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Characteristics of visitors to traditional healers in central Sudan

I.M. Ahmed, J.J. Bremer, M.M.E. Magzoub and A.M.H. Nouri

ABSTRACT Traditional healing is widespread in Sudan and traditional healers are well respected by the community. This study aimed to assess the characteristics of visitors attending traditional healers, the reasons for visits, the frequency of visits, satisfaction with visits and advantages and disadvantages of visits. The results showed that children under ten years did not take part in visits; most of the visitors were between 21 and 40 years (61%) and were women (62%). Visitors were less educated compared to the general population in the area. The main reasons given for attending traditional healers were treatment (60%) and blessing (26%). Visitors did not mention any disadvantages to visiting traditional healers.

Caractéristiques des personnes qui se rendent en consultation chez les guérisseurs traditionnels dans la partie centrale du Soudan

Resume La médecine traditionnelle est répandue au Soudan et les guérisseurs traditionnels sont très respectés dans la communauté. Cette étude visait à évaluer les caractéristiques des personnes qui s'adressent aux guérisseurs traditionnels, les motifs de la consultation, la fréquence des consultations, la satisfaction des personnes en ce qui concerne ces consultations, et leurs avantages et inconvénients. Les résultats ont montré que les enfants de moins de dix ans ne prennent pas part aux consultations; la majorité des personnes qui consultent sont âgées de 21 à 40 ans (61%) et sont des femmes (62%). Ces personnes ont un niveau d'instruction moins élevé que celui de la population générale de la région. Les raisons principales mentionnées pour la consultation des guérisseurs traditionnels étaient le traitement (60%) et la protection (26%). Les personnes qui consultent n'ont pas mentionné d'inconvénients dans le fait de se rendre chez des guérisseurs traditionnels.

Introduction

A traditional healer is defined as an educated or lay person who claims an ability or a healing power to cure ailments, or a particular skill to treat specific types of complaints or afflictions and who might have gained a reputation in his own community or elsewhere. They may base their powers or practice on religion, the supernatural, experience, apprenticeship or family heritage. Traditional healers may be males or females and are usually mature.

In developing countries, the functions of traditional healers are controversial, although the practice of such healers is widespread and well accepted by a large sector of the community. There are differences in the classifications and methods applied, in the social position of the healer and in the characteristics of persons attending. Religious healers have a much wider range of functions. They may be in a position to influence attitudes in important fields of daily life, including health care, for example the management of mental illness and somatic, obstetric and surgical disorders, especially fractures. They can also act as family counsellors in critical life events such as building a house, marriage, naming a newborn, and may have both judicial and religious functions. They often act as an agent between the physical and spiritual worlds.

In Sudan, traditional medicine is closely related to religion and other powerful beliefs. There are many traditional healers throughout the country but they are mainly found in the central states, especially in the Gezira area. Sudan, with an area of one million square miles, has a diversity of cultures within its population of 25 million inhabitants, which is reflected in the language, customs, traditions and religious beliefs.

One of the inherited traditions of Sudanese people in need of help is to seek traditional healers for different purposes. This tradition came from Sufi schools. Islamic conversion infiltrated Sudan from the north at the beginning of the 17th century through merchants and Arab immigrants who came from Egypt, the Hejaz and Morocco [1]. Islamic mystics (Sufi) aimed to spread and strengthen the principles of Islamic beliefs by advising Muslims to follow certain moral and psychological methods in simple ways, such as repeating the Lord's name (zikr) in combination with the five prescribed prayers. Followers visit the religious leader (sheikh) at Sufi schools for the purpose of religious education, advice and treatment.

The degree of influence of the sheikhs depends on their religious morals and piety (wara'), asceticism (zuhd), miracle working (karamat) and spiritual power. People believe that disobeying the sheikh brings damnation on the followers and their families. They believe in the sheikh's blessings and regard him as a mediator between the follower as a slave and the Lord [1]. They also believe that the sheikh, whether dead or alive, is capable of rescuing them and pleading on their behalf for help and release from illness. Thus the sheikhs, in the people's eyes, are true representatives of spiritual power and a source of good for the poor and downtrodden.

Generally, traditional healing in Sudan can be divided into two distinct groups:

• Religious healers influenced by Islamic and Arab culture, such as traditional Koranic healers and Sufi healers.

• Nonreligious healers influenced by African culture, such as practitioners zar, talasim and kogour.

Religious healers

Religious healers are mainly influenced by Islamic Sufis who first came to teach people the principles of Islam. Later, they became actively involved in traditional healing. The traditional methods used by them can be divided further into two subclassifications. The first group uses only Koranic treatment, derived from certain verses. This involves reading and listening to the Koran with the active participation of the patient [2]. The success of treatment depends on the reliability of the healer and the degree of his belief, in addition to the conviction of the patient and his belief in the Koran as a source of treatment. The second uses a combination of both Koran and talasim. The type of talasim used are mainly squares filled with symbolic letters which have a hidden spiritual dimension conceived only by the sheikhs as pious, holy men. They contain the 99 attributes (names) of God and some other inherited words from ancient divine books. Healers in this subgroup are influential decision-makers at the individual, family and community level. They are respected not only by their followers, but also by government officials and politicians.

Nonreligious healers

The nonreligious healers are mainly influenced by African culture and such healing has been widespread in Africa for centuries. On the basis of the treatment methods they use, they can be subdivided into the following categories: kogour, zar and pure talasim; each practice dominates a certain part of the country.

Kogour is a typical African practice found only in the south of Sudan where African culture dominates. It is used by healers who claim to have supernatural powers; it deals with souls in the belief that these souls affect the body. Such healers use their power to cure disease and to solve other problems, such as the control of rain [3].

Zar came to Sudan from Ethiopia and is based on the assumption that supernatural agents or spirits possess a person and may cause him or her some physical and psychological disorders. The zar concept of possession is based on the idea that the spirit makes certain demands that should be fulfilled by the patient or his relatives; otherwise this spirit may cause trouble for all of them [4]. Zar is the dominance of the evil soul over the human being with the intention of hurting the person. Sudanese who believe in zar go to sheikhs to solve the problems caused by such a possession. Zar is common not only in Sudan, but also in other countries such as Ethiopia, Somalia and Djibouti and some parts of West Africa. In Sudan, zar is common among Muslims as well as Christians. Although it is widespread in some parts of northern and eastern Sudan, it is rare in southern and western parts, probably because in these areas there are alternative ritual ceremonies involving similar beliefs. The sheikhs of zar are usually women. They are responsible for diagnosing and identifying the spirits and their demands and preparing and directing what are called zar parties. These parties use very loud music, vigorous dance and songs with special rhythms. They serve both diagnostic and therapeutic objectives.

The institutions of traditional healers are established in the community of Sudan. Whilst they provide some benefits, they also have deleterious effects. Visitors attending sheikhs have different characteristics, different reasons for their visits and different levels of belief. The study of these characteristics and reasons is important for assessing the effect and role of traditional healers and the levels of acceptance by the community. Such knowledge is also necessary in order to identify and develop means to encourage collaboration of all health care workers with the sheikhs so as to make use of the benefits they offer and avoid their harmful practices. This is particularly needed for programmes of preventive mental health education.

The objectives of this study were to:

• describe the demographic characteristics of visitors to traditional healers;

• study the reasons for visiting traditional healers;

• study the attitudes and beliefs of the visitors towards traditional healers.

Methodology

Four centres representing different categories of traditional healing were included in the study. After reviewing the available literature, the following research techniques were thought to be appropriate to obtain the relevant data: a quota sample, a structured interview and focus group discussion. On the assumption that the characteristics of the visitors are independent of the particular day of the visit, a quota sample was considered to be adequate and the selected day was chosen randomly.

In order to devise an appropriate structured interview, a pilot survey was conducted. About 20 questions were tested and the preliminary results were evaluated as to validity. The structured interview was subsequently modified and reorganized in accordance with the pilot study findings. It was designed as a precoded scheme, which also included open-ended questions, and it was translated into colloquial Arabic. Data were collected by five interviewers, who were well trained in the method. The final structured interview was completed for all samples and no questionnaire had to be discarded.

The structured interview consisted of three main parts. The first part addressed the visitors' personal characteristics, namely, age, sex, education, marital status, occupation and residency. The second part was related to the previous behaviour of the visitors concerning traditional healers, the reasons for past and current visits and the frequency of these visits and accessibility of the sheikhs. These variables contribute to the understanding of family ideas about traditional healers and the effect of kinship and upbringing on the beliefs of family members. The third part dealt with the evaluation of traditional healing by the visitors.

The studied population represented visitors to traditional healers who use the following three different kinds of healing: 1) talasim and Koran, 2) zar and 3) Koran. A random sample was selected from the visitors of each category according to the following system; 30 visitors from the zar category were interviewed on Wednesday 17 January 1996 and 26 were selected from the Koran category on Sunday 21 January 1996. With regard to the Koran and talasim group, two samples were selected from two different sects (Ashraf and Gadria). A sample of 35 visitors was selected from the Gadria centre at Tayba and a sample of 43 visitors was selected from the Ashraf centre at Wad Elobeid on Friday 19 January 1996.

Data were coded and analysed by computer using SPSS. Two statistical approaches were used; descriptive and analytical. The descriptive approach analysed frequency distribution for the different variables taking each variable independently. The analytical approach used the chi-squared (c²) test for independence between the variables studied and differences in visitors' characteristics. The distribution of these characteristics were compared with their distribution in the total population of the area in question, i.e. the centre of Sudan.

Results

The following results are based on the descriptive data of 134 randomly selected visitors to four healing centres in the centre of Sudan. The results are described on the basis of 16 variables.

None of the visitors was under ten years of age; most (61%) were between 21 and 40 years, compared with a distribution in the total population in the area of 30% for the same age group. Regarding sex, 62% were females and 38% were males, compared with a sex ratio of 50% in the general population. With regard to the educational level of the visitors, 52(39%) were illiterate, 8% had attended khalwa (Koranic school), 25% had had primary-school education (8 years), 15% had had secondary-school education (11 years) and only 13% had higher education (more than 11 years). The level of education was significantly lower than for the population of Gezira because of the higher percentage of females in the sample. Concerning the occupation of the visitors, 39% were housewives, 20% were labourers, 12% were employees, 5% were professionals, 10% were farmers, 1% were unemployed and 13% were not indicated. With regard to marital status, 58% were married (48% for the general population in Gezira), 30% were single, 5% were divorced and 4% were widowed. In all, 76 (61%) of the visitors lived in rural areas, whereas 39% lived in urban areas, compared to a 70% rural population in Gezira.

The reasons given by visitors for their visits showed that 80 (60%) came to the traditional healers for treatment, 26% came for a blessing, 6% came for consultation, 4% came for education and 4% came for other reasons. Many visitors 58 (43%) were brought to the traditional healers by their families, 25% came of their own accord, 16% were referred by other sheikhs and 7% came through other ways. Sixty-one per cent (61%) of the visitors had not visited other healers; 39% had. It was found that 37% of the visitors had been visiting the healer for more than a month, 35% for a year and 24% since childhood (no data for 6 cases). With regard to frequency of visits, 61% had visited the healer more than ten times. Regarding the opinions of the visitors about their visits to traditional healers, 86% thought the visits were useful and 14% thought they were either useless or could not decide. The visitors thought that other people went to healers because they are problem-solvers (45%) and because they believe in them (42%); 7% of the visitors thought that people went out of habit, while 7% mentioned other reasons. Sixty-one per cent (61%)of the visitors were satisfied with the visit during the time of the interview; only 5% were not satisfied while 34% said they did not know. When asked of the benefits of such visits, 71% of the visitors said treatment, 23% said blessing and 6% mentioned education. None of visitors felt there were any disadvantages to their visits to traditional healers.

Discussion

The results show that no children under 10 years of age visited traditional healers. This could be explained by the fact that children are less prone to psychological stress. The same is true for attendance to mental health professionals. The finding that 61% of visitors were between 21 and 40 years of age may be an indication that this age group is more at risk of psychological problems. In addition, this age group is more mobile and can travel to the healers. About 62% of the visitors were females, which might indicate that women are more susceptible to mental problems because of the low social status of women in general in developing countries and also because of their poor literacy rate. Some 47% of the visitors were illiterate or had received Koranic education and 25% had primary-school education. This might be due to the fact that the majority of the visitors were women from rural areas. Most of the visitors (58%) were married; this might again be due to the high percentage of women among the visitors in a country where women marry young. Most of the visitors (61%) were from rural areas, which can be explained by the fact that the two biggest centres in the study are located in rural areas.

The main reason for the visits was for treatment. This could be because in rural areas alternative modern health services are lacking or do not function properly, in addition to the low cost and accessibility of traditional healers and the strong belief of visitors in the curative powers of such healers. The second reason for visiting traditional healers was for blessing. This comes from the historical role of Sufi schools in Sudan as a source of blessing. Few visits were made for educational purposes despite the fact that the primary goal of Sufi centres is education. This might be due to the spread of a European type of education in the centre of Sudan in all villages.

Most of the visitors were brought to the sheikhs by their families, which gives an indication of the deeply-rooted belief among families of the role and function of traditional healers. The majority of visitors visited only one sheikh in whom they believed and who, in most instances, had been the family sheikh for some time.

The majority of the visitors paid regular visits to traditional healers, continuing for more than a year and, in many instances, since childhood. This is related to the reason for the visits which was mostly for treatment and blessing both of which necessitate repeated, regular visits. In fact, most of the visitors had made more than ten visits. The majority of the visitors had a positive opinion of the healers; only a few felt the visits were not useful.

Traditional healers are generally viewed as problem-solvers of individual health and social problems, such as marriage and social conflicts. Traditional healers are also perceived by visitors as community leaders with a range of abilities and skills. The majority of the visitors were satisfied with the results of their visits. Satisfaction is an indicator of the success of meeting the demands of the visitors and responding to the purpose of the visit. It is interesting to note that none of the visitors considered there were any disadvantages to these visits. However, based on the observations of medical students during community-based field training, there are harmful practices of traditional healers which affect health, such as slashing and chaining and fasting of patients [5].

The results of the study highlight the importance of collaboration with traditional healers, who are well accepted by the community and accessible to the people, in addition to the strong belief in them. Many countries have made efforts to make use of traditional healers in increasing the coverage of essential primary health care. Hoff reviewed 17 projects in which traditional healers were trained to carry out one or more primary health care activities in the community [6]. An atmosphere of understanding, trust and respect should be created between modern health workers, traditional healers and the communities they serve. In Sudan, traditional birth attendants were trained and utilized in a family planning programme. They succeeded in increasing the use of contraceptives from 13% to 21% [7]. The same approach might be utilized to facilitate the role of traditional healers in improving mental health services. After visiting traditional healing centres, medical students from Gezira University changed their attitudes towards them and they now consider collaboration with traditional healers would be useful [5].

References

1. Fadol Y. Tabagat Wad Daifalla. [Reviews by Wad Daifalla]. Khartoum, Sudan, Khartoum University Press, 1975 (In Arabic).

2. Bali W. Elsarim elbattar fi eltsadi llisahra walashrar. [The final word against magicians and witches]. Jeddah, Saudi Arabia, Elsahaba Library Press, 1992 (In Arabic).

3. Elsorayi A. Ten years in the south of Sudan. Kuwait, Kuwait University Press, 1985 (In Arabic).

4. Mohammed F. El-zar el-sudani. A survey of attitudes, beliefs and social perspective towards zar in the Sudan [Masters thesis]. Khartoum, Sudan, University of Khartoum, 1989.

5. Elgaili D, Hammad E, Magzoub MM. The teaching of mental health in a community-based medical school. Education for health, 1996, 9(3):353-8.

6. Hoff W. Traditional healers and community health. World health forum, 1992, 13:182-7.

7. El-Tom AR et al. Family planning in the Sudan: a pilot project success story. World health forum, 1989, 10: 333-43.