Anthropological, Cultural and Ethical Aspects of Caring for Patients in Africa ()
1. Introduction
Health, illness, medicine, and care are concepts that constantly interact with each other and are absolutely related to human life in different situations. The World Health Organization (WHO), which is the United Nations agency dedicated to health, has as its main objective the achievement of the highest possible level of health for all people in the world.
According to the Constitution of the (WHO, 1946) , health is a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity. Boorse (1975) suggests that a person would be considered healthy when all their organs and tissues, as well as their mental faculties, function harmoniously (Boorse, 1975) . In this perspective, Leriche (1936) defined health as “life in the silence of the organs.” On the other hand, disease is defined as harmful effects that alter the homeostasis, the normal functioning of a living organism. Moreover, from a quality-of-life perspective, health would become the measure by which a group or an individual can achieve their aspirations and satisfy their needs, and also adapt to this “state of complete well-being” (WHO, 1986) . The concept of care varies depending on the living beings involved, as taking care of a plant is different from taking care of a human being. The purpose of care is to meet the fundamental needs of a living organism. As for human beings, caring restores the physical, psychological, and social well-being of a suffering patient. According to Hesbeen (2017) , care is the particular attention given by a competent caregiver to a person or their loved ones to help them in their state of weakness (Hesbeen, 2017) . In this context, medical or nursing care for a patient is defined as care provided autonomously or in collaboration to individuals of all ages, families, groups, and communities regardless of the setting (HEdS.Fr, 2010) .
Originally, care in Ancient Greece was mainly related to rituals and magic (Sournia, 2004) . Hellenists did not make a distinction between medicine and nursing care; this patient care gradually became rationalized based on empirical observations, anatomo-physiological descriptions, and analyses, and became more technical. In addition, the current sources of care for the sick in the West date back to Greco-Roman culture (Sournia, 2004) . Indeed, while the history of two peoples (Greek and Roman) could be distinguished originally, over the years it became a shared cultural background, with the same approaches to caring for the sick (Durand, 2000) .
At the antipodes of the Western reflection on health, disease and care, the African vision of the reality of human contingency puts the emphasis on the structural kinship between man and nature, and between man and the supernatural world, the abode of spirits (Dime, 1995) . According to the African thinker (Omonzejele, 2008) , “all the multiplicity of things that make up the universe are mystically one and therefore constitute only one thing, one reality; everything is a part of the other that constitutes the reality, the total cosmos or the universe”. Therefore, bodily illness would be perceived as a sign of a very deep imbalance that would disturb not only the being and the spirit of an individual but also society, the cosmic universe, and even metaphysics. The objectives of this research were to present the philosophy of healthcare in ancient Greece, to expose the anthropological and cultural aspects of healthcare for the sick in Africa, and finally to present the ethical challenges of today’s therapeutic care of patients. In order to bring all peoples to the highest possible level of health, WHO should, from now on, not only instill in health professionals an ethics and a code of conduct for caring for the sick, but also encourage researchers to draw from the ancient and traditional cultures of peoples the ancestral knowledge of good practices for the care of the sick.
2. Methodology
A literature review was conducted from 1990 to 2022. The search was conducted in English and/or French using the databases PubMed, Google Scholar, Science Direct, and Web of Science. Articles from archives in Burkina Faso were also used. The key search terms used were: “traditional African healthcare”; “ancient Greek medicine”; “healthcare in ancient Greece”; “African healthcare culture”; “ethical healthcare”. The data was exported into the Endnote software and duplicates were removed. The second level of selection involved reading the abstracts of eligible articles and eliminating those without abstracts or presenting irrelevant data. Finally, a review of the full texts allowed for the definitive selection of studies included in this review. The current sources of patient care in Western countries go back to the culture of ancient Greece. And nowadays, the Hippocratic Oath remains the foundation, the reference of all medical ethics and the source of inspiration of the different codes of ethics of the health care personnel. This is why the philosophy of Greek medicine of the 4th century BC, which continues to inspire contemporary medicine, will be presented.
This study is in the area of ethics and philosophy of medicine; hence the choice of this approach and this method of anthropological research; they allow to have an overview of the skills to take care of all the needs (physical, psychological, social and spiritual) of the person who suffers
3. Results
3.1. Search Results in Figure A1
Figure A1 shows the flow diagram of process for selecting studies included in the systematic review according to PRISMA.
3.2. Introduction to the Philosophy of Health Care in Ancient Greece
Vision of the concept of “care” in ancient Greece.
The concept of “care” comes from the ancient Greek word “epimeleia” which means “concern”: someone who cares for their fellow human in difficulty, leans in, and takes care of them (Gros, 2007) . Later, the Greek “epimeleia” was translated into Latin as “cura,” which is transcribed in French as “cure, care” and in English as “care.” In ancient Greece, Socratic philosophers exhorted their contemporaries to take care of themselves and to take care of their being. Thus, when Socrates addressed his fellow citizens in the Apology, he said, “I see you taking care of your body and your pleasures, your wealth and your reputation, but do you take care of your soul?” (Gros, 2007) . For the philosophers of antiquity, philosophy is a school that teaches man to take care of himself, that is, to take care of the life of his soul (Lucas, 2007) . Therefore, for Gros (2007) , ancient philosophy largely presents itself as a therapy for the soul, in opposition to medicine, which would be the therapy for the body. Consequently, the Stoic Epictetus constantly repeats that one must go to his school to care for his soul as one goes to the hospital to take care of his body. For Epictetus, who does not care for himself and does not take care of himself, cannot take care of others well; just as no one can help their peers in distress if they have not built a firm and solid soul. This individual, unprepared to care for others, will therefore be afflicted with a kind of depression that would be called “burnout” in the modern world.
Philosophy of healthcare provision in ancient Greece.
The ancient Greeks discovered that mental and physical health were interdependent, as they observed that the body and mind had to be in harmony. Philosopher Aristotle believed that sports and gymnastics were essential to developing the human body and optimizing functional capacity and harmony between the mind and body, hence the famous proverb “Mens sana in corpore sano” a healthy mind in a healthy body (Vasiliadis et al., 2009) . In this same ancient Greece, three main categories of Hippocratic healthcare provision were observed: 1) health promotion, which included physical activity as an essential element of physical and mental health and emphasized the importance of nutrition to improve performance at the Olympic Games; 2) trauma care interventions included surgical practices developed by Hippocrates, mainly due to the frequent wars in ancient Greece; and 3) mental health care interventions and art therapy were consistent with the first classification of mental disorders proposed by Hippocrates (Kleisiaris et al., 2014) . In this therapeutic perspective, according to Kleisiaris et al. (2014) , music and theater were used as management tools in the treatment of illness and in improving human behavior. Thus, the Hippocratic philosophy of healthcare provision focused on the holistic, even integral, healthcare model. Nowadays, it is recognized that the foundations of science and the study of physiology, anatomy, and psychology in ancient Greece were developed to discover the sources of disease and promote the state of health (Tountas, 2009) . According to Petersdorf (1994) , with the development of medical science in ancient Greece, different perceptions were created regarding the practice of medicine following the formation of different schools of medicine such as the Cnidian physicians and the Methodists, who respectively focused on the disease burdening the patient (Petersdorf, 1994) and the importance of understanding the overall consideration of patients’ health and health status (Porter, 2005) . Following the Asclepius paradigm, Hippocrates focused on “natural” treatment to combat disease (Parkes & Heyse-Moore, 2008) . According to Kirsten et al. (2009) , the Hippocratic tradition emphasized environmental causes and natural treatments for diseases, the causes and therapeutic importance of psychological factors, nutrition and lifestyle, the independence of the mind, body, and spirit, and the necessity for harmony between the individual and the social and natural environment (Gordon, 1990; Kirsten et al., 2009) . According to (Nomikos et al., 2010) , Hippocrates also used olive oil in athletes to increase body temperature, warm up and loosen muscles to avoid sports injuries. And according to Kleisiaris et al. (2014) , in Homer’s “Iliad” injuries and amputations reflecting actual wound care are described in the wars of ancient Greece, and Hippocrates noticed the separation of gangrene from limbs and practiced incisions between dead and living tissues to treat the disease (Kirkup, 1995; Kleisiaris et al., 2014) . In addition to diet, exercise, application of olive oils, psychotherapy, and logotherapy (Thumiger, 2020) , in ancient Greece, music and theater were used in the treatment of physical and mental illnesses because improving human behavior was essential.
So, the Greeks of that time believed that caring for the soul through music also healed the body, and there were specific musical applications for certain illnesses (Conrad, 2010) . This suggests that healthcare in ancient Greece also included psychotherapy (Kourkouta, 2002) . In short, the basic structure of the Asclepieion in Kos indicates that Hippocrates believed in a model of comprehensive healthcare, where science met pharmacotherapy, dietary regimes, physical and mental exercise, massages and walks, as well as divine intervention (Orfanos, 2007) , all considered necessary to restore health, well-being of the soul, and inner peace of man (Kleisiaris et al., 2014) . However, to achieve the desired therapeutic outcome, the therapist had to first understand the concept of the soul and its distinction from the body according to the Platonic tripartition of the soul (Miller, 2012) . In short, according to Yapijakis (2009) , the Hippocratic physician who received a patient for consultation had to examine them, carefully observe their symptoms, establish a diagnosis, and then treat the patient (Yapijakis, 2009) . Thus, Hippocrates established the foundations of clinical medicine that continue to this day, by developing medical terms and definitions, protocols, and guidelines for the classification of diseases, which are considered the global reference for the diagnosis, management, and prevention of diseases (Kleisiaris et al., 2014) . Like the traditional African therapy option that consisted of bringing together all cosmic and supernatural elements into a whole, where nature is fully combined and associated, Hippocratic philosophy of healthcare provision also focused on a holistic healthcare model, bringing together nature, music, sport, logotherapy, pharmacotherapy, and even divinity to offer appropriate care to the sick.
3.3. Cultural Aspects of Patient Care in Africa
In the anthropology of African peoples such as the Bantu, the Mossi, the Fon, the Yoruba, the Nyô-nyôse, etc., helping a sick individual to strengthen their “Vital Force” is an admirable and commendable act that charms people, especially the ancestors who observe and judge the actions of the living in relation to the customs and traditions they left behind before definitively leaving this world (Sawadogo & Simpore, 2022) . It is through the imperative recommendation of ancestral observances, and in order to always be faithful to the ancestors, that one can understand the individual and social commitment to the therapeutic care of the sick in Africa. According to Professor Joseph Ki-Zerbo (1982) , “every culture carries within it the seeds of the greatest accomplishments, including faith. This is particularly true of African culture, which despite certain shortcomings, presents remarkably positive aspects in terms of devotion to the sick” (Ki-Zerbo, 1982) . For this great Burkinabe historian, the physical commitment of Africans towards their sick is part of an ancestral civilization. Thus, in this Africa of yesteryear, there were no hospices for the elderly, nor asylums for the mentally ill. The very idea of separating patients according to their illnesses was unthinkable, either because there was not yet a precise idea of infectious diseases, or especially because it was a sacred duty to be physically present with a sick brother, sister, parent, or friend. In traditional Africa, what was paramount was the sense of family, the “buud-yam” as the Moose of Burkina Faso would say; it was also the love of one’s village, of one’s people, in which all individuals considered themselves brothers and sisters. It is in this sense that we see long lines of relatives in the homes of patients and long and costly journeys of family members to search for therapeutic remedies and charms. Thus, in traditional Africa, all kinds of obligations were given up to physically assist the sick. And according to Ki-Zerbo (1982) , the African woman in particular is tireless in caring for her sick, she is drawn to them like an irresistible magnet. There are examples of Whites welcomed by Africans in the 19th century. They were housed, maintained, and cared for by Africans, even though they were completely unknown to them. Such are the cases of Mungo Park in Segou and Du Chaillu in Gabon. The latter, a sick explorer who was taken in by a forest hut, wrote this: “I will never forget the care that the women gave me during my illness. Poor creatures! They are mistreated by their lords and masters... And yet, at the sight of the suffering of others, their hearts are softened as in our civilized countries” (Ki-Zerbo, 1982) .
Among the Moose people, the serious illness of an adversary or sworn enemy automatically signaled a truce, and the hatchet was buried because illness is a common enemy of humanity. In any case, this physical commitment was evident in the hand-to-hand combat that Africans accepted with the sick as if to challenge the disease in place of the patient. At the bedside of a terminally ill patient, healthy individuals are often found engaged in long conversations, one-on-one, breath against breath, in intimacy with sick relatives afflicted with the most repulsive afflictions and terrifying odors. For them, it is always necessary to watch over and care for the sick because “Wênd pa ku, Naab pa kùud ye!”—if God does not kill the sick, the chief or the doctor cannot kill them. Have we not often seen men or women who sit behind a sick person, cradle them between their legs, and support them against their chest to relieve them, better nourish them, and give them water, exactly as was done for circumcision and childbirth? In the typical case of an old man of the “Nyo-noaga” caste who was dying, it was an old woman who sat and sang the glory of her ancestors, saying, “Do not be afraid, enter into the glory of your ancestors. They did not fear fire, let alone water. The ancestor Guîsga, the father of your fathers, was a hero. Storm, hurricane, and thunder, he appeared and disappeared before his enemies and put them to rout. He never accepted shame. Here is his motto: “rather death than dishonor.” Worthy son of Guîsga and Pandé, you are an authentic Nyoa-nyoaga. Fight the battle of life. For you, joining the ancestors is not dying, it is leading an even more intense life. Go, go, go...” (Simpore, 1999) . As the patient declined, this woman lowered her voice. And at the final moment, she closed his eyes.
For the traditional African worldview, illness is not only the absence of health, nor is health only the absence of disease. Bodily illness is a sign of a profound imbalance that disturbs not only the individual’s being and mind, but also society, the cosmic universe, and even the metaphysical realm. In this perspective, the mind held great importance in African thought. The “gris-gris” would be a symbol that faith makes effective in the minds of Africans. The sick person believes in the remedy because they have faith in the healer, who speaks of a disease “sent mystically,” of a para-natural or supernatural disease induced, provoked by the “Chakatu” among the Fon or by the “Ota” among the Yoruba or by the “Maanego or daare” among the Moose, particularly among the Nyo-nyonse, and the “feebre” among the Yarse in Burkina Faso. There was a kind of tripartite correlation between the sick person, the healer, and the natural environment that provides the medicine. Health would be found at the interface of this triad. Like in ancient Greece, some African peoples, such as the Moose, treated their patients simply through speech: logotherapy, while others used symbolic gestures and sacred dances. The “Bo” developed by the “Boto” among the Fon is a therapeutic gris-gris composed of leaves, herbs, and incantatory words. Meanwhile, the “bebobe” was used by the Pagibeti in Congo and among the Hausa in Nigeria to reinforce “the unusual power of a chief, a witch, a healer, or a very effective hunter” (Insoll, 2011; Almquist, 1991; Lewis Wall, 1988) . Furthermore, the “bebobe,” which tends to make a man “increase in power,” does not fall within “the science and art concerned with the healing, relief, and prevention of diseases, and with the restoration and preservation of health” (Little et al., 1955) . According to these latter authors, the Hausa concept of “magani” encompasses much more in that it can refer to anything that corrects or prevents an undesirable condition.
In ancient Africa, every traditional healer, having received therapeutic recipes from the divinity for free, asked for symbolic fees from their patients: three cola nuts or salt or three balls of tobacco. It was a misinterpretation to speak of a wealthy healer because their “priesthood” was only in favor of suffering humanity. Thus, in several ethnic groups of sub-Saharan Africa that have built a social personalism, illness appears as both an individual experience and an attack on the group and thus a collective concern. In the case of a serious pathology, the whole community feels implicated. Because “one is born and dies in the arms of their loved ones. One is healed in and through their arms” (Adepoju et al., 1999) . The traditional African option for therapy, like that of ancient Greece but opposite to so-called modern medicine, therefore consisted of bringing together all the natural, cosmic, and supernatural elements into a totality. Thus, nowadays, to promote the dignity of the person who suffers, the ethics of care requires humanizing healthcare structures by developing, alongside modern therapeutic techniques, an approach that pertains to the human and solicitude towards the other as a human being who suffers, in strict respect for their dignity and their own values.
4. Ethics of Patient Care
In a therapeutic hospital context, the ethics of care constitutes clinical ethics. Its objective is to improve the quality of care provided to patients as well as the quality of the work of healthcare providers. The Hippocratic Oath, written in the 4th century BC, belongs to the Hippocratic Collection, attributed to the Greek physician Hippocrates, born around 460 BC. The Hippocratic Oath codifies this therapeutic art of Ancient Greece by defining: the duties of the disciple towards his master; the duties of the physician towards the sick; obligations and prohibitions in the medical field; and finally, praises and curses, respectively, for good and bad observants of this code. This Hippocratic Oath, in its original version in ancient Greek, already clearly states the four major principles of modern bioethics, which are beneficence, non-maleficence, autonomy, and justice, clearly defined (Beauchamp, 2008; Varkey, 2021) : benevolence, justice “I will use the regime for the benefit of the sick, according to my power and my judgment... In every house where I come, I will enter only for the good of my patients, keeping myself far from all intentional ill-doing and all seduction, and especially from the pleasures of love with women or with men, be they free or slaves”; non-maleficence “...but I will keep pure and holy both my life and my art. I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work”; autonomy, independence “...everything that may come to my knowledge in the exercise of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and will never reveal. If I keep this oath faithfully, may I enjoy my life and practice my Art, respected by all humanity and in all times; but should I fail in it, may the opposite be my fate.” This passage also suggests medical confidentiality, respect for the dignity of the human person, the independence of the physician, and refutes conflicts of interest.
Nowadays, under the influence of emerging and converging sciences such as nanotechnology, biotechnology, information technology, and cognitive science (NBIC), as well as bioethical models, healthcare institutions are losing their “humanism”. Gradually, some hospital managers have transformed their facilities into business sites, synonymous with anonymity, solitude, anxiety, and death, with the first victims being the patients. Clinical medicine being a practical therapeutic activity of teamwork, it is important, in the face of the prodigious advance of modern sciences and technologies, to precisely define the conditions of their applications for patient care (Boitte et al., 2019) . The management of medical care, from the reception of the patient by administrative staff to hospitalization, clinical and biological examinations, and care provided, includes courteous relationships between the patient and the medical staff.
However, faced with the case of a seriously ill patient, it is clear that there are profound divergences among medical practitioners in the interpretation of ethical values to be applied; in fact, it is the four reference bioethical models (subjectivist or radical liberal model, utilitarian pragmatic model, sociobiological model, and personalist model) that guide the vision and positions taken by each of the actors in healthcare. Faced with a 98-year-old deeply comatose elderly patient hospitalized in some countries, the subjectivist, radical liberal-leaning physician will say, “if the patient’s family wants euthanasia for their patient, it is their free choice, let’s grant it!” What is fundamental in this line of thought is the freedom of the subject who acts according to their conscience. In fact, the radical liberalist model derives from the French Revolution, Popper’s subjectivism, Jean-Paul Sartre’s existentialism, Marcuse’s liberalism, and Hume’s empiricism. For this approach, morality does not come from reason but from moral feelings. And one cannot go from the verb “to be” to “ought to be”. Therefore, morality is not unchanging, it is only a matter of sympathy and feelings. Meanwhile, facing this deeply comatose elderly patient, the utilitarian-pragmatic-leaning physician will evaluate the costs and benefits of this hospitalization. They may advise unplugging everything because this elderly patient who can no longer contribute anything to society is now expensive. On this subject, the sociobiologist-leaning physician will say no less because for them, the human being belongs to the phylogenetic tree of all living beings. Therefore, human life would not differ substantially from the various other forms of life. According to this sociobiologist, the elderly person has lived, and they must be helped to conclude their life with dignity through the process of euthanasia. However, sociobiologists forget that some animals risk their lives to save their peers. A young buffalo injured by lions is assisted and defended by their herd; what can we say about animals that, wanting to protect their young, get devoured by predators? Even among chimpanzees, according to (Tiger & Fox, 1997) , caring for others, grooming, occupies a significant portion of their diurnal time and has adaptive value. Cleaning their fellows’ fur helps to rid them of potentially harmful parasites. Licking any wounds and keeping them clean helps facilitate their healing. Grooming can be reciprocal or used as currency for exchange; it can enable you to count on close protection. Thus, bonobos and chimpanzees spend much more time grooming each other than engaging in sexual activities or quarreling (De Waal & Waal, 2007; Miller, 2012) . It is in this way that Thomas Hobbes, after careful consideration of human behavior, declares: “homo homini lupus est” man is a wolf to man. At the opposite end of the three bioethical currents cited above, the personalist-leaning physician considers this 98-year-old comatose elderly person as a psychosomatic being (Simporè, 2004) . According to this personalist-leaning physician, the human person must be respected from conception to their last breath. For this approach, the ethics of care considers the patient in their entirety, in their integrity, and in all their components: physical, psychological, social, cultural, and spiritual. It requires developing, alongside technology, an approach that is human and attentive to the other as a person, in respect of their own values. At the crossroads of medical science and technology on the one hand, and humanities on the other hand, ethics leads us to question the quality of care offered to suffering individuals.
The tensions between these different values then force healthcare actors to question themselves, to be challenged, to constantly weigh the benefits and risks of the solutions considered in their therapeutic protocols for a patient. The ethics of care clearly calls for responsibility in the act of caregiving. The values of caring “cura, care” now extend to the ability to take care of others and to care for them with solicitude, compassion, affection, and attention. Therefore, therapeutic care will require the development of interdisciplinary approaches alongside medical techniques that relate to the human aspect and attention to the sick person as an individual, in respect of their own values (Quignard, 2016) .
5. Conclusion
The notion of solidarity, solicitude, and compassion gives meaning to the ethical approach within the human community, where bonds must remain strong in situations of vulnerability experienced by humans from their embryonic conception to their last breath. Through ethical reflection, the aim is not to establish a code of conduct that would provide easy reassurance, but to properly guide and humanize care for patients in health institutions. In complex clinical situations, analyzing ethical issues and potential conflicts of values is not simple. While the rules of professional ethics and laws defining patients’ rights must be known, the practice of care must be guided and delimited by indicating the red lines not to be crossed. This requires a listening attitude, dialogue, humility, and respect for the ethics of their professional order on the part of the healthcare providers. Just as therapeutic relationships between patients and healers were in traditional Africa, patient-physician relationships, beyond hygiene and prevention measures, in the modern vision of personalist ethics, are also a relationship of intimacy both at the physical and psychological levels. Various components are involved: physical proximity, patient nudity during physical examination, intimate thoughts and feelings of the patient revealed in questioning, as well as moral and ethical dimensions. Hence the importance, without entering into a “burnout,” of recognizing and respecting individual differences, values, and subjectivity of the patient by being empathic to their vulnerability while remaining true to oneself. This involves establishing and respecting personal boundaries. In this perspective, it would be opportune that doctors, pharmacists, nurses, in fact all health personnel, could have in-depth courses on the humanization of care in health structures; that institutional ethics committees could be created in health establishments in order to guarantee better medical care for patients, taking into account their rights; that these ethics committees ensure that the dignity of people is preserved at all stages of their care. Certainly, the African approach to patient care and that of ancient Greece are very rich in their science, psychosomatic dimension, and humanism. If one could combine the traditional African vision of care with that of ancient Greece and modern personalist ethics, new, more humanizing, and even holistic approaches to caring for patients in our time would be opened.
Acknowledgements
We thank the researchers-teachers of Saint Thomas d’Aquin University and of the Centre de Recherche Biomoléculaire Pietro Annigoni for the academic, teaching and research support. The authors especially thank Dr. Abdoul Karim OUATTARA for the translation of the article into English.
Author Contributions
Joseph Sawadogo = JoS; Jacques Simpore = JaS.
Study concept and design: JoS and JaS.
Drafting of the manuscript: JoS and JaS.
Critical revision of the manuscript for important intellectual content: JoS and JaS.
Study supervision: JoS and JaS.
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