Health & Place, Vol. 4, No. 4, pp. 293±311, 1998 # 1998 Elsevier Science Ltd. All rights reserved Printed in Great Britain 1353-8292/98/$ - see front matter

PII: S1353-8292(98)00033-1 Therapeutic landscapes of the Jola, The Gambia, West Africa

Clare Madge Department of Geography, University of Leicester, University Road, Leicester LE1 7RH, UK

This paper contributes to the `new' medical geography through its analysis of the therapeutic landscapes of the Jola of The Gambia. The paper advances the debate surrounding the conceptu- alisation of medicine and health through a review of literature on African medicinal systems; it examines in detail the health care system of the Jola of The Gambia, documenting indigenous human and ethnoveterinary medical beliefs and practices and focusing in particular on the role of herbal medicine; and it discusses the interactions and links between indigenous medicine and biomedicine, thus demonstrating the importance of placing an understanding of health care sys- tems in di€erent places within an awareness of global power relations. The paper therefore links cultural perspectives with a political economy analysis, to highlight the importance of place and speci®city of cultural context when investigating health care beliefs and practices. The intention of the paper is to present a theoretically informed empirical case study which reinforces the practical value of a `new' medical geography. # 1998 Elsevier Science Ltd. All rights reserved

Keywords: Jola, indigenous medicine, biomedicine, herbal medicine, veterinary medicine, The Gambia

Introduction of the health care beliefs and practices, collec- tively referred to as the `therapeutic landscapes', Kearns (1995, p. 251) has recently argued that 1 medical geography is facing an intellectual chal- of the Jola of The Gambia, West Africa . The lenge from postmodernism and social theory. intention of the paper is to present a theoretically This challenge has focused on a recognition of informed empirical case study which reinforces the variations in health beliefs, practices and ex- the practical value of a `new' medical geography periences of di€erent social groups, which are for scholars and policy-makers. constructed and played out in distinctive places. The aims of the paper are three fold: ®rst, to Medical geography is therefore moving beyond advance the debate surrounding the conceptualis- its ethnocentric foundations to highlight the ation of medicine and health through examin- variability of meanings, cultural practices and ation of literature on African medicinal systems; material conditions shaping people's relationships secondly, to examine in detail the health care sys- to disease, illness, health and medicine. In par- tem of the Jola of The Gambia, documenting ticular, Gesler (1991) has advocated studies of indigenous human and ethnoveterinary medical `folk' medicine because it serves the majority of beliefs and practices and focusing in particular people in developing countries: ``If social scien- on the role of herbal medicine; thirdly, to discuss tists are really interested in the health of all the the interactions and links between indigenous world's inhabitants, then they must study non- medicine and biomedicine, thus demonstrating professional traditional healing...research is the importance of placing an understanding of trickling in but there is not nearly enough'' health care systems in di€erent places within an (Gesler, 1991, p. 122). Having conducted ethno- awareness of global power relations2. graphic research on West African forestry (which The paper therefore links cultural perspectives included work on indigenous medicine), I was with a political economy analysis, to focus on the struck by the possibilities of contributing to this ``structure of meaning and understanding in the `new' medical geography through an examination places where people live, experience sickness and

293 Therapeutic landscapes: C. Madge use health services'' (Moon and Jones, 1994, p. tems of health care may appear to be illogical 2). This discussion will focus on one particular and irrational, resulting in ethnocentric preju- ethnic group's use and understandings of medi- dices (Sempebwa, 1983). cine and illness, highlighting the importance of In Africa the medical practitioner will inform place and speci®city of cultural context when the patient why they are ill in contrast to a investigating health care beliefs and practices. European doctor who is more likely to tell the patient how they became ill. For a practitioner to be successful in Africa, both an answer and anti- Indigenous medicine in Africa dote must be provided to explain why the illness First a short generalised discussion regarding occurred at a particular time and why it a€ected health care beliefs in Africa is needed to contex- the particular individual. The practitioner must tualise the research (see Good, 1987 and Janzen, make sense of the illness, often as important as 1978 for more detailed discussions). Medicinal the cure. If a cause cannot be deduced from daily systems in Africa have often been inaccurately experience then a cause will be sought in the regarded in the same conceptual terms as biome- spiritual realm. Diagnosis of the cause, nature, dicine in European societies. In Europe, illness is treatment and prevention of reoccurrence of the commonly perceived as due to physiological or illness is hence partly physiological, partly scienti®cally explained causes. Biomedicine is psychological. A medicine may thus be of `ma- understood to follow natural laws which have terial' origin, including preparations made from nothing to do with the supernatural, a person's plant or animal products, or of `spiritual' origin, psychological condition or their social milieu. such as jujus (amulets) or fetishes4. Most prac- Biomedicine therefore gives precedence to `tech- titioners and most remedies involve a combi- nique' over `person' and their social identity nation of both material and spiritual within a community (Good, 1987, p. 13). explanations and techniques. For example, plants In contrast, in many African societies the sig- used as medicine are thought bene®cial not only ni®cant disparity between material and spiritual for their organic properties but also due to the worlds has not been made to the same extent as spiritual force imbued by nature in living things with European societies3. Illness may therefore and the role of the ancestors, spirits and gods in be seen as having a social or spiritual origin, in blessing the plants which `activates' their use as addition to physiological causes. A medicine can medicine. A medicinal practitioner in Africa can thus be both a substance used to treat and pre- therefore help the patient live in peace with other vent illness or anything used to control the spiri- community members through herbs, spiritual tual cause of illness. Herzog (1936, p. 150) rituals and the regulation of diet and behaviour. de®ned African medicine as ``...a medicinal Indigenous medical systems in Africa are there- plant, substance or preparation, a fetish or any fore all-embracing adaptive systems of healing other substance made potent by magic so that it which are deeply embedded in religious and is capable of healing as well as causing sickness socio±cultural institutions, philosophical outlooks or some other misfortune...A medicine man and socio±economic structures (Good, 1987, pp. does not serve the medicine, he serves the soul of 2, 5). For this reason, unique systems of indigen- the medicine''. Thus according to Harley (1970, ous medicine have developed in distinct places, p. 10), a medicine is any substance whose power varying according to personal, ethnic and re- is under control, or known to be controllable, gional di€erences in cultural symbols, diagnoses usually, but not exclusively by a medical prac- and therapies. titioner. In Africa there is an acceptance of the Interest in African indigenous medicine has a metaphysical which embraces the unity and inter- long history. For example, Thunberg (1795) relatedness of phenomena whereas the European identi®ed 24 plants used as medicine by South scienti®c approach focuses on causal inter- Africans and was convinced of their therapeutic relationships between physical phenomena. A value, Thoms (1909) identi®ed 102 plants from psychosocial approach to medicine is therefore West Africa, giving brief toxicological and chemi- utilised in African medicine in which a person's cal notes while Pobe guin (1912) wrote a compen- body, mind and soul are conceived as an indivisi- dium of 654 treatments used in West Africa. ble whole; ill health can therefore re¯ect ``discord Dalziel (1937), in an important publication, also in the social body'', a ``rupture of life's har- described the medicinal uses of 700 plant species mony'' or the ``activation of supernatural forces'' in West Africa. Although it was not Dalziel's (Good, 1987, p. 14). Indeed, in Africa medico±re- (1937, p. 7) original intention, the compendium ligious or spiritual understandings of illness can also included folk law since he stated that at times lead to e€ective therapeutic action, so ``...much native medicinal practice cannot be the line between the natural and supernatural is easily separated from magic and popular beliefs''. often blurred. Without understanding the spiri- More recent research on African medicine has tual rationale to health and illness in Africa, sys- estimated that 95% of medicine comes from

294 Therapeutic landscapes: C. Madge plant material (Prescott-Allen, 1982, p. 47) and ing of health and illness from varying cultural for this reason research has focused on herbal perspectives (Franklin et al., 1996; Gyapong et remedies rather than animal cures and on medi- al., 1996; Iyun and Tomson, 1996; Opala and cine to cure individuals rather than veterinary Boillot, 1996). In this literature few links are medicine. The role of ethnoveterinary medicine in drawn between indigenous and biomedicine and Africa has only recently received attention the dearth of research by geographers is a note- through McCorkle and Mathias-Mundy's (1992) worthy and surprising observation since the geo- thorough review. They suggested that at least grapher should be well-placed to contribute to 30% of plant species used to treat animal dis- cross-cultural research through wide-ranging eases were e€ective and quoted numerous methodological training and place sensitive examples of pharmacology used by pastoralists research. throughout the African continent. They also investigated indigenous vaccination systems; for example, Fulani pastoralists of West Africa use Indigenous medicine in The Gambia infected lung tissue to inoculate livestock against While limited work has been done on the role of contagious bovine pleuro-pneumonia. Indigenous indigenous medicine in The Gambia, there has forms of surgery recorded included wound care, been considerable interest in biomedicine. The cauterisation, castration, bloodletting and obste- Gambia was selected as the `ideal' research trics. Management practices were also utilised by location by both the Nutrition Field Working pastoralists to prevent animal illness, such as sea- Party of the Colonial Oce in 1946, situated at sonal herding strategies to avoid disease out- Genieri in Middle River Division, and by the breaks and the alteration of daily grazing Medical Research Council's Dunn Nutrition Unit strategies to avoid disease-bearing pests. Pests situated at Keneba in 1949. Research at the and parasites were found to be controlled Dunn Nutrition Unit has focused on selected through washing, burning and fumigation of ani- medicinal topics of key relevance to human mal quarters. Work on ethnoveterinary medicine health, such as infancy, childhood, pregnancy is thus a relatively recent but burgeoning ®eld of and malaria (Menendez et al., 1993; De research (Fre, 1989; Grandin et al., 1991; Francisco et al., 1994; Mills et al., 1994; Lindsay Mathias-Mundy and McCorkle, 1989). et al., 1995). In contrast, work on indigenous medicinal Research on indigenous medicine in The plants has increased in the last three decades, Gambia has focused on herbalism rather than being initiated in 1968 by the Organisation of ethnoveterinary medicine, divination or mid- African Unity (OAU) through the Scienti®c, wifery. One of the ®rst recorded documents on Technical and Research Commission (STRC). Gambian medicinal plants was compiled by For example, Gbile and Adensina (1987) have Marshall (1886) for the West African Court. compiled an ethnobotanical survey of medicinal Forty-four plants used in a medicinal capacity plants in Nigeria, Macfoy (1986) in Sierra Leone, were listed, accompanied by 22 specimens. A Sarpong (1986) in Ghana and Bever (1985) in later record concerning medicinal plants in The tropical West Africa. Such surveys have, however, Gambia was contained in the Colonial Annual frequently concentrated on biological studies Report for 1908. Fifteen plant species with local devoid of cultural and other contextual data. names were given, and also indigenous methods Literature on indigenous medicine thus tends to be of preparation. Unfortunately, the colonial gov- ``...either botanically uninformed or anthropolo- ernment of The Gambia was slow to appreciate gically naive'' (Etkin, 1986, p. 2). Considering the the potential uses of herbal medicine. On 27th duel model of disease causation, a research April 1939, in reply to a request for information approach is essential which considers indigenous on indigenous medicine from the Secretary of medicine from a perspective including both State for the Colonies, the acting Governor of spiritual and material worlds. The Gambia replied that ``...no research in con- The most recent strands of research on medi- nection with this subject has ever been under- cine and health in Africa shift attention away taken in this colony''. Such an attitude was in from indigenous medicine towards three main contrast to the Governor of Nigeria who replied: foci. First, investigations surrounding AIDS and ``I have no doubt a great amount of interesting HIV (Green et al., 1995; Ulin, 1992). The second material could be gained from an intensive inves- main focus is studies of the current health situ- tigation of the indigenous drugs used in West ation in Africa (Shaw and Elmendorf, 1994; Africa'', and the Governor of the Gold Coast Walker, 1995), including research on the impact who replied ``...the potential value of the infor- of recent economic reforms on health care mation which might be derived from a careful (Mogedal et al., 1995) and management and pol- analysis of the herbs used by the more reputable icy reform (Gilson, 1995). Finally, there are also African practitioners has long been recognised in many recent studies investigating the understand- this country''5.

295 Therapeutic landscapes: C. Madge

By 1976 the value of indigenous medicine in cultivation and war. The shrines were consulted The Gambia was becoming widely recognised. In in times of illness or misfortune. The sinaati were October and December 1976 a local newspaper, believed to bring ailments to those who trans- The Gambia News Bulletin, contained two articles gressed the rules of social and ritual conduct. (Baldeh, 1976; Saidy, 1976) which, although stat- This essentially medicinal function survived, ing that they were ``old fashioned'', nevertheless although most of the population became con- extolled the merits of local herbal remedies and verted to Islam. described charms useful against witchcraft and Thus while research on indigenous medicine for attracting members of the opposite sex. The and beliefs has expanded in The Gambia, there ®rst important compilation of medicinal uses of has, to date, been only limited research on indi- ¯owering plants in The Gambia was by Hallam genous medicine from the big-behavioural lay (1979), who outlined the di€erent preparations of perspective (Bledsoe et al., 1994, is an exception). 82 plants used for `bush medicine'. Hallam Work on medicinal plants consists of compendia (1979) was concerned at the loss in knowledge of of useful species which lack explanation of the indigenous cures: plants' preparation and use in speci®c cultural contexts. Additionally, there is no work on ani- ``There are generations of children now being mal species with medicinal value or on indigen- brought up in the urban areas who cannot recog- ous veterinary medicine. It is with these research nize the common plants of the countryside. It seems gaps in mind that the ®elds of care of the Jola of that to retain the basic knowledge of bush medicine, The Gambia are examined below. which has hitherto been handed down by word of mouth in a village community, there is a need to teach school pupils about the uses of plants sur- Background, case study and methodology rounding them. This teaching could then become in- The Gambia is a small country situated in the corporated into a school curriculum'' (Hallam, westernmost part of Africa, with a GNP per 1979, p. 191). capita of $430 in 1994 (World Bank, 1996) (Figure 1). The Gambian economy is based on An attempt was made to implement this sug- subsistence agriculture, the most important food gestion by the President's Award Scheme in crops cultivated being rice, maize and millet 1988. Participants documented elders' knowledge grown on small family farms. The groundnut is of medicinal plants, recording 120 plants with the main cash crop, representing 88% of exports over 200 medical uses. The Ministry of in 1991 (Europa Publications, 1992). The tourist Education expressed a wish to include the data in industry has recently expanded in The Gambia, educational booklets for the science curriculum and with over 100 000 tourists visiting each year, (Seppings, 1989). tourism now accounts for 11% of GDP (CIA There is also limited research on the `spiritual' side of medicine in The Gambia. An exception is Sapir (1970) who outlined the concept known as kujaama by the Jola of the Fogni region of the Casamance. Kujaama represented a complex sym- bol that de®ned a set of pollution rules on avoid- ing blood and food both between generations and between husband and wife. The belief was that `separate' categories should not be mixed. Kujaama also referred to a power or spirit that punished violations of taboos and neglect of rituals. Kujaama `caught' the violators by acting as a `poison' that caused coughing and diarrhoea. The poison was neutralised by the medicine of a plant called ebunkbujam6. Kujaama was one of a number of spirits inhabiting the Jola world, col- lectively known as sinaati. They were created by a god called emit who also created humans and the rest of the world. According to Mark (1977, pp. 343±344) the sinaati were associated with par- ticular lineages and thought to inhabit large trees or specially constructed shrines. Each shrine was entrusted to a guardian. In pre-Islamic times in- dividuals would approach the sinaati both to ful- ®l ritual obligations and to ensure success in Figure 1. Ethnic groups of the Senegambia region

296 Therapeutic landscapes: C. Madge statistical data base). The estimated population of the value of indigenous medicine in relation to of the country is 1.1 million (1994) which com- biomedicine. Participant observation involved prises 14 separate ethnic groups including the daily engagement and interaction in the life of Mandinka, Wolof, Jola, Fula, Tukulor, Serer the villagers to determine how they acted with and Serahuli. The Gambia is situated in the sub- respect to indigenous medicine and to discern the Saharan tropical climate zone where annual rain- meanings and beliefs they attached to these fall variations are marked and rainfall is erratic. cures. By combining these di€erent methods over The natural vegetation of The Gambia consists one year and for two follow-up periods of two of Guinea Savannah and Guinea Woodland months each, attempts were made to interpret in- Savannah. Forests cover 200 000 hectares of the formation from within the cultural framework of country, accounting for 17% of the total land the studied population, although wide-ranging area (Hunter, 1995). Annual deforestation was methodological, analytical and ethical issues were estimated at 0.8% the total land area from 1981± raised in such attempts (Madge, 1994). 1990 (World Bank, 1996). Although the Ministry of Health actively pro- motes health and nutrition of the population as Fields of care among the Jola part of its commitment to the principle of `health A survey undertaken in the village in 1989 and for all', high infant and child mortality neverthe- followed up in 1991 and 1993 identi®ed 70 plant less persist in The Gambia and life expectancy species with medicinal uses (Table 1). These remains amongst the lowest in the world. In included remedies for intestinal problems, ortho- 1994, life expectancy at birth was 45 years dontal diseases, external skin complaints, body whereas it was 52 years for sub-Saharan Africa pain, respiratory problems, medicine relating to and 68 years for Europe and Central Asia at that pregnancy, child birth and fertility, medicine for time. The World Bank (1996) estimated the fever and malaria, medicine for bone and eye infant mortality rate in 1994 to be 128 per 1000 problems, therapies for more serious illnesses live births, these data varying with season and (snake bites, gonorrhoea, leprosy, yellow fever), showing a rural±urban di€erentiation. Child sur- spiritual medicine and preventative tonics. The vival rates are amongst the poorest in the West most common plant species used was busayeat Africa region (UNICEF, 1992). Maternal mor- (Cassia sieberiana) which was included in nine tality rates are also high and show a clear urban± medicinal recipes9. Ake Assi (1984) also found rural di€erences: 6 deaths per 1000 live births in that this species was frequently used in medicinal urban areas compared to 12 in rural areas preparations among the Ando group of the Ivory (Harpham, 1996). Despite poor estimates of Coast. Most commonly used parts of plants were health statistics, population growth in The bark, roots, leaves and fruit; less frequently used Gambia is signi®cant, being the highest in the were seeds, branches, ¯owers, stalks, oil and sap. world (3.9%) from 1990 to 1994. Knowledge on the therapeutic value of newly This work is based on research which was introduced species, such as neem (Azadirachta undertaken with one rural Jola (Diola, Dyola) indica), cashew (Anacardium occidentale) and community in The Gambia from 1988±1989 and neverdie (Moringa oleifera), was being rapidly updated in 1991 and 1993. One village, located in acquired and equally important, not only wild Western division of The Gambia, was purpo- species had medicinal value but cultivated crops sively selected for detailed study, following and trees were also used as medicine, for Gesler's (1991, p. 214) ``desirable research direc- example, lime (Citrus aurantiifolia), mango tion'' to probe more deeply into the medical cul- (Mangifera indica), cola nut (Cola acuminata) ture of a small number of people living out their and guava (Psidium guajava). Veterinary medi- daily lives in a relatively small area7. Data were cine was used by herdsman to cure 14 animal dis- collected by di€erent methods including surveys, eases by using a combination of religious, herbal, structured interviews and participant observation. physical and animal medicine (Table 2)10. One detailed survey of 38 individuals was under- Ethnoveterinary medicine included pharma- taken for a period of one year to gather infor- cology, vaccination, surgery such as wound care mation on the number and type of indigenous and bloodletting and management techniques medicine used by each individual per week8. such as pest control, dietary supplementation and Informal individual interviews were undertaken religious beliefs and practices. Similarly, the hun- to obtain in-depth information from medicinal ters were the custodians of knowledge on animals practitioners regarding their specialised medical and used 13 animal species to cure human illness practice. Group interviews were also conducted (Table 3). These ranged from serious complaints, with the village population to determine more such as snake bites and whooping cough, to com- common knowledge regarding the use of indigen- mon complaints such as fever and diarrhoea. The ous medicine, decision-making involved in the medicine usually involved ingesting some part of choice of health care treatment and perceptions the animal and was often used in combination

297 Therapeutic landscapes: C. Madge

Table 1. Medicinal uses of plants Species Disease/symptoms Part used Species Disease/symptoms Part used Cassia tora Constipation Root Fukangol ( j) Acacia albida Mouth sores/ulcers Bark Jambanduro (m) Bubrick ( j) Stomach pain Root Cissampelos Stomach pain Root Barangsango (m) Snake bite Root mucronata Acacia polyacantha Body swelling Vine Sanjelow (m) Child body sores Stick/Leaf Fukem ( j) Body pain Root Citrus aurantiifolia Fever Leaf/Fruit Bambakoyo (m) Bulem ( j) Stomach pain Root Acacia scorpioides Bad gums Bark Lemuno (m) Bubanna ( j) Cataracts Bark Cola acuminata Childbirth Nut Bano (m) Dressing jujus Fruit Kuruo (m) Acanthospermum Warts Leaf/root Combretum Warts Leaf hispidum hypopilinum Gajambaruso ( j) Katanyangkungo Itchy body Leaf/Root Semberbuko (m) (j) Adansonia digitata Nits Leaf Katangkoiyo (m) Diarrhoea with Leaf Buback ( j) Stomach pain Leaf blood Sito (m) Body blister Fruit pulp Birth tonic Leaf Diarrhoea Fruit pulp Combretum Chest pain Leaf Chest pain Bark micranthum Sores Root Buteek ( j) Idol medicine Stalk Aframomum Worms Root Kinkeliba (m) Cough Stalk melegueta Mouth sore Stalk Buroomi ( j) Gonorrhoea Fruit Combretum nigricans Body pain Leaf/Root Bayleng- Jambakato (m) Chewstick Stick kumpango (m) Combretum Diarrhoea Root Amorphopallus Stimulate lactation Root string paniculatum consimilis Kunundingdolo- Worms Root Ehkem ( j) Diarrhoea Bark jambaback (m) Wulo kono jabo (m) Datura suaveolens Body pain Leaf Anacardium Diarrhoea Bark Kubayjarrow (m) Internal in¯amation Leaf occidentale Hallusagent Leaf Casuwu ( j) (m) Dialium guineense Pregnancy Leaf Annonia senegalensis Fever/body pain Leaf Bujaala ( j) Chewstick Stick Butotok ( j) Diarrhoea Bark Kosito (m) Wulo kono Chest/back pain Leaf Dichrostachys Protection in war Root/Bark sunkungo (m) glomerata Anthocleista procera Purgative Seed/Nut Burringand ( j) Toothache Leaf Bupokeye- Corulingo (m) Body sores Leaf ehgombam ( j) Diarrhoea Leaf Fafo jambo (m) Elaeis guineensis Snake bite Oil Azadirachta indica Stomach pain Leaf Ehporkel ( j) Mosquito repellent Flower Neme ( j) Sores Leaf Tengo (m) Skin care Kernel oil Yiringdong Headache Leaf Erythrina Fresh cut Bark kunango (m) senegalensis Bombax Chest pain Bark Busontah ( j) Fever Bark buonopozense N'dolingo (m) Bunkungo (m) Fagara Toothache Bark Bridelia micrantha Constipation Root zanthoxyloides Balaneat ( j) Chewsticks Stick Bilinkit ( j) Chest pain Leaf Bisako (m) Bahfey (m) Calotropis procera Sore hands Leaf Ficus gnapalocarpa Chest pain Leaf Baniwani ( j) Toothache Leaf Bukontu ( j) Kipanpango (m) Soto (m) Cassia absus Constipation Leaf Ficus vogelii Body pain Root Jafrecake ( j) Bupok ( j) Cassia occidentalis Body pain Leaf Toro (m) Geebungeefarra ( j) Fever Leaf Gardenia Headache Root Kassala (m) Sores Leaf erubescens Cough Leaf/Stick/ Gahen ( j) Yellow fever Root Flower Tankango (m) Constipation Root Guiera Fever Leaf Cassia sieberiana Body tiredness Leaf senegalensis Busayeat ( j) Constipation Leaf Bufunuk ( j) Sinjango (m) Sores Bark Kankanango (m) Obesity Leaf Internal in¯amation Bark Stomach pain Leaf Backache Bark Chesty cough Leaf Rheumatism Bark Body pain Root Ringworm Root Chewstick Stick Fever Root Hannoa undulata Snake bite Bark Eye trouble Leaf Kulukulu (m)

298 Therapeutic landscapes: C. Madge

Species Disease/symptoms Part used Species Disease/symptoms Part used

Hibiscus surratensis Illness prevention Leaf Paullinia pinnota Fever Leaf Gagess ehramba ( j) tonic Oohtogefairgear Body pain Leaf Wulo kono kutcha (j) (m) Jambalulu (m) Diarrhoea Leaf Hyptis suaveolens Cold Leaf Pilostigma thonningii Headache Leaf Jammakarla (m) Mosquito repellent Stalk Buhangken ( j) Stomach pain Fruit Fresh cut Sap Fara (m) Back and chest pain Seed pod Icacina senegalensis Swollen stomach Root Smallpox Seed pod Furabang ( j) and constipation Sore eyes Leaf Manankasa (m) Snake bite Leaf Plumbago zeylanica Immunity in warfare Leaf Backpain Leaf Jabbond ( j) Headaches Leaf Imperato cylindrica Bladder pain and Root Prosopis africana Strength tonic Bark Eleet ( j) urination problems Bukyembo (m) Chewstick Stick Surlingo (m) Psidium guajava Constipation Leaf Jatropha curcas Constipation Seed Bujeep ( j) Tubab taro (m) Chewstick Seed Guyabo (m) Khaya senegalensis Illness prevention Bark Pterocarpus Fungal infections Bark Bukai ( j) Feet sores Bark erinaceus Jallo (m) Internal in¯amation Bark Bukon ( j) Sore gums Bark Worms Bark Keno (m) Body pain Leaf Child head and body Bark Pterocarpus erinaceus Fungal infections Bark sores Bukon ( j) Sore gums Bark Landolphia heudelottii Constipation Fruit Keno (m) Body pain Root Bufem ( j) Body pain Root Ricinus communis Sores Leaf Folay (m) Bakotaylol ( j) Fever Leaf Leptandenia Cold Sap Tumbusuma (m) Constipation Fruit lancifolia Scoparia dulcis Severe chest pain Stalk Busumba ( j) Sores Sap Timin-timio (m) Sora (m) Stimulate lactation Leaf Solanum indicium Cataracts Root Lippia multi¯ora Chest and body pain Leaf Buparpum ( j) Defence against Root Asinsilyamo ( j) Sulajato (m) witches Sinsilyamo (m) Stylosanthes Chest pain Leaf Mangifera indica Diarrhoea Bark mucronata Bruito ( j) Bankegoteer ( j) Duto (m) M'bono (m) Mitragyna inermis Juju construction Wood Strychnos spinosa Aphrodisiac Root Bujungo ( j) Body pain Leaf/Stick Ehsigeer ( j) Body pain Root Snake bite Leaf Patakooley (m) Hernia Root Moghania faginea Body/chest pain Leaf Tapinanthus Worms/stomach pain Leaf Bapomb ( j) Pelvic/back pain Root bagwensis Sanfeeto (m) Stomach pain Root Ehkorlinko ( j) Yellow fever Leaf Leprosy Leaf Kunundingdolo Chewstick Stick (m) Moringa oleifera Illness prevention Leaf Terminalia albida Malaria Leaf Neberdayo (m) tonic Bupokhende ( j) Chewstick Stick Nauclea latifolia Diarrhoea Bark Wolo (m) Hiccups Leaf/Root Burleylebok ( j) Sores Root Twitches Root Batio (m) Rheumatism Root Stomach/back pain Leaf/Root Body pain Root Fever Bark/Root Stomach pain Root Terminalia Very hot fever Leaf Thin children Fruit avicennioides Fever Root/Bark Buleetar ( j) Sores Root/Leaf Oxytenanthera Diabetes? Leaf Wuluohyellow (m) abyssinica Uvaria chamae Frequent headache Bark Fujeel ( j) Buleyoo ( j) Fever Bark Bungo (m) Sambey®ngo (m) Parinari macrophylla Constipation Fruit Vernonia sp. Old bad sores Leaf/Stick Buwell ( j) Buntart ( j) Childbearing tonic Leaf Tamba (m) Jambakunango (m) Sores Root Parkia biglobosa Tooth ache Bark Vitex doniana Fresh cut Root Bukombong ( j) Boils Seed Bujink ( j) Preventative tonic Leaf Netto (m) Strength tonic Seed Kutu®ngo (m) Sores Seed Yellow fever Fruit pulp j = Jola name; m = Mandinka name. with herbal remedies. Table 4 shows that 13 The indigenous medical and therapeutic system plant species were also used in the village as in the village was two-tiered. First, there was a medicine against illness caused by animal pests, large inventory of widely used, readily available such as nits, ringworm, worms, maggots, rats collective knowledge for treatment of common and termites. ailments, such as constipation, diarrhoea, and

299 Therapeutic landscapes: C. Madge

Table 2. Animal medicine Disease Symptoms Cure/remedy Religious Charrow/Baddeh (F) Diarrhoea with blood. Can a€ect any animal Read a verse from the Koran or write a verse on a piece of paper and put the paper in the animals drinking water. The animal must be near a well or in the forest. A fortunate animal will recover Physical Besungue (F) Rinderpest? Tongue lies ¯at on the lower jaw and the eyes Put a needle through the black blood clot on enter the sockets. Only calves contract this tongue to release the blood. Continue to make disease. Black blood is found under the the cut right to the back of tongue muscle. tongue. The calf cannot suck milk from its Put salt in mouth to wash it clean. Take fresh mother salt to ®ll the hole made by the needle. Two days later heat an iron and burn the end of the jaw. The salt enables the blood clot to be released, kills all the poison in the calves body and prevents infection Darsue (F) Johnes disease Hair stands erect on body but tail droops. Heat an iron and burn cow's back on either Animal becomes weak and backbon protrudes side of the backbone and parallel to it. Burn from body. Animal eats well but excretes a small slits at right angles to the back bone. lot, often with blood. The animal cannot walk On third day after burning cow will increase properly. E€ects only cows its food consumption and recover Koril (F) Foot and mouth One front leg and one back leg on opposite The skin is split and black blood Foot and disease sides sti€en and the cow cannot move. A mouth removed from each of the a€ected blister appears on both limbs. A serious limbs, curing the disease disease that can be passed on to humans for whom it is fatal Parf (F) Emphemeral fever? The cow cannot walk but continues to eat. Once fresh rain falls on the cow it will start to Disease common in the rains. Animals may recover. Rain water is collected and the cow is have disease for up to month but it is not washed in it. After three days the cow will fatal recover Tolse (F) Tetanus? Movement of lower joint and hoof of cow is Backbone is burnt at right angles with a hot restricted, followed by the back muscle and iron spine restriction. Fatal disease Ataie yarr sejarmen Severe goat diarrhoea A cross is burnt on either side of animal Herbal Besungue (F) Severe goat diarrhoea Outer bark of kafafee (Corchorus olitorius) pounded and water added and given to calf to drink immediately after birth before suckling Damlow (F) Cattle stomach pain. Non-fatal Pound morlinkee (F) and fajaran (F) and add salt and water. Give to cattle to drink Ehnyall Cow has worms and insucient salt in body Pound roots of fajaran and morlinkee and leaves of butomborong (Ziziphus mauritania), wulo kono duto (Cordyla africana) and bufunuk (Guiera senegalensis). Add 25 kg of salt and 8 washing buckets of water. Give to cows before eating new grass. The mixture gives the cows enough salt to last a year. Important in places without a sea or river Ataie yarr sejarmen Severe goat diarrhoea Bark of wulo kono duto (Cordyla africana) stored in a bottle and given to goat to drink every morning. Alternative cure is bark of keedy (F) pounded, dried and mixed with milk for goats to drink Ataie yarr seyarharr Severe cow diarrhoea Roots of fukem (Acacia polyacantha) stored in a bottle in water. Young cows given medicine to drink every morning Gamuyeelen To give bulls strength Samentengo (Passi¯ora foetida) plant burnt and bull made to inhale the fumes Ehleleyaner Chicken illness. Chicken head twists Fruit of buparpum (Solanum indicium) put in backwards and chicken runs in circles chicken's drinking dish Ehsorhor Maggots in animal sores Leaves of bupemba (Anthostema senegalense) pounded and water added and put on sores

300 Therapeutic landscapes: C. Madge

Disease Symptoms Cure/remedy Animal Jo€eh (F) Contagious In early morning the cows' hair stands erect. Cow must be killed immediately and the lungs bovine pleuropneumonia? Mucus runs from the nose and cow has removed which will be swollen with blisters trouble breathing and covered with clotted blood. A slit must be cut in the nose of every cow in the herd and a slither of lung inserted into the cut. The disease is thus transmitted to the whole herd at the same time, thus gaining immunity F = Fula name. (Source: Momodou Jah and Samba Bah, 1989.) fever. Secondly, there was a specialised system of often obscured by studies of indigenous health knowledge administered by medicinal prac- care focusing only on local specialists. Table 1 titioners to treat less common illnesses. From the therefore provides a summary of common medic- outset, however, it must be stated that there was inal knowledge. However, it is important to note much overlap and interchange between the two that this knowledge was not known to the same tiers. extent by all people in the village. Messer (1978, p. 144) stated that it was old women who were Common medicinal knowledge the main repositories of medicinal knowledge. The important role of diagnosis and therapy of Although in these investigations this was found disease by a large proportion of the population is to be so, there were also other groups of women

Table 3. Medicinal uses of animals Species Disease/symptoms Remedy Boa Constrictor. Yeeah General illness Fat used (preparation unknown) Dolphin. Erungafal Children with frequent illness Fat found around the brain given to patient to eat Fox. Gagargal Pneumonia Kill a fox, cook and give to the patient to eat. Tie a piece of tail on a string around the patients neck Goat. Ehjarmen Pneumonia Drink goat's milk and rub the milk on the body Goat. Ehjarmen Eye problems. The patient can Take patient into a room with no windows. The see in the day but not at night door should be closed all day and all night. The meat and liver of the goat should be eaten for one week. The patient may only leave the house to shower and toilet. After one week the patient will be cured Goat. Ehjarmen Snake bites Drink blood Hen. Ehfarra Blood in urine Cook the fowl with milk processed into oil and the roots of busayeat (Cassia sieberiana) and geebungeefarra (Cassia occidentalis). The patient should eat the whole animal and the sauce the fowl was cooked in. If the patient is a man, he should eat the fowl in the presence of a woman. Then bury the bones Hen. Ehfarra Yellow fever The leaves or roots of bupokhende (Terminalia albida) boiled and water retained. A ®ve month old chicken is cooked in this water. Eat fowl and stew. Hyena. Ehmungdungo Frequent illness, fever, body pain, The meat is used (preparation unknown) headache and diarrhoea Lizard. Gajinda Whopping cough Boil the lizard in water and drink the water Pigeon. Ehmungorh Hiccups The leaves or roots of bupokhende (Terminalia albida) are boiled and the water saved. Pound fresh roasted groundnuts and add water. Kill the pigeon and cook meat in the groundnut sauce. Eat whole pigeon and sauce Porcupine. Fusangnyell Old sores (over two years) The Quills burnt into ash and sprinkled onto sore Pu€ adder. Bullakeem Joint pain Fat melted in tin and rubbed on painful joints Red monkey. Gajeb To make jujus Skin used to make jujus Snake. Enap Hip pain Boil fat of snake and eat Wild pig. Ehyumbaehrama Body fever Boil meat and give to patient to eat. (Source: Mallang Kumba Badjie, Momodou Jah, Samba Bah, `Ayet' Jatta and Mallanding Sanyang, 1989).

301 Therapeutic landscapes: C. Madge

Table 4. Medicine to cure animal pests Species Part used Cure/remedy Adansonia digitata Leaf Pound and mix into a paste with water and use as a shampoo to get rid of nits Cassia sieberiana Seed Fish poison Root To cure ringworm Combretum paniculatum Root To get rid of worms. Wash and clean roots. Store in water for 16 hours and the worms are excreted when the water is drunk Elaeis guineensis Male ¯ower Burn and they repel mosquitos Hannoa undulate Bark Snake bite Hyptis suaveolens Fresh stalk Acts as a mosquito repellent Icacina senegalensis Leaf Snake bite Khaya senegalensis Bark Dry, pound and add to stored groundnuts. It acts as a preservative by preventing maggots eating the nuts Bark To get rid of worms Lippia multi¯ora Flower Dry and pound and add to stored food. Acts as a preservative by preventing the maggots eating the nuts Leaf Store in water for 24 hours and use as an insect repellent for fruit and vegetable nurseries Manihot esculenta Leaf Dried and used as rat poison Mitragyna inermis Leaf Snake bite Parinari macrophylla Leaf Termite repellent Tapinanthus bangwensis Leaf To get rid of worms (Source: Ansu Badjie, Mallanding Badjie, Mallang Kumba Badjie, `Ayet' Jatta, Binta Jatta, Mallanding Sanyang, Nyorita Sanyang, 1988.) who recalled a rich body of medicinal knowledge, supposedly widespread medicinal knowledge was such as women with responsibility for many chil- di€erentiated according to gender, age, wealth dren and women in poor households. These and ethnic group. women had to provide health care for their dependent family and often could not a€ord the more expensive biomedicine, explaining their re- Specialised medicinal knowledge liance on indigenous cures. The second form of medicinal health care con- Wealth, age and ethnicity also played a role in sisted of the specialised system of medicinal the retention of indigenous medicinal knowledge. knowledge. This knowledge was often kept secret People from rich households knew little about and only passed on through formal mechanisms, such remedies, possibly because indigenous cures such as to the oldest son or daughter, through were commonly considered `backward' and, apprenticeship, or was believed to be gained given the choice, rich households chose to through communication with the `spirits'. The increase their prestige by using biomedicine. To medicine usually cured more serious diseases, admit to using indigenous remedies would have incurable by non-specialists. This more special- diminished their social status. Also, if people ised system included medicinal therapies supplied from rich households had been using biomedicine by herbalists, herdsman, hunters, midwives, mar- for a long period they may have forgotten many abouts and the custodians of shrines. indigenous cures. Young unmarried people had Herbalists (amori) were considered as being only limited knowledge of indigenous remedies. either formal or informal. The formal herbalists Young individuals wanted to be `modern' and learnt their information under an apprenticeship this included using biomedicine; they had been system and were taught, and often practised, taught little about indigenous medicine by their away from their home village. This appeared to parents and were discouraged from using it by increase their status in the village in which they biomedical practitioners. Additionally, certain resided. Certain individuals were said to have ethnic groups were believed to specialise in cer- special herbal knowledge, passed on by the tain types of medicine, such as maraboutic cures family, which could apparently activate certain by the Mandinka, bone setting by the Jola, and medicine. Reputations as informal herbalists thus animal medicine by the Fula. Clearly, then, even also developed.

302 Therapeutic landscapes: C. Madge

Village herdsman (ah-hawa) had specialised secretive and specialised source of knowledge knowledge concerning veterinary medicine and available only to old women with surviving chil- animals used for medicine. In The Gambia, the dren. Control to the secrets of procreation was traditional cattle herdsman usually originated vital to the women's position and through it they from the Fula ethnic group and had learnt their retained power and in¯uence `behind the scenes'. specialised knowledge of veterinary medicine Women's role in medicine in Africa has been from their fathers. As such, there was no formal examined in detail by Ebin (1982) in Ghana, medicinal training. Table 2 gives details of the Maclean (1982) in Nigeria and by MacCormack herdsman's ethnoveterinary practice in the vil- (1982) in Sierra Leone. lage. Research elsewhere (McCorkle and Marabouts were commonly consulted in the Mathias-Mundy, 1992) documents parallel prac- village for medicinal purposes to assess the tices among other livestock owners in Africa and nature of disease a‚iction, particularly if thought suggests the scienti®c rational behind ethnoveter- to be the result of witchcraft. Marabouts were inary medicine. For example, salt and urine are believed to have the power to make jujus or sterile materials, thus useful as disinfectants for nasso. Nasso was holy water made by washing pharmacology and surgery; bloodletting serves to verses from the Koran written in soot on a ¯at produce localised stimulation of immune and slab of wood into a bottle sometimes containing haematogenic systems; infected lung tissue placed animal or herbal medicine. Nasso was used more in nostrils of livestock is an e€ective vaccination commonly than jujus since it only had to be against bovine pleuro-pneumonia. drunk once to give protection for life. Nasso was The hunters (ahweema) were a third group of used to give one children, make one popular or important medicinal specialists11. The important to prevent illness. Jujus were amulets formed by role that hunters play in the spiritual welfare of wrapping verses from the Koran in leather and African populations has been clearly shown, for attaching them to a particular part of the body, example by Marks (1977). However, less clearly such as the knee or the ankle. Jujus were used in understood has been the role of hunters in ensur- a more preventative health care role, being ing the physical welfare of village populations, employed to prevent bad luck due to spirits and although Turner (1968) is an exception. Amongst witchcraft. They were often used in combination the Jola, hunters usually left their home village with herbal remedies. Most people wore jujus for an apprenticeship of up to 10 years. The pro- constantly and washed regularly in nasso, but spective hunters learnt how to hunt, a skill used special jujus were constructed for particularly in combination with medicinal cures, particularly severe or long-term illness, or problems of a for illnesses resulting from close contact with ani- psychological nature. This form of medicinal mals. Hunters' remedies involved cures for snake health care does not appear to be declining. The bites, animal repellents and child cures, such as young `modern' men took the preparation and when young babies temporarily stopped breath- use of jujus in football matches most seriously. ing (Table 3). The medicinal cures involved learn- Jujus were used as protection against bad luck ing verses (soras) from the Koran, in wished upon the team by their opponents. combination with herbal remedies. If an individ- A ®nal form of indigenous health care was the ual killed an animal, particularly an `evil' one, use of spirit shrines (enarte). These were kept to and did not know the correct verses or herbal prevent illness from evil spirits and to discourage remedies to `neutralise' the power of the animal's stealing. The shrines were passed on through spirit, it was stated by the villagers that the per- family lineages, each shrine having its own son would die. For example, if an antelope's hair owner, usually an old woman, who acted as a stood on end when it was shot or if the saliva of medium between the shrine and human beings. a dying animal touched a hunter, it was said that Certain shrines had the ability to cause illness if he would fall ill unless treated. It was the their social rules were disobeyed. Each shrine ahweema who could cure such a‚ictions. The produced a particular illness or a‚iction, such as hunters employed strict regulatory controls on small body sores, diarrhoea or a sore throat. To using medicine. A hunter would never give all cure the illness the shrine had to be appeased, members of one family the same medicine since which usually involved a small renumeration and ``...the medicine would not work for the chil- the use of the speci®c herbal remedy needed to dren''. There was appreciation of the concept of cure the a‚iction. Often the fear of such illnesses immunity from active plant ingredients by was enough to discourage socially harmful beha- extended use of medicine over years. viour. The fourth medicinal specialist was the mid- The indigenous health care system of the Jola wife (ahjogar gukonya nganogen), usually old was therefore complex, involving several ®elds of women who had specialised knowledge on ferti- care consisting of both cure and prevention, lity-regulating medicine, pregnancy, childbirth material and spiritual beliefs and a variety of and common child ailments. This was one highly di€erent practices. A particularly important role

303 Therapeutic landscapes: C. Madge was played by herbal remedies and the discussion of the dosages of much herbal pharmacopoeia. below focuses on their use in the particular cul- What has apparently not been realized is that tural context of the Jola of The Gambia. Among speci®c dosages are often unnecessary for most the Jola, the forest is seen as vital to life, owing herbal medicine is prepared by mixing with to the healing property of trees, showing the sig- water, resulting in a dilution of the active ingredi- ni®cance attributed to herbal pharmacopoeia in ents. Moreover, when dosage was important, it Jola cosmology. was carefully measured using locally ®xed amounts, such as tea glasses or washing buckets. These measurements probably appear haphazard Discussion of herbal medicine to the outsider, but they do remain constant. Several important themes emerged from an Furthermore, cross-checks were commonly car- analysis of herbal medicine. These are discussed ried out to assess the successful preparation of below since they illustrate that the ways in which the medicine, such as ``...if the medicine is good, herbal medicine is made and used in local con- a scum will form when mixed with water''. texts may have been misunderstood, thus explain- Dosage was also administered carefully according ing why indigenous medicine may have been to individual requirement (age, sex, build of per- assigned a low value in relation to biomedicine son or animal). and why appreciation of its signi®cance is only The state of the medicine was also important. recently emerging. Methods of preparation commonly described the First, the importance of combinations of plants state of the ingredient (for example, dry, fresh, (or plants and animals) used therapeutically unopened), and the speci®c part needed (for emerged. The therapeutic e€ect of herbal medi- example, ``discard outer bark; ...use bark found cine was the result of mixtures in which whole in the middle of the tree, not at the top or plants, or parts of plants, were prepared and bottom; ...use fresh bark because in dry bark taken in combination or sequence. For instance, the medicine has been used by the sun''). It was in the village some plant species required the pre- commonly believed by the villagers that the sence of other species to activate or neutralise the `blood' (sap) of the plant contained the medicine. mixture, or to vary the strength of the medicine, As such, it was perceived that by absorbing the or to act as `inert' constituents. Little work has sap the patient was taking in some of the tree's been done on this aspect of herbalism, although own healing properties. For example, it was Hikino et al. (1977) acknowledged the import- stated that ingestion of the sap of buhangken ance of preparation methods in assessing herbal (Pilostigma thonningii) discouraged evil spirits medicine, observing that the toxicity of Aconitum because the `blood' of the tree repelled them. spp., previously thought to outweigh any thera- Timing was another factor often unappreciated peutic value, was reduced 100-fold by local in the preparation of herbal medicine. April to methods of preparation. Additionally, among the May was considered the best time to collect bark Jola it was believed that diseases developed since it was believed that during the rest of the sequentially. The progression of symptoms was year the tree was `full of water', which diluted thus a requisite of the healing process and at the sap. Roots and bark were collected at mid- each stage in the illness a new medicine or new day for this reason but leaves were collected form of medicine was used. Illnesses were also early in the morning before being dried by the often linked to more than one cause, resulting in sun. Speci®c time limits were imposed on the the use of more than one kind of medicine. This period of activity of the medicine. Most medicine sequential and multiple mode nature of medicine was only used for three days after initial prep- may appear disorganised to the untrained eye. It aration. Time limits were also placed on the is essential that when herbal medicine is tested e€ectiveness of the medicine and if a reasonable for ecacy it is done so in its correct combi- health improvement had not been made within nation and sequence, which may only be possible the allocated time limit, di€erent for each illness, in the ®eld setting. an alternative cure would be sought. This was es- A second factor that emerged was that pecially important for children's medicine. It was methods of preparation, including dosage, state appreciated that children were more vulnerable of ingredients and timing were also essential in than adults. understanding the therapeutic value of herbal Thirdly, the importance of the role of food as remedies. According to Hallam (1979, p. 100): medicine and medicine as food became increas- ``The e€ectiveness of bush medicine is a rather ingly clear as the research progressed. It was fre- hit and miss a€air depending on the time of year quently stated by the villagers that: ``Medicine is and dilution administered to the patient''. also food because if you don't take medicine you Practitioners of European biomedicine, whose will die''. When women were interviewed as to style of application is dosage-speci®c, have found the way in which food was `good' for them, they it dicult to understand the non-speci®c nature commonly replied in medicinal terms, for

304 Therapeutic landscapes: C. Madge example ``...tea is good to prevent chest pain''. from the east and west of a tree in the village The separation of food and medicine into distinct may not merely be a socially constructed beha- categories is an artifact of European `scienti®c' viour pattern but may be an observed fact passed specialisation and may be inappropriate in the down through generations that this bark shows African context; rather, research should focus on greater chemical activity than the north and the multicontextual use of plants. Studies else- south bark which may be a result of the heat of where have also indicated that food often has an the sun activating or destroying chemical con- important role to play in preventative health stituents in the bark. Preparation of some herbal care. Etkin and Ross (1982) noted that of 107 remedies stipulated that the medicine should not plants commonly used by the Hausa as gastroin- be put onto the ¯oor at any time during its prep- testinal medicine, 53 species were also dietary aration or use. Rather than irrational ritual, by constituents. Iwu (1986) also indicated that the placing the medicine onto the ¯oor the container use of plants, animal or inorganic substances for may have absorbed heat from the ground which nutrition, cure and prevention of disease could might have then altered the chemical constituents not be separated by Igbo ideology. A further in the medicine. These above examples are specu- point to note is that the preventative or thera- lative but it is important to rationalise behaviour peutic role of food and medicine has been patterns while not denying the role of ritual in obscured by the scienti®c approach in an attempt the sancti®cation of medicine, especially for med- to discover wonder cures, especially for serious icinal specialists. or fatal diseases. In the village, medicine and This discussion has highlighted a few examples food were also often taken for the sole purpose of why the ecacy and value of herbal remedies of preventing ill-health, a practice also under- may have received little acclaim in the past. taken in Nigeria (Abosede and Akesode, 1986). Trying to understand herbal remedies through a The fourth observation is that beliefs concern- Western scienti®c `®lter' will only provide a lim- ing herbal medicine are important and deserve ited comprehension of their value in the local greater research attention. In the village medicine context. A culturally informed perspective that was thought to have physical properties commen- provides an appreciation of local indigenous surate with its healing power, often portrayed as beliefs and knowledge, and medicinal preparation an opposite. Fever was commonly cured by in context, is essential to gain an understanding washing and medicine used to ``cool the body of health and medicine from an African-centred down''. In a similar manner, colours were often vision. Clearly, however, herbal remedies are not said to represent properties of the medicine. Red the only form of medicine used by the Jola in bark and other brightly coloured medicine was The Gambia: biomedicine is playing an increas- considered dangerous, for example, the bark of ingly signi®cant role. The health care system of buhangken (Pilostigma thonningii) was believed to the Jola is thus not ®xed but subject to ¯uidity be dangerous; research has shown that it is hallu- and change. In the ®nal section the interaction cinogenic if consumed. Internal gastroenteric pro- between indigenous medicine and biomedicine is blems such as diarrhoea and constipation were examined, highlighting that any culturally usually cured by the ingestion of medicine to informed perspective must also be embedded ``¯ush the body out''. Such perceptible evidence within a political economy approach which seeks of the disease leaving the body has also been to understand the unequal global power relations found by Etkin and Ross (1982) among the involved in the creation and use of particular Hausa of Nigeria where the preferred plants used health care systems in speci®c places by di€erent for the treatment of gastrointestinal disorders groups of people. were those that exerted a diuretic or laxative activity. Fifthly, the research also indicated that ritual Interaction of indigenous medicine and played an integral role in the preparation of 12 medicine, especially by medicinal specialists. biomedicines Ritual in medicine has sometimes been portrayed There has been a shift from using indigenous as a socially constructed form of irrational beha- remedies to using biomedicine in The Gambia. viour by outside observers (Sempebwa, 1983). According to Professor Nina Etkin (personal However, according to La Fontaine (1985, p. communication): ``It is most commonly the case- 12), ritual action is not irrational but purposive ...that biomedicine eventually, and sometimes and its success or failure cannot be measured in quite rapidly, supplants its indigenous counter- Western scienti®c terms: each type of ritual rep- parts, sometimes having gained an exaggerated resented a storehouse of traditional knowledge. status incommensurate with its ecacy and/or Observers are beginning to understand the im- range of applicability''. In addition to indigenous portant practical rationale underlying ritualistic cures, a combination of diverse biomedicinal behaviour. For example, using only bark taken sources were used in the case study village. These

305 Therapeutic landscapes: C. Madge included medicine from a primary village health Decision-making on the type of medicine used care service supported by the government, a tra- was ¯exible. Biomedicine was used for illnesses velling Caritas nurse, basic pharmaceuticals from that local remedies could not cure, such as tooth- the village shop, a free clinic at Marakissa, the ache, headache and eye trouble or serious ill- government sponsored clinic in Gunjur (the local nesses such as infection from a rusty iron town), the pharmacy in Gunjur and, less com- implement (tetanus) and a severe pain in the side monly, the hospitals in the main towns of of the abdomen (appendicitis). The hospitals Serrekunda and Banjul. Medicinal beliefs and were used for serious cases or only as a last practices were therefore ¯exible, indigenous medi- resort for it was stated that individuals did not cine being used in parallel with biomedicine. return from the hospital alive or were asked to The choice of the type of health care used in leave the hospital before properly cured because the village depended on individual preferences they could not a€ord to pay the cost of medicine. and constraints. Accessibility played a signi®cant Perceptions of the success rates of particular role in¯uencing the type of medicine used. As the types of treatment were therefore important distance of the health care facility increased, so variables a€ecting the balance of utilisation of the uptake of that particular facility decreased. indigenous medicine or biomedicine. A major Distances of up to 10 km were commonly walked diculty in combining the two forms of health to clinics and pharmacies if the illness was not care was that if the indigenous remedy was not too severe. The cost of bus fares acted as a con- successful, the patient might resort to biomedi- straint; for this reason many individuals preferred cine, and vice versa. This could result in the to use the travelling nurse who came to the vil- patient receiving two dosages of the same active lage every 2 weeks. The free clinic in Marakissa ingredients, but in di€erent forms, and possibly would have been more popular but its distance increasing the potential of over-dosing. was restrictive. Also, it was a Catholic funded Financial circumstances a€ected the balance of clinic and hence some of the Muslims did not medicine used. Often poorer individuals could feel that they could use the facilities. People who not a€ord biomedicine, even if they wished to were too ill to walk and could not a€ord trans- use it. For those that could a€ord biomedicinal port costs relied on indigenous cures or the tra- cures, individuals tended to choose the travelling velling nurse. nurse since her medicine was the cheapest (1 Seasonality was an important factor in de- dalasi)13. When the nurse was not available most cision-making concerning the form of health care individuals would visit the pharmacies where selected, particularly during the rainy season. untrained sta€ administered over-the-counter During the rainy season the nurse was prevented pills and injections, rather than visit the govern- from reaching the village due to inaccessible ment clinics with trained personnel, owing to the roads; this diculty was compounded by the greater cost of the clinics. Also, the local govern- suspension of local bus services. Thus, the near- ment clinic was organised by Mandinka and the est source of biomedicine was the local town Jola preferred to go to a pharmacy run by a fel- which was 6 km distance on foot on a badly- low Jola since it was stated that the Mandinka kept dust track which quickly became in accessi- teased them about using herbal remedies. The ble during the rains. Therefore, the most com- popularity of pharmacies compared to the clinics monly used medicines in the village during the had serious, often detrimental, health impacts rainy season were indigenous remedies. If these (Trostle, 1996). Mothers would sprinkle anti- were not known, or if a specialist medical prac- biotics directly onto their child's body-sores titioner could not be a€orded, then over-the- rather than administering them orally owing to counter pharmaceuticals from the village shop lack of advice from pharmacy sta€14. Pregnant were purchased. The limited use of biomedicine women took dangerous drugs, and painful arm during the rainy season has been noted else- infections were noted on children after injections where in West Africa, such as in Burkina Faso from hypodermic needles. Some individuals were owing to restricted cash supply (Sauerborn et al., experiencing and realising the harmful e€ects of 1996). over-use of biomedicine: ``Pills and injections are The type of remedy used in the village also harmful if you take too much or too often. depended on the perception of the illness. Herbal remedies can't be harmful because people Common illnesses such as sores, colds, ring have been taking roots and leaves since the worm and sore throats were treated by herbal beginning of time''. One old village woman who remedies as well as more serious diseases thought had lived in the Casamance as a child, where the to be incurable by biomedicine, such as certain integration of Western health care based on bio- medicine for pregnancy and yellow fever. medicine had arrived earlier than in The Additionally, if local cures did not work for Gambia, and who had been given many pills and some illnesses, for example, fever or diarrhoea, injections as a child, found her body no longer then an alternative biomedicine was sought. responded to medical treatment: ``I have taken

306 Therapeutic landscapes: C. Madge too many pills and injections so local medicine length and quality of training of local prac- won't work on my body any longer''. titioners varies greatly. Older individuals often preferred indigenous Although indigenous medicine has many ad- medicine because it was cheap, readily available vantages it is gradually being replaced by biome- and was observed to cure common conditions. dicine among the Jola of The Gambia. One However, the limitations of indigenous remedies young male villager noted: ``Food production has were also realized for individuals stated that ill- declined, leading to poor nutrition, so health care nesses were detected through symptoms but some has increased. People use pills and injections illnesses had the same symptoms and so oc- more than herbal medicine because everyone is casionally the wrong medicine was administered. told to use the health centre from pregnancy for In contrast, young individuals preferred `modern' the rest of the child's life. People think that injec- medicine which did not need any processing, tions are best because they help them to recover preparation or collecting. They believed that: quickly. Also, people still believe that white ``There is no illness that biomedicine cannot people know more than black people and so they cure''. Furthermore, young people often did use their medicine''. Scienti®c biomedicine, with not have the knowledge to cure themselves; they its long history of intervention in The Gambia, were more dependent on outside governmental has developed into a ``medical cultural hege- and NGO organisations to cure their health mony''; it is a pervasive and wide-spread belief problems and spent considerable income to this among the Jola of The Gambia that biomedicine end. There were a few young individuals who is superior to indigenous medicine. took an active interest in indigenous medicine Replacing indigenous knowledge by scienti®c but they had parents who were specialised specialisation is also related to the government's medicinal practitioners. Possibly in the future policy on health care. In August 1988 the widely known local cures will be lost but special- Gambian government privatised the health ser- ist knowledge, and thus latent power, will vice as part of the Economic Recovery remain? Programme promoted by the International Indigenous medicine thus has both potentials Monetary Fund and the World Bank. The price and limitations in its use. It is cheaper than bio- of government health care facilities subsequently medicine, is widely available to most of the local leapt, a feature common throughout Africa population and can be used to treat a broad (Asthana, 1994). Before these changes, hospital spectrum of illnesses. Also, the time taken to treatment had been cost free in The Gambia consult an indigenous practitioner is often longer although the patient paid for the medicine. After and more `personalised' than that of a doctor privatisation, a 50 dalasi charge each week was based on biomedicine. Local practitioners have placed on use of hospital facilities, combined `expert' knowledge of particular village commu- with increased price of medicine, clearly putting nities and the speci®c patterns of disease and ill- such treatment out of the reach of most of the ness located among di€erent groups of people at local population. Mother and child health care, di€erent times of the year; they are also generally previously free, also had charges imposed. adaptive, open to innovation and responsive to Women were required to pay 30 dalasi to have referral of serious illnesses to biomedical facili- their child delivered in the local clinic if they ties. Furthermore, indigenous medicine is part of stayed overnight and 5 dalasi to have their chil- African people's socio±cultural life and is an im- dren weighed. Such action resulted in three main portant factor promoting social cohesion, cul- alterations in the form of health care used. First, tural continuity and positive psychological well- individuals who used biomedicine shifted from being. One of the most valid arguments against more expensive forms of clinic and hospital medi- the use of indigenous medicine is the lack of cine to cheaper over-the-counter medicine of the scienti®c proof of its ecacy. Fortunately, this untrained pharmacists and shopkeepers. viewpoint is steadily changing and e€orts are Secondly, participation at distant free clinics now being made to investigate the use of indigen- increased. Thirdly, poorer individuals drifted ous cures, paying attention to speci®c methods of back to using indigenous remedies wherever poss- preparation and local cultural beliefs. Another ible, but when questioned many of them stated shortcoming of indigenous medicine can be the that their lack of knowledge of indigenous cures imprecise diagnosis given by local practitioners; was a constraint. for example, stomach pain could imply indiges- Clearly, then, any understanding of local tion, ulcer infection or cancer of the stomach, health care patterns must be contextualised resulting in misapplication of indigenous medi- within existing economic and political conditions. cine which treats symptoms rather than relying This is particularly the case in The Gambia. on a speci®c diagnosis. Finally, it must also be Having maintained a multiparty system for the acknowledged that some indigenous beliefs and three decades since independence, Sir Dawada practices may be harmful to humans and that the Jawara was ousted in a coup by young army

307 Therapeutic landscapes: C. Madge lieutenants in July 1994 (Wiseman and Vidler, disease), medicine was taken as a prime example 1995). The county has since been under military of the constructive and bene®cial e€ects of colo- rule led by Colonel Yahya Jammeh who has nial rule and was used as one of its most indispu- been supported by many Gambians owing to his table claims to legitimacy. Lyautey, the leading anti-corruption drive (De Costa, 1995). In exponent of military medicine as an aid to estab- September 1996 Jammeh was democratically lishing French power in Africa, went as far as to elected president of the APRC (Alliance for proclaim that ``La seule excuse de la colonisation Patriotic Re-orientation and Construction). c'est le medecin'' (Arnold, 1988, p. 3). According to Secka (1996, p. 1640) one reason The hegemony of biomedicine is still evident for his election as president was his excellent today in The Gambia. Biomedicine has become a record in the health and education ®eld, es- major institution in The Gambia in which people pecially in rural areas. Payment for government are increasingly becoming dependent on the `cult health care has been ®xed at 5 dalasi a ticket, of the expert' and ideological de®nitions of while payment for the travelling nurse has risen health and illness based on a Western scienti®c slightly to 6 dalasi (including medicine). Certain model, although this model may be `translated' common diseases and illnesses have been targeted within local cosmologies (Gursoy, 1996). In the for investigation, in conjunction with the Medical face of foreign-exchange shortages and declining Research Council; these include cataracts, child international support, dependence on biomedi- nutrition and malarial control. The government cine is a dangerous strategy for The Gambia to is also currently attempting to set up kabeloos or pursue15. Many indigenous remedies can be as primary health care in rural villages. Rural villa- e€ective and much cheaper, more accessible and gers are using government sponsored health easily understood by local populations than their clinics more commonly now than individually- biomedical counterparts. Hence a strategy com- run pharmacies (many of which have been closed bining the two medical traditions in parallel has as they were being run by non-quali®ed sta€). the best potential to improve the curative and The clinics are believed to be better stocked in preventative health care of The Gambian popu- important medicine and medical personnel from lation. However, despite the signi®cant role that Cuba, Egypt and Nigeria have increased in num- indigenous medicine has played, and continues to ber. The perception of rural Jola is that the play, in structuring health care in the country, health system has improved with the `new' gov- research and development still focuses on biome- ernment. It remains to be seen if these policies dicine and biomedical understandings of health can be maintained, particularly if international and illness. Hopefully this paper can go some ®nancial and technical support which was sus- way towards addressing this imbalance, through pended during the political instability is not its call for more encompassing concepts of medi- renewed. cine based on indigenous cultural development and through the provision of detailed data sets outlining various forms of indigenous medicine Conclusions used by the Jola. Global power relations play themselves out in Support must be given to research and policies the form of political and economic policies which that develop bene®cial links between indigenous structure health care. Practices at the local level medicine and biomedicine to provide improved are therefore in¯uenced by the interplay of global material outcomes for the people of The forces and local perceptions and needs (Gort, Gambia, a country su€ering from poor health in- 1989). Additionally, global power relations oper- dicators. Some examples include: indigenous ate in relation to the creation of hegemonic ideol- practitioners should be consulted to determine ogies and discourses. The introduction of how/if the advantages of biomedicine can be in- scienti®c biomedicine in The Gambia was based corporated into indigenous health care beliefs; upon the assumption of universal applicability. practitioners should be trained in the basic con- The rules of Western `science' were believed to be cepts and methods of biomedicinal practice; the all embracing which gave little `room-for-ma- site-speci®c body of common and specialist indi- noeuvre' for speci®c cultural interpretations of genous knowledge, and associated plant and ani- health and medicine. This hegemony of Western mal species and speci®c preparation methods scienti®c discourse was established during the should be recorded; laboratory and clinical colonial period. Health issues were used by the screening of pharmacological activity and e€ec- colonists as a means of spreading or exhorting tiveness of indigenous remedies needs to be control and as an intervention which represented assessed; scientists and practitioners should work `progress' towards a more `civilised' social and together to understand, test and enhance indigen- environmental order. Although the negative ous treatments through on-farm ®eld testing in health consequences of European presence were which the indigenous treatments are not allocated sometimes recognized (as in the case of venereal an inferior role to biomedicinal treatments;

308 Therapeutic landscapes: C. Madge proven indigenous remedies should be incorpor- cultural development. The term is synonymous with tra- ated into formal medical curricula and outreach ditional, alternative, folk, unorthodox, or ethno medicine. Several di€erent types of indigenous medicine exist including programmes for students and professional in the herbalism, midwifery and divination. Biomedicine is the term ®eld; ®nally, proven indigenous cures should also used in this discussion to refer to clinical medicine based on be `validated' through the education system and the principles of natural science. It is preferred to the terminol- common knowledge passed on to rural individ- ogies `modern, `scienti®c' and `Western' medicine: the term uals before it becomes `lost'. The ultimate aim of `modern' medicine compared to traditional medicine tends to imply that biomedicine is innovative and indigenous medicine any health care strategy should be to increase is stagnant; the term `scienti®c' medicine implies that biomedi- people's control over the improvement of their cine is universally applicable rather than a re¯ection of a pre- health and towards achieving this aim, indigen- vailing culture and a particular world view; and the term ous health care is worthy of greater respect in `Western' suggests that this form of medicine only developed, and is practised, in the Western world. biomedical discourses and practice. 3This process is, however, still incomplete in Europe. In the Finally, this case study demonstrates that the United Kingdom, for example, there are still strong beliefs in therapeutic landscape of the Jola is a product of both `white' and `black' magic. In rural areas herbal remedies changing social and material circumstances which are used for common illnesses. Many diverse `old wives tales' interact at a variety of scales (e.g., current globa- exist on fertility control. People o€er prayers, blessings and vows when hospitalised for serious operations to help ensure a lisation processes resulting in Structural successful outcome. There is also an increased interest in Adjustment Policies, geopolitical regional change, alternative medicines, such as homeopathy, acupuncture, dominant discourses of health and medicine dowsing and crystals by certain groups in European society. articulated through the scienti®c establishment, Beliefs about medicine are thus complex and many people are moving towards more holistic beliefs and interpretations of national government policy, international aid re- health care in Europe. Similarly, in the African context lations, changing social relations owing to rural± experiences and practices surrounding indigenous medicine urban migration, alterations in generational- and biomedicine interfuse to form a complex pattern of health based knowledge systems etc.). Health care sys- care beliefs. The discussion here, however, focuses on bio- tems do not simply develop in response to par- medicine in the European context and indigenous medicine in the African context since these systems of thought have domi- ticular cultural practices embedded in particular nated behaviour in these places to date. This false dichotomy places by particular groups of people, but they has been created for ease of understanding. Later in the also develop in the context of unequal political paper the interaction between the two medicinal modes is and economic realities. New cultural approaches discussed. 4All Jola words are indicated in bold. (Gesler, 1992; Gyapong et al., 1996) and lay per- 5Gambia National Archives Reference Number 2/1429. ceptions (Poland, 1993; Lerer et al., 1995) must 6Despite lengthy investigations, botanical identi®cation could therefore be combined within a political economy not be veri®ed for this specimen. framework to stress the dynamism involved in 7The identity of the village is not revealed for reasons of con®- health care. The progress for research therefore dentiality. Among the Jola several important terms exist: medi- cine is known as bubearben; to be physically sick, ehmass;to lies in the broader contextualisation of medical hurt, ting-a-ting or ganugurr; and a distinction is made between pluralism which is sensitive to the socio±eco- being ill, bajuser, and being seriously ill, gasomut. nomic and political context of health and disease 8Veri®cation of species was made by cross-checking with bota- (Dauskardt, 1990; Barrett and Browne, 1992). It nical manuals and local medical specialists. Unidenti®ed plant specimens were collected and were later identi®ed with the is not, therefore, adequate for `population health' help of botany specialists at Kew Gardens, London. The data to focus on `position in the social hierarchy' collected from this survey are recorded in Table 1. (Hayes, 1996); rather, what is needed is a `strati- 9Names of the plant or animal species in Jola is in bold type- graphic' analysis that examines the complex in- face, followed by the botanical name in italics. 10 teractions between human actors and cultural/ Table 2 shows the ethnoveterinary therapies used in the vil- lage. It must be noted that the naming and classi®cation of dis- political/economic global hierarchies. eases in the village was undertaken according to their most salient symptoms. As a result, scienti®cally di€erent diseases Acknowledgements may be amalgamated together in this classi®cation system. The matching of indigenous disease classi®cations with their corre- The author would like to thank everyone who participated in sponding scienti®c terms is therefore fraught with diculties; the study in The Gambia and Robin Kearns and two anon- ymous referees for their helpful suggestions on an earlier draft hence the scienti®c naming of diseases in this table should be of the paper. treated with caution, as indicated by the question marks. 11The term hunter should not be confused with individuals who hunt. Anyone could hunt, using traps, dogs, smoking, guns, catapults, nets or sticks but it was only individuals with Notes specialised medicinal knowledge, learnt away from their home 1The term therapeutic landscape is used to refer to the speci®c village by apprenticeship, and with the ability to cure other health care beliefs, practices and experiences of a particular hunters, who could be considered ahweema. group of people located in a speci®c place. This therapeutic 12The discussion focuses on human health care rather than landscape is an outcome of the interplay between speci®c cul- ethnoveterinary practices owing to lack of data. tural practices and unequal economic and political realities. As 13The dalasi is the name of the local currency. At the time of such, the term is employed rather di€erently that originally research, 10 dalasi was equivalent to one pound. intended by Gesler (1992). 14This is an interesting example. The herbal remedy for body 2Indigenous medicine refers to health beliefs and practices sores was to sprinkle the dried pounded leaves of buntart relating to disease and illness which are products of indigenous (Vernonia sp.) onto the sore which formed a `crust' or `scab'

309 Therapeutic landscapes: C. Madge drying out the infection. Women `translated' their indigenous Europa Publications (1992) Africa South of the Sahara. knowledge onto the use of biomedicine; few herbal remedies Europa: London. for sores were taken orally. Other examples of the interpret- La Fontaine, J. S. (1985) Initiation. Manchester University ation of biomedical notions within cultural beliefs may be Press, Manchester. found in Iyun and Tomson (1996) and Opala and Boillot De Francisco, A., Armstrong-Schellenberg, J., Hall, A. J., (1996). The use of biomedicine does not therefore automati- Greenwood, A. M., Cham, K. and Greenwood, B. M. cally mean that people change their beliefs about health. As (1994) Comparison of mortality between villages with and Gesler (1991, p. 119) has noted, Western medicine and medical without primary health care workers in Upper River technology may be the attraction, rather than biomedical Division, The Gambia. Journal of Tropical Medicine and ideas. 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