28 December 2016


‘The epidemiology of ‘bewitchment’ as a lay-reported cause of death in rural South Africa’ by Edward Fottrell, Stephen Tollman, Peter Byass, Frederick Golooba-Mutebi and Kathleen Kahn in (2011) J Epidemiol Community Health comments
 Cases of premature death in Africa may be attributed to witchcraft. In such settings, medical registration of causes of death is rare. To fill this gap, verbal autopsy (VA) methods record signs and symptoms of the deceased before death as well as lay opinion regarding the cause of death; this information is then interpreted to derive a medical cause of death. In the Agincourt Health and Demographic Surveillance Site, South Africa, around 6% of deaths are believed to be due to ‘bewitchment’ by VA respondents.
Using 6874 deaths from the Agincourt Health and Socio-Demographic Surveillance System, the epidemiology of deaths reported as bewitchment was explored, and using medical causes of death derived from VA, the association between perceptions of witchcraft and biomedical causes of death was investigated.
 The authors conclude
The odds of having one’s death reported as being due to bewitchment is significantly higher in children and reproductive-aged women (but not in men) than in older adults. Similarly, sudden deaths or those following an acute illness, deaths occurring before 2001 and those where traditional healthcare was sought are more likely to be reported as being due to bewitchment. Compared with all other deaths, deaths due to external causes are significantly less likely to be attributed to bewitchment, while maternal deaths are significantly more likely to be.
 They comment
Witchcraft provides a moral agency framework that can make sense of seemingly random events in space and time, and in South Africa, witches using Muthi (‘medicine’) are said to be able to cause disease and misfortune. This has important consequences for treatment choices; seeking Western healthcare and remedies for witchcraft-related illness is considered redundant or, at best, secondary to traditional rituals, medicines and sacrifices.
In the world’s poorest settings, where belief in witchcraft is prevalent and the burden of disease and premature mortality is highest, the vital events of individual lives are not recorded and medical registration of deaths and their causes is rare. Localised surveillance systems have been established in many resource-poor settings in an attempt to overcome this lack of information. These Health and Socio-Demographic Surveillance Systems (HDSSs) monitor populations in clearly defined geographic areas and record all information on births, deaths and migrations. Since 1992, every death occurring in the Agincourt HDSS, South Africa, is subject to a verbal autopsy (VA), whereby trained fieldworkers interview the closest care giver of the deceased to retrospectively record the signs and symptoms of the deceased. These data are later used to derive a probable cause of death. The VA tool also records the respondent’s opinion as to what, in their opinion, the main or most important cause of death was, which in numerous instances is ‘bewitchment’. This study explores the epidemiology of reported bewitchment and its associations with individual and household characteristics of the deceased, including VA-derived medical causes of death.
 The authors go on to comment
Exploration of the epidemiology of bewitchment as a lay- reported cause of death over a 15-year period in the Agincourt HDSS, South Africa, provides a useful insight into a population’s understandings of death. Illness duration and specific causes of death appear to be important factors associated with the likelihood of a death being reported as due to bewitchment. Deaths following a long illness and those due to obvious external causes are approximately 60-70% less likely to be reported as bewitchment compared with other causes. Conversely, maternal deaths are almost three times more likely to be reported as bewitchment compared with non-maternal deaths when controlling for age and sex groups. This association with maternal deaths, and the greater proportion of bewitchment deaths among women in the reproductive age group of 15-49 years compared with other age-sex groups, suggests that the Agincourt community may associate the sudden deaths of otherwise healthy young women with malicious supernatural causes. ...
The greater proportion of bewitchment deaths in the mid- 1990s may also be related to heightened consciousness of witchcraft activity resulting from politically motivated witch hunts in the area during the early days of post-apartheid. During this transitional period in South Africa, characterised by a climate of uncertainty and long-standing mistrust within and between sectors of society, there was an ‘epidemic’ of occult violence and fear of malicious supernatural forces within the former Northern Province, including the former homeland of Gazankulu in which Agincourt is located. It was also a social climate in which fears about witches flourished, nourished by rapidly expanding charismatic churches that offered sanctuary and support against evil brought by witches. The prevalence of witchcraft during that period has been interpreted by some to be an aggressive rationalisation of misfortune from unknown or uncontrollable forces. Time, and perhaps the gradual success of reconciliation initiatives, may have overcome some of these driving forces towards the beginning of the new millennium, and the incidence of witchcraft-related violence did diminish after 1997.
The study indicates an association between bewitchment beliefs and maternal deaths. Maternal deaths fit well into commonplace understandings of witchcraft. For example, invisible agents or those with a grudge working in mysterious ways and with intent to cause harm target seemingly healthy individuals performing the natural and expected role of child-bearing, causing unexpected illness and death that results in prolonged suffering for the immediate family. Furthermore, witchcraft has previously been identified as an important factor that affects women’s reproductive health, with pregnancy being described as a state of acute vulnerability to the actions of jealous others. Moreover, it is commonly believed that witches are particularly keen on attacking the generative capacities of families and lineages, so an affliction that special- ises in fertile victims and as a consequence of sexual activity is considered tailor-made for their craft. The relative rarity of maternal deaths, the role of women in childbirth and the importance of fertility in African society in general may further explain why maternal deaths are associated with witchcraft in some people’s eyes, perhaps echoing beliefs held in Europe until the 17th century that midwives and witchcraft were closely linked. 
Assigning blame to witchcraft may be a mechanism for dealing with the incomprehensibility of why a woman should die during the natural process of childbirth and the catastrophic consequences of death with respect to infant survival and family life. This can be contrasted to deaths caused by obvious and more comprehensible external causes, such as accidents, homicide and suicide, which were less likely to be reported as witchcraft. 
There is an increasing trend in deaths being reported as due to bewitchment in relation to increasing education level of the deceased, although not statistically significant in the multivariate analysis (tables 1 and 2). It has been shown that education is not necessarily a protective factor against belief in witchcraft and that formal education may in fact contribute to the growth of witchcraft by exposing people to new ways of thinking and conduct. Resulting changes in behaviour may clash with local values resulting in suspicions and accusations of witchcraft.   
If the true medical and social causes of illness are not recognised at the community level, it is difficult to intervene and prevent them. An ethnographical study in Nigeria, for example, shows that discussants believe that reproductive health problems and delivery complications caused by curses and witches can only be cured by traditional healers, animal sacrifices and prayers, with medical interventions considered redundant. Similar beliefs were evident from the open histories of the VAs in the current study. For example, one case report of an 18-year-old woman apparently suffering from postnatal psychosis describes how she was separated from her child and taken to an evangelical church to be healed, whereupon she was tied up with ropes so tight that ‘there were scars on her ankles and arms’. Following 2 weeks with a traditional healer, the woman was sent home and died within hours. This potentially preventable death highlights the devastating consequences that may result from inappropriate and misguided treatment-seeking behaviour, which are likely to be motivated by lay cultural understandings of illness. 
The fact that individuals who sought only traditional treatments for their terminal illnesses were almost six times more likely to have their death reported as bewitchment supports the view that traditional medicine and bewitchment are strongly associated (table 2). Nevertheless, almost 40% of bewitchment cases in this study accessed Western healthcare, occasionally in combination with traditional care (results not shown). This reflects pluralistic healthcare-seeking behaviour characteristic of the Agincourt population and South Africans in general  and is suggestive of a process of health-seeking behaviour in which personal beliefs and actions are continuously debated and evaluated throughout the course of an illness. The apparent willingness to use Western care reinforces the need to improve the accessibility and, crucially, the quality of existing services. In particular, there is an apparent need for enhanced communication to patients and their relatives regarding the meaning of diagnoses and realistic treatment expectations.
Understanding divergences between biomedical and cultural concepts of illness has implications for health measurement techniques. Rather than replicating a purely clinical paradigm, through which the social context of illness and death may edited out, VAs should instead be considered as an interface between epidemiological and ethnographical methods that are able provide important information on the chain of biomedical and social events associated with preventable mortality. As demonstrated by the current study, quantitative exploration of certain local concepts or perceptions of illness may facilitate translation of these culture-specific interpretations into more generic medical models useful for health measurement.
Insights gleaned from the people directly affected by specific health issues are also critical in developing sustainable health programmes and building health partnerships. Planners need to understand barriers and enablers to care seeking which are likely to include local understanding of the causes of illness and consequent perceived appropriateness of Western medicine in the framework of certain world views. With such insights, the perception of witchcraft and its associations with illness and death have real public health implications.