Indigenous Knowledge and Practices in the Management of Sickle Cell Anaemia among the Yorùbá in Osun State, Nigeria*

This study is an ethnological and anthropological appreciation of indigenous approach in the management of Sickle Cell Anaemia (SCA) among the Yorùbá in Southwestern Nigeria. I adopted qualitative methods (oral interview, key informant investigation) to source for primary data from the respondents. Convenience, purposive and snowball sampling methods were utilized in the selection of the study settings and the population. At the end, 44 respondents were sampled. The study population included the herbalists, Christian and Islamic Clergies, primary caregivers to the people living with SCA. Data collected were analysed using open code software package and ethnographic summaries. Important quotations from respondents during IDI and KII sessions were reported verbatim for further illustration of issues under focus. The findings demonstrated the ingenuity of Africans in using ethnomedical and spiritual healings to overcome the seemingly unending crises and accompanied excruciating pains in this disorder. Steps toward the usage started with interpretation of SCA which was heavily influenced by interpersonal relationship. Choices of treatment facilities were made out of available options. Occasionally, healing methods were combined in line with environmental dictates. Such combination included home remedies and hospital care. Traditional medicine and faith-based healing were most favoured by those who utilized more than one healthcare source. Herbal therapies, faith-based care, divination and home remedies received better patronage in the rural area. Continuous usage and perceived efficacy of these approaches therefore shows that the people have adequate knowledge of Sickle Cell Anaemia and a need for further appreciation of folkway in healing process.


MUSEDIQ OLUFEMI LAWAL 532
Introduction and Background of the Study Sickle Cell Anaemia has continued to attract attention in medical circle largely because of high morbidity and mortality associated with it. Most studies on this medical condition have remained biomedical inclined. As fallout from my involvement in series of field work particularly on health matters among the Yorùbá, I have come to realize that there are lots to be done in the course of advancing knowledge about these medical realities. Consequently, I also discovered that empirical study of Sickle Cell Anaemia goes beyond the issue of playing around with statistics because statistical approach has more or less distorted the beauty of academic discourse and dissemination of relevant research information. I discovered that this ailment has been with people from time immemorial and that they have their peculiar indigenous approaches for its management. It therefore becomes obvious that adequate contribution to knowledge will only manifest through exploration of this health issue via indigenous knowledge system using ethnographic and anthropological approaches.
Indigenous knowledge is the local knowledge, which has been institutionalized, built from and based on thousands of years of experience and done for generations (Melchias 2001, 56-60;Odhiambo and Jahan 1990, 11;Osunade 1996, 1-8;Osunade 1992, 35;Warren 1992, 86;Mishra 1989, 2-3). Individual men and women in each of the new generation adapt and add to this in a constant adjustment to changing circumstances and environmental conditions. They in turn pass on the body of knowledge to the next generation in an effort to provide survival strategies (Hoppers 2004, 98). International Labour Organisation (ILO 1989, 101) Article 1 described indigenous knowledge as that knowledge that is held and used by people who identify themselves as indigenous of a place based on a combination of cultural distinctiveness and prior territorial occupancy relative to a more recently arrived population with its own distinct and subsequently dominant culture. There is no universally accepted definition of indigenous knowledge because of its variance according to specific environment; however, its goals are often similar. In practical terms, these bodies of knowledge are considered as the indigenous technologies developed by local community to solve particular problems taking cognizance of all the local relevant factors. It showcases what indigenous people know and do as well as what they have known and done for generations, the practices that evolved through trial and error and proved flexible enough to cope with change (Melchias 2001, 56-60).
The International Council for Science (ICSU) defines indigenous knowledge system as a cumulative body of knowledge, know-how, practices and representations maintained and developed by peoples with extended histories of interaction with the natural environment. These sophisticated sets of understandings, interpretations and means are part and parcel of a cultural complex that encompasses language, naming and classification systems, resource use practices, ritual, spirit-

INDIGENOUS KNOWLEDGE AND PRACTICES IN THE MANAGEMENT
OF SICKLE CELL ANAEMIA 533 uality and worldview (ICSU 2002, 3). They traverse a wide gamut of life, cultural experiences, epistemologies and empiricisms of thousands of different cultures. Mgbeoji (2007, 77-92) submitted that indigenous knowledge systems are connected to ecology, agronomy, agriculture, medicine, animal husbandry, music, story-telling, cloth-weaving, et cetera across several thousands of different cultures and peoples. Similarly, Hoppers (2004, 98) noted the cultural context surrounding the practice of this knowledge as including songs, rituals, dances and fashion. Technological perspectives of this equally ranged from garment weaving and design, medicinal knowledge (pharmacology, obstetrics), food preservation and conservation, and agricultural practices (including animal husbandry, farming and irrigation) to fisheries, metallurgy and astronomy. In medical sector, indigenous knowledge continues to provide for the primary health care needs of some 80% of the world's population through traditional medical practices (WHO, IUCN and WWF 1993, 98-120). Examples of this were in China (Lin 2001, 34-35) and India (Mishra 2002, 479-520) where traditional medicine is actively supported and researched. According to the International Council for Science (ICSU, 2002, 3), Western medicine is strongly influenced by traditional knowledge. For instance, in the USA, plant materials remain an important component in 25% of prescriptions (Farnsworth and Soejarto 1985, 231-240). The implication of this is that large majority of the world's population relies on indigenous knowledge through traditional medicine in the management of healthcare challenges of various dimensions. Most of the health situations that have been declared as having 'no cure' or 'no satisfactory cures' such as Sickle Cell Anaemia were still being treated via indigenous knowledge system. It is on this basis that the role of indigenous knowledge in the management of Sickle Cell Anaemia is being explored. On the basis of the outcome of the study, the need for possible integration of Indigenous Knowledge with Modern Medical Practices for effective Management of Sickle Cell Anaemia is being considered as well.

Sickle Cell Anaemia
Sickle Cell Anaemia (SCA) is a term used to describe a group of genetic disorders of hemoglobin production characterized by a predominance of the abnormal hemoglobin known as hemoglobin S. It was in 1910 that James Herrick observed peculiar elongated sickle shaped red blood cells in the blood of an anemic black medical student, and then the scientific community came to know about it (Frenette and Atweh 2007, 850-858;Desai and Dhanani 2004, 34). The idea about the genetic basis for sickling was suggested by Emmel in 1917. The disease was named Sickle Cell Anaemia by Vernon Mason in 1922. Before this time around, some elements of the disease had been recognized earlier when a paper in the Southern Journal of Medical Pharmacology in 1846 described the absence of a spleen in the autopsy of a runaway slave. The symptoms related to sickle cell crises were known by various names in Africa long before they were recognized in the western hemisphere (Edelstein 1981, 557). A history of the condition equally tracked reports about this disease back to 1670 in one Ghanaian family (Desai and Dhanani 2004, 34). The African medical literature further reported this condition as a situation being 'misconceived' by Africans as ogbanje phenomenon (Nzewi 2001, 1403-16 and Asakitikpi 2008. The concept of ogbanje was noted as coming from Edo concept of Ogbankuan (Wikipedia 2019) but commonly used among the Igbo in Nigeria. Among the Yorùbá the same concept is known as 'abiku'. These concepts denote the children who come and go because of the very high infant mortality rate caused by this condition (SCA). However, this had been disproved by results of pilot studies conducted (by the researcher) among the traditional healthcare providers on the same issue. The traditional healers believe that the case of SCA is quite different from 'abiku' phenomenon.
An issue of interest here is that the Western medicine asserts that the disease cannot be cured but can be managed. Some years later, the Western medical scientists came up with new discovery that bone marrow transplantation appears to be the first treatment for sickle cell anemia with the potential to completely eradicate the disease in some patients. The traditional healthcare providers, on the other hand, contend that herbal remedies exist to correct the defective bone marrow for positive health outcome in the people suffering from SCA without surgical operation. The only point of meeting between these schools of medicine (Western medicine and African traditional healthcare) is identification of bone marrow as the origin of Sickle Cell Anaemia. In spite of this, nothing worthwhile could be laid hand on to show this point of meeting and the process involved. What now becomes area of interest to this study is the historical context of this point of meeting. This study will therefore serve as baseline data on it. On this note, the following questions arose: how far have the non-Western medical practitioners gone in knowing about SCA from Western medical angle and the effect of this on management of the disease? Have Western medical experts reciprocated this in their quest for the understanding and management of this disease taking into cognizance the cultural relativity in conception of the medical problems by the people they are managing? What are the effects of the efforts of these medical schools on the solution to Sickle Cell Anaemia and its attendant social and medical trauma?

Objectives of the Study
The study has the core objective of examining the indigenous knowledge of Sickle Cell Anaemia and traditional approaches for its management in the study area. It specifically investigates this in order to ascertain the veracity of IN THE MANAGEMENT  OF SICKLE CELL ANAEMIA  535 the theory, which stated that 'abiku' 1 was basically a cultural misconception of Sickle Cell Anaemia (Anie, Egunjobi and Akinyanju 2010, 2;Bzuaye and Olayemi 2009, 46;Stevenson and Edelstein 1981, 178-179). It also has the intent of encouraging new debate over the relationship between sickle cell disease and 'abiku' phenomenon from the Yorùbá perspective. While addressing this neglect, this study will also demonstrate the link between culture and healthcare services as well as how the two have been complementing each other for sustainable social system.

Significance of the Study
The need for this arose as a result of persistent controversy over the relationship between Sickle Cell Anaemiaand 'abiku' phenomenon most especially the recurring nature of the claim that 'abiku' is akin to Sickle Cell Anaemiaand subsequent contest of this claim by scholars. This study will therefore fill a gap being created as a result of dearth of academic works on Sickle Cell Anaemiafrom humanistic angle. It also has capability of showcasing the relevance of indigenous knowledge system through African traditional medical practices and the need to integrate this into the practice of modern Western medicine. The significance of this study further lies in its attempt to contribute to a better understanding of indigenous knowledge system as it bothers on Sickle Cell Anaemia among the Yorùbá. It will equally enhance the appreciation of relationship between Western and African traditional healthcare in the course of managing SCA. The foregoing therefore justify the need for indigenous and western medical schools to cross the boundary of their professional callings in order to ensure effective management of this health challenge.

Theoretical Perspective
The study derives its theoretical strength from Social Action Theory; The Social Construction of reality; and Health Belief Model (HBM). The baseline of social action, relying on Weber's perspective of interpretative understanding of human action (Graeff, Elder and Booth 1993, 20) involves a causal explanation of action, its course and consequence. HBM is an ideal model for addressing problem behaviours that evoke health concerns (Croyle 2005, 3-7). For instance, failure to take appropriate steps towards managing Sickle Cell Anaemia MUSEDIQ OLUFEMI LAWAL 536 and possibility of experiencing crisis occasioned by such failure. In line with the focus of this study, shared knowledge of SCA remains a collective definition, part of socio-cultural world of the patients and that of their caregivers. The model of social context of illness thus acknowledges that a problem or belief about an illness is a construct of both the family and the caregivers, and not simply a function of the sick individual's situations (Glanz, Barbara and Viswanath 2008, 45-51). Within the context of Weber's argument, it could be inferred that action is a subjective phenomenon, which involves at least two persons in an interactive process. Such interactions become routine and understanding of social phenomenon emerging from this becomes institutionalized into individual and society. Through this, people become aware of what reality 'is' (Berger and Luckmann 1966, 34). The reality in this case is Sickle Cell Anaemia (SCA) and its inherent problems. Efforts made to seek for more knowledge by the African healthcare providers depend on how the individual perceives the reality of this disorder. If an individual perceives a disease or negative health outcome to be a threat to the individual and the community at large, then an individual will be motivated to take action (source for knowledge) to assist in effective management of the disease. This concept of perceived threat is made up of two components: perceived susceptibility, or the perception that one is at risk for a disease or negative health outcome, and perceived severity, or the perceived seriousness of that disease or outcome. The HBM posits that a prerequisite to an individual taking action (seeking for more knowledge on how to better the lots of the multitude suffering from this disease) includes both perceived susceptibility and severity toward the negative health outcome (Rosenstock 1974, 328-335;Carpenter 2010, 661-669;Glanz and Bishop 2010, 399-418). The perceived effectiveness of the management option for SCA is therefore a product of such perception. The model thus notes that demographic factors such as age, gender, and ethnicity affect both the perceived threat of a disease as well as perceived benefits and barriers. In addition, cues to action, which refers to a variety of stimuli in the environment (e.g., media information, available educational options, illness of a friend or family member) are said to influence the perceived threat and perhaps trigger one's decision regarding the preventive action.

Methodology Applied
This study is descriptive in nature. The target population included the secondary caregivers (the African traditional healthcare providers) as well as people living with Sickle Cell Anaemia and their primary caregivers. The qualitative approach is being adopted in data collection for this work. The main goal of qualitative design was to offer opportunity for in-depth understanding of Sickle Cell Anaemia as a phenomenon and the approach towards its management. The data from these sources have the potential of providing information on indigenous knowledge of Sickle Cell Anaemia and the management process based on the experiences of the incidence of this disease. Specifically, the survey methods to be used include in-depth interview (IDI), Key informant interview (KII) and Literature search for existing information on sickle cell anaemia. The study population that included faith healers (the Christian, Muslim clerics and diviners) and traditional medical practitioners were purposively selected as a result of prior information about their involvements in issues pertaining to Sickle Cell Anaemia. These respondents were residents of Osun State, Nigeria. Given the focus of the study, these categories of people were adjudged as appropriate and possessed what it takes to provide the needed information that will help this study. A total number of 20 respondents involved in in-depth interview sessions were sampled through purposive approach. Those selected included people living with Sickle Cell Anaemia (04) and the primary caregivers/mothers of sickle cell patients (16). The respondents here were selected mainly from herbal therapy centers, and other institutions where sickle cell patients are cared for. Where enough respondents are not gotten, effort was made through snowball sampling method to make up for the shortfall in the nearest Local Government areas. Accidental sampling method was equally employed by us to sample respondents especially the sickle cell patients and primary caregivers met in a place other than the treatment centers. Instant interviews were sought and conducted where possible. Where it was not possible to get immediate responses from those met through accidental sampling, we booked appointment with them for interview in their respective places of residence. For key informant interview, 6 female herbalists; 6 male herbalists; and 6 Christian and 6 Muslim clerics were engaged (see table 1). Yorùbá language was utilized for the interview sessions among the respondents that were not literate in English language. This was translated to English for the analysis and discussion of this study.

Presentation and Discussion of Findings
The data presented were derived from the three dialectic groupings in Osun State, Nigeria. These dialect groups and the towns within them where the respondents were sampled are Ife (Ile-Ife, Garage Olode), Igbomina (Ila-Orangun), Oyo (Awo, Ejigbo, Ilobu, Inisa, Osogbo and Sekona). Our key informants in this study were the herbalists, the Christian and Muslim Clerics. Other participants we engaged in the in-depth interview sessions were the primary caregivers of the people living with Sickle Cell Anaemia.

INDIGENOUS KNOWLEDGE AND PRACTICES IN THE MANAGEMENT
OF SICKLE CELL ANAEMIA 539 f'ola dide had wider acceptance among the participants in key informant and indepth interviews. Other definitions of SCA derived from qualitative data were similar to those obtained from the quantitative data. Also, the conceptual views expressed about Sickle Cell Anaemia were similar in spite of variations of dialects among the people in Osun State, Nigeria. A look at the way Sickle Cell Anaemia is conceptually defined in local idioms will show three distinct understandings of the disease. Firstly, it shows that the cultural conception of Sickle Cell Anaemia takes place within outward results of the disorder (f'oniku f'ola dide, olonu and alore) framework. Conception process also takes into consideration the symptoms (r'omo l'apa r'omo l'ese, ar'omo leegun, san'gun san'gun) exhibited by the disorder and lastly the identification of causative agents of the disorder (aisan eje dudu, awoka inu eegun). Nevertheless, the indigenous knowledge articulated through cultural definitions and interpretation of Sickle Cell Anaemia did not align with its Western medical model. One of the Key Informants in this study also revealed thus: The ailment is known as San'gun San'gun; some people also defined it as Olonu based on instances where SC patients experience protruding belly. However, it can be treated but on gradual basis (Male KII, Herbalist at Ila Orangun, Osun State, Nigeria).
Another revelation was that interpretation of the causes of Sickle Cell Anaemia usually follow cultural, spiritual and superstitious milieu at the initial onset of the disease. According to a female respondent: It is not always easy to see this condition as a biological problem. My interactions with other mothers of the people living with Sickle Cell Anaemia also confirmed this. It is either this problem is seen as a spiritual attack or as heavenly inflicted problems. But in the course of wider consultations for better health outcome, the SC sufferers/primary caregivers will come to terms on the credibility of Western medical explanation of SCA (Female IDI, Primary Caregiver at Osogbo, Osun State, Nigeria) In support of the above, another participant noted that: I did not know that my second child (a boy) is sickle cell anaemic until he was one and half years old. His case was being treated as ordinary fever at initial stage, later as rheumatism until about a few months ago when he was diagnosed as being Sickle Cell sufferer (Female IDI, Primary Caregiver at Ile-Ife, Osun State, Nigeria).
Traditional healers and diviners emphasized the veracity of supernatural causes of disease and illness in general. The spiritual cause, according to them, could be in the form of attack and casting of spell, which could be determined and cured only through divination by consulting the gods and oracle. It was noted that the only way by which spirituality could come into play in the case of MUSEDIQ OLUFEMI LAWAL 540 SCA was through casting of spell to cause emotional trauma in the people living with SCA and/or primary caregivers. The expectation of such spell is to bring about frustration and impatience as well as eventual non-compliance with treatment regimen, and in the long run poor health outcome. On the other hand, experience and interactions with medical practitioners, educated and enlightened individuals influenced the position of faith healers on cause(s) of Sickle Cell Anaemia. This is why they identify with the Western medical model of SCA as a genetic-dysfunction. In spite of the belief in the biological etymology of Sickle Cell Anaemia, both Christian and Islamic faith healers (religious healers) were of the view that trauma from health problem could be spiritually induced to cause devastating effects on adopted management therapy. This reveals further that cultural conception of SCA is very relevant and an important determinant in the management therapy being adopted for the disorder. The emergence of non-scientific factors as parts of the perceived causes of Sickle Cell Anaemia in this study is a justification of previous studies (Maruzi 2005, 1-8;Akinsola 1993, 12-13, 111;Bourdillon 1991, 131-150) on multi-factorial aetiology of ill health. It showed the inadequacy of germ theory as an analytical category for understanding human behaviour on health matters.

Is Sickle Cell Case the Same as 'Abiku' Phenomenon?
This study investigates further on the possible relationship between Sickle Cell Anaemia and 'Abiku' phenomenon. Information on this was sourced from the faith healers that included the Christian clerics, Muslim clerics, the diviners and the herbalists. The respondents totally disagreed with the theory that sees 'abiku' as a misconception of Sickle Cell Anaemia. They noted that there are clear differences between the two. According to them, these differences manifest in the form of their concepts, causes and modes of case treatment. The discussion against the 'misconception theory' clearly pointed at these differences in the concepts, causes and modes of case treatment of Sickle Cell Anaemia and 'Abiku' phenomenon. In the words of one of the respondents: Sickle Cell Anaemia is a disease that is associated with bodily pain. The pain can manifest in any part of the body; if it can be in the hands, legs, neck, stomach, back or head. At that point in time, the individual living with this disease will feel uncomfortable and may resort to crying no matter the age. The primary caregivers at this point will feel the brunt of the disease when they find it difficult to bring about succor to the sufferers (Male KII, Diviner at Gbongan, Osun State, Nigeria).

Another submission revealed thus:
It is a medical ailment that manifests in different dimension, if it comes with pain; the pain is felt as if coming directly from the bones in the body. At this po-

INDIGENOUS KNOWLEDGE AND PRACTICES IN THE MANAGEMENT
OF SICKLE CELL ANAEMIA 541 int, it is call San'gun San'gun, ar'omo leegun; or r'omo lapa r'omo lese. Where the pain shifts from one part of the body to the other, it is classified as 'awoka inu eegun'. Because of unreliability in manifestation and treatment outcome, it is referred to as 'aisan alore'. There are other names by which this ailment is known. These names depend on the manifestation of the ailment on the sufferers. So, Sickle Cell Anaemia situation is quite different from 'abiku'. Individual known as 'abiku' always look healthy, the only thing about them is that they may die or develop sickness that will lead to death suddenly and this episode may happen within one hour (Female KII, Diviner at Otan Ayegbaju, Osun State, Nigeria).
It was further noted that: Sickle Cell Anaemia is a biological ailment; at initial stage of our life we believe it was caused by spiritual attack but exposure and involvement with biomedical sciences has changed this opinion. But we've discovered that spiritual challenges always crept in over time when the challenges from this ailment become unbearable. On the other hand, 'abiku' is spirit child engaging in repeated death and birth within a given family (Female KII, Christian Cleric at Iree, Osun State, Nigeria).

It was equally shown that:
It is not always easy to see this disease as biological problem. My interactions with other mothers of Sickle Cell Anaemia carriers revealed the same thing. It is either we see this problem as spiritual attack or as heavenly inflicted problems. But in the course of wider consultations for better health outcome, the SC carriers/primary caregivers will come to terms on the credibility of biomedical explanation of SCA (Female KII, Christian Cleric at Inisa town, Osun State, Nigeria).
Another submission stressed further that: Treatment of is done with the help of herbs and faith healing for spiritual and emotional stability. It is good to combine the two for effective and positive health outcome in people living with this health challenge. In the case of 'abiku', it is purely spiritual healing; no herbs can be potent when handling 'abiku' case (Male KII, Muslim Cleric at Ila Orangun town, Osun State, Nigeria) Another respondent opined that: Sickle Cell Anaemia is known as disease that has to do with blood system of the sufferers. It is only the challenges that come with it during management level that do involve spiritual attack. What happened at this point is that the primary caregiver often becomes traumatized; the enemies often use the occasion to cause emotional instability which will mislead the caregivers from the appropriate remedy that will solve the entire problem (Male KII, Muslim Cleric at Awo town, Osun State, Nigeria) A female respondent lent credence to this further:

MUSEDIQ OLUFEMI LAWAL 542
There are lots that go with blood system in an individual; this is the reason why the Yorùbá usually engage in spiritual inquiry when given out their children in marriage in order to know whether the spirit of intending couples matched. Individuals whose spirit did not match will result in disease that will create malfunctioning of the blood system. The implications of this are the manifestations that people experience during sickle cell crisis. This practice is highly effective and people who belief and practice this still live blissful marital and family life. The challenge of Sickle Cell Anaemia as it is commonly found in contemporary Yorùbá land is occasioned by people's refusal to follow this tradition. Adherence to new faith by many of these people who have crossed over to Christianity and Islam made them vulnerable to the menace of Sickle Cell crises. But the case of 'abiku' is quite different; 'abiku' spirit always demonstrate its malevolence by entering into the belly of a pregnant woman that moves around at awkward time such as 1a.m in the morning or 1p.m in the afternoon to be reborn and die thereafter (Female KII, Herbalist at Gbongan town, Osun State, Nigeria).
A respondent made revealed further that: Defective bone in the body of person living with Sickle Cell Anaemia is another major cause of this problem. It may be as a result of inheritance from similarly defective bones from both parents and diseases within the blood system. A person with such inheritance will always experience pain within the body and shortage of blood because of malfunctioning of the entire body system. In the case of 'abiku' phenomenon it is not always possible to see element of deformity in the body of 'abiku'. Where such is seen it is often a result of mark made on the body of the 'abiku' during the previous death. Parents or diviners at times put marks on the body of an 'abiku' that engage in recurrent death and birth within a particular household. Such marks are made on the prescription of oracle so that at the next coming such a child will not be able to go again (Male KII, Diviner at Ila Orangun town, Osun State, Nigeria).
In another perspective, a respondent noted thus: 'Abiku' is not a phenomenon that can be handled by a novice. It takes somebody who is spiritually well grounded to effectively handle it. It takes serious fasting and prayer to conquer this but in the case of Sickle Cell Anaemia, one may combine hospital services and faith healing for its management (Female KII, Christian Cleric at Awo town, Osun State, Nigeria) Another informant revealed thus: 'Abiku' is a dreaded scenario; the cases involving 'abiku' is always handled with appeasement, there is no herbs one can use that 'abiku' will not render impotent. Diviner or herbalist handling 'abiku' cases always know that they have to beg the spirit for breakthrough if not such practitioners will be put to ridicule. But the case of Sickle Cell Anaemia (SCA) is easy and effective provided the primary caregivers and the sufferers follow the prescription. Ingredients for the treatment and management of Sickle Cell Anaemia could be easily gotten within the immediate environment. This included 'Orin ata' (fagara anthoxyloides), Complementing this further, a participant submitted that: Marks are made on the dead child before it is buried to disfigure it and discourage it from appearing again. However, the fact that these marks reappear on the child that comes after, is a strong evidence to show that it is the same child that has appeared and a strong support for the belief in this phenomenon. It is equally an evidence that 'abiku' phenomenon exist and that we Yorùbá know what we are saying when we talk about 'abiku'. So surely know the difference between Sickle Cell Anaemia and 'abiku' phenomenon as well as having antidotes by which we handled the two cases differently (Male KII, Muslim Cleric at Iree town, Osun State, Nigeria)

Christian Faith Healer (Male/Ila Orangun, Osun State, Nigeria)
Pastor J.A. is a leading figure among the Pentecostal Clergymen in one of the Local Government Areas in the northern part of Osun State, Nigeria. His ministry has a Mission House where medical needs of the church members and other interested members of the community are attended to. He has been in the Vineyard of the Lord in the last nineteen years. He believes in the potency of prayer as capable of solving any problem, whether physical or spiritual. He affirmed various concepts with which SCA is identified in the community as including Alore, Awoka inu eegun, r'omo lapa romo lese and f'oniku f'ola dide. His experience of SCA over time was that most of the patients and primary caregivers are always troubled emotionally about this health challenge hence their usual desperate search for positive health outcome and multiple consultations for medical therapies. Emotional stability, however, plays greater role in positive health outcome, hence our insistence that patients and the primary caregivers should be steadfast with prayer and fasting for proper healing to take place.
With faith on the part of the sick and the primary caregivers, the prayer has never failed to stabilize their emotions. After this, they were always directed to the nearest Western medical clinics where necessary referral will be effected to Obafemi Awolowo University Teaching Hospital, Ilesa or Ile-Ife, LAUTECH Teaching Hospital, Osogbo or University College Hospital, Ibadan. While people were making use of hospital care, efforts were always directed towards spiritual monitoring and assistance. Pastor J.A. revealed that people do come once in a while for spiritual counseling and healing of the spirit during which they usually share their problems with him. According to him, they found it more convenient to discuss these problems with faith healers than doing the same with Western medical doctors.
Information on SCA at the home front, according to the participants in interview sessions, often comes in skeletal form. In the words of a participant: ....it is not always easy for people to know that their children or wards have Sickle Cell Anaemia except in cases where a medically informed individual is available within the family. The disease may set out in form of common cold, catarrh or malaria. At that point, community members will keep on assuring one that they have seen similar cases that have been treated successfully by one person or the other. That is why you see an average primary caregiver and people living with Sickle Cell Anaemia moving from one neighborhood to another searching for better remedy until a laboratory diagnosis will show that the case is nothing but SCA. (Female IDI, Primary Caregiver from Sekona, Osun State, Nigeria)

Indigenous Knowledge and Management Processes
There exist a small proportion of respondents who declare preference for traditional medicine due to the strength of faith in it and its perceived potency. A typical submission in this regard goes thus: .... because of our Christian background, almost every member of my family did not favour traditional healing. They see it as heretic in nature. But I've read and witnessed lots of cases that proved this position wrong. My belief in the efficacy of traditional medicine is what informed my decision to take my ward (the last born of my late parents) that has Sickle Cell Anaemia for herbal healing. Since he started to receive treatment from traditional medical provider, he rarely had SC crises. The herbal doctor does his work meticulously; apart from herbal therapy, there were instructions for complementary therapy like massaging, hydrotherapy (uses of various water forms and temperature). However, attacks against traditional therapy from the church and my family continue. My family members expressed fear over the need for laboratory test to ascertain level of perceived toxicity of the traditional medicine being administered into my ward. I eventually succumbed to the pressure in order to maintain existing cordiality in the family. The new arrangement is that the boy should continue with Western medical services like regular test and counseling and usage of traditional medical services at the same time. (Male IDI, Primary Caregiver from Ejigbo, Osun State, Nigeria) Most of the traditional healthcare providers who are key informants further asserted the efficacy of traditional medicine. Efforts at sustaining this feat as well as ensuring that the herbs produced had no negative effect were equally stressed. In the words of one of them: ... all the leaves around us including those the educated elites called 'flowers' are herbs that can effectively cure one disease or the other. What is needed is for one to identify these natural medicines and their uses. Most often one does not need incantation or special protocol before they can be used. Contemporary

INDIGENOUS KNOWLEDGE AND PRACTICES IN THE MANAGEMENT
OF SICKLE CELL ANAEMIA 545 herbal therapist is trained to take care of toxic matters in the herbs prepared.
Where the problem lies is the issue of regimen compliance. Like the case of ar'omo leegun (Sickle Cell Anaemia), it can be cured with appropriate herbs. However, the process towards positive outcome in treatment is gradual, but what is common is that people don't persevere with treatment procedure or they stay away from further consultation and medication immediately a certain degree of improvement is noticed in their wards (Male KII, Herbalist from Inisa, Osun State, Nigeria).

Faith-based Healing: Muslim Cleric (Male/Iwo town, Osun State, Nigeria)
Healing is not limited to offering prayer alone among the Muslim community. It usually involves the combination of herbs; in some instances, Qur'anic verses are written on a wooden slate and washed with water for drinking by the health seekers. Some Mallams (the Muslim scholars that also practice faith healing) utilize prayers and herbs alone. There are others who combine prayers, herbs and Qur'anic-inscription-liquid together to effect healing. Mallam B. belongs to the group of faith healers who combine herbs for healing and disease management.
A series of ailments (such as headache, fertility problems, spiritual problems and so on) are managed by Mallam B. He identified Sickle Cell Anaemia and was able to give accurate account of signs and symptoms associated with the disorder. Just like those that have spoken before him on the issue, he listed various indigenous concepts of SCA as r'omo lapa r'omo lese, ar'omo leegun, san'gun san'gun, aisan eje dudu, awoka inu eegun and f'oniku f'ola dide. He equally saw f'oniku f'ola dide as the concept that is very common among the people that have identified the disease as SCA.
Mallam B. revealed further that people that conceptualize SCA as f'oniku f'ola dide rarely go for other forms of therapy for the disorder beside Western medical management. Economic constraint, according to him, was the only factor that usually makes people do otherwise. In this case, it is either the primary caregivers have exhausted their resources in the previous services utilized or do not have enough financial strength at all. The previous sources here may include self-medication, herbal remedy, hospital care and faith-based healing. He opined that prayer plays unique roles in medication. It provides spiritual assurance and spiritual guidance. Prayer brings about spiritual assurance by removing emotional trauma from the mind of the sick or caregivers. It is through this that the sick or caregivers can have faith in the medication being given. Mallam B. noted that since drugs that worked for one person may not work for others due to body system, prayer always assists in guiding the sick or/and caregivers (primary and secondary) on appropriate medication for the sick. He therefore stressed that the combination of hospital care, herbal remedy and faith-based healing could bring about the cure of SCA. While he could not specifically say the cure would be total, he believes the health outcome would be reasonably sound provided the health seekers will be willing and able to endure the gradual processes involved.
Mallam B. did not believe in spiritual attacks as the cause of SCA. However, he was of the view that spiritual attack can be unleashed to create traumatic situation for the sick/primary caregivers. A traumatized individual in this case may not have faith in medical explanation for the ailment; rather than endure to the end for the gradual process of medical therapy being used, he will continue to imagine negative things and subsequent multiple medical consultations. A typical case like this is where faith-based healing (prayer) is needed to stabilize the mind of the sick or the primary caregivers. The positive outcome of this always endears many people towards faith-based healing and their readiness to share their intimate personal problems whether domestic or medical with the healers. This, according to the Cleric, has been assisting them in the course of tackling some of the issues being referred to them. It equally played greater role in the degree of success being recorded in medical outcome of these patients. Similarly, the Diviners recognized the importance of emotional stability of their clients as requisite for positive health outcome, hence its incorporation into every aspect of therapeutic measures adopted for the management of Sickle Cell Anaemia.

Healing through Divination -Practice and Process (Male/Ejigbo, Osun State, Nigeria)
Baba Awo A. I. is a diviner who uses Ifa divination system in making inquiry into unknown problems especially when such problems defy all available solutions. A medical misery like Sickle Cell Anaemia (SCA) is not left out of such efforts. He combines divination with healings which qualifies him as 'S'awo se'segun' 10 . Baba Awo does not believe that a disease exists that cannot be cured. The Yorùbá concept of disease that matched the story-line presented to him was r'omo lapa r'omo lese. Baba Awo stated that mortality through Sickle Cell Anaemia differs from 'Abiku' syndrome. He noted further that the Yorùbá healing system does not recognize the idea of genotype-matching. What obtains in Yorùbá land is spirit-matching which could be rightly guided upon consultation with an oracle. Couples whose spirits are not compatible are likely to have problems; such problems may manifest in poor marital relationship between the couple and the type of children coming out of that marriage. Health problems

INDIGENOUS KNOWLEDGE AND PRACTICES IN THE MANAGEMENT
OF SICKLE CELL ANAEMIA 547 like Sickle Cell Anaemia may occur in any or all of the children from such marriage, hence the usual ascription of such problem to spiritual cause. In the course of his work as a diviner, consultation of Ifa oracle is principal channel towards seeking health solution for his clients. According to him, treatment process for client sourcing for medical help passes through at least three stages. However, not all healers would necessarily pass through these stages, but the stages of diagnosis and treatment were considered paramount. The first stage entails a warm welcome of the mother or primary caregiver to the compound and greetings according to Yorùbá culture. At this session, the mother is required to explain the ailment plaguing the child, when the ailment started and the steps taken by the mother so far to address it. The second stage involves efforts towards finding out the exact cause(s) of the situation in hand. This is done through divination which is carried out through the use of cowries and cowry tray. The essence of divination was to identify appropriate treatment or solution to the problem. The warm reception of the mother by the diviner was to allay her fear and help her achieve a level of emotional stability. This will prepare the primary caregiver for a smooth treatment process. The implication of this is that diagnosis of the problem goes beyond the immediate health issue. To a large extent, it also embraces the psychosocial factors in the primary caregivers. To the diviner, a traumatized primary caregiver may not comply with treatment regimen unless the person is convinced through words and deeds to assure him/her that he/she is in the right place. In the final stage, the treatment procedure commences with the divination or diagnostic process which will lead to prescription of appropriate treatment. Very often the treatment involves the use of herbs/charms or appeasement. Charms as option may involve oral medication or making of incision on whole or any part of the body. Appeasement may also be prescribed by the oracle if it is detected that the spirit of the client does not favour the use of charms. An individual who uses charms despite the incompatibility with his spirit may not get desired results. Appeasement entails ritual; pacify ancestral masquerade, deities, head/creator or the 'mother'. It may require placing ritual objects at the intersection of three roads or in a dense forest or as may be prescribed by the oracle. Proper follow-up, according to Baba Awo, will bring about solution to any problem including SCA.

Local Management Therapy -Pigeon Pea (Male, Garrage Olode town, Osun State, Nigeria)
Mr. S. K. is a farmer, a widower and in his late 60s; he has been taking care of his grand-daughter who was left in his care after the death of his son and wife in a motor accident. As a result of this, he fully took over the role of caring for his grand-daughter who suffers from Sickle Cell Anaemia. The first challenge encountered in the course of managing this disorder was non-availability of a clinic that specializes in the treatment of SC cases. The available clinics were of a general nature, catering to patients with other ailments. During severe crises, he was referred to the Teaching Hospital in Ilesa. To complement occasional treatment from hospital care, he relied on local therapy called 'ewe' and 'ewa otili' [pigeon pea (Cajanus cajan) and its leaves] which were used as herbal remedy and nutritional supplement. The plants that produce these seeds were available in the area. The seeds have the appearance of beans, except that they are bigger and flat compared to beans. This plant is good for controlling the crises arising from SCA. It is boiled and the water drunk while the seeds are eaten as part of the therapy.
The seed, when cooked, is not as sweet as common beans but the taste is still okay for consumption. What most people, using the plant, do was to adopt it as part of family menu especially during raining season when most people living with Sickle Cell Anaemia are susceptible to recurrent crises. Inclusion of this as family menu serves as encouragement for its consumption by the individuals living with Sickle Cell Anaemia in spite of its somewhat unappetizing taste. This has been very effective in SC management. The belief is that the combination of herbaceous liquid (agbo) of pigeon pea (otili) leaves and cooked pigeon peas (ewa otili) will help in taking care of any other ailments apart from SCA within the body system. Through this, the incidence of crises has been drastically reduced to the barest minimum. As a result, consultation for hospital care was regarded as routine exercise for health talk and check-up.

Local Management Therapy -Pigeon Pea and Garlic (Male/Awo town, Osun State, Nigeria)
Another case presented here provides insight into why people are seldom involved in hospitalization over Sickle Cell Anaemia. A clergyman in one of the towns in Egbedore Local Government area of Osun State, Nigeria revealed that visitation to hospital still continues, but not as frequently as in the past. The rationale for this was alternative medical remedies that are available within this area. He stated that people living with Sickle Cell Anaemia who have attained the age of 8 to 10 years were encouraged to make use of 'Orin ata' (Fagara Anthoxyloides). This is a local plant that induces pepper-like sensation and tastes peppery when used as a chewing-stick. In the course of using it as chewing stick, a person living with Sickle Cell Anaemia is encouraged to swallow the saliva that is secreted in the mouth and mixed with this plant.
In this community, people also make use of 'ewe' and 'ewa otili' (plants and bean of pigeon peas, Cajanus cajan liquid for drinking, while the beans are cooked for eating. To accelerate the rate of cooking the seeds, garlic (alubosa aayu) is added. The garlic itself formed parts of identified traditional medicine for SCA. The inclusion of garlic in the cooking of pigeon pea or any other family food was an attempt at avoiding its unpleasant smell and taste. Consumption of the above is always on communal basis, so that individuals living with Sickle Cell Anaemia do not look odd. Through this, stigmatization will not occur. One can see as many individuals not living with Sickle Cell Anaemia embracing the drinking of 'Agbo otili' in order to motivate those living with this disorder to also drink it.

Local Management Therapy-Pigeon Pea, Garlic and Orin Ata (Ilobu town, Osun State, Nigeria)
Mr. F. T. is a retired headmaster from one of the primary schools in Osun State, Nigeria; he identified Sickle Cell Anaemia as 'aisan ar'omo leegun' and noted further that some people within the community see it as 'aisan alore'. According to him, people are lately making reference to it as 'f'oniku f'ola dide'. He could not be categorical about the prevalence of this disorder within the community. He pointed out that some people ascribed cases of 'abiku' to extreme effects of SCA; certain circumstances associated with the 'abiku' phenomenon, according to him, did not make this theory tenable.'Ewa otili' (pigeon pea) with scientific name, 'Cajanus cajan' and 'agbo otili' (herb from pigeon pea leaves) have been longstanding potent local remedies for this disorder. The peculiarity of these remedies is that their application is seasonal. People make use of the leaves and seeds of pigeon pea during raining season, a season that is noted for high incidence of SC-induced crises.
'Orin ata' is another remedy; this is all-weather in terms of its utilization. However, its usage is common among the people living with Sickle Cell Anaemia within particular age grade (from adolescence upward). Some people utilize garlic (alubosa aayu). Here, garlic is usually used as food seasoning and herbs supplement while in some cases matured people living with Sickle Cell Anaemia may eat it raw depending on individual preference. The adoption or use of these local remedies is never easy. The issue is that people living with Sickle Cell Anaemia have bitter experiences of stress and chronic pains. Very often they would have experimented with a cocktail of drugs before becoming reluctant to use drugs any further. Family members, particularly those with whom these people have developed strong relationship and have confidence in are always the lender of last resort here. Through this category of people, the people living with Sickle Cell Anaemia are usually prevailed upon to make a trial of other remedies.

Efficacy of Herbal Remedy
Mrs. Hilda Ogbe is not a medical doctor; she came from the United Kingdom to Nigeria with her Nigerian lawyer-husband in 1956. She loves her adopted country and vowed from the beginning to render all the help she could to the country and the community in which she now lives. In 1978 she was by chance given an herb which allows Sickle Cell sufferers to lead normal lives. At that time, her husband's niece, an 18-year-old girl, was always sick. She was in and out of hospital and her mother could no longer afford the hospital fees. Also, she could not bear to see her child in such terrible pain. Mrs. Ogbe took her husband's niece to a botanist who took them to a field where he uprooted some small plants and gave them to her. She was advised to break off a piece of the plant and give the girl a piece to chew with assurance that if she swallows it twice a week, she will have no more serious crisis after that. After this was done, the girl was relieved of recurring excruciating bone pains. She lived happily ever after; she is over forty years old now and has two healthy children.
When Mrs. Ogbe saw the recovery of this niece, she was amazed at the efficacy of the simple, modest-looking herb. She thought she should plant this herb in her garden maybe she could help somebody with it someday. For the past 24 years, she has been growing this sickle-cell herb in large quantities. She processes it herself, and it is now available in capsule form. A team of researchers from the University of Benin took the herbs for analysis and were excited with their positive findings. In the meantime, from a very small beginning when she helped a baby to recover, the news has spread and many people come with their sickle-cell problems. They come to her house in Benin City between 6 pm and 7 pm. After writing down the medical history of each patient, she provided them with enough capsules to last one month. After that time, the patients will come again so that she can check how effective the treatment has been. Sometimes the dosage needs to be adjusted because of differences in physiological make-up, but all of them show improvement with the use of the herbal capsules. Ogbe (2004) listed some of the cases she had handled; one of them is expressed below: The first one was a baby of four-month-old. Mrs. Ogbe wondered how a four month-old baby could chew a piece of herb, she knew it was impossible and therefore decided to dry the herb, grind it and put it in the baby's food (pap or akamu), putting the herb in one corner of the plate and scooping it up with the pap when feeding. A quarter of a teaspoonful (½ a capsule) of herb remedied the pain of this baby in a short time. When the parents took the baby back to Jos, he was not crying any more. The swelling on his hands and fees had gone and he behaved like a normal healthy baby (Extracted from a book titled 'Sickle Cell: How to Cope' written by Mrs. Hilda Ogbe).

INDIGENOUS KNOWLEDGE AND PRACTICES IN THE MANAGEMENT OF SICKLE CELL ANAEMIA 551
Major Findings of the Study The Yorùbá recognize Sickle Cell Anaemia, its symptoms and causes. Data also indicated that people were conversant with this medical condition. The findings from this study are in variance with the popular assumption that people are ignorant of the disease, as the Yorùbá in Osun State, Nigeria, have developed different concepts for this disorder as well as healthcare systems and treatment strategies at the home front (indigenous knowledge system). Most of the local concepts of this disorder largely centered on the symptoms of the disorder and differed markedly from Western medical model.
-Conception and management of Sickle Cell Anaemia were found to be heavily influenced by interpersonal relationship. Data from all sources in this study pointed to this. -The data further showed that incidence of Sickle Cell Anaemia is usually interpreted within cultural perspective based on environmental dictate. The implication of this is that the social environment remains an essential factor to be taken into consideration when studying health situation from a cultural perspective. -This study thus demonstrated that man consciously or unconsciously depend on his environment for his survival, especially in the course of defining his/her health situations and the choice of therapy to be adopted. As a result of this, home remedies usually come first in the course of treatment based on knowledge, accessibility and affordability (Kofoed et al. 2004, 17-22;Uzochukwu and Onwujekwe 2004, 6;Kottak 2004, 42-45;Heilman 2001, 104). -Traditional medicine and faith-based healing were most favoured by those who utilized more than two or more healthcare sources. On the other hand, faith-based care, divination and home remedies receive more consideration in the rural area. Efficacy of these approaches for treating Sickle Cell Anaemia was affirmed. The rationale for the purported widespread of incidence of Sickle Cell Anaemia was attributed to abandonment of existing tradition of making inquiry about spiritual compatibility of intending couple. -Distinction was made on what constitute Sickle Cell Anaemia and 'abiku' phenomenon. It was made clearer that the Yorùbá have been treating these two phenomena with the appropriate approaches that have over time brings about effective medical outcome. -This therefore showed that the Yorùbá are not ignorant of the differences between the two and that the Yorùbá have been expressing this medical condition in line with their peculiar cultural background, which has been beyond the comprehension of experts in biomedicine.

Conclusion and Recommendations
Adoption of a home remedy like faith-based healing is an indication that it was not in every situation that the adopters of non-Western medical options resorted to traditional rites (rituals) in the management of health problems. This is an affirmation of the findings of Ugochukwu (2000, 10-16), Adegoke (2001, 28-35) and Banji (2002, 24-29) that faith-based healing is a phenomenon when talking of health care management in Nigeria. Also, information (Lawal 2012, 116-120;Akinsule et al. 2005, 200-205) that the Yorùbá have over the years being using 'fagara' root (orin ata in Yorùbá language) and pigeon pea (cajanus cajan) for the treatment of Sickle Cell Anaemia because of their anti-sickling properties further affirmed their knowledge and awareness of difference between Sickle Cell Anaemia and related issue like 'abiku' phenomenon. This is a pointer to the necessity for an in-depth understanding of positive side of indigenous knowledge system in the management of Sickle Cell Anaemia to complement Western-science for the management of this disease.