In contrast, medical science (and, hence, western medicine) rests on the axiom of Cartesian dualism, or the separation of mind and body, which holds that healing is correcting disease by using appropriate medical and surgical procedures; the primary concern is healing the body and eliminating physical suffering [3]. A recent neurologic treatise suggests that the Cartesian split has resulted in the modern medical view of the "disembodied mind" and has led to the diminished role of the concept of humanity and neglect of the physical effects of psychological distress [4].

However, modern allopathic medicine has its roots in ancient traditions of healing, and some aspects of those traditions are still relevant and complementary to modern medical practice. In this article, I describe some traditional healing practices from southern Africa and the principles of healing found within them. I suggest that re-emphasizing these principles of healing in western medicine may broaden the scope and increase the satisfaction of modern healers.

Methods

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I interviewed six traditional southern African healers and used qualitative research methods [5, 6] to capture and interpret links among different elements of the interviews. This approach is suitable for studying traditional healers and for revealing insights that may underlie both traditional and modern systems of healing. My interviews were semi-structured, and I recorded responses to such questions as: "What kind of healing do you provide? How do you know when someone is healed?" The interviews lasted approximately 1 hour and were recorded on audiotapes, transcribed, and analyzed for commonly occurring concepts, ideas, and themes that provided insight into traditional health care in southern Africa. The conceptual categories were grounded in and emerged from the data [6]. The healers focused on various aspects of traditional practice.

The healers interviewed in this study treat illness mainly with plant products and some animal products and use spiritual resources to augment their healing process. They should not be confused with diviners, sorcerers, or prophets, who often function in the absence of the patient. The reader should note that all references to God and spirits must be interpreted within the context of the African spiritual world-view.

From 1994 to 1998, I interviewed six traditional healers, one of whom was still in training. My sample was based entirely on contacts made through various acquaintances. The fact that all of the healers in my sample are women does not reflect the overall distribution of male and female traditional healers; most of my respondents had been trained by men. The findings do not represent all types of traditional healers in this geographic area. The healers' names have been changed, except for that of Rae Graham, who has published her story [7].

Julia, a young Shona-speaking woman who lived outside Maputo, Mozambique, in a traditional African compound, was typical. She showed me the hut that was set aside for her patients, her "divining bones" (a collection of bones, shells, nuts, and dice), her fly whisk made from a cow's tail, her ceremonial steel knives for slaughtering animals, and the medicines she had made and stored in reused bottles. The other healers were Celia, an older Shona-speaking woman who had practiced as a healer for nearly 30 years; Susan, a middle-aged Xhosa-speaking woman from the Eastern Cape, South Africa, who practiced in an herbalist store that she co-owned with a white South African man; Elizabeth, a middle-aged Xhosa-speaking woman who practiced from her home in a village in the Western Cape, South Africa; Emily, a young, westernized Xhosa woman who worked as an office cleaner in the Western Cape, South Africa, but was training to be a traditional healer with a master healer in Cape Town; and Rae, who had trained as a nurse in England before emigrating to the rural north of South Africa.

In South Africa, I interviewed two Xhosa-speaking healers (Susan and Emily) in English and used a local translator to interview the third (Elizabeth). In Mozambique, I conducted interviews with Julia and Celia by using two translators, one who translated Shona into Portuguese and another who translated Portuguese into English.

Below, I present a case narrative from Julia. I then provide a composite description of the style of practice of traditional healers; this is based on the interviews with Emily, Celia, Julia, Elizabeth, and Susan and on a short telephone interview with Rae that was augmented by her detailed autobiography [7] and by the literature [8-11]. The ideas presented here were verified by a leader of a traditional healer organization in Johannesburg, South Africa.

An Account of an African Traditional Healer

"Once, a man came to see me who suffered pains in his legs and many other places and could not walk. First, I talked to him and I asked about his life, what life had given to him and what he had given to life. I used my senses in a powerful way to understand this man, the misfortunes that had befallen him, and his own suspicions as to the origin of the problem. I threw the bones for him. I had to throw the bones many times, until I could make sense of this person and his problem. The bones did not want to talk to me at first, so I asked the man to come back another day. The next time, it was still difficult. I asked him to move to a relative's compound to get him away from his family. This didn't work either, so I took him to my own compound.

"Every day I got up before sunrise, washed with herbs, put on my ceremonial clothes, and beat the drums. I sometimes took muti (medicinal potions) so that I could talk to the ancestors. My patient participated in these ceremonies while he lived in my compound. Then I would go alone to the bush to hunt for herbs to make muti for him and other patients. I collected herbs that I learned about in my training. This man stayed at my compound for 2 weeks.

"To heal someone is to give life. My work is to give people life so they can be happy. I knew when the man was cured because he became happy, and then I became happy, too. My gift is given to me by God, and I was called by my ancestors to fulfill my gift and become a traditional healer."

(Note: I was unable to ascertain either the healer's view of this patient's diagnosis or an independent western diagnosis.)

Practices of Traditional Healers

Traditional healers hold an esteemed and powerful position in southern African societies. Their role is that of physician, counselor, psychiatrist, and priest, and people visit a traditional healer for problems ranging from social dilemmas to major medical illnesses. The World Health Organization and other official groups acknowledge the potential effectiveness of traditional healers as primary caregivers and the potential efficacy of their treatments in the fight against HIV and AIDS, sexually transmitted disease, and other infectious diseases. The World Health Organization also supports the integration of western medicine and traditional healing, especially encouraging referrals between the two. In South Africa and in Mozambique, traditional healers are developing organizations that are recognized by the Department of Health and by the Ministry of Health, respectively.

According to my interviews and the literature [1, 2, 7-11], the three main elements of African traditional healing are prevention of and protection from problems, determination of the causes of these problems, and the eventual elimination of these problems. Also included is the traditional healers' approach to and management of death.

Prevention and Protection

Most of the work of traditional healers concerns protecting clients from possible afflictions. Because most afflictions are believed to come from destabilizing forces, protection against them involves warding off the negative forces of witchcraft and maintaining equilibrium with other people, the spirits, and the ancestors (recently departed family members). Thus, protection includes propitiation for real or possible offenses that are wittingly or unwittingly incurred against others. Protection may be accomplished by performing ceremonial acts; using medicines against disequilibrium; or wearing totemic objects, such as wrist bands for infants.

Determination of Causes

Traditional healers consult the spiritual realm by invoking and conferring with the ancestors. This consultation involves the use of naturally occurring psychotropic substances that are ingested, sniffed, or smoked in a ceremonial pipe. In addition, healers use their dreams, through which the ancestors give them diagnostic insights. Dreams are the mainstay of Susan's practice.

To augment the diagnostic process, traditional healers drum, dance, or follow specific rituals, such as washing with herbs. When traditional healers prepare to see a patient, they dress in beaded necklaces, ceremonial clothes, and headdresses, such as the special wig worn by Celia and the fur headdress worn by Elizabeth. They wear necklaces consisting of beads, totemic objects that have spiritual significance, and plant or animal parts that have medicinal uses. These objects also signify the healer's level of expertise.

As part of the diagnostic process, traditional healers determine the nature of problems by examining the symptoms directly and by using questions to reveal the illness in the context of the patient's life, social relationships, and physical environment. They find out as much as they can about the patient's signs and symptoms and any psychosocial phenomena, attempting to determine why the illness happened when it did. They ask such questions as "Do you want something you do not, or cannot, have? Do you have enemies? Does someone wish you ill? Are your ancestors displeased with you for some reason?" Believing that people are products of the extended community, they inquire into every aspect of a patient's present and past activities, focusing on the behaviors that would be most likely to provoke conflict with others.

Traditional healers may use the divining bones as diagnostic tools in conjunction with the interview questions. The divining bones are collected during the traditional healer's training period as gifts from patients (as testimony of healing powers) or as objects obtained as part of rigorous training tasks. Each item represents an important aspect of a patient's life (for example, man, woman, children in the immediate family, extended family members, happiness, bad luck, or ancestral spirits). Julia had different bones for men and women. For example, items signifying war and money were used for men, and items signifying childbirth and children were used for women. Ceila's bones included shells, bones, a bullet signifying death, dominos signifying health or illness, and an animal part (a piece of a hoof) signifying tokoloshe, the evil spirit. The bones are usually thrown like dice on a woven grass mat or on dried animal skin, and clues to the patient's problems can be interpreted from the configuration of the items. Julia said that "the bones speak to me" and that "the ancestors are speaking through the bones."

The diagnostic inquiry may take a long time and may require numerous visits. As Celia said, "If the bones are not talking, the patient must come again another day." Sometimes, traditional healers cannot discern the problem and, after several unsuccessful attempts, will consider giving referrals. In some situations, they acknowledge a purely biological basis of illness that is outside their competency. They decide whether the patient should see another traditional healer or a western physician. For example, I was told of a patient who had a hernia and was sent directly to a western hospital.

Elimination of Afflictions

Through lengthy apprenticeships with experienced healers, trainees learn the appropriate use of herbs and animal products for various ailments and for different types of patients. Traditional healers seem to work most successfully with illnesses that have a high emotional content (what allopathic medicine might call psychosomatic illnesses) and with psychological illnesses [11]. Although traditional healers do not claim to deal directly with pathogens or with pathophysiologic phenomena, they do work with the patient's mind and spirit, believing that many afflictions have spiritual causes and that psychospiritual imbalances must be fully rectified before a patient can recover physically. For traditional healers, healing involves an attempt to remove impurity or disequilibrium from the patient's mind and body. These healers claim efficacy in fertility treatments, in dealing with excessive menstrual bleeding, and in curing impotence. They also claim success with AIDS, cancer, tuberculosis, stroke, epilepsy, and other organic diseases. My interpretation is that they facilitate spiritual, psychological, and physical coping to lessen the effects of these illnesses or to contribute to remission.

Traditional healers prepare and prescribe therapeutic medicines, believing that every disorder has a corresponding plant or animal product that neutralizes its effects [11]. For example, for a condition of being "hot," a form of disequilibrium in which the patient is distressed by numerous causes but is not feverish, the treatment involves the application of ash and cooling agents, such as parts of water plants and animals [12]. Medicines are provided in the form of powders, decoctions, infusions, or ointments. They are ingested with water, beer, or maize porridge; are used as inhalants, enemas, or vaginal suppositories; or are rubbed into the skin, often through incisions. Cures usually include preventive strategies to protect the patient from becoming ill again.

Death and Dying

Traditional healers are informed by the ancestors when a patient is dying. They then summon and counsel the family of the patient, advising them to take the patient home and to seek no further treatment "because God and the ancestral spirits are taking that person who has finished what he came to do in this world." The healers ask them to talk together, give them herbal medicines, and instruct them how to perform a ceremony in which they ask God and the ancestors to take away the patient's pain and allow him or her to "go peacefully." If a patient dies before this sequence of events can be completed, traditional healers grieve and are "in a shadow." They cannot practice as healers; must not touch anyone; and must remove their ceremonial beads, ornaments, and clothes. They may practice again only after they have participated in a cleansing ceremony, which may involve other healers.

Discussion

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The idea of cultural relativism maintains that concepts of healing should be interpreted within the particular world-view of the person being healed and his or her cultural group. Like their patients, traditional healers do not necessarily distinguish between curing and caring, subjective and objective symptoms, or measurable and immeasurable clinical data. They seem to be concerned mainly with relieving suffering, controlling symptoms, and restoring physical function and social and psychological connection. For southern African traditional healers, healing rests on the assumption that if the mind is healed, the body takes care of itself. In western medicine, the converse is often considered true: If the body is healed, the mind takes care of itself. The approach of southern African traditional healers may have merit. Growing numbers of research articles show that by embracing both the psychosocial and biomedical aspects of illness and by assuming responsibility for the relief of psychogenic suffering as well as physical suffering, physicians can enhance their clinical effectiveness [13-16].

Different conceptual frameworks often lack a common quality on which to compare them [17]. However, some of the strategies of traditional healers may be viewed as archetypic antecedents of modern practice. The following similarities between the two forms of healing may remind western physicians of some practices of traditional healing that can be beneficial to modern medicine and can be expressed in modern terms.

1. Traditional healers probe deeply into the patient's social and psychological well-being in addition to the history of the present illness. They already know or are prepared to learn about the context of the patient's life, such as his or her social and economic status, attitudes, beliefs, hopes, and fears. They establish the extent of the patient's emotional and psychological turmoil and the extent of his or her disconnection from family or other groups. Traditional healers experience the unexpected death of a patient as a separation in which they grieve, and they cannot practice as healers until they are cleansed. In the African world-view, disconnectedness causes profound suffering.

Western physicians are familiar with the effects of the extreme distress caused by divorce, death of a spouse, dishonorable discharge from the military, excommunication from a church, and termination of employment. The idea that such psychological disturbances can cause diseases of the body has always been at least part of the canon of modern western medicine, and the distinction between mind and body is increasingly regarded as an artificial one in sophisticated biopsychosocial medical models of illness [4]. It might be more accurate to say that modern medicine has remembered this phenomenon and is now gathering data to substantiate it. The modern patient-centered interview is an example of an information-gathering approach that is similar to that of traditional healers [13-15]. It elicits information vital to the diagnostic process; builds rapport; and generates a sense of relationship, caring, and connection between physician and patient [16, 18].

2. Traditional healers help patients disclose what is on their minds and discern patients' concerns about, perceptions of, and explanations for their illness. Western physicians would call this practice patient attribution. Traditional healers encourage the disclosure of relevant information with such questions as "Do you have an explanation for your condition? What do you know about this condition? What are your feelings about this?" Traditional healers also use divining bones as an intermediary tool in conversations with patients.

Physicians can avoid overlooking patients' actual concerns by encouraging them to talk about their problem and about attributions of their illness during the physical examination, a setting in which patients may be able to disclose what is on their minds more easily than when they are sitting face to face with the physician. This technique is similar to the pediatric technique of encouraging children to describe their symptoms by using a doll. Such disclosure by itself may have therapeutic as well as diagnostic value.

3. Traditional healers use their intuition. Healers "make contact with the ancestors" through dreams and the use of psychotropic herbal agents. I interpret this spirituality as a way in which healers access "deep knowledge" (metacognitive or tacit knowledge) that transcends the presented facts. Contemporary western spirituality is manifested in personal reflectiveness, philosophy, and religion, which can serve as conduits for accessing deep knowledge. Such deep knowledge is useful to physicians in diagnosing patient problems. Although contemporary physicians are encouraged to practice evidence-based medicine and to master ever-increasing amounts of medical knowledge, they must also be able to access their own deep knowledge. One view of medical expertise holds that physician knowledge is based on pattern recognition of "illness scripts," which contain a wealth of information about the contexts and consequences of disease [19]. This knowledge is obtained through years of practice and may be accessed through intuition, hunches, or educated guesses.

4. Traditional healers allow time for the diagnostic process. Julia, for example, did not get the information that was necessary for diagnosis during the first meeting and required that the patient return for further visits. Many patients have signs and symptoms that are diagnostically unclear because of medically complex or incomplete data. This lack of clarity can be frustrating for physicians who are expected to make accurate diagnoses during short office visits. However, the medical concept of "the tincture of time" continues to be a useful strategy in handling uncertain medical diagnoses [20]. The enduring lesson here may be that when clinical presentations cannot be diagnosed within the time allocated for the patient visit, physicians should consider delaying the diagnosis until they have all of the necessary information. This delay can mean offering longer or additional patient visits.

5. Traditional healers provide a healing ritual; that is, a shared experience of the healing process. Southern African traditional healers dress in ceremonial clothes when seeing patients and use ceremonial instruments (knives, fly whisks, pipes, and divining bones). The traditional healers' clothing and adornments signify their particular healing skills. Clothing, adornments, instruments, and ceremonial rituals, such as those used in diagnosis, cure, and cleansing, also give the patient access to healing powers. The healing environment, often a designated space for patient visits, contributes to the healing process.

Similarly, the western physician's white coat and stethoscope and the environment of western medical clinics and hospitals create an aura of expectancy and hope for healing that is similar to the effect of the old-fashioned "black bag." Although Osler [21] wrote about the "faith that heals," many contemporary physicians doubt the relevance of religion and spirituality to modern medicine. However, recent surveys show that almost 80% of Americans believe in the connection between healing and spirituality, and there is a rekindling of interest in and focus on this spiritual dimension in medical schools [22, 23].

6. Traditional healers feel personally satisfied by the act of healing. When patients believe that they have been healed and feel satisfied, the healer also feels satisfied. Occasionally, well-satisfied healers lead community celebrations (consisting of feasting, drumming, singing, and dancing) to thank the ancestors for their guidance and power. This satisfaction is also a cornerstone of western medicine, but when third-party insurers and health maintenance organizations become highly visible agents in the care process, the direct sensation and expression of patients' thankfulness are diminished. Celebrations confirm the relationships between healers and their patients and the connection of both healer and patient with spiritual dimensions [18].

Conclusions

Although this paper describes selected traditional healing skills, I do not mean to suggest that traditional healing is preferable to allopathic medicine. Indeed, African traditional healing is limited in scope, and some of its practices are undesirable.

The strategies of traditional healers draw on aspects of healing that are viable alternatives in societies where advanced technology and sophisticated understanding of disease are lacking. Indeed, genuine human engagement and spirituality can be powerful tools in promoting well-being. The skills of traditional healers are highly respected. The healers are intimately involved with their patients and the community, and they share in the results of their work.

Can modern physicians make these claims? Scientific medicine is a powerful tool because it has both explanatory and predictive power and because it can be measured, is replicable, and is generalizable. However, modern medical science has tended to supplant older diagnostic and therapeutic approaches that involve human engagement and spirituality and still serve as valuable primary healing strategies. Physicians have long debated the danger of ignoring the patient in the effort to treat the disease. This debate is based on more than just a common concern for fellow humans and is seen as central to effective caregiving. The growing interest in alternative medical practice attests to a substantial interest in regaining humanistic medical perspectives. My interviews with these six traditional healers lead me to suggest that the style of healing they practice has value in today's world. Traditional medical approaches can be useful in engaging patients on interpersonal, psychological, and spiritual levels. These approaches re-emphasize the importance of patient satisfaction and offer physicians greater opportunity for personal satisfaction in their professional roles.