Sociocultural Aspects of Tuberculosis Control in Ethiopia Author(s): Norbert L.

Vecchiato Reviewed work(s): Source: Medical Anthropology Quarterly, New Series, Vol. 11, No. 2, Knowledge and Practice in International Health (Jun., 1997), pp. 183-201 Published by: Wiley-Blackwell on behalf of the American Anthropological Association Stable URL: http://www.jstor.org/stable/649142 . Accessed: 25/09/2012 03:23
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NORBERTL. VECCHIATO Department of Anthropology University of Washington, Seattle

Sociocultural Aspects of Tuberculosis Control in Ethiopia

This article examines ethnomedical knowledge and practices related to tuberculosis conceptualization and management in a rural southern Ethiopian community. An adult health-status survey, administered to 217 adults selected through quota sampling procedures, investigated prevailing nosological structures. Additionally, disease-enhancing behaviors were identified through qualitative-research methods. The findings show that while symptomatological concepts coincide with biomedicine, the local etiological model postulates empirically based causational factors unrelated to tubercle bacilli. Therapeutic preference hinges on the utilization of ethnobotanical remedies and their expected emetic effects. The relevance of tuberculosis-related ethnomedical knowledge and management practices is discussed in relation to primary health care and diseasecontrol programs in Ethiopia. It is recommended that health-education interventions, illustrating the nature and transmission avenues of tuberculosis and the effects of biomedical therapies, precede and/or accompany vaccination campaigns or chemotherapy. Teaching materials should valorize existing ethnomedical notions that emphasize contagion as an avenue of disease transmission, and the importance of nutritional adequacy in fighting the disease. [tuberculosis, ethnomedical knowledge, primary health care, Ethiopia]

ittle is known about the role that culture plays in the control and spread of tuberculosis (TB). This issue is attracting renewed attention as a major international health problem because of an increase in TB in both developing and industrialized countries. Globally about 1,700 million people are, or have been, infected with Mycobacterium tuberculosis. Of the 8 million new cases reported in 1990, however, it is estimated that 95 percent, and 99 percent of the 2.9 million deaths, occurred in developing countries (Kochi 1991). In these regions the disease affects particularly the most economically productive segment of the population,
Medical AnthropologyQuarterly11(2):183-201. Copyright? 1997 AmericanAnthropologicalAssociation. 183

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those in the 15-59 age group;its prevalenceis also aggravated by HIV-infection, malnutrition, low socioeconomic conditions, and inadequatehealth services (Broekmans1991; Murrayet al. 1990; Nkhomaet al. 1987). In the last threedecades, the WorldHealth Organization (WHO)-sponsored nationalcontrolmeasuresin developing countriesthat revolved primarilyaround threelong-termstrategies,namely (1) improvementin socioeconomicconditions, of and (3) BCG vaccination.The implementation (2) case-findingand treatment, these strategies,however, resulted in virtuallyno change in the epidemiological situation, given the slow pace of socioeconomic development,patients' lack of compliance with prescribedregimens, drug resistance, and limited efficacy of and Rossignol 1993; Kopanoffet al. 1992; Styblo BCG vaccination(Bonnlaender while of short-course and Rouillon 1991). The recentintroduction chemotherapy, moreefficacious thanpastlong-termregimens,is likewise beset by limitationsdue to costs, logistic problems,andpatients'lack of compliancewhen implementedon a large scale (Kochi 1991). The inabilityto overcomeby biomedicalmeansan othdisease highlightsthe urgentneed to complement erwise preventable andtreatable oriented controlmethodswith alternativestrategies presentchemotherapeutically that emphasizehealtheducationand active communityparticipation throughprimary health care programs grounded in relevant sociocultural environments (Rieder 1992; Saunderson1995). In Ethiopia,tuberculosisis a serious health problem.' Statisticsreleasedby the EthiopianMinistryof Health show that pulmonarytuberculosispersists as a majorhealth threatand as the main cause of hospital deaths;it rankedthird(6.1 percent)for malesandsixth (3.2 percent)for females amongthe top 15 diseases diagnosed in 1988-89 (MOH 1991). Researchon tuberculosisin Ethiopiahas dealt with the clinical (Zerihun and Esscher 1984), epidemiological (Azbite 1992; Ghidey and Habte 1983; Hodes and Azbite 1993:279-281; Hodes and Kloos 1988), and bacteriological(Gebre et al. 1995; Lemma et al. 1989) aspects of the behaviorand disease, but has neglected the roles played by culturallydetermined disease conceptsin the persistenceof the disease andin lack of complitraditional "false beliefs" and transmission-fostering Tuberculosis-related ance to treatment. behaviors,includingmass sharingof drinkingvessels at funerarygatheringsand in the 1960s (Schalcommunalwater-pipesmoking,were reportedby researchers ler andKuls 1972). In addition,varioussocial andculturalfactorswere recognized as responsiblefor the lack of compliancewith prescribedregimensamongpatients defaultingfrom tuberculosistreatment,including social problems,feeling of improvement, inadequateknowledge, low educational level, nearer distance, and negative attitudetowardthe TB Centre(Demissie andKebede 1994). Recognition of tuberculosiscompels closer exof the role thatcultureplays in the transmission aminationof the ethnomedicaldimensionsof the disease. This articlepresentssociomedicaldatarelatedto tuberculosisknowledge and management amongthe rural Sidama of southernEthiopia and analyzes their concepts and practices in referenceto the persistenceof tuberculosisin the region.I arguethata fundamental of the Sidamaculturalmodel of tuberculosisis essentialfor an efunderstanding to of a community-grounded andthe implementation fective intervention approach disease control.

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Ethnomedical Knowledge, Health Culture, and Tuberculosis In pointingto the repeatedfailureof disease-control measuresbasedsolely on have emphasizedthe importance biomedicalparameters, medical anthropologists withinthe framework of understanding patternsof medical knowledge articulated of culturallyembeddedethnomedicalsystems (BrownandInhorn1990; Dunnand Janes 1986; Rubel and Hass 1990). Anthropological researchhas identifiedsome that systems of ethnomedicalknowledge display. First, ethof the characteristics nomedical systems, far from being wholly homogenous,are characterized by intracultural variationin illness interpretation and management(Garro1986). This means thatlocal medicalknowledge does not consist of a normativebody of medical axioms universallyand homogeneouslyfollowed by the membersof a society. of the nosological contextualization of an illness occurrence Rather,the structuring is shapedby individualidiosyncracies,social expectations,economic constraints, and ecological determinants.Second, local medical knowledge is not shared equally among all membersof a community.A distinctionshould be recognized, for example, between curers and noncurers.In most culturaltraditions,professional curers are depositories of a more extensive body of traditionalmedical knowledge than laymen (Finkler 1984). Third, systems of traditionalmedical by the same dynamknowledge are not immutable;they are, rather,characterized ics of continuity and change as any other cultural subsystem. Patternsof ethnomedical knowledge are thus modified by the constant incorporationof new health-related ideas and practices,includingthe integration of selected featuresof biomedicine into traditionalcuring (Barnes-Dean 1986; Finerman 1989; Good 1987; Iyun and Tomson 1996; Yoder 1981). Systems of ethnomedicalknowledge form an integralpartof the "healthculture"of health-seekers and shapetheirillness meaning,behaviors,and therapeutic choices. Rubel and Garrodefined "healthculture"as "theinformationand understandingthatpeople have learnedfrom family, friends,and neighborsas to the natureof a healthproblem,its cause, and its implications" (1992:627). The notion of health culture usefully emphasizes the existence of complex patterns of ethdecinomedicalknowledge and illness management,which influence therapeutic sion making in pluralisticmedical settings and compliancewith prescribedregimens. In the case of tuberculosiscontrol,it has become increasinglyclear thatnonmicrobial factors must be included in case-managementstrategies (Jones and Moon 1987:183-185; True 1990:300). It is thus of fundamentalimportanceto but also how a patient's identifynot only socioeconomic correlatesof tuberculosis, healthcultureinfluencesthe onset, course, and outcome of the disease. In particuof "patient lar,the identificationof the socioculturaldeterminants compliance"has have provedcriticalin the success or failureof tuberculosistherapies.Researchers ascertainedthat factors such as health beliefs, etiologies, perceptionsof severity, and differentialdegree of medical knowledge are fundamental variablesthat play crucial roles in patients' compliance, or lack thereof (Barnhoomand Adriaanse 1992; Grangeand Festenstein 1993; Liefooghe et al. 1995; Menzies et al. 1993; Van Der Werf et al. 1990; Westaway 1990; Westawayand Wessie 1994). The notion of health culture should encompass also the vast arrayof pythotherapeutic practicesutilized by the great majorityof patientsin developing countries(Etkin

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herbalremediesagainsttuber1986; Kokwaro1976; Sofowora1982). Traditional culosis areoften takenalongsidebiomedicallyprescribed drugs,possibly influencing the efficacy of the latter.Awarenessof the logic and modalitiesunderlyingalternativeperceptionsof tuberculosisand therapieson the partof health planners andmedical personnelmay facilitatecommunication with, and securecompliance by, patientsin pluralisticmedicalsettings. Cultural Setting The researchwas carriedout primarilyat Dongora,a ruralcommunityof approximately11,000 people located in the mountainoussection of the Rift Valley near Aletta Wondo, approximately320 kilometers south of Addis Ababa. The of Cushitic-speaking Sidama.These comprise populationconsists predominantly approximately1.5 million people and constitutethe sixth-largestethnic group in of 6793 squarekilometers Ethiopia(Mammo1992). The Sidamaoccupy a territory at an elevation rangingfrom 1,400-3,000 metersabove sea level (Government of into the Ethiopia 1986). Although they have been incorporated administratively modem Ethiopianstate since the 1890s, the Sidamamaintaintheir traditional sowhich includes the organizationof society into a numberof patrilcial structure, ineal, exogamous clans intersectedby an age-class system (Hamer 1987). The in thatch-roofed hutsgroupedin hamletsof agnatic populationlives predominantly kin. Subsistence is based on a mixed farmingand cattle-raisingeconomy. Their staple food consists of a porridgederived from the "false banana"plant (Ensete edulis F.), supplemented by maize, legumes, coffee, and dairyproducts. The Cultural Construction of Health As for otherEthiopiangroups(Bishaw 1991; Vecchiato 1993a, 1994), the Siin terms of an equilibrium,which is dama conceptualizehealth (keranchimma) maintained through watchfulness over one's physiological cycles (digestion, evacuation,"blood level" maintenance),guardedinteractionwith naturalforces (weather,climate, fauna,and flora),qualityof personalacts (controlof emotions, moderationin drinkingandcommonplaceactivities),harmonywith fellow human of and magical controlover subeings (quarrelavoidance),andritualpropitiation forces (God, spirits,evil eye, magic, and sorcery). pernatural of A primaryareaof Sidamahealthconcernfocuses on securingthe regularity body processes, which is thoughtto rely primarilyon dietarysoundnessby eating to food in dishes. The importanceattributed "good"foods and avoidingunfamiliar the Sidamacultureis basedon two main factors.First,eating familiarfood is conto roundworms(hamasho)losideredcrucialfor the digestive activitiesattributed food is catedin the humanintestines(Vecchiatoin press).Second, eating abundant consideredessential for the formationof good qualityblood and the maintenance of adequateblood "levels." Conversely, lack of decent nutritionis believed to cause a decreasein blood quantity,a condition linked to a variety of ailmentsincluding tuberculosis. A common Sidama methodfor determiningwhether the blood level in the body is normalor low consists of examining the blood vessels of the handsor of otherpartsof the body. If they appear enlarged,it is inferredthatthe body is not re-

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ceiving adequatefood and thatthe heartproducesan insufficientsupply of blood. If blood levels are deemed to be low, a combinationof two complementary remedial strategiesmay be implemented: (1) increasingthe food intake,and (2) increasing the blood quantity.The former is obtainedby consumingmeals abundantin meat, butter,and milk; the latteris carriedout by occasionallydrinkingthe blood of domesticanimalsbutcheredfor eating purposes. Tuberculosis Morbidity Rates Epidemiologicaldatafrom large-scaletuberculinsurveysto reveal the extent of infectionin the entirepopulationare lacking for the SidamaDistrict.However, morbidityrates obtained from the records of the Dongora Catholic Clinic show that 3.4 percent( n = 350) of all new patients( n = 8312) were tuberculin-positive in 1991-92, makingtuberculosisthe tenthmost frequently diagnoseddisease at the clinic. Becauseof widespreadunderreporting and universalrelianceon traditional medicine, the numberof tuberculosisoutpatientsdiagnosed at Dongora clinic is probablyonly a fractionof all actualinfectioncases. Research Methods The main researchobjective was to study the socioculturaldeterminants of Sidama therapeutic behavior in a pluralisticmedical setting. In structured openended interviews carried out with traditionalmedical specialists, patients, and other informants,prevailing illness causation theories, ethnophysiologicalconcepts, and indigenousperspectiveson tuberculosisand otherdiseases were unraveled. Managementof predominantinfectious diseases, including tuberculosis, medicine was also investigated.Ethnomedical throughthe utilizationof traditional techniques,and illness behaviorwere recordedthroughparpractices,therapeutic ticipant-observation. behaviorand traditional medical knowlAdditionally,patternsof therapeutic were identified an adult health-status edge through survey. Following several monthsof ethnographic fieldwork,the Adult HealthStatusQuestionnaire (AHSQ) was devised to ascertainquantitativepatternsof Sidamaillness concepts and behavior.Writtenin Sidama with the cooperationof researchassistants,it was pretested on a small sample and subsequentlyadministered to 217 adults, 52 percent males (n = 113) and 48 percentfemales (n = 104) by trainedSidama-speaking interviewers.Participants were selected throughnonrandom quota sampling proceof adultrespondentsin termsof dures,which aimedat securingan even proportion sex and age. The age of respondentsrangedfrom 16 to 76 years, with an average had received age of 46. The majority(52.1 percent)were illiterate.The remainder some elementaryeducationin governmentand mission schools. Only two particifrom high school. The difficult political situationin Ethiopia pantshad graduated at the time of the fieldworkmade it unfeasibleto conducta large-scaleruralsurvey using randomsamplingtechniques.Thus, while the limitationsof the sample may preclude broad generalizations, the findings can be regarded as indicative of nosological andtherapeutic patternsof tuberculosismanagement prevailingin the region.

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Traditional Perspectives on Tuberculosis The AHSQ schedulehad two sections. The first section containeda series of questions to establish whetheror not respondentshad been sick in the previous three monthsand, if so, the type of therapeutic action they had taken.The second section askedquestionsthatattempted to captureinterviewees'knowledge andbeliefs concerningfour diseases thatare predominant in the region, namely malaria, tuberculosis,hepatitis,and leprosy. The questionnaireschedule and complete results of the survey are reportedelsewhere (Vecchiato 1985, 1991). Responses to questions illustratingprevailingSidamaperceptionsof tuberculosisare presented here. In answerto the firstquestion,"Whatdo you considerthe top 10 most serious diseases afflicting the community?" respondentsreportedthat tuberculosis,while not the most prevalent,was the most feareddisease. The reasonthe Sidamafeartuberculosismay be linked to the long-termdebilitationand discomfortit produces in contrastto other short-term infectiousdiseases, and to the threatit poses to the economic stabilityand healthof the entirefamily. conEthnographic investigationsandopen-endedinterviewswith informants firmedthatwhile no social stigmais attachedto tuberculosis,the disease is a highly fearedevent. The Sidamafearof tuberculosisis emphasizedby use of the wordfor one of the partiesmay tuberculosis,balamo,as an insultanda curse.In arguments, resortto a curse such as "Balamuamado'he"[May you be strickenwith tuberculosis!] to express his/her anger at an opponent.The fear of tuberculosisis also reflected in avoidanceof the word balamo. In the belief that if one says the disease name, he/she will contractthe ailment,older Sidama refrainfrom using the term and tend to replaceit with the Amharictermfor tuberculosis,neqarsa, or with the Sidamo word butamo.The termbuamo is possibly a cognate of butimma,which means poverty,thuspossibly indicatingthe economic impoverishment thatafflicts a household stricken by tuberculosis,particularlywhen the breadwinneris affected. To the second question, "Whatare the symptoms of tuberculosis?" respondents pointed to prolongedheavy coughing (33.4 percent),pains in the thoracic area(20.9 percent),asthenia(6.8 percent),and hemoptysis(4.6 percent)as important signs of the disease (Table 1). The "Don't Know"answersconstituted5 percent of the total. This relativelylow figure atteststo the familiarityof the Sidama with tuberculosisdue to its high rateof prevalencein the region. Etiologicalconcepts pertainingto tuberculosiswere also asked of interviewees (Table2). To the question"Whatdo you considerthe maincause of tuberculosis?" the debilitationfrom excessive work (33.4 percent)was mentionedmost frequently. According to Sidama ethnomedical tenets, overworking, excessive exposure to the sun, or carryingheavy loads are thoughtto be highly dangerous and hazardousactivities that can lead to tuberculosisand other diseases. In line with the prevailingnotion thatexcesses in commonplaceactivitiescan be hazardous to one's health,5.8 percentof respondentsalso mentionedthe termranta as a possible cause of tuberculosis.Rantarefers to a syndromecharacterized by chest and back pains, fatigue, and breathingdifficulties, and is attributed to excessive work andcarryingheavy loads (Vecchiato 1993a). It is involved in the etiology of

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TABLE 1 tuberculosis Sidama symptomatology (n =217). Source:adult health- status ofpulmonary survey. Category Cough Chest pain Asthenia Otherpain Hemoptysis Sweating Dyspnea Other Don't know Total Frequency 166 104 34 33 23 19 11 96 11 497 Responses (%) 33.4 20.9 6.8 6.6 4.6 3.8 2.2 19.5 2.2 100.0

more than one ailment and refers to a feeling of chest pressure and generalized physical condition of debilitation applicable also to tuberculosis. In addition to excessive work, other etiological factors were mentioned by participants. First, reflecting the importance attributed to dietary soundness for human health, a number of interviewees indicated that inadequate nutrition or malnutrition (11.3 percent) is a cause of tuberculosis. Additionally, a few respondents (16.5 percent) considered the disease to be "contagious" because it can be transmitTABLE 2 Sidama etiological concepts of tuberculosis (n = 217). Source: adult health-status survey. Category Excessive work Contagion Malnutrition Airborne Ranta Naturaldisease (kalaqamunni) Exposureto sun Hereditary Decreasedblood level Evil spirits Evil eye Other Don't know Total Frequency 103 51 35 27 18 16 10 4 3 3
1

6 32 309

Responses (%) 33.4 16.5 11.3 8.8 5.8 5.2 3.2 1.3 1.0 1.0 0.3 1.8 10.4 100.0

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ted interpersonallyby using an infected individual's personal belongings or throughsexual contact.2Third,environmental etiological factors were also mentioned by participants. In this context, 8.8 percentof intervieweesthoughtthattuberculosiscould be contracted by inhalingdustor otherairborne particles.Finally, some respondentslabelled it as a "naturaldisease," or kalaqamunni(lit. "from creation"),in which no supernatural agentsare involved.This line of thoughtwas confirmedby the exceedingly small numberof respondents who indicatedthatevil evil or other extrahuman factors are the (1.3 spirits percent), eye (0.3 percent), cause of tuberculosis.The etiology of tuberculosisthusrevolves primarilyaround causationis advocated for a numberof empiricalfactors, although supernatural otherailments(Vecchiato 1993b). Intervieweeswere subsequentlyasked what they consideredthe most effective treatmentfor tuberculosis. To the question "How should tuberculosis be treated?" (Table 3) the majorityof respondents(52.1 percent)felt that traditional remedies(Sidamataghiccho) are more effective to cure tuberculosisthanmodem medicine(37.8 percent).Herbalmedicineswere the most frequently(34.6 percent) mentionedcategory.Additionally,respondents pointedto good food, meat intake, and blood drinkingas essential therapies.While 8.3 percent of participantsindicated that good foods in generalare the best treatment, a few pointedout specific edibles such as raw eggs, caprineand bovine blood, and meat. A small numberof intervieweesexpressedconfidence in otherforms of traditionaltreatmentsuch as cautery and bathing in hot springs. Altogetherthe majorityof respondentspreferredtraditional remedies;37.8 percentthoughtthatmodem medicine is more effective in combatingtuberculosis.
TABLE 3 Preferred treatmentfor tuberculosis in Sidama (n = 217). Source: adult health-status survey. Category Traditional remedy: Herbalmedicine Good food Goat's blood Eat raw eggs Drinkcattle's blood Eat meat Cautery(sisiwo) Hot springs Fumigation Subtotal Modem medicine Other Don't know Total Frequency 77 18 3 3 3 3 2 2 1 113 82 2 20 217 Responses (%) 35.5 8.3 1.4 1.4 1.4 1.4 0.9 0.9 0.5 52.1 37.8 0.9 9.2
100.0

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TABLE 4 Best prophylactic measures against tuberculosis (n = 217). Source: adult health-status survey. Category Frequency Responses (%)

Avoidcontact withpatient Avoidexcessivework Eatgoodfood It cannot be prevented Other Don'tknow Total

65 54 49 9 33 58 274

23.7 19.7 17.8 3.3 12.1 21.2 100.0

Asked whatkind of prophylactic measures(Table4) are necessaryto prevent the onset of tuberculosis, 23.7 percentof the intervieweesmentionedavoidinghaving physical contact with infected individuals, which included avoiding their breathandpersonalbelongings,and not having sexual relationswith them.A second preventativestrategymentionedby respondentsreflected the notion that excessive work could bring about tuberculosis.Thus 16.4 percent recommended moderationin the daily workload,and a few advised againstcarryingheavy loads and workingin the sun. A thirdgroupof prophylacticmeasuresrelatedto the etior undernutrition can triggerthe onset of tuberological concept thatmalnutrition culosis. Thus these preventativestrategiesemphasize the need for nutritional imsuch as and blood. avoidance meat, provement eating eggs, drinking Conversely, of bad foods including the flesh of diseased animals and fresh milk was recommendedby severalinformants. Although people conceptualizedthe etiology of tuberculosisprimarilyat an entities as causal agents, some interempiricallevel, which excludedsupernatural viewees neverthelessmentionedritualagents as a means of preventingtuberculosis. For example, a few respondents pointedto the need to wear amulets(kurama) and performanceof a traditional gondoro (lit. alliance; a sacrificialritualcarried out to stave off epidemics)ritualwas advocatedby some. The high percentageof "Don't know" (21.2 percent)answers,coupled with 3.3 percentof responsesstating thattuberculosiscannotbe prevented, point to the puzzlementthattuberculosis poses to the Sidama.
Culture and Tuberculosis Transmission

Local culturalpracticesthatfoster the transmissionof tuberculosisappearto be relatedmainly to patternsof residence, cattle-herding,and social interaction. The Sidamalive in windowless, single-room,thatch-roofed huts. The small opening throughwhich people enteror leave the habitationmay be inadequateto provide the air circulationnecessary to eliminate the aerosolized dropletnuclei released into the air by infected individuals through coughing and sneezing (McDonaldand Reichman1989:134). Thus the design of Sidamahousing may fa-

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cilitatethe transmission of tuberculosis andexplainthe high morbidityrates.Addiat Sidama funerals, councils) drinking vessels and (meals, tionally, gatherings waterpipes (gaya) are passed amongparticipants and sharedwithoutregardto the presenceof infectedindividuals.Given the lack of thoroughcup washing,it is thus likely that tuberculosis bacilli may be transmittedto noninfected individuals throughthis avenue.Additionally,the Sidamaroutinelydrinkraw milk, a practice that increases the risk of contractingtuberculosistransmittedby cattle infected with Mycobacterium bovis. Sidama domestic cooking patternsinclude the use of an open-fire hearth placedon the dirtfloor in the centerof thehomesteadon which wood is burnedprimarilyfor boiling coffee andbaking.Althoughsome smoke is releasedthroughthe thatchroof, much of it remainssuspendedinside the homestead.In a study conducted in Zimbabwe,Collings et al. (1990) ascertainedthat indoor wood smoke diseases in children.Thus practiceof open-fire pollutioncaused lower respiratory cooking, and consequentwood smoke pollution,may aggravaterespiratory problems in Sidamaindividualsalreadyaffectedby pulmonary tuberculosis.While this observationinvites systematic quantificationand laboratoryanalysis, given the other culturalpracticesdiscussed, I expect thatM. tuberculosisand M. bovis will persist as a majorhealth threat. Ethnomedical Remedies Although Sidamahold modem medicinein high esteem and resortto it for a vast numberof ailments,traditional medicinepersistsas the most popularformof treatment.Traditionaltuberculosis-related therapeuticsare structuredprimarily aroundthreemain strategies:diet, cautery,and pythotherapy. First, as previously discussed,the Sidamaconsidereating nutritiousfood an essential constituentof healthy living and maintaininghigh blood levels. A good diet is thoughtto consist of enseteporridge, milk, andespecially meat.Forthis reason, Sidama do not hesitate to slaughtereven the family's bull in order to give if he or she is elderly. Highly brothand meat to a tuberculosispatient,particularly sought out by tuberculosispatientsis also the meat of boar.Health-seekersliving in the midlandscan purchasewild boarmeat at majoropen-airmarketsin the district.If this meat is not available,othermeats are given to eat with the broth. A second strategy against tuberculosis entails the utilization of cautery (sisiwo). The procedureconsists of applyingto the sick partof the body the smolderingtip of a wooden rod typicallyobtainedfrom the PhyllantusfischeriandFagara cholybea trees. Generally,the sisiwo cauteryis carriedout by an oghessa, a traditional medical specialistwho is familiarwith the partsof the body thatcan be in responseto an ailment.In the case of tuberculosisthe oghessa cauterized safely regenerallypresses the red-hotrod on the epidermiscovering the intraclavicular gion for a few seconds while carefullyavoidingthe clavicle itself. The application is repeatedthree times per session. The fundamental idea underlyingthe painful of heat into specific areasof the humanbody can procedureis thatthe irradiation destroythe pathogenicelements thatcausedpain in thatpartof the body. The procedure is consideredsuccessful if pus-likefluid is secretedfrom the wound a few days later.

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TABLE 5 Preliminarylist of ethnobotanical remedies against tuberculosis.Source: Fieldwork. Sidama 1. ARGHISA 2. BASU BAKULA 3. BULLANCHO 4. DAGUCCHO 5. GAMBELA 6. GARAMBA 7. GATAME 8. GHIDINCHO 9. MA'DISISA 10. MALASINCHO 11. NOLE Scientific Aloe megalacantha Cucumis ficifolius Labiatae fam. Podocarpus gracilior GardeniaIovis totantis Hypericum lanceolatumL. Sheffelera abyssinica Discopodium penninervium Trichocladus ellipticus Clutia robusta Effects Emetic Emetic Emetic Emetic, expectorant Emetic Emetic, expectorant Emetic, expectorant Emetic Emetic, expectorant Emetic Emetic Utilized Part Leaves Roots Leaves Leaves Leaves Leaves Leaves Leaves Roots Roots Roots

Third, in a productive use of the surrounding flora the Sidama culture has accumulated an impressive number of herbal remedies to deal with ill-health, including tuberculosis. The preliminary list presented in Table 5 is probably only a fraction of all ethnobotanical remedies employed against the disease.3 While some recipes are commonly known, the majority are secretly prepared by herbalists and sold to health-seekers for a fee. Additional herbal medicines can be purchased from vendors at open-air markets. The majority of Sidama remedies against tuberculosis seek to induce vomiting. The expected emetic effect is in line with the prevailing belief that "bad blood" must be vomited out in order for the patient to get well. The Sidama Cultural Model of Tuberculosis The Sidama ethnomedical approach to tuberculosis is predicated on an internally logical discourse on health and illness within the framework of a culturally determined nosology. The cultural construction of the disease is articulated through shared knowledge structures dealing with symptomatology, etiology, treatment, and prevention. Given the noticeable differences in respondents' perceptions, however, is it possible to infer a unified cultural model of tuberculosis?

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In her analysisof participants' andknowledgeof high blood presperceptions sure in an OjibwayIndiancommunity,Garro(1988) arguedfor the existence of a prototypicalculturalmodel of illness thatis variouslysharedby most membersof a community. Garro maintainedthat "in spite of a lot of diversity about what causes and accompanieshigh blood pressure,there is a culturalmodel that gives meaning to many of the experiences and actions associated with this illness" (1988:115). Garrosuggested that the basic frameworkfor interpreting perceived symptoms and their causes is provided by the culturalmodel, which is learned from a varietyof sources (1988:114). Garro'smodel is relevantto the Sidamacontext. Sidamaexplanationsof tuberculosis, their body of knowledge, and their practices may be understoodin termsof a prototypical model with variations.First,the Sidamaprototypicalsympof pulmotomatologicalmodel coincides largely with biomedicalunderstandings which tuberculosis external nary by they frequentlyidentify symptoms such as persistentcough, chest pains,debilitation,andhemoptysis.Second, Sidamaunderstandingsof the etiology of tuberculosisalso representa prototypicalmodel, one that is firmly groundedin the empiricaldomain.This is unlike the predominantly beliefs discussedby Messing (1972) amongruralAmahraof northern supernatural is causedby a demonof contamibelieve thattuberculosis Ethiopiawho reportedly nation(maganya)thattakes the shapeof a red snakein the belly. The prototypicaletiological model of tuberculosisis centered aroundtwo complementarycausationalcategories, namely overwork and malnutrition.Etiological variationsinclude the belief expressedby some respondentsthat "contagion"constitutesa majorcausationalfactor.While lackingknowledgeof germtheory andthe role thatbacilli play in the spreadof contagiousdiseases, ethnomedical transmissionof tuberculosis. etiology postulates the possibility of interpersonal Anothervariationon the prototypicaletiological model is the belief expressedby some respondentsthat tuberculosismay be contractedby inhaling dust particles. This environmentalfactor reveals a possible innovativenotion acquiredthrough modem healtheducation. for tuberculosisrests primarilyon the utiliThird,the prototypicaltreatment zation of traditional medicine. It was noted, however, that most Sidamaethnobotanical remedies for tuberculosisare selected because of their emetic properties, which is in accordancewith the belief thatremissionof symptomsis achievableby vomiting out the "badblood" thataccumulatesinternally.The lack of such effects in biomedical treatmentthrough the administrationof modem drugs such as isoniazid, rifampin,and streptomycinprobablyexplains why biomedicine is not choice. the preferred therapeutic The diversity of tuberculosis-related perceptionsand practicesidentified in the researchpoints to the fact that,far from being wholly homogenous,local systems of medical knowledge are characterized by differencesin the etiological and therapeuticapproachesto the disease. Variationsin etiological assessment,howAs noted by Ngokwey ever, do not necessarily signify cognitive fragmentation. (1988), disease-etiological inferences are often negotiatedand formulatedin the social arena.Ngokwey arguedthat "social interactionsare the fundamentalcontexts of the productionandutilizationof etiologicalknowledge"(1988:793). In the multicausalexplanationsafterexSidamacontext, people assign complementary, for examof an ailment.Informants, aminingthe clinical and social circumstances

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pie, agreed that the onset of tuberculosismay be triggeredby the simultaneous ranta,and sexual contact. While these are discreetetipresence of malnutrition, ological categories,they are not mutuallyexclusive and are takeninto consideration in diagnosticprocessesfor theirpossible concurrentinitiatoryrole. of inIn this context, the importance of illness semanticsin the management fectious diseases such as tuberculosisshould also be highlighted.Nichter (1994), for example, identifieda "weaklungs/tuberculosis" complex wherebythe "weak lungs" category is ethnomedicallyutilized to cover a variety of symptomsinclusive of tuberculosisin the Philippines.In a similarfashion, the rantasyndromeis semanticallyutilizedby the Sidamato categorizemore thanone ailment,although it is often referredto as a proximatecause of tuberculosis.Additionalresearchis needed, however, to identify the conceptualrelationshipbetween ranta,or other syndromes, and tuberculosis,and the role that illness semantics play in disease choices. treatment of actualillness episodes is shapednot solely by culturally The management ethnomedical transmitted axioms,but also by practical,financial,social, structural, to The pragmaticnatureof the Sidamaapproach and geographicalconsiderations. and ill-healthand healing, which entailsthe simultaneousutilizationof traditional biomedical therapiesfor the same disease occurrence,is noted elsewhere (Vecchiato 1985). Responsesin the surveyby intervieweeswho hadnot necessarilyexbody periencedtuberculosispersonallyreveal a normative,culturallytransmitted of knowledge and practicesconcerning this infectious disease. Furtherresearch theirintershould determinethe criteriathat infected individualsuse to structure managementof an actualoccurrenceof the disease. pretationsand therapeutic Implications for Intervention Researchers have highlightedthe relevanceof traditional medicalknowledge in the eradicationof infectiousand parasiticdiseases. BriegerandKendall(1992), for example, emphasizedthe crucialrole thatawarenessof local knowledgeplays on the partof healthworkersin the success of a guinea-wormsurveillance program in Nigeria. Thus, ratherthan considering local beliefs as obstacles to the implementationof control programs,they should be taken into account for effective communicationbetweenbiomedicalpersonneland health-seekers(Stone 1992). nationaltuberculosisprogramsin EthioDespite some recentreorganization, and withoutany impacton pia have been describedas "virtuallynon-functional" the tuberculosissituationin the country(Hodes and Azbite 1993:280).These programshave been criticizedfor flaws in funding,case reporting,staffing,organization, drug supply,patientmonitoring,and facilities (Hodes and Azbite 1993). The same authorsrecommendthat,given the disproportionate amountof personnelrequired by vertical programs,tuberculosis services should "be extended to the population throughthe primaryhealth care scheme" (Hodes and Azbite 1993). While acknowledgingthe appropriateness of the recommendation, it is doubtful in tuberculosiscontrol programswill be sucthat active communityparticipation cessfully elicited in Ethiopiaor otherdeveloping countrieswithoutknowledge of the "healthculture"of patientsand their supportgroups. The ways in which Sidamaconceptualizeand managetuberculosisarepredicated upon an internallycohesive nosological discourse. Points of convergence

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and divergenceexist in the traditionaland biomedicalapproachesto the disease, and these need to be acknowledgedin the developmentof nationalcontrol proto be high in the Sidama grams.Forexample, symptomrecognition,which appears context,convergeswith the biomedicalparadigmof pulmonarytuberculosis.This alignmentof biomedical and traditionalsymptomatologiesconstitutesan important premisefor subsequentdialogue between the two perspectives.Because this researchis needed in orstudydeals only with pulmonarytuberculosis,additional derto identifythe ethnomedicalclassificationof otherformsof tuberculosisandto determinewhetheror not these are subsumedunderseparatesyndromesor illness labels. Among points of divergence is the not surprisingobservationthat conceptions of etiology among the rural,largely illiterateSidamacommunityare unrelatedto biomedicalunderstandings of TB and the threatthattuberclebacilli poses to humanhealth.This realityraises doubtsaboutthe potentialeffectiveness of any curativeor preventativecontrol programsthat are implementedwithoutan extensive prior health-educationcampaign to illustratethe nature of tuberculosis,its transmission measures.Studiesshow that avenues,andrecommended preventative health-education interventionscontributeto increasedadherenceto therapyin rural service programs(Van der Werf et al. 1990). Such educationprogramsshould take into account culture-specificdisease concepts. For example, because it acknowledges empirical avenues of interpersonaldisease transmission resulting fromphysicalcontiguity,the Sidamanotionof "contagiousness," while not identical to its biomedical correspondent, could neverthelessbe usefully incorporated into teachingmaterials. In addition,traditional therapeutic practicesthatemphasizedietaryimprovement as partof treatmentfor tuberculosisshould be valorizedin health-education programs,since improved nutritionhelps a person resist disease. However, the ensete plant couheavy dependenceof the Sidama diet on the carbohydrate-rich pled with the limited availabilityof proteinsourcesmay pose seriousthreatsto nutritionaladequacydespite countervailingnormativeethnomedicalaxioms. Addiremediesform the most popularsourceof treatment tionally,while ethnobotanical for tuberculosis,their chemical properties,therapeutic effectiveness, presence or with biomedicalchemotherapies absenceof side effects, and possible interference are unclearat this time, and multidisciplinary scrutinymay be required. regimensis affected not only by culCompliancewith prescribedtreatment turallyinfluencedprocessesof perceptionanddefinitionof a disease; othersocioeconomic factorsof ruralcommunitiesaffect complianceand influenceillness behavior. Among these are farming and other subsistence activities such as at ruralopen air marketsand othersocial events such as disputesettleattendance ments and life-cycle celebrations(e.g. births,initiations,weddings, and funerals). anduse considerable All of these requirefull adultparticipation personalandcombasedon vaccinamunaltime.Therefore,in orderto be effective, controlprograms which requirefull case finding, andtreatment, tion with BCG, chemoprophylaxis, communityinvolvement(Teklu 1984), need to be carriedout within a time frameworkthatis sensitive to local events and agricultural activities,and utilize socially relevantchannelsof surveillanceand eradication (Briegerand Kendall 1996). Verticallybased tuberculosiscontrolprogramshave generallyfailed in their objectivesbecause they have not adequatelyunderstoodlocal socioculturalenvi-

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ronments (Murray et al. 1990). It is increasingly recognized that tuberculosis is a "disease of poverty" that cannot be totally eliminated without addressing issues of cultural relevance, socioeconomic underdevelopment, and inadequacies in health care services. Nevertheless, some progress could be made if local knowledge about tuberculosis is augmented by biomedical information from health education and control programs that enlist full community participation (Saunderson 1994). Awareness by biomedical personnel and health planners of prevailing culturebased models of disease and treatment practices may facilitate communication patterns with patients and local communities.
NOTES

Acknowledgments.The author wishes to thank Stan Yoder, Helmut Kloos, Arthur Rubel, Ann Millard,Gay Becker,andthe anonymousreviewersfor theirhelpfulcomments. The researchwas made possible through the generous supportof the Comboni Institute andhealerswho (Rome andAddis Ababa).I would also like to thankthe Sidamainformants patientlysharedthe richnessof theirethnomedicaltraditionswith me. Correspondence may be addressedto the authorat P.O. Box 948, Gig Harbor,WA 98335. 1. It may neverbe possibleto accuratelyestablishwhen andhow thediseasefirstmade its way into the country.Evidence shows that by the early 1840s patientswere treatedfor phthisis by Kirk, a surgeon associated with the British GovernmentMission (Pankhurst which opened in Addis Ababain 1910, was 1965:119). Lateron, the firstmoder pharmacy, of tuberculosis(Pankhurst 1990:186). reportedto be stockedwith drugsfor the treatment 2. For reasons unclearat this time, the Sidama concept of "contagion" is predominantly rendered with the Sidamized Amharic word telallafate (Amhharic:elallefe: to transmit,to pass on) ratherthan with the correspondingSidama termsa'isate, which also means "to transmit." 3. The names of ethnobotanicalremedies mentionedin this study were elicited from informants The plantswere subsequentlyidentifiedwith theirscientificnames by the author. by botanist Rev. Giuseppe Calvi MCCJ, whose importantcontributionis here gratefully acknowledgedandcomparedwith collections availableat the EthiopianBotanicalInstitute.
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