Introduction

The healthcare problems of most developing countries like Nigeria are strongly associated with its cultural and social practices and the tremendous effects they exert on it. In certain cases, it is beyond all imagination and realities to conceive of the immense impact these socio-cultural factors have in the delivery of health care amongst the Igbo people of Nigeria. The harsh and bitter effects on the individual are overwhelming. It has led to untold mortality and morbidity amongst the people of this geographical region. Ethnomedicine refers to the study of traditional medical practice which is concerned with the cultural interpretation of health, diseases and illness and also addresses the healthcare-seeking process and healing practices ¹. The spiritual aspects of health and sickness has been an integral component of the ethnomedicinal practice for centuries, a dimension ignored by biomedicine practitioners, because of the difficulties involved in validating its success using scientific principles and experiments². The ethnomedical systems (primitive medicinal systems or traditional medicine) have two universal categories of disease aetiology – natural and un-natural (supernatural) causes ^2. Natural illness explains illness in impersonal systemic terms. Thus, disease is thought to stem from natural forces^{. 3}. Un-natural illnesses are caused by two major types of supernatural forces: occult causes which are the result of evil spirits or human agents using sorcery and spiritual causes which are the results of penalties incurred for sins, breaking taboos or caused by God ^3.

The social factors affecting the pursuit of health depends on the social determinants of health and the development of disease; the social determinants of the course and outcome of disease in individuals and society; and the social determinants of how health and disease are defined ⁴.Much of the work of medical sociology is concerned with how disease and illness are defined and managed ^5. The main determinants are low educational level deficiencies in home technologies, high demographic density and ruralism ⁶

The response of any society to challenges of sickness is based on its own beliefs and practices. This response in many cases in most developing countries is irrespective of one’s educational background or standing in the society. Illness or any form of disease is mainly looked upon as a breakdown in harmony between an individual and his invisible environment or between him and his creator or between him and his ancestors or his enemies. Illness in these areas therefore is regarded strictly as a misfortune or a curse rather than a health problem.

In the Igbo speaking area, people are apt to say of an ill person – o bu ihe o dotara (It is of his own making; that is a curse) or o bu chi ojoo – his god has turned against him. Most of these people therefore believe that only the traditional healer or practitioner – the dibia - who has been endowed by God with the powers to retrieve one of any misfortunes or illness or curses can restore him back to health and normalcy.

The problem with traditional medical practice in Nigeria is the lack of scientific basis. The practitioners lack the wherewithal to explain the scientific basis for their diagnosis and therapy. The usual answer by the dibia when confronted with this question is “that the gods and especially the Igbo god of Medicine – Agwunshi –have endowed them with the power to fore see, diagnose and select the appropriate therapy and treatment”. One cannot out rightly condemn traditional medical practice, as there are some honest, devoted and conscientious practitioners who have been properly trained the traditional way. However there have been no effective ways of assessing their concepts of disease and efficacy of treatment. Most of their methods especially in the hands of the quack traditional practitioner, who are in the majority, have led to a lot of calamities in loss of lives and in the maiming of patients for life.

The norms of the society exert tremendous effect on its health care delivery. The cultural influence makes the average Igbo patient in the village to first seek and consult the dibia to determine the cause of his illness before thinking of the orthodox doctor because to him illness does not just occur – it is somebody’s doing. He also believes that – a kpo oria aha ya alaa – (if an illness is named or once a diagnosis of an illness is made it goes). This paper is therefore aimed at highlighting some of the myths, beliefs and socio-cultural factors militating against treatment of ear nose and throat diseases and proper practice of Ear, Nose and Throat Surgery in the Igbo cultural area of Nigeria.

Methodology

A study of the myths, beliefs and cultural factors affecting aetiology and treatment of ear, nose and throat diseases was carried out from January 2008 to June 2008. Through field notes, personally administered questions and interviews, 171 randomly selected patients and villagers from a rural community, Umidim in Ikeduru Local Government Area of Imo State in Nigeria was conducted. 21 of those surveyed were patients seen at the ENT clinic of Imo State University Hospital, Orlu, Imo State.

Results

Out of the total number of 171 people 93 (54.39%) were males and 78 (45.61%) were females. This gives a male: female ratio of 1.2:1. The Age distribution is shown in Table 1

Figure 1

Table 1 Age Distribution

When asked the question – Do you believe that your culture and society norms affect your response to illness and choice of medical care? – 126 (73.68%) answered “yes” while 45 (26.32%) responded in the negative with “no”. Table 2 shows the responses and percentages within each age group.

Figure 2

Table 2 Response by villagers by age group

Discussions

The results show that there were more males than females with a ratio of 1.2:1. The highest number of those interviewed was between the ages of 41-60 years accounting for 110 (64.33%). This age group is in the older cadre of who the majority 97 (56.73%) admitted that the culture and society norms affect response to illness and choice of medical care in the village. This may be because of illiteracy, poverty, and norms that have been handed down to them by their forbearers through their culture. Most of the younger age group under 40 years 30(17.55%) out of 42 (7.01%) disagree with these myths and beliefs. There is no doubt their exposure, education and awareness influenced their response. However this does not seriously influence the responses from the majority of the villagers despite the presence of orthodox medicine. It has been shown that despite availability of healthcare services certain disease specific and non-disease specific socio-cultural beliefs may influence the health seeking behaviour of the populace. Health services maybe underutilized and healthcare instructions ignored in societies where people's cultural beliefs conflict with the knowledge passed to them. ^{7 8}

Ear, Nose And Throat Diseases

Many Igbo patients with ear, nose and throat diseases as well as some traditional medicine practitioners were interviewed in other to ascertain the influence of socio-cultural beliefs in the management and outcome of these illnesses.

Ear Diseases

Within the study area, ear diseases in children especially otitis media with discharge is usually treated with levity as it is commonly regarded by the people as excess breast milk sucked by the child which lets out from the ear. McPherson and Holbrow ⁹ recorded that in Gambia discharge in children is assumed to arise following a mother allowing drops of breast milk to fall in the ear or due to small snails entering the ear. With chronicity the ear becomes painless so no urgent and proper attempts are made to treat it leading to serious complications and disabilities like deafness. When attempts are made to treat it by the traditional practitioners with unhygienic herbal preparations squeezed into the ear, the condition is worsened leading to toxicity and chronicity. By the time they report to hospital to seek for proper medical attention it is often too late. Noise in the ear or tinnitus is said to be due to evil spirits beating weird drums in the ears

Deafness

Deafness of any type, degree or dimension is abhorred by the Igbo society. A deaf person is regarded as a daft person and avoided. It is a stigma to be deaf. There is the strong belief amongst the Igbo that “agbara kuchiri ya anti “(it is the doing of the evil spirit) and so needs propitiation to the gods for well being. Most of these patients go from one healer to the other in a futile effort to improve their situation and hearing. The social discrimination creates a withdrawal syndrome and restricts those who would have sought help from orthodox doctors and specialists from seeking it in time. Bleeding from the ear without pain which can occur in aural polps, chronic otitis media and myringitis bullosa is regarded as a bad omen and easily blamed on an enemy wanting to make one deaf or take his life.

Epistaxis

Bleeding from the nose is regarded as excess blood escaping from the brain. Some Igbo people believe that the blood should be let out as it is bad blood. This method of treatment which is dangerous has led to collapse of patients, shock, syncope and even death. Some people surveyed believed that epistaxis could result from one person poisoning the other.

Throat Lesions

Vomiting, spitting or coughing out of blood in the Igbo cultural area is regarded as a serious illness and strongly associated with poisoning. Somebody or an enemy is suspected to have put something or poison in one’s food or drink. Tuberculousis is also strongly suspected when this happens. The people believe that Tuberculosis is transferred to another person through poisoning his drink or food. Often these symptoms are not thought to be due to other infections of the mouth and throat or even the gastrointestinal tract. In the bid to seek recourse in the hands of the traditional healers the patients come late to hospital where treatment now becomes more complex or difficult. Most of them die without seeing a specialist..

Uvulectomy

Traditionally in Igbo cultural area, particularly in the rural areas - tonsillitis (mgbapia akpiri) is solely a disease that is only treated well by traditional practitioners. Uvulectomy is the treatment of choice the traditional healers prescribe for tonsillitis. They have for centuries practiced this inappropriate form of treatment. This traditional surgical intervention of uvulectomy has been performed for various diagnosis like chronic tonsillitis, pharyngitis, laryngitis, cancers of post nasal space, and cough. Traditional African practitioners continue to perform uvulectomies at the request of their patients despite severe complications noted by physicians ¹⁰. These severe complications may require hospitalization ¹¹. The mortality and morbidity rate of this practice by traditional practitioners is alarming. Many of such patients have died from septicaemia and haemorrhage while others have had life threatening conditions and complications like cavernous sinus thrombosis ¹², various complications including cellulitis of the neck, peritonsillar abscess, pneumothorax, parapharyngeal abscess and pharyngo-laryngocele ¹³ as well as otitis media, voice changes and rhinolelia operta.

Face Lesions

Unilateral facial lesions are referred to by the traditional practitioners as “okporo ihu” (face lesion). These include conglomeration of complaints and affectations of the face ranging from sinusitis, rhinitis, migraine, stroke, neuralgias, facial palsy and cancers of the face and post nasal space. All these diseases are regarded at one and the same time as “okporo ihu”. The causes are assumed to be either supernatural, due to evil spirits or due to juju or magic, and therefore are not properly diagnosed and managed. Such patients end up permanently paralyzed complicated by the healers or die from the illness without availing themselves of orthodox treatment. Usually most of the patients report late to hospital when complications have set in.

Non adoption of modern curative measures cannot be attributed to poverty alone but due to cultural and social determinants of behaviour¹⁴. Several authors have emphasized the need to consider the cultural beliefs and practices of people when designing measures aimed at improving their health¹⁵, ¹⁶. The need for health planners to understand the culture of their population arises from the fact that the measuring of illness and behavioural responses to illness are basic factors influencing the reaction of the public health programs^14. In most countries in the developing world (like in Nigeria) the number of otolaryngologists is negligible, while the problem is complicated by the fact that there is no training for public health otolaryngology and other ENT-related otolaryngology personnel ^17,18. This lack of trained personnel is of particular concern in African countries because the prevalence rates of some of the ENT disease such as chronic otitis-media is as high as 65% ¹⁹. Njoroge and Bussmann ²⁰ found that this problem as well as increased costs of conventional medicine has caused local people in Kenya and in other developing countries like Nigeria to seek treatment from traditional therapies.

Conclusion

There is the need for continuous health education within the rural areas of the developing countries to enlighten the people on the fallacies of myths and beliefs so that they can embrace orthodox medical services. Immediate response to the use of these services will reduce mortality and morbidity caused by these socio-cultural factors that affect effective treatment of diseases particularly of ear, nose and throat origin.