Spirituality and biomedicine in South Africa: Finding our common ground

Categories: Care.

Last week I had a conversation with a friend and colleague of mine who works in a local clinic, providing care and anti-retrovirals to HIV infected patients. An extremely good clinician, she was expressing her frustration when patients who are just starting to become well again, ‘disappear’ into the care of a Traditional Healer and stop taking their ARVs, only to reappear months later in the throes of end-stage HIV. She moved on to talk about other patients who, despite being very poor, will go into debt to buy a goat or a cow to sacrifice to the ancestors in order to become well again. She was nearly tearing her hair out at what she saw as opportunities being lost and resources being wasted right in front of her. She said, “Why can’t we keep the spiritual stuff out of this, and just get people better again?!”

In Palliative Care, we understand that we can’t – and wouldn’t want to.  But spiritual care in Africa is a complex and tangled issue.

With colonization came Western medicine and Christianity, and for centuries these have been uncomfortable bed-fellows with the predominant local, cultural beliefs. Although in the West, religion and health care have been separated, in the Traditional African belief system, health and spirituality are intimately linked. But Western medicine and Traditional African health care operate from fundamentally differing philosophies.

Traditional African health care has been described as ‘personalistic’ – it is based on the belief that all misfortune, disease included, is explained in the same way; illness, religion and magic are inseparable; the most powerful healers have supernatural and magical powers and their primary role is diagnostic. There is a significant emphasis on restoring damaged relationships with the Ancestors (those clan members who have ‘gone before’ and who continue to have authority and influence on the lives of the living).  In contrast, western Biomedicine has been described as ‘naturalistic’ – it is based on the belief that disease causality has nothing to do with other misfortune; that religion and magic are largely unrelated to illness; that healers lack supernatural or magical powers and their primary role is therapeutic.

These differing approaches have contributed significantly to the misunderstanding that exists between the two systems – at times the approaches can seem worlds apart. When a patient stops his TB treatment to return to the place of his Ancestors and sacrifice an animal in order to appease his Ancestors, bio-medically trained carers (both black and white) often cannot understand the radically different rationale underpinning the decision, and are left open-mouthed or angry. 

In South Africa, the misunderstanding has been compounded by the political history of the country. The discrimination and racism of the Apartheid system served to increase suspicion towards traditional African health care systems, and discouraged communication between the systems, increasing the rift between them. 

Although the WHO estimates that 80% of African patients make use of both health systems, those of us providing care have very little or no idea of the rationale behind often conflicting advice from the ‘other system’. It leads to patients’ reluctance to be open about using both systems; causing an impediment to an honest and trusting relationship between patient and practitioner. It can cause a sense of misunderstanding and minimization by patients who are made to feel guilty for accessing the other system. Bio-medical practitioners often ask for the patient to abandon traditional health practices and vice versa.  It is easy to understand why patients are often confused about ‘what the right thing is to do’. Ongoing misunderstandings can cause an obstruction to holistic care in the bio-medical setting if spiritual and cultural needs are ignored.

It is in this context that many patients are battling to regain their health, restore relationships and find meaning in their struggle. The assimilation of Christianity into traditional African belief systems, which are often both practiced simultaneously, can add another dimension of complexity. Providing spiritual care in an African environment necessitates that we explore and try to understand the rationales beneath our patients’ needs and decisions.  It shouldn’t scare us off – it should just remind us that often we can be most helpful to our patients when we know that we don’t know.  It reminds us not to assume what our patients need – rather to ask. It reminds us not to project what should be important – rather to let our patients lead. And it encourages us, when we appear to be worlds apart, to look for those deeper elements of humanity that we share – the need for meaning, the need for connection and relationship, and a sense of autonomy and dignity. The more we look beneath our differences, the more we find our common ground. And this, I believe, is the only place to start if we want to provide high quality palliative care.

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