M. Paula G. Meneses

When we speak of rival knowledges today, most analyses begin by presenting modern knowledge systems—such as biomedicine—as globalized forms of knowledge (Chavunduka, 1994; Wayne, 1994; Mappa, 1998). In several studies produced in Africa, the act of situating the "others’" knowledge becomes the key moment in the production of a relationship of inequality; from this standpoint, pre-modern forms of health care are characterised, en bloc, as traditional therapies, frequently of only local relevance (Ngubane, 1981; Hewson, 1998). The definition of traditional midwifery, healing and herbal medicine as the main components of ‘traditional medicine’ (WHO, 1996) manifests an extreme simplification of the concept of health, which fails to take note of the historical, social, economic, political and cultural specificities underlying the development of knowledge about health (Meneses, 2000).

In Mozambique, in most of the work on ‘traditional medicine’, the dominant discourse confers on modern science a hegemonic status, which is defined and protected by the state as ‘official knowledge’. In contrast, local, native, forms of knowledge are given a secondary position (Marrato, 1995; Tsenane, 1999; Instituto Nacional de Estatística, 1999). The search for a definition of ‘traditional medicine’ which goes beyond the diversity and heterogeneous character of its therapeutic practices and knowledges is inscribed in the social order resulting from the process of colonisation of knowledge itself. What transforms these practices into objects is simply the state's refusal to recognise them (Santos, 1995).

The alternative hypothesis which I would like to discuss in this study is based on the argument that the forms and practices of so-called ‘traditional’ knowledge constitute in fact legitimate knowledge, a status which is conferred on them by the considerable number of patients that seek traditional doctors. This fact may help explain the enormous vitality and persistence of such practices, both in the colonial period and the present day, notwithstanding the repeated attempts at ‘epistemicide’ to which these forms of knowledge about health have been subjected. Yet, many other aspects have to be explored: for example, what is alternative medicine? Alternative in relation to what and whom? What should be considered legitimate knowledge? Legitimate in whose eyes? For knowledge to transform itself into solidarity, which guarantees the liberty and equality of each culture, it is necessary to give that ‘other’ culture the status of subject.

Questioning the dichotomous relationship between local and global forms of knowledge, seen from the perspective of the evolution of ‘traditional’ medicine, is the main analytical focus of the present research. The data and ideas presented here are the product of a research project that I have been carrying out for over 18 months in the city of Maputo, especially in the neighbourhood of Polana Caniço (in the city's suburban area).

This is an extraordinarily complex region, of considerable cultural wealth, where there are various health systems which frequently intersect and interpenetrate. To analyse this plurality of medical systems (McCormack, 1986) is not an easy task, since the interaction of elements of different medicines and the differing perceptions of individuals and social groups about health, well-being and disease create an immensely complex fabric which manifests itself in forms of ‘intermedicine’.

In a world of permanent production of cultural differentiation, this process acts as a catalyst of spaces crossed by political and economic relations deeply rooted in inequality. Therefore, in this study, the initial discussion will be focused on the questioning of the reasons that have led to the construction of this difference. Who is the ‘other’, the one that produces and preserves other forms of knowledge?

In order to evaluate existing perceptions about the distinct medical systems in place, several interviews were carried out both with practitioners of traditional medicine and their patients, as well as with participants in the elaboration of health policies in Mozambique (governmental organisations and NGOs). The in-depth interviews involved about 30 people, whose ages varied between 22 and 60 years. Most were interviewed separately. Most of the data presented and discussed comes from interviews with ‘traditional doctors’ from the new board of directors of AMETRAMO, who shared with me, almost on a daily basis, their ideas about their practice and knowledge, their problems and doubts.

To write a text using as a narrative basis ‘other’ perceptions of knowledge was not an easy task. While adapting myself to another world, quite complex and dynamic, I came to realise that a reflection on how to emancipate this knowledge could only be achieved by producing a mestizo text. This explains my decision to write a text that shifts from a situated narrative to a more detailed analysis of the topic, avoiding the elaboration of a stereotyped image of the ‘other’; this was made possible by presenting the subjects in their own words and perspectives, each with his/her own individual identity. The choice of personal narratives allows me to present the process of construction of the particular ‘self’ of each subject, while evaluating the narrators’ biases. In this text, the ‘I’s became an active component of the discourse, a part of the analysis of the phenomenon, and not the phenomenon itself, raising many questions still to be explored in the future. This has required a detour through the interpretative field of the very concept of health, a reconsideration of the place and role of existing medicines in Mozambique, in which the voices of several of the actors involved in this question are heard.

In several conversations I had with a traditional doctor, she would say to me: "there are our diseases, traditional [diseases], but there in the college [Faculty of Medicine] they don't know what these are. But when there are problems we don't understand, we send them to the hospital." These words underline the statement made by several authors about how illnesses or maladies are explained: etiologies are a direct expression of the norms and representations which sustain social structures (transgressions of prohibitions, manifestations of ancestral spirits, aggression by witches, etc.—Dozon, 1987; Hess, 1994).

In a country like Mozambique, with an extremely complex socio-cultural fabric, there is an unquestionable mixture of medical subcultures, each with its own characteristics and structures, although, through ignorance, biomedicine describes them as a homogeneous entity, resulting in the general reference to a single traditional medicine (Nordstrom, 1991; Jurg, 1992; Frelimo, 1999). This stereotype, the product of colonial situations, is still very prevalent today.

As I shall discuss in the body of this paper, it has been possible for some time to detect the development of medical hybridisation in Mozambique, an hybridisation which accepts the modern model of medicine, and even creates space for its practice. Seen from this angle, the vitality of traditional medicines reflects the difficulties of a biomedicine which seems to be unable to achieve its objectives. The hybridisation of therapeutic knowledges constitutes a complex diversity of transformed appropriations which are not by any means fixed in space and time, as so often is imputed to ‘traditional values’.

As a starting point, the analysis of this plurality of medical systems is made through the cautious use of the variables official/non-official, traditional/modern. Caution is necessary precisely because of the situation of inter-medicine, of the constant mixing and intersecting of decisions which give rise to a multiplicity of hybrid situations.

The official/non-official dichotomy is defined by the state, which establishes by law—among the wide variety of therapeutic forms—a more or less explicit distinction between what is legal and what is illicit, if not illegal. Everything recognised as official medicine is the object of support by the state. Medicine not recognised as official is tolerated, but most frequently ignored, due to its low permeability to the impositions and control of biomedicine.

The ongoing formalisation of traditional medicine is the cause of its own fragility, and this normative process is a reflex of the character of the state in Mozambique. From the perspective of modern medicine, traditional medicine encompasses several knowledges, such as biology and chemistry (i.e. plants and their extracts used as remedies), biomedicine (the treatment and curing of the body), justice (resolution of problems and conflicts which express themselves in bodily illness), and religion (explanations for beliefs described in terms of a magico-religious set of concepts). This reduction of the complexity of knowledge to a list of scientific fields, through the compartmentalisation and normalisation of knowledge, is the most visible expression of the state's formalisation.

Indeed, in the ‘traditional’ sphere, the institutions which take on the healing of illness are simultaneously political, therapeutic, juridical and religious; they cover an extensive field of competencies and functions which place the efficacy of treatment within a more enveloping efficacy, bringing into play institutions of authority, normative and symbolic structures, and relations of force, knowledge and power (Fisiy & Geschiere, 1990, 1996; Geschiere, 1995, Fisiy & Goheen, 1998; Comaroff & Comaroff, 1999).

Modern medicine appears only as another therapeutic practice in this region, and it does not constitute, even today, a real competitor to other medicines, which have maintained their vitality. The common denominator is to be found, paradoxically, in the fact that these ‘traditional’ medicines have the advantage of not constituting an autonomous domain, enclosed by a body of rules, knowledge, practices and specialists. In fact, so-called ‘traditional’ medicines are embedded in many other sectors of social life—in this sense, they require that we redefine the concept of ‘illness’, of ‘malady’, which goes beyond the notion of misfortune or unhapiness, and which includes cognitive, symbolic and institutional aspects of society.

As mentioned above, the fundamental question to be posed is how the dynamics of hybridisation of these medicines developed. This universe testifies to the coexistence in the social sphere of the institutions which treat illness and malady in general, at the same time that they treat society itself—whether such treatment is to ensure the reproduction and maintenance of the existing order (norms, representations) or its perturbation (tensions, conflicts, collective misfortunes). In this process lies the heart of the internal resilience of traditional medicines in Mozambique.

Illness, as a sign of maladjustment, of individual and social imbalance, is, like other signs, the object of ambiguous and fluid representations, constructed as practices of knowledge and the exercise of power (Appadurai, 1999; Santos, 1995, 2000). In a world where the hegemonic imposition of scientific knowledge is widely present, but in contest with other forms of knowledge, one of the main battles concerns what needs to be known (or ignored), how to represent this knowledge, and for whom.

In Mozambique, the search for a definition of ‘traditional medicine’, beyond the evident diversity and heterogeneity of therapeutic practices, has to be inscribed in the social order resulting from the process of colonisation of knowledge itself—what turns these practices into an object is simply their non-recognition by the state and its institutions. This process implies the creation of the ‘other’ as non-knowledge, included in the natural world and excluded from the civilised world (see, for example, Liengme, 1844-1894; Maugham, 1906; Pina, 1940; Silva Tavares, 1948; Santos Reis, 1952). Therapeutic knowledges and practices are then fragmented according to the classification systems of modern science. This compartmentalisation of knowledge allowed the colonial system to appropriate the pharmacological principles of various products used by local therapists, as is shown in various records of Portuguese scientists working in Mozambique: "The remedies employed by indigenous doctors are numerous; they use them in many illnesses and at times with notable success. There is much to study in local plants, some of which may be of use" (Santos Junior & Barros, 1952: 615). At the same time, the process of situating this knowledge, and then restricting it to a symbolic content, invests the communities that possess it with an exotic aura, making them relevant for anthropological study, as well as for ethnic tourism (Meneses, 2000). In identifying local knowledge as ‘sacred’, the focus of action is diverted from its creators, while at the same time the barriers between Self and Other are continuously reinforced, thus sustaining knowledge as colonisation.

The excerpts presented below constitute examples of the subterranean continuity of a discourse in which the opposition between medicine and magic is reinforced through the division between biomedicine and traditional medicine. Both in the past and in the present, ‘traditional medicine’ is associated with localised, native or indigenous knowledge (Batalha, 1985; Green, 1996; Hewson, 1998; Green et al., 1999).

In this excerpt, it is important to observe the hostility with which medical practices are evaluated, and also how the traditional doctor and the witchdoctor are conflated.

Another characteristic aspect of modern medicine is its low degree of openness towards other possible forms of diagnosis, which, because they are different, are not recognised as equally important as auxiliary means of detecting illnesses.

These last two extracts, both produced in Mozambique after independence, illustrate the attempt to impose modern knowledge through the annihilation of practices which did not fit the project of development proposed by the Frelimo party (in power since independence) and supported by the State.

Finally, the next quotation, while trying to make a clearer differentiation between traditional and modern medicine, reinforces the above proposal of Frelimo’s government (regarding the duality of practices), implicitly supporting the subordination of tradition to modernity.

By mediating between the performance of an act and the intention of those who select the content of representations, it is possible to produce phenomena which are a distortion of reality, and which justify the preservation of the binary and geographically specific opposition we/others (Goody, 1979:35; Barth, 1995; Santos, 2000).

The hegemony of modern science results in the local confinement of knowledge, which can be both the cause of discrimination as well as the basis of resistance to this form of globalisation. But how do traditional doctors see themselves? Localism appears as a form of security and affirmation of what is specific to themselves, of a knowledge which belongs to them and which thus enables them to acquire space for manoeuvre, spaces of empowerment.

For traditional doctors, their ‘medicine’ is what happens "here, in our space." The patients themselves establish a very clear distinction between the limits and application of biomedicine and those of traditional medicine. The distinction is made according to the context of production/reproduction of knowledge about good and evil.

For the majority of the population of Maputo city, and even the whole of southern Mozambique, the concept of health is very broad, referring implicitly to the existence of a social balance, a concept not unique to Mozambique or Africa, since it is present in various cultures with distinct medical systems.

"To have a good life" are words which best summarise what is meant by being in good health. A good life translates into "having a well-built house, enough food, money for clothing, for soap, for the children to go to school, for the hospital’; "we feel good when there are no problems, when we have food, and when the family is fine." The expression of these feelings suggests that in order to be in good health it is necessary to achieve an internal balance, to be at peace with one’s family (including one’s ancestors), with neighbours, with one's own body (including hygiene); to be properly fed (which means having employment to ensure income) and protected from ills, whether natural or ‘visited’. When someone produces a lot, has a good harvest, finds a good job or has a good house, a member of the family or a friend may envy such wealth and resort to a traditional therapist to cast a spell against that person. "People today suffer much from bad luck, and even die as a result of jinxes, without deserving such a fate..."

These conceptions about the role of traditional doctors require a deeper analysis, as well as a re-evaluation of both the ethical and emic principles underlying the emergence of concepts concerning traditional medicine.

A discussion of the ethical boundaries of a medical system which extends far beyond the established limits of biomedicine implies broadening the analysis to the field of so-called witchcraft.

As mentioned above, the process of negation of knowledge of traditional medicine involved the identification of the image of the healer with that of the witchdoctor. But these are in fact entirely different, as both patients and practitioners of traditional medicine attest:

To overcome misfortune or bad luck it is necessary to get the help of the traditional healer so as to re-establish individual balance. But a traditional healer can also be used with malicious intent:

The constant demand for traditional medicine is more visible today because there are many more individuals on whom the fortunes of modern or, indeed, traditional, society have not shone, and who are searching for success—through promotion, wealth, and business opportunities, for example.

The very classification of illnesses being treated by traditional doctors working in Maputo is very different from that used in biomedicine. Side by side with epilepsy, scabies, tuberculosis and ‘eye pain’, there are also other pathologies such as ‘marital problems’, ‘witchcraft’, ‘bad luck’ and ‘evil spirits’. In the ‘traditional’ sector of society, if things to do not go well, when production fails, when there is ‘misfortune’, the traditional doctor is consulted to find and explain the source of the problem, and also to give medicines either to eliminate it or to restore relations with the ancestors.

The main available sources for the analysis of witchcraft consist of accusations and rumours, which raises numerous problems in the evaluation of its persistence and efficacy.

First, we should notice the pertinence of the opposition between scientific knowledge and local representations in the discourse about the ‘other’. Although today this idea is prevalent in many studies, what is important to see is who benefits from these situations and how witchcraft is related to the reproduction or the rupture of the social order. The persistence of the phenomenon of witchcraft accusations, while implying a marked ambiguity—because it is related to some form of power—shows that it is essential to the functioning of society, providing a supplementary force which may even serve constructive ends. Thus, witchcraft should be seen as constituting a possibility for resisting change and continuously emerging inequalities; it may also stimulate attempts to appropriate new resources.

The tenacity with which witchcraft prevails in Mozambican society means that conceptions of power and its exercise have specific implications, since these situations are symmetrical in terms of feelings of power (protection—traditional doctor) and impotence (envy—witchcraft). Traditional medicine offers means to build up power, but at the same time reflects feelings of impotence, since it appears to serve to conceal the sources of power. In societies in which the role of family networks is very strong, witchcraft and the appeal to the traditional doctor for social promotion show how closely connected these two phenomena are, a subject analysed in more detail below.

The discourse on witchcraft is not exclusive to Mozambique (Geschiere, 1995; Englund, 1996; Mappa, 1998; Comaroff & Comaroff, 1999) or even to Africa (Taussing, 1987; Escobar & Pardo, 2000). However, in the region where this study took place, witchcraft operates as a privileged mirror which permits greater manipulation of the ‘traditional’ in the struggle for the construction of ‘another modernity’.

Discourses concerning witchcraft do not express a resistance to modern development; rather, they are reflexes of a constant struggle for a better life. Because traditional medicine is an open system, formally delimited only at the level of the statutes of one association, there are innumerable possibilities for explaining the problems that people experience in life. This enables an anthropophagic interaction of different elements which are part of the project of the creation of "another modernity" (Ong, 1996; Santos & Trindade, 2000). In this sense, witchcraft accusations, far from reinforcing a radically different otherness due to the strange exoticism of witchcraft, constitute a discourse of struggle concerning problems that affect the family, the community and society.

From the brief collection of opinions presented above, what seems to emerge specifically is the fact that in a context of searching for solutions for misfortune or malady, the concepts of conflict and social imbalance are the central axis around which the whole process of the treatment and cure of the person affected revolves. It is this social space which is occupied by the figure of the traditional doctor.

Although there are various designations for traditional therapists, the most common is ‘nyàngà’. The nyàngà is a doctor who heals, who knows the power of medicines and how to heal with the help of ancestral spirits.

In a text that seeks to give voice to distinct actors, it is necessary to allow traditional doctors to introduce themselves, to define their specificity as well as areas of contact with modern doctors.

An interesting aspect is the fact that all traditional doctors refer to the initial period in ‘their calling’ by ancestors’ spirits to learn to be healers as a very difficult period, of pain and suffering:

The selection of the future traditional doctor occurs through a mechanism of painful rupture (simultaneously physical and spiritual) with his/her family and community, a mechanism that seems to be beyond the control of the would-be healer. During the process of perception of his/her new social role, the candidate suffers from inummerable physical and psychological maladies which have no plausible explanation (and thus cannot be cured) within the biomedical paradigm. This unexplained malady works as a password for admission into a different universe of knowledge which is the basis of the doctor’s power of decision in the solving of problems he/she will have to deal with in his/her therapeutic practice. This ritual rupture happens whenever a problem of some gravity occurs, a problem which requires great seriousness and knowledge: "(...) afterwards, even when we are working and the spirits come out, it hurts a lot, I lose the power of my arms and legs, I cannot move or do anything at all. It is really painful when they come out in us." As several traditional doctors mentioned, ancestral spirits momentarily occupy the therapist’s body in order to help him/her with the diagnosis and detection of the roots of the problem, as well as with the selection of the necessary medication.

The period of apprenticeship of a ‘thwasana’ usually lasts from two to five years, and may be even longer. Under the supervision of his/her ancestors (who have chosen this person to perpetuate their knowledge), the candidate has to select the ‘b’ava’ with whom he will learn to become a qualified therapist.

It is not easy to learn to become a traditional doctor, and the ethical principles involving human beings are shown in the concern about avoiding errors, and in the professional secrecy about the patient’s ailments, among other aspects.

Illness is something abnormal installed in the body, which, as it comes to be felt as pain or discomfort, alters the person’s normal balance. It is therefore necessary to locate and treat the physical or spiritual source of the problem and re-establish normalcy. The ailment may be derived from not fulfilling social rules (such as ‘timhamba’), from the dead not having been properly buried, contagion from impure objects, and action of malevolent spirits (the ‘valòyì’).

Thus, the cause of the ailment is defined by identifying the alien object which has got into a person's body through different means (touch, sight or smell). To alleviate the ailment, it is necessary to use medicines—‘mìrhri’—which allow the patient to recover the full state of health. These medicines are used to heal the body, to cure the pain which assails a particular part of the person, and at the same time to restore self-confidence. The ‘nyàngà’ cures the body, heals the wounds, eliminates the suffering of the organism, using the knowledge he/she has of nature, and simultaneously treats the perturbations of mind and spirit which are caused by socio-economic imbalances or by traumas at work.

Traditional doctors seem to know best how to deal with so-called ‘traditional’ illnesses—i.e. illnesses with a heavy emotional component—because they deal with the body and the spirits which ‘invade’ the body and cause diverse problems to patients. Thus, the ‘nyàngà’ plays a double role—divinatory and curative—based on a broader conception of illness, understood at two levels: as a social phenomenon, resulting in deep changes in everyday life, and as a physical phenomenon, a manifestation of changes in someone’s body. The divinatory function seeks to treat the causes of the illness, prescribing several means to solve it. The curative function seeks to eliminate the physical symptoms. These two functions complement each other, and both help cure the patient. For the traditional doctor, healing means removing all the impurities or imbalances from the patient’s life, and thus each treatment normally ends with a purification ceremony which aims to prevent similar situations from happening in the future.

In the Mozambican society, like in other societies, witchcraft acts as a regulatory element of dissonant social pressures (Meneses, 2000; Santos & Trindade, 2000). Those who have a lot of money or power do so because they have taken it from someone else with the help of somebody. Those who die, those who suffer ‘misfortunes’, do so because they are ‘sick’, they have problems with success, or there is someone who dislikes the fact of their being different; it may also be somebody trying to break away from his/her social group.

For example, infertility is sometimes interpreted as having been caused by someone who does not want a woman to stick with her husband, which in the last instance would imply the annulment of the marriage and the weakening of family and community ties. For the resolution of this problem, all possible means are employed, including ‘non-traditional’ medicines:

Traditional doctors recognise that they are not able to resolve all cases presented to them, and frequently, after several failed attempts to treat a problem, they suggest that the patient consult practitioners of other medicines, including biomedicine (symbolised by the hospital).

Thus, the plurality of medical systems makes it possible to resort simultaneously to different forms of ‘treatment’ which can identify problems with a physical expression. In parallel, there is also a system that punishes and regulates maladies. They are two sides of the same coin, the physical and the social ills, the individual and community conflicts and tensions, in a system still very much in transition (and quite often at the brink of collapse) to a capitalist society of individual accumulation.

Another factor to keep in mind is that of contamination, since frequently an illness—if it results from the contagion of ‘unsatisfied’ spirits, and if it is not effectively treated—can affect other members of the group. If obligations to ancestors are not fulfilled, they can withdraw protection from an individual, a family, or even a community, since their spirits continue to be a part of the family structure. The ailment caused by this absence of protection is seen as a demand made by ancestral guardians that broken ties be re-established, thus calling attention again to the question of witchcraft as a regulatory system of social imbalances.

The considerable dynamics of traditional medical action can be contrasted with the project of the Ministry of Health on the collaboration with practicioners of traditional medicine as a part of its health policy (Jurg et al., 1991; Frelimo, 1999). The system of public health developed by the state after independence places special emphasis on prevention. It seeks to reach the majority of the population, rural or peri-urban, through the establishment of a vast network of basic health units and agents capable of offering elementary health care, as well as promoting health through education and the improvement of conditions of hygiene. The effect of such policies depends in the first place on the participation of the targeted populations. For this reason, the WHO (1978) has recommended the inclusion of ‘practitioners of traditional health’ within national health systems. Since this policy considers populations as partners in its implementation, and not merely passive recipients, the rehabilitation of local therapists, who have long been directly involved in such practices within communities, is essential.

The state has been using this justification to legitimize its interest in so-called traditional medicine, although this alone does not explain the underlying ambiguities which affect both the notion of valorising ‘traditional medicine’ and the practical experiments which are recommended. In promoting a discourse that supports the integration of traditional medicine with modern medicine, the state and WHO itself (Jurg, 1992; Monekoso, 1994; World Bank, 1994; Aregbeyen, 1996; WHO, 1996; Friedman, 1996) aim to remove from traditional therapists the control over the treatment (in its various forms) of the majority of the population. In supporting the formalisation of ‘traditional medicine’ according to the tenets of modern medicine, the former is circumscribed to a collection of empirical knowledge (medicinal plants, pharmacopoeia, and practical know-how), physical techniques and epidemiologies (Tomé, 1979; Marrato, 1995; Lambert, 1997). The knowledge of the traditional doctor is only seen to be valid as a complement to biomedicine; the traditional doctor is seen as one who needs to be trained, but who does not participate in the training of biomedical doctors (Norstrom, 1992; Cunningham, 1995). This fact has resulted in a certain condescending resentment among traditional doctors: "We have no bitterness toward them [i.e. practitioners of modern medicine] but we also want recognition, they have to respect us (...) we want to work with them, but also to teach what we know, it is not just plants."

All these aspects suggests that we should make a deeper evaluation of the importance and legitimacy of different bodies of knowledge.

It is necessary to conduct a brief analysis of the privileged role of the state, the arbiter which attributes itself the special status of establishing the rules as well as playing the game. By looking at who is authorised and/or favoured by the state, what knowledges are tolerated or suppressed, what practices are recognised or even ignored, it is possible to get a stronger and clearer idea of the logic of the state's action. This implies analysing the fields of power from the point of view of the social recognition of different categories of health practitioners, in the complex interplay between competition and complementarity (Fassin & Fassin, 1988).

For the state, in the present as in the past, the delimitation of what is knowledge and magic, of the official and the non-official, is done according to normalised practices which the state itself controls. In the perspective of rational legitimation imposed by the colonial system, only those who study in formal institutions of learning are authorised to practice medicine. This must have been one of the main reasons which led, at the beginning of the 1990s, many traditional doctors to establish their own association (AMETRAMO), a fact discussed in the next section.

People legitimate the health practitioners they consult, whether they are trained in biomedicine or in so-called traditional medicine. Usually, traditional legitimacy is spontaneously associated with the ‘nyàngà’ and rational legitimacy with the modern doctor (depending on his/her certificates). The acceptance of traditional doctors depends on the loyalty and confidence of those who recognise them as the inheritors of wisdom. Their legitimacy, the recognition of their competence within a field of knowledge, is ensured by those who constantly consult them. Among the traditional doctors themselves, legitimacy is reinforced by belonging to and sharing an ancestral knowledge, which is retrieved during the ‘visitations’ of the spirits. The commitment to curing a patient, as well as the ethical behaviour of the traditional doctor reflect on his/her professional success: "When you do good work, it becomes known. People know that I can cure illnesses, they come from long distances (...). They have heard of a healer in Maputo who cures this or that illness. That is how people know that I can heal properly, because I’ve healed many people."

One of the most notorious forms used by biomedicine to disqualify traditional medicine lies in the characterisation of the latter as an illegal practice, as well as in demonstrating the absence of ‘scientific’ procedures (such as experimentation) or understanding of epidemics or contagion (Polanah, 1967-68, 1987; Junod [1917] 1996). All these factors confirm the ‘local’ negative characterisation of traditional medicine from the modern ‘scientific’ point of view, which in effect omits references to their procedures of work so as to bolster the ‘scientific’ status of biomedicine. However, work on and with traditional doctors has shown that there is a continuous process of inquiry and search for new medicines and solutions, as well as the exchange of information among therapists. All of this implies the existence of experimentation, which, furthermore, is not a recent phenomenon:

What stands out in this brief historical analysis is that traditional medicine seems to be able to adjust to new therapeutic systems, seeking to negotiate positions and maintain or gain recognition and status, while biomedicine is still searching for ways and means to demonstrate its competencies.

The various attempts to suppress traditional medicine, or at least to limit its practice to ‘uncivilised native subjects’, led to changes in the traditional doctors‘ field of action, a process which in fact constitutes evidence of the extraordinary capacity of this medicine to adapt itself and appropriate the mechanisms created by the state to its own benefit (Meneses, 2000). Like any attempt of social imposition, this type of interference has resulted in periodic crises of vulnerability.

With the implantation of the colonial system, the Portuguese state attempted to eliminate traditional therapists, condemning their activities as superstition and magic (di Celerina, 1846; Cunha, 1883; Junod, [1917] 1996; Silva Tavares, 1948). This resulted in the imprisonment and banishment of numerous ‘healers’, particularly during the 1920s and 1930s. However, because of the scarcity of doctors and nurses in the territory, the colonial state rapidly came to accept the presence of healers, since it could not provide for the health care needs of the population:

As a result of the fragility of the Portuguese colonial system, traditional doctors were able to request and obtain formal authorisation (by the state) to act as therapists in areas where there were no practitioners of modern medicine, or where confidence in these was not very high.

In the period immediately after independence (late 1970’s and 1980’s), the first movement of traditional therapists attempted to gain more space for action. Among the proposals made to the Transitional Government Commission for Restructuring Health Services by a group of traditional doctors in 1975 was the creation of a School of Tropical Medicine to train more traditional practitioners. This was refused, already after independence, "because traditional medical practices are limited to empirical knowledge mixed with obscurantism. The official recognition of a healers’ organisation would amount to the institutionalisation of obscurantism (...) This implied the practice of private medicine, which was not legal at the time."

Because it was important "to make use of the knowledge, but not the person, for the attitude of the person was obscurantist," and as a result of pressure exerted by various traditional practitioners on Government and Frelimo party organs, the National Directorate of Preventive Medicine at the Ministry of Health was given the task of creating the necessary means to research and collect plants used by traditional health practitioners (Castanheira, 1979; Tomé, 1979). At a juncture in which the field of action of healers was severely limited, the collection of plants and discussion of their use with the GEMT and INIA was one of the few possibilities for the continuation of their activity, albeit with a semi-legal character.

Although the traditional doctors expected greater openness, since "now the country was finally ours," both doctors and magistrates of the post-independence period, due to their western education and the political objectives of the time, looked on witchcraft and the practices of healers as a shameful phenomenon. It was necessary to abandon them in order to construct a new knowledge, free of superstition and obscurantism. Once again, in the post-independence period, the state emerged as the unwitting ally of witchcraft, in maintaining the prohibition of ordeals and legitimising their application by traditional authorities and institutions. If in the colonial period some forms of practice by traditional doctors were still permitted, now their prohibition was instituted, with healers being persecuted (even those who could solve cases of witchcraft and cure people). In this hostile environment, ‘traditional therapists’ were now called ‘obscurants’, with old mentalities (Castanheira, 1979; Tomé, 1979; Machel, 1981; Serviços de Nutrição, 1981).

In M.F. Zimba’s words, this was a really difficult period, and only the formation of an association of traditional doctors could alter the situation:

At the end of the 1980s, with the introduction of neoliberal policies, the opening toward traditional medicine widened, until in 1991 the practice of private medicine was liberalised. This made possible the formation of AMETRAMO—The Association of Mozambican Traditional Doctors.

While traditional doctors were severely circumscribed in their practice after independence, they were nevertheless contacted by people's courts to resolve cases of witchcraft, misfortune, and others.

It must have been the role of the traditional doctor as mediator (recognised by the community) in the resolution of problems which by and large led the state to attempt to control these therapists through the creation of an association.

AMETRAMO is indeed a meeting point of centrifugal forces, representing simultaneously an attempt at control by the state (and some political parties) and a plural space of assertion for traditional doctors. In this sense, for the ‘tynyàngà’, AMETRAMO is a vital space of rational legitimation. This is all the more crucial since in their professional activity they feel they run the constant risk of being repressed by a state which defends and promotes biomedicine, while discriminating against traditional medicine:

At the same time, the association is needed to grant certificates on the healers’ capacities. Following bureaucratic procedures (such as issuing membership cards, certificates, etc.), AMETRAMO leaders seek to identify the ‘real healers’, separating them from charlatans. According to the statutes, the association intends to extend the method of certification and officialisation of traditional practitioners to the whole country, so that they can work in greater security, and participate in the struggle for better health in Mozambique. As AMETRAMO has repeatedly declared, "we would like to work more closely with the Office for the Study of Traditional Medicine [Gabinete de Estudos da Medicina Tradicional] at the Ministry of Health, with the National Institute of Health, as well as other institutions which are dedicated to the prevention and cure of illness."

Finally, as the AMETRAMO members sustain, the formalisation of the association is related to the need of reinforcing the organisational capacity of traditional doctors, so as to gain more support for them and ensure their social and professional status, restricting competition from other practitioners. Indeed, in addition to competition and non-recognition by official medicine, there is now another fact they have to face—competition from foreign traditional doctors living in the country: "We are going to ask for an explanation about the entry of foreign traditional doctors into the country. And, although these doctors have a permit, we shall demand of the Government that they present themselves to our Association first." The more threatened traditional doctors feel in their field of activities, the weaker becomes their traditional legitimacy. Therefore, they have to resort to official recognition, making use of ‘legal’ structures to repress ‘the other’s tradition’.

Although subject to some bureaucratic rules (such as the necessity of having a membership card, the payment of fees, etc.), AMETRAMO members are free to respond to the dynamic changes of context which are continuously occurring. How far can AMETRAMO go in the bureaucratisation of the organisation? In order to answer this question, we have to evaluate the distance between the intentions expressed in discourse and daily practice.

The statutes of AMETRAMO establish on paper that the role of the Supervisory Council [Conselho Fiscal], as one of the directive bodies, is to supervise the administrative affairs of the association; in practice, as was repeatedly stated by members of the current board of directors, the main function of the Supervisory Council has been "to supervise the activities of its members," that is, ensure the application of the ethical principles of traditional medicine.

On the formal plane, the recognition of traditional doctors seems to require the annulment of their traditional legitimacy, in that it reduces their therapeutic action to a ‘pure’ knowledge from which the social dimension is absent. In practice, however, traditional legitimacy remains, although at first sight it is less visible. By continously resorting to these therapists to solve their problems, patients reaffirm the legitimacy, power and knowledge of the traditional doctor. The practicioners themselves are conscious of their role in this process of social control, as previously mentioned.

The association is important for the occupation of new spaces of official recognition, in a context of competition between traditional and rational legitimacy, which reflects the use by traditional medicine of the space for manoeuvre created by the state. M.F. Zimba does not need his AMETRAMO membership card to ensure his position as traditional doctor: the number of patients and the respect he commands reveal, much better than these ‘legal’ documents, the reality of his social recognition, based on traditional legitimacy. Contrary to what some authors seem to suggest (Nathan & Strengers, 1995; Honwana, 1996; Xhaba, 1999), the reality described here suggests that it is the absence of legitimacy which creates the charlatan. Indeed, a traditional doctor without clients has as much lack of legitimacy as a health centre without means or a lawyer who cannot defend his causes.

Discourses about traditional medicine and even witchcraft have a subtext which offers explanations about current changes. What many still say about the traditional character of witchcraft, that it acts as an obstacle to change, also has some validity. A good example is the explanation on the origin of a specific illness. The person who holds knowledge and heals somebody is connected or in collusion with the structures that regulate social relationships. Therefore, to interpret and cure an ‘illness’ may have the opposite meaning (for example, concealing cases of robbery as well as their perpetrators). Depending on one’s perspective about the ‘cure’, the traditional therapist may heal one person, and simultaneously harm somebody else (such as hindering job promotions), by concentrating all his ancestral strength on only one of the parties in conflict. This explains the need for protection, for vaccination against ancestral forces, which may in fact induce ‘misfortune’ and ‘bad luck’, i.e. absence of good health. In a particular context, the same discourse can have a very traditional content, opposing development and change; in another context, the same discourse seems very much in tune with new developments, thus leading to very ambivalent situations.

The evaluation of the traditional should not be seen only from the legal and formalistic position of the state. Several traditional therapists mentioned that it was common to meet with their seniors—the mab'ava—to analyse problems about which they were uncertain, a practice that is currently being reinforced by AMETRAMO.

Thus, AMETRAMO has not come to fill a totally empty space in the relations between traditional therapists. During the meetings (‘mavandla’) for the graduation of the ‘mathwasana’, the therapists come together to discuss the matters affecting them. AMETRAMO has merely reinforced and amplified these connections. Another important aspect is the constitution of AMETRAMO as a space for claiming the social recognition of traditional medicine. In this case, the members of the association show themselves to be not in a position of weakness, but one of strength, due to the social role they represent. The concern of the current leadership of AMETRAMO in acting as the representative of the interests of all Mozambican traditional doctors in the rehabilitation of traditional medicine contributes toward its own legitimation; the power that derives from this representation acts as a confirmation of their concern and as a means of achieving their objective.

The paradox which many insist constitutes an obstacle to development—the persistence of ‘traditional’ values—should not be seen as an antinomy. Traditionalism is only what it is to the extent that it is distinguished from modernity by difference, but in fact it continuously feeds on modernity. Encounters occur at various levels: the state ignores traditional doctors while its functionaries frequently resort to them; the Medical and Law Faculties do not recognise their knowledge while many nurses and other medical personnel and lawyers do not hesitate to consult these therapists. This paradox is only an apparent contradiction: the norm established and imposed by the state is based on a legal and rational model of legitimacy. The agents that make up these institutions, on the contrary, dispense with these principles when acting as patients, obeying only practical rules. As one of the patients told me, "anything goes, you never know if they will work, but one certainly will; we just cannot risk not doing so." For the patient, the need for legitimacy diminishes in the face of ailment, social problems or misfortune. When they consult a traditional doctor to solve a problem or cure an ailment, the university professor, the minister, or the lawyer are not considering the question of legitimacy, but looking for a practical effect. For this reason, it is impossible to divide society into ‘traditional’ and ‘modern’ in terms of medicine and the search for healing. The ‘civilised’ businessman and the peasant woman with a sick child have similar itineraries, different only in the financial means involved, and, consequently, in the prestige of the traditional practitioners consulted.

Returning to the beginning of this text, I pose the same question: is traditional medicine really an alternative to biomedicine? The argument developed to this point leads to the suggestion that the struggle of biomedicine for a limited incorporation of traditional medicine (only in the restricted sense of medicines and techniques), as well as its resistance to the recognition of the wide spectrum of efficacy of traditional medicine, are really a recognition of the strength of this other medicine, which is called, by opposition, traditional. The major reason for the tremendous vitality of traditional medicine seems to lie in the fact that ‘traditional medical institutions’ treat disease and at the same time resolve society's problems, whether they are related with order (representations, norms), or with conflicts (tensions, collective misfortune). They are figures of modernity, but of another modernity, not imposed but composed of compromises with previous orders. Far from embodying the stasis of tradition, traditional medicine feeds on an eminently problematic modernity, appropriating the gaps and metamorphoses created by the state, and giving them new meanings. Traditional medicine acts as a regulatory factor of social rhythms, resolving tensions and ensuring the reproduction of the social fabric.

The main focus of interpretation consists in demonstrating that modernity is not over, that it does not cease to amplify the ‘noise’ of the traditional. If the treatment of illness is necessarily based on the therapeutic efficacy of symbolic and interpretative procedures, other forms of intervention give it a greater scope. Apart from treating different manifestations of misfortune (failure at school, marital difficulties, financial problems), the traditional doctor also operates in the preventive field, guaranteeing his clients means of protection against various sources of harm. In this sense, the traditional doctor ensures development, inserting him/herself into the heart of a modernity which, through individual aspirations and strategies, attempts to break with previous logical orders. It is for this reason that traditional medicine continues to attract not only patients from rural areas, or the economically disadvantaged; rather, patients from the urban areas increasingly come with their problems and expectations, seeking treatment, protection, success, things which all believe are possible and practicable. One can thus legitimately speak of a counterhegemonic form of knowledge and power, in which this medicine represents the dynamics and the poles of locally-used power.

In order to answer the initial question—is traditional medicine an alternative to biomedicine—I think it has been made clear that the strength of this field of knowledge lies in its ability to make use of modernity and modify it according to its needs. The alternative does not lie in ‘other knowledges’, classified as complementary, but in a complex interaction between different knowledges, all legitimate in the eyes of those who resort to them and sanction them as a form of power. Intermedicine is thus synonymous with multiple medical knowledges, which are applied in different spheres—the family, the community, the workplace, and the public sphere of citizenship—thus granting it an emancipatory character.

Would not the recognition of AMETRAMO by the state, through its legalisation, thus imply the impossible task of imposing a version of modernity which is exogenous to the one present in the social terrain? For the public powers (both at a national and international level), the political bet seems to favour the valorisation and pseudo-legitimation of traditional medicine, refusing, however, to acknowledge the social dimension of this medicine by restricting it to the simple application of drugs and plants. The constant attempts by the state to ‘promote and valorise’ traditional medicine—as a complementary alternative to biomedecine—, lead to another point of tension and conflict, the result of efforts to control politically the communities where this knowledge is produced. However, the complexity, fluidity and ambiguity of the meanders which compose the social field of traditional medicine make this process very difficult, if not impossible. In normalising traditional therapeutic processes, in reducing this knowledge to written form, which is repetitive and allows for little innovation, are we not putting into question precisely that ambiguity which is so essential to the dynamic of transformation and creative appropriation of modernity by traditional medicine?

The emancipatory character of interemedicine derives from its being ‘under construction’ at a stage in which traditional medicine is experiencing a turbulent process of transition, while trying to produce ‘another modernity’. In this process, it is the echoes and marks of the traditional world that are most noticeable, because they are at odds with ‘classic western modernity’. The constellation of distinct knowledges which is being created among different therapeutic realities leads to the reinforcement of their performance and legitimacy, as well as to a greater reciprocal control. This mosaic of heterogeneous knowledges thus emerges as a guarantee of a permanent and open dialogue ‘in progress’, as an exercise of democratic power/knowledge, justifying its emancipatory character. Hence, based on the local forms of resistance, one needs to present the different actors and their contexts of struggle, to build connections between these actors, mobilising them and supporting their campaigns for a more egalitarian inclusion in the struggle for the diversity of knowledges, for achieving a broader space of action, for enlarging the shared fields of knowledge. This unity based on difference should constitute one of the cornerstones of the elaboration of a new global counterhegemony. This kind of research has necessarily to be directed toward political intervention, toward the transformation of contemporary societies.

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