Despite a major commitment to universal healthcare, the government is heavily reliant on external funding and donors.
Ambondro, Madagascar – In Ambondro village in the remote south of Madagascar, it is said that the man whom people seek out to cure their sickness was trained by a ghost. Sixty-year-old Mbola Tohamana is a traditional healer and claims his potions and spells can treat diseases and psychiatric disorders – and even make people fall in love.
He is the sole inhabitant of a wooden house – a rare luxury in a region where many families cram a dozen people into one small living space. Inside, a brown and yellow tapestry emblazoned with depictions of butterflies and vines hangs across a wall. Pinned to it is a 2016 calendar and a weekly timetable. Tools, boxes and a bicycle are neatly stacked around a sizeable bed.
Sitting on the thatched floor, Mbola explains how the knowledge of his craft came to him. “In 1975, I fell sick,” he says. “I had to drink Zebu blood [the blood of the local humped cattle]. Soon after, a ghost came from the sea and taught me everything I know.”
Another 4,860 ghosts followed, Mbola says, and they always sit on his shoulders – even as he speaks. “I take them as gods, they guide me.” They are his counsel in healing and advise him on how to treat people, he says.
He is one of many healers practising his craft in Madagascar, one of the poorest countries in the world, where 80 percent of people live in extreme poverty.
The World Health Organization (WHO) defines traditional healing as “the knowledge, skill, and practices based on the theories, beliefs, and experiences indigenous to different cultures”. Mbola provides a face to an issue present in many developing countries – across Africa an estimated 80 percent of the population use traditional medicine to treat ailments, according to the World Bank.
The community pillar
Mbola’s remedies and solutions are at odds with modern medicine, but he is a pillar of the community in a remote place which feels forgotten by modern institutions owing to the lack of infrastructure and services.
From his small shack in Ambondro, Mbola diagnoses patients and prescribes “treatments”. “There are two kinds of diseases, those that need hospital and those that don’t need hospital,” Mbola says.
“The only thing that I cannot heal is something which has to be done by surgery, but the tools of how I do it change every six months.”
Delivering babies is not something Mbola defines as needing hospitalisation, but for cases of tuberculosis – the leading infectious killer in Madagascar – Mbola gives patients a plant and then sends them to hospital. He also admits that he cannot treat HIV.
He does not restrict his repertoire to physical ailments.
“I also break curses, and cure foolishness,” he says, referring to mental illness. “If someone is walking around with no clothes on and has no shame, he can come to me … The community will still accept him if he comes to me.”
Despite delivering results of varying quality, traditional healers are often integral members of their communities and local culture and heritage. They thrive in places where doctors are few and far between – in Madagascar, only 60 percent of the population has geographic access to health facilities, according to NGOs working in the country.
Those who fall sick in remote communities may have to walk a dozen miles or more to reach medical help. Getting around is tough: Madagascar has some of the least developed infrastructure in the world and the quality of its roads lounge at the bottom of the International Trade Centre’s global rankings at 120th out of 148 countries.
Even if a person is able to complete that journey while sick, they meet with a doctor unknown to them, who represents a healthcare system described as inadequate by officials and aid workers alike. And despite their efforts, the Malagasy healthcare system is extremely weak and heavily reliant on foreign aid. According to those working in the health sector, it faces myriad challenges, including poor management, and maintenance of infrastructure and medicine stocks.
Many of the staff work voluntarily, having not been paid for years, which means that for the sick, just making it to medical help does not guarantee recovery.
Diagnosis and treatment
Still, their diagnostic tests seem more likely to be accurate than those provided by Mbola. Back in his house, he reaches into a drawer, takes out his tools for identifying a patient’s problem and arranges them on the floor.
Below his feet are seeds, mixed in a pile with a collection of coins, both Malagasy Ariary and old francs. Next to the pile lies a deck of playing cards, some bones, a bracelet and some small pieces of wood.
Patients do not have to be present at this diagnosis, Mbola says. He can do it over the phone, sending his treatments across the country. To be diagnosed by the patterns these objects make costs just 200 Malagasy Ariary, which is less than $0.10.
When the treatment is determined, it will cost the patient several thousand Ariary (less than $1.00), depending on the case – though he provides free treatment for children under a year old.
Mbola reaches into a drawer again, and pulls out more small pieces of wood from a plastic bag. These have writing scrawled on them identifying the type of wood needed for a certain treatment.
Some are driftwood, others are from trees. One set is for physical illnesses, another for “foolishness”. Another set can be used to treat animals – this is a lucrative market in the agrarian region, where cattle are more highly valued than cash.
“The wood is made powerful when it is ground by a stone,” Mbola says. “Then it is drunk with water …Handicapped people must take the wood that comes from the sea.”
Mbola also plays Cupid for those unfortunate in love.
“If a man wants to marry someone who is not interested, I give him this,” Mbola says, reaching for a bar of bright pink soap. A special potion is made and doused on the soap, after which Mbola instructs the bachelor to wash with it, and the subject of his love will accept him.
A strategy for collaboration?
The widespread presence of traditional healers is deeply rooted in many parts of the developing world, including Madagascar.
Some traditional healer remedies have been found to be effective. For instance, the World Bank cites a study which indicated that herbal treatments for shingles used by healers in Uganda were effective.
The WHO even has a strategy for working with traditional healers whose practices are more accepted. But regulation, safety, effectiveness and evidence-based use are core to the WHO approach.
Indeed, the organisation describes the risks associated with traditional healers as the “use of poor-quality, adulterated or counterfeit products; unqualified practitioners; incorrect or delayed diagnosis; failure to use effective conventional treatments; exposure to misleading or unreliable information and direct adverse events; side-effects or unwanted treatment interactions.”
In Madagascar, working with some purveyors of such poor medicine is far from ideal. But traditional healers have access to more people, more so than NGOs and medical doctors.
Traditional healers are held in high regard among some medical professionals in Madagascar, as well. Health minister, Professor Mamy Andriamananarivo – a trained surgeon – told Al Jazeera of his appreciation of traditional healers. Although he said that some were “fakes” who were just in it for the money, he also said some were good at their craft.
“I saw people cured by traditional healers,” he said in an interview. “I saw a broken foot treated with plants. I also saw someone who had been burned cured by saliva. This happened just seven kilometres from Antananarivo [Madagascar’s capital],” the health minister said.
Andriamananarivo said he wants to “do more to work with established, good traditional healers – those who really have a gift”. He wants to give licences to “real” traditional healers, but did not say how he planned to implement regulations over what is, by its very nature, a hard-to-control business.
While not endorsing the practices, some in the international health sector believe that engagement, rather than confrontation with traditional healers, should be attempted in order to implement health policies.
Back in Ambondro, Dr Simeon Ananama, a visiting nutritionist from Unicef, says he is cautiously willing to work with traditional healers on health issues – though collaboration efforts have proved difficult.
For any engagement to work, he says, they must be organised into an association. However, when asked if he would be willing to become involved in this, Mbola refused. It would be “impossible,” he told Dr Ananama.
Mbola opposes the prospect of collaborating with other traditional healers in the locality for the purposes of improving healthcare because they are his competitors and could threaten his income.