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February 2007, Volume 57, Issue 2

Opinion and Debate

Could there be a role for Shamans in the health care delivery system of Pakistan?

Amin A. Muhammad Gadit  ( Department of Psychiatry, Memorial University of Newfoundland, St. John's, NL A1B 2V6. )


Shamans in Pakistan: beliefs and practice patterns
A shaman in Pakistan is popularly known as "baba" or "pir". The other type of healer which is a religious healer is known as "sufi" who does not fall into the category of shamans but is well respected in the community and brings relief through holy verses and some other religiously sanctioned rituals. They are the disciples of saints and a large number of people have faith in their healing powers, hence shrines and other holy places are flocked by the masses, irrespective of educational or ethnic background, seeking cure especially for mental illness. It is also believed that Sufi saints are effective healers and even after their death have spiritual influence by virtue of which they can cure or provide relief. The shamans however, have no prescribed qualifications; their spiritual powers are either conferred upon or acquired through meditation, elaborate religious rituals or lengthy spiritual training. The number of practicing shamans is very high, only in Karachi, there are about 400 such practitioners. They practice at their residences, clinics, shrines or mosques and explain mental illness on the basis of possession by the evil spirit, by jinni or by magical influences cast by enemies. The treatment given includes amulets, spiritually treated water, burning incense or reciting incantations.1 In Pakistan, where there is a dearth of psychiatrists, prevalent stigma for mental illness, poor socio-economic conditions and vast majority of population living in rural areas depend more on shamanic treatment who have conferred benefits to patients suffering from grief reactions, reactive depression, psychosomatic disorders and anxiety neurosis.1 In such conditions, the rituals as described by Peters L2 in his paper on Psychotherapy in Tamangs Shamanism on the basis of Karga puja are practiced by Pakistani shamans with desirable short term outcomes. Relapse rates depend upon the re-surfacing of the stressful social circumstances.2 Shaman use trance induction procedures that would affect the patient as a part of their healing ceremonies, although the intensity of trance induction is less than typical of practitioner training. Additional mechanisms of therapeutic efficacy might lie in the fact that trance and other collapse states are based in a common psycho physiological pattern that can lead to erasure of previously conditioned responses, changes of beliefs, loss of memory, and increased suggestibility. Since trance states increase suggestibility, this may also increase placebo or other psychosomatic effects, resulting in physiological improvement for the patient. Some shamans also use trance inducing agents like: hallucinogens as reported by the local media.

The lay people in Pakistan with a background of low literacy level and low awareness would not recognize mental disorder as such but if the person in question has displayed aggression, disinhibition, have fits, self negligence, socially withdrawn and talk irrelevantly, then he/she will be recognized as the one suffering from some mental impairment and this is generally attributed to the effects of jinni, aaseb (evil influence), magic, evil eye, nutrition factor etc. and will seek help from a shaman who would along with psychotherapeutic rituals would also prescribe amulets, holy water, and talisman.3
Many shamans in Pakistan also acts as medicine-men and would prescribe some of the following medications which are generally prescribed by other alternate practitioners.1

1. Metallic agents (gold, silver, mercury)
These are thinned, crushed and prepared in sugar solution, and are also subjected to a calcification process. These were recommended for oral use and claimed to be beneficial as a "brain tonic" and as a specific for other physical conditions;

2. Herbal preparations
Typical herbs are extracted from plants, seeds, fruits, leaves and barks. These are filtered, soaked in water, crushed and emulsified (names were not mentioned by the shamans except for Rauwolfia serpentina). These are prepared in powder form, tablet, paste and syrup and recommended for topical application and oral use;

3. Hikmat Medicine
These preparations are the extracts from herbal, animal and mineral sources. These are used orally in the form of a liquid besides recommendations for taking baths in water mixed with such preparations.

4. Salts
These include sodium chloride, potassium chloride, magnesium and calcium chloride salts; and also salts extracted from herbs. These are generally prepared from ashes of the burnt plant mixed with water obtained through a process of filtration and sedimentation. They are claimed to give "mental strength" by means of an unknown mechanism.

5. Chemicals
These are the enzyme extracts of plants or animals, claimed to be prepared by boiling the same in water. The liquor is drunk and recommended especially for fatigue and depression. It has been reported that ethno therapists at times also use cortisone or penicillin in their preparations.

6. Semi-precious stones
These stones are found in specific places and form a rich source of cobalt, zinc, iron, silver, gold and calcium. For example, coral is a stone with 100% iron: and its effectiveness is claimed in the treatment of anxiety, depression and fatigue. Other examples are pearl and green onyx stones, which are claimed to have been successful in the treatment of psycho-sexual disorders.

7. Sea-animal products
Examples include various fish, prawns, amber fish, lobster and crabs. These are crushed and mixed in oil or dried in power form. In addition to their use in skin disorders and dental conditions, they are recommended for the treatment of impaired concentration and weakening memory. Sea animal products are used either as oral or topical preparations.

Role in the health care system
Despite resentment by the mental health professionals, the shamans enjoy the acceptance of large masses of people who approach them for their mental health problems with less fear of stigma, low cost and easy accessibility. The current number of psychiatrists cannot effectively deal with the magnitude of mental health problems existing in the country and hence these shamans are sharing the burden though unofficially. In a doctoral study1 it was emphasized that collaboration between shamans and psychiatrists may go a long way in addressing the mental health problems of the country. However, the system in Pakistan is also liable to abuse as there is a very loose grip on malpractices and in some shamanic practices, adverse outcomes have been reported including adverse reactions from drugs which are mentioned above, delay in getting appropriate medical treatment in cases of organic pathologies and even death during the rituals. It has been established that these shamans act as good counselors and psychotherapists and can be very useful for masses keeping in mind the dearth of professionals for a very large population. However, collaboration is possible between shamans and psychiatrists, if following suggestions are incorporated.4

Statutory registration of shamans
This is a very important step and can be organized in the same way as the medical practitioners are registered. A body can be formed which can take the form of a council and maintain a register for registering the shamans after verifying their qualifications, experience and safe practice. These therapists can be temporarily registered in the beginning; and over a prescribed period of time, which may be up to three years; after which they may then be registered permanently. This procedure and requirement should be made mandatory by the Government.

Development of a shared code of ethics for shamans
As a code of ethics currently exists which has to be followed by all medical practitioners to ensure safe and acceptable practice, there would seem to be no logical reason why such a code should not be implemented for shamans also. The resultant code should cover issues of safe practice and confidentiality; and should be monitored through the emergent statutory council for registration of ethnotherapists.

Development of a workable collaborative system between psychiatrists and ethnotherapists
Collaboration can be achieved to some extent between psychiatrists and shamans by frequent meetings; exchange visits; and the organization of shared symposia, case conferences and workshops for exchange of clinical information. This can eventually pave the way for mutual inter-referral.

In keeping with the above proposed developments, both psychiatrists and shamans should be further encouraged to accept and respect each other; and to exchange information through joint meetings. In view of the widespread perceptions of shamans regarding the supposed negativism of western-oriented medical practitioners towards their practice, it may be necessary for psychiatrists to take the initiative in promoting this step, which could prove extremely beneficial in helping to develop a mutual spirit of cooperation and facilitating programmes of shared care. The development of a reciprocal modus for inter-professional working is a delicate exercise, depending for its success in the final analysis on the interpersonal skills and understanding of the practitioners immediately concerned.

Inclusion of shamans in multidisciplinary teams of psychiatric units
In some health centers in western and other countries, a religious person (or shaman) is normally invited to be a member of the multidisciplinary care team working within a psychiatric unit. This is based on the idea that some mentally ill people invest great value and emotion in their religious faith; and ventilate more effectively with such religious or spiritual support. A local hospital in Karachi has adopted this method; and reports that this system has produced good results (personal communication to the researcher).

Statutory moves to establish a legal ban on detrimental practices
Detrimental and frankly dangerous practices of the type illustrated in this study should be dealt with as a matter of serious urgency; and should be legally banned. This can be achieved through Governmental and parliamentary process by formulating an appropriate addendum to the criminal law; and serious action should be taken if a mental health practitioner is found to be involved in such dangerous practices.

Formation of committees to act as "watchdogs" for control of malpractice
Such committees or working groups may be formed by the new council which will assume responsibility for registering shamans. A small working group, consisting of a few members of that committee or its nominees, could be mandated to inspect and observe the practices of shamans; and could make appropriate recommendations, should they find any prima facie case of malpractice, to have the practice thoroughly investigated, if necessary recommending the removal of the offending practitioner's name from the register.

If these suggestions are accommodated by the government policy makers, the shamans can officially become part of the health care system and can be of help in addressing the huge burden of mental health issue of the country as has been suggested in a stydy.5 However, having said this, there are some questions which need answers: Can this collaboration help the existing health care system of Pakistan? Will the mental health care professionals accommodate the shamans? Will mutual inter referral between psychiatrists and shamans be possible and in motion? Will the shamans agree to give up their independent practice while coming under the umbrella of a regulatory body? Will this collaboration be sustainable in the long run?

Case Report

1. Gadit A., Reed V. Culture and Mental Health: Pakistan's perspective. First Edition, Hamdard Foundation, Karachi-Pakistan 2004; pp: 63-84.

2. Peters LG. Karga Puja: A Transpersonal Ritual of Healing In Tamang Shamanism. Altern ther Health Med 1995, 1: 53-61.

3. Gadit, A. Reed, V. Uses and Limitations of Ethnotherapy. Internati J Mental Health 2004; 33 54-95.

4. Gadit A. Health Services Delivery by Shamans. A local experience in Pakistan. Internati J Mental Health 2003, 32: 63-83.

5. Razali MS. Psychiatrists and folk healers in Malaysia. World Health Forum 1995; 16: 56-8.

Journal of the Pakistan Medical Association has agreed to receive and publish manuscripts in accordance with the principles of the following committees: