The Utilisation of Traditional Medicine among Young Malay Breast Cancer Patients

_____________________________________________________________________________________________________ This is a qualitative study examining the utilisation pattern of traditional medicine among young Malay women breast cancer patients. The study has shown that there is an increasing number of breast cancer patients to opt for traditional medicine in searching for a cure. To address the issue, an ethnographic fieldwork was carried out in Klang Valley and several selected areas of Selangor. Thirteen (13) young Malay breast cancer patients were selected as informants for this study by employing purposive snowballing technique. Guided by semi-structured interview schedule, a series of in-depth interviews, phone and online interviews and participant observation were conducted at various settings to capture informants’ health seeking behaviour. It is evident that traditional medicine is still prevalent as one of the treatment options among breast cancer patients. They strongly believed that relying on a single treatment for chronic illness like breast cancer is insufficient. In relation to this, traditional healers and health practitioners such as bomoh and ustaz were consulted by Malay informants either as an alternative or complementary for a cure. Several treatment methods such as herbal remedies for oral consumption, air penawar (healing water) for drinking and bathing and specific item such as an egg for surgery-like procedure were prescribed to treat the cancer-related symptoms suffered. In most instances, majority of the patients were guided by family and friends’ suggestions towards the utilisation of traditional medicine.


Introduction
Several studies have shown that many cancer patients have opted for traditional healing via bomoh (traditional Malay healers) for a cure (Muhamad et al. 2012;Salleh, 1989). Such decision for the option is substantially influenced by their strong cultural beliefs of the perceived benefits and compatibility in traditional medicine. This is further substantiated by the accepted fact among cancer patients that cancer is a chronic disease that requires a long-life disease-management. In most instances, the traditional healing via bomoh is sought for supernatural etiology of illnesses such as sorcery and witchcraft. As such, traditional healings like incantation, exorcism, trance, air penawar (healing water), ritual bath, herbal concoction are commonly prescribed by the bomoh to deal with it (Salleh, 1989). Muhamad et al. (2012) in their study had found that traditional healing is prevalent among cancer patients in Peninsular Malaysia. In most cases, they were recommended and motivated by family members and friends to seek help from traditional healers or bomoh due to perceived benefits, compatibility and its credibility for their health-related issues.

Literature Review
Many people in Malaysia seek traditional healers or bomoh for various reasons. In the case of Malaysia, the traditional healers or bomoh were sought and consulted for various ailments ranging from traditional complaints like charm and spirit-possession to physical and psychological complaints such as anxiety due to several events like exam and interview. This shows that, seeking help from traditional healer is still prevalent in Malaysia, not only for medical problems but also for non-medical problem. As in the case of medical, the utilisation of traditional medicine is considerably meant either as an alternative or complementary to the existing treatment, modern treatment in particular. This is evident for patients succumbing to prolonged illness and the modern treatment sought for has proven to be to no avail (Heggenhougen, 1980). Merriam and Muhamad (2013) in their study among cancer patients in Malaysia for instance, have identified the various roles played by bomoh in treating cancer i.e., as medicinal healer, emotional comforter for patients to cope with fear, uncertainty and anxiety; spiritual guide and palliative caregiver. This is very much related to the cultural compatibility embedded in the Malay cultural beliefs towards the bomoh institution. According to Osman (1972), the institution of bomoh and the practice of medicine have been regarded as part of the total Malay cultural belief system. The premise of the bomoh institution believes to be fundamentally supernatural in nature in which both the traditional Malay cultural belief and Islamic religious belief circumscribe to it. In Malay cultural belief, bomoh is commonly sought for due to his or her extraordinary ability in dealing with supernatural-caused related illnesses. The healing methods adopted by the bomoh such as the recitation of Qur'anic verses to ward off the spirits have made it significant and compatible to the lives of Muslims in searching for a cure.
Among the Batak Toba community, Namalo (traditional healers) are sought for their specialisation to treat androbion (breast cancer) and other illnesses. The treatment administered the use of herbal remedies ingredients such as betel nuts, lime, tobacco, bay oil and unused needle, to list down a few. These ingredients and other herbal concoctions will be processed in various ways before smearing them over the painful and affected areas using a clean chicken feather. The Namalo believed that those herbal remedies should be well prepared and mixed within the accepted dosage to ensure its medicinal benefits and the effectiveness of the treatment rendered to breast cancer patients (Tobing et al., 2020) Merriam and Muhamad (2011) in discussing further on cancer patients in Malaysia, have identified several methods used by the traditional healers in their treatment process. They found that the common treatments administered involve the use of herbal concoctions, plant roots and spiritual incantations. The preparation observed include preparing a paste of betel leaf, gambir, lime and a bit of sugar to treat the lump symptom in breast cancer patients. Other methods were also in used such as using yam plant or eggs to remove the disease from the affected areas. The treatment methods employed however, is only feasible if the disease is still at an early stage. As for spiritual incantations, most of the traditional healers will advise their cancer patients to continuously observe the recitation of Quranic verses as prescribed together with du'a or prayers for a cure.
Similarly, Suhami et al. (2014) have identified two majors healing approaches used by healers to treat Malay Muslim cancer patients in Malaysia. First, patients were advised to opt for spiritual healing involving the recitation of specific Qur'anic verses or surahs (chapters) such as Surah Al-Kahfi, Surah Al-Mukminun and Surah Al-Hajj, du'a, non-obligatory prayers and performing solat Tahajjud in the middle of the night to treat their illness. Second, treatment using herbal remedies, Quranic recitation, du'a and air penawar (healing water) by some healers to treat their patients. Several healers believed that the herbal remedies have medicinal benefits and potency such as anti-cancer agents. Among the herbs prescribed by the healers are pokok Kenerak, kunyit putih (white turmeric) and rumput Sambau (goosegrass).
In another study, Iskandarsyah et al. (2013) have identified several contributing factors for breast cancer patients' non-compliance to hospital treatments in Bandung, Indonesia. They decided to seek alternative and traditional medication instead. Reasons for non-compliance and medical pluralistic attitude towards the options were heavily related to financial implications, emotional burden and severe side effects of hospital treatment. The financial implications claimed to be heavily borne by patients in seeking for hospital treatments. The costs were not only related to medication, but other non-medical expenses such as transportation and accommodation. Besides, unbearable emotional pain due to long duration of cancer treatment in the hospital had caused the patients to develop fear of death, uncertainty of the treatment effectiveness and curability as well as guilt feeling for inability to perform roles as wife and mother. In addition, the side effects of hospital treatments through chemotherapy were claimed by patients to be unbearable such as pain, fatigue, nausea and dizziness.
In relation to this, the use of traditional and complementary medicine (TCM), particularly Islamic healing techniques have become increasingly popular among Muslim cancer patients in Malaysia. They believed the spiritual curative healing is imperative in seeking guidance and blessings from Allah for a cure. Thus, the mode of Islamic healing requires them to be closer to Allah through prayers, reciting Quranic verses and adopting Islamic way of life in their daily routines. The Islamic way of life includes their strong religious beliefs in respecting and obeying parents, husband and having a good, balance and harmonious relationship with immediate family members for an effective cure. In addition, the decision for TCM especially Islamic healing by cancer patients could also be justified by their strong cultural beliefs in supernatural forces such as sorcery, witchcraft, and malevolent jins of which believed to be responsible for their ailments (Suhami et al., 2016).

Methodology
An ethnographic fieldwork was carried out at various settings in Klang Valley and several selected areas of Selangor. During the fieldwork, a series of in-depth interviews through face-to-face, over the phone and online platforms with informants was conducted for data collection. Interview-schedule method and participant-observation were employed to examine the informants' health-seeking behaviour particularly in making decisions for seeking traditional treatment. A purposive snowball technique was employed to select the informants according to the criteria of inclusion for the study. The selection of informants should satisfy the following criteria 1) must be women of Malay ethnicity 2) must be of young age defined in the study which is within the age range of 25 to 49 years old; 3) must be among breast cancer patients or survivors as the study itself was carried out specifically to study the illness experiences of breast cancer patients or survivors and 4) must have undergone a series of treatments at least for a period of six months before the selection was carried out. This is imperative particularly, in examining the utilisation pattern of health services among the breast cancer patients such as attitudes towards the treatment. Thematic analysis was conducted to identify the dominant themes representing the utilisation pattern of traditional medicine among the informants.

Informants Demographics Profiles
Thirteen (13) young Malay women suffering from breast cancer between the ages of 29 to 48 years old were selected as informants for the study. They were of Malay ethnic origin who professed Islam as their religion and practiced the Malay adat (Malay customs) as their lifestyles.  Table 1 above represents informants' demographic and health profiles. It was observed that majority of the informants interviewed were in Stage II of breast cancer. In many cases, these Malay informants succumb to medical pluralisation approach as far as health seeking behavior is concerned. This includes the utilisation of traditional medicine as their treatment options to alleviate their pain and distressing symptoms due to cancer. The discussion that follows below will describe several themes that can be associated with the utilisation of traditional medicine.

Theme 1: Mode of Utilisation
Several informants narrated that they utilised traditional medicine as one of the ikhtiar (effort) to treat the symptoms suffered due to breast cancer. Ila aged 36 in one of the interviews narrated that aside from hospital treatment, she also practiced certain petua (cultural practices) obtained from other cancer patients and survivors. She had the information through her general readings and searching on the Internet. She told me:

One of the 'petua' that she practised as 'ikhtiar' to cure her breast cancer was consuming green apple and 'daun Belalai Gajah'. She blended both ingredients together with water and consumed it twice daily as a juice for cancer remedy. She believed that the ingredients prepared for the remedies particularly 'daun Belalai Gajah' were classified as 'panas' and could suppress the growth of cancer cells.
As for Juji aged 36, she narrated her experience as follow: In another instance, Teh aged 41 described the following in one of the interviews: She was advised and recommended by the healer to find several herbs like 'kulat harimau ', 'rumput Sambau' and 'kulit kerang' (clamshell)  The foregoing descriptions highlighted the role of Malay cultural beliefs in relation to the utilization patterns of traditional medicine among the young Malay women breast cancer patients. The Malay cultural beliefs have categorized the traditional medications as panas (hot) treatment that could suppress cancerous cells. They strongly believed that chronic or incurable disease like cancer requires them to secure whatever options available such as traditional medication, herbal remedies or petua for a cure.
Relying on hospital treatment alone would be insufficient. Those options, however, are considered as ikhtiar (efforts) in treating their cancer symptoms.

Theme 2: Sources of information
In relation to source of information, Sue aged 33 had this to say; Sue also seek for ustaz help, as recommended by her friends, who is also a breast cancer survivor in seeking for a cure for her illness. Sue described to me as below: One of her friends, who is a breast cancer survivor recommended her to seek help from an 'ustaz'. During the treatment process, the 'ustaz' would sit behind her and roll an egg on her back to pull out the cancer cells from her body. The ustaz also prepared 'air penawar' for her to drink and bathing. It was believed that the 'air penawar' could purify her body from impurities like cancer cells.
The 'ustaz' did not charge her any specific payment for the treatment. Instead, he left it to her discretion for the payment.
Family support is another important dimension in influencing one's decision prior to utilising any form of treatment. There are various reasons for this. Several informants strongly believed that family members especially parents and spouses, could actually assist them in dealing with chronic pain like breast cancer. They could turn their sufferings to their loved ones in alleviating the pain. In most occasions, they would seek advice on how to go about in treating the illness suffered. The role of immediate family members especially mother is imperative in alleviating pain suffered by the breast cancer patients. Most significantly, their behaviour are regulated by religious values i.e. jangan derhaka and at the same time, securing blessings for good health, barakah and finally be cured from cancer. Similarly, the role of cancer survivors in assisting the breast cancer patients to get on with their lives. The informants strongly believed that relying on the narratives given by cancer survivors could assist and eventually cure them from cancer. This was because, the information shared by cancer survivors gives the m the feeling of security and could overcome the fear of death associated with cancer diagnosis.

Conclusion
The foregoing discussion highlighted the significant roles of traditional or religious traditional healers in treating ill-health symptoms suffered by breast cancer patients. It is evident that breast cancer patients employ both hospital and traditional medications. As for patients, they presume both medical systems are working side-by-side in treating their breast ill-health symptoms. At times, the options for traditional medication are merely for complementary purpose to the existing hospital treatment rather than replacing it. Such decision is crucial for chronic illness like breast cancer patients which requires long life disease or illness management. It can be suggested that the doctor-patient's relationships observed in this study are of two categories, namely doctor-patient and healer-patient relationships. Doctor-patient relationship refers to patients consulting with medical health professionals like doctor in the hospital setting for the symptoms suffered while healer-patient relationship involves consulting traditional healer such as bomoh for their sufferings including social sufferings. This inadvertently leads to our understanding of medical pluralistic attitude among the breast cancer patients. They strongly believed that seeking hospital treatment alone for chronic illnesses like breast cancer would be unjustified. Instead, they have to seek for multiple combinations of treatments including traditional medications and traditional Malay guidelines known as petua. This is substantially evident in the case where the initial treatments sought proved to be no avail. The medical pluralistic attitude is further strengthened or substantiated by the fact that traditional medical system and modern medical system existed in parallel in society. In other words, informants or breast cancer patients had options to seek for a cure in treating their chronic pain or illnesses. This study had assisted our understanding the psychological dimension of patients of which the aim for such pluralistic attitude towards medication was aimed to seek for a cure.