Letter from Yemen
Illustration: Multiple incisions of recent cupping procedure | 
MJA 1999; 171: 684
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To the Editor:
For six months a Bedouin patient had suffered from
terrible headaches. Doctors at San'a' hospital performed blood
tests and scans, but the tablets they prescribed did not stop the
headaches, so he sought the help of a matowa, or holy man, from a
nearby village. The matowa performed readings from the Holy
Koran, but the headaches continued unabated, so the patient left
San'a' to seek the help of a traditional healer in the desert. The
healer recommended cautery and cupping.
Cautery is used throughout the Arab world and parts of Africa in the treatment of pain, paralysis and a variety of other illnesses.1,2 The instrument of cauterisation is usually a metal rod, fashioned at one end into a disc. Small deep burns are inflicted close to the site of the pain or at distant points believed to influence the affected organ.3 Cupping, on the other hand, is usually used in the treatment of metaphysical conditions, such as the extraction of malicious spells, harmful medicines, and the effects of the evil eye,3 although in some parts of the world it is also used for treating physical ailments. For example, in less law-abiding parts of Africa, it is used in the treatment of shotgun wounds, and is popular among taxi drivers, who are occupationally predisposed to firearm attack.3 The skin is incised with a razor blade or knife in a series of parallel incisions about 5 mm apart and 5 cm long in an area about the size of a large coin. Then, the wide end of a goat horn is placed over the incisions and the healer sucks out the air through a hole in the tip to create a vacuum. A piece of beeswax is placed over the hole in the horn to maintain the pressure for up to half an hour.3 "The edge of the desert", wrote T E Lawrence, "is littered with the debris of great civilisations and thoughts".4 Lawrence was honouring the resistance of the desert Bedouin to cultural incursion, but in the last four decades even the Bedouin have succumbed to change from outside, and the role of the healer has also changed. In earlier times the healer functioned as a teacher, judge and religious leader, but, with the advent of schools, courts and hospitals, his traditional role has been curtailed. Today, against this trend of acculturation, the healer survives and continues to play an important role in treating difficult ailments for which Western medicine has no cure.1,5 This case is characteristic of the management of medical problems in the region. Western medicine is the treatment of first choice. This is followed by incantations from the Koran. Failing these methods, the treatments of last resort are the pre-Islamic practices of cupping and cautery. Although the specifics of management vary, the trend is always the same: towards earlier cultural modes of treatment and cure.1,3 Social policy planners around the world have long despaired at indigenous people resorting to traditional healers. There is no evidence for the efficacy of traditional cures, it is argued, and the treatments are at times harmful or disfiguring. But Western medicine fails to understand the role of the traditional healer as a familiar and trusted repository of culture in a time of uncertainty and change.3,6 The world over, traditional medicine persists in otherwise acculturated societies because it provides the sanction of an old and trusted belief system during times of crisis.3,6 The Bedouin, surrounded by ways of life they do not fully understand or even like, return to the healer who understands them, a person they know and trust, who will guide them back to health in a perplexing and unsettling world. The patient has returned for treatment of his hypertension. He nervously fingers his prayer beads as he gazes out the door of the outpatient clinic into the blazing sunshine. There is no contradiction in this. Hypertension is an invisible Western disease which requires a Western cure. But, even so, the Western diagnosis may not be accepted as complete. Should overt complications arise which are unresponsive to treatment, he may believe that there are metaphysical or other causes at work and seek the skills of the matowa or even the Bedouin healer. Chris Cooper (Dr Cooper worked for eight years as a general practitioner in Middle Eastern countries.)
©MJA 1999
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