managing indigenous mental syndromes in the south african military health service

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MANAGEMENT OF INDIGENOUS MENTAL SYNDROMES IN THE SOUTH AFRICAN MILITARY HEALTH SERVICE

Col W Motaung

Directorate PsychologySouth African Military Health Service Headquarters

South African National Defence Force

November 2014

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CONTENTS

INTRODUCTION 1BACKGROUND 1

South Africa 2

Health Approach 3

South African Military Health Service 3

AFRICAN PERSPECTIVE 4African Psychology 4

African Spirituality 5

African Culture 6

Indigenous Healers 7

Traditional healer (Ngaka/Inyanga) 7

Head diviner (Senohe/Isangoma) 7

Herbalist (Raditlama) 7

Indigenous Mental Conditions 7

Mafofonyane/Amafufunyane 8

Bothuela/Ukuthwasa 8

Bohlanya/Ukuphambana 9

MANAGING INDIGENOUS MENTAL CONDITIONS 10Integration and Collaboration 10

Governance Limitations 11

Essential Improvement 12

Material Application 14

CONCLUSION 15REFERENCES 17

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INTRODUCTION

1. Organisations that provide health care for their members are crafting a critical advantage for their institutions. Optimum performance is mostly associated with the quality of life that members of any organisation lead. This element is important in organisations such as the South African National Defence Force (SANDF) whose mandate is to defend the territorial integrity of the country. The South African Military Health Service (SAMHS), as an arm of the SANDF, are duty bound to see to it that members of the SANDF are in a state of health that would allow them to satisfy this obligation (Surgeon General, 2013).

2. The kind of health provision given to members becomes important. The SAMHS have undertaken to provide a comprehensive health service to members of the SANDF and their immediate family members (Surgeon General, 2013). This comprehensive health service is grounded on a western philosophic outlook. In this context, a good health service is one that draws from western scientific understanding of what is good health science and what is not. Indeed lately there have been incessant calls for evidence-based interventions in whatever treatment given to patients (Pomerantz, 2011; Rowland & Beinart, 2009).

3. The bounds which allows health provision to be practiced and implemented is found in policy prescripts. Policy defines the parameters of operation. It spells out the powers and limits of execution. It delineates what services are available and what services are not available in a particular health setting. More importantly, policy entrenches the values that would guide a particular health service in its quest to serve those who make use of its offerings. Overtly it highlights the services that are available in its repertoire of expertise, and covertly those that are excluded from its menu of services. From this it is obvious that policy plays a critical role in any health care organisation.

4. When the World Health Organisation (WHO) was reviewing the chapter on mental disorders of the International Classification of Diseases (ICD-10), they realised the weakness of regarding classifications based on studies from developed countries as universally relevant. They then commissioned a study from developing countries to look at culture-bound syndromes from different countries with the view to incorporate the findings into the new version (Razzouk et al., 2011). This was a commendable move by the world health body.

5. It is known that health departments of national governments around the world follow the guidelines of the WHO in health matters. Health organisations in different countries take their cue from their national health departments. However, a cursory look seems to suggest that national governments have not been that vigilant in emulating the world health body in matters of culture-bound syndromes as these are mostly not covered by their policy prescripts. The same appears to be true in both our National Department of Health (NDH) and the SAMHS.

6. These pages will discuss indigenous mental conditions as they present themselves in the SAMHS. A brief literature overview will be done, followed by an elucidation of specific approaches to health provision. Thereafter the context of the birth of African Psychology will be discussed together with the common manifestations of symptoms of indigenous mental conditions. The debate of co-option or co-operation will follow. Policy imperatives and recommendations will form the closing part of this work.

BACKGROUND

7. Health provisioning is one of the most fundamental duties governments across the world are charged to do. Health includes all aspects that affirm the essence of being human. The United Nations (UN) considers health and well-being and access to adequate medical care as a fundamental human right (United Nations, 1948). This right finds expression in the WHO’s constitution and its often-quoted definition of health to the effect that it is “…a state of

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complete physical, mental and social well-being and not merely the absence of disease or infirmity” (Oregon Health Authority, 2012; World Health Organisation, 1946).

8. It would appear that there is scarcity of literature that focuses on the management of indigenous mental syndromes across the world. The allopathic approach has been adopted by the world at large as the paradigm through which to do health and its management.

9. This position is also true even in the African continent. This is not surprising given the reality that the training of health care professionals found in the various countries on the continent is founded on western philosophies and paradigms. The evidence of this can be observed in the nature of writings and slant of research output from the continent.

10. It is also instructive to note that the Organisation of African Unity (OAU), now known as the African Union (AU), in its African Charter on Human and People’s Rights that was adopted in Nairobi in 1981, had listed health as a right (Organisation of African Unity, 1981). It was further encouraging when in 2001 the AU declared the 2000s the Decade of African Traditional Medicine (Mbatha et al., 2012). These moves suggest a growing realisation that health management and its provision has different perspectives.

South Africa

11. The Constitution of the Republic of South Africa also states that access to health care is a right for which the government must work for its realisation for everyone (Constitution, 1996). The National Health Act 2003 enjoins the three spheres of government to strive to provide structured health care systems for all the citizens of the country (Government Gazette, 2014). The NDH ten point plan of the health sector for 2009 to 2014 had as its vision an accessible, caring and high quality health system (Department of Health, 2006, 2009). One of the objectives of the National Health Insurance is to provide improved access to quality health services for all citizens irrespective whether they are employed or not (National Health Insurance in South Africa, 2010). In another of its policy documents on health, the NDH has boldly stated that there is no health without mental health in South Africa (Department of Health, 2010). It should be noted, however, that health as found herein1 captures the idea of well-being as defined by western norms and not by African norms.

12. The year 2007 is significant in the history of health in South Africa in that the Traditional Health Practitioners Act No 22 of 2007 was made into law (Ramgoon et l., 2011). The Act was passed to address the following:

a. To establish the Interim Traditional Health Practitioners Council of South Africa;

b. To provide for the registration, training and practices of Traditional HealthPractitioners in the Republic; and

c. To serve and protect the interests of members of the public who use the services of Traditional Health Practitioners (Government Gazette, 2008).

13. Six years down the line, in February 2013, the Interim Traditional Health Practitioners Council of South Africa was inaugurated (South African Government online, 2013). It is assumed that the Council is busy trying to find their feet and define their role. It is no wonder then that in these early days their voice has not been heard.

14. However, it seems as though the work of this Council is clearly marked out. For instance, apart from attempts to develop formal structures for indigenous healers, they are

1 Ironic as it may appear, policy documents from an African country, like South Africa, do not even allude to indigenous syndromes? Health and sickness are couched in western terms only.

Health Warriors Serving the BraveRESTRICTED

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faced with the challenge of winning respect from the dominant system. To illustrate this, certificates of leave of absence from work issued by their members are not yet recognised by the dominating system. In fact, there have been a couple of court cases dealing with these concerns. It would be interesting to watch how the Council deals with these matters.

Health Approach

15. It is interesting to note that throughout this continent, including South African, health is understood and done from a western perspective. This approach has largely been based on the belief that mental disorders are universal, and that cross-cultural differences in clinical patterns derive from culture-specific illness behaviour (Aina & Morakinyo, 2011).

16. Such views have not gone unchallenged (Aina & Morakinyo, 2011; Nobles, 2014). In fact Aina and Morakinyo (2011) contend that holding that such beliefs is misleading. They argue that a full aetiological understanding of mental disorders depend largely on appropriate cultural factors. Nobles (2014) and Ally (2010) see the attempt to universalise mental disorders as part of an on-going Western Grand Narratives agenda which is rooted in western philosophic thought of dichotomy and reductionism theories. In this paradigm life is not just understood in polarity terms but it is also stripped to its barest elements. For instance, a patient has both a tangible and intangible side, physical and spiritual side, medical and psychological side.

17. In this view when a military patient consults for a headache, for instance, the military medical officer attempts to confirm the veracity of the patient’s complaint and if confirmed, prescribes a remedy that is intended to address the symptoms of the complaint. In most cases the medical officer does not concern himself with the patient’s home circumstances, his work environment or his familial and social settings. The medical officer uses this approach because his training has not equipped him with skills that may to probe other spheres of the patient’s life (Ally, 2010).

18. Although western oriented psychologists may tend to overlap into other spheres of the patient’s life as illustrated herein, they are also limited in their approach. For instance, the same patient consulting a psychologist for a headache will have the psychologist explore circumstances of the patient’s home, work and social environments and end there. It is rare that the psychologist would explore the patient’s headache in relation to the patient’s standing in matters cosmic as a matter of course. If such an exploration would be undertaken, it would be because the patient happened to raise the matter in the course of the consultation. Even so, such discussion would be pursued to diagnose irrationality and debilitating thought patterns with the ultimate aim of replacing them with rational and helpful ones (Ally, 2010).

South African Military Health Service

19. It is interesting to note that the recently published history of military health in South Africa, The fourth dimension, was accomplished under the auspices of the new political order. The book claims to cover a period of some one-hundred-twenty years of military health in the country and sub-region. In fact, its theatre of operation extends beyond the borders of South Africa where the contribution of liberation movements to South Africa’s military health legacy are explored. However, what is glaring in this work is that, although set in the African continent, and describing health work among African patients by African healthcare workers, this book does not even allude to indigenous approaches to health. What you find in this work is the glorification of allopathic health.

20. While the NDH guides all health matters in the country, the SAMHS takes its cue from the NDH. The SAMHS are focusing their energies on the health and well-being of members of the SANDF, in order to realise a healthy military community. This objective is pursued through


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a comprehensive health care system that is multi-disciplinary in approach (Surgeon General, 2012). The ultimate objective of this approach is to enable the SANDF to fully discharge its constitutional obligation of defending the country.

21. Even here, however, it is not surprising that the envisaged healthy military community and its parallel comprehensive health care system are couched in terms of western philosophies in spite of the reality that the SAMHS are located in an African country on the African continent and that a sizable percentage of its clientele are of African descent (Motaung, 2013; Rowe, 2014). Indeed one of the official documents of the SAMHS clearly states that sick leaves granted by indigenous practitioners are not recognised in the organisation (Surgeon General, 2013). The last statement reveals an apparent contradiction. On the one hand, we have seen the passing of the Traditional Health Practitioners Act by the NDH, while on the other, the SAMHS as a health care organisation, does not recognise indigenous health practitioners as health care workers. Conversely, it should be granted that it would be laughable for the SAMHS to do anything that the NDH have not endorsed.

AFRICAN PERSPECTIVE

22. The need to do mental health in a manner that affirms the being of those who consume it has long been established (Nobles, 2006; 2014). This requires that those who do psychology should take the milieu of interaction into account and shape the contact to reflect local paradigms and world-views. This raises the question whether practitioners who are alien to Africans can effectively do psychology with Africans (Nobles, 2006).

23. In this context, it should be readily recognised that the reality that something can go wrong with one’s thinking and behaviour was not introduced to Africans by psychology. Africans have known these as long as they are (Ally, 2010; Barnes, 2007; Mothoa, 2013; Odora Hoppers, 2001). The challenge has been that dominant paradigms have crowded the health care space and have not allowed alternative models to be freely expressed. Alternative models have contended with demonisation and labelling (Ally, 2010; Mothoa, 2013; Odora Hoppers, 2001; Shava, 2013). In spite of enormous challenges, however, indigenous practitioners have continued to be faithful to their calling to serve their communities.

24. It is also true, that indigenous mental conditions have been found not to fit squarely into the diagnostic criteria of known classifications. Some scholars have questioned the notion of culture related mental conditions and contend that these maladies appear to differ in degree from disorders that are known in psychiatric classifications (WHO, 1993). Others have argued that these conditions are unique to particular communities, hence the designation ‘culture-bound syndromes’ (Razzouk et al., 2011) or ‘culture-specific disorders’ (Niehaus et al., 2004). Because of the view that more work still needs to be done to establish reliable clinical description of these conditions and clarify their distribution, frequency and course (WHO, 1993), they have not found their way into the main sections of known diagnostic volumes such as the Diagnostic and Statistical Manual for Mental Disorders (DSM) and the WHO’s ICD. They are appended at the very end of these volumes under headings such as ‘Outline for Cultural Formulation and Glossary of Culture-Bound Syndromes ‘(American Psychiatric Association, 2000) or ‘Culture-Specific Disorders’ (WHO, 1993).

African Psychology

25. This is the kind of message that is conveyed to patients of African ancestry when they make use of services which are western in outlook. To be sure our services are foreign to African patients and are not geared to serving the real needs of African patients. When you visit our health service you may be pardoned for mistakenly assuming you are in some European country. Our health services reflect nothing that is of the continent. The same could be said of the practitioners who man and serve in them. Their training and approach


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reflects this philosophic tradition. It is no wonder that attempts to help African patients in these settings have been likened to giving the African patient poison to drink as if it were medicine to heal and revive the African patient (Nobles, 2014).

26. It was such concerns that led Black Psychologists to be convinced that the American Psychological Association was not adequately addressing the psychological needs of African Americans. They not only voiced their concerns but also walked out of the prestige association and formed a rival organisation named the Association of Black Psychologists in 1968. In taking this step they were aiming at reformulating the discipline of Psychology to serve the needs of African Americans by being uncompromisingly African-centred and grounded in the philosophy and wisdom traditions of African people (Nobles, 2014; Rowe, 2014).

27. While there is doubt that western psychology can adequately serve the needs of people of African ancestry (Nobles, 2014; Rowe, 2014), African-oriented psychology is suited to close this gap. This is because African-oriented psychology is rooted in African philosophy and African world-view. It is founded on the cultural interests and images of people of African ancestry and represents their collective lived histories, traditions and experiences (Rowe, 2014). It seeks to reclaim the pre-colonial definition of what it is to be motho/umuntu through African scholarship. It works to restore and re-authorise the humanness of people of African ancestry by addressing some of the legacies of their histories2 (Nobles, 2014; Odora Hoppers, 2001; Rowe, 2014). Its ultimate objective is to reconnect people of African ancestry with their own being – botho/ubuntu.

28. In this vein African Psychologists have a clearly defined duty. They are called to be of service to people of their own kind – people of African ancestry. In order to adequately execute this expectation, African Psychologists need to pledge themselves to the understanding that they are African people first and psychologists second (Jamison, 2010; Nobles, 2014; Rowe, 2014). This understanding is critical in that it forms the basis of their call and duty. It draws them back to the roots of their identity. It leads to the indigenisation of their trade and the affirmation of their heritage and self. This is where any service of significance to their kind should begin and end. It cannot be disputed that those who perform their duties through the mediation of their heritage continually affirm themselves through their work. Doing Africanised Psychology, African Psychologists are thus called to liberate the African mind, empower the African character and enliven and illuminate the African spirit (Nobles, 2014; Rowe, 2014).

African Spirituality

29. Any discussion of African Psychology without reference to African spirituality would be inadequate. It is for this reason that Nobles (2006) believes that for African Psychologists to be of genuine service to people of African descent, they should work from a framework of the illumination of the spirit. The practitioner who works from this framework is called the Skh Sdi. This approach promises to help the African Psychologist to understand the meaning and nature of being human for Africans. Thus doing Psychology in this framework would lead to the practice of Sakhu. Performing the Sakhu means the “Spirits (humans) who are led by spirit, who read spirit(s), who seeks help and protection from spirit and engages in the nurturing (healing) of spirit by performing the Sakhu as it should be done” (Nobles, 2014, p. 16). This manner of doing Psychology would enable African Psychologists to claim their own African Grand Narrative and use it to shape the African way as a tool for healing themselves and the world (Nobles, 2014).

2 Much has been said about the legacy of the histories of African people. There is no need to elaborate on the topic here.


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30. Nobles’s (2014) infusion of the element of spirituality in African Psychology is essential. One of the reasons for this is that it speaks to the core of who Africans are. Africans are known to be a deeply spiritual people. To Africans life does not have aspects of spirituality. Life is spirituality. In general, Africans function on this dimension all of the time. Africans do not assume a spiritual cloak and discard it when its use is not needed anymore, only to call for it again when circumstances so dictate. African life is spirituality and everything revolves around it. Thus Nobles (2006) argues that to the African the ultimate nature of reality is spiritual. This perspective is mostly missed by non-African practitioners who seek to help African patients. Many a times this has led to misdiagnosis and wrong labelling with their attendant consequences. It is not surprising therefore that others have questioned the wisdom of non-Africans offering helping services to Africans.

31. The phenomenon of indigenous mental conditions has been observed in nearly all cultures of the world. This is not just a reality of non-western countries only. For instance, eating disorders which are listed in traditional western coding and classification systems are regarded by some as culture-bound (Keel & Klump, 2003).

32. In the process of updating the eleventh edition of the ICD, the WHO have seen the need to move away from assuming that criteria of mental disorders developed in western countries is universally applicable. This realisation led to the commissioning of a number of studies from different regions of the world to investigate and document evidence of culture-bound syndromes with the view to incorporate the findings in the new version (Razzouk et al., 2011). Long before this WHO initiative, a number of world regions had already felt the need to develop specific diagnostic criteria for their unique settings (Paniagua, 2000; Razzouk et al., 2011).

33. It is documented that mental health workers in this continent have long realised that diagnostic criteria from standard coding systems were not doing justice to some of their observations and patient’s complaints (Aina & Morakinyo, 2011; Mkhize, 1998). In this country attempts at addressing this weakness have been individual effort by practitioners who developed interest in these unique manifestation of symptoms (Ally, 2010; Buhrmann, 1982, 1985; Mkhize, 1998; Niehaus et al., 2004).

African Culture

34. The foregoing suggests that culture has an important role here. Simply put, culture can be conceptualised as a way of life of a people. It is an internalised set of ideas, values, habits and other patterns of behaviour from a communal origin (van Rooyen & Nqweni, 2012). Focusing this to the present discussion, African culture can be understood as that way of life which governs the way Africans live. In African culture, the individual is protected against afflictions by the ancestors. And ancestors have to respected and appeased. Sometimes outsiders mistakenly understand this aspect as ancestor worship. Conversely, mental and physical afflictions are caused by failure to propitiate the ancestors or obey their wise counsel. In most cases, going against the will of the ancestors makes the individual incur their displeasure and this could lead to a range of problems (Bodibe, 1992).

35. Bodibe (1992) further elaborates that apart from ancestors, there are other factors that can cause disease, both physical and mental – sorcery and witchcraft. Hammond-Tooke (Bodibe, 1992) describes sorcery as the use of medicine or magical substances to cause harm, and witchcraft as the manipulation of psychic powers to cause harm. All of these make up the realm of indigenous health practitioners.

Indigenous Healers


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36. Individuals called to serve society in the capacity of healers are trained to discharge their duty in different indigenous disciplines.

Traditional healer (Ngaka/inyanga)

a. This is an individual who has been called by ancestors, through illness or dreams, to undergo initiation and training to be a healer.

b. The training will equip the healer with skills to harness healing powers that reside with the healing spirits (Bodibe, 1992).

Head diviner (Senohe/isangoma)

a. Diviners are healers who can see into the remote past and the distant future. They are thought to have a special relationship with the spirits of the ancestors.

b. Once in a trance, they are able to communicate with the ancestors and thus disclose to patients what may be wrong in their lives.

c. At times this is regarded as the superior form of divination (Bodibe, 1992).

Herbalist (Raditlama)

a. Other writers have called this kind of healer as the traditional pharmacist (Bodibe, 1992).

b. The individual practising this form of healing is usually knowledgeable in pharmaceutical effect of herbs, plants, roots and leaves.

c. These are mixed in a manner that makes them deliver the desired cure (Bodibe, 1992).

37. As can be observed, the different types of indigenous practitioners listed here represent different approaches to indigenous healing. They can also be conceptualised as specialisations in their own right. It is also safe to assert that some conditions may be more amenable to particular types of styles than others.

38. In the process of their work, indigenous practitioners mainly work for a mind-body unity. Their work aims at restoring a balanced relationship between individuals and their environment, the people around them and their spiritual world. Here disease is understood as a state of disharmony in the body as a whole and sometimes as a disruption within society (Ramgoon et al., 2011).

Indigenous Mental Conditions3

39. Hereunder follows a brief description of some indigenous mental conditions that are likely to be known in the organisation. The causes and signs of the conditions will be outlined as well as their prognosis:

Mafofonyane/Amafufunyane

3 The content of this section (Indigenous Mental Conditions) is gleaned from the works of Buhrmann, (1982), (1985); Mkhize, (1998); Niehaus et al., (2004); Paniagua, F.A. (2000); Razzouk et al., 2011; Robertson and Kottler, (1983) and van der Riet, (2001).


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d. Causes : This condition is thought to be caused by evil intent.

e. Symptoms : It affects mainly women under the age of thirteen (13).

i. It is marked by abdominal pain and rumbling.

ii. Patients may run around, be confused, violent and with enormous physical strength.

iii. Often they faint and display epileptic-like behaviour.

iv. They may utter strange languages and become breathless.

v. In its worst form they may appear psychotic: exhibiting uncontrollable behaviour such as weeping, tearing their clothes and throwing themselves to the ground.

vi. They may also attempt suicide and be violent when efforts to restrain them are made.

f. Prognosis : The condition mostly defies allopathic medical intervention.

i. It has good chance of effective management if it is done through indigenous interventions.

ii. Given the nature of the manifestation of the condition, patients who suffer from it should be disqualified from enlistment into the military as they may pose danger not only to themselves but also to others in their immediate environment.

iii. However, with appropriate intervention the condition usually clears up and the patient returns to normal functioning.

Bothuela/Ukuthwasa

a. Causes : Nearly in all cases this condition has positive connotations.

i. It is a sign of a calling from higher powers, the patient’s ancestors or even god.

ii. As the term suggests, ukuthwasa means the emergence of something new (new moon, new season, new heavenly constellations).

iii. To be a thwasa, means that the ancestors or the gods are working on the patient, leading the patient to a new beginning, a new vocation, a new calling.

iv. Appropriate treatment will open new horizons of service for the patient.

b. Symptoms : The manifestation of the symptoms may be unique for individual patients.

i. However, most patients are aware of the reasons behind the appearance of the symptoms.


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ii. In its benign form, the patient may display unusual psychic abilities.

iii. There may be physical and unexplained bodily pains.

iv. In other instances, physical accidents may occur to the patient or those close to the patient.

v. Symptoms may intensify if the patient resists the calling.

vi. In its worsening form, the calling may manifest as violent physical illness which flouts western medical intervention.

vii. There may be hallucinatory symptoms such as hearing of voices calling the patient to be of service to the community.

viii. Delusions in the form of dreams and visions with a calling message are common.

ix. Death may also result as a form of punishment.

c. Prognosis : The condition defies allopathic medical intervention.

i. However, it has good chance of successful resolution if the patient complies with the directives of the calling.

ii. Patients who present themselves for recruitment before completion of their traditional initiation training should be disqualified from enlisting into military service.

iii. Review of their application can be considered after they have fully complied with the requirements of their initiation and calling.

iv. However, this condition usually clears out completely once the patient has fulfilled the requirements of this calling and the patient regains effective functioning.

Bohlanya/Ukuphambana

a. Causes : This condition may have different causes.

i. It may develop because the patient resists the calling of being of service to his community.

ii. Sometimes, however, it may be the result of evil intent.

b. Symptoms : In its simple expression, the condition is marked by unexplained illness, bodily pains and visual delusions and auditory hallucinations.

i. There may be signs of losing touch with reality.

ii. As the patient continues to resist the calling, the conditions may worsen.

iii. This phase is characterised by crude delusions and hallucinations, growing disorientation and total breakdown of rational behaviour.


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iv. The resisting patient may die through unexplained accidents.

c. Prognosis : Western medical interventions are also not effective here. Allopathic medicine only serves a temporary relief.

i. Patients who present themselves for enlistment into military service before completion of their traditional initiation should be disqualified.

ii. However, review of their application could be considered after they have fulfilled the requirements of their calling.

iii. The good news is that this condition usually clears out completely after the patient has complied fully with the demands of the calling and regains full functioning.

40. These are not the only indigenous mental conditions known by some members of the SAMHS. There are few others that are known. These have not been included in this list because of their rarity. Context does not permit the discussion of indigenous syndromes from other parts of the world. The reader is referred to Akbar’s (1980) work on mental disorders of African Americans. His approach is instructive.

MANAGING INDIGENOUS MENTAL CONDITIONS

41. The critical question about indigenous mental conditions relates to their management. As these conditions fall outside of the mainstream health paradigm, they are not acknowledged by the SAMHS policy provisions. Allopathic mental health practitioners in this organisation who come across patients who present with these conditions find themselves in a tight corner. In order to be of service to patients, they have developed creative means of navigating around this shortcoming (Motaung, 2013).

42. Their creative ways of managing the problem could raise a couple of ethical concerns in some circles. Health practitioners are torn between upholding ethical codes, on the one hand, and servicing their patient’s everyday needs adequately, on the other.

Integration and Collaboration

43. Recognising that the present health care system is not adequately serving the needs of our diverse patient population, two propositions are sometimes proffered as a way of responding to the challenge. First, integration is proposed as a means of responding to the challenge. Here the basic intent labours to co-opt indigenous practitioners into the mainstream health care paradigm with the aim of incorporating them. In practical terms it means allocating consulting rooms to indigenous practitioners in the clinics and hospitals. Envision indigenous practitioners sharing a corridor with allopathic health care practitioners and doing their work within an allopathic health setting.

44. The obvious difficulty here is the power relations implied–one paradigm being swallowed by the other. This arrangement suggests that the one is superior while the other is inferior, and thus ready for co-option. Consequently, the one paradigm is bound to maintain its integrity, while the other would be expected to live up to the expectations of the other. Indeed the idea of one paradigm moving into the premises of the other implies skewed power relations. The one is a giver, the other a receiver. In this situation, it should be obvious as to who the boss would be. Integration is not favoured by some indigenous health practitioners because of such implications.


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45. The second proposition is that of collaboration. Here the two health care paradigms maintain their integrity and boundaries intact. They retain their separate premises to consult their patients. Each system follows its own rules of conducting business. However, where the one system hits a brick wall and realises that it lacks capacity in one area, it is free to refer patients to the other without hesitation. In this arrangement there is mutual respect and mutual recognition of the skills inherent in each system. Instead of competing to outdo one another both paradigms hold hands and co-operate for the sake of optimum patient health care.

46. It is obvious that this kind of approach is favoured my most indigenous health practitioners. There is no doubt that even allopathic health practitioners would welcome such an arrangement. The attractive feature here is the reality that each health care paradigm maintains its own integrity. There is no pressure to conform to certain standards that may not be speaking to one’s values. Each paradigm pursues health care objectives within the parameters of its own traditions and philosophy. Where there is need to conform, it would be conformity in line with own values and context. For this reason, practitioners in the respective paradigms would be congruent in their practice because they would be doing what they were called to do in the spirit of the initial summoning. In the same vein, it is doubtful whether indigenous health practitioners are interested in wearing white coats and rambling through the corridors of clinics and hospitals. The same could be said regarding allopathic health practitioners in indigenous practitioners’ gear.

Governance Limitations

47. It should be obvious by now that the basic line of thought herein is that current rulebooks do not cater for indigenous mental conditions (Motaung, 2013). From time to time allopathic mental health care practitioners see patients who report to have conditions that are not amenable to allopathic treatments but seek indigenous interventions. Proper indigenous intervention in some of the cases require patients to be absent from work for up to six months. When confronted with such a dilemma some allopathic mental health care practitioners hit a brick wall and become stuck. Other allopathic mental health care practitioners become creative and devise means to skirt around this policy impediment. The skirting is done with the view to satisfy human resource policy demands regarding the granting of leave of absence from work.

48. One of the ways in which this is done is to give the consulting patient an ICD diagnosis code. After an officially recognised diagnosis is attached to the patient, then the patient is granted leave of absence from work on medical grounds. The patient will then use the leave days to undergo indigenous treatment from an indigenous mental health care practitioner. When leave days are about to be exhausted, the patient approaches the allopathic mental health care practitioner for extension of leave. The leave4 is continually extended until the patient completes the indigenous treatment.

49. There is no need for this kind of skirting around policy points. This calls for policy review and recognition that the bulk of our patients are of African descent and that they subscribe to the African world-view even in matters of health and disease (Motaung, 2013; Ramgoon et al., 2011). It should go without saying that policies governing this establishment should acknowledge and reflect this reality. This contradictory stance is particularly strange in that South Africa is located on the southern tip of the African continent and is ruled by an ‘African’ government. One would try to understand their attitude had this government been of persons of another race. If a creature from another planet would land in South Africa and

4 I have hinted to possible ethical questions surrounding the act of ‘beating the system’. This is a debate that needs to move away from the ivory tower and be led by those mostly affected by it – the marginalised.


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observe the laws that are used to run the country, I am sure that the strange creature would vouch that South Africa is not an African country.

50. In the same vein, an argument can be made that allopathic mental health practitioners who bend rules to accommodate their patients may be guilty of violating ethical imperatives. A relativist counter-question can also be posed to the effect that whose ethical code are they violating? Is upholding ethical codes more important than serving human health needs? What if those ethical codes are a burden to the down-trodden? If allopathic mental health practitioners are aware that these ethical codes are adding to the marginalisation and stigmatisation of alternative paradigms to health are they expected to uphold them? Where does social/medical activism start and where does responsible health practise end?

Essential Improvement

51. The foregoing illustrates the hurdles that alternative paradigms have to contend with in order to find space under the sun. They have to prove themselves and come up with multiple reasons to justify their right to co-exist with other paradigms in the health space. Mind you, we have not even alluded to their right to practice their craft. If this is not the politics of power, I do not know what it is. Politics has to do with the exercise of power. Paradigms are steeped in political power. Their custodians reserve the right to allow certain views to be expressed and others to be marginalised. Research output or any work that does not toe the line and meet ‘international standards’5 is disregarded and remains unfunded, unpublished and unrecognised. Voices that do not sound the familiar tune are ostracised, silenced and banished from the airwaves. This is the power of politics (Sithole, 2009).

52. The foregoing suggests the need for an open mind approach. Even here, this could be viewed as a pipe dream because power tends to envelope those who wield it. They tend not to understand any other language except that of power. Be that as it may, however, there is a need to use power to innovate rather than stagnate. One of the ways in which this could be done is to move away from a tunnel vision, where focus is only on what is known, and marginalise anything that we do not understand or know little about. There is no doubt that tried and tested ways of doing health should be maintained. In the same vein, this should not preclude us from opening our eyes to other ways of doing health. These should not be marginalised and relegated to the periphery. Advocates and practitioners of indigenous health should be engaged and their methods interrogated with the view to appreciate their efficacy and usefulness. This engagement should not be premised on the objectives of pharmaceutical companies whose sole reason for existence is the accumulation of super profit with little regard for ethics. In pursuit of this objective nothing deters them from adding to the plight of the poor by stealing their knowledge of indigenous remedies that have been used by indigenous practitioners for centuries. On the contrary, this engagement should be premised on the need to understand the work of indigenous practitioners better.

53. How can we explain the reality that some seventy per cent of South Africa’s population do make use of indigenous practitioners for various health reasons (Ramgoon et al., 2011)? Can we justifiably attribute their faith in them to pure ignorance and backwardness?

54. The other important matter relates to education and training. Our education resembles little of our heritage. It instils very little of our culture. The only practical thing about our heritage and culture remains at the level of rhetoric. For instance, despite decrying colonial oppression that was visited on indigenous people for centuries, when the new political order came into being, mother tongue instruction in primary schools was scrapped in favour of English. This was the doing of an African government! Further, it is known that departments 5 That is another way of towing the line. International standards are another word for western views. In this view, all things western are to be emulated. Others from elsewhere are to be worked and reworked until they mimic western models.


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of African languages in our universities are closing or scaling down their operations because of various reasons.

55. However, it is encouraging that other institutions of higher learning have become discontent with the prevailing thrust. Particularly in matters Psychology, some universities have begun reshaping their approach in the teaching of Psychology and training of Psychology practitioners. They have developed modules where students are introduced and trained in indigenous and African Psychology. It should be pointed out, however, that introducing modules here and there on matters indigenous although commendable, is an insult to Africa as a continent, to say the least. If this was done in some western country it could be commended. Taking such measures with African students in an African country on the African continent is difficult to understand!

56. Another matter that calls for serious attention is the issue of policy contradictions. It is confusing to have a bill establishing a council for indigenous practitioners and have other state departments issuing policy pronouncements which stress the non-recognition of indigenous practitioners and their work. This obvious lack of harmony among state departments is not encouraging. It creates the impression that the left does not know what the right is up to. It suggests that bureaucrats are allowed to follow their whims and display them in the manner in which they feel on the moment of the day. If this was coming from a government of a far-away country, one could excuse the contradiction. However, if it comes from a supposedly one government, it is confusion of the highest order!

57. Research and validation is another important aspect that needs brief mentioning. This element is always cited as lacking in indigenous health practice and that this deficiency makes it hazardous. It should be stated that research in the western sense is incompatible with indigenous health practice as the two are based on two different premises. If one were to use the assumptions of one epistemology to interrogate another, one is bound to observe supposed contradictions and limitations. To avoid this pitfall one must first understand the basic assumptions of that novel field before attempting to have dialogue with it. Dialogue must be conducted within the framework of those basic assumptions. If this is done, then a meaningful dialogue is bound to ensue to the satisfaction of all concerned.

58. This element is critical when the idea of research and validation is applied to indigenous health practice. Validation of indigenous health practice should be done in context of its basic assumptions. One must first understand the basic assumptions before one could begin meaningful dialogue with it. Nobles (2006) argues that the African researcher should use African concepts to describe and give meaning to African phenomena. If one were to do this faithfully, one is bound to be struck by the realisation that indigenous practitioners know what they do and that the methods employed by them have been used for centuries by their predecessors. That is, if the methods of indigenous health practitioners were to be placed under the spotlight, that scrutiny must be founded on the assumptions of indigenous health practice. This point will be taken up later again.

59. In the interest of a comprehensive health care service for our patients there is an urgent need to tackle these matters. The NDH needs to move with speed to address matters of policy that impinge of indigenous health practice. It is not surprising that other state departments such as the SAMHS are still not accommodating towards indigenous health practice because the NDH has not addressed this matter purposefully. Other entities that are concerned with health in the country, including the SAMHS, follow the lead of the NDH. If the NDH is lukewarm towards indigenous health practice, then other health entities are bound to adopt the same attitude because they follow the lead of the NDH. Likewise, any policy reform from them will find resonance throughout the various health organisations that are serving the country.


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Material Application

60. The foregoing might leave someone with the impression that this work is all about identifying weaknesses without suggesting solid solutions. To the contrary, the remaining space will propose envisaged solutions. First, it would be sensible to work to win the co-operation of indigenous mental health practitioners in the delivery of military health services. Intention is critical here. It is granted that the SAMHS are in no position to usurp the NDH’s prerogative of setting policy and dictating its amendments. Even here it should not mean that the SAMHS are impotent and cannot do anything to that effect. The SAMHs are in a position to influence intent and ultimately policy shifts. For instance, the SAMHS have a seat in the meetings of the National Health Council where matters of national health are discussed. It is in such forums that intention of the SAMHS could be articulated with the aim of influencing policy amendments. Of course for this strategic objective to succeed, SAMHS representatives in such forums should have moved beyond mere rhetoric in their deliberations and be completely sold to the need for co-operation between the current approach to health and indigenous mental health practitioners.

61. Second, it can be argued that health rather than education is the core business of the SAMHS. In the same vein, it cannot be denied that the SAMHS are involved in military health education and training through its various institutions. It is here that the SAMHS can play a meaningful and progressive role. Whether it is the training of nurses or medical or psychological interns, or military health practitioners of any kind, curricula could progressively be worked to reflect the African heritage and world-view. For instance, the African heritage could be infused in the training by roping in indigenous practitioners as part of the training staff. Incorporation of indigenous practitioners in the training staff would not be aiming to turn the military health trainees into indigenous practitioners but to confirm their heritage, raise awareness and to emphasise the reality that there are other paradigms of looking at matters of health. For this to be realised, the SAMHS leaders need to have moved beyond oratory activity and live out the truth that the SAMHS are an African organisation that is located in an African country with a rich African heritage to serve an African clientele (Odora Hoppers, 2002). The African heritage should be the context in which health education is conceptualised and done.

62. Third, and closely related to the foregoing, is research that is useful in the African context. Herein the SAMHS are uniquely placed to make important contribution in military health provision. Until now, our military health approach has been largely based on research observations that are generated in foreign lands. Even the text books that are prescribed and methods taught are imported from other continents with the intent of adapting them for our conditions. With the numbers of military personnel at our disposal and the calibre of scholarship South African universities have produced, notwithstanding the aggregate of universities the country has, the SAMHS are in a position to address and reverse this weakness. Establishing partnerships with local universities, through its various professional directorates, the SAMHS are uniquely placed to champion exceptional African military health research that speaks to African environments and needs, rather than rely on ideas that are born elsewhere. It is a moot point to elaborate on what each professional directorate can contribute in this endeavour, save to suggest that the potential is unimaginable. As much as adequate budgetary allocations are made for various aspects of health delivery, research provisions should not be ignored. Time has long past where doubts are expressed about the need to prioritise this aspect of military health and leave it to chance allocations or allotments made grudgingly. As the purchase and maintenance of medical equipment and medicine receives high priority in budgeting, African military health research should enjoy the same prominence. It is a known fact that observations from military research have improved life for the average citizen when those projects are commercialised. There is no reason why the SAMHS cannot play that role not only for the country or region but the continent as well.


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63. Finally, it has already been acknowledged that the SAMHS are not mandated to decide on national health policy prescripts. Their duty is to implement health policy. This policy implementation should be done within the framework of an African military health service organisation. The emphasis here is on the word ‘African’. That is, the SAMHS need to understand that before being a military health organisation, they are an African organisation. Being African comes first. It is their roots. It is their heritage. This origin cannot be wished away. The SAMHS are not only an organisation that is found on the African continent; the SAMHS are also manned by African health practitioners for African military patients. They cannot be anything else in the name of medical science. The other emphasis is in the phrase ‘military health service’. This phrase means that the SAMHS exists for the sole reason of providing health service to members of the SANDF. They were trained to perform health duties and that is what they are mandated to do. However, their training and credentials have no power to alienate them from their heritage because doing otherwise is self-denial. Although trained in a foreign world-view, they are astute enough to indigenise their health practice through their heritage. They do military health through their heritage. When the SAMHS conduct their business in this spirit, it is difficult to imagine policy makers failing to notice that kind of commitment.

CONCLUSION

64. These pages sought to bring the issue of indigenous mental conditions onto the agenda. World bodies have come to realise that this aspect of health care is a reality to a sizable percentage of people of the world. This has led compilers of the ICD to commission studies to examine this aspect with the view to incorporate the findings into the newer volumes. It is also true that there was a time in South Africa in which health authorities began mentioning about these matters in their articulations. This appeared to be an encouraging development which suggested that the efforts of marginalised groups were having the desired effect.

65. However, it is true that the health space is dominated by powerful paradigms. This state of affairs obtains even in non-western regions of the world. The dominant paradigms hold sway in conceptualising questions of health and illness and their management. These paradigms are also fundamental in the training of health care practitioners and their partners. Without doubt the dominant paradigms have entrenched themselves in the health space with the result that other competing models have had difficulty in carving respectable room for themselves.

66. It is not as though the tenets of the dominant paradigms were worshipped across the world. There have always been others who questioned the wisdom of one paradigm being touted as universally applicable without taking into account unique contextual factors. Others have even gone to the extent of questioning the tendency of ignoring long standing local traditions and imposing imported notions of health and sickness on communities. This discontentment led to the emergence of African Psychology and its essential attempt to indigenise Psychology. Rather than attempt to build a brand new paradigm, African Psychologists have gone back to ancient African philosophies and African traditions and African histories to relearn how their ancestors and forbearers understood the world and life. What they observed from those inquires is that even before the birth of western Psychology as we know it today, our ancestors were doing Psychology.

67. What is remarkable about this is the realisation that our ancestors were doing Psychology in context. They knew of indigenous mental conditions, and did not need to have someone come from some other place to teach them. They adopted this posture because they were content with the work of their hands as they witnessed their patients getting better through their interventions. They did not envy to be like practitioners of the dominant paradigm nor did they wish to use their facilities to conduct their business. All they yearned


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for was mutual respect and recognition to the effect that they too were celebrated helpers in their respective communities.

68. Mutual respect and recognition of their work as health work would require amendment of policy because as things stand now policy regards their work as non-work. There have been many undertakings to do something about this shortcoming. However, until now those undertakings have proved to be just empty rhetoric. There is need to seriously examine this matter because it is fundamental in the management of health provision, patient administration and human resource demands. The day this weakness is addressed fully, the organisation would truly be embarking on the road of providing its constituency with a comprehensive excellent and world-class health service.

69. In the meantime, practitioners who come across patients whose symptoms appear not to fit book description of standard diagnostic criteria would be wise explore the local resources that are available in their immediate work environment. It is standard practice in professional circles that practitioners tap on the knowledge of colleagues on matters that are beyond their training and expertise. Even colleagues who function at a different level to that of the professional practitioner could prove useful in matters indigenous. For instance, a nurse, clerk or even a cleaner in the immediate working environment of the practitioner could be an important and useful resource. Someone may suspect ethical issues in a professional practitioner consulting a non-professional. This concern should never come up because the professional practitioner would not be discussing patient matters with a non-professional, but would be raising matters indigenous to a non-professional in a manner that satisfies professional expectations. The matter is even better when a practitioner happens to work in a multi-cultural environment. Exploiting the value of differing cultural perspectives on issues could be useful to most who work from a dissimilar outlook. An argument could made to the effect that this approach has its own strengths. After all has been done, however, it still remains the responsibility of the practitioner to formulate his understanding of the problem and plan the intervention.

70. Our patients expect help from health practitioners when they do consult them.

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