Traditional Medicine in Madagascar-Current Situation and the Institutional Context of Promotion

Following WHO recommandations and in order to improve medical coverage, Madagascar officially recognized in 2007 its traditional medicine as a legitimate practice. UNESCO, to sustain traditional healers in the Indian Ocean, wanted to use anthropological tools to explore the current situation in Madagascar. Despit a plurality of practices, data collected for three months in the Southeast of the Island, allowed us to identify some fundamental aspects of Malagasy traditional medicine, such as the omnipresence of symbolism or the complexity of healers’ roles at the crossroads of social, sacred and therapeutic registries. The study shows that the national policy on traditional medicine improves gradually the promotion of these practices too often undervalued. Nevertheless, the institutional context exposes weaknesses which might explain the difficulty encountered by some tradipractitioners to find their place in this new regulation. Indeed, regarding the current context, a reducing process of the healers' practices is likely to emerge.

Traditional Medicine in Madagascar -Current Situation and the Institutional Context of Promotion

I. Introduction
Madagascar is the largest island in the Indian Ocean.Classified among the countries where endemism rates are among the highest in the world, the red island presents a multiethnic context with more than eighteen groups which are spread all over the territory.Each community possesses its own culture which expresses itself in its relations with the environment, most notably in the management and the exploitation of natural resources, at the origine of various local knowledge.
According to the WHO1 , approximately 70 to 80 % of the population in developing countries use traditional medicine (TM).TM represents a more accessible therapeutic from an economic and geographic point of view than biomedicine, and it justifies itself in terms of identity because it provides an answer culturally adapted to the conception of misfortune and disease of local populations.In Madagascar, even through Western medicine is very present, especially in urban zones, access to healthcare still remains difficult in certain remote areas.The exceptional biodiversity of the island, combined with the knowledge passed on from generation to generation by the ombiasy, the local healer, allows TM to continue.
Following the WHO recommendations2 , the Malagasy State officialised the status of traditional medical practices, recognising them as complementary to conventional therapeutics.The aim is to encourage an exchange of knowledge between tradipractitioners and conventional doctors in order to improve the medical coverage of the country.This political decision was followed by the creation of the Pharmacopoeia and Traditional Medicine Service (PTMS) within the Public Health Ministry.The government therefore commits the structuring and the professionalization of this sector in order to integrate it into the healthcare system.
We are here reporting a synthesis of the data collected during a study led in Madagascar from April to June 2013 (Pierlovisi, 2013).This work was part of a Unesco project to support local healers of the Indian Ocean 3 .For three months, we explored a Southeast portion of the island to meet the main actors who are involved in the TM issue: healers in urban or rural areas, institutional staff, doctors, etc.Through semi-directive interviews and by adopting the participant-observation method, we focused our research on two main axes: the TM as it is practiced currently, and its institutional framework.
Firstly, this article will describe the medicine men and their medical practices, especially the symbolic and spiritual dimension throughout the therapeutic act today.Then, through an analysis of the legal framework which regulates TM in Madagascar, we will study the way it is perceived by the healers and try to understand how these local practices are evolving.

II. Today's Traditional Medical Practices
Traditional medical practices are complex healthcare systems combining therapeutic, sacred and sociocultural levels.Based on a different paradigm from the one used in biomedicine, they put the patients in their social and familial context, thus allowing for a hollistic care.In contrast with popular knowledge, they are held by a few persons, called ombiasy, determined by a socially accepted way.The term ombiasy, used to describe the traditional healer, means olona be masina, i.e. "the man who has a lot of hasina" (Dahl, 2006).The hasina or masina concept is a fundamental element of Malagasy thought, i.e. an invisible and supernatural force, a "sacred power which possesses all the beings especially the ancestors, the kings, the natural places where the spirits live, and that are maintained by rites to guarantee its advantages" (Blanchy, 2006, p13).A few characters whose status is specific to the community, such as the religious leader or the medicine man, are said to possess a lot of hasina which confers them a power stemming from ancestors, the razana.
Different sorts of traditional healers exist in Madagascar such as herbalists, masseurs, traditional midwives, soothsayers, astrologists, etc.Their categorisation is quite difficult because names and functions depend on regions and societies (Lorre, 2006).Respected but also feared by the community, the tradipractitioner have an ambivalent character because he can cure the disease as much as be a source of it, in which case he is called wizard (Rakotomalala, 2006).

Acquisition of knowledge: transmission and learning process
Traditional medical knowledge is passed on in a strict family setting (direct lineage or by alliance).Generally, any sibling can holder this knowledge if he decides to receive it.Sometimes, a particular child is appointed to succeed the medicine man, either from his youngest age according to his vintana (destiny), or during adolescence if he develops a singular feature which differentiates him from the others.The traditional healer can also acquire this knowledge as an adult: it is called a gift.The gitf expresses itself through the appearance of strange events and symptoms, which disappear only if the individual, generally stemming from a healers' family, agrees to receive it.After that, he communicates with spirits through practices such as possession (tromba or bilo) or divination by sikidy4 .Even today, most of the healers strictly follow these rules and prefer to take their secrets to their grave rather than to reveal them to foreigners.Nevertheless, exceptionally, some of them accept to share their knowledge with those outside of their own lineage: in this case, the symbolic incorporation of the individual within the family is necessary and is made with a specific ritual.
The preservation of this knowledge in family finds several explanations.On the one hand, it represents a hova, that means an inheritance bequeathed by the ancestors of the lineage: it must be thus transmitted to a direct descendant.On the other hand, the ability detained by the healers is very powerful, which implies assuming heavy responsibilities.The practice of TM has to be made honestly, with respect for ancestors, at the risk of exposing the healer and his family to some sanctions, such as disease or misfortune.Thus, belonging to the same lineage represents a reliable security which assures that the practice is made in agreement with the will of the ancestors.
The learning process of TM is mainly made through observation.From his youngest age, the novice attends consultations, follows the medicine man to pick medicinal herbs in the forest, learns the art of deciphering geomancy figures, observes preparation and administration of remedies, etc.In the case of the tromba (possession), knowledge is directly revealed by the spirit during possession.Here, the apprenticeship is more subtle and could be the consequence of an unconscious process which would appear automatically when the healer is possessed or communicates with a spirit.
Many healers use the dream to enrich their knowledge: the oneiric space is then an interface where the world of spirits meets that of men.It allows the ancestors to show themselves and to dispense their teaching.Some of them also make initiatory journeys throughout the island to exchange their expertise with others (Rakotomalala, 2002).Finally, TM is now growing richer with modern knowledge, in particular in cities where healers have access to a great deal of information through reports, articles, training courses or books about herbal medicine, reflexology, naturopathy, etc.

The enthronement ritual
The process of knowledge acquisition always ends with a ritual which confirms the healer's skills and gives him legitimacy within the community.Its progress depends on the function that tradipractitioners will fulfill in the village, in particular of the social and religious importance which will be granted to them.The ritual can be either public and gather all the villagers around the sacrifice of a zebu, or take place in the intimacy of a family setting.It can take several forms: exchange of live poultry, sacrifice of animals, purification by bath containing water or sacred wood.
Rituals appeal to symbols recognised by the society which uses them: each element has a precise meaning, refers to a particular concept or conveys a message.From surveys conducted in tanala5 society, the ritual called "transmission of the hand" was evoked several times.Different variations exist, one of which consists in the healer washing the hands of his successor with some blessed rum before drinking it with him and proceeding to an exchange of saliva.This ritualisation symbolically stages the transmission of the knowledge and the "savoir-faire".The knowledge of the medicine man is an oral tradition which is passed on by the word and materialized in the saliva, considered as sacred.The "savoir-faire" itself, is classically located in the healer's hand.Many Malagasy expressions about the therapeutic act refer to this organ: the tradipractitioner will have "the hot hand" (tanana mafana), will be "the inheritor from the hand", "will take the hand of a healer" or will receive a payment for "the exploit of the hand" (hasi-tanana).So, the healer's hasina, the sacred strength which gives him the power to cure, is concentrated in his hand.
The ritual of enthronement allows to socially stage the function which the medicine man will play in his community.It corresponds to a new birth of the individual, not biological but social, which makes sense for the population who attends it.The ritualisation shows the healer under his new appearance to the members of the visible and invisible world, in order to be recognised by the community of men, as well as that of the ancestors.

The healer's function
The healer's role illustrates the permeability which exists between therapeutic, social and cultural aspects in Malagasy thought.A disease is an "elementary event" (Augé, 1984) perceived as a biological disorder resulting from a social disorder in the visible or invisible world.The therapist's skills exceed the domain of health to enter into the social and sacred areas.The therapeutic aspect appeals to empirical practices or to magic, ritual and symbolic acts which are going to help the healer to restore the harmony, to reinstall his customer on the place which he had before his disease, in the cosmic and human order which has to be his " (De Rosny, 1992, in Faye, 2001).The social dimension is represented by the healer's ability to preserve the social cohesion of his group.Finally, the cultural part is based on beliefs and representations which are going to be recognised by both healer and patient.Therefore, these three registers would not appear to operate independently of each other but they are connected.
At the end of the ritual, the healer accepts his new function: to take care of the members of his community, individually and collectively.He becomes the holder of a power, transmitted by his ancestors, which allows him to communicate between the visible and the invisible world so as to restore the natural order whose dissolution was expressed by a disease or a misfortune.He does not receive a set remuneration for his work but is rewarded according to patient satisfaction.
The medecine man regularly treats simple diseases due to a biological disorder, thanks to his knowledge of the local pharmacopoeia.Nevertheless, his role is essential in the treatment of more complex diseases attributed to supernatural causes in connection with the Malagasy cosmogony (contrevention of taboos, wizard attacks, possession by a vazimba6 ) because in that case, modern medicine is perceived as ineffective, even aggravating.
Traditional remedies are mainly developed from plants of the local pharmacopoeia.They are largely administered orally with decoction, but they are also used in steam baths or reduced to ointments applied locally.
Other elements can take part in the treatment, not for their therapeutic virtues but for their symbolic value.The cure for many pathologies appeals to the symbolism of plants.The "cold diseases" will be treated by remedies containing hot or spicy plants such as hot pepper or ginger, whose aim is to warm up the body.Another example consists in treating possesions by using a plant whose unpleasant smell is supposed to symbolically chase the evil spirit out of the body of the afflicted individual.
According to the severity of the disease, the healer can associate the remedy with specific elements in order to increase the efficiency of his treatment.These elements can either be part of the remedy (plants or woods with sacred virtues), or be worn during the treatment (amulets, pearls or fabrics with a specific color), or used at a moment of the care (use of the magical power of a moara 7 to apply the remedy or establishment of a diagnosis thanks to the transparency of the quartz).Their use is generally reserved for serious illnesses, often of supernatural origin, the treatment of which is delicate.Then, the medicine man's skill expresses itself in his ability to master powerful objects whose manipulation can be dangerous.The healer's knowledge in geomancy and astrology also allows him to intervene regularly as soon as a new event affects the community.He can be requested by villagers for various reasons, such as the compatibility between future spouses or the favorable location to build a new house for example.In this way, the traditional therapist has a preventive action by assuring that the actions of the people are in agreement with the invisible world, in order to avoid the occurrence of a misfortune or a disease.Indeed, as an intermediary between men and their ancestors, he has the responsibility of identifying and solving collective problems to which people attribute a supernatural origin (famine, epidemic, etc).In this case, his function is curative, understanding how the balance was broken and acting to it.In the same way as he treats an individual, the healer cures the collective entity of the village as if it was a patient.

III. Where Symbolism Stands in the Therapeutic Act
Some specific elements are used in the therapeutic act to symbolically activate the remedy so that it becomes "effective", that means that it acquires its efficacy (Pourchez, 2005).As mentioned previously, saliva is a key component of the curative process: considered as sacred, it is a materialisation of the hasina passed on by ancestors which is used as an activator of the treatment.
The hasina is a major concept in determining therapeutic efficacy in Madagascar.During the course of medical intervention, the healer makes, more or less discreetly, a succession of gestures and utters precise words whose purpose is to endow his remedy with hasina in order to make it active.By these symbolic actions (blessing, laying on of hands, use of saliva), he stages the power which was passed on to him to cure people.In this way, it is not the plant which is effective itself, but it is the power transmited by the healer to the herb which makes it an active ingredient.Without it, the treatment will be ineffective.The remedy is thus holistic, both material and spiritual: material because plants which compose it are not chosen randomly, but they result from a long learning process, and spiritual because these plants become effective only after having been activated through the hasina.
The therapeutic act follows the specific rules of the Malagasy cosmogony, full of invisible beings, beneficial or fatal.Traditional medical practices are the reflection of a particular conception of the disease and its transmission which is dictated by beliefs.They underline the impact of the invisible world on human concerns, and conversely, the possibility for men to act, through the healer, on the spirit world in order to preserve or restore the balance.In this way, the therapeutic act highlights a fundamental element of Malagasy thought which is the existence of a continuity between the worlds of the living and the dead.

The permeability between therapeutic and sacred registries
As emphasized by several authors (Benoist, 1993;Pourchez, 2005), the boundary between religious and therapeutic domains can sometimes be imperceptible.In certain practices, the sacred dimension in the therapeutic act appears through purification acts, loans of specific objects, blessings and prayers.
The association of temporary taboo (fady) during the treatment is an essential element of the curative process.It is a sign of the medical intervention's sacred dimension (Douglas, 2005).Fady concerns food which has a symbolic value in Malagasy beliefs such as "warm" food (hot peppers, ginger, alcohol), salt (which is associated to vazimbas) or pork (which is considered, under the influence of the Islamic tradition, as impure).For patients, the need to respect fady is a temporary purification act which allows them to penetrate, during the treatment, into the sacred sphere where they are placed in contact with ancestors.
Other forms of purification can be observed, such as washing, completely or partially, before the consultation.Once again, this practice, which consists in eliminating the stain of the body of the patient, testifies of his passage, for a moment, from the secular to the sacred.
For the medicine men who are in permanant contact with the spirits world, to respect the fady is also a necessary condition that responds to moral and religious values which reflect the sacred status of this character.Any action which goes against it (contravention of a fady or misuse of the hasina for example) will entail an immediate penalty from the ancestors.
The resonance of the religious register also appears through the borrowing, during the therapeutic act, of some objects usually encountered in a place of worship.For example, the moara is redolent of the religious symbolism of the zebu's horns which connect the land of the living to that of the dead, and will be used to apply a remedy whose efficiency must be strongly increased.In the same way, quartz, used during divination because its transparency allows the soothsayer to "see" the things of the invisible world, allows to diagnose the nature of a disease more accureatly.
Finally, the religious dimension appears through the omnipresence of prayers and blessings during the care.In rural areas in particular, where the razana cult is still very prevalent, the invocation is often sent to the domestic ancestors, to the One God Zanahary and to the spirits of kings or characters from other regions.Consequently, the healer is set into his family history because he appeals to the members of his lineage.Furthermore, by inviting all the island's ancestors, the ritual also puts the therapist and his patient in a wider global context.The therapeutic act becomes then a complex process, without temporal, geographic or even social limits, because all ancestors, spirits and divinities are urged to participate in the care.It is through the penetration of the invisible world into the visible one, expressed by the invitation proposed to the ancestors to participate in the human concerns, that the cure process becomes established.
Symbolism appears throughout the blessing asked to the razana, the ancestors.It is expressed through words and offerings.Among them, rum, especially toaka gasy (malagasy rum produced locally), is a fundamental element which accompanies most of the Malagasy therapeutic and religious rites.It can be drunk by the healer, the patient or the persons who participate in the session.This offering to ancestors often involves a symbolic gesture which consists in throwing this alcohol to the Northeast of the house, a place generally dedicated to them.To offer the toaka gasy to the razana is an act which refers to the sharing, to the sociability, to the relaxation and to the link between people.It is a way of gathering people, but also of connecting them to ancestors.The use of rum is therefore a way for the healer to call the beings of the invisible world to share a moment of the daily life of men.By this symbolic act, he shows the continuity which exists, in the Malagasy thought, between life and death, and the permeation between the worlds of humans and spirits.
Even if symbolism is as a major element in the traditional therapeutic care in Madagascar, we sometimes observe a decrease of it and of the sociocultural dimension in the practice of some healers, especially in urban areas.We find for example traditional consulting rooms modelled on modern hospitals: patients are waiting in a corridor, then pass one after the other in the therapist's office; they leave the place with a prescription which will be executed by a second traditional practitioner.Here, we can observe a task-sharing (the first one diagnoses and prescribes, the second one administers the treatment) that weakens the function of the healer.The care is reduced to a simple therapeutic act and limits the social and religious role of the medicine man.The modern world influence is probably responsible for part of this loss of symbolism.These therapists answer nevertheless to a need of the urban population which is marked, in their construction of the efficiency of the care, by the western model.The traditional therapeutic act, reflecting a rich and complex worldview, is not rigid but it evolves along with the Malagasy society.
With globalization, Madagascar is rapidly evolving with the contact of western culture.Local knowledge deals with this influence whose impact varies between urban and rural areas.Today, the national policies on TM set up by the government participate in its evolution: it is relevant to wonder how healers perceive this regulation and its potential impact on the future of traditional practices.

IV. Traditional medicine in a legal context of promotion
The Malagasy society is characterised by a pluralism of access to healthcare for the population.Today, four categories of healthcare coexist on the island: biomedicine, Malagasy traditional medicine (still called indigenous medicine), complementary and parallel medicine (MCP) and miraculous guerisons boosted by new christian movements.
Since the eighties, TM has benefitted from a renewed interest in the Malagasy national scene.In this context and following the international conference of Alma-Ata in 1978 which recognised the position of traditional healers in the centers of primary health, several political decisions were taken by the government.
In 2006, the Malagasy State allowed the integration of the Improved Traditional Remedies in Madagascar in public health centers.Afterwards, in 2007, TM was legalized by a ministerial decree, as biomedicine, allowing healers, if they performed the necessary steps, to practice their art freely.Thanks to this instutional recognition, the government wishes to promote this form of healthcare in order that, on one hand, it can be used efficiently and safely, and on the other hand, it can collaborate with modern medicine.
To meet this objective, two structures were set up.The Pharmacopeia and Traditional Medicine Service (PTMS) has been working since 2008, within the Ministry of Public Health, on the integration of TM in the healthcare system.This unit collaborates closely with the National Association of Tradipractitioners of Madagascar (NATM), an independent association created in 1996, which is assigned with doing the inventory and recruitment of the totality of the healers practicing all over the island, from urban areas to the most remote villages.
Other actors take part in the establishment of this legislative framework, directly or indirectly, such as CNARP8 or IMRA 9 , or some private laboratories or NGOs that participate in public health policy directions concerning TM.

The registration with NATM
The PTMS estimates at 60 000 the number of healers practising in Madagascar: only 2000 are registered with the NATM by means of a dozen local associations.Registration cannot be made individually: beforehand tradipractitioners must belong to a local association already member of the NATM.This fact can sometimes be problematic, in situ, if conflicts of interest emerge between local associations and healers, a situation that slows down the membership for some of them.
Registration requires to perform complex procedures: submitting files, drafting letters, contacting institutions, etc.It involves two administrative structures: the Advisory Communal Committee (ACC) and the Advisory National Committee (ANC).The ACC is composed of respectable and chosen members of the community, from traditional and modern worlds.It is responsible for evaluating the legitimacy of the healer through his social recognition and his reputation.Thereafter, the ANC, based in Antananarivo, officially validates the files of membership.The tradipractitioner, having acquitted an annual contribution, will then be registered in the NATM register which will allocate him a specific number and a professional card.
These procedures are complicated and tedious, especially where the ACC is not set up yet.They follow a philosophy which is not familiar to the healers, in particular for those living in rural areas.Then, they often have to lean on western structures, such as ONGs or research centers, which provide a logistical and financial support necessary for their registration.This situation may in the long run favor the establishment of a certain dependence of the healers on these organisms.

Legal framework analysis
The Malagasy legislation regarding the practice of TM leans mainly on Article 2 of the decree n°2 007_805.Its analysis indicates some weaknesses in texts, especially the absence of precise standards to estimate the legitimacy of healers and identify « charlatans ».The subjectivity of the decision-makers is likely to involve social and sanitary impacts because their choices could be influenced by moral values, rivalries or issues, or simply by the fact that they have their personal representation of what the difference between a tradipractitioner and a charlatan is.The establishment of regulations makes it possible to tell the real healers from the false: then, those considered illegitimate will risk prosecution if they practice.If social recognition is not easy to quantify, the setting up of reliable and objective criteria is nevertheless essential to avoid the occurrence of injustices.
Besides, indigenous medicine (which has its origin in Malagasy tradition) and complementary and parallel medicine (stemming from the foreign tradition) are referred to by the same general name of traditional medicine in the current legislation.However, these two forms of care are effective using different symbolic components.One might wonder about the real meaning of the acronym NATM.In other words, to which tradition do we exactly relate by promoting the traditional medicine of Madagascar ?This question underlines the risk of reducing TM to its only opposition to the dominant modern healthcare system.
Finally, the absence of a strict legislation on intellectual property rights constitutes a major obstacle to the development of plans to promote TM.This report is very troubling in a context where cases of biopiracy are regularly reported.The healers are badly informed on this issue.For some, especially in the countryside, this concept is unknown and generates some indifference because they do not perceive its impact in daily life.Contrary to others for whom intellectual property rights represents a very worrying subject because they dread that someone will steal their knowledge.This fear is often supplied by rumors which circulate from one village to another, and maintains a climate of mistrust towards the representatives of the western world.These different worldviews, resulting from poor information of the affected populations, are the consequence of the legislative gap which currently exists about this question.By waiting to fill this gap, the PTMS offers to serve as an intermediary between healers and laboratories when a collaboration is emerging.

V. Healers' perceptions about this new regulation
The progressive establishment of this regulation is received in various ways by healers: some of them see it as an advantageous evolution meeting their expectations, while others consider it with more mistrust.
The official status of tradipractitioners decided by the government has generated a strong sense of social recognition and contributed to revalorize progressively TM which was too often depreciated by its western equivalent.This new legislation confers them a legitimacy supported by governmental authority.This impression is more marked in the cities than in the countryside where healers already benefit from an important recognition emanating from traditional power.Indeed, this regulation allows healers to develop a practice which can become a source of income.
However, this officialising is opposed to some concepts that exist in TM.The notion of secret for example is a fundamental element in the practice of many medicine men who work with humility and discretion, according to the ancestors' wishes: being registered with the NATM is therefore considered as a contradiction with their their ancestors' education.
There is a second contradiction in the way healers evaluate the plants' efficiency.For many of them, the plant only obtains its efficiency through the hasina and the blessing of ancestors: each part of the therapeutic approach, from the diagnosis to the of the remedy (even after the cure) is justified by this symbolic process.In this vision, pre-packaged dry plants becomes dishonest by giving an ineffective remedy.Furthermore, our experience has shown that the organization of the legal framework sometimes seems better adapted to the healers' practices in cities than in the countryside.
In rural areas, TM is rarely a significant source of income.The registered procedures becomes an important financial charge for medicine men because they have to pay a double subscription every year: one to the NATM and another one to the local association.This registration gives them the possibility to follow training sessions to improve their skills, but they generally occur in the capital Antananarivo: without necessary financial resources, they can not follow them even if they wish to.
Finally, it should be underlined that the official registration of the healer forces him to maintain a record of his activity.This duty brings him brutally from oral to written tradition.

VI. Collaboration between traditional and modern medicines
Collaboration between traditional and modern health practitioners is a priority aim for the PMTS.It would allow to witness a change of social interaction between the different actors of healthcare, in order that tradipractitioners and conventional doctors could consider themselves as colleagues and not rivals.Otherwise, besides improving health coverage of the country, it would free medicine men and their patients from any guilty feeling for resorting to TM.
Currently, many conventional doctors remain sceptical towards traditional medical practices which are based on an empirical knowledge which strays from rational concepts of science.Many people admit that medical herbs have pharmacologic interest, but they struggle to accept the spiritual dimension of these practices as a fundamental element of the healing process.For their part, tradipractitioners have mixed feelings: some of them are very proud to consider a collaboration with biomedicine, finding there a recognition of the predominant scientific model, while others fear to be depreciated or dispossessed of their knowledge if they cooperate.
In practice, this collaboration is difficult to set up, because there is a potential risk of establishing a unilateral relation between doctors and healers.The awareness campaign of all healthcare actors, both traditional and modern, is necessary and represents a priority for the PTMS.

Current evolution of traditional medical practices
TM is a dynamic concept: while referring to the past, it does not stop renewing itself in the present, according to choices made by the population and to the sociocultural context.Today, we observe an incorporation of new knowledge in native medical practices, in particular stemming from the modern medicine.This syncretism can be seen in cities as much as in the countryside.It appears in some reinterpretation of the illness causes, or in treatments combining allopathy with traditional remedies.With the western influence, the mode of transmission of traditional knowledge is also transformed and passes progressively from spoken to written expression.
Besides, TM is at the core of numerous issues (economic, social, cultural, patrimonial, sanitary, etc.) and the sudden change of legislative context in which it is progressing has consequences on its evolution.The setting up of national policies on TM requires many precautions because they can sometimes be diverted from their first goal (Dozon, 1987;Fassin, 1900;Epelboin, 2002).Some distortion could occur, such as reducing these practices to their single phytotherapic virtues.Such a situation can often be a catalyst for social and environmental impacts: loss of identity of the healers (Dozon, 1987), decline of the sociocultural basis of TM (Faye, 2001), additional pressure on natural resources (Yelkouni, 2006), etc.
In spite of the SMTP's intention to promote TM in all its complexity, the political speeches and orientations value mainly its pharmacological aspect to the expense of its sociocultural dimension.This process appears currently through the importance given to the pharmacological research on local plants, as in a leaflet on the traditional medical training focusing on its scientific aspect, or still as in the census form of healers performed by the NATM which is mainly centered on the use of plants.
On the other hand, as mentionned previously, the current law makes an amalgam between indigenous medicine, and complementary and parallel medicine.This confusion reflects a reductive vision where all traditional medicines become mixed up and become simply defined by their only opposition to the dominant biomedical model.These reductionism processes are worrisome because they can catalyze a transformation of traditional medical practices which does not reflect reality.For example, some healers appear today as stemming from the Malagasy tradition only because they use local healing plants.Yet, as explained before, to hide the magico-religious and cultural part of the traditional care means distorting it by amputating one of its fundamental elements.To fight against this phenomenon, the Governement's position is decisive.The establishment of collaborations with other Ministries, such as the Heritage and Culture Ministry or the Environment Ministry, would allow the TM, besides benefitting from new public financing, to be valued in its globality.

VII. Conclusion
The Malagasy TM is widely used for local populations, both in urban and rural areas.Through a diversity of practices, some fundamental features can emerge, especially the omnipresence of symbolism during the care.The healer appears as a complex character at the crossroads of therapeutic, social and sacred spheres.Holder of a divine power passed on by his ancestors, he guarantees the protection of his community by acting both in the visible and invisible worlds.The therapeutic act reflects a fundamental concept of Malagasy thought: the existence of a continuity between the land of the living and that of the dead.
The setting up of national policies on TM is delicate.In Madagascar, the anthropological tools highlighted weaknesses in the institutional framework which can explain the difficulty of certain tradipractitioners to find their marks in this new legislation.Indeed, the current context seems to favor a reducing process of the healers' practices.These problems should be considered by the institutions to improve the social and sanitary impact of national policies and favor a better coherence between national decisions and local realities.
For the Unesco who wants to support durably the healers of the Indian Ocean, the Malagasy situation is interesting because it is the only territory of this area to have officialised the status of its local medicine.This way, it can easily be an example for elaborate strategies in the nearby islands.The anthropologist can play a crucial role in the setting up and the evaluation of the national policies on traditional medicine, analyzing how these strategies are set up.