| The Participation of African Traditional Healers in AIDS/STD Prevention Programs |
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Dr Edward C. Green
A Widely-Available Resource It is widely accepted that at least 80% of people in Africa rely on traditional healers. This had led some who work in public health to think that healers ought to have some role to play in curbing the spread of AIDS in Africa. Indeed, from a public health viewpoint, this would seem to make a great deal of sense. Traditional healers are found everywhere, unlike doctors who tend to work primarily in the larger towns and cities. Healers are culturally acceptable; they explain illness and misfortune in terms that are familiar, that are part of local belief systems. What is less well-known is that they seem to treat most of the case of sexually transmitted diseases (STDs) cases in Africa. In fact studies in several countries show that both healers and their patients have a great deal of confidence in plant-derived medicines used to treat locally recognized illnesses that resemble gonorrhea, syphilis, genital ulcer disease and other common STDs. AIDS prevention programs in Africa have lately been putting more effort into the treatment and prevention of standard STDs as a way of preventing the spread of AIDS, since it is now accepted that STDs facilitate the transmission of HIV (although we may not understand exactly why). Again, it has occurred to some that traditional healers ought to somehow be involved since they are the ones who see and treat (or attempt to treat) most cases of STDs. It must be acknowledged that the medical sciences have neither proven nor disproved that plant-derived medicines might contain enough antibiotic compounds or immune-system enhancing properties to actually cure an STD. This is an area of research needing urgent attention. The Nature of Collaboration In the meantime, some collaborative programs involving traditional healers have been attempted in several countries, including South Africa, Zambia, Mozambique, Swaziland, and Uganda. The major objectives of these programs has been to develop healers as promoters of condoms and fidelity to one sexual partner. Other objectives are to prevent HIV infection through sterilization of healers' instruments that come into contact with bodily fluids (there is actually little evidence that HIV is spread this way, but hepatitis and tetanus can be); to modify healer's practices that may put them at risk themselves for HIV infection, and to encourage referrals of healers' STD patients to hospitals. It has also become recognized that traditional healers can play an important role in care and counseling of patients who are already HIV positive. Healers practicing in Dar es Salaam were found to be giving sound advice to AIDS patients about diet and exercise, avoiding alcohol and tobacco, and avoiding despair and depression. Patients were advised to refrain from sexual intercourse not only because it will spread the disease but because patients would "waste their survival energy." Healers helped AIDS patients maintain hope and spiritual faith. Hospitals in that city, and elsewhere in Africa, are rarely equipped to provide the same kind of personal attention and understanding to chronic patients. Who has funded AIDS prevention programs involving traditional healers? USAID, the Swiss Cooperation, and the European Union are among the international donors. Some programs operate in the public sector, typically involving a ministry of health. Others may be small scale and involve only non-governmental organizations. Usually there is a workshop or seminar lasting 3-5 days or more during which traditional healers and nurses or health educators exchange views and information. The learning should not be only one-way; "modern" health workers need to learn about traditional health beliefs and practices that can have effects on AIDS and STDs. There may be discussion about other "players" in AIDS or STD treatment, such as untrained injectionists who give shots of antibiotics, perhaps watered down to make the drugs go further. Traditional healers can be enlisted to discourage people from seeking this type of treatment. Are Modern and Traditional Beliefs Compatible? Some skeptics of these collaborative programs argue that there is too much basic incompatibility between modern medicine and traditional African beliefs regarding illness in general, and perhaps STDs and AIDS in particular, and that traditional healers will never change their practices. It is--or should be--part of the basic approach of collaborative programs that they are not confrontational. Instead, we look for the common ground between the two systems of health and then try to build upon this in an atmosphere of mutual respect and understanding. And there happens to be quite a bit of common ground to build upon. STDs are often thought to be illnesses that are not caused by witches, sorcerers or evil spirits, but instead are caused by having sexual intercourse with a person who is "contaminated" or "dirty" with some sort of dangerous essence. Often blood, semen and/or vaginal fluids or thought to become contaminated, polluted or--in our terms--infected in the case of this class of illness. Traditional healers are often open-minded about in what they are taught about AIDS because, as they usually admit, it is a new disease and they are just learning about it. They tend to have no difficulty understanding AIDS as an illness transmitted through sexual intercourse by a dangerous substance found in blood, semen and/or vaginal fluids. Avoiding AIDS by "sticking to one partner" makes sense to traditional healers because they already interpret locally recognized sexually transmitted illness as resulting from a violation of the codes that govern proper sexual behavior. They typically feel encouraged and vindicated to learn that their own governments as well as the international community also wish to warn people against having sex with "just anyone", with too many people, with strangers, with prostitutes, with someone other than one's wife or husband. The promotion of responsible sexual behavior happens to also be the specific area that Christian and Muslim clergy are willing to participate in--much more than condom promotion. Will African Healers Promote Condoms? But what about condoms? Are African healers willing to promote what is often seen as an alien technology from the west? In fact, traditional healers are usually very interested in learning about "modern" medicine and in collaborating with doctors or nurses on whatever terms are presented to them. This is because they tend to gain prestige in their local communities and respectability in the broader society by having links with modern medicine. This helps explain why, before AIDS emerged, African healers were willing to promote oral rehydration salts to combat dehydration from diarrheal diseases. Once the role of condoms is explained--especially if this can be dome in terms that make sense in terms of traditional STD beliefs--healers are usually willing to advise their STD patients to use them to avoid becoming "contaminated" with the same illness once again, and to avoid catching AIDS. At this point the problem becomes one of supplying healers with condoms. Contraceptive social marketing programs are supplying traditional healers in countries like Zambia. Healers can make a few cents' profit on the sale of condoms, and of course this is an added incentive to the healer. Program Impact How have these programs fared? A private sector program in South African (funded jointly by AIDSCAP and AIDSCOM) had an internal evaluation at the end of its first year. The evaluation used survey methods and a semi-structured, flexible questionnaire. According to findings, a high percentages of the sampled healers interviewed were able to:
There was also evidence of positive impact on healers' practices. Almost all healers reported providing correct HIV/AIDS preventive advice as well as demonstrations of condom use. Condom provision had occurred but had been held back by lack of condom availability (this was to have been the government's responsibility). To be sure, this preliminary evaluation data came from traditional healers only. Hopefully a more thorough evaluation in the future will include interviews with, and direct observations of, the clients of traditional healers exposed to AIDS workshops. This can give a better idea of what advice healers actually provide, and whether they really promote or supply condoms.
It must be admitted that we don't know the best way to work with traditional healers in the fight against AIDS. We are still learning. There is often medical opposition to the whole effort, with some doctors arguing that we "encourage" and lend undeserved respectability to traditional healers by having anything to do with them. Perhaps the most powerful argument for involving traditional healers is that whatever our attitude may be about traditional healers, they enjoy the confidence of most of the people. AIDS prevention and other public health goals probably cannot be realized in Africa without some type of collaboration that involves these important health care providers and opinion influencers. There simply aren't enough "trained" health personnel to do the job, and those we have are to often remote from the population--culturally and socially as well as geographically. There should however be more careful monitoring and evaluation of programs involving healers, so that the fundamental question of whether these programs work and are cost-effective can be answered. And so that the best model of community-based prevention of AIDS and STDs can be defined and presented for adoption on a broader scale.
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