Chris Ellis is a general practitioner in Pietermaritzburg, KwaZulu-Natal, South Africa.
“It is fabled that we slowly lose the gift of speech with animals, that birds no longer visit our windowsills to converse. As our eyes grow accustomed to sight they armor themselves against wonder.”
Leonard Cohen. The Favourite Game
In the 1970s, I did a weekly rural clinic in KwaZulu-Natal.* The clinic was near a river and outside were some tall gum trees that quietly sang when the warm summer winds came sweeping down the valleys. There were usually some African cattle slowly cropping the grass near the clinic while unperturbed goats would tug at the lower branches of a thorn tree under which the patients sat, discussing the affairs of the day. They were what the prophet Zechariah called “the days of small things”.
The patients had either walked for miles or saved up to get a communal ride to see the doctor. Very few, especially the older patients, spoke or understood English. It took me many difficult years to learn their language of isiZulu with all its intonations and clicks.
My days were spent treating worn-out hands and backs, listening to the heartbeats of unborn babies, pulling teeth and examining children with wide innocent eyes as they looked into the faces of their African mothers.
The patients had either walked for miles or saved up to get a communal ride to see the doctor.
One day, a middle aged woman came in to see me as a patient. She requested that I give her some medicine to reduce the number of voices she was hearing. I was not experienced enough at the time to ask her about the voices and what they said, but she was otherwise mentally normal.
I had with me a Zulu interpreter/assistant. He often helped me with interpreting the cultural aspects of the patient’s illnesses. Unfortunately, in these consultations, I never really got around to asking her whether she was hearing voices (izwi), or dreams (phupha) or was overthinking (cabanga kakhulu). I prescribed a phenothiazine (antipsychotic) and at subsequent visits she said that they helped her a lot.
I have since wondered about the line between rural indigenous people hearing voices and the auditory hallucinations of the schizophrenic spectrum disorders. The boundaries are often blurred and difficult to separate. On one end of the spectrum are the obvious schizophrenic hallucinations that are bizarre and out of context accompanied by other features of schizophrenia that make the diagnosis of schizophrenia more likely. This is when the dark riders of true madness are chasing out the voices of reason and sanity.
On the other end of the spectrum are people in rural communities with often little or no education, whose culture accepts and allows them to hear the voices of deities, spirits and ancestors. Their cosmology and world views are connected more to the natural world around them as well as the supernatural world. If your ancestors or spirits are an integral part of your daily life then it stands to reason that one’s connectedness to the numinous and supernatural allows thoughts, voices and dreams to acquire a measure of formed reality. One of the problems in this area is when does a thought become a voice and how do you explain it to the external world.
Formal education in school may also suppress these indigenous thought processes and voices. In school we learn linear cause and effect reasoning and logical and rational thought processes. With education the pathways in our neurocircuitry become more focused and goal-directed along with the increased load of information that we now have to process.
In these rural communities voices from spirits and ancestors may help guide or warn them of events and may be accepted as normal. There is regular communion with clan ancestors by visions and dreams and there is a culture-bound syndrome of ukuthwasa which is the “calling” of a person to become a traditional healer (sangoma).
With these cases I had to be careful to rule out medical diseases as a cause of hearing voices as hearing voices can also be caused by anxiety, sleep deprivation and medication side effects as well as specific medical and neurological conditions.
When I started practice, I occasionally saw patients with pellagra, which is due to the deficiency of niacin (vitamin B3). We were taught that the symptoms of pellagra were the three Ds of Dementia, Diarrhoea and Dermatitis. When I suspected that a patient had pellagra, I would ask them if they dreamt a lot (uyaphupha ebusuku?) which is the stage before the dementia. Those with pellagrinous predementia would enthusiastically reply in the affirmative.
My patients who I treated at the clinic in the 1970s, which is now 50 years ago, lived in a different world to that of today. There was no television and very little radio reception and no Ctrl-Alt-Delete-Enter. They lived a traditional rural life in the mountains that was relatively untouched by modern Western influences except for those younger ones who went to work in the cities or mines and came back to visit them.
I sensed that they also lived in a different dimension of time. The soft chattering of the patients waiting and sitting on the grass outside the clinic had an unhurried acceptance of just waiting. In the consultation when I asked when their symptoms started (kuqale nini?) they would sometimes refer to the season or the moon as their reference. I myself was living in a rushed, measured tick-tock time and wanted exact answers framed in the precision of the Gregorian calendar. Their time frame was different and their symptoms started at the time of the moon when the yellow-billed kites were nesting (inyanga uNhloyile) or at inKhwenkwezi, when the bright star of Canopus first appeared in the predawn sky, in the third week of May. They travelled lightly through the timeless African days and nights.
There was also this well documented connection that rural people have with the animals around them, especially cattle. This extended to the surrounding environment and the trees as sentient beings breathing for our increasingly fragile planet. It is from these trees that the forked-tailed drongo still calls out the praise names of the cattle, as the sun sets slowly over the horizon.
I have since wondered about the line between rural indigenous people hearing voices and the auditory hallucinations of the schizophrenic spectrum disorders.
There also appeared to be, in those days, a strong architecture of social relationships. The hierarchy and discipline of the traditional family was yet to be displaced by the modern stressed triad of grandmother, single mother and one child. They had not yet stepped through the looking glass into the new fragmented world.
In the past, philosophers such as Jean Jacques Rousseau, romanticised these rural lives into a sort of untroubled garden of Eden, but their lives were mostly hard and poverty-stricken. Even so their expectations of life appeared less than today. Their trust and beliefs were less questioned and unexamined compared to today’s almost ceaseless media dissection and analysis of life and its contingencies. The world had not yet become the complicated surveillance state it is now, saturated by noise, contradictory opinions and fake news. Nowadays the outside world enters their lives shouting and asking questions, trampling on their thoughts and words. Sirens wail, phones ring, appliances bleep and gates are rattled while roadworks roar in the distance.
I find now that I can hear the voices better when there is less of this “noise” and “traffic” of modern life. My thoughts can then become clearer when there is silence in the magic gardens of the mind. When I am back in the mountains, I have learned to listen to the wind sing again in the trees.
Sometimes, in the quiet of a starry night, I sing along with it.
*Deputy Editor’s note: This account narrates events taking place approximately 50 years ago and it is no longer possible to obtain informed consent from the patient or the interpreter, individuals and locations have nonetheless been anonymised.
