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The treatment of infertility using ethnomedical practices in northern Jordan: a medical anthropological study.

Introduction

Throughout history, man has used various natural materials to improve his health and cure illness. Traditional human populations tended to use wild plants and animal species as a natural pharmacopoeia. According to the World Health Organization, 80% of the developing world's rural population use traditional medicine for primary health care (1) and the same percentage can be applied to world populations. (2)

The study of traditional medical practices combined with the cultural interpretations of health, disease, illness, health care, and healing practices is known as ethnomedicine. (3) The study of ethnomedicine is complex because it consists of plants and animal materials as well as spiritual practices. (4) Infertility, in particular, is one of the major concerns of ethnomedicine as many ethnomedical procedures have been developed to treat this condition, utilising many different plants. The use of plants in the treatment of infertility is gradually gaining popularity in different parts of the world due to its availability and affordability. (5) An ethnomedical research project has been conducted to document herbal medicines used to treat infertility amongst women in Baham, Cameroon, West Africa, where infertility rates have been recorded to be as high as 25%. (6)

According to Reproductive Health Outlook, (7) between 8 and 12% of couples in the world have difficulty conceiving at some point during their reproductive lives. However, the percentage is higher among non-Western societies and may affect up to one-third of couples attempting to conceive. (8) According to Centres of Disease Control, (9) infertile women represent 35% of infertility rates worldwide, whereas men represent 35%, and in the remaining 30% the problem is either shared by both partners or is of undetermined origin.

Ethnomedical practices of any ethnic group are considered important components of culture, which are transmitted systematically across generations. As a result of several factors including expansion of modern medicine and globalisation, a huge part of ethnomedicine is gradually disappearing. In other words, a significant part of societies' cultural heritage may be endangered as a consequence of modernisation.

This ethnographic study is considered to be valuable as it seeks to analyse and document some of the ethnomedical practices related to fertility treatments in northern Jordan. This topic has not been researched extensively from an anthropological perspective in this particular region to date.

Methodology

This study has relied primarily on the anthropological methodology in which in-depth interviews were conducted to gather the needed ethnographic data. Several folk healers from different villages in the northern part of Jordan were interviewed many times. Some of them were interviewed twice to follow up on some treated cases. A set of questions was asked during each interview (Appendix 1). For the sake of documentation, rituals of healing and medicinal plants preparation were photographed and videotaped.

Videotaping was used to document parts of the healing procedures to complement other tools of data gathering employed in this study. It should be mentioned here that we partially relied on these images to process and analyse the gathered ethnographic information.

To gain a better understanding of the healing procedures for men and women, the research team included two physical anthropologists and three social anthropologists to apply an interdisciplinary approach; given that the research problem crosscuts the two fields, the treatment of infertility by medicinal plants has various intertwined sociocultural, economic, and biological aspects. Access to healers was made possible through the assistance of some informants from these local communities. Most of these field visits were prearranged by local informants.

We assured the interviewed healers that the data provided by them will be utilised for the purposes of scientific research. Taking into consideration that the participation of healers and informants is voluntary rather than obligatory, several of those we planned to conduct interviews with declined to participate in the study. Reasons for this refusal include cultural factors and legal issues.

In terms of data processing, after collecting infertility treatment-related ethnographic materials, data were processed through classification and analysing. In regard to categorisation, the gathered materials were categorised in accordance with diagnosis and treatment of infertility. In the following section, we present three case studies of traditional healers, followed by a discussion of these cases and the main results of the study.

Traditional healer 1

The first traditional healer, * who did not inherit his knowledge, has been practising folk medicine as a hobby for almost seven years. He acquired the needed knowledge through personal efforts including special TV programs, Internet, and readings about medicinal plants. In addition to that, he has the habit of reading the leaflet which contains important information on the chemical components of each prescribed drug. In his treatment protocol, he tends to combine folk medicine knowledge with modern knowledge. He also uses some of the Islamic medical teachings to perform certain healing rituals. He is not specialised in treating a specific category of diseases but rather seeks to diagnose any disease based on its symptoms.

According to him, the most important task of the ethnomedical practitioner is to identify the cause or aetiology of the disease rather than just to prescribe a medicine. In diagnosing the disease, he takes genetic factors into consideration. Thus, he does not refer the patients to medicinal plant shops during the first round of treatment but rather to modern medical laboratories for testing.

He has treated a number of infertility cases throughout the years. In one of these cases, a man who had appendectomy was infertile for eight years after having his first two children. Many pathology tests, including sperm count and motility, and scans of the uterus and ovaries, were performed; however, no abnormalities were found. When referred to the folk healer, they are given two prescriptions: the first one is composed of one kilogram of Brassica alba seeds and a hundred grams of Viscum album. After grinding and mixing both components, two large teaspoons were added to 6 litres of warm water (Table 1).

The client and his wife were asked to soak their feet in the mixture for half an hour daily. According to the healer, this prescribed mixture activates the nerve endings and opens the blood vessels located anatomically in the lower abdominal part.

The second prescribed regimen is composed of four main components: Phoenix sylvestris (100g), royal jelly (40g), le pollen (50g), and Liquidamber styraciflua (5g). They are mixed very well, preferably by a wooden spoon, and should be taken by the husband twice a day in the morning and the afternoon. If there is noticeable progress, this regimen should be repeated for a period of three months as sperm are reproduced every 70 days (Table 2).

However, if the wife suffers from fertility problems, she is instructed to take the following prescription: (100g) Viscum album, (150g) Phoenix sylvetris, and (1000g) honey. A small spoon of this mixture should be taken daily in the morning and the afternoon for three months. The progress can be noticed each month as her menstrual cycle returns to 28 days (Table 3).

In case of defects or abnormalities in sperm as a result of increased viscosity of semen, a different homemade prescription is used. According to the folk healer, two pieces of garlic should be taken with orange juice daily in the morning. When there is a total lack of sperm, the healer believes that the client may have suffered from mumps which causes complete infertility or from injury or inflammation which has caused a blockage in the vas deferens. In both cases, the client is advised to have a surgical intervention, taking into consideration his/her medical history.

In addition to repeated vaginal washing and soaking the feet in Brassica alba and Viscum album, a spoon of Alchemilla vulgaris is ground and dissolved in one litre of water to be taken by the wife if she suffers from a prolapse of the uterus. Among other causes of female fertility problems are irritable colon that may result from cold and grief, constipation, psychological factors, and lack of knowledge about time of ovulation occurrence. Factors such as heat (temperature of work place higher than body temperature) and varicosities may cause fertility problems amongst men.

Traditional healer 2

The second healer ** acquired knowledge of treating infertility from her mother and her own personal experience. She was motivated to practise ethnomedicine when she visited a healing centre out of personal curiosity during performing pilgrimage to the Holy City of Mecca. She was informed that the most common and proven infertility prescription consists of Phoenix sylvestris (2 powder bottles) added to one kilogram of royal jelly. They should be mixed together and taken in the morning and afternoon by both the husband and wife.

She treated many cases of infertility using the above mentioned prescription. The first women she assisted had been unable to conceive for four years prior but conceived and delivered a baby after taking the course of treatment. For better results, the healer recommended that no food or drink should be taken within the first hour of taking the mixture, keeping in mind that the preferred time to take the mixture is the pre-fertile time (13th, 14th, and 15th day of each month).

The second treated case was a woman who was unable to become pregnant for 11 years. Using a traditional procedure of diagnosis, in which she placed her hand above the umbilicus and found no pulse there, she diagnosed the problem as uterus displacement. She treated this case by a massage therapy of the abdomen to bring the uterus back to its normal location, cupping, and inserting a vaginal suppository for five consecutive days.

When the inflammation is characterised as severe, Ricinus communis (castor oil plant), egg white, and alum are mixed together, and the formed suppository is implemented for half an hour. The same prescription is tried twice a day in the morning and afternoon for three days. This treatment procedure was very beneficial for a woman who had been unable to conceive for 4 years as she became pregnant after the use of this prescription.

To diagnose vaginal inflammation, this healer asks several questions regarding the vaginal discharge: whether it has a bad odour or not, and its colour. Sometimes it is necessary to test the urine.

Another woman, who complained of back pain when she was very active, was prescribed cupping, Phoenix sylvestris, and back pads to aid conception and she became pregnant after two months of treatment.

The viscosity of semen among men should be examined using facilities of the modern medicine. Men should take a mixture of Phoenix sylvestris and honey twice a day for four months. If there is no progress, the same prescription should be repeated. This particular method of treatment was used to cure 100 clients. Only four cases did not show any progress, as a result of not repeating the given prescription.

Traditional healer 3

The third healer *** has been practising ethnomedicine for almost 30 years. She acquired the required knowledge from her mother. The most common method of treatment she uses is vaginal suppository. As she narrates, she has treated most of her clients using a suppository which she prepares at home from the following components: Nigella sativa, Cuminum cyminum, Sesamum indicum, Cicer arietinum, Ervum lens, honey, Myristica fragrans with Nerium oleander, Trigonella foenum-graecum, Cherry prunus, and a piece of unwashed wool (Figures 1, 2, and 3). This suppository is inserted in the vagina for 10 to 15 consecutive days. To prepare it, all these components are mixed and rolled in the wool piece after being cleaned of thorns. If this suppository is dropped with some blood on it, it indicates that there is a significant progress. Otherwise, the same procedure should be repeated (Table 4).

In diagnosing the health problem, she follows a similar procedure used by the second healer, especially the use of palpation in which she places her fingers tips on the woman's abdomen above or on the umbilicus to examine the presence of pulse. If there is pulse, this means that the uterus is placed in its normal anatomical location. If not, she uses massage therapy on the client while fasting to bring the uterus back to its normal position.

Discussion

It is clear from the above mentioned cases treated by folk healers that a significant part of Jordanian rural people still refer to traditional healers to seek treatment for several health problems, despite the fact that Jordan has recently witnessed a remarkable development in the medical sector. Jordan is ranked among the top countries in terms of its advanced medical system and health services. (10) Most medical doctors are trained in the Western medical institutions and are fluent in English. Nonetheless, traditional healing has continued to flourish along with this medical development, given that Jordan's ecosystem is rich in medicinal plants.

Infertility, in particular, is considered one of the most common health problems that are treated by both medical systems: ethno- and biomedicine. As several folk healers mentioned, clients come to them only after a negative experience with the institutions of modern medicine. This particular result of the study is in agreement with the finding of Maclean's study on South Africa, in which he found that 70% of people of Johannesburg seek help from traditional healers, but only 30% seek it from medical doctors. (11) As indicated by the report of the World Health Organization (WHO), 80% of people of the world still ask traditional healers rather than health professionals for health care. (12)

It should be noted that clients who seek help from folk healers belong to various socio-economic classes including educated and rich people as narrated by the interviewed healers. This testifies to the fact that folk medicine is not exclusive to people of lower socioeconomic class and uneducated people as it is commonly believed. This conclusion was reached based on the narratives of the interviewed folk healers who indicated that their infertile clients, both men and women, belonged to different socioeconomic classes within the Jordanian community in the north.

Educated and higher class people usually seek initial medical care from modern medical institutions either in the public or private sector as found in Yemen society. (13) Part of the reason behind this practice is due to their financial capability even when they are not medically insured. However, when they are not satisfied with the results, they have no option but to refer to folk medicinal healers.

Given that fertility-related issues are highly stressed according to the Arab cultural norms, people, regardless of their socioeconomic status, are willing to seek help from any source, whether medical doctors, folk healers, witches, or sorcerers. These norms highlight the cultural, social, and economic values of large size families. This requires a very high fertility rate which is considered among the highest globally. For example, the fertility rate in Jordan has remained almost constant since 2002, being 3.8 (children per family) in 2010. (14) Therefore, the need to study fertility related problems cannot be overemphasized as it has a great impact on certain cultural aspects that influence the way women see themselves in society. This clearly expresses that there are no cultural or economic barriers when it comes to health problems in general and fertility in particular. Women, over human history, invested huge amounts of effort by using medicinal plants in order to control their fertility with various forms of societal approval and support. (15)

As shown in the cases discussed above, most healers have inherited ethnomedical knowledge and skills from their parents and grandparents. This demonstrates the importance of family network and the process of culture transmission from one generation to another. This process of acculturation plays a vital role in preserving ethnomedical practices and knowledge, which are endangered by processes of modernisation and globalisation. This clearly demonstrates the urgent need to document these various traditional practices before they completely disappear.

The relationship between the two systems, the traditional one (ethnomedicine) and modern one (biomedicine) can be described as dynamic and intertwined. In some cases it is complementary in the sense that each acknowledges the role and the importance of the other. This can be clearly noticed in the number of cases that has been referred from ethnomedical practitioners to medical doctors when necessary. For instance, folk healers refer their clients to the laboratories for sperm count and semen analysis. In a study on the integration of modern medicine and traditional health sectors in Swaziland, some medical doctors treat folk healers as inferior to them, and pretend that healers do not exist. (16) They refer to them as diviner-healers and driven in their work by money. As a study conducted on ethnomedicine in Jarash governorate of Jordan concluded, the relationship between two medicines is a one of struggle. (17)

Concluding remarks

This paper tackles an important issue in the rural Jordanian society, which has both medical and cultural significance. Traditional healers tend to use different procedures to treat many of the same health problems reflecting their diverse knowledge. As a result different medicinal plants are prescribed for the treatment of infertility. (18)

Fertility assumes significant importance in Jordanian cultural traditions. Therefore, treatment of infertility is considered a major concern for Jordanians in general and rural people in particular. People are willing to spend money, even if the cost is high, and refer to both modern doctors and traditional healers. Traditional healing practices, which represent an integral part of Jordan's cultural heritage, are a product of the dynamic relationship between culture, ecosystem, and individual agency.

Appendix 1

Biographical data

Name:

Age:

Sex:

Marital status:

Years of practice:

Current occupation:

Educational background:

Question 1 How did you acquire this knowledge?

Question 2 How do you diagnose and treat infertility problem?

Question 3 Describe and show us how you prepare the prescribed medicine?

Question 4 Where do you get the prescribed herbal medicines?

Question 5 Discuss some of the rare complicated treated cases of infertility?

Question 6 What are the socio-cultural - and economic characteristics of your patients?

Question 7 Do you refer your clients to the facilities of modern medicine?

References

(1.) Alves R, Rosa I. 2005. Why study the use of animal products in traditional medicines? J Ethnobiol Ethnomed. 1:1-5.

(2.) Ahmad H. 2005. Issues regarding medicinal plants of Pakistan. Udyana Today: 6(3):6-7.

(3.) Krippner S. 2003. Models of Ethnomedicinal Healing. Paper Presented at the Ethnomedicine Conferences, Munich, Germany. April 26-27 and October 11-12.

(4.) Lowe H, Payne-Jackson A, Beckstrom-Sternberg S, Duke JA.2000. Jamaica's Ethnomedicine: Its potential in the healthcare system. Canoe Press: University of the West Indies, Kingston, Jamaica.170.

(5.) Erhabor J, Idu M, Udo, F. 2013. Ethnomedicinal survey of medicinal plants used in the treatment of male infertility among the IFA Nkari people of Ini local government area of Akw Ibom State, Nigeria. Res J Recent Sci 2 (ISC-2012):5-11.

(6.) Telefo P, Lienou L, Yemele M, Lemfack M, Mouokeu C, Goka C, Tagne S, Moundipa F. 2011. Ethnopharmacological survey of plants used for the treatment of female infertility in Baham, Cameroon. J Ethnopharmacol. 14: 136(1):178-87.

(7.) Reproductive Health Outlook. 1999. Infertility: overview and lessons learned. Availabl-from www.rho.org

(8.) Collet M, Reniers J, Frost E, Gass R, Yvert F, Leclerc A, Roth Meyer C, Ivanoff B, Meheus A. 1988. Infertility in Central Africa: infection is the cause. Int J Gynecol Obstet. 26: 423-28.

(9.) Centres for Disease Control. 2010. Outline for a national action plan for the prevention, detection and management of infertility. Atlanta, Ga, USA.

(10.) Ministry of Health. 2013. Annual Report, Jordan.

(11.) Maclean U.1971. The Magical Medicine. A Nigarian Case-Study. London: Benguin Books.

(12.) WHO. 2001. Legal Status of Traditional Healers Medicine and Complementary and Alternative Medicine: A Worldwide Review, 2001.

(13.) Makkawi A. 1994. Medical Anthropology: Theoretical Studies and Field Researches.Alexandria: Dar Al Ma'refh. (In Arabic).

(14.) Higher Population Council. 2010. Impact of changing contraceptives method mix on Jordan's total fertility rate.

(15.) Lans C. 2007. Ethnomedicines used in Trinidad and Tobago for reproductive problems. J Ethnobiol Ethnomed. 3:13.

(16.) Green E. The Integration of Modern and Traditional health Sectors in Swaziland. In: Wulff R, Fiske S, editors. 1987. Anthropological Praxis. Boulder: Westview Press. p. 87-97.

(17.) Al Otum M. 2002. The Treatment Patterns in Jarash Governorate: An Anthropological Field Study. Unpublished Master Thesis. Yarmouk University (In Arabic).

(18.) Rahmatullah M, Nuruzzaman, Hossan S, Khatun MF, Rahman M, Jamal F, Or-Rashid H, Nasrin D, Seraj S, Jahan R. 2010. An ethnomedicinal survey of folk medicinal practioners of Shitol Para village, Jhalokati district, Bangladesh. Adv in Nat Appl Sci. 4(1):85-92.

Ahmad Y. Abu Dalou [1], Ayman Alshboul [2], Mahmoud Na'amneh [2], Wassef A.Sekhaneh [3], Mohammad Alrousan [2]

[1] Corresponding Author - Department of Anthropology, Faculty of Archaeology and Anthropology, Yarmouk University, Irbid, Jordan Email: aya9af@yahoo.com.

[2] Department of Anthropology, Faculty of Archaeology and Anthropology, Yarmouk University, Irbid, Jordan

[3] Department of Conservation and Management of Cultural Resources, Faculty of Archaeology and Anthropology, Yarmouk University, Irbid, Jordan

* He is 40 years old. He lives in Southern Shunah, Irbid governorate.

He has a B.A in political science and a masters degree in tourism from Yarmouk University, Jordan.

** A female folk healer who lives in Samer village in northern Jordan.

*** She lives in Hatem village in northern Jordan.

Table 1: Herbal medicines, preparation, usage, method of
administration, timing, and duration of the first
prescribed regimen of the first healer for the couple

Duration      Timing       Method of
                         Administration

Until        Half hour   Soaking
  progress     /day        the feet
  shown

Duration       Preparation          Herbal
                                  Medicines

Until        Ground and mixed   Brassica alba
  progress     together then      seeds (1 kg)
  shown        added to 6L        Viscum album
               of warm water      (100g)

Table 2: Herbal medicines, preparation, usage, method of
administration, timing, and duration of the second
prescribed regimen of the first healer for the infertile
husband

Duration           Timing         Method of         Usage
                                Administration

Three months   In the morning       Orally         A spoon
               and afternoon                     twice a day

Duration           Preparation              Herbal Medicines

Three months   Mixed very well by a     Phoenix sylvestris (100g)
                   wooden spoon             Royal jelly (40g)
                                             Le pollen (50g)
                                      Liquidamber styraciflua (5g)

Table 3: Herbal medicines, preparation, usage, method
of administration, timing, and duration of the third
prescribed regimen of the first healer for the infertile
wife

Duration         Timing           Method of             Usage
                                Administration

Three      In the morning and       Orally         A spoon of the
  months     the afternoon                       mixture twice a day

Duration    Preparation         Herbal Medicines

Three      Mixed together      Viscum album (100g)
  months                    Phoenix sylvretris (150g)
                                  Honey (1000g)

Table 4: Herbal medicines and other materials,
preparation, usage, method of administration,
timing, and duration of the prescribed regimen
for the third healer

Duration       Method of         Usage             Preparation
             Administration

10-15 days   Intra-vaginal    Suppository     All the materials are
                                            mixed together and rolled
                                                in the wool piece

Duration          Herbal Medicines
                and other materials

10-15 days         Nigella sativa
                  Cuminum cyminum
                  Sesamum indicum
                  Cicer arietinum
                     Ervum lens
                       Honey
                 Myristica fragrans
                  Nerium oleander
             Trigonella foenum-graecum
                   Cherry prunus
              A piece of unwashed wool
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Author:Dalou, Ahmad Y. Abu; Alshboul, Ayman; Na'amneh, Mahmoud; Sekhaneh, Wassef A.; Alrousan, Mohammad
Publication:Australian Journal of Herbal Medicine
Article Type:Report
Geographic Code:7JORD
Date:Mar 1, 2015
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