
participation in adult-role is post-pointed while most of the drop-outs often get
married.
After the age of 18 years and/or 21 years, very few significant events
occur. What often becomes significant is the decade ages .i.e, 30, 40, 50 etc.
"Middle age", begins at the age of 40 and lasts til150.k has also been observed
that age of 30s and 40s are decades of having most responsibilities and to
accomplish most (Neugarten, Bernice, Moore and Lowe 1965). From age 30
and the middle years of adulthood, events such as marriage, parenthood,
occupational advancement, child rearing, launching the children from the home
leading-to 'empty nest' (Thompson, 1988), and the death of parents occur: It is
also during this period that the individuals make most of their contributions to
the society. This segment of the population support the children, students, and
par of the elderly population.
The most significant events, decades after the adolescent, are
menopause and retirement. The former occurs among when during which the
production of sex hormones cease. and this is physiologically determined. This
often has both negative and positive effects on women. This is because the
accompanying physical changes such as weight gains or changes in fat
distribution around the waist and hips may make dieting and exercise necessary
to maintain the figure. Some may feel useless that they can no longer bear
children wholesome may be happy that they no longer bear children wholesome
may be happy that they no longer attractive which could, in turn, affect their sex
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life. Some may isolate themselves to avoid social contact. Yet still others may
be positively disposed Such that they may achieve even educational or new
career opportunities in business. They may also have a renewed interest in
sexuality and better relations with their spouses. Furthermore, since the home
is now an 'empty nest' with the children gone, these renewed interests may
indeed lead to a grater acceptance of themselves (Thompson, 1998). For women
who live in the rural areas, .the post-menopausal period may have more negative
effects than women in urban areas. While the men in both rural and urban areas
may re-marry and urban women may, in their Western orientation, decide to
seek out men who are loving and young, the rural women cannot do such. At
this period, they are neglected and rejected. Except their married children invite
them to assist in taking care of their children, rural women at the age of 50 and
above in modern Nigeria would have looked far older than their age. In fact
they would encourage their husbands to marry new wives who may also help
them to survive their old age.
The second most significant event, i.e. retirement, is a phenomenon that
is gradually gathering momentum and is socially determined. It is a non-colonial
experience since most of the people employed in European establishments from
the colonial period only reached the retirement age after independence.
Nonetheless, the pension and gratuity schemes left behind by the colonial
government bas not experienced any significant change. As at now, the
retirement age is generally 60 years or 35 years in service (whichever comes
tirst). After retirement, the retiree is· entitled only to pension and gratuity.
Unfortunately, apart from probably retired politicians and private employees,
retired civil servants are very poor. The chances are that years after retirement
will mark declining physical health and economic hardship. Only very few enjoy
health, economic security and freedom from traditional occupation and family
responsibilities.
Death is the final point in the individual's life. In traditional Nigeria,
this position is perceived s meeting with the ancestors i.e. family re-union. This
is being gradually e.rodedwith Moslem and Christian religions. This is because
religion is now dissociated from the immediate family.
CONCLUSION
In this paper, we have tried to show the importance attached to the
process of age and aging in traditional as different from modern Nigeria. What
comes out most- clearly is the fact that age and aging process in Nigeria,
especially in urban areas, is gradually becoming like the process in United States
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and Europe in the nineteenth century.
As in all capitalist societies, age is not respected, not even as status
position. Bureaucratic organizations recognize the position occupied in the
organization rather than (the age of) the person occupying .it, Consequently
immediately the person occupying a position retires as a result of old age, he/she
becomes more 01' less, irrelevant, in the scheme of things. It is also common for
even the government to argue that there is a need to'pump new blood into the
system'. In spite of this however, the young adults now occupying the
bureaucratic establishments often still show certain respects to those lower to
them in rank, For example, they may, in greeting, bow (as in traditional system)
to those older. than them but lower in rank:. In the same vein, the traditional
system of greeting is still very common in urban capitalist establishments.
Students tend to prostrate/kneel down to their lecturers and junior lecturers do
the same to their senior 'colleagues'.
Furthermore, it is becoming common to see the 'aged and children
roaming the streets begging for money in urban areas. In other.words, the aged
and children are being neglected and uncared for in the urban areas unlike in
rural areas even in present day Nigeria. This is not surprising because of the
increasing monetization of the society. The dependency ratio of 100 in Nigeria
(UNECA, 1994) has made it difficult for the working age group to be able to
care for these age groups (0- 15 and 60+ years). The situation is being further
compounded with high unemployment rate among the working age group. Also,
there is the increasing difficulty of children to gain admission to school or
receive appropriate education. Hence the children on whom parents may want
to rely on, for a better future, themselves have no future!
Consequently, and especially for persons in the lower socio-economic
classes the aged tend to perceive themselves more negatively less happy, and
less self-confident. The aged also have the tendency for increased anxiety.
(Kuhlen, 1964). Generally, there is a regressive physical growth and biological
decline among the aged. This is in spite of medical break through that have
prolonged the years of survival both in the developed and the developing world.
In the latter, however, 'life' has not been added to the years of the aged not only
are they being retired, their relevance to social and politic~ problems are being
jettisoned. In fact, even the treatment of ailments peculiar to the aged is not
being given required attention in medicine.
For instance, one of the most common health problems relating to aging
is hearing impairment. This medically known as- presbyensis. According to
Thompson, (1988), it is not medically tr-eatableand is caused by degenerative
changes in the inner ear. Hearing improvement among the aged often lead to
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unusual behaviour such as irritability, fatigue, withdrawal, depression, anxiety,
rudeness, appearing stupid, and so on.
The problem of vision is another area about which little efforts have
been made with regards to the aged. As one ages, the ability to see objects
clearly decreases and adaption time from lighno darkness is increased because
the eye share become dryer and depth perception changes. The implication of
this is. that the aged need to sleep early enough before it becomes dark. Yet,
associated with aging, the elderly often have difficulty falling asleep and they
may make up more often at right.
Furthermore, the internal excretory organs and even the mental capacity
of the elderly also decreases. The bladder becomes inefficient such that the
elderly may not themselves before getting to the toilet. Unfortunately, some old
people may have become accustomed to bad odour and their sense of perceiving
bad odour may have diminished. They may not, therefore, he conscious of the
urine odour on them.
For those who live in rural areas of the developing world, their farming
life, apart from the above ailments, also affect their physical stature. Most of
them have-difficulty in standing erect and often need staff (i.e. wooding stick)
to support their weight in order to move around. Consequently, their diminished
depth perception and inability to see clearly is further compounded.
Aging, indeed, is a social problem that requires urgent attention. The
attention required however transcend the establishment of old peoples' home. It
entails the need to resuscitate the age-old culture of maintaining family ties with
the elderly. African societies are not too far from this position and this,
therefore ,should '{lotbe too difficult to achieve. Its success however involves
de-emphasizing the urge for material wealth. The old ways of life even in the
developed world, it has been argued contributes to the development of one's self
image and self-worth by providing love, affection, approval and support. It helps
to establish a sense of belonging and provides opportunity for sharing
information and ideas that are essential for survival and life satisfaction.
(Thompson ibid). In short copying withold age is a family affair which in itself,
helps to enrich the quality of life of both the youth, middle-aged, and the aged.
It entails mutual understanding which can only be easily achieved among
members of the immediate family who have known themselves. It is only among
this group that tolerance should and is, expected. '
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REFERENCES
Ade Ajayi, J. F. (n.d) "On the politics of being mortal' Transition issue position
Vol. 59 pp. 32 - 44.
Aldous, Joan (1965) 'Urbanization, the external family and kinship ties in West
Africa' in Van Den Berghe P. L. (ed.) Africa social problems of
change and conflict. (California: Chandeliev Publishing Company) pp.
106 - 116.
Anene, J. C. (1966) Southern 'Nigeria in Transistor. (Cambridge University
Press).
Demographic and Health Survey (1992) Adolescent Women in Sub-Saharan
Africa: A Chart book on marriage and child rearing (Columbia).
Gulliver, P. H. (1963) Social Control in an African Society: A Study of the
Arusha: Agricultural Masai of Northern Tangayika (London: Routledge
and Kegan Paul).
Huntingford G. W. B. (1960) 'Nandi Age Set' In Simon and Phoebe Ottenberg
(eds.) Culture and Societies of Africa (New York:Random House).
Isichei E. (1976) A History of the Igbo People (London and Basinstoke: The
Macmillan Press).
Jallands Pat and Hooper, John (1986) Women from Birth to Death: The Female
life cycle in Britain 1830 - 1914. (Great Britain: The Harvester Press).
Kenniston, K. (1971) Youth and Dissent: The rise of a new Opposition
(Harcourt).
Kimmel, D. C. (1980) Adulthood and Aging: an interdisciplinary development
view (John Wiley and Sons) (2nd Edition).
Kuhlen, R, G. (1964) 'Development Changes in Motivation During the Adult
Years' Birren, J. E. (ed.) Relations of development and Aging
(Springfield Illinois Charles C. Thomas).
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Lammers W. W. (1983) Public Policy and the Ageing (Washington D. C. C.
Q •.Pres).
Lloyd, P. C. (1962) 'Yoroba Myths: A Sociological Interpretation. ODU, No.2.
Nadel, S. F (1960) 'Witchcraft in four African Societies: An essay in
comparison' . in Simon" and Phoebe ottenberg (eds.) Culture ,00
Societies of Africa (New York: Random House).
Neugarten, B. L.; Bernice, L.: Moore, J. W. and Lowe, J. C (1965) 'Age
norms, Age constraints and Adult Socialization; AJS 70 (6) pp. 710 -
777.
Oke, E.A. (1984) An Introduction to Social Anthropology (London and
Busingstoke: Macmillan).
Olutayo, A. O. (1994) 'Adolescent Female prostitutes: The Case of a Nigerian
University' Paper presented at a seminar organized by PSYWOM.
Otite, O. (1972) 'Contiauance ~ Change in an Urhobo Age grade organization
in Nigeria, in Chaiers De'tudes t\fricanes Vol. XII (4b).
Owumi, B. E. (1993) 'A socio-cultural analysis of female circumcision among
~ Urhobos: A study of the Okpe' People of Delta State'. A
Monograph submitted to the Inter-African Committee (lAC) on
Traditional practices Affecting the Health of Women and children in
Nigeria.
Population Reference Bureau (1992) Adolescent Women in sub-Saharan Africa'.
A Cbart Book on Marri"ge and Child bearing(WashingtonD. C).
Roxborough, I (1979) Theories of development (London: Macmillan Press Ltd).
Thompson Wendy (1988) Aging is a family Affair: A Guide to Qualitv Visiting
Long Term Care Facilities and you: (Toronto: .NC Press Ltd.
United Nations Economic Commission for Africa (1994) Third African
Population Conference 7 - 12 December 1992 Dakar, Senegal (UNECA
Addis Ababa).
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Vogt, M (1992) 'The Military in African Politics', A paper presented at a
Conference organized by Voice of Nigeria, June.
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Chapter Six
WOMEN AND THE RISK OF mv INFECTION IN NIGERIA:
IMPLICA TIONS
FOR PREVENTION AND CONTROL PROGRAMMES.
Ademola Johnson Ajuwon
African Regional Health Education Centre,
College of Medicine,
University of Ibadan,
Ibadan.
And
Wuraola Shokunbi,
Department of Hematology
University College Hospital, Ibadan,
INTRODUCTION
Sexual transmitted diseases (STDs) pose a threat to the health and well
being of the sexually active population in Nigeria (Asuzu and-Idoko 1994:
Asuzu, Omotara and Padonu 1992: Mersusmith, Kane, Odebiyi and Adewuyi,
1994). The eommon STDs in the country are gonorrhea. trichomoniasis,
chlamydia, candidiasis, syphilis, human papilloma virus. lymphogranuloma
venereum. genital warts and chancroid (Brabin et al, 1995: Adekunle and
Ladipo, 1992: Ogunbajo 1989). Although there is no national 'data on the
incidence and prevalence of each of these infections, most scientists in Nigeria
agree that the incidence of STDs is high and increasing due to inadequately
trained health manpower, scarcity of functional laboratories, treatment facilities
and change, from restriction to a more liberal attitude towards sex especially
among teenagers (Adekunle and Ladipo, 1992).
The consequences of STDs are devastating: infants of infected mothers
may have ophthalmic infections (which may later lead to -blindness) and
pneumonia: chronic pelvic inflammatory disease (PID) may complicate STDs.
and patients may develop infertility as a result of untreated infections. STDs are
also associated with spontaneous abortion, ectopic pregnancy and cervical cancer
(Adekunle and Ladipo, 1992; Lande. 1993). Thus, th~ management of these
complications places a heavy toll on the. health care delivery in Nigeria.
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The advent of HIV /AIDS in Nigeria in 1984 and the increasing number
of those infected since then, have compounded the STD problems in that the
prevention of HIV and the management of AIDS now place an additional burden
on the health care system already overstretched by other preventable health
problems.
Heterosexual contact is the main rout of HIV transmission in Nigeria
(Federal Ministry of Health and Human Services (FMOHHS), 1992; 1995). This
suggests that there is a parity of risk of infection between men and women.
However, we argue in this chapter that women in Nigeria are more at risk to
HIV infection than men. We have described the biological, cultural and
economic conditions which make Nigerian women susceptible to HIV infection
and have suggested that intervention strategies that will address them.
THE HIV /AIDS SITVA TION IN NIGERIA
The first case of AIDS in Nigeria, involving a sexually active 13 - year
old girl, was officially reported in 1984 (FMOHHS, 1992). Since then, the
number of persons infected with HIV and those who have developed AIDS has
been increasing rapidly. For example, in 1992, 367 new AIDS cases were
reported in the country; the number rose to 917 by September to 1993 (WHO,
.1993) and 1,490 at the end of 1994 (FMOHHS, 1994). FMOHHS project that
between one to three million adult Nigerians will probably be infected with HIV
by 1996 (FMOHSS, 1994).
As shown in Table 1, HIV has ben reported among a broad spectrum
of the Nigerian Population. These are apparently heathy persons (Mohammed
et al, 1988: Olusanya, Lawoke and Blumberg 1990). Blood donors (Shokunbi,
Saliu and Essien, 1993) clients of STD, clinics, tuberculosis (TB) patients, long
distance truck drivers (FMOHSS, 1994) pregnant women attending antenatal
clinics (ANC/2) (Nnata, Anyiwo, Obi and Karpas, 1993) commercial sex
workers (CSW) (FMOHSS, 1992; Chickwem, Mohammed, and Ola, 1989;
Mohammed et al .• 1988) and their clients (Williams, Heart and Udoifa, 1989).
However, because the CSWs engage in many risk-behaviours they have the
highest reported rates of HIV and in addition are responsible for the
transmission of others STDs that facilitate HIV transmission (FMOHSS 1994;
1992). Using the HIV prevalence among the ante natal clinic attendants as an
index, the FMOHSS has put the national seroprevalence rate of HIV in Nigeria
at 3.8 per cent of the sexually active population in the country (FMOHSS,
1995).
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The figure is low in comparison to 28 per cent and 30 per cent HIV
prevalence reported for a. comparable population in Uganda (McGratt et al,
1992) and Kenya (Kiragu, 1995) respectively. However, the Nigerian figure may
believe the extent of the problem because AIDS is under reported due to paucity
of HIV screening centres (only 16 out of the 30 States in the country have
screening centres) inadequacy of laboratory resources for testing and in-complete
reporting from some centres (FMOHSS, 1995; Isiugo-Abanihe, 1994). In
addition, the fact that AIDS may mimics other common health problems in
Nigeria such as tuberculosis. mal-absorption syndrome and malnutrition may
mislead Nigerians to think that AIDS is now a new disease. and therefore under-
report it. Under reporting and the long latency period of HIV suggest that many
HIV infected Nigerians may not be detected for several years during which they
can transmit the virus to others.
Both HIV 1 and HIV 2 are common in Nigeria (Olusanya et al, 1990;
Shokunbi et al, 1993). These have been reported in virtually all parts of the
country, but particularly in urban areas with Plateau, Benue, Delta, Lagos and
Enugu States leading (in that order) in the number of reported cases (FMOHSS,
1995,. The explanation for this may be the fact that these states have some
features which favour the rapid spread of HIV. Plateau, for example, bas a cold
climate and is therefore. a popular holiday resort with a relatively high number
of CSW. Delta and Lagos have major sea ports which attract a large influx of
sailors who are likely to engage in causal sex during their stay in these states.
Despite the wide publicity given to AIDS by the local media, the efforts
of governmental and non-governmental organizations (NGOs) to educate the
public about the threat of AIDS and the report of the increasing. number of
persons infected with HIV. majority of Nigerians continue 'to engage in
behaviours which place them at risk of HIY,. For example, in s survey on sexual
networking in five locations in Southern and Northern Nigeria, Uche-Abanihe
(1994) found that 54 per cent men and 39 per cent women have had extra-
marital relationship. with 18 per cent men and 11 per cent women having done
so during the week preceding the survey. Majority of these respondents have not
used the condom which is known to offer protection against sexually transmitted
HIV (Roper. Peterson and Curran, 1993: Van de Perre, Jacobs and Spencer -
Goldbergers. 1987). High levels of unprotected sexual networking has also been
reported by other investigators in Nigeria (Ososanya and Brieger. 1994;
Ajuwon. Oladepo, Adeniyi and Brieger. 1993/94: Orubuloye. Caldwell and
Caldwell. 1990).
The explanation for the problem is that many Nigerians perceive
themselves to be at low risk of HIV infection, even though they engaged in high
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risk behaviour (Onile, 1993; Osowole, 1992). Some Nigerians believe -that
because they have not .yet knows or seen any AIDS patient AIDS does not exist
in Nigeria. Others view the danger posed by AIDS with fatalism.rarguing that
one will eventually "die of something", and so are not prepared to change their
sexual behaviour because of the threat of AIDS (Uche-Abanihe, 1993). In this
situation and also considering the pattern of the AIDS epidemic in other sub-
saharan African countries, there is likely to be an exponential rise in the
incidence of AIDS in Nigeria in the next few years.
CuRRENT NATIONAL HIV PREVENTION AND CONTROL EFFORTS
The Federal Government of Nigeria responded to the threat of AIDS
in 1986 by setting up the National Expert Advisory Committee on AIDS
(NEACA) which was later reconstituted in 1992 and renamed National AIDS
and STD Control Programme (NACP). The NACP is located in the Department
of Disease Control and International Health of the FMOHSS, Charged with the
responsibility of co-ordination AIDS prevention and control" activities
nationwide. the NACP is divided into five sections: Programme Management,
Epidemiology and Surveillance, Information, Education and Communication
(IEO); Laboratory; and Clinical Management and Community-based care
(FMOHSS. 1992)".
The NACP has recorded some achievements since it inception. For
example. it had decentralized its operations by appointing one AIDS co-ordinator
for each of the thirty states and the new capital city. Abuja, whose charge is to
oversee ongoing AIDS prevention and control effotip>in their respective states.
In addition, the NACP had "establishedHIV screenin~ centres in some states to
tract the incidence and-prevalence of HIV and design intervention measures to
control further spread of the virus in the country. To this end, routine
anonymous unlinked method of testing is being used to screen six groups: CS;
Clients of STD clinic; TB patients; long distance truck drivers; and women
attending ANC (FMOHHS, 1992). With respect to education, the NACP had
developed many IEC materials (posters, brochures. pamphlets), trained some
health workers and sponsored several educational programmes on the electronic
media.
Various individuals.Iocal and international agencies have complemented
the efforts of the NACP through production of educational materials. training
of health workers, education of CSWs and donation of equipments and HIV
Screening resources (F:MOHSS, 1993Webster and Nnabugwu, 1993, Williams.
1994). Despite these achievements. however, a nuniber of problems continue to
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undermine the current control efforts in the country.
First, the number of screening centres is grossly inadequate for the 88.5
million population in the country. The centres are concentrated in towns and
cities thus creating an urban bias in the sero-prevalence data. Second, as
mentioned earlier, there is incomplete reporting in some centres. For example,
some centres do not screen the desired sample from the groups (FMOHSS,
1995). In addition, vital information such as the gender of clients of STD
clinics, TB patients, and apparently healthy persons were omitted. As a result,
we do
not have national data of the gender distribution of HIV infected persons in the
country.
Finally, educational efforts have relied heavily on the use of the print
and electronic media despite the limitations associated with them. Although the
media campaign has raised the level of public awareness about AIDS (Oladepo
and Brieger.' 1994; Odujinrin and Akinkuade 1993), its impact on behaviour is
limited because many Nigerians who have heard about AIDS continue to engage
in sexually-risky behaivour (Uche-Abanihe, 1994; Orubuloye et al, 1990).
The cause of the problem is that some of the media messages are too
diffused, hence they do not address the socio-cultural and a economic constraints
to behaviour change. For example, many educational messages encourage the
sue of a condom to prevent HIV infection without suggesting how women can
overcome the many difficulties they face in convincing me to use it.Such
messages are also unrealistic" because the cost of the condom may not be
affordable to many rural dwellers. Also, campaign messages request Nigerians
to stick to one sexual" partner without suggesting how women can overcome the
economic problems which cause many of them to resort to risk-taking
behaviours to survive. Furthermore, the message about having one partner, may
be quite dicey for a woman in polygynous marriage. A faithful woman in such
a marriage still runs the risk of contracting HIV if her husband or any of the
other women have extra-marital affairs with an infected person. Innovative
educational interventions are needed to address these issues. We now turn to the
discussion of the conditions which make women susceptible to HIV infection.
STDs AS A GENDER ISSUE
The physical differences between men and women affect their risk of
suspectibility to STDs including HIV. Women are three times as likely as men
to become infected through sexual intercourse because the vaginal wall is
delicate and prone to sores and abrasions, which may create pathways for the
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rransnussion of STDs during sexual intercourse with an infected person
(Skelmerud, 1995). Yet, STDs are more difficult to diagnose in women than
men (Cates and Stone, 1992).
Since STDs are common a-Symptomaticin women they are likely to
harbour untreated STDs, some of which are known risk factors for HIV
transmission (Pallangyo, ·1989; Johnson and Pond, 1988; Piot et al, 1988). This
makes the long term complications of untreated STDs far more serious in
women than men.
In Nigeria, there are some cultural barriers that may prevent infected
women from seeking prompt and appropriate treatment for STDs. First, there
is the stigma associated with STDs. In Nigeria, it is a serious embarrassment
fora women to be publicly seen attending an STD clinic. As a result, many
infected women often seek treatment from traditional healers or patent medicine
sellers who are likely to provide confidential but inappropriate treatment for
their conditions. Secondly, the practice or purdah, (the system of seclusion of
women from public places) which is widespread in many Muslim communities
in Nigeria, may prevent infected women from seeking prompt and appropriate
care, especially in areas where medical units are staffed by male doctors
(Adekunle and Ladipo, 1992).
Nigeria is a male dominated society where women are expected to
produce a many children as possible, preferably males. The woman is blamed,
therefore, for infertility or reproductive failure, consequently-many Nigerian
women may value pregnancy more than their health and may engage in sexually
risky behaviours which would raise their chances of contracting my (Adekunle
and Ladipo, 1992). Nigerian pregnant women infected with HIV face a serious
dilemma. They are likely to develop AIDs sooner than other HIV infected adults
if they carry their pregnancy to term, and run the risk of transmitting HIV to
their babies (Sabatier, 1988), thus contributing further to the spread of the virus
in Nigeria. Yet, many of these women may not accept the option of an abortion
given the high premium placed on fertility in Nigeria.
CULTURAL PRACTlCES THAT CONTRIBUTE TO THE
SUSCEPTffiILITY OF WOMEN TO mv INFECTION:
Genital Mutilation
In Nigeria, it is unfortunate that women are victims of a range of
cultural practices which undermine their health and well being. Of relevant to
the issue of risk of HIV infection is genital mutilation of which there are two
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UNIVERSITY OF IBADAN LIBRARY
~: 'gishiri cut' and 'sunna' circumcision. 'Gishiri cut' is a type of mutilation
practiced by the Hausa of Northern Nigeria in which the vagina is cut usually
by old women using unhygienic razor blade or knife (Adekunle and Ladipo,
1992). The cut is usually done to treat conditions such as infertility, generalized
body pain etc. 00 the other hand, the 'sunna' involves excision of the clitoris
of infants and young girls. The practice has persisted in Nigerian despite
concerted efforts to eradicate it (Ajuwon, Brieger. Oladepo and Adeniyi, 1995;
Ebomoyi, 198; Oduntan and Onadeko, 1984; Olamijulo, Joiner and Oladeji,
1985).
The 'sunna' mutilation is a violation of the rights of the girl-child, but
bas always been justified by men on the' grounds that it prevents promiscuity.
The excision of the clitoris is, therefore, aimed at controlling the libido of the
females,"thus suggesting that sexual pleasure is the exclusive right of men.
Although there is no research evidence yet that female genitation
mutilation is a risk factor for HIV transmission in Nigeria, the fact that
mutilation and subsequent Scaringcould result in vaginal tears during intercourse
imply that it carries some risks. Such tears could create a pathway for the
transfer of HIV during sexual intercourse with an infected person, thus
increasing further, the efficiency of male to female transmission of HIV. HIV
may also be transmitted to the girl-child through use of unsterile instrument
which could harbour bacteria and HIV (Ajuwon et al, 1995).
Sexual Abstinence, polygyny and divorce
The practice of sexual abstinence by Nigerian women shortly before the
several months after delivery has been well documented in he literature
(Orobuloye, 1979;Caldwell and Caldwell, 1977; Ajuwon, 19Q(). Among the
Yoruba of Western Nigeria, married couples are expected to abstain from sexual
intercourse while the infant is being breastfed, after which they can resume
normal sexual intercourse with their husbands. Sexual intercourse is discouraged
during breast feeding because of the belief that the semen could have an adverse
effect on the growth of the infant. Although the duration of post abstinence after
delivery has declined in recent years due to increasing use of modem
contraceptives, the practice itself is still common especially in the rural
communities
where access to modem contraceptives is limited (Ajuwon, 1990).
Inherent in this practice is a system of double standard of sexual
morality between men and women. Although women are expected"to abstain
from sexual intercourse while the infant is being nursed, men are not affected
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by this rule because they have other sexual outlets. For example, polygynous
men could easily turn to other wives and monogamous men could have extra-
marital sexual relationships while their wives abstain (Ajuwon, 1990). Thus,
sexual norms prompt sexual license' for men and sexual purity for women.
Whereas the wife is expected to be absolutely faithful to her husband, men have
the freedom to philander.
This system of double standard in sexual relationship is also reflected
in divorce practices. Under Nigerian customary laws, men are normally granted
divorce if it is proven that wives have had extra-marital relationships (Ajuwon,
1990). Unfortunately, women married under customary and Islamic laws in
Nigeria do.not have that same opportunity because these laws permit polygyny
(Ekundare, 1969). An adulterous man can therefore easily justify his action by
claiming that he plans to marry the other women.
Under an ideal situation, wives of adulterous men could encourage their
husbands to use condoms, as a means of protection against HIV. However,
persuading men to wear the condom may be a difficult if not an impossible task
for many women because in Nigeria, a man will consider a woman 'loose' (that
is promiscuous) if she request him to use a condom during sexual intercourse.
Women may also encounter problems with the use of the female condom, which
is now available but not yet used on a large scale in Nigeria because of its
prohibitive cost.
This situation places women at a disadvantage in that they lack to ability
to control the sexual risky aspects of the behaviour of their spouses and do not
have the economic power to take action which would protect them from
infection with STDs including HIV. Indeed, many women in Nigeria ar
expressing concern that their OWn fidelity may not be a guarantee for safety
from HIV, considering the fact that previous researchers in Nigeria show that
a high proportion of women acquired STDs from their spouses (Elemile, 1982).
WOMEN, ECONOMIC CRISIS AND SEXUAL RISK - BEHA VIOURS
The Nigerian economy has been in recession since the early 1980s. To
revamp it. the Nigerian government introduced in the last half of the 1980s, the
economic structural Adjustment Programme (SAP) which consisted of cuts in
public spending, removal of subsidies, trade liberalization, currency devaluation
and retrenchment of workers. These measures caused a tragic decline in real
income and living standards of majority of the population. For example,
following the removal of subsidies, inflation got out of control and cost of living
in Nigeria doubled between 1986 and 1987 (Webster and Nnabugwu, 1993;
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Alubo, 1990).
Women have been particularly hard hit by the cnsis. Faced with
minimal economic support from their spouses and the need to care for their
children, some married women in Nigeria have been compelled to exchange sex
for additional material support for themselves and their children. As one rural
married women pointed out during a' focus group discussion on the cause of
sexual net-working, "sometimes we are unable to leave our poor husbands and
marry men who are better off because we do not want to abandon our children.
Instead we have 'ale' (non- marital male sexual partner) who can assist us
financially" (Ajuwon et al. 1993/94). The incidence of non-commercial exchange
of sexual favours is also on. the increase among young girls in institutions of
learning who accept gift, food or many from other men with whom they
established casual sexual relationships.
Furthermore, some out-of-school young girls have responded to the
economic crisis by entering occupations in which they are vulnerable to being
lured or forced to having sexual risk relationship with men. For example,
several incidents of sexual exploitation of the itinerant female hawkers (IFH) in
the course of their work have been reported (Orubuloye, Caldwell and Caldwell,
1993; Obot, 1986). Because of their relatively young ages, and the fact that they
earn little income, the IFH in Nigeria are easily lured,' harassed and sometimes
raped by men inside the bus/lorry stations where the IFH sell their wares.As
public awareness about AIDS is increasing in Nigeria, the IFH have become
sexual favorites of men because of their believe that the IFH are not likely to
have HIV" are sexually inexperienced and are not regarded as full time
commercialsex workers. Unfortunately, there are no programmes in Nigeria
that specifically target the AIDS education need of this group.
Another consequence of the economic crisis in Nigeria maybe the high
proportion of Nigerian women who go into fun time commercial sex work, as
a means of survival. This situation is reflected in the change in the profile of the
CSW in-Nigeria in recent years. Previous researchers show that CSW were
usually old women with limited education who have ben separated or divorced
from their husbands (Cohen, 1969; Oleru, 1980). However, recent researchers
indicate an increasing number of single, well educated young women and even
teenagers involved in full-time sex work (Adedoyin and Adegoke, 1995;
Orubuloye, Caldwell and Caldwell, 1994).
Despite .the vigorous social marketing campaigns for condom in
Nigeria, many CSW still do not use it (Chickwem et al, 1989; Adedoyin and
Adegoke, 1995; Orubuloye et al, 1994). This increase their risk of exposure to
STDs some of which are known risk factors for HIV transmission (Pallangyo,
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1989; Johnson and Pond, 1988; Piot et al, 1987). Another source of risk to
CSW in Nigeria is heir practice of receiving injections of antibiotics as
prophylactics against STDs from patent medicine dealers who re-use needles and
syringes (Chickwem, 1989; Ajuwon et al, 1993/94). Intervention measures that
address these problems are required to reduce the risk of infection among CSW.
We now discuss strategies that can reduce the susceptibility of women to HIV
infection.
IMPLICA TIONS FOR AIDS PREVENTION AND CONTROL
PROGRAMMES
The following suggestions are made to reduce the risk of women.
I. Assessment of the nature and extent of STDs in Nigeria
. Since STDs are risk factors of HIV transmission, their control will have
a salutary effect on the prevention of further spread of AIDS in Nigeria. There I
is currently no national data on the incidence and prevalence of STDs in
Nigeria, therefore, there is need to assess the current situation to determine the
extent of the problem in the country. In addition to clinic-based collection of
STD data, there is need to conduct routine community surveys and develop a
surveillance system whereby STD trends can be monitored, interventions
implemented to control them and their impact assessed. The NACP, in
collaborating with secondary and tertiary health facilities is appropriately
positioned to implement this proposal.
2. Development of women specific interventions
Interventions specifically designed and targeted at women in Nigeria are
urgently needed. Different intervention measures will be used to address the
range of AIDS education needs of the Nigerian women. For women in general,
realistic media campaigns and formal ,and informal associations can be used to!
sensitize them to the risk AIDS pose to their health and motivate them to take I
action.. Women of privilege who belong to professional associations such asl
Federation of Women Lawyers (FIDA) , Medical Women Association,
Association of Lady Pharmacists can be easily reached through these
associations. Other less privilege women can be educated _through informal
associations, which have been found to exert a powerful influence on the
behaviour of members. Women in high risk occupations such as CSW, IFH and
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long distance traders, and others who engage in risk behaviours including in and
out of school adolescents can be reached through peer education approach which
bas prov.en to be effective in influencing risk behaviours (Williams, 1994).
These Intervention approaches should be incorporated into the current structure
of the NACP. However, the NACP will require the collaboration of
international agencies such as the
society for Women and AIDS in Africa (SWAA) to be able to fully implement
the programmes.
3. Improvement of access to medical care
As a way of improving their well being and protecting them from mv
infection, comprehensive health services including reproductive information and
treatment of STDs must be made more accessible to all Nigerian women. One
way of reaching this goal is to use women volunteer health workers (WVHW)
who will. be trained to provide women-friendly health services to their
counterparts. This intervention option may be integrated into the existing
Primary Health Care Programme in the country and may be particularly
appropriate in medically undeserved rural communities. Advocacy can also be
done by NACP to mobilize the directors of health facilities in urban centres to
provide women-friendly services.
·4. Economic empOwerment of women
The health and well being of women need to be improved by creating
more opportunities for them to be educated. Such education would enable them
become economically independent from their male partners. Both formal and
adult literacy programmes need to be organized for women with the assistance
of local and international agencies interested in improving the well being of
women in Nigeria. The ability of women to become economically independent
can also be enhanced by improving their access to seed funds which can be used
to set up small scale income yielding business. Tbe Ministry of Women Affairs
recently created by the Nigerian Government to improve the conditions of
women should be responsible for achieving this goal.
S. Enlisting the support of men
Tbe suggestions mentioned above have policy implications, hence the
support of men is required because in Nigeria more men than women occupy
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important policy making positions. NACP need to sensitize opinion and policy
makers, health care providers and media men to the nature of the risk women
are exposed to and the need to formulate policies that would address them.
CONCLUSION
The epidemic of HlV IAIDS is growing rapidly in Nigeria and until a'.
cure is found, primary prevention through education is the only realistic means
of controlling further spread of AIDS in the country. Women in Nigeria are
particularly susceptible to HIV 'infection, but unfortunately, few of the
intervention programmes being implemented in the country have addressed the
social and economic conditions which place women at risk to HIV infection.
Women in Nigeria constitute a significant proportion of the Nigerian population,
therefore, there is need fora change in the direction of AIDS programming in
the country. Women specific interventions, planned and implemented with the
strong input from the women themselves are required urgently to address the
AIDS education needs of this disadvantages segment of the Nigerian population.
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...
SOURCE POPULATION LOCATION NO. NO. % OF
SCREEI':lED TESTED HIV HIV
POSI POSI
TIVE TIVE
1 Mohammed Healthy persons Maiduguri, 5,238 12 0.23
et AL and patie~s Potiskum, %
(1987) Calabar.
Enugu
-
2 Chickwem, Commercial sex Maiduguri 353 18 5.1%
Mohammed workers (CSW)
and Ola
(1989)
3 Williams, Clients of CSWs Ikorn, 133 2 1.5%
Heart and Calabar
Udofia
(1989)
4 FMOHSS CSW, Women 11 sentinel 11.907 482 4.04
(I991/92) attending ante- sites" %
natal clinics
(ANC) clients of
SID clinics and
TB patients
5 Olusanya, Health business Ogun State 385 3 0.77
Lawokeand employees %
Biomberg
(1993)
6 Shokunbi Blood donors, Ibadan 6,389 41 0.93
Saliu and healthy %
Essien international
(1993) travellers and
patients
7 Nnatu et al Pregnant women Lagos 230 2 0.8%
(1993) attending ANG
8 FMOHSS CSW, women 16·· sentinel 22,569 1,490 6.59
(1995) attending ANC, sites %
SID and TB
patients, long
distance truck
drivers
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UNIVERSITY OF IBADAN LIBRARY
*The sites are in Benue, Delta, Lagos, Enugu. Cross-
Rivers. Kaduna, Kano, Osun. Edo, Oyo and Jigawa States.
** These are in Plateau, Benue, Delta, Lagos, Enugu, Adamawa,
Borno, Cross-River, Kaduna, Kwara, Kano, Osun, Anambra, Edo,
Sokoto, Oyo and Jigawa States.
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Infections in Nigeria, challenges for Fragile Health
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Alubo, S. O~ (1990): Debt crisis, Health and Health Services in
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Ajuwon, A. J. (1990): Socio-cultural Practices that may favour the
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Asuzu, M. c., and Idoko, L. O. (1994): Incidence and Treatment
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Caldwell, J. C. and Caldwell, P (1977): The Role of Marital
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Cohen, A (1969): Custom and Politics in. Urban. Africa: A
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Ebomoyi, E. (1987): prevalence of Female circumcision in Two
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Chapter Seven
WOMEN AND FAMILY PLANNING PRA-CTICE IN
NIGERIA
Uche C. Isiugo-Abanibe
Department of Sociology, University of Ibadan,
Ibadan.
INTRODUCTION
Bongaarts has identified four key factors that determine
fertility in any population, namely the age at marriage,
contraceptive use rates, the number of months of postpartum non-
susceptibility or sterility, and the rate of induced abortion: Of these
four proximate fertility determinants, contraception, which is
usually achieved through family planning programmes, has the
strongest effect in reducing fertility inmost developing countries
(Bongaarts, 1978), except in sub-Saharan Africa where postpartum
non-susceptibility has the most powerful negative effect on fertility
(Nongaarts et aI., 1984).
Family planning is an organized effort essentially to assure
that couples who want to limit their family size or to space their
children have access to contraceptive information and services, and
are encouraged to use them as needed. Of course, anthropologist,
sociologists and medical doctors have known for many years that
couples in various parts of Nigeria have consciously and
effectively controlled pregnancy and births, hence nowhere in the
country does recorded fertility approach the biological maximum.
Taboos on intercourse during lactation with intentional long
periods of breastfeeding, intentional physical separation of wives
from their husbands, permanent and periodic abstinence, herbal
medicines and waist bands, incantations, and even abortion, have
traditionally been used to regulate family size among Nigerian
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cultures and to enhance the health of mothers and their children.
Family planning saves lives. It enables couples to decide
for themselves when to have their children as well as how many
children to have. By helping women bear their children during
healthiest times for both mother and baby, family planning helps
to prevent deaths of infants, children and mothers. the use of
family planning allows women to avoid unwanted pregnancies
dangerous illegal abortions, and childbearing under circumstances
that will threaten their infants' lives and their own health. Thus
modern family planning is beneficial even though it remains a
controversial issue.
The impact of family planning programmes on fertility vis-
a-vis economic development has perhaps drawn the most
controversy (Davis 1967; Berelson 1975; Isiugo-Abanihe, 1994a).
Family planning advocates argue that if birth control information
and services are widely available, knowledge and access to
services can prompt couples to limit their childbearing, leading to
significant fertility declines, even without substantial economic
development, essentially a 'supply-side' argument. On the demand
side many scholars and policy makers argues that economic
development is a necessary precondition for fertility decline
(Donaldson and Tsui, 1990). This argument is anchored on the
belief that the social and economic transformation brought about
by development and rising standards of living force couples to re-
evaluate the desirability of large families and motivate them to use
family planing. The consensus of opinion, however, suggests that
for developing countries a complementarily of organized family
planning and development achieve the best result with respect to
fertility transition (Maudlin and Berelson.. ·1978; Lapham and
Mualdin, 1987). -
Clearly, organized family planning programmes do improve
the availability and accessibility of contraceptive services, and the
presence of such services may constitute the motivating factor to
many couples. At the same time, social and economic development
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affects a broad range of variables which are conductive to- fertility
reduction, among which are increases in the age at marriage, the
level and quality of schooling and consequently labour force
participation, improvements in infant and child mortality and
increased motivation for contraceptive use. Thus, socio-economic
change in Nigeria, for instance, has increased female education
and employment, has tended to enhance the status of women and
conferred a legitimacy for smaller family sizes, thereby providing
a fertile ground on which family planning will thrive. Therefore,
even in the Iikely event of a temporary increase in fertility which
may accompany the declining prevalence and intensity of
breastfeeding, erosion of postpartum abstinence rules, and greater
control over diseases which had hitherto impaired fecundity, the
overwhelming influence of the forces of social change and the
increasing cost of children to parents are sufficient to predispose
coupes to family planning. This may take some time to happen;
only a beginning has been made.
This chapter provides a brief overview of organized family
planning activities in Nigeria, and examines latest national figures
on the levels of contraceptive awareness and prevalence. The issue
of family planning in Nigeria is the study of women, who as child
bearers have been the target of organized family planning activities
in the country. But women face a lot of social and cultural barriers
which hinder their adoption of family planning. Most important is
the male-dominant family and social milieu in which production
and reproduction take place. Although this article attempts a
justification of the female emphasis of family planning in Nigeria,
we also make a case for more male involvement and support for
family planning practice not only for their wives but also for they
themselves. Lastly, we question the adequacy of family planning
\
I as a means of population control in Nigeria.
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TIlE DEVELOPMENT OF FAMILY PLANNING IN
NIGERIA
. To a large extent, the development of family planning in
Nigeria is the history of the Planned Parenthood Federation of
Nigeria (PPFN), formerly know as the Family Planning Council
of Nigeria (FPCN),. which wa a metamorphosis of the Family
Planning Committee. The' visit to Lagos of Edith Gates of the
Pathfinder Fund, first in 1956 and many times subsequently,
marked the beginning of family planning awareness and activitie!-.
in Nigeria (Olusanya, 1989). Her concern for family welfare issues
.led to the formation of the Lagos Marriage Guidance Council
which undertook the responsibility of organizing courses in family
welfare and sex education for select groups of women. The
Marriage Guidance Council became aware of the problem of
unwanted pregnancies following the occurrence of two tragic cases
of septic abortions in 1957 (PPFN, 1988). Subsequently, a sub-
committee set up to investigate the need for family planning
services revealed: that illegal abortion was a common practice
among married and unmarried women with unwanted pregnancies,
and recommended the establishment of a family planning clinic to
be run once a week in the domiciliary mid-wifery centre of the
Lagos Local Health Department. The clinic was to be named
Marital Health Clinic "to forestall any opposition to the concept of
birth control or family planning as a new and foreign discipline,
and to give expression to the intention to offer advice, information
and service on both birth control and infertility" (Olusanya, 1989).
The first family planning clinic was thus opened in Lagos by the
Marriage Guidance Council in 1958, but
due to financial constraints -its activities were seriously
curtailed.
In 1962 the National Council of Women's Societies
(NCWS) founded the Family Planning Committee with the
responsibility of providing family planning services and marriage
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counselling. The family Planning Committee was in 1964
transformed into the Family Planning Council of Nigeria (FPCN),
with the International Planned Parenthood Federation (IPPF) and
Pathfinder Fund as the main source of funds (PPFN', 1988;
Olusanya, 1989). The FPCN implemented its family planning
activities through loosely affiliated clinics that were directly
responsible to a hospital, maternity home or other heath agency
whose policy and personnel the FPCN did not control. Also during
these early years of its existence the government did not openly
support or identify with the family planning activities of the
FPCN. Up to 1976, the Council did not receive financial aid from
the government and when government subvention was eventually
granted it was relatively small.
In 1987 the FPCN underwent a drastic re-organization and
was re-named Planned Parenthood Federation of Nigeria (PPFN),
adopting a federal structure of operations. The need for re-
organization was precipitated by organizational, financial,
administrative and image problems which greatly undermined the
operational effectiveness of FPCN. Significantly, the new name
did away with the term 'Family Planning' and in Council's name,
thereby placating government and public suspicion or opinions
which equated 'family planning' with 'population control'. Also,
the term 'Planned Parenthood' in the new name was in consonance
with the name of the parent organization, International Planned
Parenthood Federation, which remains its main source of funds.
The primary objective of the PPFN is the development of
healthy and happy families through family planning, an objective
which contributes to, as well as complements, other efforts aimed
at improving the quality of family life in Nigeria (PPFN, 1988).
This objective . also '. necessitates the development and
implementation of birth spacing activities that promote maternal
and child health, counselling and treatment of infertility and the
delivery of sex and family life education to adolescents and youths.
Currently, the PPFN works closely with the government, and also
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with international and national non-governmental organizations,
and operates clinics in virtually all states of the federation,
recording an ever increasing number of clients.
The launching of the national population police in 1988 has
greatly enhanced the activities of PPFN, and family planning in the
country. For a long time different Nigerian governments had
assumed a laissez-faire posture on family planning,and population
policy generally (Isiugo-Abanihe, 1979). Rather surprisingly , the
first post-independence development plan (1962-68) recognized the
country's high rate of population growth as a serious problem
(FRN, 1962). However, it offered no solution to the problem;'
there was no mention of family planning. In the Second National
Development Plan (1970-74), government planned to' provide
family planning services within the framework of the overall' health
and 'Social welfare programmes of the country (FRN, 1970).
However, by the end of that plan period family planning had not
been integrated with the health-care delivery system as envisioned,
and the government-had not supported any family planning efforts.
The Third National Development Plan (1975-80), did not differ
from the lone before it. It declared that "emphasis- is being
deliberately placed on accelerating the rate of growth of the
economy rather than direct action to achieve a drastic or immediate
reduction of overall birth rate" (FRN, 1975). While asserting, ,like
the one before it, that the present demographic situation in the
country did not call for 'emergency action', it recommended that
family planning activities only be integrated into an overall health
and social welfare programmes; there was no federal budget on
family planning.
The Fourth National Development Plan, 1981-85,_gave
some indication of a change of government's attitude to population
growth and control. The document states inter alia that:
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For meaningful and sustained economic
development ... to take place, population growth
will have to be more closely monitored and shaped
in a way that will make them consistent with our
resource potentialities. Consequently, appropriate
measures will be introduced to influence vital
population variables . .. a long directions which
enhance the country's growth and development
prospects (FRN, 1981).
The plan observed that the forces or social and economic
change were already lending to small average family size,
especially in urban areas, and expressed. government's intention to
strengthen these forces during the plan period by encouraging the
provision of facilities for family planning in health institutions and
educating couples to take advantage of such facilities to regulate
thesize of their families (Olusanya, 1989). However, government
would not do this directly but supporting the activities of private
organizations in the country.
A rather dramatic change in government's attitude to
population issues happened in 1985, when the military government
set in motion plans for the formulation of a comprehensive and
explicit population policy aimed at reducing the rate of population
growth in the country, with a heavy reliance on family planning.
To a large extent. the increasing difficulty of government in
implementing programmes and achieving planned targets or goals
may have been the predisposing factor. According to Olusanya
(1989), part of the explanation for this change was the worsening
economic situation in the country (huge external debts, mass
unemployment, gross inadequacy of social services, etc.), which
made it difficult to implement development projects. The new
government posture on population was also influenced by the 1984
Second African Population Conference in Arusha, Tanzania from
which emanated the Kilimanjaro Programme of Action which
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\
\
guided the position of African governments in the 1985
International Population Conference in Mexico City (Isiugo-
Abanihe, 1994a). At that conference the then Head of State,
General Buhari, declared:
We in Nigeria now feel that in the face of rapid
population growth, a well-articulated population
policy is necessary. Such a policy would have as its
main focus, guidance in fertility behaviour which
will emphasize the health of both mother an4
child... something has to be done to ensure that the
galloping population growth rate and over-
urbanization do not eclipse efforts ... to improve
the economy and enhance the quality of social
services available to the people (Population
Institute, 1984).
The Nigerian Population Policy, as adopted in February
1988, is a comprehensive document outlining the population
problems facing the country, with their consequences, all of which
informed the goals, objectives, targets and strategies of the policy.
The goals of the policy include· the achievement of lower
population growth rates trough reduction of birth rates by
voluntary fertility regulating methods ... ' (FRN., 1988: 12)~
Among its seven objectives is one that will 'make family planning
means and services to all individuals easily accessible at affordable
prices, at the earliest possible time, to enable them to regulate
their fertility' (FRN, 1988: 13). Thus the policy gives a new
impetus to family planning activities in the country, and although
the emphasis remained on women, there was the recognition of the
role and responsibility of men in family planning and family-size
decisions. Consequently, there are new initiatives throughout the
country to educate Nigerians on the need to regulate family size,
and services are being provided through many outlets, including
PPFN outfits, government hospitals and maternities and even
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private clinics and NGOs. In spite of all these, the prevalence of
family planning in Nigeria remains low.
KNOWLEDGE AND PREVALENCE OF FAMILY
PLANNING
Given the relative recency of family planning in Nigeria
and the hitherto laissez-faire government attitude toward it, it is
hardly surprising that both knowledge and use of family planning
are low. Two national surveys, the 1981/82 Nigeria Fertility
Survey (NFS) and the 1990 Nigeria Demographic and Health
Survey (NDHS), provide us with national and comparabledata on
knowledge and prevalence of family planning methods in the
country, although ad hoc KAP-type surveys, some dating back to
the 1960s, abound for different parts of the country.
The NFS shows that knowledge of family planning methods
was very low among Nigerian women in 1981/82 (NPB, 1984).
Only one out of three women have heard about any method of
family planning, including inefficient (traditional) methods; even
fewer women, one out of five, knew about modern methods (Table
1). Abstinence was the commonest method known, perhaps in
consonance with the traditional practice which is still observed by
many women, especially in rural areas. Among modern methods,
the pill and injection were known most, even though by slightly
more than one in ten women.
The NDHS data show that knowledge of family planning
methods witnessed a remarkableiinprovement between 1981 and
1990 (Table 1). About 46 per cent of all women aged 15-49 knew
at least one method of family planning, with about 44 per cent
identifying modern methods of which the pill, injection, condom,
IUD and female sterilization were the most commonly known.
Knowledge of these methods experienced more than 100 per cent
increase between 1981 and 1990. This recent improvement in
knowledge of modern family planning methods may be related, at
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least in part, to the national population policy which has tended to
give legitimacy to family planning through widespread discussion
and communication in the media, hospitals and clinics and even in
civic activities. As a result of the official approval given by the
policy, advertisement of family planning has received an
unprecedented impetus throughout the country, including the use
of drama and music that eulogize the virtues of the small family.
AT the same tim-e, the HIV /AIDS pandemic has -had a profound
impact on condom advertisement on both the radio and television
in the past few years. -
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TABLE I: PERCENTAGE OF ALL NIGERIAN WOMEN AND
CURRENTLY MARRIED WOMEN BY KNOWLEDGE OF
CONTRACEPTIVE METHODS AND SOURCE OF METHODS. 1981/82
AND 1990
NFS 1981/82
Contraceptive All Currently All Currently Knows a
Methods 'Nomen Married Women Married Source
Any method 33.6 32.9 ' 45.7 36.0 34.0
Modem
methods 21.1 20.3 43.5 43.6 33.2
Pill 13.4 12.5 35.1 41.2 25.0
I.U.D 4.4 4.4 20.3 33.8 15.9
Douche 3.2 3.1 - - -
Condom 5.6 5.1 24.1 21.6 17.7
Injection 10.7 10.1 34.2 33.6 25.2
Foaming
tablet - - 10.7 9.6 8.1
Diaphragm/
foam/jelly - - 7.9 7.3 6.2
Female
sterilization 6.9 '7.0 ~0.4 19.4 15.7
Male
sterilization 2.1 2.0 7.5 6.7 5.6
Traditional
method 12.5 12.6 25.7 23.6 -
Rhythm 9.3 8.7 17.3 14.7 -
Withdrawal 6.3 5.6 14.2 12.7 -
Abstinence, 19.4 18.8 - - -
Herbs 6.7 6.5 - - -
BJJJds 4.8 5.0 - - -
Rings 7.0 6.9 - - -
Others - - 10.0 10.3 -
Source: For NFS data, National Population Bureau (NPB), 1984, for NDHS
data, Federal Office of Statistics (FOS), 1992,
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If knowledge of contraceptive methods is low among
Nigerian women the practice of contraception is even lower. Only
about 15 per cent of ~11'women have ever used any contraceptive
method in 1990, and only 9 per cent have ever used a modern
method. Among currently married women, the figures are slightly
lower: 14.per cent and 8.4 per cent respectively. Compared with
the result of the NFS, which indicated that 14.5 per cent of
currently married women ever using family planning, the level of
ever use of family planning appears to have remained 'constant
between 1981 and 1990.
(Table 2). It should be pointed out, however, that
prolonged abstinence formed a large share of the ever-used data
reported in NFS, while the NDHS did not include abstinence
among, family planning methods. That ever use of family planning
increased between the two periods is clearly evident from the use
of modern methods. Only 2 per cent of currently married women
had ever used modern methods in 1981/82 relative to 8 per cent in
1990.
Table 2 also contains data on current use of family
planning, that is, the percentage of women who were using any
method of family planning at the time of the respective surveys. In
1981/82 6.2 per cent of currently 'married were using any family
planning method: the remaining 93.8 per cent were not
contracepting. A closer look at Table 2 reveals that nearly all the
contracepting women (5.5 per cent) were using methods that are
not considered reliable. The NDHS also gives a contraceptive
prevalence rate of 6 per cent among currently married women;
however, there are more women (3.5 per cent) using modern
methods relative to those using traditional methods (2.5 per cent).
While overall use of family planning is low, the analysis of the
NDHS shows a wide disparity in contraceptive prevalence among
socio-economic groups with urban residence, education above the
primary level and residence. in the southern part of Nigeria,
especially the south-west, having the greatest effect on
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contraceptive use (FOS, 1992). Also contraceptive use seems to
increase with age and the number of surviving children, suggesting
that family planning is being used to space births at low parity, but
more so at higher parity as women approach or attain the desired
family size. For instance, while only 3.5 per cent of women with
one surviving children were currently using family planning, 7, per
cent of these with 4 living children were deing the same, as were
9.6 per cent of their sisters with 5 or more children (FOS, 1992).
Also as should be expected, older women and those with more
surviving children are more likely to be currently using more
effective contraceptive methods such as the pill, IUD and injection.
For instance, NDHS data show that 2.2 per cent of women with
5 or more surviving children were using the pill, 1.4 were using
IUD and 1.5 were using injection. The corresponding figures for
women with 2 surviving children are 0.9 per cent, 0.3 per cent
and 0.6 per cent respectively.
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Table 2: Ever Use and Current Use of Contraceptive Methods
among Currently Married Nigerian Women, 1981/82 and 1990
1981/82 NFS
Family Planning Ever Current Ever Current
Methods Use Use Use Use
Any method 14.5 6.2 14.0 6.0
Modem methods 2.2 0.7 8.4 3.5
Pill 1.4 0.3 4.8 1.2
I.U.D 0.3 0.1 1.7 0.8
Injection . 0.5 0.2 1.9 0.7
Foaming tablets 0.0 0.0 0.5 0.1
Diaphragm 0.0 0.0 0.1 0.0
Condom 0.7 0.0 2.0 0.4
Female sterilization 0.1 0.1 0.3 0.3
Male sterilization '0.0 0.0 0.0
. Any Traditional 0.0
method. 12.4 5.5 8.1 2.5
Rhythm 3.1 0.4 4.3 1.4
Withdrawal 1.4 0.1 2.8 0.5
Abstinence 11.8 4.9 - -
., Others 0.6 0.0 2.3 0.6
Source: As in Table 1.
Clearly, contraceptive prevalence rate (CPR) is very low in
Nigeria. The CPR for Nigeria is low even when compared with
her two West African neighbours: Ghana and Togo, where the
Demographic and Health Survey (DHS) also took place. The CPR .
for Ghana and Togo are 13 and 12 per cent respectively (at least.
twice that of Nigeria). For Africa as a whole DHS data indicate ..
that CPR is highest in Zimbabwe (43 per cent),Botswana (33,per
cent) and Kenya (27 per cent) PRB, 1992). Little wonder that
these are the same sub-Saharan African countries where fertility
has began a, decided decline. Because of the low contraceptive
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prevalence in Nigeria, the current pattern of high fertility will
persist well beyond the target year 2000 envisioned by the
population policy, and achieving the stated goal of four children
per woman may remain unr-ealisticand unattainable well into the
next century. Thus, organizing and implementing family planning
in Nigeria remains a challenge. The task is made more difficult
because of the rapidly growing number of women entering the
reproductive age, who are to be served with family planing
services, and because those who are least likely to use family
planning services are -often the hardest to reach, such as rural
residents, the poor, uneducated and muslim women.
Yet many Nigerian women who are not practising family
planning would like to-delay the birth of their next child or cease
child-bearing altogether. These women form a large pool of
potential family planning users, women whose need for family
planning is 'unmet'. The NDHS shows 'unmet need' for family
planning among currently married Nigeria women as 20.7 per cent
- about 11 per cent of currently married Nigerian women do not
want.any more children but are not using a contraceptive method,
and another 10 per cent expressed interest in birth spacing but also
are not using a method to achieve it (PRB, 1992). Reasons for the
observed high level of unmet need for family planning in Nigeria,
as iri other African countries, are many. Foremost, Nigerian
women still lack access to high-quality family planning services
and would take advantage of such services if they were available.
As has happened in Latin America and Asia, easily accessible,
well advertised and high quality family planning services will go
a long way in reducing the number of unintended births and
abortions in the country. Table 1 indicates that many"Nigerian
women who know about family planning methods do not know
where such services could be obtained. We have shown elsewhere
that many Nigerian women who seek family planning services are
unaware of the range of methods available at the clinics, and there
is a general concern about the side-effects of contraceptive
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methods (Isiugo-Abanihe, 1992). Still others fail to use family
planning because of their husbands' disapproval- real or imagined;
unilateral use of family planning by a woman is rife with
suspicion, and is a sufficient reason for divorce. These issues can
be addressed through information campaigns and education
programmes for the general population, but especially for men, to
underscore their role and responsibility in fertility, and
contraceptive decisions.
MALE INVOLVEMENT IN FAMILY PLANNING
Historically, men have provided a major impetus for the
practice of birth control. The European demographic transition was
achieved not through the use of present day female contraceptives,
j but mainly through widespread use of coitus interruptus orwithdrawal (van de Walle and Knodel, 1980), which is essentially
a male method. Apart from withdrawal, many couples relied upon
periodic abstinence, and alter condoms, long before modern female
methods made their appearance in the 1950s and 1960s. Still, the
increasing popularity of male surgical methods or vasectomy in
many developed countries, suggests that men, not only play a
important role in fertility and family planning decisions, but also
are willing to take responsibility for contraception (Gallen, 1986).
The spread of family planning followed a different route in
the developing countries, guided mainly by the development of
modern female contraceptives, which are usually offered in the
context of maternal and child welfare programmes. Implicitly,
these programmes promote female methods, such as oral
contraceptives and intrauterine device (IUD), and ignore male
methods, such as condom, since the clients are usually women.Jn
line with this approach, surveys on attitudes of fertility and family
planning were typically focused on females as the bearers of
children; the opinions-of men were considered secondary, even in
patriarchal Nigerian societies where male views prevail in the
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social, economic and political spheres of life.
Nigerian men are often assumed to have little interest in .
contraception; they are generally thought to be opposed to family
planning because of their tendency to favour a larger family size
than their wives. Recently, however, policy makers; scientists
(including physicians)' and family planning organizations are
beginning to recognize the need to actively focus family planning
activities on men. This makes a lot of sense in view of the
dominance of men in all spheres of family life (Isiugo-Abanihe,
1991). Male dominance in Nigeria is the product of the patriarchal
system which, among all ethnic groups, confers on men decision-
making roles on matters affecting the family; their authorization is
crucial even in trivial matters (Isiugo-Abanihe, 1994b). As the
main opinion leaders, therefore, efforts to influence the attitudes
of men on population issues, and motivate them toward family
planing use, would form the bedrock of a successful family
planning programme. Reaching men with messages and methods
that encourage the use of family planning will also motivate them
to support their wives in family planning decisions.
It is note worthy that the new Nigerian population policy
took cognisance of the important role of men in the family and the
need to focus educational programmes on them on that account.
The document succinctly summarized the position of Nigerian men
with respect to family life:
In our society, men are considered the head of the
family and they take far-reaching decisions
including the family size, subsistence and social
relations . . . The average man bears greater
paternalistic burden in caring for the family. Special
information and enlightenment programmes are
necessary to increase awareness of men as to the
need of having the appropriate size of family they
can foster within their resources (Federal Republic
of Nigeria, 1988: 19).
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It is equally important to focus attention on men because
they have indeed been active in family planning in Nigeria, even
if that role has not ben obvious. Our analysis of the NDHS data
indicate that about 48 per cent of ail women (or 38 per cent of
currently married women) who are currently using a .method of
birth control, use any of three methods that require male
participation or cooperation: the condom, rhythm and withdrawal.
There is also evidence that men's attitudes toward family planing
are changing in Nigeria, with men now favouring family planning
for child spacing to enhance the health of mothers and children and
to have a family size they can adequately cater for (lsiugo-
Abanihe, 1992). Also, most of what has ben tagged men's
opposition to family planning could be due to the characteristic
lack of communication between husbands and wives. The fact that
men's attitudes on family planning have typically ben derived from
information supplied by their wives rather than from men
themselves, may well have misrepresented men's views on the
matter. In all, evidence suggests that programme emphasis of
family planning information and services on women alone is not
justified by the social reality of the Nigerian family. Indeed, male
participation and involvement constitute the bedrock of a successful
family planning programme in Nigeria, at least because male
values affect female behaviour. In the case in point, a more
positive male attitude toward family planning would be expected
to enhance female adoption of the innovation.
ON WHY WOMEN SHOULD BE THE TARGET OF
FAMIL Y PLANNING
Although the case has ben made for male involvement-in
fertility and contraceptive decisions, primarily, women constitute
the major target of family planning. Male role is mainly a
supportive one. Because women are the ones who bear the brunt
and risks of prolific childbearing, which include various
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disabilities, deformities and a high level of maternal mortality.
they are the ones for whom contraceptive use is more imperative.
One of the eight strategies for the implementation of the Nigerian
population police is to make family planning easily affordable, safe
and culturally acceptable. The policy notes that:
In recent times, the incidence of unwanted
pregnancies, abortions, abandoned babies and child
abuse has greatly increased and now constitutes a
national social problem. Voluntary fertility
regulation and organized family planning have
proved to be effective, preventive and low cost
measures to control such social problems. Also,
family planning reduces maternal and infant
morbidity and mortality as well as stems rapid
population growth in the shortest possible time ...
It is necessary to adopt fertility regulation as a code
of ethics (FRN, 1988: 16).
Nigerian women spend the majority of the years. between
15 and 50 conceiving, carrying, delivering and suckling babies.
The pattern of early and universal marriage means that most
women initiates childbearing in the teenage age, during which
period they face considerable health risk. Childbearing also.
continues till the late 40s, where the health risk of childbearing is
also high. Thus pregnancy and delivery of babies constitute a
special life-threatening hazard for Nigerian women; childbearing
is the cause of a large proportion of all deaths of women in the
reproductive ages. Hence in many developing countries where the
data available, female life expectation in the prime childbearing
years is often lower than that of males. Indeed, motherhood is a
dangerous preoccupation in countries, like Nigeria, where medical
facil ities are rudimentary.
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Apart from high maternal mortality, Nigerian women suffer
severe measures of physical and nutritional stress given the high
proportion of their lives spend pregnant, breastfeeding and caring
for children. Chid rearing in Nigeria is an exclusive preserve of
women, and this takes place a longs ide other activities, as is
evident from the common sight of children straddling the back of
working and trading women everywhere in Nigeria. Sometimes,
such children suckle their mother's breast from their precarious
position, while their older siblings are being dragged along.
Clearly, family planning is god for Nigerian women. By helping
them bear their children during the healthiest times for both
mother and baby, it helps to prevent deaths of mothers, infants and
children. Family planning is an effective, inexpensive way to
prevent many deaths: it is an investment in human resources that
can be a key part of programmes designed to improve material and
child health. By focusing on the right of parents to decide the
number and spacing of the children they wish to have, or to have
babies by choice rather than by change, family planning enables
women to avoid unwanted pregnancies, dangerous illegal
abortions, and childbearing under circumstances that will threaten
their lives. Unwanted pregnancies result not only from none use of
contraceptives, but also from the use of ineffective methods or
from improper use of contraceptives. Thus the use of effective and
culturally acceptable methods, administered in a clean
environment, by medically qualified personnel, will be profoundly
beneficial to the teeming population of Nigerian women, many of
whom are literally dying in ignorance.
Yet such a woman is typically a worker (in the family farm
or outside the home), the household cook and caterer, and a wife
to a man whose demands and expectations are often tasking.
Nigerian women have ben very active in the economy, they work
long hours in the farms; clearing the bus, planting, weeding,
harvesting, preserving and processing agricultural products, often
with the most crude of implements. Also, women generally are the
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ones to gather fuel wood, fetch water and market household
produce. In all Nigerian cultures, women occupy a subordinate
position relative to men, are generally discriminated against in the
home and society. Women issues and concerns are often treated
with laxity by the patriarchal family. In spite of their relative
poverty and powerlessness, strangely many women see prolific
childbearing as a mean to status enhancement, at least in future
when the children become adult. Conversely, our research
indicates that under the weight of physical, maternal and emotional
burden they bear, many are compelled to secretly accept family
planning, fully aware of the risk of their action to their marriage.
The foregoing justification of family planning for women
should not suggest that women unanimously approve of family
planning. On the contrary, Nigerian women are generally
apprehensive of the side-effects of modern family planning
methods, apart from the concern for high social and monetary
costs of the device. Thus the perceived availability of contraceptive
services, involving knowledge of sources of method, distance to
location, cost of services; treatment by service providers, follow-
up medical care, etc., should be sufficiently encouraging to women
who are motivated to adopt family planning. In time, such satisfied
users will constitute effective advertisers of services and important
change agents. Clearly, an efficient family planning programme
constitutes a profound benefit to Nigerian women and the family
at large.
IS FAMIL Y PLANNING ENOUGH?
Family planning is advocated for women to enable them
plan their childbearing given to the prevailing social, economic and
health constraints. However, because family planning connotes
individualistic planning, it may not necessarily be relied upon to
achieve national goals (Davis, 1967). Even couples who use family
planning effectively can still plan to have eight or more children,
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which is antithetical to the national goal of four children per
women. By definition, thus the voluntary nature of family planning
renders it ineffective as a means to plan or achieve a national goal
or target. It is highly unrealistic to achieve the kind of fertility
control envisaged by the Nigeria population police merely by
encouraging couples to have the number of children they can
'adequately cater for', given that they 'have the basic right to
decide freely and responsibly on the number of spacing of their
children' (FRN, 1988: 2). Since it is not a punishable offence for
a woman to have more than the stipulated four children, and given
the apparent demonstration effect emanating from public figures
who have exceeded that number by a wide margin, the policy
strategy of 'encouraging couples' is indeed a tough one to sell.
Furthermore, as Davis (1967) has observed although family
planning enables couples (if they so choose) to restrict the number
of children, it offers only those means that are considered
'respectable' or morally acceptable, not necessarily those that are
the most effective. Hence, the proponents of abortion as a means
of family planning are few, even though it plays a considerable'
role in the recent fertility transition that took place in Japan and
other countries.
Additionally, by suggesting four children as the desirable
number per woman, rather than per couple, the policy tended to
ignore the role and responsibility of men in family size
determination, and doing so despite the fact that Nigerian men
generally want more children than their wives (Isiugo-Abanihe,
1991: 1994b). Thus, in the unlikely event that the policy of four
children per woman is enforced in future, the incidence of
polygyny may be expected to rise as a consequence, since the
policy merely encouraged men 'to have limited number of wives
and optimum number of children they can foster within their
resources' (FRN, 1988: 19).
Nevertheless, that a policy legitimizing family planning is
in place in Nigeria, despite decades of passivism on population
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issues, is a landmark event in Nigeria's development planning. The
rapid population growth being experienced in the country, with its
long-term momentum and widespread ramifications, requires the
for sighted statesmanship shown in 1984/85 by the government in
power, which was the first to recognize the population problem
confronting the country. Yet the experience of Ghana, whose
population pol icy was first formulated in 1969, suggests that a
policy per se does not necessarily do the magic; a strong
government commitment in all aspects of the policy
implementation is the only panacea for its effectiveness. This is the
major weakness of the Nigerian population policy.
Finally, it hardly needs stressing that the improvement of
the position and status of Nigerian women would have a positive-
feedback on family planning. It is now well-established that
improved female education, female participation in the modern
work force, and other' female empowerment indicators are
associated with the adoption of family planning. All these tend to
increase the: cost of childbearing and work or career aspiration,
and invariably redispose women to family planning. In such a
situation" fertility comes within the calculus of conscious choice,
and reduced fertility is seen as an advantage not only to the woman
but also to the couple and the family. Being a modern way of life,
it is hardly surprising that only women who have been sufficiently
exposed to modern lifestyle embrace family planning as a way of
life. From the experience of the developed countries and countries
that are recently completing their demographic transition, it is only
when family planning is accepted as a way of life that it becomes
sufficient in bringing fertility to- a low level nationally. This
another reason why government development efforts should
deliberately target women for status enhancement.
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REFERENCES
Berelson, Bernard, 1975.The Great Debate on Population Policy:
.\n Instructive Entertainment. An Occasional Paper of the
Population Council,
New York.
Bongaarts, John, 1978. 'A framework for analyzing the proximate
determinants of fertility, Population 'and Development
Review, 4 (1): 105 - 132.
Bongaarts, John Odile Frank & Ron Lesthaeghe, 1984. 'The
proximate determinants of fertility in sub-Saharan Africa,
Population and Development Review 10 (3): 511 - 537.
Davis, Kingsley. 1967, 'Population Policy: Will current programs
succeed?' Science, 158: 730 - 739.
Donalson, P. & Amy O. Tsui, 1990. The International Family
Planning Movement. Population Bulletin, vol. 45. No.3,
Washington, DC: Population Reference Bureau, Inc.
Federal Office of Statistics (FOS), 1992. Nigeria Demographic and
Health. Survey 1990. Columbia, Maryland: IRD/Macro
International, Inc.
Federal Republic of Nigerian (FRN), 1962. First National
Development Plan, 1962 - 68. Lagos. Federal Ministry of
Information.
Federal Republic of Nigerian (FRN), 1970. Second National
Development Plan, 1970 - 74. Lagos: Federal Ministry of
Information.
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Federal Republic of Nigerian (FRN), 1975. Third National
Development Plan, 1975 - 80. Lagos. Federal Ministry of
Economic Development.
Federal Republic of Nigerian (FRN), 1981. Fourth National
Development rIan, 1981 - 85. Lagos. Federal Ministry of
National Planning.
Federal Republic of Nigerian (FRN) , 1988. National Policy on
Population for Development. Unity and Self-Reliance.
Lagos: Federal Ministry of Health.
Gallen, M. E., 1986, 'Men - New focus for Family Planning
Programmes. Population Reports. Series J(33). Baltimore:
Population Information Program, The John Hopkins
Un ivers ity .
Isiugo-Abanihe, Uche, C. 1979. 'Population Policy of Lack of it:
The Case of Nigeria. Seminar Paper Series, Population
Studies Centre, University of Pennsylvania, Philadelphia.
Isiugo-Abanihe, Uche, C. 1991 'Promoting small family norms:
Reaching out to Nigerian Men, in Population Information,
Education and Communication. Proceeding No.8, pp. 178
-190,. Population of Nigeria.
Isiugo-Abanihe, Uche, C. 1992. 'First-time family acceptors in
Nigeria: Their characteristics, motivation and awareness of
the National Policy on Population, 'Nigeria Journal of
Sociology, 2 (1): 32 - 49.
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Isiugo-Abanihe, Uche, C. 1994a. 'Demographic transition in the
context of Africa's development, in UIF Himmelstrand, K.
Kinyanju & E. Mburugu (eds.), African Perspectives on
Development. pp. 61 - 73. Londori: James Currey.
Isiugo-Abanihe, Uche, C. 1994b. 'Reproductive motivation and
family-size preferences among Nigerian men, 'Studies in
Family Planning, ,25 (3): 149 - 161.
Lapham, R. & W. P. Maudlin, 1987. 'The effects of family
planning on fertility Research findings,' in R. Lapham &
Simmons (ed s.), Organizing Effective Family Planning
Programs. Washington, DC.: National Academy press.
Maudlin, Parker & B. Berelson, 1978, 'Conditions of fertility
decline in developing countries, Studies in Family
Planning, 9 (5) 90 - 147.
National Population Bureau (NPB). 1984. The Nigeria Fertility
Survey 1981 - 82. Principal Report, Vol. 1 WFS,
International Statistical Institute.
Olusanya, P.O., 1989. 'Evolution and status of family planning
. in Nigeria'. In Development in Family Planning Policies
and Programmes in Africa, pp. 408 - 450: Regional
Institute for Population Studies. /
Planned Parenthood Federation of Nigeria (PPFN), 1988. Profile
-r of Planned Parenthood Federation of Nigeria. Lagos:
PPFN.
Population Institute, 1984, 'Nigeria's leader calls for National
Population Policy Popline, Vol. 6 No. 12. Washington,
DC: Population Institute.
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Van de Walle, E. & J. Knodel, 1980, 'Europe's fertility transition:
New evidence and lessons for today's developing world'.
Population Bulletin, 34 (6). Washington, DC.: PRB.
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Chapter Eight
ORGANIZATION AND MANAGEMENT OF
HEALTHCARE SERVICES AND FACn.ITIES
, 'Austin, Isamah
Department of Sociology
University of Ibadan
Ibadan.
INTRODUCTION
The World Health Organization's long standing definition
of health as "a complete state of physical, social and mental well
being, not merely the absence of disease or mfirmity" represents
an ideal state towards which all human societies strive to achieve
for their members. This is borne out of the rather aacient
realization that only healthy people can fulfil their various
obligations to society and in the process ensure its survival and
development. In the pursuit. of this goal, each society. or more
comprehensively, each culture, no matter its level of development,
evolves a healthcare system best suited to its own peculiar
circumstances and environment. With this emergem medical
system. The society tries to bring about a high status of healthcare
for its members.
Thus in all parts of the world, various kinds of healthcare
system evolved, these are known in many developing countries as
the traditional healthcare system. Pearce (1986) characterized the
traditional medical system as found in Nigeria thus:
It was a decentralized system in which community-
based practitioners served clients from their
compounds or the patients' homes. Easy access to
the healers was one of its main assets. A variety of
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pracnnoners competed for clients including
herbalists, diviners, bone setters, psychiatrists,
soothsayers and birth attendants.
The point to note here is that this traditional system of
healthcare was (and still is) quite adequate and relatively efficient
for its millions of patrons for centuries hence its persistence to the
present in large parts of the world.
However, although each culture evolved its own concepts
of physical health and illness as has been stated above, much of
what is now recognized as medicine derives from developments in
western society over the past two or three centuries (Giddens,
1989) from where it spread to almost all parts-of the world. The
consequence of this is that in Nigeria today, as in other sub-
saharan African countries. There exists a dualism in the healthcare
system, a situation where the traditional medical system exists side
by side with the modern medical system, with the modern system
however, being relatively dominant.
Perhaps the most important features of this modern
healthcare system is that it is highly centralized and organized. It
is an understanding of the manner in which the services and
facilities of the modern healthcare system are organized and
managed which forms the main interest of this chapter.
THE ORGANIZATIONAL IMPERATIVE
One major factor which had a great impact on, among other
things, the evolution of modern healthcare, is the emergence of'
large scale organization within which most of human activities now
take place. Although organizations are not in the real sense of it
modern intention - for instance, the Pharaohs used them to build
the pyramids - it is in contemporary society that they have
assumed an aI-pervasive nature. As Etzioni (1964) puts it:
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Modern civilization depends largely on organization
as the most rational and efficient form of social
grouping known. By coordinating a large number of
human actions. The organization creates a powerful
social tool. It combines its personnel with its
resources, weaving together leaders, experts,
workers, machines and raw materials. At the same
time, it continually evaluates how well it is
performing and tries to adjust itself accordingly in
order to achieve its goals.
Due to its vital importance to social life in modern society,
it is not surprising that organizations have become subject of great
interest to scholars. Similarly, attempts at defining what is meant
by organization are as numerous just as perspectives of analyzing
it are several. Thus Barnard (1938) defines organization as "a
system of consciously coordinated activities or forces of two or
more persons". Parsons (1960), on the other hand sees it as "a
social unit (or human grouping) deliberately constructed and
reconstructed to seek specific goals". Wh ile these and several other
definitions have contributed immensely to our understanding of the
workings of organizations, for present purposes Lawrence and
Lorsch's (1967) definition is considered as most suitable.
According to them, an organization is a system of interrelated
behaviours of people who are performing a task that has been
emphasis into several distinct sub-systems, each sub-system
performing portion of the task, and the efforts of each being
emphasis to achieve effective performance of the system.
(emphasis added).
Two. concepts are crucial to this definition - differentiation
and integration. "Differentiation" is defined as "the state of
segmentation of the organization system into sub-systems each of
which tend to develop particular attributes in relation to the
requirements posed by its relevant external environment". On the
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other hand, "integration" is seen as "the process of achieving unity
in effort among the various sub-systems in the accomplishment of
the organization's task"
This definition is particularly useful for present purposes
because it enables us to view ar organization, for example, a
healthcare facility, as a unit or a whole made up of several units
of departments all of which contribute in one way to the other to
the achievement of the organization's goals or objectives. In this
instance the curing or taking care of sick people. Thus the
coordination of the activities of the various units constitutes
perhaps the most important management function.
Finally healthcare facilities, just as other types of
organizations. Share certain common characteristics, which most
importantly distinguished them from other forms of social grouping
such as the family or friendship clique. These characteristics
include:
(i) division of labour, power and communication
responsibilities, divisions which are not random or
traditionally patterned, but deliberately planned to enhance
the realization of specific goals:
(ii) the presence of one or more power centres which control
the concerted efforts of the organization and direct them
toward its goals; these power centres also must review
continuously the organization's performance and re-pattern
its structure, where necessary to increase its efficiency:
(iii) substitution of personnel i.e., unsatisfactory persons can be
removed and others assigned their tasks. The organization
can also recombine its personnel through transfer and
promotion (Etizioni 1964).
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Of particular importance for present purposes is the second
characteristic ego the present of one or more power centres from
where the various activities of the organization are controlled and
coordinated. This characteristics simply points to the fact that each
organization must be if it is to attain its goals or objectives.
Management is defined here after Kohn (1977) as "a process that
consists of planning,' organizing, activating and controlling the
resources (personnel and capital) of an organization so they are
used to the best advantage in achieving the objectives of the
organization" .
Although a complex activity, management is the important
variable which makes the difference between an organization which
achieves its objectives and that which does not. Thus a well-
managed organization is that which is able to use available
resources, both manpower and equipment, to achieve it goals
efficiently and effectively. On the contrary, the poorly managed
organization is that which no matter the resources available to it,
is not able to produce optimally and is thus unable to provide. For
instance, adequate services for its clients. In the final analysis
therefore, the point being made is that every organization requires
an administrative structure to enable it arrange its resources
economically and control-deviant behaviour.
HEALTHCARE SERVICES AND FACILITIES IN NIGERIA
Having made the point that modern society is an
organizational society in which most of human social life., -
including healthcare, takes place in organizations which possess
more or less determinable characteristics or features, it is
important at this juncture to examine the various forms which
modern healthcare facilities have assumed in Nigeria. This would
serve as an important prelude too an understanding of their internal
structure and functioning.
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Health care facilities, according to Okafor (1987),
constitute the most tangible features of healthcare delivery systems
and their provision constitutes society's most obvious response and
investment in health. In this connection, there can be no doubt that
Nigeria has expended a great deal of resources in the establishment
of such facilities although the social and economic returned on
such investment in terms of efficiency and effectiveness of
healthcare services to the citizenry is another matter entirely.
As with other former colonial territories, modern medicine
in Nigeria is a colonial legacy first introduced by medical
missionaries as early as the 1850s, Pearce (1982) points out the
colonial administration later converted this emergent medical
system into the colonial medical service, "a centralized system
under the authority of British medical officers" she argues further
that:
As with other acquired territories in East and West
Africa, the British initially developed the facilities
for the europeans serving abroad. Only lager was it
extended to indigenous government officials and
after 1952 to the general public. From the onset,
the new medical system was modelled after what
existed in Britain. It was thus organized around the
hospital which had since the industrial revolution in
the West become the specialized medical care
institution (emphasis added).
Since colonial times, therefore, the hospital has remained
the central pivot of the modern medical system in Nigeria. The
concept 'hospital' is used here in a generic sense to refer to several
types of establishments, of various sizes, in which both medical
practitioners of various types are brought together with modern
medical equipment for the sole purpose of attending to ill people.
Thus it is clear that hospitals are not of the same size or of
the same sophistication in terms of manpower and equipment. On
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the basis of this distinction, Onokerhoraye (1981) suggested that
in most parts of Nigeria, four different categories of healthcare
facilities may be distinguished.
The first categories comprise dispensaries, health centres,
maternity centres and health officers. The second category
comprise general hospitals and cottage hospitals. Thirdly, there are
the teaching and specialist hospital ... Finally there is the fourth
category of health centres which cannot fall within the hierarchy
discussed above. This category comprise specialized hospitals such
as dental clinics, mental health centres, leprosarium and
tuberculosis hospitals.
Okafor (1986) goes further by dividing these healthcare
facilities into two broad categories: lower-order and higher-order
healthcare facilities based largely on "their size, variety of services
offered, their range, threshold or similar considerations". In this
hierarchical system, the teaching hospital occupies the top position
while dispensaries occupy the bottom. According to him,
.... lower-order healthcare facilities handle routine
and in some cases very simple health problems that
do not require hospital care. As such they are
cheaper to provide and therefore more numerous
than hospitals.
On the other hand,
.... higher-order facilities offer services of their
respective orders as well as the services offered by
all lower-order facilities below them. Accordingly,
a teaching hospital such as the University College
Hospital Ibadan performs the functions of a
dispensary, a clinic, a maternity centre, a health
centre, a general hospital, a specialist hospital and
a teaching hospital.
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It is evident from the foregoing that there are several types
of healthcare facilities ill Nigeria offering all kinds of medical
services to the population although the point must be emphasized
that this medical system from inception to the present revolves
around the hospital.
Before going on to examine the internal structure and
functioning of a hospital, something needs to be said about the
Primary Health Care (PHC) system, which provides additional
healthcare services outside of the hospital although very much
integrated with it.
The PHC system was launched officially in Nigeria in
August 1986 as an entry point to the healthcare services aimed at
providing general heath services of preventive, curative, promotive
and rehabilitative nature to the population. Its importance lies in
its non-specialized nature, its easy accessibility coupled with its
resultant acceptability, sustainability, appropriateness and
affordability by the mass of the citizenry (FMH, 1988).
Thus the primary healthcare system together with order
healthcare facilities form a high centralized system of medical care
in Nigeria as Figure 1 below clearly illustrates.
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FIGURE 1 REFERRAL SYSTEM OF THE PHC SERVICE
TEACHING HOSPITAL
I
I
I
I
GENERAL HOSPITAL
I
I
I
COMPREHENSIVE HEALTH CENTRE
I
I
I
HEALTH CARE
I
I
I
MOBILE CLINIC MATERNITY CENTRE DISPENSARY
Source: Adapted from' PHC Unit, Abeokuta South LGA .. Ake, Ogun State.
Finally, the question of ownership of the healthcare
facilities also has some implications for the analysis being
undertaken here. Since privately owned healthcare facilities are
still comparatively smaller in number in most parts of the country,
much of the existing medical facilities tend to be government
owned and this, as will be show later in this chapter, has important
implications for the type of management structure that has emerged
in these facilities. Furthermore,ownership and management also
varies with the size and sophistication of the facility. Thus higher-
order facilities are owned and owned and managed by the Federal
government: the state governments managed the medium sized
facilities, such as the general or cottage hospitals, while the local
governments manages the lower-order facilities and the primary
healthcare system.
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The Hospital
As was state earl ier, the hospital is the quintessential modern
healthcare facility in Nigeria and therefore deserves closer
study. Hospitals belong to the larger class of service institutions of
the community along with such organizations as the fire
department, the police force and so on.Just as other serve
organizations,ttheyperform a vital service for the community and
as a consequence they have been subjects of intense study by
medical sociologists and other interested scholars especially in the
United states of America.
What has been noted numerous scholar however is that certain
features of the hospital makes it more efficient in providing
healthcare services than other types of facilities. These include the
fact that it houses in one place medical experts of various
I specialties and their increasingly sophisticated equipment which
enable them to undertake relatively precise diagnosis,treatment and
rehabilitative procedures. Two issues arise at this juncture: first,
what are the functions of the hospital, and second, what are the
main features of the management structure of the hospital in
Nigeria?
On the first issue, there are severai functions which have
been associated with the hospital. In this regard, Lentz (1968)
provides a very adequate characterization of the functions of the
hospital, interestingly within a historical framework:
The original function of the hospital ... was
custodial care of the dying poor. Curative care, as
contrasted to custodial care, became a second
function. Custodial care was relatively easy to
provide, but curative care requires highly trained
personnel. The education of such personnel became
the th ird function of the hospital. Once doctors were
the only recognized therapeutic agents. Today
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nurses, dietitians, social workers and a wide variety of technicians are
so required, and the hospital has become their school and laboratory.
Scientific research into the cause as well as the cure of diseases is still
a more recent addition to hospital functions. And finally ... preventive
medicine (has) placed upon hospital management the necessity of
allocating money, time and personnel to health education.
It is clear from both figure 2 and from the quotation above
that the functions of the hospital go beyond simply caring for the
sick. It includes in addition, research and educational functions,
however all of which are geared towards providing better and more
efficient healthcare services. The varied nature of its functions helps
account for the relative success of the hospital as a centre of
healthcare and its phenomenal growth all over the world.
However, given the diversity of its functions, the hospital
cannot but be. a very complex organization indeed. Its complexity is
further heightened in that it combines an administrative structure wit
the therapeutic structure and each of these structures possesses its
OWh priorities and personnel. The figure below gives in indication of
the configuration of a typical hospital.
Figure 2 A Typical Health Manpower Pyramid
Leader of the team
Patient-centred
Personnel
achnicians Laboratory-
entred
Medical Laboratory Personnel
Biochemists
Anatomists Research and
Nutritionists Teaching Person-
nel
Sociologists
Neurologists
Source:Adapted fromM. Smith and D. Knapp, Pharmacy,Drugs andMedical
Care,Baltimore.TheWilliamandWJ.lkinsce., 1972,
p.209.
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FIGURE 3: ORGANIZATIONAL CHART OF A TYPICAL
HOSPITAL
Medical Director
. I . I
Director of Director of C~ef C~ef
Admin. Nurses Pharmacists Technologist
I II I IAcc6untants Personnel Matron Pharmacists Technologists
I I I I
Accounts Security Nurses Laboratory
Clerks Officers Assistants
Thus the first important management feature of the hospital as
can be seen from the abbreviated organizational chart shown above in
figure 3 is that to a very considerable extent, it possesses the character-
istics of a bureaucracy. A cursory look at most hospitals in Nigeria will
show that-they possess a bureaucratic type of administrative structure.
By bureaucracy here is meant the type of administrative structure first
identified by Max Weber (1947) and which has the following distin-
guishing characteristics:
1. Specialization: The work of individuals and departments is
broken down into distinct, routine and well defined tasks.
2. Fonnalization: Formal rules and procedures are followed to
standardize and control the actions ofthe organization's members.
3. Clear hierarchy: A multi-level 'pyramid of authority' clearly
defines how each level supervises the other.
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4. Promotion by merit: The selection and promotion of staff
are based on public criteria (e.g. qualification or proven
competence) rather than on the unexplained preference of
supenors.
5. Impersonal rewards and sanctions. Rewards and
disciplinary procedures are applied impersonally and by
standardized procedures.
6. Career tenure: Job holders are assured of a job as long as
they commit themselves to the organization.
7. Separation of careers and private lives: People are
expected to arrange their personal lives so as not to
interfere with their activities on behalf of the organization
(Handy, 1985).
These ideal type principles define a system of
administrative structure which exists in most fairly large and
complex organizations irrespective of the goals they were set up to
achieve. Weber believed that the bureaucratic type of
administration was by far the bureaucratic type of administration
was by far the most efficient compared with other types of
administrative structures. According to him.
Experience tends universally to show that the purely
bureaucratic type of administrative organization - i.e
the monocrotic variety of bureaucracy - is, from a
purely technical point of view, capable of attaining
the highest degree of efficiency and is in this sense
formally the most rational known means of carrying
out imperative control over human beings. It is
superior to any other form in precision, in stability,
in the stringency of its discipline, and in its
reliability.
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Many scholars have of course disagreed with Weber about
bureaucracy being perhaps the most efficient way of achieving
organizational goals (see for instance, Merton, 1952: Schaffer,
1967). However, the reality on the ground is that when an
organization attains a certain size and complexity, it develops the
characteristic of a bureaucracy.
Thus, in the hospital organization, a great deal of division
of labour and delegation of authority occurs between the various
levels of officials and between the various functional units. The
Chief Medical Director of a teaching hospital for instance, is
responsible for both the administrative and therapeutic activities of
the hospital. However, while he or she exercises leadership in both
interdependent areas of responsibilities, it is obvious that he
cannot carry out all the duties involves alone. So he/she must
delegate power to the Head of Administration to exercise control
over such duties as recruitment, staff welfare, remuneration,
procurement of materials etc. Similarly, delegation of authority
also takes place between the medical director and the Head of
Nursing Staff, and so on. In the final analysis the primary duty of
the medical director therefore is mainly coordinative, bringing
together the various contributions of other people towards
achieving the stated goals of the hospital.
On the other hand, for most members of staff, whether
medical, para-medical or administrative, their job constitutes a
career for wh ich they are paid a fixed salary and ar entitled to
pension on retirement. They expect to be promoted at fairly
regular intervals and expect to obtain some job satisfaction from
their jobs based mainly on expected enlightened management
practices on the part of the hospital's administration. Finally, they
are subject to control via established disciplinary procedures in the
performance of their jobs. All these are features of a bureaucratic
form of administration and are present in all hospitals in Nigeria
to one degree or the other.
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Another important feature of the hospital is that the
multiplicity of skills and professions represented there has been a
source of great conflict. This conflict is perhaps exemplified by
that. between nurses and doctors, a conflict which often takes the
form of a power struggle between these two groups of
professionals over control of the work process. The origin of this
particular conflict in Nigeria dates to the colonial era when doctors
enjoyed a very high status, in fact next in status to the regional
governor, according to Alubo (1995). Alubo maintains that during
this period, doctors earned higher salaries than other civil servants,
'an advantage they maintained until recently'.
For a large part of the post-independent years, doctors have
struggled to maintain their privileges and status vis-a-vis other non-
physician medical workers. The struggle has also extended to the
maintenance of the dominance of medical practitioners over the
political leadership not only of the Federal Ministry of Health but
also at the level of the states as well. As the Nigerian Medical
Association (NMA) argued on one occasion:
Since only doctors received training in the art of
patient care, the appointment of paramedical
professionals, pharmacists included, as head- of the
health team would amount to enthronement of
mediocrity . . . it would be absurd to appoint a
person who was not a lawyer as an Attorney
General, just as it would be if a professional, other
than a medical doctor assumed the secretaryship of
the Health Ministry (quoted from Alubo, 1995).
While doctors no doubt deserve very high status and
rewards for their relatively rare skills and contributions to the
maintenance of the health of the society, modernization and the
technology revolution have however led to the professionalization
of other health related occupations with the consequence that these
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other professionals now increasingly question the preeminence of
doctors in the health team. Experience however shows that this
conflict is rather needless as any of the professionals can provide
effective and efficient leadership in the pursuit of health related
goals.
Thus nurses, for instance, who spend the greater amount of
time weight the patients and thus bear the greater burden of patient
care often resent the greater degree of authority traditionally
granted doctors. The conflict, although often muted, is greater
where the doctor is younger and thus considered as less
experienced by the nurses who have to work with him/her and take
orders from him/her. Issues of deferential pay and fringe benefit
between doctors and nurses are also sources of conflict and have
actually led to strike action in the past.
As Shepard (1961) saw this inter-professional conflict,
differences in orientations create points of tension and conflict.
Often the tension and conflict remain latent and is expressed
largely by isolation and in feel ings and expressions of such things
as pride and superiority. Sometimes, however, the tension and
conflict become manifest and create a barrier to cooperation.
Similarly, but arguing from a broader American
perspective, Hall (1951) saw the struggle between the various
specialists employed in the hospital as a 'struggle for prestige'
which extends beyond the boundaries of the hospital. In his words,
the various specialists are sensitive regarding the
invidious evaluation of their respective specialties.
The struggle extends beyond the hospital, in so far "
as there exists a public which is sensitive to medical
prestige and its symbols.
At this societal level, the struggle is waged by the various
professional associations who acting as interest groups seek to
influence public policy in favour of their own members and
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preferable at the expense of other groups. The continuing attempt
by the Nigerian Medical Association to exclude other professionals
from leadership positions in health institutions and in the sector as
a whole has already been alluded to above. Experience shows
however that this conflict could be (and sometimes actually is) a
serious problem indeed in Nigerian hospitals with each
professional group asserting, its superiority over other and thus
making cooperation in patient care difficult if not impossible.
Finally, having argued that the hospital is a bureaucratic
organization, an important question that arises then is, does the
bureaucratic structure enhance the efficiency of Nigerian hospitals?
The answer is obviously to the negative. The fact of the matter is
that over the years, the performance of Nigerian hospitals has
deteriorated and a large number of reasons have been advance to
explain the prevailing state of affairs, including lack of funds ..
absolute equipment. Low morale of staff, etc. What is clear
however, is that for more efficient services, the conditions under
which the various people work must be improved and adequate and
up-to-date equipment provided. Perhaps of greater importance is
that the bureaucratic structure will need to be modified to give
greater autonomy to the various units and allow greater use of
initiative on the part of staff. This will reduce to a very great
extent much of the conflict that a present afflict many of the bigger
hospitals.
CONCLUSION
This chapter has examined the manner in which healthcare
services and facilities are organized and managed in Nigeria. The
fundamental basis of the analysis is that health is central to societal
well being and has important implications for individual
productivity and hence societal social and economic development
Various types of healthcare facilities exist in Nigeria, conveniently
divided into lower - and higher - order facilitates. What is however
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important is that in Nigeria, the modern medical system is hospital
based. Such hospitals, owing partly to government ownership of
most of them and their sizes, are bureaucratic organizations
exhibiting the various features of typical bureaucracies as first
articulated by Max Weber.
The evidence on the ground shows that for a number of
reasons public establishments, including hospitals, have usually
performed below expectation. Perhaps the solution lies in the
loosening of the bureaucratic structure in favour of more organic
administrative structures which wold allow for more individual and
group autonomy in pursuit of organizational goals. In such an
administrative structure ... now relatively common in many private
sector organizations in Nigeria, centralization and standardization
are greatly reduced and more attention is paid to the building of
work teams to whom high targets are set. The corollary of course
is that the requisite equipment and motivational provisions are
made available so that high performance can be achieved and
sustained.
REFERENCES
Alubo, O. (1995) Medical Professionalism and State Power in
Nigeria, los, Centre for Development Studies.
Barnard, C. I. (1938) The functions of the Executive, Harvard
University Press.
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Engels, G. V. (1969) The effect of bureaucracy on the professional
autonomy of the physician, Journal of Health and Social
Behaviour" 10 pp. 30 - 41.
Etizioni A (1964) Modern Organizations, New Jersey, Prentice
Hall.
Federal Ministry of Health (1988) The National Health Policy
and Strategy to achieve Health for aUNigerians, Lagos,
Federal Government Printer.
Giddens, A (1989) Sociology, London, Polity Press.
Hall, O. (1951) Sociology research in the field of medicine:
progress and prospects, American Sociological Review 16.
Handy C (1985) Understanding Organizations,
Hammondworth. ,Penguin.
Kohn, M (1977) Dynamic Managing: Principles, Processes and
Practice, California, Cummings.
Lawrence, P and 1. Lorsch (1967) Differentiation and integration
in complex organizations, Administrative Science
Quarterly. 12.
Lentz, E. M. (1968) Hospital administration: one of the specie,
Administrative Science Quarterly, 1 pp. 444 - 463.
Merton, R. K (1952) Bureaucratic structure and personality, in R.
K. Merton et at. (eds) Reader in Bureaucracy, New
York, Free Press.
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Okafor, S. I (1986) Inequalities in the distribution of healthcare
facilities in Nigeria. in R. Akhtar (ed) Health and Disease
in Tropical Africa. London, Gordon and Breach, pp. 383 -
401.
Onokerhoraye, A. G (1981) Public Services in Nigerian Urban
Areas, NISER.
Parsons T. (1960) Structure and Process in Modern Societies,
Glencoe, III. The Free press.
Pearce, T. (1982) Medical systems in the Nigerian Society, in L.
Erinoso (ed) Nigerian Perspectives on Medical Sociology,
13, Studies in Third World Societies, USA.
Pearce, T (1986) Social change and the modernization of the
medical sector, in S. Afonja and T. Pearce (eds) Social
Change in Nigeria. Longmans.
Schaffer, B (1987) The deadlock in development administration,
in C. Leys (ed) Politics and Change in Developing
Countries. Cambridge University Press.
Shepherd, C.R. (1961)Orientations of scientists and engineers
Pacific Sociological Review, 6, pp. 79 -83.
Weber M. (1947). The Theory of Social and Economic
Organization, (Translated by A. M. Henderson and T.
Parsons). Oxford University Press.
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Chapter Nine
PROFESSIONS, HIERARCHY AND MANAGEMENT
WITIDN THE HEALTH COMMUNITY: A DOCTOR'S
VIEW
M. C. Asuzu,
Department of Preventive and Social Medicine,
College of Medicine, University of Ibadan,
Ibadan.
INTRODUCTION:
There has ben more development in the world in the last
hundred years alone than in the thousands of years before this time
all pur together. This development has ben largely in the areas of
science and technology. Of necessity, this growth must put stress
on the way that society is organized and functions. These stresses
are found in virtually every ramification of life - the value
systems, the morals, the religion, the family (structure and
function), of politics (and of leadership and participation in it), etc.
The health services organization and functions cannot be
exceptions. to this. In order for the health services to continue to
function efficiently, it is important for the people involved in
1 leadership at all levels of such an industry to understand the nature
of these developments. They also need to understand the direction
of the pressures that such developments bring about. In that
way, they can work to tandem with such development, allowing
true development to take place but without allowing it to do
fundamental damage to the system itself, or to the other structures
and functions.
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The nature and development of medicine and the medical and
health industry
In its historical development, medical practice was a very
personalized service that its practitioners gave to ill people. At its
beginning, there would seem to have been little science to it. It
was mostly an art, mixed with religious ministration. Hippocrates
was to change all that in the 4th century before Christ. But even
until the industrial revolution, the developing scientific medical
practice remained an individualized service rendered to people
either in the physician's home or at the home of the client. All the
nursing care needed by the patient was provided by his family.
Even though temples were reportedly used as centres for medical
training, and -sometimes used as a refuge for the sick and infirm,
they did not perform the same function Iike those of modern
hospitals.
Hospitals as the standard place of care of acutely ill people
away from their homes developed during the middle ages and for
a long time still functioned as a refuge for the sick and homeless,
and for the dying poor. Medical practice continued as a service
which doctors gave to patients who wilfully subjected themselves
to their professional knowledge and skills concerning health and
disease. They did for the patients things which were by far outside
of the knowledge and skill competence of the patient. Because
medicine dealt with grave issues of life and death, the drugs and
other interventions that can affect these gravely, even if one were
a doctor himself, ethics make it unacceptable for him to practice
his medicine on himself, or to people of very close (1st degree)
relationship with him. This has continued to be the nature of
medicine and medical practice as a profession.
Within just a little over a century of the recent rapid
developments, medical knowledge and skills have expanded so
greatly that it is no longer possible for anybody to acquire and
exercise all the medical skills and knowledge by himself alone.
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Fields of the curing practices such as surgery and dentistry (which
were not allowed for medical practitioners by the Hippocratic
codes) have also become admitted into the expanded professional
understanding of medicine and of its practice. This has largely
been so because of the reduction of the brutality seemingly
involved in these later practices through the science of
anesthesiology. Dentistry however, unlike surgery, has managed
to maintain a relative distinction from medicine as newly
developed: even though ethically and organizationally, it has
virtually remained inseparably bound together with medicine. For
this reason, persons can enter dentistry as a primary profession
from the start, and nota s a post-graduate specialization in
medicine'.
The rest of the newly expanded medical profession has
however developed several specialties for its post-graduate
practice, both of broad areas such as medicine, paediatrics and
general surgery, as well as of narrower specialties such as
ophthalmology or even cardiology, etc. What all these have meant
is that the former overwhelming authority that doctors wielded
while they had-sole charge to treat all of the patients illness in the
past, has now to be shared among this growing number of medical
care givers. The line of authority over the patients care has
become more diffuse in the big or especially specialist hospital
settings. This phenomenal growth in medical practice in terms of
the diversified areas of knowledge, of technology and of people
involved (even in a single patient's care) has resulted in the
situation in which medical care is to dy referred to as an industry.
The medically-allied professions; their development, nature and
relationships
Just as medicine in its later scientific and technological
development has resulted in its incorporation of surgery, the
development of many postgraduate specialty areas and the closer
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al igning with dentistry, it has also dropped some practices which
were earl ier thought to be part of medicine as a single profession.
Some other professional practice areas have also developed, either
independent but aligned to medicine or out of what doctors could
naturally incorporate with their practices but usually would not,
because of the large areas of knowledge and practices more in the
heart of the profession which they would need to stick to. Thus
pharmacy developed as a profession of its own out of apothecary,
previously considered an inferior aspect of medicine. Nursing
developed from the need to takeover the care that the family would
normally have provided for the patient were he to have been
treated at home. Its science and art ordinarily consist of things that
the patient should be otherwise able to do for himself. The
laboratory and other diagnostic and therapeutic science practice
areas also developed with the application of basic science to those
aspects of patient care beyond those strictly applicable at the clinic
examination couch for reaching a clinical/medical diagnosis and
direct medical or scheduled surgical intervention. These get passed
down as ancillary services to be rendered by others. In this later
group are physiotherapy, radiotherapy, laboratory sciences and
radiography.
Even though many of these disciplines have developed as
full professions, physicians in their undergraduate training are
required to train in all the basic sciences as applied to all these
areas of practice, as well as some degree of the services provided
by these service areas. At the postgraduate level, doctors may still
specialize in the whole or aspects of these disciplines, except
dentistry, pharmacy, physiotherapy and nursing which have
remained fully not entered for post-graduate specialization by
doctors. Thus doctors may specialize in clinical pharmacology, the
laboratory sciences, radio-diagnostics and therapeutics. The
common factor in all these disciplines outside of medicine,
dentistry and midwifery is that patients usually ethically, do not
attend health care primarily to see their practitioners. Their need
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is subsequently determined by the doctor or dentist. Midwifery
itself (like its related nursing profession, as dentistry is to
medicine) concerns the determination of the normalcy of a
pregnancy and the monitoring and supervision of same for any
serious departures from the normal: so that if it remains normal,
a simple natural delivery may be allowed to take place without
medical intervention. The aspect of midwifery that implies
abnormal pregnancy and interventional manage and delivery has
become incorporated into medicine as obstetrics. Hence, even
though midwifery has remained a distinct profession form
medicine, it would require a functional link with an obstetric
health care system to take over any abnormal pregnancy
managements identified by it. Nursing however has remained not
practicable independently, except in the case of old people with no
relatives willing to take adequate care of them; and who may then
make use of old peoples/nursing homes.
The impact of the recent developments on integrated medical
care
The impact of all the above developments on medical care
has been what has been called "the fragmentation of the medical
care" by some people. Within the medical profession itself, it has
given rise to repeated calls for the development of a coordinating
specialty practice area so as to curtail these negative effects. This
specialty is to maintain the singly controlled care for individual
patients by the medical practitioner as was the case of old. This
specialty has been called general medical practice in some
countries and primary medical care or family medicine in others.
It is reckoned that if individual patients entered the medical
services through one such general practitioner, or family
physician, the latter will have the responsibility of looking after
that patients total care.
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He will help him avail any other specialized care which he
may stand in need of since he has basic professional knowledge of
those. This will avoid the fragmentation of service and physician
allegiance of the patient that may otherwise arise in the care if he
were to seek it entirely all by himself. In this situation, the patient
maintains his health are trust to the family physician while all
other care givers literally function as technical experts to provide
these needed services.
The basic nature of professions
Professions have been described in management and social
science circles to be areas of service involvement characterized by
at least three attributes: firstly, a profession has an existing body
of knowledge which has developed over the years from established'
principles. Secondly, professions have definite standards of
performance in their job which gives them a unique status in the
community and prevents charlatans from finding easy access into
such a profession. Such standards of profession performance
allows the cl ients to repose some levels of confidence on such
professionals. Finally, professions are governed by a strict code of
ethics which protect the professionals and their clients from the
abuse of the practice: as well as indeed, the society at large.
Usually, members of given professions bind themselves into
guilds or associations which help them to pursue and maintain the
professional attributes mentioned above. In addition, professions
are able to demarcate practices and privileges which belong to that
profession, especially in areas in which they share served
relationship with other professions or technical services. The
professions differ from what are called the arts and trades in
several ways. This includes the fact that the professional
associations are not trade unions and do not identify with them as
such. Unlike professional associations which concern themselves
mainly with the ethics of their profession, the maintenance of high
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standards of practice, the regulating and standardization of
training, research to improve and further develop the professions
knowledge base, trade unions are concerned primarily with the
creation of cartels, or bargaining with employers for better pay and
conditions of service. The arts and trades in human life really
constitute ancillary service enterprises; and in the area of science
and technology, the term technicians or technologists have ben
applied to people who give those services in relation to the main
professional disciplines in such areas of their services - e.g.
engineering technologists, legal draughts-men, medical laboratory,
technicians and technologist and X-ray technicians.
Medicine and the health services
It is important to draw a line between medicine and medical
practice on the one hand and healthand the health services on the
other. While medicine and its medically aligned disciplines concern
primarily the care of sick people, health concerns the whole areas
involved in being well maintaining it.
Preventive medicine is the aspect of medicine that delves
into the whole domain of heath and well-being principally. Thus,
while all the aligned medical disciplines in their preventive
practices also can get involved with health, there are more
professional and technical services involved in health than the strict
medical and allied professions: food and nutrition, education and
training, public works and environmental sciences, good societal
organization and employment/labour etc.
Hence while the hospital is a medical institution and the
medical and medically aligned professions are easily recognized in
it, in the area of health, other workers not easily recognized as
medical or health workers are very important in it as well. Nobody
interested in or properly trained in preventive/community medicine
and/or health can really under-rate such people. However, since
medicine constitutes the important ingredient in the pursuit 01
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health, it continues to be the focal point when health IS being
considered.
Hierarchy and the medical industry
Since medicine grew beyond the point when one man can
provide all the services possible to get from it into a complex
industry, it has developed a need for a bureaucracy to be able to
run its services. professional management skills are needed in
order to be able to run the medical or health industry than is
needed in the simple/solo medical practices of old. Attempts to
develop professional managers in the full sense of the word (other
than physicians) to run hospitals and other health services have
however not managed to work; for without technical medical
knowledge, such so-called managers may only function as
administrators, with skills in human and resources management
only, but no technical or only limited knowledge, or skills to really
be able to function as real managers. Thus, large/public hospitals
with corporate management and professional administration but no
official medical directors have functioned largely as acephalus
organizations. Corporate management may determine the policies,
budget, remunerations etc. but the doctor at once takes up the
functional headship when it comes to the actual function of the
hospital in individual patient management, even it no doctor is
officially designated to be responsible for this at the top. level of
management. The services of the other professionals therein at
once become ancillary only. The creating of hospital hierarchy of
staff, of course, occurs for each profession in its designated
service area as they each contribute to patient care.
Health Management
Health Management has become very important as medical
practice developed into an industry. It is recognized that three
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areas of knowledge and skills are needed for anybody to perform manage-
ment functions; namely technical, human management and conceptual
skills.
Below is a schematic illustration of the compilation of these skills
that is needed at the three different levels of management.
Fig. I: Proportion of management skills at the usual 3 levels of
management
finrtlevel~gement Middle level Top Level Management
(Ratio: 1:2) (Ratio 1.1: I) (Ratio 3:3:2)
.Conceptual skills Conceptual skills Conceptual skills
Human management skills Human management skills Human management skills
Technical skills Technical skills Technical skills
In the health field, more technical skills are needed at top level
management than on other fields of endeavour because of the life and
death issues involved. A1~0,concerning the functions actually performed
by management (Fig. 2 below), asPf.cts such as training, directing, supervi-
sion and coordination in the medical field would need someone who has
technical knowledge and skills in all the areas of practice involved, even at
the top management level. It is particularly in view of these issues, both in
the principles of management and the very nature of medical care and
patient expectation and allegiance, that it is not really possible-to create the
top management of a hospital or any health care system with a doctor
playing other than the top level leadership in it; otherwise such non-
physician will function not as a true top level manager but merely as an
administrator in a largely acephalous institution. This fact in no way denies
the importance of everybody in the medical or health team; but only
reflects its interest nature.
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Fig. 2: Structure of Management functions
...--__ - More Lmuted Functional Items
Situation Analysis (needs and resources
assessment
Policy setting
Objectives setting
Planning - Macroplanning and budgeting
Programme identification and planning
* Microplanning (obstacles identification,
strategy setting, fine budgeting etc.)
Organising
Staffing + *training
* Directing, ,. Supervising, *Monitoring & discipline
Implementaton - * Motivating, renumerating and *Coordinating
Administration
Evaluation (Re-planning, *on-going and
Evaluation - summit, including economic evaluation)
* Areas that need technical knowledge of the practices involved.
Problems of doctors in the leadership of the health team
From the nature of medical care as a service which patients sought in the hands
of doctor. the physicians have always presided ever all that it takes to give those services.
With the growth of medical field into a multi-disciplinary industry, doctors remain the only
professionals in the field of health care whose profession stipulates that they must be
trained in the basic science of all the fields that is required to give medical care. Even in
the broader area of health, physicians who enter the post-graduate discipline ofpublic
health medicine (preventive and social or community medicine etc: as it may be called in
various places), their discipline
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stipulates training in all the theoretical and practical areas of the
public health endeavour which will not be required of any other
public health practitioner. Because of these facts and the three skiU
areas needed for adequate health management, doctors have always
felt that even in public health and large corporate settings in which
medical care has become truly an industry, the medical doctor
should always be at the leadership of the team to avoid
unnecessary friction and blamable inadequacies. Patients have
always seen it these way as well. Other health workers have
naturally felt similarly until lately, the reason for this being the
secular humanist cultural one.
However, because doctors' undergraduate training do not
involve detailed training in management, much as doctors may
have inherent capacity for conceptual ization of the needs in the
health field as well as the needed technical skills, they often have
no skills in human or resources management. Also because of the
social role-modelling inherent in the profession, doctors grow up
expecting acceptance of their leadership of the health team without
question from the other members of the health team. Modern
secular humanist trends which encourage people to assert
themselves however they can (and so making human management
a more difficult thing) would indicate that doctors should have
more training in management at the undergraduate level so that
they are better able to give the needed leadership to the health
team. One of the important functions of management is motivation
of the subordinates, including due recognition of their importance
and a balanced effort at improving their remuneration and welfare
on the job. Leaders who do not do that will fail to merit leadership
, and would end up extracting it at great psychosocial cost to the
industry. Such problems however do not arise at private medical
practices where a medical bureaucracy does not exist.
Because human management is often more of a natural than
a learned skill, it is obvious that not all doctors who climb the
ladder of their profession in public enterprises can give it.
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Professionals in other health fields who reach the top of their
professional ladder and have natural human management skills may
wonder why they cannot step beyond that profession and manage
all of the medical industry since the intellectual needs of all the
professions require that they already have enough intelligence for
conceptual skills. Because of the social nature of medicine, it
would be obvious that they cannot do so unless they go and train
in all of that medicine. Itwould therefore seem to me that apart
form expanding the undergraduate medical training in human
management, and providing further postgraduate training for
doctors who later function in the areas requiring such skills, the
problem of discontent by other health workers concerning the
permanent leadership of the complete medical team by doctors is
something that we will have to live with until better understanding
by these workers takes care of it. No doctor would go to head a
purely pharmaceutical industry or service centre, a mere maternity
centre, a nursing home, an independent medical laboratorv or X-
ray centre. The professionals in those narrower or less technical
disciplines have to do so. If they affiliate their services to a
hospital, the doctor functions as a referral person or to visit such
places as an external consultant as may be requested. Why would
these other professional not leave a doctor to preside over the
medical centre/hospital which is his full professional centre? The
secular humanist culture that is spreading worldwide and
encouraging people not to accept any status-quo no matter the
obvious and valid fact or rational for it is the apparent reason for
the clamour for anybody to be able to allowed to do anything.
However, apart from the already recognized need to train doctors
in management at all levels of the profession, the other health
professions may also need to train in the sociological realities
which make it unreasonable to expert more th¥ such improvement
for the god leadership order in the medical and health team. .
Such training should encourage these professions to indeed
try to develop and define their professions so well that they would
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not try to confuse themselves with professional medicine itself, or
have medicine interfere in these professions unduly. For example,
midwifery as a supremely technical and exacting profession should
define itself as such. Even though it would need to have a place to
refer obstetrical acute medical cases to, when they arise, a
supervisory relationship with such an obstetric until will not be
mandatory for its functions as long as health centres do not need'
a supervisory relationship or even an existing secondary health
care centre to exist; nor such secondary centres a tertiary one,
even though it will be good to have those. To insist otherwise is
impractical. Similarly, while it is a medical decision that a
cardiovascular accident patient encountered at OPD or casualty
clinic requires hospital admission for their medical care, whether
that patient can actually be admitted to particular ward is a nursing
decision, based on the nursing staff strength, the equipments and
the nature of the other patients already admitted to that ward.
These are some of the issues that have not been professionally
studied and ethically refined and claimed by the nursing and
. midwifery professions. Instead, they are busy trying to practice
invasive therapeutics of patients that actually should belong to
medicine as in the IUD, ner plant and similar contraceptive
practices (if ethically admissible even in medicine itself). These are
obviously the result of the present secular-humanist-induced moral
and ethical weakness in the world and the medical profession.
Because pharmacy has refined itself in similar regards, a doctor
may determine that a patient should take a given drug for his
therapy. But ifhe writes an underdose or overdose of such a drug,
no matter how senior a doctor he may be, even a pupil pharmacist
can (should and usually do) refuse to dispense of the drug; call the
doctor to review the order, and only administer the drug when
appropriately dosed. This is the result of professional refinement.
Other health professions aligned medicine need to do likewise.
Even in the individual professions, they should mind the
growth of charlatans. If medical laboratory technologists for
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example develop themselves into a full profession as medical
laboratory scientists, and radiographers as such, they must ensure
that in establishing independent medical laboratories or X-ray
centres, medical laboratory technicians or X-ray technicians'do not
go ahead and establish such centres as well, just because they can
exercise some of the skills of such professionals. So also with the
case with so-called nurse-assistants and pharmacy technicians and
patent medicine dealers! These professions obviously have more
work to do on their own professions, their refining and leadership,
than struggling to become medical doctors by default, the dearth
of physicians in some disciplines and geographical areas
notwithstanding. The different professions, the patients and the
world at large would be better off with these more relevant
growths and developments.
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REFERENCES
Susser M. W. and Watson W. W (1975) Sociology in Medicine.
London. Oxford University Press.
Stoner J. A. F. and Wankel C.(l988} Management (Third
Edition). Prentice-Hall Inc. Englewood Cliffs NJ. USA
1988.
World Health Organization (1985). On being in charge. Geneva.
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Chapter Ten
PROFESSIONS, IlIERARCHY AND MANAGEMENT
WITHIN THE HEALTH COMMUNITY A NURSE'S VIEW
J. O. Aina
Department of Nursing, University of Ibadan,
Thadan.
INTRODUCTION
Man has been described as a social being whose life
involves a variety of social interactions. Some of these interactions
may be intimate, personal and persistent, others may be transient,
impersonal and intermittent. As a result of those interactions, man
continually manifests characteristics of a social being.
As' a social being, man belongs to a number of social groupings
such as race, society and community. Race is a biological term
which identifies man's physical traits. A society is usually defined
by territory and it is made up of people who share habits, ideas
and attitudes. A community is a smaller grouping of people within
the larger society who carryon among themselves some essential
activities.
On the basis of the above definition of community, one may talk
of the health community. The health community which has been
variably called the health care complex (Aina, 1986) or the
medical care complex (APHA, 1965) is made up of three distinct
components. Only one of these is the subject of this chapter.
In 1965, Myers talked of a medical care complex consisting of
three interrelated components. According to her, it was the
interactions and interrelationships among these components that
provide the structure Of the complex including its form and
functions. She went on to state that the boundary, scope and
direction of the complex are determined by and large by thevaried
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goals and expectations of each of the components.
The three identified components are the professional,
personal and the social. The professional component consists of
those who provide personal health care services. This is the subject
of this chapter. Included here are a variety of professional and
semi-professional people who provide diverse health care services.
This includes but not limited to physicians, dentists, nurse,
pharmacists, .physiotherapists and medical laboratory personnel.
These varied personnel are trained to render personal health
services. It should be noted that these various health care personnel
may have diverse and sometimes divergent goals an expectations
as a result of their different characteristics, background and
practice pattern. The common objective however is to provide
adequate health care to all those who need it.
The personal component comprises of people who need
health care services. These maybe individuals, families, groups B-
Orcommunities who at one time or the other will need the services
made available at the health care complex. These people will
arrive with various needs, values, goals and expectations of which
alleviating pain and suffering may be the greatest ones.
The social component is the organized arrangement, which
is a combined efforts of those needing health care services and
those providing them with the aim of achieving mutual goals.
Hospitals, clinics, dispensaries, community health centres and
maternity homes are some of the various organizations within the
society that perform certain functions designed to make health care
services available to people.
The goal of the health care complex is to promote, protect
and restore the health of individuals, families and communities and
to alleviate pain and suffering. Major functions in the health care
complex are organizing delivery of health services, financing
health services, regulating health services, developing and
allocating resources, planning and coordinating relationships.
, These functions although performed by the social component, must
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involve the other two component because of their interrelatedness.
In order to properly harness the resources of the complex, there is
a need to understand fully the structure of the complex.
Fig. I Structure of the Health Care Complex
The interactions among these three components take into
consideration specific goals, values and expectations of each of the
components. One of the major interactions is between the people
who need health care services and those whose duty it is to provide
these services.
The Professions
Social Scientists find it very difficult to agree on a common
definition of a profession and its characteristics despite the fact that
numerous studies have been and many books writing on the
subject. This is due to the complexity of the term. What
differentiates an occupation from a profession? Originally, there
were three professions - Clergy, Law and Medicine but as time
went on, other professions emerged.
A profession can be defined as an occupation for which
preliminary training is intellectual in nature and which involves
accumulation of theoretical knowledge and learning and not mere
acquisition of skill. We cannot overemphasize the importance of
professions in the health care industry. There is no other industry
with such a large number and an array of professionals at different
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levels of skills.
Many characteristics have been advanced for differentiating an
occupation from a profession. In a 1971 treatise, Palvako identified
the following characteristics that a given occupation must satisfy
before it can be accorded a professional status. The occupation
must:
1. Perform a unique, definite and essential social service.
2. Depend more on intellectual than' physical techniques in
performing its services.
3. Have long period of specialized training.
4. Possess a broad range of autonomy for individual practitioners
and the group.
5. Accept personal responsibility of its members
6. Emphasis public service rather than economic gain.
7. Have a clear and easily understood code of conduct to guide
members.
8. Possess a unique body of knowledge exclusive to its members.
9. Have an association to set and monitor standards.
Over the years, these characteristics have been modified
and redefined as more and more occupations become
professionalize. In recent years definition of a profession in the
United States has come from court decisions based on the
following four parameters:
1. A long period of training
2. A predominantly intellectual work that also varies in character.
3. Exercise of individual discretion in work performance.
4. The work can neither be standardized nor routinized.
There are several occupations in the health care industry.
Milio (1971) identified 125 different occupations with an additional
250 alternative job titles. Health care professionals have diverse
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goals and expectations because of their personal characteristics,
professional backgrounds and practise patterns.
They require different kinds of skills, have different kinds
of relationships with clients and their attitudes and methods are
influenced by their practice settings. In order to make sense out of
the many professional and occupational groups in health care they
can be classified in several ways. We may classify them as
professionals, semi-professionals or non-professionals. We may
also classify them according to task they perform.
Table 1: Health Care Team
A. PROFESSIONALS B. SEMI- C. NON-
PROFESSIONALS PROFESSIONAL
1 PHYSICIANS/SURGEONS PHYSIOTHERAPIST SOCIAL
WORKER
2 DENTISTS OCCUPATIONAL ADMINISTRATIO
N
3 NURSES RESPIRATOR Y MEDICAL
RECORDS
4 PHARMACISTS DIETICIANS TECHNICIANS
The above are some of the examples on each of the categories of
the health care team. As can be sen, the health care team is
multidisciplinary.
Table 2: Health Care Team According to Tasks
A. Those involved in diagnosis and therapeutics
Physicians (Medicine and Osteopathy
Optometrists and Opticians
Dentists
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Pharmacists
Occupational therapists
Physiotherapists
B.Those involved in care of dishabilitated
Nurses and Midwives
Auxiliary Nurses
Nursing Aids, Orderlies and Attendants
C.Those involved in Counselling and Education
Social workers
'.. Psychologists
Dietitians and Nutritionists
D.Those involved in Machine-related technologies
Bio-medical engineers
Laboratory workers (Technologists and Technicians)"
,X-ray, E. C. G., and E. E. G. technicians
E.1bose involved in management and interrelations
Administrators
Medical records
Finance workers (Accountants and Book keepers)
Source: Milio (1975).
The above table categorizes the health care workers
according to the tasks performed by each member of a particular
group. In the hospital, doctors and nurses are the two largest
professional groups. Most of doctors are males while most of the
nurses are females. This gender disparity has some influence on
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hierarchy and management in the health care complex.
Professional groups should have autonomy which is based
on the body of knowledge and a unique service to render to
society. This autonomy means that the profession is self-regulating.
This implies total control of its functions and practice. Since the
body of knowledge is specialized, then only those who possess that
knowledge are competent and qualified to decide on its practice.
IllERARCHY AND MANAGEMENT
Hierarchical relationship in the health care complex creates
management problems especially when certain groups insist on
permanent leadership of the community. The. Military-type
relationship which operates in most health institutions in Nigeria
is not conductive to professional practice.
It is not only inappropriate but also dangerous for those
who do not posses any competence in a particular field to make
judgement about how the knowledge in that field ought to be used.
A profession must have authority to control, manage, and direct
the practice of its members.
It is customary for professionals to advise, consult,
coordinate and collaborate with their colleagues in the same or
similar discipline, but responsibility and accountability for policy
and professional decisions and actions must reside with individual
members of the profession. Professional judgement requires the
use of specialized judgement which no one but members of that
profession possess.
Management has been described as a socio-technical
(Parsons, 1966) process that users resources, influences human
activities and facilitates changes in order to achieve a set goal. The
development of modern organizational management is credited to
such people as Taylor (Scientific Management), Fayol
(Administrative Management), Grant, Mary Parker Follet, Eton
Mayo, Carl Max and a host of others who pioneered theory and
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model development in the field of Management.
As pointed out earlier, the social component of the health
care complex represents the various organized arrangements
designed to bring health care to individuals, families and
communities. The hospital is the epitome of such an arrangement.
The hospital is a system made up of people with needs, goals,
expectations and it possesses specialized technology. It has certain
characteristics that differentiate it form other organizations
(Georgopoulos, 1972). .
As an organization, the hospital defines the roles of its
members which is constrained only by its own socio-technical
limitations places on it by societal demands. Hospitals usually
prescribe relationships which are task-relevant, impersonal and
authority-oriented and expect members to comply. There are
different cadres of workers operating at different levels of skills.
All these people with extremely different skills, diverse
backgrounds and different goals and expectations must be brought
together to achieve the main objective of the hospital professionals
(doctors dentist nurses and pharmacists) have strong demands for
personal independence in their work and they usually have an
aversion to organizational regimentation.
Although, these professionals seek progressive
independence in their work,' the hospital cannot function effectively
without a good deal of compliance with certain rules and
regulations by members of the professional groups. Sometimes,
some of these rules and regulations may be opposed to the tenets
(If a professional calling .. While seeking to run an effective
organization, the managers of hospitals must not allow the main
objective which is patient care to be compromised.
The .hospital as a living system should be capable of
problem-solving and self-regulating including that of resfructuring
itself without much loss to its identity and continuity fErnery and
Trust, 1960, Buckley, 19(8). In order, to be effective; the hospital
must pay attention to both human and material resources. Adequate
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functioning of the hospital depends upon the proper coordination
of the workforce, majority of whom are professionals.
. Effective functioning of the hospital depends upon its
paying attention to personal goal attainment, meaningful
participation' in: decision-making, getting individual members to .
identify with- the hospital, satisfying individual motives and
attainment of psychological rewards. The hospital must also deal
with problems of adaptation, allocation, coordination, integration,
strain, output and maintenance.
The present situation in the country in which Medicine has
assumed preeminence and has tried to keep other professional
groups out of management cannot fulfil the above requirements of
proper mana.gement. The best approach to health care should be'
that of team management. No particular professional group should
delude itself into believing that it has monopoly of knowledge of
health care. Each group has its contribution to make to health care.
The health care industry is a system and with all systems,
it consists of several components. One property of system is that
what affects one apart of affects the whole system. This has been
aptly demonstrated each time a section goes on strike or embarked
on work to rule, the other parts cannot function properly.
The functions of management are four folds:- Planning,
Organizing, Motivation and Controlling. One needs to study
management in order to become an effective and efficient
manager. The present system whereby one is made the manager of
a health institution simply because he belongs to a particular
profession has not worked well in this country. It IS about time
that changes in that system take place.
Management is a serious business. It is on the basis of.this,
that we suggest that management of our health institutions be
undertaken with all seriousness. The peculiarities of health
institutions earlier identified put some kind of pressure on
managers but with proper understanding and harnessing of all the
resources, the well trained and experienced manager can make a
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success of the endeavor.
Health care-providers should be able to, from time to time, '
define their goals, structure and functions. Each professional group
within the health care industry should be able to manage its own
affairs realizing that professional practice connotes a professional
relationship between the care providers and the care receiver.
The framework or relationships among members of an
organization is known as the structure. It is a logical interplay of
management levels and functional areas arranged in such a way
that allows the organization attain its objectives in an effective and
efficient manner. The structure of management in the health care
complex should reflect professional competence.
The head of the complex must have the ability to weave
together its various part in order to make them work together in an
effective and efficient manner. This individual would likely
perform better if he/she does not belong to any of the professional
group within the system. He must exercise power and authority in
a way that would not jeopardize the professional autonomy of each
professional group.
The management board of the health care complex must
have membership from all major professional groups within the
system and each group must have adequate representation in other
areas of management. The ultimate goal is to bring health care to
the people, so all must be involved in the planning and execution
of health care programmes. It is more likely to be successful if
everyone has a say in its plan and implementation.
CONCLUSION:
The health care complex is made up of people who need
health care, those who provide it and the organized arrangement
for providing it. The chapter has dealt mostly on those who
provide health care, and management of health care.
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There is need for cooperation and team work among the
various groups within the health care system. IUs this cooperation
that will allow for effective and efficient practice which will lead
to achievement of goals.
The goal of the health care complex is to provide health
care to those who need it irrespective of sex, age, and national
cngm.
REFERENCES
Aina, J. O. (1986) The professionalization of nursing: A challenge
to the leadership. New Era Nursin~ Ima~e International, 2:
2 60 - 62.
Aina, J. O. (1986). The role of leadership m achieving efficiency
and effectiveness in health care delivery. Proceedin~s of
the National Workshop on economic Use of Man and
Material in Health Care Industry Ibadan, Department of
Nursing.
American Public Health Association (1965). A guide to Medical
care administration. Vol. 1. Concepts and Principles.
Author.
Buckley, W. (1968) Modern systems research for the behavioural
scientists. Chicago. Aldine.
Drucker, P (1973) Management. New York, Harper and Row.
Emery, F.E. and Trist, E. L (1960). Socio-Technical Systems in
Management Sciences Models and Techniques, Vol. 2,
London: Pergamon Press.
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UNIVERSITY OF IBADAN LIBRARY
Hellriegel, D. and Slocum Jr., J. W. (1979) Organizational
Behaviour, Ed. 2., St. Paul: West Publishing company.
Georgopoulos, B. S. (1972). Organization Research on Health
Institution. Ann Arbor: Institute for Social Research,
University of Michigan.
Goldsmith, S. B. (1987) Health Care Management: A
contemporary' Perspective. Rockville, MD: Aspen Systems
Corporation.
Grimes, J. and Burns, E (1972) Health assessment on Nursing
Practice. Ed. 3, Boston: Jones and Bartlett.
Milio, N. (1975) The Care of Health in Communities: Access for
Outcasts: New York, McMillian.
Palvako, R. M. (1971). Sociology of Occupations and Professions.
Itaca , III: Peacock.
Parsons: T (1960). Structure and Process In Modern Societies
;, Glencoe, III: Free Press.
Taylor, T (1990). Health Care Marketing and the Nurse Manager.
Nursing Management, 21: 5, 84 - 85.
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----- - -- -
Chapter Eleven
BIOCULTURAL ADAPTATION
E. Adewale Oke
Department of Sociology
University of Ibadan, Ibadan.
INTRODUCTION
Medical Anthropology is an aspect of Human Biology
which is an integral part of physical and/or Cultural
Anthropology depending on the subject matter, This chapter
draws heavily on materials from physical anthropology
otherwise referred to as human biology in the widest contest.
Human biology more often centres on human as a whole or to
human populations than to individuals.
Moreover, the subject of medical anthropology is people,
and people are the only culture - bearing animals (Lasker,
1976). Medical anthropology therefore deals substantially with
the interaction of socio-cultural and environmental factors with
genetic processes in explaining health related behaviours. In
other words, medical anthropology is concerned both with
cultural and environmental influences on health behaviours and
with biological/genetic preconditions.
From the anthropological point of view, there are two
quite distinct types of heredity:
(1) Genetic Heredity: By which physical traits are passed
from one generation to he next and
(2) Social Heredity: The process by which one generation
teaches its cultural inheritance to the next (Bleibtreu et
aI, 1971). Genes and culture traits often affect one
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another., It has been suggested, for example, that the
invention of the spear replacing the club probably set in
motion an entirely different conditions for survival to
which the genes that control physical structure must
adapt. Spear users' physiques would then be selected for
the leverage of broad shoulders and long limbs whereas,
club users would be better off with ruggedly compact
physiques.
The bio-cultural approach emphasizes the evolution of
man's biological capacity for culture and the mutual influence of
genes and culture traits. Culture as represented by the massive
use of tools and symbols constitutes the basic adaptive
mechanism of man. Bleibtreu et al summarize this view point as
! follows:
But adaptation is an on-going evolutionary
process. Although culture proper is unique to
Homo Sapiens, it is nevertheless the biologically
adaptive technique of this particular animal, built
physically and functionally as he is. The use of
fire and weapons has certainly affected man's
dentition and jaws, eye-brow ridges and skull in
general. But even more subtly and drastically,
cultural adaptation has altered the basic biology of
man (Bleibtreu et aI, 1971).
The biocultural approach to the study of human health
helps to illuminate what man is and how he behaves as a culture
- bearing animal. -
In a wider perspective environment is an aspect of both
cultural and physical factors. Now, let us look more precisely
into variable interaction with the environment. Green et al
(1993) had earlier observed certain modifying factors thought to
be both genetic and environmental. They argued that even if a
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woman has the gene for a disease, there is still a 1 in 5 chance
she will not develop the disease.
This implies that most disorders with a genetic
component rely on the interaction of genes and environment to
bring about a clinical manifestation of disease (Davison,
Macintrye and Smith, 1994), about 4000 disorders are identified
as being affected by such interactions. Takagi (1991) even
suggested that it is difficult to think of many diseases from
which this is not the case.
However, in diseases characterized by highly expressive
genetic material, environmental influences may beexpected to
be of little importance as the
pathonegic effects of genetic inheritance will be manifest
whatever conditions are experienced. Nevertheless, the timing
and severity of the onset of such diseases would wholly and
partly be determined by the interaction of the individual and the
environment. In such cases, genetic components are grealy been
influenced by the environment.
ADAPTIVE PROCESSES
Adaptation implies the series of changes by which
organisms surmount the challenges to life. It involves major
evolutionary events, the growth of the individual and
behavioural and physiological changes which may last only
hours or minutes (Lasker, Op. Cit). Adaptation in this sense
implies its antithesis, that is, if one way of functioning is
adaptive, another is less adaptive or maladaptive under
comparable circumstances.
Adaptive selection is the central theme of the Darwinian
theory of evolution, the natural selection of better-adapted
organisms and the extinction of the less well adapted through
earlier death or reduced fertility. In this perspective, we can
view adaptation as a modification in structure and/or function
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which enables an organism to survive and reproduce. This can
apply to a particular organ or the whole individual and the entire
population or the whole species. Questions of different
adaptation remain among the most pressing and the most
practical facing medical anthropology, such questions often
arise: Are different populations differentially adapted to the
differing environments in which they live? What are the
implications of these for example, to national heath care
delivery services? Meanwhile, we shall discuss the main
channels of human adaptation.
Two main channels of organism-environmental
interaction have been identified, these are:
(1) Physiological adaptabil ity and
(2) Biological response (Hamson et ai, 1964)
Physiological Adaptability
Physiological adaptability is concerned mostly with
biological changes induced in the human body by the stresses or
demands of the environment. It may be necessary to distinguish
the responses and activities of the individual man, woman and
child from those that concern the group as a whole.
Individual responses are physiological, the body can
adapt, acclimatize or become immune to a wide variety of
external factors such as nutritional, climatic, and pathological by
virtue of the general somatic property. Physiological adaptability
is a species property, all members of our species, for example,
can exhibit this flexibility of response, it is an evolutionary
product of the species.
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Biological Responses
Biological responses are specific to particular individuals
and are determined by particular genotypes. Traits of this type
may be peculiar to a few individuals or may confer special
advantages on particular populations such as narrowness of nose
in cold or excessive dry conditions, dark pigmentation in the
tropics.
Homeostasis
The significance of adaptation is the maintenance of
biological homeostasis. Homeostasis is defined as the totality of
steady states maintained in an organism. It involves two
interwoven processes:
(1) Steady balance and
(2) Self regulation.
In the physiological sense, it refers to the preservation of
that constancy of internal cellular conditions necessary for the
life of the body.
Steady states are attained within the same limits in all
races such as body temperature, blood Il-ion concentration,
sugar content or osmotic pressure though the exact level within
the range may be set at values depending on particular factors or
activity or environment. Human group by virtue of its genetic
constitution displays homeostatic properties. There is a strong
tendency to stability in the range of bodily features with a
clustering of the majority round a mean value. This distribution
arises inevitably from the fact that many adaptive genes are
involved.
The mean represents the greatest degree of
heterozygosity while the extremes represent a greater degree of
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homozygosity. The mean value is on the whole the most
favourable, the extremes, the less favourable expression of the
phenotypes. Elimination of the less fit, in the interest of group
adaptability, does not however, deprive the group of genetic
variability since the more favoured heterozygotes continue to
supply this. There is thus a genetic homeostasis maintaining
both the optimum and the range and providing the material fora
shift to the appropriate genotype should circumstances change.
Social and technical factors are also responsible for
maintenance of homeostasis. These are social and technical
activities which allow the group to come to terms with or to
dominate the environment. These include social organization or
institutions, division of labour, the arrangements for
constructing shelters, the disposal of working energy and the
measures for caring for offspring. Although these institutions
and customs were not designed to serve biological purposes,
nevertheless, they do:
Homeostatic Adjustment-Physiological and Behavioural
The difference between biological" adaptation (which
covers both functional processes and structures on which they
depend) and human biology (which essentially addresses the
ways in which organism relates to the circumstances it must
meet to live) become blurred upon careful analysis of
homeostatic adjustment. Homeothermy implies the ability to
maintain constant and congenial temperature particularly under
~thelcondition of extreme heat or cold. This is common to allmammals and hence mammals, especially man, are more activeall the time and cover wider geographical area;The concept of Heterodontism/Mastication explains the
structure and function of the teeth of mammals. The teeth were
shaped differently (structure to perform different functions, that
l is, the teeth were highly specialized. However, man now has the183
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most generalized teeth of all animals. This can be explained as a
product of human evolution, an interplay between culture and
biology.
Reproductive Economy Pre-natal
Reptiles lay eggs and they are programmed to produce in
quantity to maintain their number due to wastage. In man and
great apes on the other hand" off-spring are usually only single
at birth, they are referred to as monotocous creatures. In
polytocous creatures, intra-uterine selection would put a
premium on the quicker-growing embryo since space and
nutrition are limited. Only a few of the promsimians produce
single young. Twins are common among the most primitive of
the New World Monkeys (particularly the callithis) but in the
rest of Anthropoidea, single birth is the rule.
The suppression (by selection) of the multiple conditions
in man is evidenced by the fact that it still occurs in low,
frequency (about 1 in 90). Selection against multiple births
proceeds both naturally and artificially. The vigour and life
expectancy of twins is somewhat below that of single infants and
many primitive societies ruthlessly eliminated twins at birth.
Single young can then be considered a re-adaptation for
progressively increased maturation time, in this respect, man
shows a clear continuity with the great apes.
Another prominent characteristic of mammals is the
periodic estrus cycle, this is more pronounced among the
prosimian primates. Estrus or heat is an event characterized by
bleeding or show and the readiness of the. female to receive the
male. The human female however undergoes the continuously
recurring monthly menstrual cycle. The two types of cycle are
physiologically, endocrinologically and morphologically closely
related, but the differences between them are sufficient to cause
significant differences in the sexual and social hehaviour of both
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males and females.
Unlike the menstrual cycle of man, that of the great
majority of the '\nonkeys and the apes is characterized by
changes in the external genitalia and sexual skin. In the
menstrual cycle' of baboons, chimpanzees and gorillas for
instance, there is at ovulation no 'show' but under the influence
of estrus, there is swelling and discoloration of the sexual skin
round the external genital organs. This is absent in man and has
important implication in human sexual behaviour.
Post-natal
The long growing period is characteristic of the
anthropoid groups but it is more prominent among human
species. It has certain advantages in regard to human social
structure. The increased dependence of the young is associated
with a strong material instinct particularly in monkeys and
chimpanzees. In man, this combined with the sexual bond
between the parents provides the enduring linkages for the basic
family unit whether polygamous or monogamous.
The delay in attaining full maturity greatly reduces
competition between males and their offspring. The father
maintains his dominance for the greater part of his reproductive
period. The long period of rearing between mother and child
ensures protection of the child. Slower growth rate provides
enough time to learn and enhances survival of safe environment
learning enhances flexibility and better adjustment to the
environment. This could be inform of:
(1) Trial and error which is somewhat dangerous
(2) Imitation, which is faster but rather inflexible and
(3) Instruction which involves the use of language and
mostly used by modern man.
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TECHNIQUES FOR SURVIVAL IN HARSH
ENVIRONMENTS
The history of man is full of contrasting examples of the
dynamic nature of the relationships between different kinds of
Jiving things in a community. These relationships form one of
the most important aspects of the environment to which
creatures must adapt. Hulse (1971) once observed:
Life itself is a process and since each organism is
born, grows, and dies, the relationships between
organisms are constantly changing. Even if the
purely physical aspects of the environment remain
constant as they may over considerable periods of
time, the biotic aspects, those due to the activities
of ~nimals and plants cannot be the same even
from day to day (Hulse, 1971).
The degree to which most creatures appear to be adapted
to their ways of life at any given moment may easily lead one to
conclude that each variety was designed to fit its proper place
and to fulfil its functions in the living community. We must
emphasize however that there is no conflict between heredity
and socio-environment, their joint action produces the
characteristics of all living things including ourselves. We shall
- give a few examples of the interactions, that is the coping
measures between man and his environments starting from the
penman apes or the great ancestors of man to the contemporary
primitive peoples.
Pre-man A pes
The pre-man was a successful hunter, utilizing, all the
resources of the environment available to him, this resulted in a
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fairly satisfactory nutritional intake. Aegytopithecus. our
common ancestor. from which modern man and apes descended
lived about 30 million years ago. He was a forest dwelling
primate and moved on all fours. The Australopithecus
I Africanus, regarded as the great ancestor of man lived about 5
I
million years ago. He lived in open-land. He was an hunter and
gatherer and used simple stone tools and hand axe.
The HOMO - erectus (Java man) lived between 500,000
and 300,000 years ago. He was wide spread and had about three
fourth of modern man cranial capacity (1050 cc). He
successfully hunted animals such as bison, horse, rhinoceros,
deer, beer, big horned sheep, mammoth, camel, water buffalo,
wild boar, hyena etc. His nutrition included vegetables and
fruits and he used fire (as evident from Choukoutien cave near
Peking in China).
The Neanderthal man' lived about 100,000 years ago. He
had an average of 1450 cc, just about the same with modern
man (1400 cc). This shows some relationships between the
volume of brain and the growth of culture and hence capability
to manipulate, exploit or control diverse environments. He was
wide spread, also known as:
(a) Rhodesian man of central Africa
(b) Solo man of Java
(c) Palestinian mount carmel man and
(d) Sharidan man of Iraq.
The Neanderthal man was able to exploit the varied
resources of his habitant. The likely food animals includes
horses, pig, otter, bear and chinocerors. It is doubtful whether
the extinction of the Neanderthal could be attributed to
nutritional causes (such as vitamin D deficiency) considering his
wide geographical spread and the food resources available to him.
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- - 1
It must be noted that our early ancestors, during their
long period of arboreal life took full advantages of the
opportunities of the period, anatomically, physiologically and in
social behaviour, they carried with them the marks of a
continuous process of selection which persisted through several
million generations of arboreal existence. Adaptations for
efficient operation in various ecological zones are responsible
for many of man's abilities (and stabilities). It was the good
fortune of our ancestors to make the sort of adaptations which
later proved to have been most adequate as a basis for
evolutionary developments in the direction of generalized rather
than spec ialized ab iIity .
Primitive Peoples
Today man lives in a range of settings from desert to
arctic tundra to steaming jungle. When we look at him in
ecological terms, we-see him as one component in complex
webs of interrelationship with his physical environment. We are
centrally concerned here with culture as mediating man's
relations with environment. We will concentrate (illustrating
with contemporary primitive peoples) on the way adaptation to
an ecosystem shapes a culture and on the way a culture shapes
an ecosystem and man's place in it. The four illustrations-
include:
(a) The Australian Aborigines
(b) The Bushman
(c) The Pygmies and
(d) The Somali
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Australian Aborigines
The Australian aborigines live in parched desert in
central Australia. They wrestled a living from an unpropitious
environment through hunting and through collecting grubs,
plants, roots. Material possessions are minimal. Keesing and
Keesing (1971) reported that an Australian aborigine may travel
with no more than a digging stick, hunting weapon and bundle
of sacred objects with no shelter or with crude lean-tos that are
abandoned as the band moves on.
Hunting weapons for large animals include bows and
arrows, spears, snares, pit traps, blowguns, boomerangs. Fire is
produced by friction in various ways. Read reported that the
aborigines built up what they regarded as a measure of security
through rituals which linked each band to an area and to the
possible food to be found there and ensured continuity and
preservation through a system of seasonal ceremonies and
taboos. She stated further:
The food quest was a such vital importance to the
aboriginal population that all their life was
organized around it, and measures of severe
social discipline were enforced in the small
communities to ensure that on one individual
.exploited the scarce resources so as to deprive his
fellows of the deprive his fellows of the necessary
food for keeping al ive (Read, 1966).
It is apparent that the technologies of the aborigine are
highly limited in terms of the control they give him over the
environment and the efficiency with which investments of
energy yield a return. Nonetheless, the aborigine is highly
ingenious, at this technological level, he has adjusted to an
environment, changing his pattern of living to follow the cycles
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of an ecosystem. He has a oneness with the world of nature that
modern man has lost.
The Bushmen
The Bushmen are about the lowest possible level of
subsistence. They perpetually face the danger of death from
hunger or thirst. They have to wander continuously seldom
staying in one place more than a day or two (Turnbull, 1963).
They live in the Kalahari Desert in south West Africa. Although
the desert was not their natural homeland, they have adapted to
it in a remarkable way.
It is almost impossible for anyone else to live there even
with all the equipment and tools of modern civilization, yet, the
bushmen survive and refuse to leave. The golden-brown athletic
little hunters who are only about five feet tall can hunt down
and kill any animal however big or dangerous with their bones.
They know the land well, every rise and fall of it, every
chimp of scrub, every three has a name. In the whole barren
waste, they are never lost, but always know exactly where they
are Turnbull further observed:
And where everyone else would think there was
no food or water within a hundred miles or more,
a Bushman will walk a few feet to a little patch of
scrub and pull out a, 'tsama' melon or he will dig
down into the sand with a hollow reed that he
always carries with him and begin to suck and in
time it (water) comes up through the reed, enough
not only to slake his thirst, but perhaps enough to
fill the shell of an ostrich egg (Turnbull, 1963).
Consideration of his fellow extends right through his
whole life. A family is close and intimate, but a Bushman will
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not Ignore th=e needs of others merely because they are not hrsrelatives.The go off to hunt and the women and children go
off to search for whatever growing thing that can be eaten be it
fruit or root on daily basis. They often return too exhausted to
do anything but sleep. But at times, they gather together and
sing and dance. This act of singing and dancing is both a
recreation and an expression of their joy. They dance under the
open sky and they sing to the stars which they regarded as their
fellow hunters, chasing their quarry across the sky. The slim
physical feature of the Bushman and rarity of problem of
overweight or obesity is attributed in part to his rigorous life
style and simple diet.
The Pygmies
The Pygmies (Bambuti) live mostly in the northeast
Congo. They live a simple life, hunting and gathering almost
daily.· They are hunters because they have never, have had the
need to be otherwise. There has always been plenty of food all
around them and they are perfectly content. Their organization
is equally simple, not living in large groups and having plenty
of land in which to hunt without a band coming into conflict
with another. -
The forest shelters the pygmies from the heat of sun, it
provides them with fresh drinking water wherever they go and it
supplies an. abundance of game vegetable foods, sometimes, a
hunt will be successful enough to make it possible for the
entire band to relax for the following day or two, during this
time, they will sing and dance.
The technology is simple, comprises bow, arrow, spear
and nets. They live in small bands of about three or four
families. In the morning, the men go off together to find fresh
animal trial. They cIimb up into trees and wait for the animals
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to pass, sometimes calling them by imitating their cries. While
hunting, the women would be gathering mushrooms, the sweet
Itaba roots and whatever nuts they can find and these will all be
used in cooking the evening meal. The game is divided up so
that nobody goes without, and special preference is given to the
old people who can n.o longer hunt for themselves. The Pygmies
have an excellent understanding of their physical and social
environment and seem to 'have adapted to it perfectly.
The Somali
The Somali live in the arid region of Northeast Africa.
Their life style brings out the rigours of a nomadic life. They
depend on their herbs and there is the need to find pasture and
water for them. The perpetual search for water governs their
migration.
There is always shortage of food, the Somali strongly .
. . believe that milk, the chief element in their diet, is the only
food that can sustain life by itself. Among the women there is a
high fertility rate, but there is also a high rate of infant
mortality. In a study of heart disease among Somali tribes
men,it was suggested that there was a relationship between the
diet, consisting almost entirely of camel's milk and the extreme
rarity of artherosclerostic cond itions (Read, 1966). .
The study concluded that in spite of the simplicity and
monotony of the diet, physical development is good and shows a
remarkable power of resistance to hard and demanding living
conditions. It was also observed that the people live in
accordance with country •.old custom, and are emotionally
balanced and free from nervous tension because their way of
living is closely adapted to the surrounding conditions into
which they were born and in which they will spend all their
lives.
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SUMMARY AND CONCLUSION
This chapter emphasizes the notion that biocultural
adaptability is a human attribute. Human beings are, the most
widely distributed species, they have to adapt to altitude, cold,
heat, and various kinds of diets. As Keesing and Keesing (Op:
Cit) noted, man's uniqueness, in ecological terms likes in this
"what a lion does in any environment will be broadly the same.
He is not likely to eat berries or fly south for the winter. He can
survive in only a limited range of settings. Yet man's culture,
particularly his technology, can radically alter what kind of
animal he is". .
The techniques for survival in harsh and isolated
environments are summarized as follows (Read, Op. Cit):
(1) The people learned to adjust their forms of livelihood to
the limitations of their surroundings in which their basic
needs for food, shelter', and care for their health had to -,.. ..
be met.
(2) The people were organized in relatively small groups and
so preserved their mobility in search of food and water
and
(3) They accepted the rigours of their life and believed in the
value of establishing harmony with their environment
through rituals and ceremonies.
The need to live in harmony with the natural
environment in a give - and - take relation cannot be over
emphasized. The relationship between man and nature should
not be of opposition but of mutual dependence. The environment
is not fixed and immutable, even the environments of individual
humans differ with a characteristics of each person. In this
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sense, the physical body and the socio-cultural environment are
one indivisible entity hence as far back as the time of pre-man-
apes, our ancestors have been adapting/modifying their
environments in ways that. have made them to survive and
ensures the continuity of human race, anything contrary have
been a total extinction.
REFERENCES
Bleibtrell, Hermann et al (191'1) Physical Anthropology Today
Del Mar California. Communications Research Machines
inc.
Davison, Charlie, Macintyre, Sally and Smith, George Davey
(1994). The Potential Social Impact for Susceptibility to
- common Chronic diseases. A Review and ProposedResearch Agenda. Sociology of Health and Illness: A
Journal of Medical Sociology Vol. 16 No.3, 340 - 71.
Green, J., Murton, F and Statham, H (1993) Psychosocial
Issues raised by a familial Ovarian Cancer Register.
Journal of Medical Genetics 30 575 - 9.
Hulse, Frederick S (1971) The Human Species: An Introduction.
to Phys~cal Anthropology New York, Random House.
Keesing, Roger M, and Keesing, Felix, M (1971) New
Perspectives in!Cultural Anthropology.
New York. Holt, Rinehart.
Lasker, Gabriel W (1976) Physical Anthropology New York,
Holt, Rinehart and Winston.
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UNIVERSITY OF IBADAN LIBRARY
Read, Margaret (1966) Culture. Health .and Disease.
Philadelphia, J. B. Lippicott Company.
Takagi, K. (1991) Genetic Screening - Policy making aspects. In
Genetics Ethics and Human Values Proceedings of the
XXIVth CIOMS, Conference. Tokyo. Geneva.CIOMS.
117-25.
Turnbull, Colin M. (1963). The people of Africa Leicester.
Brock-hampton Press Ltd., Market Place.
-
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Chapter Twelve
SOCIETY AND HEALTH: SOCIAL PATTERN OF
ILLNESS AND MEDICAL CARE
B. E. Owumi
Department of Sociology
University of Ibadan, Ibadan.
INTRODUCTION
It is a common belief today particularly in Africa and the
developing societies that the perception, conception and
management of ill-health is culture bound though the significance
which ill-health holds for the population remains the same among
all groups of people, In other words, remaining healthy is vital to
all people in all societies but the ways and means of evaluating and
___ treating the problems of ill-health varies from one group to the
other. This is the more reason why understanding of the subject at
hand is crucial to all members of society.
The concepts of society and health are interrelated and
mutually in exclusive especially as the latter finds its expression
and context within the former. It is in this light that we intend to
examine the concept of society and how it informs health beliefs,
associated illness pattern and medical care available to the people ..
Society and culture
In most discussions of health and its management" the
concept of culture features more frequently in the prediction of
patterns of health management than the concept of society. That in
itself does not imply the meaninglessness of society as a heuristic
method in the understanding of health issues in sociology. what is
rather significant is the fact that both concepts are not mutually
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independent of one another because ~ society cannot exist without
a culture while a culture exists only within a society (Chinoy 1967)
and given the fact that most discussions in the health realm focus
on the role of culture in the management of ill health, it would be
pertinent to discourse culture within the context of a society'.
Society:
The conception of society varies from one authority to
another and according to the subject under review (Onwuejeogwu
1981). This implies that no single and uniform concept of the term
is acceptable among social scientist (Chinoy 1967; Otite and
Ogionwo i'981). Given this background and the nature of the
subject our emphasis would be directed at presenting a definition
which would best illustrate and give meaning to illness pattern and
health.
A society is an aggregate network of social relationships of
a group or groups of people who may have lived, worked together
long enough to get themselves organized and to think of
themselves as a social unit and live a common life. The
environment thus defined as a society may inhabit one, two or
many groups with their distinct norms and values. A rural
community may inhabit one group while a modern urban centre
may inhabit many groups. In this sense, a society can be classified
as folk-urban (Redfield 1947), sacred-secular (Howard Becker and
Harry Barners 1952), status - contract (Sir Henryt Mainer 1872),
communal - associational (Chinoy 1967), and that which is
sustained by mechanical and organical solidarity (Durkheim 1933).
In each of these classifications a group or groups with common
values obtains in a society with a distinct culture, implying that
there could be one culture or more in a society as in the case with
the Okpe society .in Delta State and the Nigerian society.
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Culture:
In the same token, culture connotes different things to
different authorities. The word is not only abstract in nature but
the range of objects or phenomena it refers to is diverse hence its
complexity and empherical nature. this fact probably accounts for
the conceptual controversy. The concept in the views of Oke
(1984) is borne out of the desire to characterize in an empirical
terms the similarity and wide differences between groups of
people. In this sense, group or groups of people can be demarcated
based on their ways of living. It is that artifact which equips the
group to cope with the environment that is referred to as culture.
For instance, Taylor (1891) defined culture as the complex whole
which includes knowledge, beliefs, arts, morals, laws, customs and
any other capabilities and habits acquired by man as a member of
a •society. These acquisitions enhance man's adaptability and
mastering of the environment. The artifact which essentially
qualifies to be defined as cultural traits must be acquired by men
through learning and are shared by all members of the same group
and are transmitted from one generation to another.
The approach and methods of dealing with ill health or
discomfort and the maintenance of health is rooted in the culture
of the people and therefore a cultural trait. Lambo (1961, 1969)
observed that his experience of non-literature societies have
demonstrated the influence or Importance of cultural factors in the
management of mental patients. Similarly, Oke (1994) writ-ing on
the influence of culture on health services utilization noted that
even some organic diseases have at least indirect cultural origin,
he therefore, concluded by alluding to the fact that human
behaviour is a manifestation of his culture. His behaviour is
culturally conditioned.
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Health:
Health according to the World Health Organization(WHO):
is a state of complete, physical, mental and social well being and
not merely the absence of disease or infirmity. Put differently,
being healthy goes beyond not having any diseases or infirmity but
compete physical, mental and social well being. Given this
definition and considering its complexity it may not be practicable
to pursue the subject under examination adequately. In this light it
may be convenient and pragmatic to adopt the concepts for
understanding the social pattern of illness and medical care in
society.
Diseases in the words of Idler (1979) is an abstract
biological-medial conception of pathological abnormalities in
people's bodies. This is indicated by certain abnormal signs and
symptoms which can be observed, measured, recorded, classified
and analysized according to clinical standards of normality
(Mechanic 1968, Coe Rodney 1970). Viewed from this angle, it
is objective and empirical consequently therapy is predicated upon
the findings of the investigation.
Scientific as the above conception may appears, its utility
in sociological analysis in the management of health is limited by
the values and perception of problems which are hinged on the
culture. For instance, an Egyptian physician says: -
Peasant people in the villages of rural Egypt believe
that illness must be associated with pain and
discomfort otherwise it is not illness. He want
further to observe that bilharziasis and other
parasitic infections are not illness because they do
not cause pain and therefore do not require
treatment". (Read 1966).
In the same token, chronic ailment may also be responded
to different by people of differential social status and age. The
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~9ed might perceive ailment at old age as normal in the same 'way
as. mild ill-health is accepted as a normal part of life even when it
has biological underpinnings and consequently not induce illness
behaviour amongst many groups of people in society.
This fact brings us to the essential subject of illness which
is a subjective evaluation of ones state of being (Mechanic 1968).
In the same vein Idler (1979) conceives of illness as the human
experience of disease which is social. This state is indicated by
personal feelings of pain, discomfort etc. which may lead to
behavioural .changes. These. changes mayor may not preclude
objective disease realty but rooted within a social context. The
above contention is aptly contextualized by Low (1982), he
observed that illness is .given socially recognizable meanings. That
is they are made into symptoms and socially significant outcome
consequently adequate classification on causation and therapy are
designed withirl the socio-cultural context for its management.
Read (1966) for instance observed that in African systems there
are three groups of illness. The first are trivial or everyday
complaints treated by home remedies. The second are European
disease - that is disease that respond to Western scientific therapy
while the third categories is of African disease - those not likely
to be understood or treated successfully by western medicine. This
observation is true of many ethnic groups in Nigeria. Erinosho
(1976) and Oke (1995) working among the Yorubas and Owumi
(1989) among the Okpe people of Delta State noted that illness
etiology could be traced to three basic factors, viz: natural, super-
natural and mystical. Thus illness evaluation and management is
predicated on the .presumed causative agent and thus defines the
pathway to health care delivery.
Dlness Behaviour:
Illness behaviour as distinct from health behaviour refers to
how illness is evaluated perceived and acted upon by people who
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--
experience discomfort and-pains. It is the consciousness of the
state of health that is the cue to the action taken (illness
behaviour). For example, it is likely for an individual to have a
disease and yet be unaware or be mindless of its and therefore,
take no actin. The effort made to relieve one of the associated
discomfort and pains experienced that is referred to as illness
behaviour. The utility of this concepts of disease and illness are
considered in the light of the social determinants of health services
utilization and health status evaluation within a cultural context.
Medical System:
The medical system of a given state, community or nation
reters to the available health care facilities in place for the
__ management of the health problems. The existing health care
system is defined by the culture and the belief of the members of
the community. In the Nigerian context as it is with many other
developing nations of the world, a variety of medical systems are
available.
First, there is the indigenous health care model which
existed and still existing in the community. This system is defined
by the cultural values of the people and thus varies from one
community to the other (FMOH 1988). In other words,
it is community based while practitioners practice their art in a
solo manner to their clients (Pearce 1986, Alubo 1995). A variety
of practitioners known as either herbalists diviners, bone setters,
psychiatrists sooth-sayers and birth attendants all of which fall
under the tag of traditional medicine men or practitioners now
operate in the urban and mostly rural areas of the developing
world and Nigeria in particular. It should be mentioned, however,
that the practitioners of traditional medicine in Nigeria have been
operating under difficult and hostile environment (Alubo 1995) due
partly to government attitude/policy and, the operator of western
medicine and the educational status of traditional medicine
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practitioners (Mume, 1985) that prevented them from galvanizing
their ideas and forming a formidable group.
In addition to the above, western medical services were
introduced as a result of missionary activities and the colonization
of our society. These services though scientific and modern were
alien and unavailable to the generality of the population due partly
to our culture and the cost of providing the facilities. Today, this
system of health care management is the predominant system in
most societies (developed and developing) though not the most
patronized in the developing world with special reference to
Nigeria (Oyebola 1981, Heggenhougen 1981).
It is also noteworthy to state that syncretic health care
services (that is Islamic religious teacher are recognized as healers
and priest in churches, Pearce 1986) are also added to the help
seeking service sources availa~ in our society. It is therefore, not
out of context to say that a -plurality of health care services are
available from which patients would make choice when the need
arises. Given the existence of a variety of health care services the
social pattern of illness and medical care choice could be examined
within the context of a society.
Social Pattern of llIness and Medical Care Choice
The pattern of illness and medical care discernable in any
community is a function of the culture, value and context within
which the people operate and conceive the ailments. The patter of
illness/disease may be viewed from "epochal" angle where the
major diseases are classified according to seasons and ties. That is
pattern of disease associated with pre-agriculture age, agricultural
societies and modern industrial society. During each of these
stages particular forms o,fdiseases are more prevalent as causes of
morbidity and death. For instance, diseases of the degenerative
types like cancer and cardiovascular diseases are more prevalent
in the modern industrial era as causes of death (Fitzpatrick 1984).
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Patters of illness may also be conceived from the social
perspective where attention is focused on the life conditions, status
and environment of the population as determinants of the
prevalence and the perception of ailments. It is tbis fact that
essentially determines the nature of medical care (that is whether
the care should be preventive, curative or interventionist in
approach) and invariably utilization pattern. Fitzpatrick (1984)
observed that in many parts of the third world life expectancy at
birth is much lower than in Europe or North America. He went
further to say that many aspects of the environment in the third
world provide much more favourable conditions for the spread of
infectious diseases than those that prevailed in historical Europe.
The tropical ecology according to him is particularly favourable
for such vectors of diseases as malaria (mosquito) and sleeping
sickness (tse-tse fly). Beyond the environmental factor, socio-
economic status of the people also determines the pattern of
diseases and mortality rate. Odebiyi (1980) observed that people
of low socio-economic status judged from residence pattern in
Ibadan, conceive of disease differently and also have differential
access to health care facilities. Beside the question of perception,
the low socio-economic status person is most likely to live in the
"run-down area" of the society than the high socio-economic status
person where the Iife conditions are generally poor consequently
high morbidity and mortality rate largely due to infections and
parasitic diseases. In this sense, one can discern a patter of disease
prevalent among groups of people in a society. For instance,
Guineaworm disease is prevalent among the poor and rural people
whose main sources of drinking water are wells, brooks and
rivers. The high socio-economic group are most likely not to suffer
from these forms of ailments.
The conception of disease by the low and high socio-
economic group may also enhance the examination of illness
pattern and medical care choice. The low socio-economic group
person who is largely illiterate conceive of diseases from the
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cultural world VIew as against the high socio-economic group
person (literate) who is more modern and westernized and thus
perceive disease from the biomedical angle. The preponderance of
any of these groups in society would largely determine the
utilization patter of health care services available and invariably
health care development approach as earlier argued (Owumi 1994).
In other words if the literate group constitute the majority of the
population, western health care model would be mainly patronized
where the contrary is the case, where the majority are illiterate
they will rely on traditional methods of therapy or other
alternatives. It should be stated, however, that there is no clear cut
line of action as suggested above because the people might be
literate (modern) and yet not patronize western services due partly
to the cost of availability/accessibility of the services and the
existence of the necessary cue to health care actions.
Essentially, the path ways to health care is very intricate and it is
influenced by a number of factors particularly ina society where
alternative health care facilities are available.
CONCLUSION
Generally, men constitute the society and the various ways
they have designed to enhance their survival within the
environment is what constitute the culture. Health, a system of
sound (healthy) is one of such tool to facilitate man's survival
consequently the pattern of ailment and illness management
technology in existence is patterned by the culture and the society
at large. "
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Alubo s.: Ogoh (1995) Medical Professionalism and State Power in
Nigeria. Centre for Development Studies, University of
Jos, Jos, Nigeria.
Chinoy Ely (1967) Society: An introduction to Sociology, Random
House, New York.
Coe Rodney (1970) Sociology of Medicine MacGraw Hill Book
Coy. New York.
Durkheim, E (1933) (G. Simpson trans) The Division of Labour
in Society. Glencoe III. The Free Press.
Erinosho, 0 (1976) Notes on Concepts Diseases and Illness: The
case of the Yorubas in Nigeria, Nigerian Journal of
Economic and Social Studies. Vol. 18, Number 3.
Federal Ministry of Health (1988) The National Health Policy and
Strategy to Achieve Health for all Nigerian October.
Fitzpatrick R. M. (1984) Social Concept of Disease and Illness in
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& Graham Scrambler Baillire Tindal England.
____ (1984) Society and Changing patterns of Disease in
Sociology as Applied to Medicine (eds) Donald C. Patrick
and Graham Scrambler (ibid).
Heggenhougen, K. (1981) Discussion on Professional Associations,
Ethics and Discipline Among Yoruba Traditional Healers
of Nigeria. International Journal of Social Science and
Medicine 15, 97 - 99.
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Howard Baker & Harry E. Barners (1952) Social Thought from
lore to Science 2nd edition, Washington DC Hanen press.
Idler E. (1979) Definition of Health and Illness and Medical
Sociology International Journal of Social Science and
Medicine, Vol. 13A number 723 - 726.
(1969) Traditional African Cultures and Western
Medicine (A critical review) inc. Medicine and Culture
proceedings of historical symposium ed FNL Myntes
London, Well come institute of the History of Medicine.
LDw S. M. (1985) Culturally interpreter symptoms or culture
bound syndrome: A cross cultural review of nerves.
International journal of social science and medicine Vol.
21 ,number. 2.
Mechanic D. (1968) Medical Sociology Free Press, New
York Macmillan Publishing Coy. inc.
Maine H. S (1872) Village Communities in the East and West
London, John Murry cited in Bottomore T. B. (1972).
Sociology a guide to problems and l·iterature. London
George allen and Unwin.
Mume J. O. (1985) The Revolution of Traditional Medicine
practice Bendel State Traditional Medicine Board Health
fair/jamboree (Tradome '85) Nov. 15 - 19.
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Behaviour Science Journal Vol. 3, number 1 and 2
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Oke Adewale. (1995) Traditional health services: An investigation
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the Yoruba Ibadan, Sociological Series No.1, Department
of Sociology, University of Ibadan.
---- ( 1984) An introduction to social anthropology London
Macmillan Publishers.
--- (1993) Culture, man and utilization patter of PHC and its
implication for developing societies-in Primary Health Care
in Nigeria: State of the art. (eds) Oke E. A. and Owumi B.
E. 1993. Department of Sociology University of Ibadan.
Onwuejeogwu M. A. (1981) The Social Anthropology of Africa:
An introduction London Heinemann.
Otite O. and Ogionwo W. (1981) An introduction to Sociological
Studies Heinemann educational Books (Nig.) Ltd.
Owumi B. E. (1989) Physician-patient relationship in an alternative
health care system among the Okpe people of Bendel State.
An unpublished Ph.D thesis submitted to the University of
Ibadan.
___ (1994) Traditional medicine and the Nigerian society: A
case for the development of traditional medicine. African
Journal for the psychological study of Social Issues Vol. 1,
number 1.
Oyebola D. D. O. (1981) Traditional medicine and its practitioners
among the Yoruba of Nigeria: A Classification
International Journal of Social Science and Medicine, Vol.
14A, 23 -29.
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Pearce T. Olu (1986) Social change and the modernization of the
medical sector Social Change in Nigeria (ed) Simi Afonja
and Tola Pearce. Longman Ibadan, Nigeria.
Read M. (1966) Culture Health and Disease. London Tavistock
Publications.
Redfield Robert ~1947) The folk society American Journal of
Sociology, Vol. LII, number. 4
Taylor E. B. (1891) Primitive Culture: Research into the
development of mythology, philosophy religion, language
art and custom. 3rd edition revised Murry.
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Chapter Thirteen
-
DISEASE DIAGNOSIS AND ETIOLOGY AS A SYSTEM
OF THOUGHT
-S. A. Osunwole
Institute of African Studies
University of Ibadan,
Ibadan
INTRODUCTION
Explanatory theory of disease has generated a lot of interest among
scholars who are curious in ascertaining how disease are caused
and diagnosed most especially in non-Western cultures. Scholars
like George and Anderson, 1978; Janzen 1978; Turner, 1975,
Westerlund, 1989; Yoder, 1981 and others who have conducted
some studies on indigenous health and healing systems are of the
view that causality concept is a reflection of the system of thought
of most traditional societies. It has also been observed that
traditional diagnostic methods are equally influenced by cultural
and religious beliefs of most indigenous communities, where the
concept of two worlds predominates and where human problems
are traceable either to heaven which symbolizes the spiritual
world, or earth which represents the physical entity. Man's
spiritual and physical constituents which correspond to the nature
of the universe, have given him to capacity to interact freely with
the visible and invisible worlds. God is accepted as the Creator of
/ the universe where events are ordered through the instrument of
natural laws. Although the spirits and humans are under God's
control. yet they have the capacity to manipulate either the
physical or spiritual environment to cause events to happen through
supernatural means. Thus, there are events that take place quite
-<; naturally without the intervention of either humans or spirits and
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there are those which happen through the involvement of living or
dead human agents. Traditional medical beliefs therefore provide
explanation for diseases thatare naturally or supernaturally-caused
while diagnostic methods address the issue of natural and
supernatural dimensions in causality concept.
The data in this study were based primarily on available
ethnographic accounts of some non-Western cultures and the
author's interaction with Nigerian healers who share traditional
beliefs and attitudes in disease causation and diagnosis. The study
revealed that traditional societies have two or three major classes
of diseases viz: natural, supernatural and mystical. Since there are
overlapping areas in the classification, particularly between
supernatural and mystical, the author prefers to refer to diseases
that are caused verifiable means as naturalistic while those caused
as a result of spirits combined with human activities are referred
to as personalistic. Indigenous methods of diagnosis are quih.,
relevant to the two classificatory models.
Etiology
Causality concept is an important aspect of ethno-medicine
where health and religion are interrelated. In traditional system of
thought, diseases can occur naturally in the course of human
interaction with the physical environment. He may contact disease
on the farm when harvesting his crops, in the bush while hunting
animals or in the river during a fishing exercise. If his source of
water is polluted or the environment is in a poor sanitary
condition, he is likely to have infection. Naturalistic conception of
disease follows the laws of natural which stipulates that as long as
human beings comply strictly with naturally-ordered health
behaviours, their health is not endangered unnecessarily. But when
such behaviours are in opposition with natural laws, disease or
death may follow. Among the Yoruba of South-Western Nigeria
and other African societies, diseases can occur naturally as a result
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of germs or worms believed to be parasites that either reside in the
stomach, inside the blood, on the skin or any part of the body. It
is also accepted that certain illnesses can pass from parents to their
children. Mental disorders, leprosy and sexually-transmitted
diseases are in this category. Thus, hereditary diseases constitute
naturally-caused diseases that are preventable through a careful
investigation of the health background of both parties in marriage
before sexual love can take place or the marriage is consummated.
Health is also believed to be threatened through unwholesome food
or water, over-indulgence in food and sex, bad weather, unrefined
alcohol, unripe fruits and strew (Buckley 1985: 1). Diseases in this
category include diarrhoea and dysentery, malaria fever, guinea-
worm, gonorrhoea, syphilis, cough, barrenness, sorethroat,
convulsion, stomachache and mental cases.
Generally, these health problems are common and their
causes can be explained or verified by lay or popular knowledge.
Like the Yoruba, the Ndembu also recognize natural illnesses as
it has been observed:
Some sickness are so common that the element of
the untoward which makes people immediately
suspect sorcery or witchcraft is lacking (Turner,
1975: 301).
Naturally-caused diseases are not difficult to manage as
they respond to simple medication easily which could be applied
by the sufferer, his kin or neighbours. Most patients of naturally-
caused diseases are usually not referred to specialist healers or
diviners for treatment. But where health is difficult to restore
within a short time, and causality cannot be easily determined
physically, personalistic factors are believed to be involved. It
could be argued therefore that traditional etiology is a multi-causal
system in which naturalistic and personalistic illness categories
usually overlap. In Janzen's view, when an affliction deteriorates
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almost to the level of incurability, there is a suspicion that spirits
of human agency may be involved (Janzen 1978: 77). In Western
cultures where etiology is not a product of cultural
beliefs, personalistic or supernatural classification is not popularly
acclaimed.
Personalistic category of diseases are best understood within
their religious or social context. Causation is not easily determined
by physical examination of the sufferer as signs and symptoms of
illnesses are obscure. Self medication is quite irrelevant as
specialist healers and diviners are consulted for therapy
management.
Diseases in this category are believed to have different causes
outside the laws of nature and the assumption has generated a lot
of debate among Western scientists. Health problems are often
traced to the involvement of neglected gods whose devotees have
failed to accord necessary rites.
Witches also have the capacity to cause affliction. They ale human
beings with inexplicable supernatural power to harm or protect
their victims. Sorcerers are also human beings with evil intentions
whose pre-occupation is to interfere with the well-being of
innocent people by using bad contagious medicine to harm them.
In many traditional societies. breach of cultural norms, envy,
quarrels or strife within the family, and curses are catrses of many
health problems. All naturally-causes diseases are in this class
when they exhibit strange behaviours that are not readily perceived
or comprehended.
They are anxiety-provoking and bring a iot of social,
economic and psychological problems to the sufferer and his
family. In most cases, patient cannot even explain the nature of his
ailment. While examining witchcraft among the Navoho, Clyde
Kluckhohn (1970) observes:
Nothing is more intolerable to human beings than
being persistently disturbed without being able to
phrase the matter in such a'way that relief or
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control is potentially available.
In many African societies, fertility concept is almost taken
for granted and barrenness not only on natural factors but on either
problems with co-wives, quarrel between parents as to the choice
of husband and mystical powers of witches andsorcerers. Also,
where episodes of headache which is regarded as a common health
problem start in the morning and almost become a mental disorder
a few hours later calls for causal explanation outside natural laws.
An African woman who has a cut on her finger while doing
domestic work thinks of the involvement of witchcraft or sorcery
when she cannot stop bleeding with application of simple available
therapy. These 'strong' health problems are often seriously
discussed at family level in order to determine effective therapy.
(Yoder, 1981).
Another interesting aspect of traditional classificatory
system is the recognition of misfortunes as health problems which
are not actually the same as diseases because they lack
physiological explanation. They are social problems whose
psychological effects often give rise to stress, mental agony,
hypertension and even stroke.
When misfortunes give rise to such illness episodes, they are
regarded as diseases. They are caused by human agents. A number
of socially-sanctioned problems such as poverty, bankruptcy,
marital problems, failure in business, politics and administration
may cause disequilibrium between body and soul of the afflicted
and make him sick. while misfortunes are mere assumptions quite
irrelevant to any known medical theory, they are effectively
managed by traditional practitioners in most African societies
including Nigeria. Misfortunes as health problems can best be
understood as just as product of cosmos, emotion and people's
psychology in providing a Imk between social disharmony and
human pathology. In sum, study has not shown orthodox doctors
prescribing medication for poverty, bad luck, broken home and
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failure in business like traditional healers and diviners In many
non-Western societies.
Diagnosis
Every culture has some ways of ascertaining causation of illnesses
and treating them. Because of cultural diversities, we expect
variation in disease diagnosis and treatment in each cultural I
setting. In orthodox medicine, for example, doctors make use of
medical apparatus such as stethoscopes which enable them listen
to the beating of the heart and sounds of breathing. They also
carry out some laboratory examinations of the patients urine,
excreta or blood and make bacteriological and isotemic
investigations (fu Weikang, 1985: 1). Although traditional
practitioners do not make use of modern diagnostic equipment in
ascertaining causation, there are indigenous methods of knowing
people's health or health-related problems and treating them. The
methods, which are informed by the people's thought system, have
natural and supernatural explanations. It has been observed that
traditional diagnostic systems see man within his biological
spiritual, and psychological contexts (Janze 1978: 189).
The bio-psycho-social model of diagnosis is based on the
naturalistic and personalistic causal factors of illnesses, which he
practitioner belief conform with human nature and his
environment. Some indigenous methods of investigating diseases
include:
(a) Divination
(b) Use of herbal remedies and invocation of supernatural forces.
(c) Water or oil gazing
(d) Visual observation of the patients urine, tongue, palms, faeces
and skin.
(e) Feeling the smell of the patients Hoses and ears.
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(f) Palpating the various parts of the body and interpreting patients
illness behaviours as related by them or their kin (Osunwole,
1989: 157).
Divination
It has ben argued that since the practitioners in traditional
cultures do not have basic knowledge and equipment necessary for
modern diagnosis they cannot actually distinguish between diseases
and the symptoms they manifest. The assumption therefore, is that
the practitioners treat symptoms and not diseases. Truly, the
tradition bearers are not pathologists in the modern sense, but it
should be realized that indigenous methods of disease investigation,
some of which are in conformity with orthodox approach, are quite
appropriate in determining disease symptoms and causes. In
disease diagnosis, practitioners employ all kinds of divination such
as Ifa, sixteen cowries, sand markings and the involvement of
some deities who have the ability to predict events and prefer
solutions to problems. All divination systems are culture-bound
where arts and symbols employed are meaningful within a cultural
context. Of all these systems, Ifa divination seems to be the most
popular, comprehensive and dependable. The reason for this
assumption is that it cannot be faulted easily because If.a poems
have been transmitted in the same manner over many decades and
it takes the practitioners many years of training before they are
qualified to recite and interprets the verses of the poems. Judging
by their training and experience in psycho-therapy, diviners see far
beyond the present since they also foresee the future. In effect,
they see beyond signs and symptoms as diseases is the target of
their investigation.
Because of the intensity of the training and level of
competence that is required from diviners, riot aU Ifa priest can
successfully interprets the poems verse by verse and give authentic
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predictions. Only the experienced diviners can decode tnesymbols -
of Ifa paraphernalia and come out with any useful or relial! e
information. While examining divination among the Ndembu,
Turner (1975: 208) noted:
__The experienced diviner can allocate more meanings
to the items of his divining apparatus than the
novice diviner, and the latter can interprets them far
more fully than the uninitiated villager.
Among the Yoruba, there are other divinatory systems
which are less complex and differ from Ifa both in structure and
operational techniques. For example, the sixteen cowries system
of divination is popular among the women-folks because it is easier
to operate. Men who divine with sixteen cowries are those who
lack the competence and capacity to compete with Ifa priests. In
the system of divination sixteen cowry-shells are used for
divination ~n~not divination chain as in Ifa divination (Bascom,
1980: 4). Its objects of divination are also put in raffia basket. The
sand markings are also used in ascertaining causation of diseases.
This system is -widely acclaimed and practiced by the muslim
practitioners particularly in North and West Africa. In these
divination systems, the clients themselves, and sometimes assisted
by their kins, play an important role both in the choice of therapy
and diagnostic process. Just like a Nigerian healer, an Ndembu
practitioner allows the cl ients to take part in the divinatory process
(Ibid). People who want to unravel the mysteries surrounding their
afflictions.often visit the practitioners in their homes which usually
serve as clinics.
In emergency situations, diviners are invited to the homes
of high risk patients who may die before getting to the
practitioners clinics. Divinatory process starts by asking the patient
or his representative to take a cowry shell from the divination tray
or raffia basket and relate the problem brought for divination
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silently. The patient is asked to rub his/her chest and forehead with
the cowry shell. The symbolic transfer of the patients intention to
the cowry shell for interpretation and analysis during the actual
divination exercise is only meaningful in a magic-religious realm.
Nowadays, money is used instead of cowry shell for ritual transfer
of intention from the patient. A Yoruba diviner related that the
consultation fee originated from Orunmila, the founder of Ifa and
as contained in one of the principal poems (Ejiogbe) it is to
enhance good predictions. In actual divination, the practitioners
chant relevant corpus during which they possess the spiritual
power to relate with the super-natural forces for divine direction.
The divination instruments are cast and interpreted accordingly. In
Simpson's view (Simpson 1980: 73 - 74):
When the opele is thrown on the ground, one can
tell which odu is indicated by the combination of
nut segments which fall "up" (inner side up) and
which fall "down" (inner side down).
Before giving his prediction, the practitioner asks the
patient or his agent a number of questions which will enable him
arrive at the root-causes of the affliction. The questions usually
touch on the social, economic, political, historical and religious
factors that are likely to induce the health problem. Another
pertinent aspect of traditional diagnosis is consultation with the
gods. The Yorubas god of herbs (Osanyin) like some other local
deities are consulted for purposeful direction during an epidemic.
It is an African deity that can be likened to a modern pharmacist
based on his knowledge of all medicinal plants. It whistles to his
priest and communication between them cannot be understood by
the uninitiated public. The priest can however give accurate
predictions and recommend remedies for all forms of ailments
whether natural or supernatural.
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There are some practitioners who use a combination of
herbal remedies and chars in investigating diseases. Among the
Yoruba, pregnancy test is done by the use of a mixture prepared
by squeezing some leaves of Boerhavia diffusa (etiponola). Any
woman who reports for pregnancy test is usually asked to wash the
body with it and if itching of the body follows, there is an
establ ished case of pregnancy. Some traditional practitioners also
use some medicinal powder to make some specified number of
scarification on their lower lips or eyes in order to give accurate
predictions and solution to health problems as directed by the
supernatural forces.
In fact, there are some Nigerian healers who diagnose their
patients just by mere gazing at water or oil. The client says his
intention silently to the ritual water put inside a medicinal basin.
A virgin girl is asked to gaze at the water and tell the client her
experience as reflected in the ritual liquid. Aside from spiritual
diagnostic methods, there are other rational approaches which the
practitioners adopt in ascertaining causation of afflictions. One of
these is by visual observation of the patient's urine, tongue, palms,
faeces and skin. The client initiates the process of diagnosis by
looking at himself if there is any physical change in his
complexion, tongue or eyes. He may ask his neighbours or kip to
observe his physical appearance for him where he notices any
malfunction of the body. If any obscure features are noticed, he
may be advised to consult a healer or diviner. The practitioner
whose expertise is essentially based on his experience goes into
actin by observing the patient's urine, tongue, palm, faeces and
skin. If it is observed that the patient's palm and skin are turning
pale or yellow, it is a symptom of yellow fever or jaundice. When
the tongue coating becomes white and cloudy, the healer either
thinks of yellow fever, sore throat or an infection. A careful
observation ofthe patient's faeces may reveal sorrie worm infection
or episodes of pile and dysentery when mucus or blood is noticed.
The practitioners know that when someone urinates and the urine
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attracts some ants, this is an obvious sing of diabetes. or
gonorrhoea infection if it has some blood or white fluid. If a
patient complains of general weakness of the body as well as day
and night dreams, these are signs of measles or witchcraft
poisoning. In diagnosing mental disorders, an African psychiatrist
may feel the smell from the client's noses and ears. The case of
mental disorder is established if the smell is abominable (Ayodabo,
1993. Personal communication). Another traditional method of
diagnosis that seems rational is by palpating the various p-arts of
the patient's body since it is believed that the episodes of any
illness whether natural or supernatural. will surely reflect in the
physical appearance of the sick. The practitioners use their fingers
and palms in feeling the patient's temperature. If it is higher than
that of the healer, there is evidence of malaria. Loss of weight is
usually diagnosed by asking the patient to jump up at least two or
three times and if he staggers at the first or second jump, he must
have lost some weight. Moreover, any loss of blood is not only
determined by mere perception of the patient's countenance but by
what the practitioners refer to as body press. The diagnostic
method involves the use of the thumb in pressing any part of the
body especially the palm, arm, leg and back. If there is a hollow
impression and the skin is unable to shoot up and come back to
shape immediately after the press, then the patient has-lost some
blood.
Other rare forms of diagnosis that are not actually
verifiable include the symbolic interpretation of each day of the
month and associating it with an event in human life. The belief is
strong that each day of the year has a message for everybody
concerning his health and general well-being. The practitioners
therefore ask their clients to touch any day on the calendar which
is symbolically interpreted before predictions are made. Dram
interpretation is another popular method of diagnosis. Events in
dream are regarded as imagination of the mind about life
originating from the supernatural world which may reflect life
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situation. There are good and bad dreams depending on their
understanding by the practitioners who mostly handle diseases
. involving human agents. The practitioners are good psycho-
therapists who understand the cultural dimensions of illnesses.
Also, they are familiar with events, traditions and social life in
their cultures and are able to say categorically what health
behaviours lead to particular health problems. Good (1987) has
observed that in bio-medicine:
"... few doctors and medical assistants have the
theoretical and practical training in cultural analysis
and psychology that is crucial to providing an
appropriate diagnosis" .
CONCLUSION
It is obvious from the foregoing that in traditional cultures,
responses to illnesses in terms of causation and diagnosis are
informed by indigenous beliefs and practices. In such communities,
especially in Africa, therapists are of the view that disease etiology
and diagnosis can only be effectively determined through a careful
consideration of cultural variables surrounding a particular
affliction. Since the cosmos provides explanation for the physical
and spiritual worlds and the dual nature of man, naturalistic and
personalistic concepts of diseases will continue to be
acknowledged. In this regard indigenous diagnostic systems that.
operate between the religious and psycho-social realms wiU also
continue to be relevant in ascertaining disease determinants.
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REFERENCES
Anita Jacobson-Widding and David Westerlund, eds. (1989)
Culture, Experience and Pluralism: Essays onAfrican Ideas
of Illness and Healing. Uppsala, Sweden.
Basom, Williams (1980) Yoruba Divination from Africa to the
New World Indiana University Press, Bloomington.
Buckley, A. 0.(1985) Yoruba Medicine. Oxford University Press.
Fu Weikang 1985 Traditional Chinese Medicine and Pharmacology
Foreign Languages Press, Beijing.
Forster, George(1978) and Barbara G. Anderson "Enthomedicine"
in Medical Anthropology
Good, Charles (1987) Ethnomedical Systems In Africa. The
Guilford Press. New York.
Janzen, J. M.(l978) The Ouest for Therapy: Medical Pluralism in
Lower Zaire, University of California Press.
Kluchohn, Clyde (1970) "Navaho Witchcraft"in Witchcraft and
Sorcery Max Marwick (ed.) Penguin Books.
Lola Romanucci-Ross, Daniel E. Moerman, Laurence R.Tancredi
(authors) (1983) The Anthropology of Medicine: From
Culture of Method. Bergin and Garvey Publishers Inc.,
Massach usetts, U. S. A.
Osunwole, S. A.(1989) Healing in Yoruba Traditional Belief
Systems" Unpublished Ph.D. Thesis, Ibadan. University of
Ibadan.
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Simpson. (1980) Yoruba Religion and Medicine in Ibadan. Ibadan
University Press.
Turner, Victor (1975) Revelation and Divination in Ndembu Ritual
Cornell University Press, Ithaca and London.
Yoder, P. S, (1981) "Disease and Illness Among Cokwe: an
Ethnomedical Perspective" Ph.D Thesis. University of
California, Los Angeles.
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Chapter Fourteen
Tradltienal Practitioners (Healers & Healing Practices)
B.E. Owumi.
Department of Sociology,
University of Ibadan,
Ibadan.
INTRODUCTION
The term traditional pracunoners brings to the fore the
nature and concept of traditional medicine which gives basis for
the existence of the professionals practicing the art. It is within this
general framework that healers and heal ing process can be
understood. Again, this context is fixed within a larger body which
in 'fact informs the appellation tradition(al), way of doing things.
It is essentially thevariability of the cultures within society that
leads to the variety of terminologies describing the practitioners
(such as native doctor healer, traditional practitioner, medicine
men, indigenous doctors, witch doctors to mention but a few) and
various but differing specialists with different modus operandi
which are dictated by the cultures and perception of the people
(FMOH 1988),
It is against this background that this chapter attempts to
examine the subject using the Okpe people of Delta State as a case
study. We would also draw from existing stock of knowledge to
enrich our experience of the ethnic group which constitutes our
case.
First, let us conceptualize the term traditional medicine
before examining the typologies of practitionals available, The
range of items and structure which it applies have been descried
with differing terminologies by different authorities. Some refer to
those as native medicine, indigenous, primitive, folk, black
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medicine and in extreme cases Juju; (Oke, 1995, Owumi 1989,
Macleans 1971; Odebiyi 1976; Oyebola 1981). The reasons for
these difference may be due to the various biases of writers and
the ways -practitioners of the art have professed their art and the
variability of culture which invariably gives credence to the
existence of the art. These differences in terminologies and
practice across ethnic groups have tended to inhibit the
growth/development of uniform national traditional health care
structure. The national health policy and strategy to achieve health
for all Nigeria (FMOH 1988) clearly stated that:
"Noting that traditional medicine is widely used,
that there is no uniform system of traditional
medicine in the country but that there are wide
variations with each variant being strongly bound
to the local culture and beliefs, The local health
authorities shall, where applicable seek the
-collaboration of the traditional practitioners of
promoting their health programmes ... "
Irrespective of the above fact, it is clear that traditional
medicine exists (Owumi 1994), with time, enough data would be
generated about the practice from different cultures, on the basis
of which a national structure would be put in place. What is,
therefore, traditional medicine ? The World health Organization
(WHO) conceive of traditional medicine as the sum total of all
knowledge and practices whether explicable or not used in the
diagnosis, prevention and elimination of physical, mental
imbalance and relying exclusively on .practical experience and
observation down from generation to generation whether verbally
or writing. Germane as the above conception would appear, It is
relevant to expatiate further the WHO conception by saying that
traditional medicine is an art which is original or originates
to/from the group where it obtains. A mechanism designed by the
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people from their past experiences. (For instance, early men learnt
to avoid poisonous food after eating them) to cope with the
environment. In this sense, the practice of traditional medicine'
goes beyond just maintaining stable health to encompass protection
from wild animals, evil spirits, motor accidents, successful
harvest, haunting to a host of other human activities that impinges
on survival of man in his environment (Sofowora 1984; Owumi
1989). It is against this background of the vast array Which it
caters for in addition to his indigenous ethos that traditional
medicine has continued to appeal to the people inspite of the
availability of western (scientific) medicine. 1t is within this
general outlook that the subject is examined.
Belief Systems and Conception in Okpe-Land.
The existence of traditional medicine in our society owes
much to the values and perception of the members of the
community. It is with this understanding ,that a belief examination
of the belief system of the Okpe people is pertinent as a w~y of
creating an adequate background for the comprehension of the
subject under examination. The belief system of the Okpe people
is quite embrasive. The belief varies from the ideas of the people
about the Almighty God to other divinities and taboos which must
be observed for the purpose of ensuring man's 'survival.
An average Okpe man is highly religious. He seldom does
, or engages in any activity without praying to the Almighty God
for protection (Otite 1973; Owuini 1989). He .believe that God
(Osolobrugwe) created him and thus should be worshipped-This / '
God is supreme and believed to reside in the sky. There is usually
no special place designated for the worship of the supreme God but
in some cases a long pole with a folklike top used for holding
plantain as food for God exist among the group (Otite 1973,
Nabofa 1982). This is usually found at the front of compound.
Here prayers can be offered to God for the protection of members
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of the family.
In a similar manner. the Okpe people veserate their
departed ones. Both males and females are worshipped theugh with
a higher premium being placed on the male ancestors'. The
worshipping of ancestors among the OKpe people is highly
entrenched in the culture of the group. There are three basic level
of ancestral worship. First is the central ancestral worship located
at Orerokpe the cradle of the Okpe people. Here, all the four sons
of Okpe and their descendants worship at Edio annually. Secondly,
they worship at the ward level and lastly the family (compound)
level where each household would remember their departed ones.
These departed loved ones are believed to be the custodian of the
living and so when they are not properly attended to could cause
misfortunes, in from of ill-health or poor harvest etc. Their spirit
could cause or harm living members of the family. So central is
this belief that marriages are presumed incompleletely performed
until the spirit of ancestors have been involved and offer ings and
prayers made to "them". (Nabofa 1982). The worshipping items
consists of animals like goat, ram, pig, chicken, and some time
fish including drinks which are consumed by members of the
family. The remains (skull) of the animals are usually displayed at
the entrance (door) inside the home. The officiating pr'fst is usually
the eldest male or female ancestral worship respectively.
The belief in witch craft is also very rife among the Okpes
just as the case with the Ibibio people (Offiong 1983). They
believe that a witch can harm his kinsmen or such harm can be
done with the knowledge of a member of the family who is also a
witch. It is believed that witches can cast spells on their victims
spoiling their crops, causing ill health and killing people. Usually,
when such spells are discovered early enough, it is believed that
only the native doctor can intervene by atoning the witches and
wizards (Owumi 1994).
This belief system in addition to others beliefs (Owumi .'
1989) largely explains the conception of disease among the group.
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The Okpes generally believe that ill-health or misfortune could be
induced by a number of factors or that it could be traced to many
sources. First and foremost, they believe that ill-health or
misfortune of any kind can be natural occurrence. In this sense ill-
health could be attributed to poor diet, mosquito bite or some
natural disasters like earthquakes or death due to famine or an
ailment which is hereditary. Though,the Okpes believe in this,
some problems that are natural in outlook originally may be
defined differently when it persist. It is under this situation that ill-
health is believed to be supernaturally or mystically induced. Some
ailments are believed to have been induced by some supernatural
forces in the environment. It is a common belief among the people
that witches and wizards and soarers can kill and cause some
forms of misfortune for members of the community. Consequently
when difficult problems are encounter such supernatural forces are
.referred to as the agent of such problem for example the witches
are at it again. Why me ? They want to kill me. In the same way
as the Okpe man believes in the evil forces of supernatural beings
so also does he believes that the ancestors can also inflict
punishment on the members of the family when they are angry.
The spirits of ancestors are believed to be around to protect living
members who have accorded the their due respects and those have
not would be punished. This fact is account for ancestral worship
among the group.
Traditional Practitioners and Practices
Traditional medicine practitioners are persons who are
endowed with the knowledge and skills to maintain the health
needs 'of the members of the community. They basically rely on
the local materials that are available within the community. That
in a way suggests that everyone who has the local skill to use the
local material available for the maintenance of health living is a
traditionalhealer (see Read 1966). That is a person who possesses
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some knowledge that can facilitate the management of
common/minor household problems. Beyond this group, there are
a number of categories of traditional practitioners with specialized
skilIs that transcends the everyday experience, In this light we
could discuss the followings as the major practitioners among the
Okpe people:-
( 1) The general practitioner
(2) Oracle men/women
(3) The Traditional Birth Attendants (TBA)
(4) Psychiatrist
(5) Bone setters
(6) Massagers
The General Practitioners:- They are persons versed in diverse
skills in the management of different forms of problem; in the
community. That is they perform general services. This group of
practitioners combine their knowledge of herbal medicine with
their skills in divination. The function of the other categories
mentions can be performed by this group of practitioners, It
should be noted that inspite of this general skills in all aspect of
management. there are special aliment where they are more
proficient and so in times of serious problems specialist in those
areas are consulted for assistance and special attention. (This point
would become clearer when the subject of witch doctor is
examined.)
They use a variety of materials which ranges from herbs,
backs, animal parts such as the eye, skin of tiger, cat, snakes,
cobra I and local gin among others. These are made into mixture or
powder or pomade which are administered to the patient. Every
preparation is made according to the need of the patient regardless
of the ailment because the spirit of the patient and the
circumstances surrounding the ailment are crucial component in
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health management in this realm.
Before the mixture is prepared, the general practitioner would
have consulted the oracle for a possible prognosis and course of ill
health management.
Oracle men/women :- The oracle are endowed with the special skills
of divination. They basically divine the cause of the problem because it
is believed among the Okpe people that ailment does not just come on
their own and so something must be responsible for its occurrence,
beyond this, it is when the cause of the problem is known beyond this,
it is when the cause of the problem is known that an effective why of
management can emerge. The main instrument of the oracle man in
Okpe land is known as 'Evwa. This instrument consist of shells"
collected from a special tree known as "Agbrogodi". These shells are
laced with a string, with each strand consisting of four shells. The total
number of strands are normally four, making a total of sixteen shells in
the whole paraphernalia. See the sketch below:
QQ
A QQ B
6 6
Another instrument used with the evwa is the tusk of a "bush
pig" which the oracle-man uses in tapping the four stringed parapher-
nalia while making some un-intelligible statement which
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are regarded as oracular language. The client also makes his
inaudible complaint into this instrument. The oracle man holds the
stringed instrument in pairs at a time and flings them on the floor.
with the aid of the tusk, he taps the shells while speaking the
special language during the course of divination. His findings are
made known to the client during and at the close of the
consultation and he advises accordingly.
Traditional Birth Attendants:- They are mostlywomen who have
the skills in the management of maternity issues and delivery of
babies. Their activities cover pre-natal and post-natal services.
They have special skills in the management of women during and
after birth and childhood diseases which they cure with the use of
herbal medicine. Some of these services are administered orally,
or through laceration and other forms of prophylactics against evil
machination.
Psychiattist:- He is a specialist in the management of mental
problems. The management of the patient is determined/dictated by
the nature of the mental derragment, violent patient treated with
some level of violence which ranges from flogging, chaining,
confinement, to the administration of sedatives. When the level of
violence in the patient has been brought under control he is placed
on special treatment of a variety of mixture prepared from herbs,
barks, Local gin among others.
Bone Setters: - Bone setters are traditional practitioners who are
versed in the art of "fixing" fractured bones with special reference
to the hand and leg bones. They rely on herbs barks and some
other material which they apply to the fractured part of the body
in addition to their special skills in setting the fractured bones. The
medicine is applied to the fractured part of the body while it is
kept in place with the support of sticks woven around the fractured
area. This protection is meant to keep the medicine in place and as
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well guide the fractured bones and enh-ance easy recuperation. This
approach depends on natural healing process which is a property
of the body, some practitioners use some supernatural means as
part of the healing process.
Massagers:- These are massagers who possess the special ability
to rub the body, and dislocated bones. They also preform services
to expectant mothers in order to facilitate easy delivery. They
assist to put the foetus in its proper position in the womb.
The above discussion shown the basic category of
traditional practitioners in Okpe land. This is not suggest that there
is a distinct between the different classification except of course
that it tends to highlight the major area of proficiency.
Finally, It must be stated that these taxonomy can be
regrouped into tow, based on the values and belief system of the
Okpe people. Generally, the Okpe people believe that ailment can
be induced by various forces and so management should take
cognisance of these sources.
It is in the light of the above understanding that the Okpe further
classify traditional practitioners as witch doctors (edjele) and an
"ordinary doctor" Oboh.
This classification is based on the belief that the witch
doctor has some element of witch craft in addition to his prowess
in the art of traditional medicine and is consequently - able to
resolve problems with witchcraft undertone by stoning the witches
and wizards. This is also true of the Ibadan Yorubas (Maclean
1971) while the Obon (Ordinary healers) does not have the element
of witchcraft substance and thus not able to handle problems which
centres on the evil machination of witches. He only has a wide
knowledge of herbal medicine which he uses to treat his clients
(Owumi 1989; 1993; 1994).
/
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CONCLUSION
The preceding discussion reveals that the Okpe people have
developed a variety of experts entrusted with the management of
ill-health and other associated human problems of survival within
the environment. These experts and their mode of practicing as
discussed above is dictated by the culture and value systems which
both practitioners and thelcl ient share.
REFERENCES
Maclean Una (1971) Magical Medicine; A Nigerian case study
Allen. The Penguine press London.
Nabofa M. Y. (1982) A survey of Urhobo Traditional Religion in
Urhobo People (ed) Otite Onigwu Heineman Educational
Books Nig. Ltd., Ibadan.
Odebiyi A. I. (1976) Yoruba Folk Medicine Its Practice, Research
Development and Relation to Modern Therapy Journal of
Pharmacy Volume 7.
Oke Adewale (1995) Traditional Health Services:- an investigation
of the providers and' the level and pattern of utilization
among the Yoruba Ibadan Sociological series No 1.
Otite O. (1973) Autonomy and Dependence: The Urhobo Kingdom
of Okpe in Modern Nigeria. C. Hurst and Co. Publishers
Ltd. London.
Owumi B.E (1989) Physician Patient Relationship in An alternative
Healthcare System Among the Okpe people of Bendel
State: An unpublished Ph. D. Thesis submitted to the
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UNIVERSITY OF IBADAN LIBRARY
University of Ibadan .
......... (1993) The place of Traditional Medicine in Primary
Health Care. Primary Health Care in Nigeria: State of the
Art (eds) Oke E.A. and Owumi B.E. Department of
Sociology, University of Ibadan; Nigeria .
. ~1994) Traditional Medicine and Nigerian Society; A care
for the Development of Traditional Medicine. African
Journal for the Psychological Study of Social Issues.
Volume one, number one
Oyebola, D. D. D. (1981) Traditional Medicine and its practitioners
among the Yoruba of Nigeria; A classification International
Journal of social Science and Medicine. Volume 14
Read M. (1966) Culture. Health and Disease. London; Tavistock
Pub Iications.
Sofowora A. (1984) Medicinal Plants and Traditional Medicine in
Africa. Spectrum Books Limited Ibadan Nigeria.
Federal Ministry of Health; The National Health policy and
Strategy to Achieve Health for all Nigerians.
World Health Organisation. "African Traditional Medicine" AFED
Technical Report series No, 1, 1976.
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Chapter Fifteen
FAITH/SPIRITUAL HEALERS AS ALTERNATIVE
THERAPEUTICS: SUCCESSES AND FAILURES.
M.Y. Nabofa
Department of Religious Studies
University of Ibadan
Ibadan.
INTRODUCTION
Healing is a term which covers a very wide area of human
study. It is a term which ,ranges from the therapeutic activities of
the orthodox medical practitioner to the services of the more
unorthodox faith cum spiritual healers. While the former healing
techniques are based upon scientific investigations and applications,
the latter rely on the intuitive insight and faith of both the healer
and his patients, which, in most cases, defy empirical and
scientific verifications. Between these two therapeutic systems, we
have a whole range of "fringe medicines." They include such
practices as herbalism, hydrotherapy, massage, cupping or blood-
letting, health-therapy, surgery, fasting and faith healing. We are
not unmindful of the fact that some faith-healers subject their
clients to some of the above tradomedical treatments. Thus they
adopt a kind of holistic approach in therapeutics.
The art and science of restoring and preserving health have
been closely associated with religion since time immemorial. In the
ancient time the sick consulted their priests for health; because
therapy has been regarded as "the possession of a Divine Healer
who dispensed it through the agency of a priest (ldowu 1967).
According to E.B.ldowu, it is the Babylonian belief that Ea "is the
great physician of humanity who has under his control all remedies
needed to cure diseases inflicted by demons".
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In both Ancient Egypt and Rome "men and women slept in
the temples of Isis and Serapis .... to recover their health" (Idowu
1967). In many parts of Africa people also sleep in traditional
temples and shrines to receive healing. In Nigeria, for example,
the Yoruba regard Osanyin and Orunmila as tutelary divinities of
healing as the Igbo have Aziza as their tutelary divinity in charge
of health and healing activities. Igbo Ubiesha, a traditional
monotheistic religion among the Urhoro, has healing as its major
ministry. Hence the sick sleep in its shrines to be cleaned of all
infirmities. (Nabofa, 1982)
Nowadays many people sleep in some (Christian temples
and Islamic centres to receive healing. We subscribe to Bolaji
Idowu's opinion that "whatever happened through the agency of
the priest, or prist-doctor, in the Temple, the patient believer that
healing comes directly from the divine enshrined in such sacred
place (ldowu 1967), went further to opine that.-
"the origin of hospitals or infirmaries could be traced to such
practices. Thus healing ministry has been concomitant with
religion from time immemorial. Religion is still playing that role
because people have faith in the efficacy of spiritual healing.
The above posture assumed by the religious man has not
been left unchallenged. In the 19th century Pasteur and Ehrlich,
through their scientific investigations, Came to establish that
diseases are caused by microbes, (Biema 1996) and that the only
way to cure any illness is to destroy the viruses that bring about
ill-health. Since that time medical scientists have regarded belief
in faith and spiritual healing as a distraction and should it make
claims to medical efficacy, as a possible symptom of a pathology
called fraud (Biema 1996).
In view of the above Western medicine has spent the past
hundred years trying to rid itself of remnant of mysticism. Since
then psychiatrists have become hostile to spirituality. In fact,
Sigmund Freud has dismissed religious mysticism as infantile
helplessness and regression to primary narcissism. (Wallis 1996).
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In the thinking of the African faith healers and their
patients, the major causes of diseases are of spiritual origin. These
healers believe in the duality of all beings. As man is made up of
body and soul likewise every community is made up of physical
and spiritual entities. As man has his soul's guardian angel in the
same way the community of the living or the quick in the physical
society look up to other spiritual beings as the guardians of the
physical society. That is every community has a spiritual tribunal;
and the well-being of the individual and the physical society
depends upon the good will of the spiritual entities or forces that
guard either the individual and the community.
The belief also states that for one to enjoy good health and
total-well-being one must adhere strictly to the behest of his
spiritual counterpart. Any onewho behaves contrary to the dictates
of his spiritual counterpart would amount to violating some
spiritual and natural laws. Sickness could result from act of
transgression. 't is also believed that human beings are constantly
violating these laws in ignnrance or willfulness. In fact, the belief
is that some people often engage in activities which they know are
"injurious to their health.
Once such deviance happens the transgressor's spiritual
guardians would step aside and any disease may set into the
physical part of such a person. In that situation on physical
therapeutical system can restore wholeness to such a patient. The
psychic part of the matter needs to be addressed first before any
cure can be effected.
The other causes of unwholesomeness ':. is the evil
machinations of mysterious powers and malevolent spiritual
entities. They are among others. witches, wizards, sorcerers, imps,
demonic water-spirits 'and spiritual spouses, estranged human
double. family and community divinities that require one to be
their priest or votary, and a disgruntled spirit of a departed
ancestor. The other sources of sickness are traced to breaking of
taboos, heredity and violating the terms of predestination which
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one had accepted before one crossed the threshold from the
spiritual dimension to the present incarnation.
No orthodox medication can handle, successfully, any
malay that may result from the above area. It would require
spiritual warfare cum placation (pacification) before the patient can
be made whole.
While the orthodox medical sciences approach is to identify
and attack and over-power the virus and repair the damaged part,
the faith-healer directs most of his therapeutic effects towards the
spiritual part of the patient, attacking and placating the spiritual
agencies believed to be responsible for the diseases.
As they operate at different levels from Which the disease
emanated they employ different tools and techniques. The use of
inappropriate tools and methods may not yield good results. The
orthodox medical doctor may have no tools to diagnose
successfully, diseases that normally originate from those
malevolent spiritual forces consequently he cannot cure them. But
the spiritual healer has the technical know how, due to his call and
special endowment, to probe successfully what is happening in the
spiritual realm, and bring solace to the rnvalid. This ia where we
can find the relevance of the spiritual healer for present day
society and his practices could thus be accorded a place as
alternative therapeutics.
The Faith/Spiritual Healer
Faith/Spiritual healers are considered as people who are
specially called for the specific duty of divine healing ministry.
Thus, no one could just wake up .over-night and claim to be a
faith-healer, He needs special endowment calling and, in most
cases, on the job training. Thus like all other therapists he is
expected to have received special training and knowing that will
enable him practice and carry out divine vocation successfully.
He deals with the spiritua1 cause and effects of the disease
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which have manifested in the physical body and/or in the l-atient's
aura. Consequently he is believed to receive more of his training,
knowledge and information from higher and immoral intelligences.
In fact, most spiritual healers claim that they receive their
knowledge from the psychic realm, especially while they are in
dream state and in an altered state of consciousness ..The spiritual
healer is believed to be spirit unto which he has been specially
espoused. Thus there is alway') a constant communion and
communication between both of them. As his total being has been
infused by the divine he has the power of clairvoyance and
clairurdience. He can thus see through the veil of obscurity and
know the real cause and remedies for any type of illness. Thus
noting can be hidden him. His knowledge would thus be unlimited.
Although the traditional African spiritual healer situated in
; a particular shrine obtains most of his training from the spiritual
realm he needs the assistance of some mortals in carrying out his
day to day duties. In his daily affairs he needs the guidance of
some refigious elders. These are the people who direct him in the
ethics and some practical aspects of the profession. While he can
know the causes and treatments of any ailment the elders are the
ones who instruct and direct him on how he should relate to his
clients. They also assist him in the area of taboo observances and
purificatory rites.
Thus, the traditional African spiritual healer receives his
training from two principal realms that is the physical and the
spiritual. But the one he receives from the spiritual realm takes
precedence over that of the physical. He prefects his knowledge
and training through constant practice. That is, through constant
atonement with the divine and assistance he receives from elders
he has on-the-job training, improves upon his work until he
becomes proficient. His fame on the job depends upon how he
relates to both hi.s divine and moral instructors as wel.l as how his
clients assess his performances.
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Elements of Faith-Healing
It is common experience that where-ever one goes to
receive faith-healing one is likely to be subjected to almost the
same procedure. It has thus been observed that most spiritual
therapeutic practices contain the following elements: diagnostic
rituals, confession cum mind reading, counselling, atonement,
exorcism, fasting, use of symbolic elements such holy oil and
water, prayers, dance and drama, giving of testimonies coupled
with thanks-giving.
Diagnosis:
Like every other healing system, faith-healing has its
diagnostic procedure. The orthodox healer believes that sickness
is caused by physical agencies, such as germs, consequently he
uses physical laboratory tools such as microscope and stethoscope
to investigate the causes and cures of ailments. But the spiritual
healer does not rely on those physical elements. He believes that
most diseases are caused by spiritual/psychic agencies.
Consequently he probes the spiritual realm in seeking solution to
the problem. It is here he could demonstrate the power of his
intuitive faculties, clairvoyance and ability to se through the veil
of obscurity. He may subject his client to serious questioning and
rigorous mind-reading exercises. Different forms of divination
acknowledged by the spiritual therapeutist are also employed in the
diagnostic exercise. We should note that divination is
communication between the moral and the divine, and such
communication could take any form.
There are different forms of divination. It may be in the
form of gazing at the mirror, palms, eyes, aura reading, use of the
Bible or any other holy book or items. Diagnosing the problem
may be carried on along with the other preliminary therapeutic
procedures such as confession, mind-reading and counselling.
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Confession:
There are two basic reasons why the person seeking
spiritual healing is required to confess his sips. These are religious
reasons and psychological outwork. The patient undergoing
spiritual healing is a religiousman who has faith in the efficacy of
divine healing.
Nearlyevery religion teaches that sin, in its various forms,
estranges man from the divine and it also brings about sickness,
pain and suffering. It also goes to state that for the patient to be
saved from his sickness he should first of all own-up and confess
his wrong-doing. It is a strong belief among the Christians that the
only way for one to be really saved from the power of satan
demons, pain and suffering is for one to confess his sins (Kock,
1972).
They always base their argument on St. James injunction which
goes thus:
Confess your faults one to another that you may be healed
(James 5:'16).
The position is almost the .same among the adherents of
Traditional Religion. They believe that breaking of taboos is one
of main causes of illness. Consequently, those who are sick or
suffering, in one way or the other, are encouraged to search their
minds, probe deep into their conscience and confess which-ever sin.
they must have committed. The idea is that if sins are not
confessed before therapeutic adventures the positive effects of any
therapeutic measure on the patient could be neutralised by the
aggrieved divine being.
This is where the roles of the cult of Ancestor- as religious
and cohesive factors in traditional Africa are better appreciated.
The belief is that if one is in good relationship with his ancestors
they (the. ancestors) would protect him from all forms of
negativity. But if one failed to carry out his finial obligations
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faithfully his ancestors would abandon him and he may be exposed-
to·all forms of vicissitudes of Iife. He has to go to sins before he
can become whole again.
On the importance and practice of confession during faith
healing in a traditional religious beliefs and practices. Mume
(1976) remarked:
In the practice of religious (sic) Igbeuku,· patients
are persuaded to confess their sins which torture
them, and once this is ilone such patients feel
emotionally relieved after the priest has pronounced
them clean and subjected them to rigorous dancing
exercise.
There are also psychological explanations for the inclusion
of confession in therapeutics. It is common experience that wrong
doing imposes a heavy burden on one's heart. When a person
becomes conscious of an act or experience which he considered to
be sinful he may manage to repress it but at the same time, such
will make his heart to become tense. Thought-of it makes the heart
skip beats. such a heavy burden the heart is bearing may result in
an illness which may not be cured unless the person's heart is
relieved of its heavy load.
According to Sigmund Freud (James, 1980)
"Many of the mental events of which a patient is
conscious in fact represent other unacceptable past
experiences which the individual has managed to
repress. The psychoanalyst (confession) attempts to
help the patient to remove the disguises of those
intolerable past experiences so that the true situation
may be seen in perspective and the tension which it
created may be released.
James has also observed that if a normal person has a
conflict in his mind, or is having difficulty in coping with his
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environment, ... it often helps a great deal if he can talk to some
other sympathetic but involved individuals. He also opines that
while in some cases this listener may be. able to make helpful
suggestions, the main value of the interview usually comes from
the troubled person talking and thinking about his own problem.
By so doing he is making a conscious attempt to resolve the
conflict and will have feel much better for having done so because
he will reduced his own mental tension.
The importance of confession in faith healing has also long
been expressed by William James (1975). In his own opinion
confession corresponds to a more inward and moral stage of
sentiment:
It is a part of the general system of purgation and
cleansing which one feels one's self in need of, in
order to be in right relations to one's deity. For him
who confess chains are over and. realities have
begun; he has exteriorized his rottenness. If he has
not actually got rid of it, he at least 11':> longer
smears it over with a hypocritical show of virtue -
he Iives at least upon a basis of veracity.
It should however be noted that most of the so-called
religious leaders who claim to have healing power may not be pure
morally or spiritually nevertheless, the act of confession helps the
patient to align himself with the constructive natural healing
elements in his body. The act of confession helps him to open up
the pent-in abscess to burst and again relief, even-though the ear
that heard the confession were unworthy (williams James 1975).
The experienced faith-healer reads the mind of his patient
confession his sins which he may feel must have been responsible
for his ill-health. when he come out of his close study of the
patient's confession and the inner recesses of his mind, he would'
get a true picture of the patient's problems. He would then be. able
to guide him aright. The patient will· begin to have faith in the
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healer's spiritual ability to save him.
One fact which must be noted is that, the human mind has
great control over every part of his body. Most of what happens
to man depends uponhis life style from day to day. As it is the
belief of the faith-healer that disease is the result of a violation of
some taboos, natural laws or sins, the first thing that a faith-healer
does to his patient is to find out what (is bothering his mind) and
to correct that cause and result of the imbalance. The above should
be done instead of treating the disease and allowing the cause to
continue at the same time. Very often the cause is deeply rooted
in the same time. Very often the cause is deeply rooted in the sub-
conscious mind of the patient. Surgery, drugs and were laying on
of hands nor any other material method will help such a patient.
Here we find the' importance of confession, psychoanalysis and
counselling. It IS after the above that whatever treatment is given
to the sick can become effective,
Confession alone does not guarantee automatic release from
the negative effects of the wrong deeds. Thus as a continued aspect
of faith healing exercise, after confession and counselling the
patient is made to atone for his wrongs. The form which the
atonement takes varies from one heal ing house to the other. It also
depend upon the nature and gravity of the sin and ailment. It may
be payment of some fines, or some kind of self mortification, and
providing materials for some sacrifices. In the main, attornment is
making reparation for a wrong done or payment for a sin. It is
only when such be assuaged. Atonement and sacrifice are, indeed,
major factors in spiritual healing and these are wide fields of
study(Williams James 1975).
Faith healing procedure can thus be arranged in the
following chronological order: Confession, atonement, sacrifice,
absolution, purificatory rites and counselling.
They constitute a chain of events and one leads to the other.
The form each of them takes varies from one system to the
other. In some cases the acts of atonement, sacrifice, absolution
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and purificatory rites are so intertwined that it is not easy to notice
where one ends and the other takes off. For example , in some
faith healing homes the sacrifice victim or item is used to asked
to lay his hands on the victim or hold the item while making his
confessions. In some cases it may be used to sweep or touch
different strategic parts of his body, especially his head, chest,
back, around his solar plexus up to the navel and feet before it is
ritually disposed off. Many healing, churches use candles, water
and oil in preforming such rites. In the cause of emulation the
cultic functionary could be pronouncing absolution and forgiveness
on the patient. The belief is that while such is going on the
impurities in the patient would be exorcised extracted from the
body or environment of the patient and transferred. into the
sacrifice victim or item.
The successful completion of all these acts have much
psychological impact on the mind of the patient. They go a long
way in relieving the heavy burden in the patient's heart. Much of
the healing ritual drama is geared towards arousing, is the patient,
some feelings of awe and reverence. These will generate
confidence in his mind. While the patient is thus predisposed, his
mind will vibrate positively and set in motion constructive and
healing natural forces within his body. His mind will become
relaxed and the body will begin to heal itself. The success of the
above depends much on the personality and expertise of the cultic
functionary, and the amount of the aura of awe and reverence he
has infused into the healing ritual drama.
In faith healing practices it is believed that the surest way
to be really delivered from the power and effects of malaise,
especially those caused by demons, is through constant religious
devotion or prayer. It is believed that "Medicine does not always
do justice tp the spiritual side of illness. This is where counselling
is strongly emphasized.
Each spiritual healing cult drums it into the ears of its
patients that if a patient really wants to be delivered from his
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ailments he must commit his: life completely to the spiritual power
behind the cult or heating system. There has been no thorough
deliverance without there having been a thorough counselling
session before hand. In most cases this goes with prayers of
renunciation in order to have a thorough brake from his erstwhile
sinful acts.
Exorcism
Exorcism is a form of therapy for the unbalance mind.
This is a therapeutic measure which pre-supposes the common
belief that some ailments or unwholesome conditions are caused by
the presence of some evil spirit which has pitched its tent in the
human body. It infers that with positive respond to any forma
patient could be neutralized by the demon indwelt in him. In fact
this is the root of exorcism.
Almost every faith-healing system, be it (Christian
charismatic group or Islamic system or traditional African belief
system, practices exorcism. Such practice can only be possible
when the exorcists bel ieve that they are endowed with a power
mightier than that of the demons causing the malaise.
It is with this understanding that made Roger Baker, (1974) to
opine thus: -,
"Del iverance through exorcism is common p-lace for
charismatic who believe that they have been
possessed by the Holy spirit and therefore have the
gift of discernment of other spirits,especially
demons working in other.troubled, people.
Roger Baker argued further that exorcism is a kind of
spiritual equivalent to surgery. Nad also suggested that just as the
appendicitis or a cyst can be cut out: by a trained surgeon, so a
troublesomedemon may also be 'cut out' as it were, byan expert
on the subjects. -
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The faith healing exorcist operates mainly by invoking the
power-of higher force to bind and suppress the demon believed to
be the cause of sickness. Such is usually accompanied with the
laying on of hand and use of some symbolic items like holy water,
salt or oil and herbs.
In most cases exorcism is a highly dramatic ritual; and its
effects are quit profound in the mind of the patient. In the word of
Roger Baker :Obid)
"With its quasi-magical use if water, salt, perhaps
oil, ecclesiastical robes and holy objects, exorcism
is, in the words of Pere Joseph de Tonguedec, "an
impressive ceremony,capable of acting effectively
on a sick man's subconscious. Even, one might
add, on his conscious state as well."
There has been a great deal of mental poisoning in the
human society. Many people still believe that there are no
accidents, consequently they think that nothing happens by chance.
Thus, whether an illness has been brought about by socio-cultural
pressure or some other natural causes, many individuals still think
and believe that some myster\ous powers arer,espon-si\)\'eforit-s
manifestation. Hence exorcism forms parts of most therapeutics
that are administered on the psychologically immature and
unscientific. minded persons who quit often patronise faith-healing
homes.
There are as many 'exorcism symbolic forms and rituals as
there are faith-healing system. We shall only mention and describe
briefly a few of.them. The main idea behind exorcism is to cleanse
all impurities from the body an~ mind of the patient and thus make
him whole. It is a spiritual warfare and it is only through exorcism
that such battle can be won.
In Nigeria there are both traditional and Christian and
Islamic method/of exorcism. In the traditional system the people
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use herbs and ritualistic items for this purpose. For the example.
among the Urhobo, when the need arises for this kind of rituals
one of the herbs they use is Gran, or tea-bush. The Yoruba call
Efirin.
It has a very strong aroma and its scent is believed to
cleanse all impurities and attract good fortune and whole-someness
to man.
The purification rites take the following forms. The person
performing therites holds a small branch of this shrub first in his
right hand and goes to stand in an open space facing the sun or the
main entrance of the compound. while standing thus he does a kind
of confession and self-purgation inwardly. After such confession
to the self and the ever present and omniscient, he would use the
small leafy branch to touch or sweep the different parts of his
outer body while enchanting an 'appropriate supplication which may
take the following from:-
It is cleansed
All impurities are cleansed off.
Continuity of life is not cleansed-away
Longevity of life is not cleansed away.
Children are not cleansed away.
Money/prosperity is not cleansed away.
Good health is not cleansed away.
Death is cleansed away.
Sickness is swept away.
Poverty is swept away.
Misfortune is swept away.
He does the above four times with his right hand and threes
times with his left. At the end of each round he would stretch the
hand, holding the leafy branch forward, and spits breathily over it.
At the completion of the seventh round he would use it to describe
three circles round his head and cast it away following it with
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contemptuous heavy exploration.
The belief is that once this is done the person would no
longer regard himsetf as ritually impure. It is not only the physical
part of the man that has thus been cleansed but also his 'spiritual
counterpart. In fact, in Urohobo belief, such expiatory rituals have
more direct effects on the soul personality which has been defiled
than the physical body which could be washed clean with soap,
sponge and water.
It is a common practice to make magical solution, black
soap especially, for bathing. It is believed that such soap can
cleanse the sick of all impurities of mind and body and make him
.whole. There are also specially prepared creams which are capable
of exorcising evil out of the sick.
It is not only out of the body that demons or evil spirits are
exorcised. They can also be sent out of the sick person's
environment This was the type of exorcism which Simpson (1980)
came across in Ibadan and reported thus:
. . \
1\ A magical fire: may be prepared to get rid of an
' evil spirit that may be persecuting a house-hold. Or1•....\ '
one may prepareese (food and other materials that
will .injure the tormenting evil spirit ifne sees or
eats it). Ese is placed where evil spirits are thought
to come."
1 .
Among the Kumbowel Ijaw people in.both Delta and Rivers
state of Nigeria, the people use the cracking of iron metals to
exorcise evil spirits from the environment of the sick.
Healing through exorcism is also common place among'
Christians, especially among the charismatic, who claim to have
specially endowed with the power of the Holy spirit to overthrow
the satan and its kingdom. They use different kinds of oil
(especially Olive oil and coconut oil) for this ourpose, According
to Roger Baker (1974):
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"Sometimes the sign of the cross would be traced in
oil on the candidate's forehead in order to avert the
devil's gaze. On the other occasions the whole body
would be anointed, a ritual intended to supply the
initiate with a source of strength for the ensuing
struggle with the devil. Olive oil was used, also
chrism-olive oil blended with a scant, balsam
usually. "
Roger Baker also has it that the church exorcises negativity
from objects and places as well. Objects such as oil, water, and
salt, as well as holy objects, where they are to be used in the
various rituals of the church, are also cleansed of impurities. Sites
for church are also exorcised. The idea behind this practice is to
free everything that comes the church from dominion of the devil.
The other formula which some Christian groups use for
exorcism and faith-healing are what have generally been referred
to as breast-plate prayers. Roger Baker opines that "they are
designed to be self-applied for comfort or protection in an
emergency. Psalm 23, especially the last verse of it, is the one
used mostly by Christians of all denominations. St. patrick's
breast-plate or invocation is the best known formula of this kind
among the members of Roman Catholic Church. Most faith-healers
prescribe special Psalms, or Quranic verses passwords, holy names
and incantations for their clients to use, not only for exorcism, but
also to attain wholesomeness in both mind, body and estate.
The belief is that a sick person who uses the forms of
exorcism faithfully could easily get rid of any evil spirit which
may be responsible for his ailment. Dancing, as a therapeutic
measure, is common feature in many faith-healing, especially
among the charismatic groups.
It is employed by both the traditionalists and Christians. Such
dance sessions are well co-ordinated and streamlined to achieve
specific purpose: Like to pay homage 1:.0- the divine, for adoration,
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exorcism and heal ing, just to mention a few.
The mechanism and efficacy of the use of dance in faith-
healing enterprise had been succinctly expressed thus: (Nabofa
1990):
" The vibration coming from the dance and
percussive instruments are believed to infuse and
cleansed his bring and he soon gets well enough to
take part in the vigorous dancing processes which
are in themselves health-giving and health-
promoting exercises ... "
Fasting
Fas1ing is another main method employed in spiritual/faith
therapeutics. Faith-healers urge their clients to fast in accordance
with their prescriptions. All methods of orthodox therapeutics have
one thing in common, viz, they either give the body something or
tamper with it in some fashion.
However, it has been scientifically proved that denying the
body something - namely, food-and then not tampering with it- in
any other way, is a major factor in renewing the body. There are
ample scientific evidences to support fasting as an effective means
of therapy (Herbert Shelton 1978).
One may want to ask why deny the body food, of all
things? Is not nourishment necessary for life and healing? It has
actually been ascertained that in fasting one rids the body of the
bad effects of excess food, and gives the digestive system a rest.
If one took in only the exact amount of nourishment that he
needed, and of the proper kind, than he might never need to fast.
However, in all societies where plenty food is available,
most people (end to over eat, and also consume many things that
are unsuitable, if not downright harmful to the system.
Fasting helps the body throw off toxins formed by wrong eating
habits, along with using up excess fats (Ibid)_~
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From the spiritual angle, fasting humbles one and makes
the believer draw closer to his God. It is an important religious
duty and sacrifices. Hence many faith-healers, especially the
charismatic, include it as one of their religious obligations and
therapeutic practices.
It is a pity that for lack of scientific knowledge on the part
of most believers, many of them tend to ignore the scientific
explanations of benefits derivable from fasting. It has been
scientific proved that fasting actually works to rejuvenate the body
and bring about good health. It does this through the processes of
catabolism and anabolism.
There are two processes taking place continuously in the
human body, almost at the same time. There are anabolism, which
is the building up; and catabolism, that is, the tearing down.
Together they make up metabolism.
When one is fasting a cleansing of the body takes place,
thus allowing anabolism rise higher than catabolism. The building-
up process of life is accelerated, while the tearing-down process is
slowed. In that process all the cells in the body will undergo
refinement. Sometimes dramatic changes and improvements take
place in the body. The way the heart and bowel function is
improved, and the person sleeps more restfully. In that way the
body is allowed to heal itself more naturally.
Dr. Herbert Shelton's findings also revealed that there may
be increased acuteness in the physical senses of taste and smell,
better digestion, stepped' up vigour and of course, lose of weight.
Many faster subjects/respondents from Shelton's investigation
reported increased mental power, more powerful sex drives, a
clearing of their complexions, the disappearance of some the finer
lines in their faces and improved vision and hearing. (Shelton
1978) Commonly, the eyes become more sparkling, and more
youthful bloom become more evident. The faster's blood pressure
goes down.
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Dr. Herbert Shelton, who experimented andsupervised the
fasts of over 40,000 people in his clinic in Texas, reported thus:
Fasting can bring about a virtual rebirth, a revitalization of the
organism. In fact, fasting is also ameans of enabling the body to
free itself, not only of its .accumulated toxic, but also of its burden
ofaccumulatedabnormal changes in the tissues. This explains the
success of the faith-healing using it as a means of healing and
rejuvenation.
Prayers:
Praying fervently is one of the most powerful and effective
weapons of the faith therapist. It is the key to success in spiritual
healing. This practice is based on the believers strong faith in the
efficacy of prayer.
, It presupposes a God that is ready to Iisten and answer
prayers of His faithful servants.
Christians quite often make reference to the advice given in The
General Epistle of James Chapter 5 verses 14-16:-
"Is any sick among you? let him call for the elders
of the Church' and let them pray over him,
anointing him with oil in the name of the Lord:
And the prayer of the faithful shall raise him up;
and if he committed sins, they shall be forgiven
him. Confess your faults one to another ,and pray
one for another, that ye may be healed. The
effectual fervent prayer of a righteous man availed
much.
The Muslims, the adherents of African Religion, and other
religious groups and philosophical/mystical associations, which
practice faith-healing, through prayers and meditations also have
,references from their sacred books to support their belief in the
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efficacy of prayer.
But there are some physiological- occurrences that take place in the
human system during prayer which help in healing. They are
worth bring noted here. It has been noticed that prayer relaxes the
body because it promotes deep breathing. The person praying may
not be aware of this scientific cum psychological effects of prayer.
It is a common experience that our style of breathing
effects our body relaxations or tensions. That is, the way we
breath and exhale affects our health. In both praying and listening
to prayer we seem to adjust our breath to the punctuation,
especially pauses by the one- uttering the prayers. According to
John Palo and Dr. R.S. Woodworth, a directly controllable part of
the body can be used to reflex relatively uncontrollable body
system. And by controlling our breathing we can.control our state
of relaxation. Our breathing, offers us a means of self control and
adjustment (Cannon 1970).
John Palo and his colleagues also reported that shock-
inducing and sudden inhalation raised the pulse rate as well as the
blood pressure. He explained further that great excitation with
rapid breathing forces the muscles used in breathing to push more
blood to lungs for oxygen. At the same time, the heart pumps
more blood back to the oxygen-hungry muscles, (Ibid)
In controlled, extended exhalation, as it occurs during prayer
sessions, weare actually holding back the blood from reaching the
heart. Thus the heart with less blood to pump, pumps more
slowly, beating less rapidly.
When one is praying or is being prayed for, he naturally
inhales deeply, holding his breath for a while, so as to be able to
listen attentively and hear the words of prayer being said by person
praying. And in the process of saying the Amen, he exhales
slowly. Thus, in that process he would be holding back the blood
from reaching the heart.
Consequently, the devotee's heart with less blood to pump, pumps
more slowly, beating less rapidly and thus normally.
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This is the psychological role that prayers play in faith
therapeutic ministry. The process described above occurs rn a
subtle manner, consequently not everybody is able to notice or
aware of it. As it is the breath of God in man that is behind the
above functioning, prayer are the most effective drugs that faith-
healers administer t~ their patients.
The efficacy of prayer and meditation in therapeutics has
also been confirmed by several scientific researches in recent
times. Some of such recent findings are those of Herbert Benson
of Harvard University and David Felten, Chairman of the
Department of Neurology, at the University of Rochester USA.
According to Herbert Benson (1996) religious faith has
some direct influence on physiology and health. In his book, The
Relaxation Response. He demonstrated that patients can
successfully battle a number of stress-related ills by practicing a
simple form of meditation. According to him, the act of focusing
the mind on a single sound or image brings about a set of
physiological changes that are the opposite of the "fight-or-flight
response". He opines that with meditation, heart rate, respiration
and brain waves slow down, muscles relax and the effects of
epinephrine will diminish. Benson also holds the view that prayers
operate along the same biochemical pathways as the relaxation
response. That is, praying affects epinephrine and other
corticosteroid messengers or "stress hormones" leading to lower
blood pressure, more relaxed heart rate and respiration and other
benefits.
David Felten's recent research (Time 1996) has also
revealed that these stress hormones have a direct impact on the
body's immunological defenses against disease. He explains that
anything involved with meditation, including prayer, and r:
controlling the state of mind that alters hormone activity has the .
potential to have an impact on the immune system.
It was on the basic of their above findings that both of them
came to draw the conclusion that those who attend religious
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services regularly have been found to have lower blood pressures.
less heart diseases. lower rates of depression and generally better
health than those who do not attend. None church goers have also
been found to have a suicide rate four times higher than those who
attend church services regularly.
Many other possible explanations have also been advanced
for such findings. One of such explanations is that since church
goers are more apt than none-attendants to respect religious
injunctions against drinking, drug abuse, smoking and other
excesses, 'it is possible that their better health merely reflects these
healthier habits. Churchgoing has also been seen as offering social
support and such has a salutary effect on the health and general
well-being of the religious person (VIDE TIMES 1996).
Cyberphysiology:
A new technique of mind/body communication has been
graphted into the realm of faith/spiritual healing enterprise. It is
scientifically known as-cyberphysiology. It works on the principle
that a -person's thoughts, attitudes and emotions can make him
sick. They can also make one well. This is an old and well known
principle; however it is less understood and hardly adhered to by
many people.
Cyberphysiology teaches people how to use their mind to make
them well and maintain constant health.
According to R.S. Stone, the key to using cyberphysiology
is to activate the right hemisphere of the brain. This is done by
relaxing and' using one's. ability to imagine. Stone opines that
relaxation is very 'simple, but we often make it a difficult task, He
also explains that the right part of the brain is associated with the
creative realm from which we obtain our basic life energy:
Activating the right section of the brain through relaxation and
imagining connects us to this source of life's energy for healing
and communication. (Vide Time 1996).
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Secondly, that the usual methods of communication used by
one person to contact another is objective or left brain
communication. Mindlbody communication is subjective or 'fight
brain communication. It is accurate and sure, hence it can be
successful used handing stress associated diseases.
Cyberphysiology, being mindfbody communication is a
resource for creative' healing used in avoiding the ill-effects of
stress and combating negative attitudes and emotions that stress
brings on. Practitioners 'of cyberphysiology believe that affirmation
repeated mentally at the relaxed level helps to blunt the causes-and
thus- the effects of stress. It is thus recommended that appropriate
affirmations should be repeated daily for maximum effect. When
the spiritual healer advise his patient recite certain psalms,
affirmation and incantations a number of times he is using
cyberphysiology principle to help him.
The other cyberphysiology healing procedure Stone
advocated is the one he styles support Group-Talking Health to one
another. According to him if a person has a healing effect on his
body, other bodies can help heal him too. He opines that people
who share their experiences with others survive illness longer.
People with friends and family live longer than loners. (Time
1996). He also emphasizes the idea that support groups are not
people comforting each other in their illness. Rather, they ate
people comforting each other out of their illness. They do not
provide pills to each other. They communicate mind-to-body with
each other. People who are seriously ill can magnify positive
mind/body communication by part of a support group. This is'
where people benefit from most when they worship together
physically as a group. Stone as well affirms that by helping others
you help yourself. He moves a step further by saying that a person
also helps himself when he attains (spiritual) unity with something
larger than himself or a group of supportive others. He sounded
like someone who is deeply religious and psychic when he say:
There is a healing supportive universal energy that can and most
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be tapped into if you are truly to be in touch with your own self
and the needs of your mind and body (Vide Times 1996).
The above situation is what obtains amoQ,g most religious
groups, especiaIiy among the Christian,Islamic and Traditional
religious pentecostal groups. The same psychical unity is also
experienced among some mystical groups such as Eckanker-the
Religious of the Light and sounds of God, Christian science, The
Rosicrucian Order (AMORC) the Grail Message, Transcendental'
Meditation, and the Hare Krishna, just to mentiona few. It is
claimed that most of the mystical exercises that members of these
groups perform are meant to raise the level of their psychic
consciousness which will enable them achieve a close relationship
with the -source of Iife energy. And once such is attained spiritual
healing can be easily effected. He also recommended and actually
demonstrated how certain vowel sounds and mantras, can be used
to effect cure and ensure total wellness in the human body.
Shortcomings of Spiritual Therapeutics
There seems to be some major problems in faith and
spir-itual healing in many parts of Africa, including Nigeria. They
border on narrow-mindedness and selfless on the part of the
spiritual healers and their fanatical followers . Many people still
believe that only their religion or religious sect can offer spiritual
cures. They regard what obtains in other place apart from theirs as
works of satan. Their religious leaders have brain-washed them to
think and believe so. Consequently they hardly feel free to consult
other faith healers outside their own sect.
In Europe and America where spiritual faith healing. is
being scientifically studied and perfected; People combine methods
from different systems in their spiritual healing enterprise (Vide
Times 1996). American spiritual healers like Deepak Chopra, who
combine medical advice with Indian metaphysics in his faith,
healing ministry can hardly be whole-heatedly accepted and openly
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patronised by both Christian and Muslims in Nigeria. It is such
combination of mysticism with religion and orthodox methods that
has enabled him to Ieveal to the Americans the place where spirit
and body interact.
Spiritual innovations, _who will be free to combine
beneficial elements form' classical and modern Christian mysticism
with sufism oriental and traditional African mysticism in their
healing ministry are needed in Africa. And those in need of
spiritual healing should be spared Of religious and sectal
antagonism and free to enlist their services.
. The other short-coming of the faith healer, which many
have reproved, is that of schism. The motive of commercialization
makes people believe that someone who is spiritually gifted and
capable of healing people must found a Church or his own
ministry. It is also believed that his followers and all those who
must have benefitted from him must necessarily remain with him
permanently. For fear of schism and for some other selfish reasons
they do not train their clients to be independent. They only heal
them and solve their problems, but they do not release them. they
are required to run to them (the spiritual master) at each time they
(the clients) have problem.
Some other more critical views have been expressed against
faith-healing practices. It is often argued that majority of faith
healers have very little knowledge of human anatomy and what
constitute the psycho-chemistry of the human body. Consequently,
they do not understand fully causes of most ailments. Hence they
attribute every malaise to the; evil machination of some negative
forces. To this one could respond that while the orthodox .medical
doctors rely on their brains, reasoning and man-made gadgets in
diagnosing cause of ailments, which are limited and could be
faulty, the faith-healer claims that his knowledge about ailments
and cures comes from the divine, which does n6t make mistakes,
nor deceive his faithful servants. One could also 'add that not all
ailments are caused by virus infections.
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The ways the faith-healers wreak confession from their
ailments have also been called to question. They force those who
patronise them to confess. Those, who refused to adhere to their
subtle coercion are severely beaten. There have been several
reported cases of pastors or some other faith-healers who had
tortured some of their clients to death because they failed to
confess. In- order to avoid being tortured some have made false
confession. So the whole of confession exercise has been reduced
to a ruse and fake affairs. They thus make a mockery of
confession.
Due to false accusations and faked confessions, practice in
these healing homes have brought disharmony into many families.
especially in polygamous extended families/homes and even in
nuclear families. They have broken many homes where there in no
loves-lost. They always sow_ seeds of suspicion among friends,
relations and co-workers.
Many faith-healers have sinister power and tricks with
which they work on their clients psychically and mesmerise them,
to the extent they would be looked upon as- semi-gods or super
human beings. At such stage they carry out mental poisoning on
their clients. they manipulate the unwary with their power of priest
craft. They promote ignorance among their clients and make them
believe that they have really been chosen by God and whatever
problem they are unable to solve no other person can unravel or
solve -iL:They are type of people who promote the idea of a jealous
:Go~;IClnd 4Ia;.ve' sown ,the need of religious intolerance and
':d4stu~ua}lte~hI modern, Nigerian society.
! I Some pi them have been accused of immorality and
~ exploitatiori of their members.' There are cases of some of them
~.wHo'; haye ,seduced other peoples wives who went to them for
,healing'. M~my exploit unmarried ladies and have illicit sexual
.• ret laiio..•n•. s wi•th t'hem. Some of these beautiful ladies are mesmerised
n'l~de/fqrced' to marry them or some of their favourites against
iheir'WiSh~S.,An affair they would have not gone into if they were
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in their right frame of mind.
The way the faith-healers exploit their members is so much .
that while they, the so-called men of God,grow fatter and' fatter,
their clients grow thinner and thinner from day to day. They are
also accused of not giving their clients a permanent cure. Most
faith-healers can easily handle ailments brought about by fear. As
they can counsel one to have 'confidence and thus feel relaxed in
both body and mind, likewise they can create fear in the mind of
those who believe in them. Such fear can generate a kind of stress
that can easily lead to a serious sickness. They thus always tie
them to the strings of their aprons so that they can always draw
them nearer to themselves for further exploitations.
Some have constituted themselves into public ceremonial
magicians. They make public show of their spiritual powers by
means of testimonies which some make in their favour.
These have been branded as public advertisements which are meant
to promote their religious business. They arrogate.oo much
spiritual power to themselves. It has often been alleged that most
of these public testimonies and acclaimed healing of the sick,
lame, and blind in the public are faked.
Most of them are pre-arranged and well-rehearsed public
displays or ritual drama meant to aggrandize the fake-spiritual
healers-cum-religious business man.
Most faith-healing enterprises have been commercialized.
This is a common features in the Church. There are some genuine
spiritually gifted people who can heal. But no sooner than this is
realised people wilt begin 'to rush to them. Soon they St2LIto build
up a large following around themselves. Such a group could
become a Church within the main church. Members will soon
begin to have divided loyalty between this "holy" man and the
Church authorities. If care is not taken the person may-break away
and form his own ministry. This is one of the major causes of
proliferation of Churches in Nigeria.
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Faith-healers have no areas of specialization as it happens
in"the orthodox therapeutics. They claim to have power to heal all
manners of sickness. They are jacks of all trades but they are
masters of none.
Inspite of the above short comings and handicaps of faith-
healings we must not lose sight of their following positive sides
and contributions to holistic health-care delivery in "the SOCiety.
There are many of them who are really called to this ministry and
are competent healers. As we have chalatants in faith-healing
ministry so there are and careless ones in orthodox medicine
enterprise.
It is often said that what the drugs (which are mainly
chemicals) taken into the body do is to introduce harmonious
vibration into the human system and thereby enabled to heal itself.
At the same time they produce side effects in thereby body they
are supposed to heal. Such side effects may even be worse
ailments than the ones they were meant to ameliorate. The
harmonious vibrations coming through. the faith-healers
counselling, prayers, exorcism, fasting, and other healing
techniques, into the sick person's body have no negative side
effects.
Faith-healers have recorded huge successes and they are
still receiving patronage for the following, among others, reasons.
The orthodox medicine only looks at the physical aspect-of ill-
health. While the orthodox medical doctor can repair a broken
limb he cannot repair a broken heart and a damaged aura which
are the major causes of mental imbalance. In Nigeria many people
complain of psychic attacks manifesting through the evil
machinaton of witches, mami-water, spiritual spouses sorcery and
born-to-die children syndrome-(Ogbanje or Abiku or Edah), These
are manairfeests of damaged aura or disoriented man's psychic part.These cases that cannot be successfully handled by the
orthodox medicine practitioners. This is the area where the faith-
healers have proved their expertise in health-care delivery.
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Unlike orthodox medical doctors. faith-healers do not
require much capital to set their healing homes. Consequently they
are found in every nook and cranny of society. They constitute the
grass-root health-care centres. For an orthodox medical
practitioner to start operations, he needs a huge sum of money to
buy his equipments. His premises also needs to be thoroughly
inspected by competent government agencies before he could be
given licenses to operate. But the faith-healers does not need such
inspection and licenses. The only license required of him is his
spiritual call and results of his efficient healing ministry.
As a result of the above their charges are quite minimal.
In fact, the patient may not need to pay any consultation fees
before he is attended to in faith-healing therapeutics. They thus
serve the urgent needs of the lowly people.
Practitioner of faith-healing believe strongly that sin is the
author of most ailments that befall man. Hence, they always urge
their clients to confess their sins before they can be heeded. This
doctrine has made many of their clients to be always cautious in
whatever they do. They strive to live upright and clean lives. This
has helped, to some extent, in promoting ethics and good moral
behaviour among their clients and the society in general. This
could be ascribed to the spiritual healer as great success in nation
building health wise.
CONCLUSION
There are many since-re and dedicated therapists in all
branches of health-care deliveries, orthodox and unorthodox. Many
of them are overworked. As the Master Jesus Christ once said:
"The Harvest is great but labourers are Few". We agree with the
Atlantean opinion that the stark realistic attitude of the orthodox
medical associations of the world contracts with the nebulous
approach of many sincere but of times misled members of spiritual
healing groups. whose cause is hardly furthered by ignorance of
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elementary anatomy and non-acceptance at known biological
factors innate in the human physiology (Helis Arcanophus 1977).
On the other hand, where the two can join together and work as
a complementary group much can be achieved. -'-
Itis reported that in Brazil-spiritual and psychic healers are
allowed to work freely in hospitals alongside qualified orthodox
practitioners and the results are to the satisfaction of all concerned,
especially the patient (Ibid). Many patients employ services of all
privately.
Faith/spiritual healers are often criticised for inaccurate
diagnosis and for poisoning the minds of their patients; and also
that they promote ignorance and superstition. But if we consider
individual cases of patients, the spiritual healer is probably more
successful in his or her initial assessment than the doctor who
relies in many cases upon the description of the. symptoms relayed
to him by his patient. In agreement with the Atlanteans, also, if
the symptoms are classic text-book ones diagnosis presents little
difficulties, but this in not always the case and patients are obliged
to undergo long and tortuous period of observation and exploratory
operations in hospitals before the truth of the matter can be
reached (Ibid). There are. of course, many doctors who are
intuitive. Usually these are the more successful physicians.
In fact, an orthodox doctor who is psychic would be the most ideal
therapist.
This is one of the explanations for why healing ministry is
included among the functions of most African traditional priest-
hood and in pentecostal cum spiritual idengenous churches. The
Africans realise 'that a combination of doctor/priest encompassed
a far wider field of human experience than that afforded by a
purely academic background. It could also be argued that there is
far less danger for the patient when the faith/spiritual healer makes
a wrong diagnosis than when the doctor or surgeon makes the
same mistake. We have not heard of a faith healer amputating the
wrong leg or sewing up the forcepts inside. It could as well be
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ar-gued that an inaccurate spiritual healer can do more damage to
the mind of the patient through mental poisoning, but this is
debatable.
In Nigeria today most people unofficially combine the
services of both orthodox and spiritual therapists in seeking cure
and people are looking forward to the time when all the therapeutic
systems would be officially combined in. hospital.
One of the serious arguments raised, in the Western world,
against orthodox treatment by purists is the fact that many efthe
drugs are tested on animals. The suffering endured by these poor
creatures during experiments can only reap an ever heavier Karma
for mankind which witl doubtless manifest in the very field where
it was sown, that of health.
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