Involving healers.

PIP: There is increasing recognition on the role of traditional healers in preventing and controlling HIV/AIDS and other sexually transmitted infections (STIs). In Africa, a number of HIV prevention programs have involved traditional healers. These programs have helped them to improve their skills in diagnosing, treating, and counseling clients with HIV/AIDS and STIs. This article presents the policy and program recommendations to consider when planning to work with traditional healers: 1) be fair and democratic in selecting healers for training; 2) try to identify and train motivated healers who are respected in their communities; 3) do not make membership of a traditional healer association a requirement for participation in HIV/AIDS training; and 4) encourage healers to promote sexual abstinence among youth, and fidelity within marriage among adults.^ieng

A targetted intervention research on traditional healer perspectives of sexually transmitted illnesses in urban Zambia. Current research.

PIP: Interviews with 81 traditional healers from 4 Copperbelt towns in Zambia (Chililabombwe, Chingola, Luanshya, and Mufulira) investigated healers' understanding of, attitudes toward, and management of sexually transmitted diseases (STDs). In general, Zambian traditional healers had detailed constructs of the physiology and infective processes underlying syphilis, gonorrhea, chancroid, and AIDS. STDs were considered to be caused by "dirt" or contamination residing in sperm or vaginal fluids and were closely linked to violations of moral codes. Healers shared complex nosologies based on distinctions between symptoms of different STD pathologies that were more inclusive than biomedical categories. Although condom use was not promoted, healers understood the importance of preventing an infective agent from passing from one person to another. Except for AIDS, STDs were considered curable by expelling the dirt through purgatives or emetics. Modern medicine was perceived as treating only STD symptoms, not curing. Most traditional healers insisted that the infected partner bring the other partner for consultation or treatment was withheld. Since these findings identified some areas of compatibility between indigenous and biomedical models of STDs, the Traditional Medicine Unit of the Ministry of Health and the HIV/AIDS Prevention Project of the Morehouse School of Medicine (Lusaka) established a program in which traditional healers receive AIDS training and learn to counsel clients on safer sex behaviors. Follow-up entails monthly meetings between health professionals and traditional healers. Since program initiation in June 1994, 800 traditional healers and 70 health professionals have participated. Traditional healers now sell condoms to their clients through a social marketing program.^ieng

Purity, pollution and the invisible snake in southern Africa.

There exists in parts of southern and eastern Africa an apparently widespread belief in the existence of an invisible, internal "snake," often described as a power or force of some kind that dwells in the stomach but that can move throughout the upper body. Although some anthropologists have described this snake as related to witchcraft, findings from diverse parts of Mozambique, South Africa and elsewhere suggest that it may (also) be thought of as a symbolic expression of the need to respect the human body, specifically to protect it against the introduction of impurity. Belief in nyoka, as Tsonga- and Shona-speakers call the invisible snake, suggests the importance of purity and pollution beliefs as they relate to health in a particular society; the presence of nyoka belief may even be taken as an empirical measure of their importance. Going beyond nyoka, it is argued that pollution beliefs are more central in southern African ethnomedicine than the literature suggests, perhaps more so than witchcraft and sorcery beliefs. It is hypothesized that pollution-related illnesses tend to be roughly coterminous with diseases biomedically classified as contagious. Apart from ethnographic and theoretical significance, establishing the nature and centrality of pollution beliefs, aided by analysis of cultural metaphors such as the invisible snake, can point to culturally appropriate ways of presenting health education messages in societies where pollution beliefs are important. Pollution beliefs may be characterized as quasi-naturalistic and they in fact represent an area of potential interface between indigenous and cosmopolitan medicine-far more than witchcraft beliefs.

The experience of an AIDS prevention program focused on South African traditional healers.

A national HIV/STD prevention program focused on traditional healers was started in South Africa in late 1992. An initial group of 28 healers (the 'first generation') was trained in HIV/AIDS and STD prevention. These 28 in turn trained a total of 630 additional healers (the 'second generation') in formal, week-long workshops within seven months of the first workshop (this figure grew to 1510 healers by the end of the tenth month). This paper reports results of an assessment of the impact of training during the first seven months of the program. The second generation appeared 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. Healers also reported advising their patients to use condoms, and demonstrating methods of correct condom use. Healers were initially recruited through national, formal associations of traditional healers, of which there are several in South Africa. Yet several months into the program, healers were critical of donor groups working with and through such associations. Most preferred that membership in such associations not be a prerequisite for participation in donor group-supported collaborative programs. The present program accordingly began to explore the possibility of recruiting healers through existing, indigenous associations of diviner-mediums known as impandes.

Sexually-transmitted diseases, AIDS and traditional healers in Mozambique.

Qualitative research was conducted with traditional healers in Manica Province, Mozambique to develop an empirical, culturally-appropriate strategy for communication between government and traditional healers related to the prevention of STDs including AIDS. Most Manica healers regard AIDS as a new disease for which they lack medicines. However, when questioned on other sexually transmitted diseases, as defined by healers themselves, relatively complex disease taxonomies based on fine distinctions between symptoms emerged. Manica healers recognize two broad categories of STDs: siki and nyoka-related. The former seems to correspond with the more serious common STDs of Western biomedicine--syphilis, gonorrhea, chlamydia and chancroid--and is believed to be caused by a common invisible, microscopic agent, khoma. Nyoka-related illnesses are understood in terms of traditional ideas of pollution, and denote less serious, self-limiting genito-urinary conditions. Healers express great faith in the efficacy of traditional medicines. Based on the ethnomedical research findings, a culturally-sensitive and -specific AIDS/STD health education strategy for Manica indigenous healers was developed and began operating in a week-long workshop held in Chimoio, Mozambique in November 1991.

The anthropology of sexually transmitted disease in Liberia.

In sub-Saharan African countries where AIDS is established, HIV transmission is primarily by means of heterosexual intercourse. A major co-factor in such transmission is the presence of other, sexually transmitted diseases (STDs). Efforts to limit the heterosexual transmission of HIV in Africa must therefore address the high prevalence of other, standard STDs. The present study attempts to establish a preliminary information base for interventions to prevent the spread of HIV in Liberia where there is relatively high incidence of standard STDs but low incidence of HIV seropositivity. Employing in-depth, key-informant interviews with traditional healers, prostitutes and others, as well as focus group discussions with groups selected on the basis of several criteria, knowledge, beliefs, attitudes and behavior related to AIDS and STDs were elicited. Although evidence of exposure to scientific concepts was found, traditional, ethnomedical views predominated. Notions of sorcery, taboo violation and contamination were often expressed when describing the etiologies of locally-recognized sexually transmitted diseases. More 'naturalistic' explanations were often based on simplified notions of human anatomy and biochemistry. Three basic messages about AIDS that were broadcast in a recent radio campaign were retained, namely 'AIDS kills;' 'there is no cure for it;' and 'it is transmitted through sex.' There was also evidence of Liberians beginning to view AIDS in frameworks of interpretation compatible with traditional ethnomedical beliefs, such as sorcery. Most traditional healers reported they knew little or nothing about AIDS, including those who had a lot to say about other STDs that are well-established in Liberia. Many cases of STDs seem to be handled by traditional healers. Treatment typically consists of decoctions from the leaves and roots of various medicinal plants, administered as teas--less often as enemas or vaginal implants--to be taken over a 2-4 day period. It is recommended that efforts to lower incidence of standard STDs be given priority comparable to promotion of condom use and 'safer sex' in efforts to slow the transmission of HIV in Liberia. Strategies for combating STDs will have to take into account popular beliefs and attitudes regarding STDs as well as the role and influence of traditional healers. Strategies of this sort are recommended.

Sexually transmitted disease, ethnomedicine and health policy in Africa.

Compared with both industrialized countries and other less developed parts of the world, most of sub-Saharan Africa suffers inordinately from sexually transmitted diseases (STDs). It has high prevalence rates of traditional STDs, such as gonorrhea and syphilis, and if accurate seroprevalence surveys were to be done, it would probably prove to have the highest HIV seropositive incidence in the world. Unlike the pattern in the West, AIDS is primarily a heterosexually transmitted disease in Africa. This appears to be largely because of the prevalence of other untreated or improperly treated STDs. Therefore to lower the incidence of STDs would be to curtail the spread of HIV infection. The problem becomes how exactly to accomplish this. Most STD cases are never even presented at biomedical health facilities; they are presented to traditional healers. Both healers and their patients seem to believe that traditional STD cures are more effective than 'modern' cures, although the former are probably biomedically ineffective. While there is scant ethnomedical literature on STDs in Africa, the present paper presents Swaziland findings and related evidence from other African societies that the ultimate cause of several common STDs is believed to be the violation of norms governing sexual behavior, requiring traditional rather than biomedical treatment. Traditional healers therefore need to be a central part of any scheme to lower the incidence of STDs.

Can collaborative programs between biomedical and African indigenous health practitioners succeed?

The paper explores the various factors that appear to constrain the implementation in sub-Saharan Africa of the WHO/UNICEF Alma Ata resolutions that member states support the use of indigenous health practitioners in government health programs. It also presents arguments and evidence that suggest ways to overcome the constraining factors. Discussion focuses on traditional healers as distinct from traditional birth attendants. The question posed in the title is not fully answered, but a considerable amount of fact, programmatic experience, and observation related to the issue is assembled and discussed in order to approach an answer, and to inform those who hold a variety of positions with regard to the Alma Ata resolutions.

Diarrhea and the social marketing of oral rehydration salts in Bangladesh.

An anthropological study of knowledge, attitudes and practices relating to child diarrhea and specifically to ORS was carried out in Bangladesh. The purpose of the study was to help design a culturally-sensitive social marketing program. Information was gathered on indigenous classification of diarrheas, patterns of therapy recourse and diarrhea management, and understanding of dehydration symptoms as well as use and attitudes regarding ORS. Among the findings were that 58% of households sampled had tried ORS at least once; ORS was perceived as a medicine with several positive attributes; literacy was positively related to ORS use; and there were no significant cultural barriers to ORS adoption.

Traditional healers, mothers and childhood diarrheal disease in Swaziland: the interface of anthropology and health education.

A study of beliefs and practices relating to childhood diarrhea, relying primarily on traditional healers as informants and survey respondents, revealed an indigenous classification of childhood diarrhea into three main types. Enemas are used as a treatment in two types of more serious diarrhea regarded as due to unnatural causes. Most children with diarrhea are taken to clinics only after home treatments and those of traditional healers have failed, by which time a child may be severely dehydrated. The role of oral rehydration and strategies for health education are discussed in the context of Swazi culture.

Traditional healers in Swaziland: toward improved cooperation between the traditional and modern health sectors.

The paper describes applied research efforts, requested by the Swaziland Ministry of Health and funded by U.S. AID, aimed at providing an information base for new government policies regarding traditional healers in Swaziland. Information reported relates to: health care manpower in the traditional sector; treatment seeking behavior in a pluralistic medical setting; traditional health beliefs and practices; payment practices; patterns of patient referral; attempts to establish an association of healers; attitudes of healers toward paraprofessional training; and possibilities for specific types of cooperation between modern and traditional health sectors.