On searching and finding health : setting the scene for health-seeking behavior in Sunga Ward, Tanzania

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6 Kutafuta na kuona:

on searching and finding.

Setting the scene for health-seeking behavior in Sunga Ward, Tanzania

E.G. van Putten

10517081

Medical Anthropology and Sociology 2013-2014

Supervisor: Eileen Moyer

Graduate School of Social Sciences

June 23th, 2014

University of Amsterdam

Amsterdam

Kutafuta na kuona afya

On searching and finding health.

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English language editing by N. Blankvoort MOT MSc. GH

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Acknowledgements

This thesis could not have been what it is today without the help of various people. Each person involved has supported me in different ways, but they all have been of great importance to me in the process of preparing and doing fieldwork and writing my thesis. I am very grateful to all of you.

First of all, Sefu my research-assistant, gatekeeper, translator, key informant and above all, friend, deserves special attention for his help. His never-ending patience, unlimited helpfulness, and high level of objectivity in interviews were invaluable. His efforts to arrange appointments for me, his lessons in Kiswahili and Kisambaa and all the hours we walked around Sunga Ward and talked about various topics are moments that have been very important to me. Without Sefu, I would not have been able to accomplish as much as I have in this project. I am also thankful to Simon, who has spent many hours transcribing my interviews and therefore freeing me time that I could spend gathering data. Simon was always willing to help me with my research and with his sharp eye and high intelligence taught me valuable lessons that helped with my fieldwork.

I would like to thank Wolter and Kim for their helpfulness, advice, reflections and supervision on my research. Moreover, with their hospitality and good facilities, they have provided me with a tremendously beautiful, comfortable and convenient place to stay during my research. It was a pleasure to live in their lodge. This pleasure has also been made possible by the friendly and cheerful staff of the lodge and the ‘professional volunteers’ Rafael, Jan Peter, Maud and Niek who have all in their own way helped to make me feel at home in Mambo.

Beyond Tanzania, there are also several people back home that have been of major importance to the realization of this thesis. First of all, thank you to Eileen Moyer, my supervisor, for her

supportive and contributing words and advice before, during, and after my fieldwork. Her motivating feedback has been of central importance to the quality of this thesis. She and Rene Gerrets have furthermore helped me out in periods of stress and doubts. Without their help I would not have felt so confident entering the field.

Special thanks to my parents Piet and Mem for their strong confidence in me and my

academic performances. Their constant support and motivating words strengthened my confidence in myself. The warmth, joy, room and care back home enabled me success during my study, and of course their trip to Tanzania was special and unforgettable.

Last but not least, my informants. The knowledge I gathered by them sharing their personal stories, opinions and lessons with me are the foundations that enabled the existence of this thesis. They are the ones who live with poverty, witchcraft and often failing healthcare services. I dedicate this thesis to them.

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Summary

This is a study of health-seeking behavior in the rural community of Sunga Ward, Tanzania. Sunga Ward has a medical pluralistic setting, meaning its inhabitants must routinely make decisions about which healthcare provider to approach when confronted by illness. This study focuses on the

contextual variables that influence their decision making. Choosing biomedical, traditional or religious healthcare, or approaching one’s therapy management group for financial or caring support is shaped by factors including personal characteristics, financial resources and available services. However, the major variable in health-seeking behavior is, reasonably, need. This study follows-up on the seminal research by Feierman (1981), examining contemporary relationships between illness causation and health seeking behavior and analyzing general trends between illness categories and therapy choices among Sunga Ward’s inhabitants. Illnesses are generally categorized according to whether they solely affect the physical body, and/or social and moral aspects of health. Correspondingly, different

healthcare traditions offer different kinds of treatments, based on the physical, the social and the religious. The co-existence of different healthcare traditions nevertheless influences the execution of treatments forthcoming from these traditions, either strengthening authenticity claims, or unifying their practices. As long there will be illnesses from different categories, Sunga Ward is likely to remain pluralistic in terms of healthcare, with varying treatments relating to varying illness causations.

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1. Introduction

It is a humid Wednesday afternoon at the beginning of rainy season at the Sunga dispensary, where I am helping Samuel, the clinical officer, during the monthly HIV clinic. Together we sit in his stuffy, tiny consulting room. Samuel gives out medicines folded in an old piece of newspaper to the HIV-infected patients as I write down their names and patient numbers for administrative purposes. Samuel and I are chit-chatting about the difficulties of working with few staff members in a dispensary with so many patients when two tall men enter Samuel’s office. They are from the Center for Disease Control (CDC) in Dar es Salaam and are investigating the expenditures of dispensaries with HIV clinics in Tanga Region. They start talking with Samuel in English and mention his planned transfer to Mlalo, a village 15 kilometers away as the crow flies and where already several clinical officers work. The discussion of this transfer is accompanied by very loud but awkward laughter from all three men. Samuel’s transfer means the absence of a health professional with higher education than a nurse for the estimated 30.000 people living around Sunga. “No, you cannot go! Then there is no professional healthcare facilitator for all those people anymore!” I call out, joining their awkward laughter as a way of expressing my frustrations and discomfort over the seeming arbitrariness and absurdity of Tanzania’s healthcare system.

1.1 The setting

The aforementioned situation shows the functioning of Tanzania’s public healthcare system, which seems for myself, as someone accustomed to the healthcare system in my own country of the

Netherlands, often illogical. Sunga Ward, already wrestling with understaffing of health professionals for its high number of inhabitants saw their only clinical officer being transferred by the district executive officer (DEO) to Mlalo, a village that already has several clinical officers for fewer inhabitants. The reason behind this transfer? The DEO comes from Mlalo and decided that ‘his village’ could use another health professional, leaving Sunga with nothing but poorly educated

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nurses.1 When I heard this, my first reaction was one of surprise and irritation. I deemed this as deviant behavior by the DEO, resulting in corrupt practices. However, Anders (2002:2) shows in his article how corruption can be explained by civil servants who try to keep up with the obligations and expectations between them and their relatives. They have the position and resources to make certain decisions or to transfer money in such a way that their relatives will benefit from it. When refusing this, you risk punishments such as witchcraft and banishment. This is probably what made the DEO from Lushoto decide to transfer Samuel to Mlalo, where many of his relatives live. While in the consulting room of Sunga dispensary, discussing Samuel’s transfer with the three men that were present, all men reacted quite fatalistic to this news. Samuel shrugged his shoulders and said that this is just how it is. It is a governmental decision that he has to live up to. Also the employees of CDC did not seem very surprised, let alone irritated by this decision. For them, this was just one of the

occurrences in the world in which they live. As being an occurrence that affects the available

healthcare services in Sunga Ward, situations like these influence decisions made by and behavior of Sunga Ward’s inhabitants. This thesis will show how contextual variables influence and shape the health-seeking behavior of Sunga Ward’s inhabitants.

Sunga Ward is located in Lushoto District in the Western Usambara Mountains of northeast Tanzania. Sunga Ward is inhabited by approximately 22.500 people, mostly from the Shambaa ethnic group. They live in a religious pluralistic setting where almost all inhabitants believe in Shambaa religion, but are meanwhile also mostly Muslim, in addition to a substantial number of Christians (Thompson 1999). In 1981, Feierman wrote that at that time, a significant number of the Shambaa people were farmers, but many also worked in big cities and still had a house on the countryside (Feierman 1981:354). In 2014, the majority of Sunga Ward’s inhabitants were still farmers. Most families had one or two cows and a shamba, a plot of land on which they cultivate vegetables and staple food. The Shambaai, the area where the Shambaa lives, is highly bio-diverse and quite cool compared to other parts of Tanzania and therefore an ideal homeland for an ethnic group that relies to a great extent on agriculture and cultivates numerous different food crops (Feierman 1974). The Eastern Arc Forests of Tanzania, where the Usambara Mountains and forests are part of, are unique for

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their high level of endemic flora and fauna species (Myers 1990:248, Hamilton in Thompson 1999:324-325). Because of this high biodiversity, the Usambara Mountains have many medicinal plants and a resulting flourishing culture of traditional healthcare (Thompson 1999:325). The closest city to Sunga Ward is Lushoto, which is a two hour drive by car or three hour drive by bus over unpaved roads. Despite its remote location but because of its beautiful landscape and convenient climate, the Western Usambara’s are relatively touristic. The area is a popular spot for tourists who want to hike, bike or ‘sniff a bit of local culture’. Sunga Ward’s inhabitants are therefore regularly confronted with people coming from intercontinental, international or national destinations and who bring with them different sets of behavior, values, norms, languages, ideas, opinions, etc. De Bruijn et al argue that mobility as an umbrella term for all types of movement is fundamental to an

understanding of African social life. Through travelling, they state, ‘connections are established, continuity experienced and modernity negotiated’ (de Bruijn et al 2001:2). We should thus keep this high level of intercultural contact in mind for a thorough understanding of health-seeking behavior among the inhabitants of Sunga Ward. Despite of or maybe because of these intercultural influences and its remote location, Sunga Ward has a strong community spirit. Characteristic for the Shambaa people is the importance of the extended family, or in terms of healthcare, the therapy management group as labelled by Janzen (1978).2

Feierman already mentioned in the 1980s that due to urban migration many people have left the area where Sunga Ward is part of. They now live in towns and cities such as Dar es Salaam, Tanga, Moshi, Arusha or Korogwe. Some of them still have a house in Sunga Ward for themselves or for their family, but others left permanently and only occasionally return to visit relatives. Especially after independence, when colonial rules that restricted rural-urban migration were abrogated, the number of people that moved to the cities increased tremendously (Lugalla 1997). In the 1960s and 1970s, more than 40 percent of urban growth in Africa was ascribed to rural-urban migration (Tacoli in De Bruijn et al 2001). Consequently, employment was scarce in urban areas, resulting in a

flourishing informal sector to combat urban poverty. The economic crisis and introduction of ‘structural adjustment programs’ (SAPs) for economic reform in the mid-1980s gave another strong

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boost to the informal sector. Living costs rose but salaries stagnated. SAPs moreover devaluated the local currency, stopped government expenditures on social services and thereby counteracted

employment opportunities. Also in rural areas poverty increased and more people moved to the city to look for better living conditions, thereby increasing the pressure in the cities. This changed the urban labor markets and the informal sector was consequently an outcome to earn some extra money and survive in those hard times (Lugalla 1997, Tacoli in de Bruijn et al 2001). Urban migration was thus not a solution to rural poverty. Accordingly, in the 1980s and 1990s, rural-urban migration accounting for urban growth in Africa declined to only 25 percent (Tacoli in de Bruijn et al 2001). These trends in movement were recognized around the continent. Also in Southern Africa, SAPs and urban economic decline triggered rural return migration in the 1990s (Andersson in de Bruijn et al 2001). 3 Generally speaking, poverty turns out to be a limiting contextual variable in health-seeking behavior. Limiting, because hard accessibility and poor availability of health services caused by an inability to pay can withhold people from approaching the healthcare facilitator they prefer. This research will moreover show that urban relatives are, despite poor living conditions, often approached as being member of someone’s therapy management group, to support financially a sick relative.

Sunga Ward has a medical pluralistic healthcare system, meaning that its healthcare system is made up of diverse healthcare providers, working from different healthcare traditions that exist alongside each other and on different levels of Tanzania’s healthcare system. Kwesigabo et al (2012) describe that after independence, in 1961, the new Tanzanian government developed a national health system with the aim of providing the whole, mainly rural population access to health services. A multi-tiered and decentralized health system was established with health facilities organized from small-scale to more specialized facilities, in order to make also the rural population able to approach public healthcare. Later on in this study will however be shown that despite this decentralized system, (satisfying) public healthcare is still hard accessible for the population living in Sunga Ward.

3_{I limit myself to this short explanation of poverty, mobility and structural adjustment programs (SAPs) in} Tanzania. A lot more can be written on the big changes in Tanzanian society after independence and in the mid-1980s, and on poverty, migration and (participatory) development and its effects for (the use of) healthcare services. Time and space limits withhold me studying these concepts more extensively in this paper. Further research on those topics can be found by Lugalla (1997 and 1995), Green (2000), Willis (2011), de Bruijn et al (2001) and De Waard (2013), with the last one providing a study specifically on participatory development in Sunga Ward and the role of the eco-lodge herein.

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Nevertheless, Tanzania’s healthcare system nowadays still exists of six levels. The first level contains the ‘grassroots’ which entail midwives, home based attendants4

and local healers, in Swahili mganga (singular) or waganga (plural). The second level contains dispensaries in rural villages that provide simple medical care and which also hold a Reproductive and Child Health Clinic (RCHC) and some, among which Sunga dispensary, have a monthly HIV clinic. Thereafter, at the third level, come the health centers existing at Ward level that provide preventive and reproductive healthcare and do minor surgery. The forth level contains the district hospital that does outpatient and inpatient care and diagnostic and surgical services. Then, there are the bigger regional hospitals in the bigger cities that provide more specialized care and make up the fifth level of healthcare facilities. Finally, Tanzania has four specialized referral hospitals for specialized care and advanced technology (Kwesigabo et al 2012).

In Sunga Ward, the first and second levels of the national healthcare system are represented. Sunga Ward contains eight villages, of which three have a governmental dispensary that is

functioning: Sunga (build in 1993), Mambo (build in 1997) and Mbaru (build around 1976) and three have a dispensary that is not (yet) functioning (Masereka, Tema and Kalumele). Those dispensaries provide biomedical healthcare. Governmental dispensaries were mostly built after national

independence in 1961 (Feierman 2000:341, Feierman 1981), which is also the case in Sunga Ward. Tanzania was from 1885 till 1918 a German and afterwards a British colony (Thompson 1999:70). Feierman (1981) writes that biomedicine entered the region during colonial times and by missionary influences, where it was confronted with local and traditional healing practices (uganga). During colonial times, the British minimally invested in public health and education and the missionaries stressed the influence of religious faith, personal practices and scientifically based care on health, illness and treatment. Consequently, people’s ideas on health and illness changed by both religious and colonial forces. However, due to insufficient financial and material resources by the British, uganga – traditional healthcare – remained flourishing. Only after independence, the new government led by president Nyerere revitalized the education and national health system, intensifying medical services

4_{Home based attendants are educated by staff in the dispensary and are able to provide very basic healthcare,} assist those who are unable to visit the dispensary or help out with emergencies. Every village in Sunga Ward is supposed to have two home based attendants (open interview Samuel 20/2 and 11/3).

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Photo 2. Sunga dispensary. Photo by author.

in rural areas. The increased literacy rate in this period made people able to form an opinion on biomedical healthcare based on what they read and to relate this to their own experiences with uganga (Feierman 1981:353-354). In Sunga Ward, this resulted in an interaction between European style medicine and Usambara style medicine right after independence. Consequently, the local healthcare system changed because of an availability of modern treatments in a world that was until recently limited to traditional healing, which led to a blurring of differences and reciprocal influences (Feierman 2000:341). Nowadays, Sunga Ward has a medical pluralistic healthcare system offering both modern and traditional healthcare.

Dispensaries and hospitals are the heritage of modern healthcare influences in the region. The closest hospital to Sunga Ward is in Lushoto, which is 60 kilometers away and depending on vehicle, two or three hours’ drive.5

Mtae, adjacent to Sunga Ward, was supposed to have a health center, but during my interview with one of the nurses working here it became clear that since its establishment in 2012 this is still a dispensary and not yet registered as health center. The clinical officer from Mtae was moreover put in jail because he had sold medicines that were meant to be provided in the dispensary in his own private

pharmacy in Korogwe.6

Considering biomedical healthcare providers, this study mainly focuses on Sunga dispensary, and to a lesser extent Mambo

dispensary. Besides treatment of different ‘normal’ illnesses and diseases, the dispensary in Sunga

offers a vaccination day in which all babies and some of the mothers are getting vaccinated against diarrhea, tuberculosis, polio, tetanus, measles and pneumonia.7 Samuel furthermore told me that Sunga dispensary is the only dispensary in the Ward that offers, since 2005, a monthly HIV clinic. The

5_{Open interview Samuel 11/3, Sefu 15/2} 6

informal conversation Sefu, Kim, semi-structured interview Theresa 18/3 7_{See appendix 3 for a categorization of different types of diseases.}

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dispensaries in Sunga Ward are therefore also used by people living in neighboring wards.

Considering staff in Sunga Ward, there are two clinical officers, of which the one working in Mambo dispensary is sick himself and therefore not able to carry his position. Samuel, the clinical officer in Sunga dispensary was treated positively by the community.8 Unfortunately, he is recently transferred to Mlalo and as a result, there is currently no capable clinical officer working in Sunga Ward and its direct surroundings for an estimated 30.000 people (Ruzicka 2013). The medical attendants and nurses of Sunga dispensary told me that they are now taking care of all the patients, even though they do not had the necessary education for this.9

Besides biomedical healthcare, there are around fifty waganga in Sunga Ward of which two use both biomedical and traditional medicines for healing. There is furthermore a group of herbalists who offer local medicines and there are three religious prayer leaders. The therapy management group is a final source of (health)care that is of importance. Chapter 5 extensively addresses all these

healthcare providers present in Sunga Ward. Despite this presentation of a clear classification of healthcare providers, it is for a healthcare provider also possible to perform several roles of healthcare provider at the same time; for example, both biomedical and traditional healer, or both prayer leader and herbalist.10 There are nevertheless a lot of complaints by Sunga Ward’s inhabitants about the insufficient number of medical personnel in the ward. In Tanzania, the number of physicians is twenty-five times lower when compared to the average number of physicians in Africa (WHO 2013). Together with the high birthrate this leads to the workforce crisis as called by the Ministry of Health and Social Welfare in Tanzania, which is a major challenge for its healthcare system. Poverty among both the population and within the health system and poor education are among the main reasons for this workforce crisis (Kwesigabo et al 2012). The number of healers in Sunga Ward has on the other hand increased over time in relation to the population growth.11 Quite often, uganga fills the gap in accessibility of biomedical healthcare services that resulted from understaffing, which might be shown in the health-seeking behavior of Sunga Ward’s inhabitants. Such pragmatic reasons, along with

8

Open interview Sefu 15/2, informal conversation Samuel 28/2, Hussein in focus group discussion 24/2 9_{informal conversation Soraya, Nancy, Francis 10/4, open interview Sefu 11/4}

10_{open interview Sefu 11/4} 11

semi-structured interview Majid 2/4, Farida in focus group discussion 15/4, informal conversation Selemani 13/4

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individual characteristics and preferences, historical and social change, and other factors that shape health-seeking behavior will be examined in this study to the existence and functioning of the medical pluralistic system in Sunga Ward and how the local community uses this system.

1.2 Central question

I entered the field with a curiosity for getting to know the arguments behind people’s choices for which healthcare provider or tradition they choose when there are several options available. The question “What motivates people’s use of biomedical and traditional healthcare in Mambo and, to

what extent is the use of specific healthcare shaped by people’s ideas and feelings towards indigenous, biomedical or syncretic healthcare?” was the guideline in my research in the first few weeks in the

field. But after having gathered the first bits of information, I missed a focus on the context of medical pluralism. I thought studying the development of medical pluralistic or syncretic practices as a product of social and cultural medical systems (Kleinman 1978) in relation to health-seeking behavior was more interesting and useful than a study that solely focuses on the result of health-seeking behavior. I changed my central question to “How does the health-seeking behavior of individuals and therapy

management groups and their ideas and feelings towards biomedical and traditional healthcare lead to medical pluralistic practices and syncretic healthcare?”. The second part of my research unfolded

along this question.

I conducted research for eleven weeks, investigating the health-seeking behavior of my research population in a medical pluralistic setting and working with sub-questions that touch on the availability of health services in Sunga Ward, the health-seeking practices and use of the healthcare system by the community, and finally, the communities’ values and opinions towards healthcare services in Sunga Ward. However, in a study on health-seeking behavior, context influences the outcome of this behavior to such an extent that this behavior can only accurately be studied when taking contextual variables into account as important factors in setting the scene for health-seeking processes. Therefore this thesis will unfold along the central question “How do contextual variables

influence the health-seeking behavior of the residents of Sunga Ward, Tanzania?”. With this thesis I

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religious aspects, shapes the health-seeking behavior of the community. Elucidating the influence of these aspects gives insights in and helps us understand the functioning and use of the healthcare system in Sunga Ward. This study moreover charts the desires, requirements, ideas, feelings and motivations of Sunga Ward’s population towards healthcare use and outlines local healthcare needs. Concrete plans from the eco-lodge where I stayed that are currently at stake for improving the healthcare situation in Sunga Ward can consequently benefit from these insights by corresponding to these contextual variables, needs, desires, ideas, feelings and motivations in healthcare (use) of Sunga Ward’s inhabitants.

1.3 Structure

Subsequent to this introduction is a chapter on methodology, reflexivity and ethics, in which I give special attention to ‘the Card Game’, a method I developed and that will repeatedly turn up in this thesis for supporting or giving information on health-seeking behavior in Sunga Ward. Following is a theoretical chapter that gives a short overview of the relevant theoretical concepts ‘medical pluralism’ and ‘health-seeking behavior’. After this theoretical outline, the first empirical chapter touches on health-seeking behavior in Sunga Ward in the light of a medical pluralistic setting. It starts with an analysis of the health-seeking behavior of Sunga Ward’s inhabitants, followed by a section in which the outcome of this health-seeking behavior is contextualized, after which a discussion is given on the opinions towards different healthcare facilitators in Sunga Ward by its inhabitants. The second empirical chapter shows the pillars on which the medical pluralistic setting of Sunga Ward is built. It addresses sections to biomedical, traditional and religious healthcare facilitators and therapy

management groups as being the operating healthcare providers in Sunga Ward. The last empirical chapter gives particular attention to religious and cultural influences in health and healing. It

furthermore examines the existence and execution of medical pluralism and syncretism in Sunga Ward and questions if the distinction between different healthcare traditions is fading away or maybe even strengthened. To end, the conclusion will give recommendations on how to improve the current healthcare situation in Sunga Ward and of course gives an answer to my central question by which it shows the complexity of the functioning and use of what is an essential human need: healthcare.

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2. Methodology and reflexivity

2.1 Methodology

This thesis is based on data I gathered while doing fieldwork in Sunga Ward. From February till May 2014, I lived in Mambo, a village in Sunga Ward. I lived and worked as a professional volunteer in an eco-lodge that tries to bring development into its direct surroundings. I will discuss the effect of this position for my research and my position in the field in the next section on ‘reflexivity and ethics’. For this section on methodology it is nevertheless important to stress that my position as a professional volunteer enabled me to work with Sefu, my research assistant, gatekeeper, key informant and translator. Sefu is 57-year old Shambaa man who works as a project coordinator in the eco-lodge. His daily work is to manage the efficiency and effectiveness of projects and small businesses in Sunga Ward and to support professional volunteers like me. By being an older and highly respected man in the community, Sefu had direct access to Sunga Wards residents and could introduce me to potential informants.12

My group of informants was a representative of the Sunga Ward’s population. The group was comprised of both men and women and ranged between the age of 24 and 94. Except for the nurse in Mtae, the employee of CDC, and the tourists in the eco-lodge they all lived in different villages in Sunga Ward, but a majority of my informants lived in Mambo village. I furthermore made sure that I spoke to a proportionate number of both Muslims and Christians. Considering occupation, I spoke to several biomedical healthcare providers and several waganga, two religious prayer leaders, a group of staff members from the eco-lodge, a group of inhabitants that were farmers, and a group of inhabitants with other jobs in the Ward such as teacher or shopkeeper. An overview of informants is provided in appendix 1.

I conducted twenty-two interviews, both open and semi-structured, with nineteen informants. Depending on the preference of the informant, the interviews were conducted in Kiswahili or

Kisambaa. Twelve interviews were translated by Sefu, three by Simon, one by Neema and six were

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conducted in English. Those interviews were helpful for that they gave me answers to my research questions and an opportunity to grasp my informants’ opinions on the local healthcare system. Also, I could collect personal (illness) narratives during interviews and ask my informants for examples, additional information or clarification on certain topics. Simon, my second research-assistant,

transcribed all my interviews in English. Subsequently, I checked by myself for all the transcriptions if they were accurately written down. Besides interviews, I had several informal conversations with partly the same, partly different informants. These conversations provided additional information that I had not gained from formal interviews and which gave me a better understanding or extra insight into health-seeking behaviors within the local context. In the first part of my research I conducted a focus group discussion with eight participants to identify themes and topics that were relevant to my

research and of extra interest or importance to my research population. In the last part of my research I conducted another focus group discussion with four different participants to check if my general findings were confirmed or rejected among my informants when they had direct interaction and could discuss with each other. In addition, I used the method of participant observation to check or amplify the information my informants gave me during interviews and conversations. Right after every

worthwhile observation I wrote down what I had seen and experienced, which I also did after informal conversations. During fieldwork, I have myself manually coded these notes and the transcriptions of interviews. I used both indexing and coding codes, mainly making use of the techniques repetition, indigenous typologies or categories, transitions, similarities and differences and theory-related material (Ryan and Bernard 2003).

Besides the aforementioned methods, I created my own method, which I call ‘the Card Game’. It was on the 11th of March, one of those days that I had time to kill waiting for an interview that was postponed for a few hours. In those hours, I read Stacey Leigh Pigg’s article ‘On sitting and doing’ (2013). The paper is about doing ethnography, and Pigg describes how she did her fieldwork in Nepal. At one point she describes the difficulty of talking about sexuality, and her next paragraph starts with “what if, what if we started from a different premise” (Pigg 2013:4). Here she describes how she used scraps of paper to note the local vocabulary on sexual relationships and arranged these papers on a table to find patterns. It is exactly this paragraph that inspired me to develop my Card Game. Pigg’s

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use of simple scraps of paper and a big table to come closer to people’s worlds triggered my creativity. I figured that I could do this as well. The longer I brainstormed about it, the more enthusiastic I got. This method could serve to chart the health-seeking behavior of my informants.

I made two piles of papers, the first one with different healthcare providers and the second one with different illnesses, diseases, mental and physical health problems. The first pile of papers was spread out on a table in a horizontal line. Informants were asked to put the pile of papers with health problems vertically below the papers with the healthcare provider they should turn to when suffering from the health problem that was written on the paper of the second pile. The first pile of papers contained the healthcare providers herbalist, hospital Lushoto, healer, family (with which I meant therapy management group), health center Mtae, dispensary, other, I don't know, combination. I came to this list of healthcare providers by what I knew was available to my informants, and where they therefore in real life also had to choose between when needing healthcare. I also put ‘combination’ because that could give me extra insight in people’s complex health-seeking behavior and possible medical pluralistic practices. The paper with ‘other’ was put in because it gave people the chance to also approach a healthcare provider that I possibly had not encountered yet prior to making this categorization. That was a good thing to do, because only after I created the Card Game, I learned religious prayer leaders are another source of healthcare in Sunga Ward. Also, after developing the Card Game I came to know that the health center in Mtae was actually a dispensary. However, most of my informants also did not know about this ‘fake status’ of the public health institution in Mtae and therefore I decided not to change this paper because my informants might still think they would have access to a health center when needing it.

The second pile of papers contained forty different health problems. Those health issues were organized according to Feierman’s categorization of causes of illnesses. Feierman (1981:355) provides an illness categorization in which he gives five kinds of causes for illnesses; ‘an illness brought by God’, ‘an illness people bring upon themselves’, ‘sorcery’, ‘jini’ (spirits) and ‘acts of the individual’s moral will’. In my Card Game, I also made a sixth category, for ‘other’ diseases. I choose several health problems for every category, except for the category ‘jini’ because besides ‘jini disease’ I did not know of any other illnesses part of that category. The health problems that I chose were a

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combination of what I heard by informants were serious or frequently occurring health problems, health problems I read in literature that existed at my research site, and what I thought of myself and discussed with a medical intern in Tanzania. Together with Sefu, I discussed which health problem was part of which category and he translated the health problems in Swahili. The table in which the Card Game is elaborated can be found in Appendix 2.

The Card Game turned out to be a useful method to discover which choices people make in their health-seeking behavior. The Game enabled me to get a quick and clear overview of which healthcare provider or tradition is mostly chosen for which health problem or even for which illness category in general. I made photos of the result when an informant finished the Card Game and put the results altogether in an Excel document. The colors I gave to the different healthcare providers made the process of discovering general patterns or certain deviations easier. Moreover, I noted down for every participant his or her demographic (age, gender, marital status, religion, place of residence) and social structure characteristics (education, occupation, ethnicity, family status, since when (s)he lived in the place of residence). This enabled me to evaluate if those characteristics might correlate to the choices made in health-seeking behavior.

In this thesis I will use the Card Game as a guiding model, helping me to study health-seeking behavior of Sunga Ward’s residents. I will reflect upon Feierman’s categorization (1981) and try to discover eventual changes that have taken place in categorizing health in the 33 years between the time Feierman made up his categorization and the time that I did my field research.

2.2 Reflexivity and ethics

Working and living in an unfamiliar area inevitably yields surprises, obstacles and changes to initial plans. I planned to study illness trajectories by joining informants during their health-seeking process. Following people with health issues in their search for treatment seemed a helpful method in getting to know people’s health-seeking behavior and discovering possible medical pluralistic practices in Sunga Ward. I informed the staff of the lodge, with whom I have become friends, about this method and asked if I could join them in case they needed healthcare. Unfortunately, no opportunity to join them occurred. Maybe because they did not need healthcare, or maybe because they did not want me to join

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them in this path, which is reasonable to me. When sick, most people are not willing to have a curious stranger around. Consequently, I missed data that I could have gathered at illness trajectories and that could serve as additional information or an extra check for verifying or refuting already obtained data. As a solution, I asked people to tell me a personal illness narrative. This also gave me useful

information, but was less useful in verifying or refuting the rest of my data. Nevertheless, the invention of the Card Game could also partly solve this problem for its ability to discover sides of informants’ health-seeking behavior which some of them initially had not mentioned.

Additionally, the position of professional volunteer for the eco-lodge gave me lots of benefits for my research. However, this position also implicated the expectation that I would gather new, useful information concerning local healthcare practices that would help the eco-lodge to improve its plans for improving the local healthcare situation. One of the owners of the lodge was furthermore a development worker herself. Therefore, I worked in the tension between anthropology and development work, and doing academic research versus gathering quick, useful and immediately applicable information for improving the local healthcare situation. Consequently, I sometimes faced the dilemma of how to carry out my fieldwork. I choose to keep to the purpose of doing academic anthropological fieldwork, since that was in the end the reason that I entered the field. However, wherever possible I tried to satisfy both goals by also asking informants for their recommendations and complaints or concerns in regards to the local healthcare situation. Intermittently, I showed the owners of the lodge the data I had gathered to date, and discussed my findings with them, in the context of asking ourselves how we could improve the situation. This suited to one of the aims of my research to leave a legacy to my research population in the form of improved healthcare services. I do not only want to extract information, I also want to give something back. This academic

anthropological study to the health-seeking behavior of Sunga Ward’s residents might contribute to better understanding people’s choices and health service use. Only after understanding people’s behavior, the current situation can be improved in such a way that it will satisfy the requests of both the healthcare providers and the healthcare users.

Regardless of this tension, I experienced working with Sefu as a great help during my

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research population. The assistance of Sefu moreover helped me with ensuring the quality of my data. Sefu is a well-known and highly respected man in the community who has a wealth of knowledge on many topics, as well as on the community itself. Since he joined me to many interviews as my translator, informants generally dared not to lie or make up answers since Sefu would know when people lied about general topics.13 However, I acknowledge that his constant presence in my research has undoubtedly influenced my research. Informants may have wanted to present themselves in a certain way to me, or to Sefu. It might be that informants – maybe unknowingly –approached my questions differently because they associated me with Sefu. Given the importance of gender and generational differences in rural Tanzanian society, Sefu as being an older man and me being a younger, foreign woman likely shaped the narratives we collected.

Likewise, due to its remote location and few touristic facilities, every white person (mzungu) in Sunga Ward is associated with the eco-lodge. The majority of the community also knew of Sefu’s employment at the lodge. My cooperation with Sefu and the eco-lodge thus surely influenced how the local community saw me. Our association with the lodge consequently might have influenced people’s answers. They could for example mention more often how the healthcare situation should be

improved since they know the lodge possibly has the power to carry out these improvements. I did not ask any questions directly related to the lodge or its management and I introduced myself as a Dutch student, temporarily living at the lodge for being able to do an investigation for my studies in the Netherlands. Due to this, I feel I have not experienced this association of me with the lodge as a serious obstacle in my research. Instead, it has been more of a benefit since it provided me with helpful research facilities such as research assistants, informants, accommodation and supervision.

This research is done in an informal research setting. The difficulty of acquiring official research clearance by Tanzanian authorities for preliminary exploratory research made me decide to carry out this research on an informal basis. This required that I approached my research population and location through unofficial channels such as the staff of the eco-lodge and the network of Sefu. I introduced myself to my research population as a Dutch student studying the health practices of Sunga

13_{Once I did an interview with another translator I received socially desirable answers, which can partly be} explained by the fact that this translator was younger than the informant and had a lower status in the community than Sefu. However, this confirmed my idea that informants were honest when Sefu was joining the interview.

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Ward’s community with the aim of writing a report on my findings. Another consequence of my informally based research was that officially, I was not allowed to do research in governmental healthcare facilities. However, my research location only had two small governmental healthcare facilities. Via Sefu I was able to come into contact with the staff of these healthcare facilities. They were very willing to help me with my studies and therefore I could still do research in these

governmental healthcare facilities. In general, they have been helpful in providing me with

information on biomedical healthcare in Sunga Ward in addition to waganga who provided me with detailed information on traditional healing practices.

Finally, I have asked all of my informants for their informed consent with the sentence “do

you agree if I use the information you tell me for my studies?”. All my informants agreed. When

recording the interview, I always recorded the informed consent of the informant. Moreover, to protect the privacy of my informants, I use pseudonyms for all of them in this thesis. I will leave out

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3. Theory

This study aligns itself with the theory of medical pluralism. I will firstly provide a short overview of the available literature in this tradition and the relating concept of health-seeking behavior to position my work in relation to what is already written before turning to my findings in the field. I start with an examination of the concept of medical pluralism, after which I will examine the concept of health-seeking behavior.

3.1 Medical pluralism

Pluralism is described in the Oxford English Dictionary as ‘a theory or system that recognizes more than one ultimate principle’ (Hsu 2008:136). Applied to medicine, medical pluralism can be defined as the co-existence of epistemologically diverse therapeutic traditions (Lambert 2012:1029). In practice, medical pluralism entails a diverse range of healing systems and the many combinations in which patients seek them and healers practice them (Bode 2011:17). This thesis will solely focus on medical pluralism as the co-existence of ‘Western’ or biomedical, and ‘non-Western’ or traditional healthcare practices as existing in Sunga Ward.14

According to Worsley (1982) and Marsland (2007), different healthcare traditions have a long history of intercultural reciprocal influence, which proves the capacity of healing systems to exist in transcendence of national boundaries. In the past, biomedicine has been introduced to existing medical systems in ‘non-Western’ regions (Worsley 1982:315). Western ‘civilization’ was brought to the ‘primitive’ under colonial rule (Janzen 1978, Langwick 2006). Janzen argues however that when a new medical system enters a society, this causes changes in the current system, but language-like obstacles make that a complete adaptation of a foreign healthcare system into the existing culture is not possible (Janzen 1978:37-38). As a result, different systems still existed next to each other and categories were constructed between different healthcare practices. The boundaries between those categories were constructed as a way to establish biomedicine as a form of expertise and authority

14

Hereby, I acknowledge the limitations of this theoretical review for neglecting to focus on other aspects of medical pluralism or other institutionalized healthcare traditions such as homeopathy, Ayurveda or Chinese medicine.

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during colonial times, when there was a quest for proper and reliable healthcare knowledge. Creating this boundary was therefore a solution to a problem of social order (Langwick 2006). Janzen

additionally states that those boundaries are constructed on the fact that the different systems are based upon different premises. Biomedicine is based upon biology, physiology and science, where

traditional medicine is based upon non-rational and magical elements (Hahn and Kleinman 1983:306). Synthesizing these systems is complicated and consequently, people often approach the different systems separately (Janzen 1978:37). Medical pluralism neglects power differences between different medical practices and therefore the term ‘medical pluralism’ assumes equality (Bode 2013, Lambert 2012:1029). This should mean that neither biomedicine nor any other healthcare tradition has monopoly over healthcare, but instead they compete with each other (Hsu 2008). In reality, medical pluralism is often a hierarchical system (Bode 2013, Lambert 2012:1029). In this hierarchy,

biomedicine is often the real or perceived state medicine. It is therefore worldwide structurally dominant and powerful, which is reflected in the link of biomedicine to the professional and cultural domain in various national as well as international politics. Biomedicine is even allopathic, meaning that it is mainstream or, the ‘invisible standard’ in healthcare (Bode 2011:17). Thus, despite the fact that Western biomedicine might not have a worldwide monopoly over healthcare, as Hsu (2008) has argued, it does have a lot of significance.

Medical pluralism has a long history, starting when different healthcare traditions entered new societies, which is a hard to define event. Besides the aforementioned introduction of biomedicine into the ‘non-West’, ‘non-Western’ healthcare traditions were also introduced in ‘the West’ (Marsland 2007). Therefore, in the history of the cross-cultural introduction of ‘Western’ and ‘non-Western’ medical systems, those different systems have influenced, shaped, innovated and challenged each other despite the strong boundaries that have been created between these different healthcare

traditions. We therefore cannot speak so much of ‘non-Western’ versus ‘Western’ medicine since they would not exist in their current form without this mutual influence that has taken place years ago (Marsland 2007). The boundaries between the different healthcare systems are blurred, since these distinct systems only exist with the help of each other. Besides looking at the constructed boundaries between different healthcare systems, we should therefore just as much focus on the interactions

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between those systems since this is just as important for understanding medical pluralism in its current form.

Similar to the boundaries of Western and non-Western medicine, the boundaries between traditional and modern medicine have never been clear (Langwick 2008:437, Marsland 2007:755). This vagueness around the borders of the distinct categories is at the same time a reason for strengthening the differences, or boundaries, between these categories. This practice principally started in the West, when medical practitioners wanted to preserve the category of biomedicine from influences by traditional healthcare (Langwick 2006). Anxiety by especially biomedicine for

amalgamation of medical traditions and losing cultural practices lead to ‘purification’, as called by Latour (1993) and Langwick (2006). Purification enhances existing boundaries. However, intercultural contact leads to the movement of different healthcare systems towards each other. This partly causes a merging of healthcare practices, but at the same time causes a drifting apart of those systems. Medical pluralism, thus, is characterized by the process of assembling medical practices and at the same time divergence of these practices.

Consequently, the boundaries were maintained which still assumed a distinction between healthcare in the West, and healthcare in the non-West. Despite this homogenization, these terms are widely used. Biomedicine is called ‘Western’ medicine, or ‘modern’ medicine, even though it is not the only modern medical tradition in the world. This assumes an opposition to traditional medicine, since it might seem as if biomedicine is the only modern medical tradition and moreover, incompatible with traditional medicine. This opposition consequently makes a fusion of biomedical and traditional healthcare seem far away or unrealistic and therefore reinforces the boundaries between the categories. Likewise, for traditional or indigenous medicine, being perceived as non-modern assumes a kind of backwardness, irrationality or marginality and strengthens the idea of biomedicine as ‘the best’ (Hahn and Kleinman 1983:306, Marsland 2007, Janzen 1978).

According to Marsland, traditional medicine is attempting to develop itself. In her article, Marsland (2007:756) states that traditional healthcare practices are innovative in their constant effort to adopt certain aspects of modern medicine. She argues that biomedicine is in this way more

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lack of innovation. Janzen (1978) agreed with Marsland on this issue, as he described how Western medical professionals in Africa preserved the boundaries and consequently the content of Western medicine whereas at the same time a professional African ‘Western medical’ group of healers emerged (Janzen 1978:217). As a result, many traditional healers in Africa present themselves as ‘modern traditional’, which seems oxymoronic from a Western view, but is logical to those healers themselves. Those healers claim modernity but are as well still perceived as representing traditional healthcare. Therefore, traditional healers might be seen as medical practitioners who are able to transcend, contest and make use of the constructed categories in healthcare practices. In this they are opposed to

biomedical practitioners who are overly concerned about guarding their cultural practices and trying to keep them from any intercultural influence or medical amalgamation. Those biomedical practitioners are therefore performing behavior of purification for strongly trying to conserve the existing

boundaries between biomedicine and traditional medicine (Marsland 2007:764).

Additionally, Bode states that medical pluralism exists in socially stratified and culturally diverse societies that have already encountered different healthcare practices (Bode 2011:17). Patient’s health-seeking behavior in socially stratified and culturally diverse societies therefore easily leads to a pluralistic approach because of the broader offer of medical traditions. Medical pluralism moreover appears to be a solution in accessing healthcare for people living in poverty, when in the absence of good accessible, available or satisfying healthcare, people approach and combine different healthcare traditions with each other.

In conclusion processes leading to or existing as part of medical pluralism can eventually be understand only by taking into account social dynamics such as current and historical events, geographical location, local medical idioms and sociocultural life expectations (Lock and Nguyen 2010:63). Medical pluralism is therefore a cultural construct which can only be known in the light of its sociocultural background. Explaining or understanding the utilization of a medical pluralistic system therefore requires a critical look at the sociocultural background in which this utilization takes place.

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3.2 Health-seeking behavior

Within a field where multiple healthcare providers are available, medical pluralistic practices may be a result of the search for suitable healthcare facilitators by the people that are in need of healthcare and who act in this field. Medical pluralism is therefore to a great extent the product of the individual patient. It is the patient who decides which medical system(s) he or she approaches, and in case of a plurality how these will complement, relate to, and influence each other. This process is called

health-seeking behavior. It displays the agency of the individual patient in the field of healthcare (Hsu 2008).

Health-seeking behavior occurs in either the family, community or healthcare services structures and can be seen in physical, socio-economic, cultural and political contexts (Shaikh and Hatcher 2004:49). Kleinman (1980) and Andersen (1995) stress the importance of seeing health-seeking behavior in its sociological context, on which Hsu (2008) adds that it can partly be explained by Bourdieu’s theory of

habitus. Habitus can be understood as a complete set of variables, such as perceptions, beliefs, values,

personal and social characteristics that are innate to someone’s social environment. This diverse set of variables shape one’s way of perceiving and valuing in general and consequently influence or

determine someone’s course of life or way of acting (Bourdieu et al 1989:13, Brown 2014). When applying the theory of habitus on health-seeking behavior, one’s upbringing and social environment can eventually be important in the course of action when this person is in need of and making choices in regards to healthcare. In other words, the theory of habitus shows that it is the circumstantial social, economic and political dynamics that influence an individual’s choice in treatment seeking (Hsu 2008: 318-319, Beals 1976, Shaikh and Hatcher 2004:49).

In the existing literature on health-seeking behavior, several authors like Andersen (1995), Kleinman (1978) and Green et al (1980) have given models that try to explain this behavior. They touch on circumstantial variables that influence or even determine health-seeking behavior. The models are helpful for they focus on many different aspects in explaining health service use. The model by Andersen (1995) shows how predisposing population characteristics can correlate to the outcome of health seeking. Predisposing’ is defined by the Oxford Dictionary as “make someone liable or inclined to a specified attitude, action, or condition” (Oxford Dictionary 2014). Predisposing characteristics are thus the place where the habitus is expressed and transformed into concrete acts.

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Another variable in Andersen’s model is ‘need’. Need is highly subjective and entails the personal perceived and professional evaluated need in healthcare. It touches on personal experiences of pain, illness, health problems and opinions on when to seek external help (Andersen 1995:2-3). Need is also highly influenced by its socio-cultural context, since different societies might enclose different

diseases. Kleinman (1978) has created a model in which the medical system is perceived as a social and cultural system. Meanings and behavioral norms are attached to particular social relationships and institutional settings, states Kleinman (1978:85). He thereby acknowledges the importance of habitus on people’s behavior. Bode (2011:14) also describes medical theories and practices as social

constructs created out of the shared medical culture of a group and therefore states medicine as being culture dependent. The decision on healthcare provider to approach is therefore mostly culturally embedded, meaning that the decision by the individual is often not completely an individual choice, but one that is rooted in the culture or society of the individual and thus inherently forthcoming out of the sociocultural environment of the individual. In Kleinman’s model, the healthcare system is within a socio-political structure and local environmental setting perceived as an encounter of external and internal factors, which are in Andersen’s model (1995) labeled as ‘environment’ and ‘predisposing characteristics’ (Kleinman 1978:86). Kleinman and Andersen agree that the healthcare system is a constitution of meanings, values and behavioral norms that are highly culturally influenced, showing again the relation with Bourdieu’s theory of the habitus.

Despite the helpfulness of these models to understand people’s behavior, efforts to rationalize human beings’ behavior can never be completely accurate. Andersen and Kleinman mention the complexity and dynamics of different factors influencing people’s health-seeking behavior, but their models still try to capture the logics behind people’s behavior. But, behavior is often irrational, reasonless, changeable and spontaneous. There might always be external or even internal factors that influence people’s behavior, undermining the predictive character of a behavioral model. Heuristics can be helpful in studying human behavior, but is in itself not satisfying to capture this behavior. Therefore this study to health-seeking behavior will not unfold along the lines of such a rational model, but instead contributes to the existing body of anthropological literature on health-seeking by studying the motivations and contextual variables influencing people’s behavior. The aforementioned

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models by Kleinman and Andersen will only sometimes be referred upon to relate findings in the field to academic studies that show the importance of among others, habitus and environmental variables.

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4. “Mganga hajigangi”: health-seeking behavior among Sunga

Ward’s residents

Health-seeking behavior unfolds in a particular context, therefore being influenced by contextual variables. Environmental influences, enabling resources for use to take place,15 and factors such as affordability, availability, social inequality and cultural factors as mentioned by Bode (2011:18) are, among others, stimuli that might shape the choice whether someone approaches biomedical, religious or traditional healthcare, or a combination thereof. These factors can both limit and help the decision making process in the search for good medical care. What is good medical care differs per disease, illness, person and situation but an old, yet still workable definition of good medical care is given by Lee and Jones (1933) in a key work on medical care: ‘The Fundamentals of Good Medical Care’. They write: “good medical care is the kind of medicine practiced and taught by the recognized leaders of the medical profession at a given time or period of social, cultural, and professional development in a community or population group” (Lee and Jones 1933:6). This definition suits to this research as it acknowledges that the leaders of the medical profession should be recognized in a particular

community or population group. Especially with traditional healing practices, the practitioners hereof are often not recognized as medical professionals by, in particular, the biomedical health sector.

This can be explained by Pool who argues that African and Western healthcare systems are based on different premises. Translating the domains of meaning from one cultural system to a system in another culture can only be successful when the context is adhered to (Pool 1994:15-16). Pool’s argument that the African medical system is focusing on more and other aspects of life than the mere physical condition of the individual body can be clarified by Scheper-Hughes and Lock (1998). Their study shows that it is worthwhile to question how healthcare and the society relate to each other. They offer a study in which they present the ‘three bodies’. The individual body is the personal experience of the wholeness of the body, both mental and physical. The social body is how the body is

15_{Enabling resources are for example availability of health facilities and personnel, as well as the knowledge and} means of people to reach those services and make use of them. Income, insurance, reliability of healthcare to be available and infrastructural factors are all part of enabling resources (Andersen 1995:3).

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represented as a natural symbol. The body is in itself a kind of paradigm that shapes how we think about the world around us and can be seen as a symbol of (dis)harmony and (im)balance between the ‘natural’ and the ‘social’. The third body is the body politic and touches on control and regulation of individual and collective bodies. Protecting and controlling the body is essential for the individual and social body to exist (Scheper-Hughes and Lock 1998:209). Overall, this study shows the body as a representation of the society on micro-scale. When applied to Sunga Ward, the individual body is the citizen, the social body is the society in the Ward and the body politic are circumstantial factors such as poverty, corrupt practices or the power of witchcraft. These last factors can control the wellbeing of the other two bodies. How physical bodies are treated and valued can thus show something about the norms, values and power relations in a society on macro-scale. Scheper-Hughes and Lock (1998) thus teach us that treating the individual, the social and the body politic, striving to a coherent wholeness of the body, can result in a healthy society.

Pool (1994) argues that the African medical system recognizes not only physical, but also social and moral aspects of life. The African healthcare system therefore involves concepts that are unfamiliar in Western healthcare systems and that even in Africa can only be understood with observance of its context. Therefore, Pool argues that we should not use the same terms for two systems that are so different (Pool 1994:16). Using the same terms invites comparing, and that will in this situation undoubtedly lead to confusion because of the great differences between African and Western medical systems. He even goes so far as to argue that we therefore should not speak about a medical system at all, but that the complexes of behavior, sets of beliefs and spoken discourses touching on medicine together constitute part of a ‘cultural camouflage that enables one to survive’ (Pool 1994:17). This fundamental difference between how to approach health and treatment in different medical systems can clarify why the biomedical health sector often neglects the importance of traditional healthcare practitioners, whereas the local community in Sunga Ward did recognize

waganga as medical professionals. Sunga Ward’s inhabitants consequently saw them as a serious

alternative to biomedical healthcare providers, therefore one of the options in their health-seeking behavior.

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This thesis starts with a chapter on the outcome of choices made between all these actors playing a part in health-seeking processes. This behavior is subsequently, by means of the Card Game, related to Feierman’s (1981) categorization of illnesses. This categorization is helpful for

understanding causes of illnesses, but Feierman does not write about which kind of treatment is generally approached for which category. This study will present a preliminary research to this relation, thereby filling the gap between having a mere categorization and having a study that relates people’s health-seeking behavior to this categorization, which might be helpful for predicting this behavior and maybe even adjusting the local healthcare system to this behavior.

4.1 Where to find your health? The outcome of health-seeking behavior

In Sunga Ward, we can distinguish healthcare facilitators between professional medical systems, institutionalized by the Ministry of Health and Social Welfare and therefore public, and the private realm, the medical systems of lay people, coming from the society (Bode 2011:15). The general health-seeking behavior of Sunga Ward’s residents is to first approach biomedical healthcare, and in case that fails, uganga.16 Even Selemani, a jini healer in Mambo, told me during a conversation that he visits the dispensary when he suffers from a health problem he thinks cannot be cured by uganga or when he wants an examination. 17 Additionally, an interesting observation I had was when I walked with Sefu trough Mambo village. We saw a lady being carried to the dispensary by other ladies. When Sefu asked what was going on, the ladies told him that this lady was probably suffering from malaria and they were bringing her to the dispensary. Even though this lady was a traditional healer herself, “mganga hajigangi” Sefu said, meaning ‘the healer cannot heal himself’.18

In the theoretical section of this study is mentioned that biomedicine is often allopathic, mainstream. This is also the case in Sunga Ward because people generally tend to first approach biomedical healthcare over uganga. But the Card Game shows that when diseases are immediately recognized as mental disease, local or traditional disease, witchcraft or jini disease, people first

16

informal conversation Selemani 13/4, open interview Neema 16/3, Samuel 20/2, Hussein 24/2, Youssef 8/3, Sefu 15/2 and 11/4, Angelica 22/3, Audrey 23/3, semi-structured interview Salum 20/3, Shamira 18/3, Salat, Maryam 1/4 and Mehmet in focus group discussion 22/2

17

informal conversation Selemani 13/4 18_{informal conversation Sefu 4/3}

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approach uganga, instead of biomedicine. These illnesses correspond with Feierman’s (1981) categories ‘sorcery’, ‘jini’ and ‘acts of the individual moral will’ (see appendix 2) and with Scheper-Hughes and Lock’s (1998) ‘social body’. According to Pool (1994), uganga treats more than just the physical body, but addresses social and moral issues as well. Uganga is therefore a suitable solution to problems of the social body. Health-seeking behavior is thus for a great deal depending on the

problem that one suffers from and under which category or body this problem can be placed. ‘Need’ is therefore maybe the most important factor determining health service use.

Perceived need requires an interpretation of the disease, illness or health problem that is the initial trigger in the search for healthcare. We see that people in Sunga Ward understand the need of visiting biomedical healthcare in particular cases, e.g. anemia, broken bones, HIV/Aids or syphilis. These are all part of Feierman’s categories ‘illness brought by God’ and ‘illness brought upon yourself’, relating to the ‘individual body’ by Scheper-Hughes and Lock (1998). Since biomedical healthcare focuses on human biology, it can properly treat individual body problems (Hahn and Kleinman 1983:306). Other cases require traditional healthcare like allergy, chango, zongo, nyungu or

jini.19 These are, except for allergy which I classified as an ‘illness brought by God’, all part of ‘sorcery’, ‘jini’ or ‘act of the individual’s moral will’ categories. Some diseases can be treated by multiple healthcare traditions, like epilepsy, infertility, asthma, cancer or skin infections. Those diseases all have a natural cause and are therefore part of the first category ‘illness brought by God’, except for skin infection that people can both cause themselves but that can also have a ‘natural’ cause.20 This is confirmed by Good (1987 in Hausmann-Muela 1998:44) who writes that for ‘natural’ causes of illnesses people usually first approach biomedical healthcare services.21

19_{See appendix 3 for an explanation of different local and traditional diseases.} 20_{Data gathered from the Card Game, see appendix 2}

21

‘Natural’ causes of illnesses; a typology Feierman (1985:77) uses in opposition to sorcery and spirit causes of illnesses