Traditional psychiatrv in Mali
A study of the traditional psychiatrie resources of the Dogon area in south- central Mali and of the Tuareg people of the north suggests how traditional and modern psychiatry can be integrated side-by-side within primary health care
by Piero Coppo
M
ental disorders are much rarer among the rural communities of the Dogon high plateau than elsewhere. Nevertheless, the problem is made more serious than the number of cases would suggest by the bard condi- tions in which sufferers have to live.They are shut up, isolated or sometimes even physically assaulted.
A system of "traditional psychiatrie centres"-there are 14 of them, or one for every 10,000 inhabitants-has spon- taneously grown up in this area and serves the whole district. They use un- usual and effective methods, but have features which "modern" psychiatry should try to understand and possibly adopt. At the same time, these methods do have limits which traditional psy- chiatry alone cannot overcome.
lt seems essential to have a psychia- trist with a modern training, who is first and foremost a physician, to diagnose cases requiring purely medical attention, 10
for instance, cases of dehydration or mental conditions caused by organic diseases. This person should also be able to build up mutual trust with the tradi- tional therapists so that the two ap- proaches to treatment can be almost spontaneously combined on the spot.
This idea deserves consideration be- cause the social, economic and cultural changes brought about inevitably by the process of modernisation and the growth of towns cannot fail to produce an increase in mental illness. New disor- ders such as neuroses, de pression and psychosomatic conditions are bound to appear, which the traditional psychia- trist would find bard to fit into his familiar framework.
So the information obtained from traditional communities needs to be tak- en into account when mental health care systems are being set up in rural areas where both modern and traditional methods can be deployed.
The Dogon communities tend to be in inaccessible areas; historically they were set up because their animist populations rejected Islam. Now their main occupa- tion, which involves everyone, is agricul- ture. They grow millet for food and onions for trade. The population is high- ly uniform and has not so far had any access to modern psychiatrie treatment.
Treatment of mental disorders, there- fore, is still wholly in the bands of the traditional healers.
What is the Dogon attitude to mental illness? The layman makes no differ- ence between the various forms of what he calls "qué-qué" or "madness". The traditional psychiatrist distinguishes be- tween several forms of madness, which he ascribes to various good and evil spirits living in the bush or in dwellings, some of them in human form, or to the malice of someone using sorcery to harm his enemy. The treatment of psychotic illnesses is often the same, but
This traditional medicine centre in Africa is in effect a hospital. Patients-some of them with mental ailments-may stay there for several days during their course of treatment.
Photo WHO/R. C. da Silva
the practitioner always makes an indi- vidual diagnosis.
Epilepsy is well known in the Dogon communities, where it is called "tibi sougo ", or "falling like a stone ". The healer observes the victim's fits, takes his pulse and examines the iris of the eye, and then suggests treatment. If, however, the patient has at any time fallen into the fire during a fit or if the disease is too far advanced, any treat- ment is considered to be useless.
During our studies in this area, we carried out an epidemiological survey in 16 villages with a total population of 6,448 and identified twelve cases of
psychosis (" qué'-qué "), affecting 1.85 per 1,000 of the population, and eight of epilepsy (" tibi sougo ") involving 1.24 per 1,000.
People from outside the study area also came to consult us. Several showed psychotic or epileptic symptoms, and the only cases of neurosis came either from urban areas or from environments which cannot be described as "traditional ru- ral communities ". In such rural com- munities, the types of "madness" are always similar. There is a striking ab- sence of depressive symptoms, neuroses and conditions which may be regarded as psychosomatic.
Sorne mental disorders, moreover, which are not regarded as "madness "
by local culture, do not seem to have been referred to us for observation. To avoid any entanglement in the insoluble problem of the borderline between what is "pathological" and what is "nor- mal", we preferred to leave the defini-
tion of "madness" to the local people whom we consider, for the purposes of our study, the only possible judges.
Traditional treatment
Traditional Dogon psychiatrists usu- ally apply therapies handed down from father to son, although sometimes they do develop their own. Sorne holy men from other, sometimes distant, cultural areas or local recent converts to Islam use Moslem methods based essentially on the reading of the Koran. There is a trend now for the animist and Moslem methods to be used side by side, but they do reflect the difference between the world's two approaches to insanity.
The animists believe that it is caused by spirits with which they must com- municate. To the Moslems, insanity is the result
of
action by a malevolent spirit, a" devil", which must be cast out.11
Each of these open-air cooking pots contains a different herbai preparation, being brewed under the supervision of a traditional healer in the Congo. Herbai recipes are just one form of treatment for mental illnesses.
Photo WHO/R. C. da Silva
Deeply embedded in the culture of the few Tuareg tribes, some nomadic, some settled, living in northem Mali is a well- ordered system of traditional psychiatry closely linked to Islam. lnsanity always has something to do with the Devil in Tuareg culture. A man goes mad be- cause he has met the Devil or is afraid of meeting him. Insanity can also be the result of poor hygiene because the Devil frequents dirty places.
lt is interesting to note that the origin of any illness, and thus also of mental conditions, is ascribed to an imbalance between hot and cold. ln the Tuareg culture, these two elements are as im- portant as the yin and the yang in oriental cultures, and must be taken into consideration in any treatment.
I The Tuareg holy men believe that mental problems are increasing because those with powers to stop the devils are becoming ever fewer, giving the devils new opportunities to spread insanity. lt is a sign of the "beginning of the end"
which, for some, must result in the 12
annihilation of the human race, while others believe that the time is coming when what was always hidden will be revealed, "as if a man who has always been clothed should walk around naked."
In prescribing treatment, the holy men rely on their own dreams, which may be good or bad, and also draw a great deal on the Koran. They read the texts, write verses on the patient's body and make up amulets containing the holy writ. They also give the patient water to drink in which pages bearing texts from the Koran have been soaked. lt is worth noting that the ink used is made {rom the ashes of a shrub used elsewhere in treating epilepsy and mental disorders.
The patient is also treated with medicines from various plants, is made to sweat and is spun round to make him lose his sense of direction. Rituals of the psycho-drama type are also used.
The importance of research into these various methods is obvious. First of all, the study of the development of the concept of mental illness in traditional rural communities makes it possible to stress the links which certainly exist between psycho-pathology and culture.
lt also makes it possible to discover what is universal and inherent in human na- ture, as distinct from that which arises from specific cultural, social, economic
or environmental factors. Finally, and most important, traditional psychiatry is still very much alive in many developing countries, where in some areas it is still the only way of helping the mentally ill and of defending the community from the disorder which anti-social behaviour could create.
If this contribution is properly under- stood and absorbed by the psychiatrie services which form part of primary health care, these countries will be bet- ter able to provide effective treatment for the mentally ill within their own
community. •
Examples of what is considered psy- cho-pathological behaviour in Mali's traditional rural communities:
- Anti-social behaviour, like making children afraid, hitting or injuring other people, theft,' or non-observ- ance of beliefs and social customs.
- An inability to maintain a place in society, to the point of having to look to others for sustenance.
- Strange behaviour, like undressing in public or taking to the bush.
- True psycho-pathological symp- toms, like verbal incoh~rence, visual or aurai hallucinations, ta/king to devils, negativism, fixations, agita- tion, confusion and insomnia.
