| The Experience of an AIDS Prevention Program Focused on South African Traditional Healers |
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Dr Edward C. Green
Introduction: Collaborative health programs involving traditional healers have been advocated by WHO and UNICEF since 1977-8. Pilot collaborative programs that focus on primary health care have been started in Nigeria (1-3), Zambia (4), Ghana (5), Swaziland (6,7), Kenya (8,9), Botswana (10); and Uganda (11), among others. Due to a variety of constraints including opposition to such programs from biomedical interests (12,13), these programs have usually not been replicated on a national scale. Some have faltered or been discontinued. However, in the last few years there has been a rekindling of interest in traditional healers on the part of African governments and donor organizations concerned with HIV/AIDS prevention. Collaborative AIDS programs have already begun in Swaziland (14), Zambia (15), Zimbabwe (16), Mozambique (17), South Africa (18) and no doubt elsewhere. It is regrettable that both primary health care and AIDS-related collaborative programs are seldom evaluated, judging by the published literature. The reasons for this are not clear. This paper will sketch the features of an HIV/AIDS prevention program in South Africa and provide details of a preliminary internal evaluation based on research that was carried out seven months after initiation of a collaborative program. Given the preliminary nature of our effort, we will use the term assessment rather than evaluation to describe it. The AIDSCAP Program in South Africa In November 1992, an HIV/AIDS prevention program focused on traditional healers was initiated jointly by the AIDS Control and Prevention (AIDSCAP) project, funded by USAID and administered by Family Health International (Arlington, Virginia), and the AIDS Communication (AIDSCOM) project (Washington, D.C.), also funded by USAID but administered by the Academy for Educational Development (the program is now run by AIDSCAP alone). The overall or ideal plan of the "traditional healers initiative" in the first year was for an initial group of 30 healers (the "first generation") to be trained in HIV/AIDS and STD prevention. These 30 would in turn each train 30 additional healers (the "second generation") within six months of the first workshop. By the end of the year, healers of the second generation would then each train 30 healers of their own, resulting in a third generation of healers trained in HIV and STD prevention. The second and third generations would be trained in special AIDSCAP-supported workshops but it was recognized that "peer education" and other types of informal sharing of AIDS-related knowledge would also occur. A preliminary national workshop for traditional healers was held between November 22-27, 1992 at Tsitsikama, Cape Province. Twenty-eight traditional healers representing five national traditional healers associations attended. Workshop facilitators were from AIDSCAP, AIDSCOM, and three South African non-governmental organizations: the ANC (African National Congress) Health Department, SABSWA (South African Black Social Workers Association), and PPHC (Progressive Primary Health Care). Workshop topics included the epidemiology of AIDS; traditional healers' STD-related beliefs and practices; counseling issues for at-risk populations; family life in South Africa; care and support for HIV/AIDS patients; the psychological impact of HIV/AIDS on individuals, families, friends, and communities; keeping records of patient contacts; confidentiality of record-keeping and HIV test results; death and dying in South Africa; and educating other healers and clients about HIV/AIDS. A panel of HIV-positive/Persons With AIDS (PWAs) also attended and participated for 3 days of the workshop. Immediately prior to the first national workshop, a knowledge, attitudes, beliefs and practices (KABP) survey of participating healers was conducted for both formative and baseline purposes. The week-long workshop also served as an extended focus group which complemented and illuminated the survey-derived information. Between July 11-16 a second workshop for the original group of trained traditional healers was held in Emaweni (Northern Transvaal) for the purpose of: (1) assessing the impact of the earlier training; (2) assessing the experience of healers who trained other healers; (3) discussing problems that arose since the first training; (4) making plans for the future AIDS prevention activities involving traditional healers in South Africa. At the Emaweni workshop, as at Tsitsikama, a KABP-type of survey was conducted to assess the impact of the earlier training on the first generation of healers. Ten of the 28 participants from the first workshop were absent from the second workshop. Not all first generation healers had trained other healers in formal workshops during the seven months preceding the second workshop, for reasons that often related to problems with national healer associations (see below)(19). Nevertheless by this time, some 630 second generation healers had been trained in 12 workshops held in diverse parts of South Africa: the Western Cape, Eastern Cape, Transkei, Qwa-Qwa, KaNkwane, Rustenburg-Boputhatswana, Nknowanknowa Township, Vosloorus, Koinonia (Natal), and four in the Johannesburg area. The second generation of healers come from several districts of all regions of South Africa except the Orange Free State (although the "homeland" of Qwa-Qwa lies within that region). The total direct cost of training these 630 was about $23.30 per healer, or $5.90 per day per healer. In addition to these 630 direct beneficiaries of training, up to 229,320 patients or clients of these healers may have benefitted from AIDS education within seven months of the first generation training (calculated as 26 weeks times an average of 14 patients a week per healer [see below] times 630 healers trained). Not all these healers specialize in STDs or AIDS, but most of them see a great number of at least STD patients. Finally, an inestimable number of friends, family members, and others in the local community (local associations, sports teams, youth groups, etc.) benefitted from informal AIDS education. The findings that follow are condensed from the full assessment report (20,21). Some topic areas had to be omitted due to space limitations. Methodology For an assessment of the impact of the second generation of trained healers, we first selected seven representative and geographically-dispersed sites where training took place. We then contacted the first generation healer-trainers from those sites and asked them to invite a sample of 10 of the healers they had trained to one or more central locations where we could: (a) conduct individual, formal one-on-one interviews in private; and (b) hold an informal group discussion about various issues related to healers and training. In addition we conducted home visits to second generation healers when time allowed, during which we (c) had informal discussions and made direct observations. An open-ended interview schedule was used for the formal interviews; response categories were constructed after reviewing all answers to a question and they were based on those answers. We recognized that the healer-trainer might introduce a bias into the sample by tending to choose those healers who would make the best impression on those representing the funding organization. Indeed we cannot be sure that healer-trainers did not assemble the "sample" earlier and give them special coaching. However, this would have been logistically difficult in most cases and would have incurred possibly prohibitive monetary costs to the healer-trainer. Regarding the process with less suspicion, the healer-trainer may not have really known which of their trainees had learned and retained the most. Furthermore there were the practical matters of where healers live, whether they could be reached directly or indirectly by phone, and whether they were available on a particular day. Had we randomly selected a sample of healers ourselves we no doubt would have faced problems of reaching all or perhaps even most of the sample in the short period of time available for interviewing. Moreover it is probable that whatever our plans might have been, the healer-trainer would in the end have assembled those healers reachable and available at a given time. Thus while it is possible that the sample interviewed might have been biased to some degree towards those who would make a better impression, the costs and time required to eliminate this bias--assuming this were possible--would have been considerable. We interviewed a sample of 70 healers, or 11% of the total number trained at that time: 14 in Northern Transvaal (Gazankulu), 13 in Qwa-Qwa, 10 in Eastern Transvaal (KaNgwane), 10 in Alexandra (Johannesburg), 10 in Durban and environs, 7 in Capetown environs, and 6 in Soweto/Orlando townships. The plan to interview 10 from each area had to be modified somewhat in the field. Since 93 were trained in the northeast Transvaal, we interviewed 14 there. We interviewed 13 in Qwa-Qwa to ensure better a rural/urban balance overall. Only 7 were interviewed in the Capetown area because circumstances such as bad weather and violence in local townships prevented us from reaching more trained healers within the allotted time. Altogether, 33 healers were from predominantly urban areas and 37 from predominantly rural areas (self-governing "homelands"). Characteristics of the Universe and Sample The first generation of healers were selected by the leaders of five national associations of traditional healers, however AIDSCAP itself chose the associations based on their presumed national membership and their reputation. Association leaders were given selection criteria to help ensure fairness in gender composition and rural/urban residence. It is interesting to note the respondent characteristics of the second generation of healers as there were no restrictions or suggested selection criteria from AIDSCAP. We see that virtually all are diviner-mediums (sangomas in Nguni languages). Sangomas in fact tend to be ranked higher than herbalists, the other major category of healer in Southern Africa (Christian and Muslim healers should be considered religious- or faith- rather than traditional healers). Hammond-Tooke implies that sangomas are less likely than herbalists to engage in anti-social activities (39:104-5), which might suggest that sangomas are more appropriate candidates for collaborative programs. We also note that some 85% of the 630 healers trained are women (judging by names, a few of which are gender-ambiguous). A plurality of these women are in their late 40s. Sangomas membership in fact tend to be overwhelmingly female in Southern Africa (39:105,30), perhaps as much as 90% (6:1073). Turning to the characterisitics of our sample, 82% were female. Six years of formal education was the modal average. Of the 14 that reported less than 3 years, 8 healers had no formal education whatsoever. There was considerable ethnolinguistic diversity among the sample as it consisted of 20 Zulus, 17 Tsongas, 13 Sothos, 11 Swazis, 8 Xhosas, and 1 Pedi. Note that Tswanas were trained in Rustenburg, including some from self-governing Boputhatswana, however there was insufficient time available to visit all training sites. If Tsongas seem over-represented it is because 93 healers were trained (instead of the suggested 30) by a dynamic healer (in fact a Pedi) in a predominantly Tsonga area of the NE Transvaal, therefore her area was over-sampled. Xhosas predominated among the first generation of healers. In any case there was no complaint from any quarter that one group was favored in selection. South African traditional healers appear not to be ethnocentric in the sense of "tribal;" instead they tend to be active promoters of cultural pluralism, as discussed below in the context of impandes. Regarding the number of patients seen weekly, there was a range of 1-70 patients with the mean, median and mode clustering around 14 per week. This is comparable to the number of weekly patients claimed by the first generation of healers in 1992 (mean of 20.8, mode of 10). Almost all healers cited the AIDSCAP-supported workshop they had attended as their primary source of knowledge about AIDS. Although we lack formal baseline data on knowledge levels, informal interviews with healers provided evidence that their pre-workshop knowledge about AIDS ranged from minimal to non-existent. Some said they had picked up many misconceptions about AIDS, having heard rumors about toothbrush sharing and transmission by other casual contact. They appeared to know nothing about the possible role of razor blades or needles, and almost certainly nothing about a relationship between standard STDs and AIDS. Most had heard only that AIDS is something that kills people. Condoms were described as something associated with commercial sex and not something one spoke about openly. A few cited newspapers, radio and television as secondary sources of information about AIDS but several characterized the information derived from these sources as fragmented and incomplete. AIDS and Sexually Transmitted Diseases All 70 healers had heard of HIV; 51 healers gave a fully correct definition of HIV; 7 gave an ambiguous answer; and 12 gave a minimal or inadequate answer. Examples of a fully correct answer include: a virus or iciwane (an Nguni term meaning germ or virus, and the term used in training) that causes AIDS, or one that "kills your body's soldiers (amasoja, the Nguni term referring to the immune system) until you have none and you can easily die of any sickness," or a virus that "makes a patient vulnerable to all diseases;" or a virus passed through intercourse or intravenous blood contact such as sharing needles or razors. An inadequate answer was simply that "it kills;" "it causes AIDS;" or "HIV is AIDS." Regarding the symptoms of AIDS, 60 (86%) gave fully correct answers; 6 gave ambiguous answers; and 4 gave inadequate or incorrect answers. To score fully correct on the answer a healer had to mention 3 or more correct symptoms and none that were incorrect. For example, a healer in Qwa-Qwa said the symptoms are "loss of weight, energy and appetite, diarrhea, dry skin, septic sores, swollen glands, STDs, thrush, boils, constant thirst, loneliness, self-pity, and the need to have the skin massaged." An inadequate or incorrect answer was one that had no or only one correct symptom and/or one or more incorrect symptoms such as "having a great appetite." Sixty-five healers (93%) gave fully correct answers about the modes of HIV transmission; 4 gave correct but flawed answers; and only 1 gave an inadequate or incorrect answer. A fully correct answer was one that mentioned sexual transmission (because this was emphasized in all the workshops) and at least one other correct mode. Blood-to-blood contact (such as through needles) and mother-child transmission were usually mentioned in addition to sexual intercourse. One healer commented after listing correct modes, "since HIV is a devil you cannot know all the transmission modes. It's very tricky." All 70 healers affirmed that AIDS can be prevented. As for means of prevention, 50 (83%) gave fully correct answers (3 or more correct means of prevention); 9 gave correct answers (1-2 correct means of prevention); and only 1 gave a flawed answer (i.e., 1 or more correct means mixed with an incorrect one such as sharing dishes or toothbrushes). Fully correct answers usually mentioned condom use, sticking to one sexual partner, sterilization of razor blades, abstinence, thigh sex, and wearing of gloves on the part of health practitioners. One or two even mentioned the screening of blood supplies. Use of traditional herbs was not counted as a correct method of prevention for our purposes. Some healers mentioned the need for education in the wider community, or for community mobilization. One healer mentioned the spermicide Nonoxynol-9 by name. We next asked about ways to prevent gonorrhea or "drop." This was not a leading question; we had reason to believe all healers thought that this illness is preventable. Fifty-seven (81%) gave fully correct answers, meaning 2 or more correct preventive means (not 3 because gonorrhea was given less emphasis than HIV/AIDS in the workshops); 10 gave correct answers (1 correct preventive means); and 2 gave inadequate or incorrect answers. Use of herbs for prevention of gonorrhea--very widespread in South Africa--was counted neither as correct nor incorrect. Condom use was usually mentioned, as was sticking to one partner. Experience in Treating AIDS In answer to the question, "Have you treated any cases of AIDS or HIV?" 18 healers (26%) said yes; 48 said no and 4 were not sure. The relatively low number answering yes is unsurprising as AIDS is still relatively new in South Africa. HIV seroprevelance rates appear to be highest in Natal, KwaZulu, and in the large cities. They also appear high in the Swazi self-governing area of KaNgwane. Of the 18 who claim to have treated one or more HIV/AIDS cases, 16 said they knew what they were dealing with because their patients were tested for HIV/AIDS in a hospital. Seven specified that they have only treated these cases since their training in the AIDSCAP workshop; 11 said they encountered cases both before and after the workshop. Some additional comments were: "I treated a commercial sex worker and her partners. I had treated AIDS patients before the workshop but I didn't understand the symptoms or why they didn't respond to treatment. I've had more HIV patients since the workshop."
In case advice and counselling were not mentioned previously, we asked, "Please describe generally what advice and counselling you have given a person with AIDS or HIV." More than the 15 who claimed to have treated AIDS answered this, some others thinking that the question meant what advice one would or might give.
We next asked whether AIDS can be cured, either by traditional or "modern" treatment. Judging by healers' comments, the question was often interpreted to ask whether AIDS is curable in the future rather than curable at present. Others took the question to refer to treating or curing the opportunistic infections of AIDS rather than AIDS itself. Still others took the question to refer to prevention rather than cure. In any case, 32 said yes; 30 said no; and 8 said they didn't know. A number of healers mentioned preventive measures such as condom use and marital fidelity. One healer said that AIDS is not curable "unless we combine knowledge with traditional healers all over the world." Other comments include: "Not right now. Healers need to consult their ancestors." For those answering yes, we asked how AIDS can be cured. Thirty-seven mentioned herbal treatment, or consulting or beseeching the ancestor spirits; 11 said this will be possible in the future through traditional-biomedical cooperation; and 7 said both traditional and biomedical healers can now treat symptoms or opportunistic infections. At least one mentioned condoms. Again we see that many healers took the question to refer to hoped-for cures in the future while some took it to mean prevention in the present. Sexual Behavior We asked healers to estimate the average age at which boys and girls usually begin to experiment with sex. The mean, median and mode clustered around 13.5 years for boys and around 11 years for girls. There were no significant differences in answers by ethnolinguistic group or by rural/urban residence. In the November 1992 workshop survey, we found means of 14.2 years for boys and 12 years for girls. During that workshop, healers commented that in former times, elders took boys to the bush to educate them about proper sexual behavior. This included instruction in "thigh sex" (ukusoma, ukufema), or other intercourse where there is no penetration, intended for youth and the unmarried. In the present survey, we asked healers if any people in their area practiced thigh sex or other non-penetrative intercourse. Only 13 (19%) said yes, usually with the qualification that the practice had become increasingly rare; 42 said no, and 15 did not know. In some urban areas such as Capetown, healers commented that the practice is "unknown" among younger people. A number of healers in the predominantly rural Tsonga "homeland" commented that people were no longer interested in thigh sex (mantanga), one noting, "even the youngest want penetrative sexual intercourse." Thigh sex was reported to be common only in the Swazi self-governing area of KaNgwane, where healers sometimes encourage the practice when a wife is menstruating. (Note the potential that might be exploited for promoting safer sex, at least with this group.) We also asked what types of sexual behavior are forbidden, or considered bad, or dangerous in the healer's area and tradition. With multiple responses possible, the results are shown in Table 2.
The taboos surrounding intercourse with widows and women who have aborted or miscarried reflect the widespread belief in Africa that death is a mystically polluting force that can adversely effect health (22,17,24). Pollution through death-contact is fundamental in a good deal of ethnomedical theory of disease causation in diverse parts of Africa, including theories of diseases biomedically known as sexually-transmitted (25,26). We next asked if any men in the healer's area engage in homosexual behavior. Sixteen answered yes with certain qualifications; 9 answered no, and 45 did not know. This is another question that, based on experience in the 1992 workshop, yields more useful information when explored in group discussion or in-depth interviews. The consensus in group discussion then was that homosexuality is quite rare among black South Africans. Experimentation occasionally occurs among boys, but in adults, where it occurs, it usually originates from men being deprived of normal sexual outlets such as those living in prisons or mines. Some respondents thought that deprivation of contact with women accounts for the origin of male homosexuality. Elite economic status or Western/white influence was said to account for some homosexual experimentation among blacks, a belief found elsewhere in Africa (25). Apparent Consequences of Training We asked how healers felt generally about the usefulness of the AIDS workshop they had attended led by local healer-trainers assisted in most cases by a facilitator from AIDSCAP. All rated their workshop as "very useful," the highest category. Healers were then asked to describe the two most useful lessons they learned. Results are seen in Table 3. Multiple responses were allowed.
Miscellaneous answers included role-playing, the anatomy and physiology of genitalia, learning more about STDs, and tuberculosis. The popularity of condom demonstration may be due to it having been an actual participatory demonstration--not just something spoken about--and because healers were given a new skill along with a dildo which they could use with their clients. All healers as shown below reported having given condom demonstrations to not only clients but to essentially anyone in their communities with any potential interest. There is indirect evidence that this new skill along with the accompanying AIDS/STD knowledge has increased healers' status and improved or expanded their practices. For example, some healers reported that local medical personnel have begun to refer HIV-positive and STD patients to them for condom demonstrations and HIV counselling. While this is not always an unalloyed blessing (see below), it is usually a positive development for at least the patient. Other healers reported that "demand" for condoms and other AIDS/STD-related services provided by workshop-trained healers has led to an overall increase in their number of clients. It would seem important to follow up on this line of inquiry in future studies, since among other things it might help explain what motivates healers to take time out of their presumably busy practices to attend a week-long workshop in AIDS and STDs. We next asked if healers have tried to influence the sexual behavior of their patients by counseling them or giving them sex education, since the AIDS workshop. All said yes except for two healers who took the question to mean that they must have already had AIDS patients. The advice given was to avoid risky sex, remain faithful to one partner, use condoms, get tested for HIV, learn the dangers of STDs, and have existing STDs treated. In response to another question, all healers reported that they had advised friends, family or people in their community (other than patients) about AIDS or STDs. Community people designated include young people, people at community meetings, sangoma apprentices (amatwasa), people at ANC meetings, civic society members, sports team members, healers who couldn't attend a workshop, healers at traditional gatherings such as graduations, traditional circumcisors or surgeons, friends on commuter trains, and people in nearby squatter camps. This, of course, is a most welcome consequence if true. Regarding the advice given, healers mostly specified condom education, the means of prevention and the modes of transmitting AIDS, responsible sexual behavior, and "AIDS 101" as the basics were called in the first workshop. We next asked how healers felt about seeing a condom demonstration with a dildo, and we probed for whether such demonstrations were culturally acceptable or offensive. We asked this partly because at the Berlin international AIDS conference, a healer from the November 1992 workshop was asked publicly whether South African healers had been pressured into accepting dildos to use in condom demonstrations, since these might appear to offend African tradition. In the present survey all healers said they liked the demonstration and that the use of the dildo made it realistic. Furthermore all healers had already given condom demonstrations to other healers, to patients and to others in their communities, using dildos in all cases with the exception of the few healers who had not yet received them. The subject of condoms and dildos was discussed at some length at the 1993 national workshop for first generation healers. Healers were emphatic in saying they wanted to use lifelike dildos in their counselling and education of clients. The issue was in fact put to a formal vote. No healer preferred to work in AIDS education without use of a dildo, or with a wooden dildo. It was thought to be dangerous to demonstrate condoms using bananas, fingers, or bottle necks. Healers commented that while dildos may be alien to African tradition, there is a traditional mechanism for introducing objects unfamiliar to the ancestor spirits. These healers reported that they have ritually presented dildos to their ancestors and explained their beneficial use, either in their ritual huts (indumba) or in a special corner of their house if they are urban-based. Some second generation healers corroborated this. Dildos have thereby been incorporated and added to the standard healing instruments of the practitioner. One female healer reported at the workshop that the dildo has proven useful in diagnosis and discussion with male patients. She is able to discover by indication on the model the exact location of sores or other symptoms, rather than try to describe them in vague, embarrassing terms. She implied that a patient showing his penis to a female healer would violate rules of decorum. Informal discussions also showed that both dildos and books which provide photographs of symptoms are highly valued by healers, perhaps partially as symbols of prestige and of cooperation with medical doctors. We asked if healers have ever advised a patient to use a condom. All but one said yes. Circumstances cited refer to the prevention of HIV/AIDS as well as STDs and sometimes unwanted pregnancies. One healer volunteered the comment that a patient must use a condom if he wishes to have intercourse while taking herbal treatment for STDs. We also asked if healers have ever shown a patient how to use a condom; 56 (93%) said they had. Virtually all said they used a dildo in demonstrating the condom, even in front of friends and in public gatherings. Among the four who had not, we were told, "No, I haven't seen an STD patient since the workshop;" and "No one has consulted me yet." One healer gave an extremely detailed description of correct advice regarding condoms including proper hygienic disposal after use. Many healers specified that they demonstrated condoms for STD prevention. One noted, "I demonstrated this for my family; both my children have had STDs." Finally, on condom use we asked, "Have you encountered any problems promoting or demonstrating condoms?" Only 18 (26%) said yes and an additional 2 said "slightly" or "a little." Problems proved to be with the availability of condoms, not with audience reaction (only one Natal healer mentioned patient aversion to condoms). Several healers volunteered that they "like" or "enjoy" demonstrating condoms. Other volunteered comments are illuminating: "Some laugh at first. Some women were a bit shocked, but it was okay...it's serious; we can't hide from this AIDS." The Issue of National Healer Organizations Finally we asked what organizations of traditional healers (national, regional, or local) the healer has belonged to, beginning with their present organization and going backward in time. The number of healers who had switched association membership recently or who had dropped out of associations altogether is considerable. A group of urban healers estimated that only about 20% of all healers in the Johannesburg area are currently affiliated with formal healer organizations. They believed that a greater number may have belonged to an organization at one time and then dropped out. National and regional organizations appear to be unstable due to power struggles and politics. One widely respected healer commented, "As soon as a leader starts talking about 'my people' he or she is going to cause a lot of resentment and that leader is on the way out." Another commented, "Formal associations breed jealousy among healers. No one is treated with respect in them." In the course of group and individual discussions during site visits, the following charges were made against healer associations that claim national membership. Many of them have to do with the nature and behavior of association presidents.
South African healers appear to be strongly egalitarian; they are deeply suspicious of any peer who claims superior status and tries to exercise authority over the rank-and-file. Although there is a traditional hierarchy of statuses, status differences are either between types of healers or they relate to seniority, meaning that today's trainee will become tomorrow's senior gobela. It is also the case that formal associations are a historically recent attempt on the part of healers to exercise power in the larger state polity (28,29). As such they are still in an inchoate and unstable developmental stage; they have not yet developed structures that ensure stability and continuity. Most seem bedeviled by problems of financial management. Impandes Because of the foregoing criticisms of formal associations, we decided to explore the possibility of AIDSCAP not formally dealing with national associations but instead with existing, indigenous associations of healers that seem to have been in South Africa for many generations, namely impandes. This term is used or at least understood by virtually all black groups in South Africa; the Xhosa may use the term ingcambu. Ngubane (30) describes them as sangoma networks without using an indigenous name to designate them. An impande is a named network or association of sangomas that trace what might be called spiritual kinship ties through association with a gobela (initiator or trainer of diviner-mediums), a gobela's initiator (koko) or a gobela's initiator's initiator (kokogasi for females or kokokhulu for males). The term impande refers not only to people but to the medicines and distinctive rituals and ceremonies used by all who descend from the same gobela. Initiates (a term preferable to members) in the same impande refer to one another as sister or brother if they have been sangomas for roughly the same period of time. Those who are two or more "generations" of initiates above a sangoma are both addressed and referred to as gogo (grandmother) or koko (great-grandparent). Like lineages, impandes may be subdivided or segmented into smaller groupings consisting of more restricted membership, depending on need or purpose (38). As impandes become too dispersed and too large, new impande groupings or segments develop, yet a sense of belonging together remains between members of the larger, older impande. Members of an impande are known by special insignia, such as beads of a certain color or other decorative items that are worn. Names used to designate impandes may refer to a recent gobela, although the full name is actually a succession of names of senior gobelas--one's lineage of initiators--as well as the places where initiation took place. An impande name may also refer to a class of spirits, such as emandau or emanzawe (believed to be the spirits of people from tribes other than one's own who were slain during the period of tribal warfare). The insignia of diviner-mediums possessed by emandau consist of a necklace of white and red beads from which is suspended a beaded object. No one knows the exact size of an impande since written records are not kept and since new impandes or impande segments develop at a perhaps indefinable point. Certainly they grow exponentially: a gobela may train or initiate as many as 100-200 healers in her lifetime. Her amatwasa may in turn train 100-200 others in their lifetimes, as may their amatwasa. Even if some amatwasa, upon becoming gobelas themselves, initiate far fewer numbers, an impande of several thousand members may easily develop within a generation. The question arises: how feasible would it be for AIDSCAP or other donors to work with impandes rather than national healer associations in AIDS prevention? We note immediately that the former are indigenous, existing structures; foreign donors would not seem to be forcing healers to join formal associations in order to benefit from AIDS-related training--just because donors might be more comfortable dealing with formal, "national" associations. It would seem preferable to build upon a time-honored structure that already exists. We discovered several additional characteristics of impandes that would seem to recommend them further over national--and perhaps any formal--associations. One is their multi-ethnic membership. It can be observed that sangomas often train under a gobela from a different ethnic group. Sangomas are emphatic in insisting that it is one's ancestors and not oneself who choose the gobela, but it can be observed that ancestors often guide would-be initiates to a gobela from a different ethnic group. We might refer to the mechanism that ensures impande multi-ethnicity as ethnic discordance in the initiation process, and it would doubtless be interesting to speculate why it evolved in Southern Africa. One result of the practice is that sangomas have some intimate familiarity with another culture. This might be a factor of how a healer practicing in a plural society can attract clients from diverse ethnic groups, although a sangoma would never explain this feature of the initiation process in such terms. Nevertheless we saw that urban-based healers attract clients from diverse groups. At a deeper functionalist analytic level, ethnic discordance in the initiation process might be seen as a functional mechanism that has developed to mitigate and reconcile ethnic divisiveness and strife in the broader society as it moves toward greater socio-cultural integration. In any case the structure and function of impandes seem to make it unnecessary for AIDSCAP or other donors to issue criteria designed to ensure equal access by "tribe" to donor resources; South African healers are already practitioners of cultural pluralism. Impande membership is also geographically dispersed. As noted, healers may train and be initiated in a different area of South Africa--even a neighboring country--and then return to practice healing at home. Moreover healers are at least as geographically mobile as the rest of South Africans. In these ways, initiates of an impande quickly spread all over the country and beyond. A sangoma can travel anywhere in the region and expects to see another sangoma wearing the beads characteristic of her impande. When this happens, the two greet each other joyfully and there is an immediate sense of kinship and intimacy. Another characteristic of impandes is that members are bound to each other by spiritual ties; they are forbidden by custom to squabble with each other but if this occurs, mechanisms exist for conflict-resolution. A dispute is brought to the common gobela (gogo, koko) who with the ancestors serves as a kind of court of appeals that provides a spiritually sanctioned resolution for any conflict. Impandes are described as apolitical or above political concerns. Again the explanation lies with the ancestors: they are said to care nothing about politics. In the words of one sangoma, "The ancestors don't know who the ANC or Inkatha Freedom Party are; they have never heard of them." Impande initiates meet on a regular basis, such as during ceremonies when newly-initiated sangomas demonstrate their spiritual qualifications. Initiates are also expected to share healing information with one another and with their gobela, and to refer clients to one another. There is said to be mutual respect. As already noted, second generation training in the Northeast Transvaal (Gazankulu) was especially successful. Here healers were recruited and trained through the N.E. Transvaal Tinyanga and Herbalists Association (NETTHA), a regional, as distinct from national, association. We found that about 95% of NETTHA's membership belonged to the same impande. Most members formerly belonged to a larger formal association based in the Tsonga self-governing area of Gazankulu, but they became disillusioned with it for most of the reasons already cited as problems with national organizations. At the time of the assessment NETTHA was trying to build upward, joining with local organizations in Venda, Lebowa, and elsewhere to form a truly regional, multi-ethnic organization for the Northern Transvaal. The passage of time might show if it is better to build from regional associations-up than from Johannesburg-down. It may prove useful to work with or through regional as distinct from national healer associations, if that is what healers in areas such as the Northern Transvaal wish to do. However paid membership in any association should not be a pre-condition for benefitting from AIDSCAP-supported training. Some General Problem Areas
As outlandish as this might seem to the outsider, we were told that if a sangoma turned away an AIDS patient who moaned and complained at her front door, and then died a few days later, it would seem to the whole community that the healer was not working with the ancestor spirits let alone fulfilling her responsibility as an AIDSCAP-trained healer. Some AIDSCAP healers were interested in discussing the limits of a healer's responsibility, considering that AIDSCAP training was in prevention rather than treatment (although care and counselling was part of the training). They also wished to discuss with AIDSCAP and other healers the issue of people who try to "manipulate the system". One might expect that the training provided to the first generation of healers would become somewhat diluted in the second generation. Yet according to our assessment, the second generation apeared to be as well trained as the first, if we can rely on measures such as reporting correctly how HIV is transmitted and how HIV transmission can be prevented. Why might this be so? First, we know our method of selecting first generation healers was not the best because we worked through national healer associations, which seemed to be our only entry point at the time. First generation healers were probably better than AIDSCAP in selecting participants for second generation training. Secondly, the organization of the workshop and much of the training was American-designed, whereas second generation training was conducted by healers themselves, assisted in most cases by a (black) South African AIDSCAP facilitator with extraordinary communication skills and cultural sensitivity. One change in curriculum made after the first workshop in 1992 was in including a section on death and dying. This was the least favorite section according to the "evaluation" of the first workshop.(18, p.44) In fact sangomas believe that death is mystically polluting and therefore taboo for certain possessing spirits. The death of a client under a healer's care leads to legal culpability, especially if the client dies on the premises. Even a rumor of death is deleterious to a healer's reputation and practice. Naturally this has implications for healers who may be caring for AIDS patients. In fact legal protection for the healer might be the only context in which death and dying would be a discussion topic acceptable to healers. All sangomas consulted on the issue liked the idea of AIDSCAP working with impandes, most offering comments to the effect that the impande is a "natural" organization and that there is no conflict among fellow initiates. In view of the foregoing evidence and experience, it was recommended that AIDSCAP/South Africa discontinue recognizing or dealing with healers on the basis of their membership in formal, national organizations of healers. Instead AIDSCAP should seek to identify and train motivated healers who are respected in their home communities. Experience including the present assessment suggests that these healers need not be educated or even literate, but they should possess leadership skills and be able and willing to train other healers. AIDSCAP should encourage these healers to disseminate AIDS knowledge through their impande; if training extends beyond this (as it tends to), so much the better. Healers already know how best to share knowledge with their fellow impande initiates; indeed there are already opportunities and mechanisms to do such. By shifting focus from putative national organizations to impandes, donors such as AIDSCAP should be able to avoid many of the problems that constrained the program for its first seven months. Another consideration is that a number of black South Africans have criticized USAID-funded programs including AIDSCAP for working only through major NGOs, which are often white-dominated. These critics suggest that USAID work instead with genuine community-based organizations (CBOs) characterized by indigenous leadership. Although impandes cut across many communities they are nevertheless existing, indigenous grassroots organizations that exhibit many CBO features at the local level. We have found that impandes have cooperated fruitfully in some workshops and even in some formal associations, especially at the regional level. However we need to discover more about the conditions for establishing a cooperative working relationship between two or more impandes. It should be noted that the AIDSCAP traditional healer program is heavily focused on women. Working with and through impandes should further this since impande membership is primarily women, perhaps 80-85%. There are any number of reasons why emphasis on women is justified in South Africa, including their relative vulnerability to HIV infection, their subordinate status and inability to negotiate sexual relations, their role as childbearers and child-rearers, their role in family health care, and their disproportionate contribution to food production and hence to nutrition (31-34). There is also health program experience in Africa which suggests that women may be more willing than men to modify health-related behavior. Question arises about the involvement of non-diviner-mediums, especially herbalists. Would they be excluded if donors work directly or indirectly with impandes rather than with formal organizations? Herbalists seem to lack organizational structure comparable to that of sangomas. Yet sangomas and a very few herbalists we were able to consult, reported that herbalists routinely work together with sangomas in order to include divination in the treatment of their clients. In this way they are associated with the cooperating sangoma's impande. Herbalists are often invited to initiate "graduations" and other impande gatherings. Some Christian "Zionist" (amazioni, mazioni) faith healers(35,36) are also said to be associated with impandes, in fact two Zionist healers were invited to, and attended, the AIDSCAP-supported workshop in the Capetown area. Still, the participation of herbalists could and perhaps should be monitored in the future in order to ensure their inclusion, assuming AIDSCAP works with impandes. Other questions that must surely arise include: can and do different impandes cooperate with one another? Can projects work with more than one impande in the same area? The answers seem to be yes to both, according to preliminary evidence. Of the 34 healers trained in Soweto and Orlando, six impandes were represented. These townships are ethnically heterogeneous but this alone does not insure cooperation between impandes. We believe there are qualities inherent in impandes that contribute to such cooperation. We recall that healers themselves chose those who were trained and we note that the present assessment shows that the training seems to have had the desired impact. The position being recommended has already begun to be implemented in some areas by healers themselves. Second generation healers in the Capetown area have organized themselves into an association of some 100 members from nine townships: Paarl, Stellenbosch, Ceres, Langa, Nyanga, Khayelitsha, KTC Squatters Settlement, and New Crossroads. The association consists of four cooperating impandes. There was a conscious decision not to form a Western-type formal association with a president presiding--some of the local leaders had already had negative experiences with a Johannesburg-based national association. Instead Capetown healers decided to follow the impande structure in their new association. In descending order of status, this consists of "elders" or established sangomas, recently-trained initiates, amatwasa, and herbalists. There is an Executive Committee consisting of two representatives from each category. Because the AIDSCAP training was done with input from the national women's association Phambile, the name taken by the healers for their new organization is Nompumelelo Phambile, ("Traditional Healers Progressing Under Phambile"). There are no fees to belong to the organization and all decision-making is by full consensus of its membership, as dictated by tradition. Although we are describing an association rather than an impande, it seems to stand as an example of an urban-based organization of cooperating impandes governed by consensus as well as the shared traditional values and mutual understandings that characterize impandes. It should be noted that our recommendation is at odds with the official mid-term evaluation of the AIDSCOM/AIDSCAP project that occurred in early 1993. It observes, "The sustainability of the traditional healer initiative depends on the ability of the project to work in a disciplined way with the traditional healer organizations..."(37, p. 64-6). These evaluators unfortunately interviewed only five traditional healers; all are or were presidents of putative national associations. Only one of these healers had had direct contact with AIDSCAP. There was not a single interview with a rank and file member of a healer's association let alone a non-member. It is not surprising that the evaluators' recommendation was for AIDSCAP to work more through the formal authority structure of national organizations--a recommendation bound to please association presidents. It should also be noted that there is little or no tradition in Southern Africa of healers organizing themselves beyond the local level, such as under a chief within a chieftaincy or under a gobela. It is to be expected that there will be power struggles, ethnic and other rivalries, accusations of financial mismanagement and of leaders or followers acting "superior," etc. within these unfamiliar organizations that are based on urban-western models. We have seen evidence that leaders of national associations become threatened when more junior members attend workshops and become more knowledgeable than their leaders about AIDS prevention, and perhaps better able to organize a workshop. Part of the problem here is that some entrenched leaders regard themselves as too senior to attend an AIDSCAP workshop in what they regard as a student role. Instead they send a hand-picked member of their association in their place, but then try to undermine this person later because he or she is viewed as a potential threat to the leader's authority. The total number of healers trained by September 30, 1993 appears to be 1,510: 28 of the first generation, 1,237 of the second generation, 245 of the third generation. By this time, healers and sponsors agreed that training achievements should be consolidated by providing in-service training and other support for those already trained before any more healers are trained anew. Discussion were in progress between AIDSCAP and USAID to design a larger evaluation that would attempt to measure actual practices of healers more directly.
The authors would like to thank Jacob Gayle and Godfrey Sikiba for their support of the program, as well as as two anonymous reviewers from Social Science and Medicine for their suggestions. REFERENCES 1. Lambo, T.A. "Experience with a Program in Nigeria." in R. Williams and L. Ozarin (Eds.), Community Mental Health: An International Perspective, San Francisco: Jossey-Bass, Inc., 1967, pp. 97-110. 2. Green, E.C., "Collaborative Programs for Traditional Healers in Primary Health Care and Family Planning in Africa." in Fyfe, C and U. Maclean (eds) African Medicine in the Modern World, Edinburgh (U.K.): University of Edinburgh Press, 1986, pp.115-144. 3. Tahzib, F., Sokoto Traditional Medical Practitioners Project. Second Progress Report. Nigeria: University of Sokoto, 1988. 4. Hall, C., (ed) "Report of the First National Workshop on 6. Green, E.C. and L. 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Dupree, The Role of South African Traditional Healers in HIV/AIDS Prevention and Management. Arlington, Va.: Family Health International, AIDSCAP Project, Dec. 1992. 19. Green, E.C., B. Zokwe, and J.D. Dupree, J.D., "Report of the Second AIDSCAP Workshop for Traditional Healers, July 1993, Emaweni, South Africa." Arlington, Va.: Family Health International. 20. Green, E.C., B. Zokwe, "Evaluation of the 'Second Generation' of South African Traditional Healers Trained in HIV/AIDS Prevention and Management." Arlington, Va.: Family Health International, Aug. 1993. 21. Green, E.C., AIDS and Sexually Transmitted Disease in Africa: Toward Collaboration Between Indigenous and Biomedical Healers Westview Press. (in press). 22. Janzen, J., "Health, Religion, and Medicine in Central and Southern African Traditions." in Caring and Curing: Health and Medicine in World Religious Traditions. L. Sullivan, ed. New York: MacMillan, 1989b pp. 225-254. 23. 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London: Oxford University Press, 1976. 37. Nell & Shapiro Consulting Co. "Evaluation of AIDSCOM/AIDSCAP/South Africa." 1993, p64, pp35-6. 38. Cf. Middleton, J. and D. Tait, Tribes Without Rulers London: Routledge and Kegan Paul 1964, p.4. 39 Hammond-Tooke, D., Rituals and Medicines: Indigenous Healing in South Africa. Johannesburg: Donker, 1989.
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