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Two ways of explaining reality: the sickness of a small boy of Papua New Guinea from anthropological and biomedical perspectives.

IN SEARCH OF A MEDICAL ANTHROPOLOGICAL POINT

'Medical anthropology is, internationally, the most rapidly burgeoning subfield of the discipline' (Keesing 1989:58). The terminology of medical anthropology is correspondingly distinctive; concepts like 'medical system' or 'medical pluralism' (see e.g. Frankel & Lewis 1989) are part of the basic vocabulary of each medical anthropologist. The distinction between 'disease' and 'illness' is today a matter of course in medical anthropology (Fabrega 1971, Colson & Selby 1974, Eisenberg 1977). Kleinman (1980) introduces 'sickness' as a generic term and subdivides this into the two aspects 'disease' and 'illness'.(1)

Disease belongs to the biomedical model (Fabrega 1971:213, Lieban 1973:1043, McElroy & Townsend 1979:49). Diseases are classified by only one set of (presumed) universally valid and culture-independent categories. In the 1980's the concept of disease is linked to the professional sector and its practitioners, who in the Western world belong to the biomedicine (Kleinman 1980:73, Chrisman & Johnson 1990:110). The term illness, on the other hand, refers to the culturally defined perceptions and experiences of the patient and his/her social group (Kleinman 1980:72, Young 1983:1208, Kleinman 1986: 144).

Regarding the two terms, Kleinman (1978:88) observes:

'Neither disease or illness is a thing, an entity, instead they are different ways of explaining sickness, different social constructions of reality'. Leslie (1980:193) says: 'People have diseases without being ill or assuming sick roles, and they experience illness and take sick roles when they do not have diseases'. Illness and disease may coincide, but do not necessarily.

Most medical anthropologists find the distinction between disease and illness useful (Brown & Inhorn 1990:189, Rhodes 1990:165, Chrisman & Johnson 1990:109), a means 'to create a single language and discourse for both clinicians and social scientists' (Schepper-Hughes & Lock 1987:10). However, some have taken the view that 'one unanticipated effect has been that physicians are claiming both aspects of the sickness experience for the medical domain. As a result, the "illness" dimension of human distress (i.e. the social relations of sickness) are being medicalized(2) and individualized, rather than politicized and collectivized' (Schepper-Hughes & Lock 1987:10).

In addition, as Brown & Inhorn (1990:189) indicate, 'it [the distinction between disease and illness] is based on a questionable assumption that the biomedical definition of disease is objective and culture free'. For most medical anthropologists today, it is understood that biomedicine is not a culture-independent discipline either. It is heavily influenced by the values of the Western world, it is only one 'emic'(3) system (our own) among others (cf. the essays in Lock & Gordon 1988). Nichter (1991:139) aptly points out: 'Biomedical research is not the "objective other" which it is often made out to be. "Scientific reasoning" is motivated and as much a product of culture and practical reason as are traditional systems of ethnomedicine'. For Singer (1989:1194), (following Taussig 1980), 'Disease, seen only as a malfunctioning in biological or psychological processes, possesses a phantom-objectivity'. Rubel & Hass (1990:118) define biomedicine succinctly as 'the ethnomedicine in which physicians are trained'. For Wright & Treacher (1982) it is certainly not 'clearly and distinctly independent of social forces by virtue of its special scientific status' (loc cit, 5), but a 'social construction' (loc cit, 9).

In the 1970s and into the 1980s, ethnomedicine was often regarded as a 'subdiscipline' or 'subdivision' of medical anthropology (Foster & Anderson 1978:5, Pfleiderer & Bichmann 1985:21). Nichter (1991:138) vehemently opposes this classification and outlines the field of ethnomedicine as follows:

All too often, ethnomedicine is simplistically compartmentalized as a subfield of 'medical anthropology' and delimited as the study of folk illnesses, traditional medical systems, herbal remedies, and healing rituals. While these subjects are central to ethnomedicine, they are points of departure, not the focus of a fixed gaze. Ethnomedicine is . . . grounded in the study of everyday life, perceptions of the normal and natural, the desirable and feared, and that form of embodied knowledge known as common sense as it emerges in efforts to establish or reestablish health as one aspect of well-being. Ethnomedical inquiry entails the study of how well-being and suffering are experienced bodily as well as socially . . .'

Judgments of suffering, being ill or well in an ethnic group are culturally defined, as they are closely connected to the view members of each culture take of life -- i.e. the way people perceive and structure their environment -- and to the characteristics of their social and religious system as well as their social values. There is also a connection to the concept of the person, including the dimensions of definition of the self. Therefore such judgements belong to the 'anthropology of the body' and the 'anthropology of the self'.(4) In short, ethnomedicine today presents itself as 'multidimensional and metamedical' (Nichter 1991:137).

Out of increasing uneasiness and distrust in previous medical anthropological studies of cultures in Papua New Guinea(5) (cf. Frankel 1986, Jones 1980, Lewis 1975, Schiefenhovel 1970, 1980), I developed my own view,(6) which I would like to present here briefly. My criticism of these studies is based on two points.

1. It struck me how little these researchers -- Frankel and Lewis with their dual professions as anthropologist and physician, Jones as an anthropologist and Schiefenhovel as a physician -- were able to deviate from their own biomedical frame of reference, insofar as they integrated their own terms into the investigation of cultural-specific medical systems of the Huli, Gnau, Faiwol, Kaluli, and Eipo.

2. It seemed to me that along with this mingling of two different medical systems went the implicit conviction that physical symptoms -- so important in Western medicine -- must correlate with traditional concepts of illness if only to fulfil the frequently cited requirement that the results be comparable.

Their approaches could also be explained by the fact that they, like many medical anthropologists, are 'overwhelmed by the complex of values upheld by medicine' (Pflanz 1974, cited in Singer 1989:1194).

We may see this statement as typical:

The physiology of the healthy and sick organism is not understood by the natives, not even when the connection is evident (from our point of view). The incapacity to recognize causal relationships of this kind becomes especially manifest when the Bosavi are asked about the 'why' of a physical disorder (Schiefenhovel 1970:26).

Lewis (1975:129) mentions as his starting point for his study among the Gnau:

One question lying behind my account of the Gnau view of illness is to know how it corresponds to ours.

He also writes:

If I asked how the patient was sick, they most often answered by generalities; or by symptoms which were not confirmed by the patient; or telling me sites of pains which were diffuse or proved inaccurate (Lewis 1975:135).

In order to do justice to a representation of the Yupno medical system from the Yupno point of view, and to avoid the unfortunate mixing of two different models of explanation while also considering the biomedical point of view, I chose a different method: I decided to favour interdisciplinary cooperation with physicians. Thus, the research topics could be clearly divided. The physicians would examine the physical condition of the Yupno from the biomedical point of view, i.e. deal with the complex of 'disease'. I would dedicate myself to the complex of 'illness' by investigating the Yupno point of view. During the initial stages of fieldwork, however, this open approach without relying on the existing Western system of reference was confusing and it took some time until I began to understand the logic of the Yupno system.

This article centers on a case history of a boy named Nstasinge. It becomes possible to contrast in one case study the biomedical and medical anthropological explanations of sickness. I am able to give to the case history another important element which moves it closer to an adequate ethnomedicine (and also, today's cognitive anthropology). Without any doubt, culturally defined concepts of illness, its causes and treatments, are present (in a static and abstract way) in the minds of the members of a society. More important, however, is the way this knowledge is actually applied in everyday life in the concrete case of a sick person. Examination of the use of this knowledge in an everyday situation shows how interpretation of illness depends in a crucial way on the social position of the participants, and on their cultural knowledge, which varies within the group. Finally, it shows that these interpretations may be subject to change during the course of an illness.

YUPNO REGION

The Yupno(7) inhabit a rugged, extremely remote mountainous region of the Eastern part of the Finisterre Range, Madang and Morobe Provinces, Papua New Guinea. Today, the roughly 4400 inhabitants of the upper Yupno live in relatively large settlements (up to 600 people per village) at an altitude of approximately 2000 m. The name Yupno, 'he brought with him and deposited (at the bank)' refers to the river that flows through the main valley. According to local mythology, from the river there washed ashore the bamboo stems from which the first human beings originated.

The Yupno cultivate mainly sweet potatoes, and, more recently, introduced vegetables, which are marketed in Teptep, the Government station and only airfield. Their impressive houses, which look like big hay stacks, are found only in this area of Papua New Guinea and are well suited to the cold climate. There are no windows, and in the middle of the house burns a fire which provides the only light (and also creates a lot of smoke). People roast sweet potatoes in the fire, and cook food inside bamboo stems or metal cooking pots.

The Yupno were christianized by the German Lutheran Mission of Neuendettelsau, which started missionary work around 1930, increasing its efforts in the 1950's. Since 1963, with the opening of an aid post and its later extension into a health center, the Yupno have the opportunity to make use of biomedical health services.

Yupno society is organized into patrilineal clans. Two clans form a unity, a pair of clans. Before missionization the system of paired clans was important in different stages of initiation as well as in warfare. Today, this system plays a significant role in the distribution of land, in cases of sickness and death as well as in the marriage payments, the most important event in Yupno everyday life. The handing over of the marriage payment, called annok ('to prepare food and give away') is an event in which the whole village participates. If the handing over of this payment is not done correctly, and somebody feels neglected, this usually leads to severe conflict which may result in illness, often years after the actual payment.

THE YUPNO MEDICAL SYSTEM

For Yupno, to be ill, sit, (literally: 'I burn, am hot, cook') is to be in an exceptional, different, 'upper', 'hot' state. The contrary term is sitni mi (mi: to be absent), 'I am not ill'. In order to understand illness, one must know the Yupno conception of human nature. A complete human being consists of several elements. Apart from the body (ngodim) there is tevantok ('vital energy')(8) which is relatively impersonal and super-individual. Moreover, there are the psychic factors which determine the individual's personality, monan ('body-soul') and wopm ('free-soul'). Whereas monan ('body-soul') dissolves upon death, wopm ('free-soul') becomes a konwop ('soul of a dead person') and, in the course of time, a quite anonymous kon ('ghost'). Just as important as the physical and psychic elements of a human being are the kongap-melody,(9) which is unique to each individual, as well as the individual's social relations with others and the quality of them.

Being ill or 'hot', is an extreme point on a scale which consists of the three terms tepm 'hot', yawuro 'cool', and mbaak 'ice-cold'. The ideal state of a human being is the 'cool', balanced state of social integration. The 'hot' state, on the other hand, is exceptional, unwelcome and dangerous. Thus, the goal of each therapy is to 'cool down' the 'heated' (ill) person and get him/her back to the ideal, 'cool' middle state. The third state, 'ice-cold', is as unwelcome as the 'hot' one, since the person concerned has lost his/her balance in this condition as well. Yet this state is not considered as belonging to illness and thus plays little part in this discussion. Each of these states can be changed. What is important here is the initial state and the desired result. As a rule, a few male specialists possess the detailed knowledge required for the manipulation of these states. The principle of contact is essential. Someone in the ideal, 'cool' position can be 'heated up', i.e. be made 'ill' with the help of 'hot' objects. Likewise, a 'heated' person can be 'cooled down' to the ideal temperature, i.e. be healed, through contact with 'cool' substances. The target of manipulation is the 'body-soul' of a person, which is connected with 'vital energy'. The 'body-soul' of a healthy, socially integrated person is 'cool'. If it is brought into contact with 'hot' or 'cool' things or agents, the 'heat' or 'coolness' is transmitted and, accordingly, the person falls ill or recovers. This 'hot-cool-cold'-spectrum is, as other studies show (Wassmann n.d., Wassmann & Dasen in press b), the central organizing principle in Yupno thinking. It can be called an 'interpretive system' and is valid not only for the complex 'illness' but for all realms (e.g. the relationship to the environment, social relations, and the classification of food and magic).

The Yupno, like many other Papua New Guineans, classify illnesses according to their presumed causes. Thus, they ask not what an illness is, but why a person is ill and who is responsible. The Yupno look for an answer to these questions since, for them, most causes of illness are socially determined, whether this be because the sick person has misbehaved, or another person has made him sick out of anger or hate.

Their system of illness covers several levels. A first large group of conditions are 'natural disorders'. These cause a person to be 'hot' but not yet 'ill'. These disorders are recognized and named, yet assigned very little importance. Only this first level comes close to some symptoms and diseases of biomedicine. While from the biomedical point of view these 'disorders' are taken to be symptoms and diagnoses and may already constitute a serious disease, the Yupno see them at first as absolutely trivial 'disorders' (and not as 'illness') which can be treated with traditional therapeutical means (in the lay sector or by home remedies including elements of diet, phytotherapy, rest or massage). If this does not produce relief, they either consult a 'cooling' specialist or resort to Western medicine. The 'cooling specialist' is one of the herbalists and treats the patient by ablution or with a mixture of certain 'cool' plants. Western medicine is available at several aid posts or at the health center in Teptep. If there is no cure, these 'disorders' take on a different character in the eyes of the Yupno and become 'real illness'.

If these 'disorders' had an actual cause -- if there is a 'why' to an illness -- then the 'real illness' starts. This is called njigi. This term has both physical and figurative senses: a stone is njigi and oppressive problems are njigi. These unsolved 'oppressive problems' are caused by conscious or unconscious wrongdoing of one or several members of the kin group. These wrongdoings may have an effect on the guilty person directly or they may affect the person indirectly. For example, the victim may react furiously, get into a 'hot' emotional state and transmit that 'heat' (in a pathological way) to the guilty person or a member of this person's kin group. Not only the living but also the dead or rather their 'ghosts' (kon) can transmit their 'hot' anger and thus cause illness if they have died in a state of anger or hate. Such 'oppressive problems' are diagnosed with the help of tauak 'signs' made by the ill person, or through the interpretation of dreams. Therapy consists of an open discussion of the presumed wrongdoing, the attempt to find a solution accepted by all participants in the discussion (in other words, the re-establishment of social harmony), as well as compensation payment which should pacify and 'cool down' the 'hot' person. If an enraged 'ghost' is responsible for the illness, it can be banished through ritual.

The most serious illness is caused by two 'techniques', sit and mawom. Sit, the generic term for illness, is also used to denote a particular procedure, called 'poisin'(10) in Tok Pisin. A specialist, commissioned by a second person, steals and heats a piece of the victim's 'body-soul', which then leads to the victim becoming ill. If the victim is to die, this little piece of 'body-soul' is actually burnt. Without the 'body-soul', the 'free-soul', too, will leave the victim. The victim finally dies because of the loss of his self. Yet the ill person can recover, if the specialists find out who has stolen and heated this small piece of the victim's 'body-soul' in time. The 'thief' must now give the ill person something 'cold' so that he/she 'cools down'.

Mawom, 'sangguma' in Tok Pisin,(11) is the second extremely serious cause of illness. It is practised solely by the people of the lower Yupno areas and is highly feared by the upper Yupno. One commissions mawom by giving the name of the victim to the specialist, the mawom-man. The latter will then supervise young men who have ritually made themselves 'hot' in order to get close to the victim unobserved and shoot him or her with a special arrow whereupon he or she briefly loses consciousness. They remove the arrow, close the wound with soil and fix the day on which the victim is to die. The victim returns home but is unable to say what happened to him or her. In no time at all he or she will gravely fall ill. The only remedy is said to be for the victim to eat an (imported) coconut picked in a special way.

The basic pattern of the Yupno method of coping with illness, establishing a diagnosis and deciding on a therapy can now be roughly summarized. Yupno start by assuming a 'natural disorder', a minor ailment (which is not considered to be an illness). They move on to the worst state by the method of 'trial and error', or rather of the principle of exclusion. The physical symptoms do not necessarily have to change and yet they can be traced back to different causes.

NSTASINGE'S SICKNESS ACCORDING TO HIS MOTHER AND RELATIVES

This pattern of coping with illness can be seen in the story of Nstasinge's sickness episode as it is reconstructed from his mother's account, from long discussions at several meetings and from conversations with people involved.

His mother Mayu told how she noticed the first physical changes in her seven months' old son, Nstasinge, while she was on her way back to the village of Gua from a visit to a neighbouring village:

I thought the little boy wanted to play a trick on me and that he was thumping me [he was tied to her back with a piece of cloth] because he wanted to be breastfed. I went on a bit further down, I heard he was breathing heavily, I heard it and got him out [of the cloth he was carried in], and I felt, his skin was completely hot, like fire, I went into my garden, I sat down, and I saw, his eyes were all red, his skin was trembling, he wanted to die, and what was I to do?

I saw Susune [her husband's mother], she was busy digging up sweet potatoes, and I called out to her: 'Hey, no time to dig up sweet potatoes now, get yourself up, you hold onto him!' I held him and she also took him into her arms, he was not well, he was close to dying. He wanted neither his grandmother nor me. I had not walked far away with him and something was on his skin and I became afraid and I left the sweet potatoes [which Susune has dug up] behind, took the baby and came down [to the village of Gua].

There she tried to calm the child down.

He screamed and wailed, he was still sick, and I saw, that his skin was all hot and I got up and took him to Teptep [to the health center] during the night.

The dokta(12) came, he carried the baby into the treating room [for outpatients] and examined him, looked at him and said: 'At what time exactly did he get sick?' He asked me and I answered: 'Only now'. And they lit the lamp and filled water into a basin and laid him in this basin [bathed him], and he was not afraid or shaking, he did not budge, he was like dead and lay in the basin. 'Tomorrow morning you bring him back here again', so the doktaboy told me. And I got to Virin's house [a male acquaintance], lit a torch and went [at night] back again to Gua.

The first signs of a 'disorder' Mayu noticed in her child were bodily changes, problems with breathing ('he was breathing heavily'), fever ('his skin was completely hot') and an altered appearance ('his eyes were all red'). The sudden onset of the physical disorders combined with the behaviour of the child ('he wanted to die', 'he screamed and wailed') scared her and made her helpless ('what was I to do?'). When all attempts to calm down the child failed, she no longer interpreted its condition as a 'natural disorder' which would pass or which she could treat but resorted to the health center. Mayu, a young woman, regarded biomedicine as an alternative to the traditional phytotherapeutical 'cooling down' therapy which would take hours of preparation (collecting of the leaves etc.). She could quickly reach the health center, which is only three quarters of an hour by footpath from her village. She hoped that at the health center the physical symptoms could be cured. But the condition of the child worsened and she began to reflect on possible causes of the child's behaviour, i.e. she now started to interpret its behaviour as sit 'ill'. She assumed a njigi 'oppressing problem', so that the intrafamiliar framework was extended to a larger social one. The illness became a social event. She excluded herself as the one who had possibly caused the illness: 'I had not walked far away with him'. Her statement can be interpreted as a self-justification vis-a-vis the clan and associated clan of her husband Tanowe who had made her marriage payment, which also entitled them to certain rights to the child. They expect the child's mother to look after the baby, the 'product' of the marriage and thus a new member of the clan. A mother moving out of the control of the village runs certain risks (such as the danger of mawom attacks).

I reached my house and saw that Tanowe [her husband] sat there and I yelled at him: 'Where have you been hanging around and now you are sitting here and I am having such a hard time!' That is how I yelled at him and told him: 'I think he has got a njigi ["oppressing problem"] from you!'. That is what I said and I was very mad at him. And Tanowe did not give it any thought, he did not think of the baby, he left us and disappeared and it was very hard for me to watch the baby the whole night alone.

The next morning when I woke up I was still very mad at Tanowe [who had come back]. The others, Megau and his wife [Megau's clan was instrumental in raising Mayu's bride-price] came and the two of them got very angry at the two of us [Mayu and Tanowe]. 'We do not know anything about you, where have you been and killed him [because of it]!' That is how the two of them talked to us. Megau added: 'I cannot really tell you off now.'

And the two of us, I and the baby, went to the health center. The baby was not thinking of his grandfather [meaning here: Megau] or anything else, he only thought of me, glued himself very close to my skin and did not drink anything, he just sat there and screamed and screamed.

She came back to the village and in the evening was visited by some relatives from her husband's clan who got into a fight among themselves.

And the baby lay there like dead. They all yelled around and then they left. 'We cannot think of the baby now, this is something that concerns everybody, whatever he will do (meaning: whatever tauak "sign", he will give], we will see it.' That is how they talked and I picked up the baby's carrying-cloth and held him, and the two of us went to sleep. I felt him kicking again, then losing consciousness, then kicking again and I got up and said: 'Mian [a woman who spend the night with her], my child is dying, come quickly and hold him!' The two of us were busy holding him and Susune [her mother-in-law] was thinking of all kinds of relatives, where they might be now, and she was running around looking for them and told it [the news that the baby was ill] to them.

We took the baby to the house of Erarape [a relative]. Erarape started to fight with me . . . he screamed: 'Why does your child have such a serious illness?', and I did not say anything. They were all holding him and they could not keep their eyes open and they went to sleep all over the place and old Marope [an evangelist] sat there and watched over both of us. I got up and said to Saop [a girlfriend]: 'My behind hurts, my back is all stiff and everything is painful. I am going to hand him to you now.' I handed him to Saop, Saop was holding him and I stretched out. Saop was ill, too, and how should the two of us hold him? We both had a hard job holding him but we managed and my eyes were closing and I only dozed and Saop held the baby and the two of them sat there and Saop noticed that he wanted to die and she woke me up. 'Hey, Mayu, your child is going to die now!' This is what she said and she shook me awake. So we spent the night until it was very late. Old Marope was feeling ill, too, and he said: 'I feel very bad and therefore I am going to sleep now, what are the two of you going to do? You two stay here.' This is what he said and he went into his house. 'Too bad if you do not watch out and he dies'. This is what he said and he went.

And the two of us [Mayu and her mother-in-law Susune] sent a message to Tsarau and his relatives [clan-relatives who live in another village] and this group did not come. This is what we did and daylight came and it was also Monday, 'komyunity de', they came to get us and all went off to work. Tinko [the wife of the neighbour Jurenu] got up and helped me and the two of us took turns holding the baby and Tinko was also ill, I could feel it.

I said to Tinko: 'I feel as if I am ill, Tinko, you hold the baby', and Tinko held the baby and I went outside and I slept at the door to Manau's house (which is very close], I slept there. I slept very deeply and they woke me up and I got up, went inside Jurenu's [the neighbour's] house. Very early in the morning we had sent a message to Tsarau and his relatives and they did not come quickly, they were all still running about, and late in the afternoon they then all came and all shook the baby's hand and they went outside and the baby was like dead and Kewenu's wife, Pelon [a neighbour] got up and said: 'Oh, he has died!' So she went outside and disappeared.

I took water and poured it into the baby's mouth and the water gurgled inside and came out again, the baby vomited, this is how I did it, and the baby slowly became a bit livelier again.

At night everybody called a meeting and talked about some njigi 'oppressive problems' which concerned them, admitted their 'misdemeanours' [nduara from nduat: half, a rest, meaning: misdemeanour which left something behind] and they gathered a kollekta [collection], and this is how they did it, and everybody went outside and everyone in his own direction, and the baby was in Tinko's arms.

Now an 'oppressive problem' was assumed to be the cause of Nstasinge's illness. Mayu was the first to express this suspicion vis-a-vis her husband ('I think he got a njigi from you!'). Megau and his wife, representatives of the group which had been instrumental in raising Mayu's bride-price, looked upon Mayu and her husband as the causers of the illness ('Where have you been?') and the relative Erarape swamped Mayu with reproaches ('Why has your child got such a serious illness?'). On February 10, 1987, there was a discussion amongst the family members, the child's clan and Mayu's matrilateral relatives, in order to shed light on the 'oppressive problem' which was causing the illness. Two possible causes of the illness were discussed at the first meeting.

First, it was considered that a kon 'ghost' and/or his living son from the matrilateral kin group might possibly be angry because, exceptionally, they had a claim to a part of the marriage gift. As they had not received it, they were now suspected to have caused the child's illness out of anger. This assumption was confirmed by the fact that the child had almost ceased to drink any breastmilk - a tauak 'sign' pointing to the matrilateral kin group.

A second problem was found in the patrilineal kin group. Tanowe, the baby's father, had rebelled against his own father's instructions after he had died, so that now the father's 'ghost' would have transferred his 'hot' rage to Tanowe's child. This accusation was confirmed by several people's dreams in which they saw the deceased cutting bamboo at precisely the place where he had once planted it, a 'sign' pointing to his own clan or rather his own patrilineage.

As it was impossible to clarify which 'ghost' was responsible for the illness, the participants in the discussion, the 'therapy managing group', combined the two 'ghosts' and arranged a ritual which should dispel them. Then they gave the child a new name stemming from a different clan, and they remitted a small sum they had collected to the account of the Teptep congregation.

At the same time Mayu again visited the health center.

And I got up [the next morning], got my things together, the two of us were ready, and the two of us went to the health center. The doktaboy examined the baby, found nothing, and they poured medicine on a piece of cottonwool and rubbed it on the baby's back, they rubbed and rubbed and gave him an injection. They pumped blood and water into his skin, and water and blood they pumped out, and they said: 'You have no reason to be afraid, and you should not think about it so much, go and do not worry and look after him, go and take good care of him.' This is what the doktaboy said to me. I came to the village, and I did not follow the admonitions of the doktaboy, I saw, my skin was afraid, and I did not put the baby down to sleep, I held him in my arms the whole time. I did not wash myself, I stayed dirty, and I sat down and held him. His eyes bulged and he just stared, and this is how he spent the whole night, and the sun came, and he just looked.

[She went again to the health center.] This is how the baby behaved, and the dokta went and tickled him and he laughed at the dokta. He was babbling to himself and he was laughing with them and Saop [the girlfriend who had accompanied Mayu] held him and carried him around outside. At night I took him again, and he screamed again, and we came again into the ward, late at night, and I held him until very late. This is how we did it and we said: 'People have died in this house, and many konwop ["souls of dead persons"] are therefore here, and the konwop are holding on to him, and this is why he is crying, and we take him to Virin's house'. We went and slept in Virin's house and went back [to the health center] in order to get medicine, three nights we slept, this is how we did it, we were slowly getting fed up with it, and his illness was not over, it was still there, and 'he will become [and remain] like a small boy' [meaning: he will be mentally retarded], we were completely exhausted and talked like that. This is how we talked and we came back to the village. We came . . . and they [their relatives] held more discussions, and they were all talking about a njigi 'oppressive problem' and they all admitted their nduara 'guilt', they all did it like this.

When the child was so ill, I did not think that maybe a man might have carried him and dropped him, because only I carry him around. I thought he would die, he was so ill, or somebody from Yupno valley had made him ill with mawom-technique, this is how I thought and I was afraid of my own thoughts, I was only thinking of mawom. I thought they [the mawom-men] might kill him or do whatever with him, and I was afraid and carried him around.

This is how it went for a while, the baby did not get well, all rumours and njigi 'oppressive problems' had been discussed to the end, without success, it did not get well.

As the child did not recover, they arranged a new debate. There were no signs pointing to other causes, however, and so there was a rather vague discussion as to the possibility of a member of the mother's (Mayu's) clan having killed a member of the father's (Tanowe's) clan (or the other way round) generations ago by sit-techniques and now being angry about the fact that two members of formerly hostile clans had married. The child did not recover, and so the mother moved for a week to another village to go to see some relatives.

At a third meeting, two other possible causes of illness were discussed. First, it was related to an incident in which a woman who had for a long time been jealous of the grandmother on the mother's side, had entered Mayu's house one day screaming loudly and beating about her with a stick. This frightened the baby's wopm 'free-soul' so much, that it left the baby. And second, they discussed the payback of Mayu's marriage payment which had not been transacted according to custom. Tanowe, the child's father, had come to his wife's native place to fetch the return presents. But, as he had fallen out with some members of his own clan, he had not intended to give it to them and had sold the pig and used up all the money for himself. The participants in the discussion did not agree whether it was Tanowe's lapse or the anger of the people for whom the pig was intended, which had caused the child's illness.

The meeting at which these possibilities were discussed lasted from nine o'clock in the evening until two o'clock in the morning. There were 21 people present, relatives from Mayu's clan, Tanowe's clan, clanspeople from the partner clan, the pastor and the 'hedman' of the village.

All misdemeanors were cited. The jealous woman publicly regretted her behaviour and enjoined the baby's wopm 'free-soul' to return to its place within the child. She pronounced the little boy's name and sang his kongap-melody. She then put a kina coin, which had been touched by all participants, around the child's neck, and his mother Mayu gave him holy water, consecrated by the evangelist.

The child, however, continued to be sick and the mother now thought of mawom, one of the most serious causes of illness. Her apprehensions were not shared by her relatives, or at least they were not followed up by them.

We went to the health center [to Teptep]. Everybody accompanied me and then they left me and in the afternoon the baby screamed again, and urinated and excreted. And Saop [the girlfriend of Mayu] cleaned it all up, and we sat there. The first doktaboy [meaning: the highest in rank because of his better training and head of the health center, a Health Extension Officer, H.E.O.] was playing badminton, later he came and looked and said: 'Man, I have not seen this child yet, did only the small doktaboy [meaning: his subordinate aid post orderlies] treat him?' This is what he said and he felt insecure and was chewing his fingernails.

Then very quickly everything was arranged to transport the child to Madang, the provincial capital.

The first doktaboy told us all: 'This woman here and her child will take the plane tomorrow.' This is what he said and he went away.

It was still night when we got everything ready to go to Madang. The next morning they all came to visit us and walked around [in Teptep]. At that time I was afraid, where would the two of us go and with whom? And the two of us [she and her child] thought a lot. It is not good if I alone take him there and something happens to him. Everybody will be mad at me then. Or, if I take him there and something happens, what am I to do then? I was scared.

She asked some people to accompany her, but the H.E.O. forbade it when the plane arrived.

[The H.E.O. said:] 'In case some men want to climb into the plane with you two, I shall throw them out, well then, leave them all behind and sit down in the plane!'

Yes, I climbed into the plane now, and the others [some men] unloaded its cargo, and afterwards the other passengers got on, and we took off. We landed in Madang, and they had already called the hospital, and we left the other passengers, and the ambulance-driver asked: 'Where are the patients from Teptep?' and I said: 'Here we are' and we went to him. We [she and her baby] said to Kwanbe [a schoolboy who happened to fly with them from Teptep and who goes to high school at the Rai coast]: 'We have never driven in a car and do not know the way, well then, you come with us.'

Well, we got into the car and took off. We got to a street and saw Mannau [one of Tanowe's relatives] he was at the market. I waved to him but he did not see us and we drove by him. We got to the hospital, Kwanbe said good-bye and said: 'Go and tell them your names, then you go into the house, into the house where all the children and babies are. I will go and see his grandfather' [meaning the above-mentioned Mannau]. And Kwanbe left. At the same time the doktaboy got the baby's card ready [filled it in], and we went to the sleeping-place [to the ward].

There was a man from Urop [a neighbouring village] with his wife [who had accompanied her sick son to the hospital], and the two of them said: 'Put your string-bag here, at the place for string-bags.' I put it down and went to the office. And they examined Nstasinge, this took a long time, and they did not know what was wrong, and they thought about it. And I thought now he would die and I was very scared.

They sent us back to the bed, and there we stayed. And they brought the sick boy from Urop there where the people are cut up [to the operating theater].

Mayu witnessed how the small boy from Urop underwent an operation on his intestines.

We were quite well, and then they said they wanted to cut up the baby. I was afraid and told them: 'Only if I give you my permission can you cut him up.' And I stopped them. Because it was at the same time that they were fighting for the life of the boy from Urop, and he died. And his relatives begged the dokta to enable them to return to Urop [to pay for the plane-ticket]. The dokta said: 'I have no way of sending you to Teptep, if you want to buy your own ticket, okay.' This is what he said. And at the same time I got scared. I told them: 'My child did not get well, therefore you should send him back to the village.' This is what I said to them. 'It will be bad if he dies and I have no chance to take him back. I did not come with a husband, I brought the baby here on my own, so please send him back.' And the dokta said: 'We think he is not going to die. There is no illness in his body, it is only on the skin, we are trying very hard, and you, do not think so much about it, you stay here.'

This calmed me down, my feelings were mbit yawuro 'cool', [mbit 'belly', yawuro 'cool'], and I stayed there. The dokta took blood and water from his back and sent it to Mosbi [the capital Port Moresby] and to other places. And the dokta examined this water and blood. . . .

We were sent to a different ward, time passed, and he did not get well, and again they sent us to a different house . . . . So there we were, and the first dokta came and said: 'This is your last week here, next week you will go to Teptep!' This is what the dokta said. During this week which we still spent in Madang, we washed our clothes and visited the town, then it was time for us, and I was very much looking forward to going back to the village. They told us that we had to go to the airport when it was still the middle of the night.

We waited at the road, the hospital ambulance picked up all the people, and at the very end it came and got us. And we came back here [to Gua].

In Mayu's report of the H.E.O.'s decision to send her to Madang to the Modilon Hospital with her child, her thoughts were mainly about how the clan members and members of the partner-clan would react to the eventual death of the baby, and her fear of these reactions and the blame that would be laid on her. Her fear was reinforced when she witnessed the death of the boy from the neighbouring village of Urop and the problems of his parents in getting back to their village. She clearly had difficulties making decisions on her own in this new social environment: the town and its people were strange, and she knew no Tok Pisin. It was hard for her to decide if she should go back to the village with her sick child or if she should wait to see whether the baby got well again; here there were no relatives, as there would be in the village, who would make decisions together with her and take the responsibility.

NSTASINGE'S SICKNESS FROM THE WESTERN MEDICAL VIEWPOINT

The following is an account of the same sickness episode, seen from the point of view of Western medicine. It is reconstructed from conversations with personnel of the Teptep health center and from the interpretation of the clinical record of the Modilon Hospital in Madang by the physician Sandra Staub.

Nstasinge was taken to the Teptep health center by his mother on February 3, 1987, for the first time. He was then seven months old and weighed 7 kg. The boy showed signs of a cerebral inflammation which pointed to meningitis. For further clarification, a lumbar puncture was made. The results confirmed the diagnosis of a bacterial or tubercular meningitis. Therefore, a two-week therapy with the antibiotic Chloramphenicol was administered. A second lumbar puncture showed that the liquor was clear. The child was discharged from the health center.

More than two months later, on April 13, 1987, after all traditional means (discussions about potential 'oppressive problems' etc.) had been exhausted, the mother again consulted the health center. The Health Extension Officer in charge described the child as without fever, but with stiffness of neck, back, feet and hands, staring eyes, loss of weight, and signs of malnutrition. As he himself was unable to make a precise diagnosis of the child's disease -- he supposed that 'he has a big problem in his head', as he wrote in his letter of transfer. He treated him for eleven days with Phenobarbital (to stop the spasms) before he had him transferred to the Modilon Hospital at Madang.

DOCUMENT: LETTER OF TRANSFER

Teptep Health Centre, Teptep, Madang

24th April, 1987

The Admission Officer, Madang Hospital, P.O. Box 2030, Yomba.

Attention: DR PHILIP WATT (SMO) PEDIATRICIAN.

Subject: ZASINKE TAHANUWE M/7 MONTHS

Dear Doctor,

I would like to bring to your attention about the condition of above small boy. He was admitted to Health Centre on the 3rd February, 1987. With signs and symptoms of cerebral inflammation.

I thought he may had meningitis therefore did LP on him. It was cloudy. The diagnose was confirmed therefore commenced him on chloramphenicol for two weeks. Repeat LP was done with clear CSF. With this satisfaction of improvement he was discharged home after two weeks.

How-ever he was re-admitted again on the 13th April with similar signs and symptoms. This time without fever, stiffness of neck, back, feet, and hands. Made worse when irritable on disturbance. Has starring eyes, weak, losing weight, and becoming malnourished. He is being getting phenobarb only to calm him down a little bit.

It is most likely that he may has a big problem on his head. I thought it could be malnutrition, brain damage, mentally retarded, TB meningitis, encephalitis, and may be a tumor.

I can't do much for him here with this complicated illness therefore decide to send him down to your hands for advance care.

Yours sincerely,

BOKUNG WENANI OFFICER IN CHARGE

In Madang, the examination on admission of April 24 showed loss of weight (the child weighed only 5.5 kg), scabies, ulcers, bilateral creps, decreased turgor, and sunken fontanels. Based on these clinical findings, the following diagnosis was made: meningoencephalitis, brain damage following the meningitis, possibly tuberculosis and pneumonia. As therapy the first prescriptions were the antibiotic Chloramphenicol, the antiepileptic Phenobarbital to suppress the child's spasms, Pyrantel, a highly effective antihelminthic, draining of the ulcers, treatment of the scabies, and finally, physiotherapy. Following a blood test on the same day, Amodiaquin, an anti-malarial drug, was prescribed. The child was also vaccinated during the first week of his stay at Modilon Hospital. They vaccinated him against diphtheria, tetanus, whooping-cough, polio, tuberculosis and measles. Frequently repeated blood tests pointed to an inflammation, but did not result in any distinct finding. Lumbar punctures, performed almost daily at the beginning of the therapy, also produced little result. All too often they proved to be traumatic. The few successful lumbar punctures produced normal findings, no agitator could be detected.

For weeks the child's condition hardly changed. He put on weight only very slowly and the symptoms of stiffness and frequent high temperature continued. The notes in the clinical report read again and again: 'neck still stiff', 'fever', 'feeding o.k.', 'condition much the same'.

On May 8, he was transferred from the 'A-ward', the ward of the acutely ill, to the 'B-ward', a convalescent ward. Mayu mentions this: 'We were sent to a different ward'. On May 26, tuberculosis therapy with Streptomycin, Isoniacid, Rifampicin and Pyrazinamid was begun. During the following four weeks, there were still no real changes in his condition. The child continued to have peaks of temperature and to be restless, and he hardly gained any weight. He was then transferred to the 'C-ward', a ward where there are no daily visits. (Mayu's comment: 'And again they sent us to a different house'.) In mid-July, after a three-months' stay at the hospital, an improvement of condition was diagnosed for the first time. The child was now without fever, had no more spasms, had lost the stiffness of neck, and ate and drank well. The last entry on July, 1987, reads: 'Seen by paed. [paediatrician] team. arrange repatriation, cont [continuing] B Regime [tuberculosis-therapy] cond. [condition] no new problems, afebrile'. On July 31, 1987 the child was discharged and flew back to Teptep with his mother.

In Nstasinge's case, both traditional and biomedical treatments failed. The failure was interpreted in different ways.

According to the statements of relatives and friends of the child's family, there had been too many 'oppressive problems', both between the child's father and mother and within the kin group. Consequently, the situation had been too heavily charged with conflicts, and these problems had never been really solved. Although various problems were discussed and identified, it still remained open which problem exactly was responsible for the child's illness. Thus, the initial cause could never be identified.

From the point of view of Western medicine, the child probably came too late to the Teptep health center where it was (supposedly) treated neither correctly nor regularly enough. The further sickness episode shows that the child, who weighed only 5.5 kg, was immoderately treated with drugs of various kinds. It received several vaccinations and had to endure many critical treatments and examinations (such as the many lumbar punctures) which can easily cause permanent damage if not carried out correctly. The approach of modern Western medicine was equally unable to identify the precise cause of the disease, i.e. the decisive agitator was not detected. The child was discharged as cured from the Western point of view, i.e. in a stable condition that could not be further improved.

THE MOTHER'S EPILOGUE

I met the mother and her child again during my third visit in the village in 1988, one year after completion of the treatment. Mayu was living with her mother-in-law Susune in Gua and had given birth to a little daughter; her husband Tanowe had left the family and was living in Madang. The little boy was now two years old and mentally and physically handicapped. She commented on her situation:

I do not think about it a lot, I am not angry, I am all right now. Honestly, he wanted to die, but I was torn this way and that, he almost wanted to die, but I felt so sorry for him, and I looked after him, I loved him and looked after him. I never give him to anybody else, I alone walk around with him. If I want to go to the garden, I give him to his grandmother and I only go to get sweet potatoes and I come back at once. If I go further away into the garden, I carry him, the two of us go to the garden, and I put him down, I do the gardening and look for sweet potatoes. I hear if he cries, I think, he is hungry, and I give him the sweet potatoes cooked beforehand and put him down again and go on with my work digging up sweet potatoes. This is how I do it, and when I have found enough sweet potatoes, I carry him, and the two of us go back to the house. This group of young girls here [who also sometimes spend the night in her house], they do not help me and sometimes carry him a short way, no. At times I am mad because of this. That is all.

CONCLUSIONS

Nstasinge's sickness serves to illustrate conceptions of illness and disease and corresponding responses in a concrete case of everyday life.

A clear distinction between illness and disease or, in other words, the division of a case of sickness into these two aspects, shows how very differently they are perceived and explained. While in the case of the little boy Nstasinge's sickness the Yupno again and again discussed new possible causes, from the biomedical perspective the symptoms stayed relatively the same.

Juxtaposing the two systems, the ethnomedicine of a given ethnic group, and the biomedical approach (as in Schiefenhovel 1970, 1980, Lewis 1975, Jones 1980 and Frankel 1986), or correlating them, leads to totally inadequate conclusions in two ways. If an ethnomedical system is described and at the same time (or in a further step) more or less explained in biomedical terms and measured and evaluated against the latter, such statements result as 'bush spirit x causes malaria, bush spirit y causes vomiting'. The reverse seldom happens and it is indeed hard to imagine: if one described the biomedical system of classification and then compared it to the Yupno medical system (taken as an 'absolute' basis of reference), equally inadequate conclusions would result, only in this case for the biomedical system. Such a reversal could run as follows: social disorders cause a 'raising of temperature' of the body which could manifest itself in any number of illnesses.

For the Yupno, illness only begins when more than one person is concerned. Illness is therefore not just private misfortune. It is an event which always concerns several persons and their relationships, and it has an underlying cause.

Being ill is always linked to a disturbance of the ideally 'cool', middle state of a person as well as of a social group. The ill person is 'hot' and has risen above the middle state. All therapies aim at 'cooling' the person down and reintegrating him or her socially. Thus for the Yupno, illness is not a biological accident of the body. Illness is very closely connected with social and kin-group relations and can only be explained in terms of the Yupno system of belief, knowledge and thought which determines and structures their social as well as their non-social environment.

ACKNOWLEDGEMENTS

Fieldwork among the Yupno in the Finisterre Range, Madang Province, Papua New Guinea, was made possible with the permission of the National and Provincial Governments as well as the affiliation with the Institute of Papua New Guinea Studies. Financial assistance was provided by the Studienstiftung des Deutschen Volkes (Bonn Bad-Godesberg, Germany), other assistance by the Institute of Ethnology, Basel (Switzerland). I conducted the 20 months' fieldwork from 1986 to 1988 within the framework of a project called 'Ethnographic-Cognitive Research among the Yupno of North-Eastern Papua New Guinea'. My fellow participants in the project were the anthropologist Jurg Wassmann, Cognitive Anthropology Research Group at the Max Planck-Institute for Psycholinguistics, Nijmegen (The Netherlands), who initiated and guided the project; the physicians Sandra Staub and Andreas Allemann, Basel, (Switzerland); and the psychologist Pierre R. Dasen, University of Geneva (Switzerland). I wish to thank all of these institutions and individuals, and I am grateful to Jurg Wassmann and Andrew Strathern for helpful comments.

NOTES

1. In the more recent literature, this distinction is disputed, cf. Shweder (1988:492) who based his criticism of Kleinman (1986) exactly on these two terms and clearly states: 'And what I think makes me confused and nervous is that shaggy distinction between illness and disease'.

2. For Singer (1990:181) the 'medicalization of medical anthropology (is) . . . reflected . . . in the treatment of non-Western ethnomedicine as a component of culture but biomedicine as an example of science; the assignments of afflictions not identified by biomedicine to the category of culture-bound syndromes; the development of cultural or psychological interpretations of successful healing in non-Western medicine but organic explanations for biomedicine; and efforts to test empirically the efficacy of folk healing systems but not biomedical treatment'.

3. For a discussion of the concepts 'emic' and 'etic' see Headland, Pike & Harris 1990.

4. As an example of how concepts of the self are incorporated within and articulated by a healing system see Laderman (1991).

5. See Sinclair (1987/88) for an historical review of the development of medical anthropological writings in Papua New Guinea since the 1960s.

6. The elaboration of my point of view dates from the time when I was preparing my research, i.e. 1985-1986. Since then, some things have changed (cf. Lewis & Frankel 1989).

7. Until recently, the Yupno were a largely undocumented ethno-linguistic group. Schmitz published an article in 1958, based on his three-weeks' walk through the valley. For more detailed studies see Wassmann (1992, n.d.) Wassmann & Dasen (in press), Kocher Schmid (1991) and Keck (1992).

8. The terms 'vital energy', 'body-soul', 'free-soul' are approximate glosses.

9. Each Yupno has his/her own melody, called kongap (kongap from kon: 'ghost', gap from kaap: melody), which is an extremely short sequence of sounds serving as a unique signature tune. Just after giving birth, the mother invents this melody for her child, which the child later on will exchange for a different melody either invented or dreamed (see Niles 1992).

10. Patterson (1974/75:141) calls it 'personal leavings and food remains sorcery', Knauft (1985:110) 'parcel sorcery'.

11. Mawom corresponds in many ways to what is usually termed 'assault sorcery' in the literature (Glick 1973:183-184, Patterson 1974/75:143-144).

12. 'Dokta' or 'doktaboy' refers to an medically trained orderly, in this case to one of the employees at the health center at Teptep.

REFERENCES

BROWN, P. J. and M. C. INHORN. 1990. Disease, ecology, and human behavior. In T.M. Johnson & C. Sargent (eds.), Medical Anthropology: A Handbook of Theory and Method, pp. 187-214. New York, Westport, London: Greenwood Press.

CHRISMAN, N.J. and T.M. JOHNSON. 1990. Clinically applied anthropology. In T.M. Johnson & C. Sargent (eds.), Medical Anthropology: A Handbook of Theory and Method, pp. 93-113. New York, Westport, London: Greenwood Press.

COLSON, A.C. and K.E. SELBY. 1974. Medical Anthropology. Annual Review of Anthropology 3:245-63.

EISENBERG, L. 1977. Disease and Illness: Distinctions between Professional and Popular Ideas of Sickness. Culture, Medicine and Psychiatry 1:9-23.

FABREGA, H. 1971. Medical Anthropology. In B.J. Siegel (ed.), Biennial Review of Anthropology, pp. 167-229. Stanford: Stanford University Press.

FOSTER, G.M. and B.G. ANDERSON. 1978. Medical Anthropology. New York, Brisbane, Toronto: John Wiley & Sons.

FRANKEL, S. 1986. The Huli Response to Illness. Cambridge: Cambridge University Press.

FRANKEL, S. and G. LEWIS, (eds.) 1989. A Continuing Trial of Treatment: Medical Pluralism in Papua New Guinea. Dordrecht, Boston, London: Kluwer Academic Publishers.

GLICK, L.B. 1973. Sorcery and Witchcraft. In I. Hogbin (ed.), Anthropology in Papua New Guinea: Readings from the Encyclopaedia of Papua and New Guinea, pp. 182-186. Carlton: Melbourne University Press.

HEADLAND, T.N., PIKE, K.L., and M. HARRIS, (eds.). 1990. Emics and Etics. The Insider/Outsider Debate. Newbury Park, London, New Delhi: Sage Publications. (Frontiers of Anthropology vol. 7.)

JONES, B.A. 1980. Consuming Society: Food and Illness among the Faiwol. Ph.D. Dissertation, University of Virginia.

KECK, V. 1992. Falsch gehandelt -- schwer erkrankt. Kranksein bei den Yupno in Papua New Guinea aus ethnologischer und biomedizinischer Sicht.
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