In these two therapeutic contexts, the notion of "cure" is relative and subjectively defined. Although ex-patients may still be troubled by their illnesses, they find that their eccentricities are usually better tolerated by others if they join a Protestant congregation. There is no equivalent alternative community outside the asylum for the psychiatric patient. The manner in which success is defined from the practitioner's point of view is also relative. For the psychiatrist, it is defined in practical and functional terms: is the patient able to rejoin the greater society and perform as an active member? For the Protestants, success is conditional, based on conversion to the faith. Conversion by Sakalava is regarded as a major success by the Protestants; among the Sakalava, converts are anomalies.
In Madagascar, exorcism, in contrast to psychiatry, is effective, and it may even be empowering for the patient, ironically because conversion is such as important part of the process. The conversionary tactics of the Protestants are invasive and, at first, require the patient's submission; soon, however, the patient is actively involved in a dialogic therapeutic system which redefines reality and, ultimately, the patient's illness and identity. Psychiatrists in Madagascar, on the other hand, fail to assist their patients. A simple explanation for this would be that they do not acknowledge their experiences as legitimate; as Kleinman would recommend, they need to comprehend the patient's belief system. As these examples from Madagascar illustrate, however, the problem runs far deeper than this, and it lies with the very nature of biomedicine. Biomedicine is an exclusionary belief system, one that denies the legitimacy of others. These psychiatrists employ oblique tactics; where patients remains passive, uniformed of the therapeutic process and alienated from their communities. In addition to disempowering the patient, as other studies of medicalization assert, it also disempowers the doctor. It is perhaps for this reason that at least one psychiatrist in northern Madagascar has received training as an exorcist.
The data reported here were part of a larger study on spirit possession and were collected during 12 months ( January 1986-January 1987) of anthropological field research in Madagascar. Generous financial support was provided by the following institutions: The U.S. Department of Education Fulbright-Hays Doctoral Dissertation Research Abroad Program (Grant No. G008640345); the Wenner-Gren Foundation for Anthropological Research; The Sigma Xi Foundation; and the Lowie Fund of the University of California, Berkeley. I wish to thank the informants who gave of their time, and H.T. for her invaluable work as an assistant throughout the tenure of this research. Finally, the following people gave helpful comments on different versions and portions of this manuscript: two anonymous reviewers; B. Benedict, J. Cornell, F. Dunn, A. Fox, G. Feeley- Harnik, S. Foster, L. Green, M. Lambek, M. B. Mills, L. Rhodes, N. Scheper-Hughes and M. Watts.