Transrational traits of healing in competing medical epistemes in. Botswana. Klaus Geiselhart. Abstract: The WHO suggests integrating traditional health ...
This is the author’s original whose final and definitive form has been published in South African Journal of Philosophy 2018, 37(2): 178-192 © 2018 copyright NISC (Pty) Ltd. South African Journal of Philosophy is available online at: http://www.tandfonline.com/10.1080/02580136.2018.1443775
Reasoning matters: Transrational traits of healing in competing medical epistemes in Botswana Klaus Geiselhart Abstract: The WHO suggests integrating traditional health practices into national public health systems. However, cooperation between both systems of healing seldom works. Traditional healing practices often attract accusations of irrationality and mysticism. From a scientific point of view, inferences based on spirituality are not considered as having the same significance as those drawing on rational thinking. However, spiritual intuition is in line with abductive reasoning, which is a core element across all systems of thinking and central to the development of new hypotheses in the sciences. Traditional healing practices in Botswana serve to present the notion of transrationality, which appreciates the specific character of spiritual healing and thus may aid in establishing better cooperation between traditional and modern health practitioners.
Introduction Traditional healers received official recognition in Botswana in 1973, when the Dingaka Society and the Botswana Dingaka Association were registered as societies. These organisations of healers thus attained the authority to regulate healers' practices and issue traditional healer licences (Staugard 1986). The hope was to bridge the divide between two systems of care, the modern and the traditional health system. However, the healer associations of Botswana soon divided into various different organisations, and many healers refrain from registering with one of them altogether (Last 1986). The 1980s saw the emergence of a discussion around the professionalisation of African medicine, one of whose aims was to pinpoint reasons for the lack of cooperation between modern medicine and traditional healthcare. The debate was triggered by the assumption that “knowledge as the source of power or authority is central to the notion of ‘professional', whether he be a hospital specialist or a practitioner of traditional medicine” (Last 1986, 8). In the course of societal changes in Botswana, a belief arose that traditional healers were turning toward more “rational elements of healing” (Staugard 1986, 52). It was identified as problematic that traditional medicine in Africa did not have an explicit corpus of knowledge. Referring to Foucault, it was argued that „in the last twenty years analyses of systems of knowledge and how they alter over time have undermined the solidity of scientific ‘truth' or fact. The result is a certain convergence of the scientific with the traditional: no longer can a facile contrast be made between ‘primitive' and ‘scientific', at least in the sphere of thought“ (Last 1986, 8). Accordingly, “indigenous knowledge” became a focus of research. What is meant by the term “indigenous knowledge”, however, is by no means clear. No matter how the term is conceived, it is “always contrasted with ‘formal', ‘modern', ‘Western', ‘scientific' or ‘international' or ‘cosmopolitan' knowledge” (Bar-On 2015, 781). After the turn of the millennium, modern medicine further established its hegemony in Botswana due to its effectiveness in combating AIDS in the aftermath of the severe impact of the HIV and AIDS crisis on the country in the 1980s. A countrywide free-of-charge ARV medication scheme was introduced and broad swathes of the population were able to observe how those whom they ((179)) had considered close to death came back to life. In the course of such medical success, indigenous knowledge frequently found itself deemed inadequate, with traditional beliefs referred to as “untrue”, “irrational” or “mythical”. In a number of
instances, cultural beliefs were subject to attempts to stamp them out, as they were perceived as hampering the spread of modern knowledge on health matters. (Tabalaka 2007, 63) Today, thirty years after the discussion around the professionalisation of traditional medicine, traditional healers seem to be even more marginalised than in the 1980s. The Baitseanape ba Setso mo Botswana is the umbrella organisation of traditional healers' associations; one of its purposes is to undertake negotiation with government authorities. Its president, John P. Setilo, states that healers feel patronised: „We are working closely with the ministry of health. That I would admit. But we are working closely with them, not as equal partners really, because at the end of the day all they do is to run workshops for us, for purposes of wanting us to help solve their problems. They concentrate maybe on HIV/AIDS. Nowadays there is diarrhoea. So they will workshop us on diarrhoea. And that's it“ (Setilo interview, 18 August 2012). Measures such as deconstructing the scientific understanding of truth, recognising that “beliefs” are in practice not separable from “knowledge”, and casting a spotlight on the fact that modern and traditional medicine both show practical shortcomings and treatment failures (Last 1986) evidently failed to prove sufficient to overcome the dualism between the two systems of care. In recent decades the conviction has arisen “that practices are neither secondary nor opposed to beliefs, nor do they arise directly out of beliefs, but rather that practices and beliefs are mutually constitutive” (Naraindas, Quack and Sax 2014, 2). Accordingly, it is important to consider the epistemological foundation of different schools of healing and to how they become naturalised within the triad of ideas, practices and institutions. In this article I intend to act upon and broaden these principles by pointing out that reasoning takes on a special role when analysing medical epistemes. Reasoning mediates between practical actions and beliefs/knowledge, as in instances when practitioners diagnose patients by consulting their knowledge in order to interpret their observations or when they use their knowledge to guide additional examinations. The way I examine how modern doctors and traditional healers come up with diagnoses is inspired by Mol (2002). Mol questioned the idea that the outcome of modern medicine is highly standardised. Within a process of diagnosing, each and every step is co-produced by the patient and the doctor, generating a multitude of references to a “body” or a “disease”. In this way, multiple bodies, or multiple diseases, emerge, each constructed from the perceptions contained in these fields of reference. However, I challenge Mol in her assumption that such a practice-oriented approach represents a shift away from epistemology. I argue that conventionalised practices of inferring are deeply embedded in each and every step a practitioner or a patient performs. My argumentation should not be misinterpreted as a universalistic theory of an African culture of diagnosing. The categories of “Africa” and the “West” “have become mutually defining in that both are born historically and culturally out of the other” (Stambach 1999, 350). The characteristics of modern and traditional medicine can thus only be approached in comparison between the two. Modern medicine's emphasis on rationality and the associated devaluation of traditional thinking as “irrational” demand reflection on reasoning in traditional medicine. Some readers may not consider this article to be anthropological in a strict sense. Although my work is based on ethnographic methods and a review of anthropological literature, I refer to a current problem in public health politics. In fact the WHO (2002) recommendation is that modern and traditional medical practitioners cooperate, but such cooperation rarely works well, at least in Botswana. I translate some core elements of traditional healing into the terminology of Western philosophy of logic in order to challenge a common prejudice about healers. I suggest rewording by replacing the devaluing term “irrationality” with the appreciative term “transrationality”. I undertake here a mediating attempt to be “a messenger, a liaison officer, making reciprocally intelligible voices speaking provincial tongues, and thereby enlarging as well as rectifying the meanings with which they are charged” (Dewey 1929, 410). The concept of transrationality might help advance ((180)) what Wiredu (2004) calls “conceptual decolonisation”, which entails awareness and critique of the Western coining, claiming and connotation of concepts such as “reality”, “entity”, “truth”, “fact”, “belief”, “knowledge” and “rationality”. After outlining the methodology employed and characterising the sample, I present a theoretical discussion on the epistemological status of different forms of reasoning which in effect give knowledge different statuses. I will then proceed to introduce the concept of transrationality to the discussion, which I propose as a replacement for the derogatory idea of irrationality. Further, I will show that modern medicine also employs this type of reasoning, but for different purposes and in different phases of its scientific processes. Finally, I will demonstrate that modern and traditional medical practices in Botswana each display consistent combina-
tions of specific forms of reasoning, practices and knowledge. Modern medicine has developed a different cognitive style to the tradition of spiritual healing in Botswana. Both styles of reasoning mainly differ in the way they combine the basic modes of reasoning they use. Both medical epistemes can be seen as distinct cultures of healing, each in itself diverse and taking a multiplicity of forms, but identifiably different from its dialectic other. Each of them has arisen from historical conditions and circumstances and cannot be described in the terminology of the respective other.
Methodology This paper is based on a review of literature and presents empirical data from various field studies. Between 2004 and 2009, I conducted research on the social effects of HIV in Botswana and the benefits of the biomedical ARV scheme. During this project, alternative healing practices were also investigated with regard to their appeal to HIV patients. Between 2011 and 2015, a follow-up project explored the social determinants of treatment adherence. The latter project was also interested in developing an approach capable of analysing the full range of local health services. Between and after these main phases of work, several short visits helped to confirm preliminary findings. In addition to expert interviews, I also employed ethnographic methods to study traditional healing. Through snowball sampling and then theoretical sampling1, a total of 16 healers participated in the study, all by taking part in structured interviews. Some healers were studied more closely through repeated interviews and participant observations. I observed rituals, consultations, and the collection of medicinal plants, and was introduced to some basic healing techniques. I employ a grounded theory approach, which used all datasets collected, in order to unpack the notions of medical epistemes and transrationality. Such methodology cannot evaluate the effectiveness of traditional medicine, nor can it provide representative figures regarding its use and distribution, but it can give insights into its epistemological foundation. With the exception of public figures, names in this study have been anonymised.
Healers in the study There are two major emic terms indicating a doctor in Botswana: ngaka (plural: dingaka) and sangoma (plural: basangoma). Ngaka is often interpreted as referring to a herbalist doctor and sangoma as a spiritual healer. However, these interpretations appear to mainly derive from the Betchuanaland Protectorate administration, where techniques using herbs for healing were accepted and all practices making reference to a spiritual world, such as divining and trance dancing, were labelled as witchcraft, presumably because they were “incomprehensible and intolerable to Western thinking” (Hedberg and Staugard 1989, 27). The respective plural forms indicate the probably most important difference between dingaka and basangoma. The prefix “ba-” in Setswana indicates affiliation to a category of human members, for example a tribe or a group. Basangoma are considered to share common healing practices as they are committed to their respective schools of their training. In contrast, the prefix “di-” is an indefinite plural form, indicating here that each and every single ngaka stands for his or her individual healing powers. ((181)) In this survey I did not find any ngaka ya ditshotshwa, that is, one who solely uses herbs for treatment without utilising any form of spirituality. One ngaka was a porofeti, better known as a prophet healer, who combines traditional healing with Christianity. All interviewees, both dingaka (10) and basangoma (6), had been trained in a way that largely relied on spirituality. Most healers had received a calling which had impelled them to find a traditional doctor to train them. They had either suffered from an illness that modern doctors had been unable to cure or had experienced recurring dreams or visions. To varying degrees, trainers were reported to demand their trainees gain knowledge about herbs and treatment mainly through spiritual intuition. One ngaka reported that he had attained his knowledge directly from spirits without being instructed by another healer and that he was taught solely by natural spirits such as snakes. Generally, many people stated that they possessed knowledge about herbal treatments, but did not call themselves dingaka. All individuals who referred to themselves as healers stood out due to their commitment to a process of developing spiritual relationships with transcendent entities such as God, ancestors or natural spirits. The recognition that spirituality is an essential element of traditional healing in Botswana was a fundamental insight of the research process and, at a certain stage, began to guide further inquiry. This idea gained trac1 Theoretical sampling is a method stemming from the grounded theory approach in which interviewees are chosen according to considerations around who might present an additional perspective or contribute aspects which have not yet been covered.
tion through reading about other regional contexts in which it had also been found that traditional medicine „inverts the valuation of the mainstream binary between reason and intuition. Intuitive knowledge is considered the highest knowledge of all; rationality is seen at best as useful, at worst as deceptive“ (Barcan 2010, 131; cf. also Thornton 2015). In order to diagnose patients, all healers employed oracles of one form or another. These included an intricate apparatus, a calabash which turned under the fingers, holy water, and different sets of “bones”. These oracles are all produced individually and the variations among them are huge. However, their common purpose is to guide the practitioners' actions in a ritualistic sense. All healers explained that working with the oracles establishes a connection to their spiritual sources of healing powers. What is commonly referred to as “casting the bones” will be discussed more closely below. Most sets of bones, alongside many individual pieces, contain some specific bones which make up a complex four-tablet divining system which is standardised among the basangoma. The following analysis will explicate the core functioning of this oracle system.
Reasoning as a “doing” Talking about reasoning requires consideration of what rationality is, which has a long tradition in anthropology. Interestingly, the discussion around Placide Temples' account of Bantu philosophy mainly circled around the question of whether African cultures can be regarded as containing “philosophies” or only “worldviews” (Malibabo 2006), in other words around the question of whether or not Africans are able to think philosophically. Subsequently, the so-called rationality debate, as detailed by Stambach (1999), gave rise to two relativist positions. Both agree that all “worldviews” or “ontologies”, no matter whether they are called magic or scientific, are intended to control experiences and predict outcomes of actions by proposing causal relations. However, these worldviews do not control reality because they offer elementary truths, but because they guide behaviour in everyday situations. An exploration of what guides practitioner behaviour during examination of patients reveals a multiplicity in praxis. Even in modern medicine, where definitions are explicit and fixed, “no object, no body, no disease, is singular” (Mol 2002, 6). The immediate sensations experienced in a given situation are singular, but a perceived object is never so. Each time something is perceived as an object, the perceiving mind creates an entity by applying precedent established categories. „Objects come into being – and disappear – with the practices in which they are manipulated. And since the object of manipulation tends to differ from one practice to another, reality multiplies. The body, the patient, the disease, the doctor, the technician, the technology: all of these are more than one. More than singular“ (Mol 2002, 5). Each consultation brings the patient into another stage, making them another person. Each ((182)) consultation is a challenge to the practitioner, as they are called upon to prove their abilities by employing their skills. Practices exist in order to make the infinite multiplicity of praxis manageable. Conventionalised sets of actions guarantee the reproducibility of outcomes which are pre-established as desirable. It is the combination of attainment of knowledge and the mastering of such practices that makes practitioners professional. Each consultation is a novel moment in which the practitioner has to prove not merely their theoretical and practical expertise, but also their abilities of reasoning. Practitioners have to draw a conclusion in the form of a diagnosis relevant to the patient. Relevance in this context means that the diagnosis serves as a starting point for therapeutic measures and treatment. Contrary to Mol's suggestion, observing practitioners and patients in the process of establishing a diagnosis does not represent a move away from epistemology. I do not consider the notion that “epistemology is concerned with reference: it asks whether representations of reality are accurate” (Mol 2002, vii) to be correct. Epistemology looks at how people arrive at convictions, how they process inferences and why they privilege a certain conclusion by ascribing to it the status of knowledge while denigrating another idea by terming it a belief. Reasoning matters because it is also a doing which is habitually embodied in individuals (Dewey 1929). Reasoning is the process via which lived experiences undergo abstraction into truths, and the reverse process of the application of knowledge to singular cases. It is a procedure through which judgement applied to singular perceptions endows these perceptions with significance. Practitioners learn certain practices of reasoning throughout their training. Later, they establish these modes of inferring in their daily contact with patients. Practitioners thus acquire specific, professional intellectual habits during training and practice. Such professional cognitive styles of reasoning determine how practitioners make a diagnosis out of their perceptions of
a patient. The reasoning employed is culturally framed by the school of healing from which a practitioner has learned a specific, conventionalised style of processing knowledge, data and perceptions.
Epistemes and the hegemony of modern medicine Epistemes are particularly embedded in the habitual behaviours of those who, as professionals, are concerned with institutionalised sets of actions (Naraindas, Quack and Sax 2014). These professionals need to be trained in order to meet the requirements of their profession. Professionals adhering to a specific medical episteme draw their self-efficacy and confidence from their experience of the coherence of their professional view. Further, an episteme guides perception; with the effect that lived experiences recurrently confirm the presupposed assumptions at work. In The Birth of the Clinic, Foucault analyses the development of a modern medical episteme as “a type of discourse” reflecting an emerging new “medical experience” (Foucault [1963] 2003, xx). Foucault explains the appearance of modern medicine as closely related to the development of practices such as diagnosis (xxi), post-mortem examination (152) and the training of young doctors in the institution of the clinic (71). The incipient field enforced scientific reasoning by applying mathematical standards and techniques (126) resulting in rigorous notions of factuality and objectivity. The clinic brought about tremendous changes in medical perception: „The whole relationship of signifier to signified, at every level of medical experience, is redistributed: between the symptoms that signify and the disease signified, between the description and what is described, between the event and what it prognosticates, between the lesion and the pain that indicates, etc“ (xxi). Modern medicine privileges the visible, measurable, and communicable signs of a disease as its manifest expressions. It is not only professional actions which endow a particular worldview with power, but also the extent to which the professional discourse manages to enter the popular repository of “common sense” and influence lay discourse. For example, the development of antibiotics and hygiene, through their obvious lifesaving effects, evidently contributed to the hegemony of modern medicine to such an extent that “in modern Western society biomedicine not only has provided a basis for ((183)) scientific study of disease, it has also become our own culturally specific perspective about disease, that is, our folk model” (Engel 1977, 130). Biomedicine has become the hegemonic medical episteme, spreading bio-political discourses about heath and disease globally. Such discourses are not simply intellectual concepts or societal debates. The worldwide spread of Westerntype public health services and first-aid interventions has made the benefits of biomedicine visible, tangible, and experienceable. The power of discourses additionally derives from recurring collective productions of reality. The internal logic of the permanent reproduction of practices and knowledge, along with the current social conditions with regard to norms and social values, constitute an episteme. Epistemes thus define what can be said, what is socially accepted, and even what can be done. Epistemes go beyond the representation of intellectual convictions to encompass the whole societal setting which affords them relevance, influence, credibility, and support. The rapidity with which Botswana's public health system was implemented, primarily through foreign expertise, has left a legacy of co-existence and competition between two medical epistemes, each in restricted and separate spaces. Both have long-standing historical characteristics and specific repositories of knowledge and repertoires of dealings, and both, regarded from within, appear reasonable.
Reasoning and epistemes In general, dealings or thoughts gain acceptance when they appear to be “reasonable” or “rational”. Such attributions of rationality are never impartial, but can only be made due to implicitly or explicitly accepted standards (Schütt 2011, 13). The theory of rationality draws a key distinction between practical and theoretical rationality in which “practical reasoning…leads to (or modifies) intentions, plans, and decisions. Theoretical reasoning…leads to (or modifies) beliefs and expectations” (Harman 2004, 45). Theoretical rationality is the main source of the development of new knowledge, as it proves new ideas according to their consistency and coherence with regard to currently held convictions or in relation to old convictions and new experiences (Spohn 2011, 144). “A major source of theoretical rationality, and perhaps the basic source of it – particularly
in the form of justification for belief – is coherence among one's beliefs” (Audi 2004, 27), or, in this instance, among the accepted knowledge sets of the episteme one is part of. Someone who is socialised within an episteme experiences coherence among their beliefs. Their everyday practices, the outcome of their actions, their practical experience, conform with their beliefs to a sufficient extent. There is no occurrence of a logical irritation that questions the episteme as a whole. This means that actions are under pressure to be successful. Otherwise, failures need to be explainable within the theoretical framework of the episteme. However, praxis always provides surprises, and practices need to meet two demands. First, practices need to be flexible enough to adapt to disturbances. The conditions within which a new consultation takes place may be exceptional. This is where praxis becomes multiplied into infinite singularities (Mol 2002). Second, practices also need to be stable enough to safely guide practitioners and those on their receiving end – here, the clients − alike. “Though nothing is sure or certain,…tensions are tamed” (Mol 2002, 181) by conventions which do not define the exact execution of practices, but their borders. Conventionalised practices make an episteme appear reasonable to insiders and include modes of reasoning which shape knowledge and determine what is regarded as a valid inference.
Rationality, intuition, and states of consciousness Modern sciences demands a high degree of reliability and replicability of inferences. Conclusions are supposed to be true; science therefore prizes and privileges deduction or induction as sequacious inferences, despite the fact that induction requires particular conditions to produce such a “true” conclusion. However, sciences cannot escape cases of inferences that lack such reliability. Peirce (1992) took the notion of logic beyond a theory of sequacious inference. He noted that not all reasoning meets the standards of deductive or inductive inference, and introduced the notion of abductive reasoning, which contains a specific uncertainty in the resultant conclusions. “Deduction proves that something must be; Induction shows that something actually is operative; Abduction ((184)) merely suggests that something may be” (Peirce 1992, 5.171; emphasis in original). Simultaneously, he recognised that abduction is essential if scientific thinking is to progress and not come to a standstill: „Abduction is the process of forming an explanatory hypothesis. It is the only logical operation which introduces any new idea; for induction does nothing but determine a value, and deduction merely evolves the necessary consequences of a pure hypothesis“ (Peirce 1992, 4.171). It is important to recognise that abduction cannot be processed deliberately, but happens unintentionally. It happens best in what we might call a state of musing, a casual, relaxed and playful condition of the mind which ideally does not commence with a particular goal or purpose. Musing begins with “drinking into” a state of consciousness where impressions arise and associations creatively emerge (Peirce 1992, 6.459). States of consciousness in which ideas might arise intuitively promote abduction. Abduction happens overwhelmingly when „the abductive suggestion comes to us like a flash. It is an act of insight, although of extremely fallible insight. It is true that the different elements of the hypothesis were in our minds before; but it is the idea of putting together what we had never before dreamed of putting together which flashes the new suggestion before our contemplation“ (Peirce 1992, 5.181). Abduction is in line with intuition but is by no means irrational. As I pointed out above, abductions cannot be processed deliberately, but occur. Returning to our discussion of traditional healing practices, ritualistic or trance techniques are intended to alter the healer's state of consciousness and thus promote the occurrence of abductive conclusions. Rather than appending a label of irrationality, I suggest that we should consider such processes, in which the scope of current thinking becomes transcended by new ideas, as “transrational”, no matter whether this happens in the creation of a new scientific hypothesis or within the practices of traditional healers. Abduction plays a major role in traditional healers' praxis of diagnosing, and occurs very little in clinical decision-making in modern medicine.
Clinical decision-making As I have previously indicated, abduction is a mandatory part of thinking in general, as well as of each and every process within the sciences. However, different epistemes evaluate abduction differently and assign
different realms of reasoning to it. In modern medicine, abduction is restricted to the process of basic research, in which new ideas about natural processes are developed as hypotheses. Such hypotheses then need to be validated by means of deductive and inductive reasoning before they are permitted to enter the corpus of medical knowledge. In modern sciences, abduction as a non-consequential mode of the development of ideas receives very limited recognition as a distinct form of reasoning. Diagnostics in modern medicine – at least in theory – is meant to be free of uncertainty. Professionals are not expected to act intuitively, but instead to carefully compare patients' symptoms with explicit knowledge of disease patterns and then deduce the patients' diagnoses from the general presentations of the diseases (Wulff and Gøtzsche 1999). In praxis, the situation is more complex: „Many treatments may produce serious unwanted effects and many diagnostic procedures (e.g. liver biopsies and endoscopic examinations) are unpleasant and may cause complications. The clinician must carefully consider the consequences of her actions“ (Wulff and Gøtzsche 1999, 6). However, decisions are always made on the basis of knowledge which is expected to be true or, at least at the given moment, state of the art. “Deductive and empirical reasoning constitute the scientific component of clinical decision-making” (Wulff and Gøtzsche 1999, 7). Nosographic knowledge regarding the manifestation of different diseases or the effects of different treatments is always the point of reference from which deduction of diagnosis proceeds. With regard to choice of treatment options, doctors have a degree of leeway for taking decisions either on the basis of their ((185)) own empirical experience or on the basis of the findings of randomised clinical trials (Figure 1).
(Figure 1: Flow chart illustrating the clinical decision process. Source: Wulff and Gøtzsche 1999, 6 ((185))) The modern doctor is expected to act rationally, but by no means are they allowed to infer intuitively on the basis of their general experience of life, nor on the basis of spiritual intuition. In contrast, traditional healers in Botswana focus in training and practice on honing their capacity to attain spiritual intuition. In consultation, a healer fosters abductive reasoning by means of entering a trance or lighter trance-like states of consciousness. The very foundation of reasoning in traditional healing in Botswana is spiritual intuition; and this means that knowledge has a different status than in modern medicine. I will now summarise some basic tenets of the practices of dingaka and basangoma, principally drawing on my own fieldwork, particularly with regard to the four-tablet divining system I was introduced to. However, I supplement my findings with references that confirm them.
Patients can be cured while clients are to be healed In general, dingaka and basangoma understand illness not solely as a bodily problem. They take a specific look at their client's problem in relation to the course of their life thus far. All healers interviewed articulated a more or less similar explanatory model of health and illness based on ancestral belief. In contrast to illness, which is understood as “ill relations”, health is seen as a state of being in harmony with relatives, neighbours, the community, ancestors, and the environment. People can become spirits when they die. As spirits, they retain influence on the living and can bring about happiness, health, and prosperity, but also death, sickness, misfortune, and poverty (Larson 1971; Ulin 1975; Amanze 2008). Ordinary people are not able to detect these influences, nor can they counter or manipulate them. Healers are “seen as intermediaries between the living and the ancestral spirits (badimo)” (Ingstad 1990, 31). Trance dance is performed by basangoma only, but other rituals, such as sacrificing food, beer, or snuff, or performing animal sacrifices, are other ways to worship ancestors, propitiate them, and encourage them to give information when necessary. As each and every healer receives information from her ancestral spirits, the field of traditional healing is highly individualised. Medical knowledge is not explicitly fixed, but is subject to permanent transformation “under constant influence from religious and cosmopolitan medical sources” (Ingstad 1990, 28). ((186)) A common distinction made during a diagnostic process is whether an illness is a “Tswana disease” or a “modern disease”. In the latter case, healers may refer the client to modern health services (Ingstad 1990, 32; see also Ulin 1975). In contrast to modern medicine, symptoms do not play a major role for healers in their arrival at a final diagnosis: „Patients who have been diagnosed by healers as having the same Tswana disease may differ considerably in their illness presentations, and similar symptoms may lead to quite different diagnoses depending on the social circumstances surrounding the illness episode“ (Ingstad 1990, 32). A client's unique nexus of environmental, spiritual and social relations determines their health status. Each relationship co-constitutes the client and the entity to which they are related. Such connections are manifold and the healer's task is to identify those which are harmful to the client's health. This idea of the client's nature is based on botho/ubuntu, which is a metaphysical notion of the interdependence of all beings within the universe and is frequently paraphrased as “a person is a person through other persons” (Metz and Gaie 2010, 274). The concept has far-reaching implications for approaches to consultation and treatment in the context of the relationships between individuals and their societal environments. According to botho/ubuntu, one person's sickness is a concern for the whole community (Mmualefhe 2007), and health for all individuals depends on a strong and supportive community. Despair reduces resilience, while distrust, envy, and hostility make people sick. Even if clients cannot recover from bodily symptoms, dingaka and basangoma may be able to help them develop their sense of coherence by re-establishing sound relations within the spiritual and social fabrics of which they are part (Antonovsky 1996). What in a traditional sense is called “healing” is therefore not the same as modern medicine's “cure” and “the ‘client' of the healer is not the patient at all” (Thornton 2015, 364). While the patient of modern medicine is essentially an idealised sample of the population, the healer's client is a unique person and clients are infinitely different. As I will now go on to discuss, the sole method of accessing a client's uniqueness is the integration of the transrational character of abductive reasoning into diagnostics.
Approaching the singular uniqueness of the client In general, traditional healers diagnose clients by employing an oracle. Most dingaka develop individual oracle techniques, while basangoma practise a more or less standardised technique which entails “casting the bones”. Basangoma enter an altered state of consciousness which might be characterised as a very light form of trance. The client then blows into a small fur bag which contains four tablets of bone, wood, or ivory, in addition to many individual objects. “Traditional wisdom is said to reside in the divining bones, themselves immutable and ordained by God at the creation of man” (Ulin 1975, 97). These four “bones” are each shaped individually and marked on one side. Depending on what side they land on, they are either “open” or “closed”. Together they provide one of sixteen possible combinations (cf. also van Binsbergen 2001).
Each tablet has its own name. For example, the first tablet represents a king or an older man Morimogolo/Kwame (the first is the Setswana name, and the second is the name in Kalanga). Accordingly, the second tablet represents a somewhat younger, less powerful, or less important man (Chilume/Jaro). The third tablet represents a queen, or an older or powerful woman (Thwakwala/ Mmakgadi), and the fourth a younger, less powerful woman (Kgatshana/Lurtgwe)2. The names might suggest that the tablets have a fixed meaning, but in the process of diagnosing the tablets gain their significance in combination with one another. For example, looking at the Morimogolo and Chilume tablets together may reveal a dynamic in which the client appears in an unequal relationship. The client might also be subject to a superior spiritual or natural influence. The tablets can thus be understood as integrating the general principles of seniority and superiority. ((187)) Each combination of tablets likewise has its own name. If only the first tablet lands face up, and the others are face down, the combination is called Morimogolo, like the first tablet itself. Kaone3 explains the meanings thus: „Any habit related to an old man. An old man who is seated, it takes long to stand up, while he is thinking of his life. So, if a thing is stolen…It shows, that that thing is still put, sleepless, not yet disposed of, not yet sold. It is still situated somewhere. Hidden somewhere. Not yet used. Because an old man doesn't go anywhere…Then the other meaning ‘ancestors', related to paternity. Paternal ancestors. Leading to father, ‘ancestors' leading to father… If the person is seriously ill, and it comes quite often, know that this person can't survive. Might will die. So it's a ‘grave'“ (Kaone interview, 16 March 2011) The sangoma does not present a clear-cut and unambiguous definition of the Morimogolo combination. The way Kaone infers here shows how he uses the symbolic character of the core meaning to create ideas associatively. The imagery of the combination can be related to experiences the patients have had in their lives. In the example cited above, it is the old man's physical capability (“takes long to stand up”) which is associated with a case in which something was stolen (“if a thing is stolen”, then “it shows that…”). In the same manner, the distinct themes such as “habit of an old man”, “ancestors”, or “grave” can each be linked to specific dimensions of health, such as physical conditions, social relationships, success, good luck, or fortune. Similarly, each of the sixteen combinations can refer to social and/or spiritual relationships which, by means of their symbolic imagery, can be related to conditions of the body, economic status, social relations, and/or the spiritual balance of the client. Not each and every sign is equally capable of driving such processes of semiosis (weakness through age => the stolen item is not yet sold). The symbolic power of the bones helps the healer to extract such ideas (old man => power/infirmity/wisdom/obstinacy => current problem of the client). A factor further augmenting the openness of this process of interpretation is the possibility that healers might additionally interpret the individual pieces they have added to their divining set and the cardinal direction in which the bones have fallen. Healers believe that the ancestors have “attached different meanings to how the wind blows in a particular direction. That's why we speak of winds” (Setilo interview, 4 August 2017). Again there is strong symbolic reference to essential lived experiences. Within any given consultation, the process of inferring is quite similar (Figure 2). First, the sangoma explains a meaning which intuitively appears to them as being relevant. Previously, the client may have provided some background information which the sangoma may have integrated into their statement drawn from the first cast. The healer may ask the client to comment on such statements. It is not only the healer who has to create an association between the reading of the bones and the client's problem; clients themselves need to establish connections between what the healer says and their own lives. In general, clients are unaware of the oracle's ambiguous structure of meaning. The healer verbally establishes the symbolic power of the bones when, for example, he says, “I see an old man” or “there is an ancestor”. Such phrases may resonate with a client and trigger the client to make sense of a particular experience in his or her life. If a symbol is powerful, clients experience it as an allegory of aspects of their own lives. Clients thus assign their personal meanings to the symbols, which the healer can in turn recognise. The sangoma senses the patient's reactions, interprets them intuitively, and uses them as springboards to further conclusions. 2 The names and the meanings of the tablets, even in publications by one single author, are not consistent (compare, for instance, van Binsbergen 1995; 2005). Reasons for these inconsistencies might include oral transmission of knowledge, regional spelling differences or orthographic errors by healers. This paper uses those names which occurred in the course of my research. 3 Anonymised.
The diagnostic procedure continues with a sequence of several casts, often four. The sangoma repeatedly decides intuitively which meaning to explicate. The openness of the meanings, the intuition of the sangoma and the client's responses generate a unique narrative which explains the client's individual life situation: „The specificity of the message, its symbolic and verbal virtuosity, the generous attention for the patient's predicament, and its being inadvertently guided by the client's input, produces the effect of opening up an entire world hitherto hidden“ (van Binsbergen 2005, 339). ((188)) The consultations offer a new interpretation of the client's problems. The identification of stress factors in areas of life such as relationships, combined with the advice given by the healer, can promote a client's self-efficacy. The emphasis is on breaking established patterns of thought, which permits the client to access a new perspective on life and further their personal self-development.
(Figure 2: Flow chart of abductive sangoma reasoning. Grey dots represent suggested health-threatening factors that appear to be irrelevant. Black dots represent ideas that are carried further to the next step of assessment. ((188))) Healers' power resides in their ability to guide the emerging narratives, rather than in any knowledge of mandatory definitions affixed to the combinations of tablets. During a healer's training, „the purpose of the hours of relaxed joint exercise with the tablets was not so much to memorise the correct meaning of every tablet and combination…but to develop the ability to spin stories, of increasing depth, relevance and drama, on the basis the evolving sequence of throws“ (van Binsbergen 2005, 341). A consultation may produce impasses of interpretation which call for recognition, clarification and resolution. Each new throw offers a broad spectrum of opportunities for interpretation. The healer needs to make what has already been said more precise and come up with a more plausible narrative, refining it each time.
The transrational character of sangoma reasoning Abduction is a highly unreliable approach to inferring. However, it is not irrational, because it is the only way to create hypotheses. It is an essential component of all scientific thinking. We can describe abductive reasoning as transrational because it transcends the theoretical framing of a specific mindset in order to come up with a new idea or solution which cannot be deducted or induced by means of the premises previously considered.
The ambiguous structure of meaning carried by the bones explores the infinite multiplicity of health-threatening factors in order to provide a suggestion about a client's individual life situation ((189)) and his or her personal ill-relations with family members, neighbours, the community, ancestors, and the environment. Such harmful factors are diverse and multifaceted; methods of theoretical rationality would inevitably fail in their identification. Their observation calls for the establishment of hypothetical narratives. „It [a consultation] is not a question of you the practitioner telling the patient what you want to tell them. It is a question of a practitioner and the patient having a conversation with regard to the patient's problem. Because, what does happen is I will tell the patient what the bones are saying and ask them if what I have been told by the bones is correct. But if you allow the patient to talk, if you ask them questions and you allow them to ask questions, than you are able to arrive at a more fitting solution“ (Setilo interview, 4 August). In the final analysis, the client decides whether to accept or reject the diagnoses. Although healers try to make their dealings compelling and performatively impressive, they do not see their inferences as being beyond any doubt. This is an indication that healers are well aware of the limitations of their transrational manner of reasoning (cf. also Thornton 2015). Fallacy is not a failure of spiritual medical epistemes, it is an integral part of them, anticipated and responded to within the process.
The spirituality of herbal medicine After the diagnosis, the sangoma decides which treatment is needed. Treatment might include muti (traditional medicine) and/or rituals. Research on traditional healing often concentrates on traditional medicinal plants, due to their tangibility and accessibility to modern sciences. However, Tswana herbalists do not always use medicinal plants in a rational manner, if “the term ‘rational' is used in this context in order to characterise a prescription of herbal drugs which is understandable to the modern researcher on the background of his own bio-mechanical, medical paradigm” (Hedberg and Staugard 1989, 28). Viewing traditional herbal medicine only in terms of whether it contains pharmaceutically active constituents disregards the full range of traditional treatment. Understanding how herbs are used requires us to additionally comprehend the symbolic and ritualistic value of herbal therapy. Any understanding of muti must have regard to aspects related to social or spiritual disturbances. Depending on the character of an illness, rituals might also require members of the family or the larger community to take part. If so, why do Hedberg and Staugard (1989, 128) restrict their conclusion about the medicinal use of Monamontso (or Monnamontsho) (Euphorbiaceae: Euphorbia sp.) to “stomach pain and stomach bloating caused by constipation”? Healers might have different understandings of the herb, and often incorporate herbs into performative treatments. In the interviews, healers explained their knowledge about herbs with phrases such as “that one is not known by many doctors” or “my ancestors, they taught me…”, which serve as indicators for an individualised use of that herb. For example, Kaone uses Monnamonstho „to treat diseases which are very complicated, like cancer. In traditional ways, we are able to treat it with the application of this one, this black man, Monnamontsho. You boil the herbs, you boil the roots, no matter powdered, no matter unpowdered. You give the person to drink…That thing which is inside there [he points to his body], forming disease – we call it cancer – will accumulate in one place. And then you have to remove it with the use of Kghalahadi [another herb which the healer is supposed to take], which will give you power to remove it“ (Kaone interview, 7 May 2011). The medication is thus part of a therapeutic procedure which finally results in the doctor taking out the disease from that part of the client's body where it has amassed. The life-prolonging effect of such procedures on cancer patients is unclear, but psychosocial intervention has been proven to at least be beneficial with regard to quality of life (see, for instance, van der Pompe, Antoni, Visser, and Garssen 1996, Wojtyna, Życińska, and Stawiarska 2007). Some healers, according to their own assessment and that of their clients, are highly successful and are consulted frequently. The WHO recommends the integration of traditional health services into national health systems (WHO 2002). However, such cooperation seldom works in practice, and Botswana is one of the last countries in ((190)) southern Africa to not yet have instituted legal cooperation between the systems.
Conclusion According to a pragmatist account, the dichotomy of modern and traditional medicine can only be resolved if practitioners start cooperating. However, cooperation requires mutual appreciation. Starting from the actually given separation, a first step could be to establish a notion of the respective qualities of each camp. Despite the great diversity of the field of traditional healing in Botswana, we can perceive, through the observations detailed here, the distinct quality of traditional medicine in the country as a discrete medical episteme. This perception is accessible in comparison to a dialectic other, which in this case is modern medicine. Awareness of the differences between the two aid us in drawing boundaries and lines of identification, which at first sight might seem to reify the distinction, but allow us to show firstly that differences are just gradual not essential; secondly, that both approaches bear benefits and do not exclude each other, and thirdly, that epistemes are historically contingent phenomena that primarily exist because they are practised in the way they are believed, reasoned and performed. An episteme is characterised by a certain worldview (ideological dimension), enacted practices (performative dimension), but also specific forms of reasoning (logical dimension). The episteme appears as a coherent system because these dimensions smoothly fit together in praxis, where the epistemes permanently reconfirm themselves on an everyday basis. Traditional healers and modern doctors alike experience their profession as meaningful, well founded, and effective. Ideas, opinions and convictions are central to the ideological dimension of an episteme. Modern medicine prizes nosographic knowledge because consequential deductive and inductive reasoning and/or conventionalised probabilistic threshold practices confer upon it the status of “truth”. Traditional medicine does not endow “knowledge” with the same authority. The ideological dimension of an episteme refers to premises of thinking, which derive from historical processes of societal inquiry about the world and may include the assumption of a strict causality to natural processes. As they emerge, they are accompanied by associated knowledge/ beliefs, such as the biomedical model of illness and its concomitant catalogues of diagnoses. Such belief patterns mostly imply a broader assumption about the condicio humana, which incorporates moral notions; one example relevant to this field might be whether avoiding death or improving quality of life is more desirable. Knowledge is thus always connected to ethical codes. Practices, like beliefs and knowledge, are also derived from historical processes of trial and error; they emerge from a performative dimension of the episteme. Assessing an episteme necessitates both having regard to the ideal-typical manner of accomplishment of practices and taking into account cases in which these practices fail or are interrupted. The ways in which professionals respond to such incidences may uncover the blind spots of the episteme. Rules and norms of reasoning determine the assessment of ideas or practices as either reasonable or unjustified (in the terminology of modern sciences, rational/irrational) and thus constitute the logical dimension of an episteme. These rules and norms determine how empirical experiences justify knowledge and, conversely, how practices come into being on the basis of accepted knowledge and beliefs. It is thus enlightening to identify which ideas receive the vague status of “beliefs” and which are awarded the cachet of “truth”. The logical dimension requires special attention because reasoning mediates between the ideological and the performative dimensions of an episteme. The deductive, and partially also empirical, manner of clinical decision-making leads from the singular case of a suffering person to a universal sketch of a diagnosis (see Figure 1, Wulff and Gøtzsche 1999). In contrast, traditional healers derive diagnoses from a series of abductions guided by ritualistic procedures. The bones' symbolic power and inherent ambiguous structure of meaning are appropriate means to lead the healer from the indefinite multiplicity of possibilities to the singularity of an individual's health-threatening factors (Figure 2). Healers do not renounce rational thinking, nor do they forget about their knowledge of effective medicinal plants. They just deliberately put rationality aside for a while. The notion of transrationality is appropriate to describe how healers use empathy, lived experiences, happenstance, and faith in ((191)) order to draw conclusions. Such diagnoses may have the capacity to offer a new perspective on the client's life, a matter which
the client evaluates. As rational inferences are most suited to the procedure of comparing patterns of symp toms exhibited by a patient with a catalogue of explicit disease descriptions, transrational reasoning is the only way to generate a suggestion of what might be the unique pattern imperilling a client's health. Psychosomatic medicine and psychotherapy, at least in the therapeutic process after diagnostics, similarly aim at seeing patients in their individual needs and the unique difficulties of their life courses. Moreover, the implications of psychoneuroimmunology, salutogenesis, and the biopsychosocial model of illness point to strikingly similar views on an infinite multiplicity of health-threatening factors which calls for a rejection of the body-mind dichotomy (Pauls 2013). The notion of transrational thinking might thus also offer inspiration to modern medicine. Traditional healers in Botswana tend to be relatively open to adopting influences from other cultural and medical regimes and from “changing social, economic and environmental relations” (Andrae-Marobela et al. 2010, 4; cf. also Thornton 2009). Preserving their specific understanding of healing, illnesses, therapeutics, and reasoning is crucial to the maintenance of their identities. However, as things stand currently, healers feel patronised and see themselves as subject to a modern attempt to control their business. What is labelled as “cooperation” appears to them as indoctrinatory re-schooling (see above: Setilo interview, 18 August 2012). It is unlikely that collaboration between traditional healers and modern medicine will be successful to any degree until modern doctors respect the transrational character of their traditional colleagues' reasoning.
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