Combination Therapies

Eric Lis

I've written before about "traditional" medicines and how they differ from modern ones. The inherent flaw in this thinking is that it treats them as two distinct things that never meet. For us, it's easy to think of the two as separate; studies show that the people who make use of one tend to have something of a bias against the other. If we consider magical and cleric-based healing to be the "modern" medicine of fantasy, then one has to imagine that to a large extent they co-exist. In reality, the two coexist in the modern Western world too; most people who use traditional medicines also use modern medicine and, depending on what you consider traditional or magical medicine (prayer, for instance), a significant percentage and perhaps even a majority of consumers of modern medicine also use traditional practices. In fantasy, though, I personally imagine them co-existing much more equally. Even though magical healing clearly works better, it's costly, difficult to access, and may be at the mercy of people who don't share your ethics and world-view, so herbal or alchemical healing presumably remains a common mainstay. Of course, "costly," "inaccessible" and "elitist" may equally describe the experience of obtaining modern medical care in the third world, so it's not at all surprising that those are the parts of the world where traditional healing traditions still openly flourish. As those parts of the world work to integrate modern and traditional medicine, rather than separate them, it can teach us a bit about how medicine might work in fantasy.

This paper came out in early 2015, which describes how the State of Eritrea has worked to integrate these two traditions. Since most of Eritrea has no formal hospitals or clinics within accessible range, traditional healers are the only health care available to many people. One of the things that makes Eritrea's system interesting is the author's suggestion that traditional and modern medicine never split there as they have in most nations; I have no idea how true this is, but it's an intriguing notion.

From interviewing over a thousand people in different parts of Eritrea, most of them subsistence farmers or other "petty" labourers, the authors showed that about half of their sample preferred traditional healing. The reasons why included the belief that it was as effective or better -- which probably isn't the case based on the list of treatments listed in the paper, but who knows -- and because it was either cheaper, easier to get, or had fewer side effects, and therefore was worth trying first. This, I think, illustrates one of the important principles which carry over into fantasy. Your average townsperson in a fantasy setting knows that magical healing is better than herbal healing -- consider healing your broken leg in six seconds instead of six weeks -- but that magical healing costs between one hundred and one thousand times more. Doesn't it make sense to try the non-magical healing first? The problem comes in when the problem in question is a snake bite or something, that has to get treated urgently. By way of illustration, as this author points out, Eritrea has historically had the highest infant and maternal mortality rates during pregnancy and delivery in sub-Saharan Africa, in part due to lack of competence among traditional healers. Integrating traditional healers into the formal medical system, and ensuring that they get some minimum training, has cut the death rates in half in recent years.

Interestingly and importantly, one of the other major reasons that people sought traditional healers was for procedures that hospitals would refuse to perform, such as female circumcision. There's probably truth to that, or at least, I would hope that such things wouldn't be available from physicians. In a fantasy setting, though, the moral judgment may go the other way; it's not impossible to imagine a Pelorian or Tormian cleric refusing to cure, say, a non-life-threatening sexually-transmitted infection due to their own feelings of moral censure, in which case the afflicted individual might go to an herbal healer.

Universally, people seemed to feel that traditional healers were better at taking into account their whole social and life context than modern doctors were. I wish I could dispute that, but I'd be lying. There are some things that traditional healers really do tend to do better.

What Eritrea has done primarily involves establishing communication between traditional and modern healers. Systems are in place for healers to refer to each other when a problem lies outside of their strengths, just as a family doctor in the West will refer to a dermatologist or psychiatrist when they need specialist insight into a problem. Interestingly, in this study, although about 4 out of 5 modern healers favoured this communication, only about one in three traditional healers wanted to collaborate. The traditional healers argued that they don’t' get the same recognition or respect from the government's health regulation bodies and don't want to cooperate until they're treated with the same respect. This is definitely an argument that I could see playing out between a cleric and an herbalist, as the cleric thanks the herbalist for helping out "even though you're a godless heathen."

What this sort of work shows us is that in a fantasy setting, magical and non-magical healing probably interact quite a bit in so far as they each address the others' weakness. Magical healing is faster and more reliable, but there simply aren't enough clerics to meet everyone's need, even if cost wasn't a factor. By the same token, traditional healers might be less effective, and some of their remedies might even be overtly harmful, but they're accessible and they have the people's trust in the way that a cleric dressed in silks and gold might not have the trust of a farmer. Ideally, the two would cooperate, communicate, and learn from each other, and whether that happens or not might go a long way to determining how dark a fantasy setting is. 

More than four years ago, Dr. Eris Lis, M.D., began writing a series of brilliant and informative posts on RPGs through the eyes of a medical professional, and this is the one that appeared here on February 28, 2015. Lis is a physician, gamer, and author of the Skirmisher Publishing LLC OGL sourcebook Insults & Injuries, which is also available for the Pathfinder RPG system