IK Monitor Articles (7-2)

Indigenous Knowledge and Development Monitor, July 1999

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Views on tuberculosis among the Igbo of Nigeria
by Ezinna Enwereji

Tuberculosis is a communicable disease that causes the untimely death of some 75,000 Nigerians each year. The persistence of tuberculosis in a given area is due to a complex web of factors: cultural values, beliefs and practices, poor socioeconomic conditions, migration and urbanization, in combination with an ill-managed and ineffective tuberculosis programme. Any effective treatment of tuberculosis must be based on an understanding of traditional cultural views and insights concerning the cause, spread and treatment of the disease. This article assesses these views and suggests ways to improve communication at the community level.

In every society certain general beliefs exist. Some of these insights are easily changed and may be described as 'soft views'. Others--the 'hard views'--are so deeply rooted in the culture that they are quite difficult to alter. This is of particular relevance when it comes to contagious diseases, in particular, such issues as how individuals contract diseases, how these diseases are spread and how they can best be treated. This article deals with such hard and soft views on tuberculosis.
In Igboland, doctors and epidemiologists continue to wrestle with the problem of tuberculosis, which is currently spreading at an alarming rate, especially among rural dwellers and the urban poor. Without appropriate treatment, tuberculosis is fatal. According to a recent NTBLCP (1997) report, each year 150,000 Nigerians contract tuberculosis, 50-60% of whom die due to lack of adequate treatment. This article evaluates various aspects of indigenous beliefs and traditional therapeutic claims related to tuberculosis, in an effort to identify and ultimately encourage those that are beneficial, while discouraging those that do not help to promote public health. The aim of this article is to find ways of synthesizing certain indigenous beliefs and practices related to tuberculosis with Western knowledge, in order to heighten awareness of measures to treat and prevent tuberculosis among rural dwellers.

Health and disease in Africa
In Africa people seeking health care are usually quite pragmatic and turn to different systems for treatment (Wood 1977). They go from one practitioner to another, seeking treatment for different symptoms of the same disease (Zeller 1979). My research has shown that among the Igbo of Nigeria, the way the symptoms are identified and interpreted determines largely the type of help people seek. The Igbo typically proceed from the cheapest and most accessible form of treatment to one that is more expensive and harder to procure.
In present-day Africa the majority of the people lack access to modern health care, and where it is available, the quality is often below acceptable levels (Bodeker 1994; Monekoso 1994). In many parts of Nigeria, traditional medicine is the major--or even the only--type of health care available. In those areas the efficacy of traditional medicine in the treatment of disease is widely accepted (Gesler 1979).
In Igboland many individuals, especially rural dwellers and the urban poor, rely on traditional medicine when they are ill, seeking help from one of the many types of traditional practitioners. Some use herbs to cure disease (herbalists), some specialize in the use of incantations (spiritualists), while others are experts in bone-setting (bone-setters) or delivering babies (traditional birth attendants). Despite the differences, the therapeutic regimen they employ is marked by a high degree of convergence. Herbal medicine, divination, exorcism, symbolic rituals, incision in different parts of the body, and non-formal psychotherapy are the most common types of healing. The services of these healers are used extensively by both the literate and the illiterate, and by Christians and non-Christians (Uchendu 1965; Erinosho 1989).
Thus we may conclude that the treatment of many diseases in Igboland, including a communicable disease like tuberculosis, consists of traditional medical practices based on indigenous beliefs, knowledge, skills and cultural practices.

Tuberculosis Tuberculosis is caused by the bacillus Mycobacterium tuberculosis, which usually attacks the lungs. Pulmonary tuberculosis is an airborne disease, which is spread mainly by coughing or sneezing. It is possible to avoid spreading the disease unnecessarily by controlling such coughing and sneezing, and this is why patients are usually isolated. The Western treatment of tuberculosis consists in a relatively lengthy regimen of medication (initially injections, followed by oral drugs), and rest, with a strong emphasis on proper hygiene, in particular with respect to sputum, and improved nutrition.

Tuberculosis as seen by the Igbo In Igboland, tuberculosis is generally believed to be caused by such things as cold weather, cold water, and dust. The eating of beef, especially the liver, and other high-protein foods such as crayfish, donkey meat, milk, snails, and crabs are also thought to cause and spread tuberculosis. Eating poisoned food administered by an enemy is also believed to be a cause of tuberculosis. Some people think that the disease is the result of a curse from the gods of the land for violating the laws of the land, while others believe that the disease is hereditary.

Igbo treatment of tbc
In the treatment of tuberculosis in Igboland, herbal mixtures containing animal dung, calcium carbonate (Nzu) and charcoal are used. The animal dung is believed to act as an antidote, neutralizing the poison which causes the disease. Calcium carbonate acts as an astringent, shrinking the mucous membranes, while charcoal is supposed to increase the production of sputum. The ability of the patient to cough up large quantities of sputum --which are usually not properly disposed of--is seen as a sign of a speedy recovery. In addition, the traditional healer may make several incisions on the patient's body. Letting out a sufficient quantity of blood is supposed to remove the poison causing the tuberculosis.
Another part of the treatment consists in avoiding oily and high-protein foods which prevent the patient from producing sputum, thereby delaying recovery.
The appeasement of the local deities by sacrifices, with the help of traditional healers, is seen as an integral part of the treatment. In addition, in rural areas people often crowd together indoors during cold weather, because cold is thought to cause tuberculosis.

Views on tuberculosis
As we shall see when we turn to the interviews with people being treated for tuberculosis, some individuals in Igboland hold rigidly to their views. Others hold very soft views and are prepared to modify them if given the proper information. It was also found that there are often two approaches to the eradication of a particular disease, one involving a soft view and the other a hard view.

Interviews and findings
Tuberculosis patients currently receiving treatment in Uzuakoli Leprosy and Tuberculosis Centre were interviewed in an effort to determine the extent to which they still held their original views. It was hoped that these findings would shed some light on the implications of integrating proven scientific Western knowledge, skills and practices with traditional beliefs pertaining to the health of tuberculosis patients in the rural areas.
The interviews revealed that those who had expressed hard views on tuberculosis still felt the same, even though they were receiving treatment. The patients who held the hardest views were found to be among those who reported late for treatment. They were also very selective about their diet, and their relatives provided them with food containing no protein or oil. Such patients were malnourished and emaciated (see photo 1: The patient, who holds a hard view, looks malnourished and wasted.), and their rate of recovery was slower. All efforts to encourage them to increase their intake of protein and oil in order to promote recovery were unsuccessful.
The patients who held soft views--who were in the minority--reported early for treatment. They did not appear to be malnourished and their rate of recovery was faster (See photo 2: This patient holds a soft view, and her rate of recovery is encouraging.). They quickly changed their views to accomodate new and beneficial suggestions. Unfortunately, some of these patients were occasionally negatively influenced by those with hard views. All of the patients interviewed were in the habit of carrying around a container for disposing of their sputum.
It is noteworthy that the traditional belief that tuberculosis is caused and spread by eating foods rich in protein is deep-rooted and held by many tuberculosis patients. This may be a precipitating factor in the development of oedema, a striking feature of the type of malnutrition prevalent among tuberculosis patients in Igboland. Most of the patients interviewed in Uzuakoli avoided eating protein-rich foods and appeared malnourished indeed.

Evaluation
The widespread belief that tuberculosis can be spread through foods such as beef (especially the liver), milk, donkey meat, crab, and crayfish may be based on fact, in cases where the food is contaminated and then not thoroughly cooked. For instance, bovine tuberculosis can be contracted by eating meat from infected cows and other animals, or by using raw milk that has not been thoroughly boiled. Leaving aside any discussion about whether tuberculosis can be caused by angry gods of the land or by eating food poisoned by an enemy, one thing is certain: eating good and hygienic food will enhance immunity and protect the body from many diseases, including tuberculosis. The practice of crowding together indoors during the cold weather in order to avoid catching tuberculosis actually encourages the spread of the disease, since individuals who are infected cough into the air that others must breathe. The belief of some Igbo that tuberculosis is hereditary is probably based on the fact that an airborne disease like tuberculosis can easily spread from one member of the family to another.
In conclusion, these views on the causes and treatment of tuberculosis are responsible for the different ways individuals perceive, evaluate, treat and respond to a communicable disease like tuberculosis. They also greatly influence the extent to which this disease interferes with the everyday life of people in Igboland. When these views are integrated with Western insights, it will be possible to reduce or eradicate fatal diseases like tuberculosis. If the two types of views are well synthesized, patients will be motivated to accept the lengthy regime of Western treatment and the use of drugs for the treatment of tuberculosis.

Policy implications
Studies have shown that as a result of their traditional beliefs, most African countries lag behind in the vital task of improving the health of their people. For instance, the World Bank (1994) and Campbell and Cutting (1996) stress that some Africans see hospitals as places where infections spread easily, rather than places where infections are treated. They fail to recognize that if serious disease and death are to be avoided, early diagnosis and correct treatment are imperative (Marsh 1997). This is eminently applicable to the Nigerian situation. Let us consider the prospects for controlling tuberculosis in the modern Igbo society. The main obstacles to the effective control of disease are migration, urbanization, socioeconomic conditions, and a lack of adequate communication between researchers, health workers and the population. Some of these barriers can only be surmounted by long-term or large-scale rural employment programmes, housing, sanitation and hygiene projects, education and job-training facilities, and the general improvement of living conditions in Igboland. However, the problem of public information can be solved: by synthesizing indigenous knowledge and scientific knowledge on tuberculosis.
One of the reasons why many preventable communicable diseases have such high mortality rates in Igboland is the reluctance of the victims with 'hard' views to accept proven measures that are capable of controlling such diseases. The lack of adequate communication between researchers and health workers is a problem. To quote one response from a patient in the Uzuakoli centre who were interviewed for this study: 'In the communities, nobody tells us the effects of some of the things we do. How on earth would I have learned these things if I hadn't been admitted here?'
This lack of communication has resulted in an uncoordinated and wasteful duplication of efforts devoted to disease control in the Igbo communities. There is no adequate forum for the prompt and regular reporting of the results of research activities. Establishing such a forum and seeing to it that the health workers in Igboland benefit from the results will equip them to organize periodic seminars and conferences in the communities. Hearing from the communities on a regular basis will enable health workers to identify the best ways to involve individuals in disease control measures. This will also help the health workers to determine the socioeconomic feasibility of new strategies, not least their acceptance in the communities. Periodic seminars and conferences will help to adapt traditional views on tuberculosis to Westernized lifestyles, incorporating such practices into daily life. From a professional point of view, the study has shown that when striving to bring about the effective treatment of tuberculosis patients, it is advisable to integrate 'hard' views and 'soft' views. This will help to create greater understanding and increase readiness to accept treatment measures.

Ezinna Enwereji
College of Medicine
Abia State University
Uturu, Abia State
Nigeria

References
- Bodeker, G. (1994) 'Traditional health knowledge and public policy', Nature and Resources 30 (2): 5-16.
- Campbell, H. and W. Cutting (1996) 'Small hospitals provide opportunities to combine treatment and prevention', Child health dialogue. International newsletter on child health and disease prevention 1 st quarter (2) 1.
- Erinosho, O.A. (1989) Health care and health care series in Nigeria. Report on research for African Development Foundation Washington D.C. USA.
- Gesler, W.M. (1979) 'Barriers between people and health practitioners in Calabar, Nigeria', The South Eastern Geographer 19: 27-41.
- Marsh, K. (1997) 'Early diagnosis and correct treatment are important', Child health dialogue. International newsletter on child health and disease prevention 3 rd quarter issue (8) 1.
- Monekoso, G.I. (1994) 'Who deplores Africa's health crisis?', WHO Newsletter 9 (2).
- NTBLCP (1997) National Tuberculosis and Leprosy Control Programmes Nigeria.
- Uchendu, V.C. (1965) The Igbo of South East Nigeria. New York: Molt, Rinebart and Winston.
- Woods, C.M. (1977) 'Alternative curing strategies in a changing medical situation', Medical Anthropology 1(3): 25-54.
- World Bank (1994) Better health in Africa: Experience and lessons learned. Written by R. Paul Shaw and A. Edward Elmendorf. Washington, DC: World Bank.
- Zeller, D.L. (1979) 'Basawo Baganda: The traditional doctor of Buganda', pp 138-143 in: Z.A Ademuwagun, John A.A. Ayoda, Ira E. Harrison, Dennis M. Warren (eds) African therapeutic systems. Waltham, MA: Crossroads Press 1979.
- See also Tuberculosis at 'Websites'