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WHO Partnering with Traditional Healers in Africa

There is an AIDS epidemic in Africa, and efforts to fight it are hampered by the endemic social problems of that continent. Chief among them are the lack of sufficient modern health resources, the spread of destructive rumors and myths about HIV/AIDS, and even the persistence of HIV denial in Africa (although this last factor is better than in the past).

The World Health Organization (WHO) and the International HIV/AIDS Alliance are teaming up with the Traditional Health Practitioners Association of Zambia (THPAZ) to address the first problem – the lack of health services. Most Zambians use traditional healers for primary health care. The WHO has therefore decided to utilize traditional healers in the fight against AIDS. There are interesting pros and cons to this policy, but it must first be recognized that there is no ideal solution to the problem. The resources to provide optimal modern health care to treat and prevent HIV/AIDS (which would need to include a massive education program) in Zambia and the rest of Africa simply do not exist. One might argue that the world should provide those resources, but let’s put that issue aside and focus on what to do in the meantime.

The arguments given in favor of this WHO strategy are:

Traditional healers far outnumber biomedical workers in the rural areas.

They are consulted, not only because they are closer and more affordable than their Western-trained counterparts, but also because they are embedded, extensively and firmly, within Ugandan culture.

Traditional healers are highly respected and widely consulted by communities.

In the various articles I read discussing this issue, even those entirely favorable to the idea, conspicuously absent is any mention of whether or not the interventions provided by traditional healers are safe and effective. It’s not even an afterthought – it’s as if it is a non-issue.

However, if we are to focus on the potential benefits of such a policy we could envision a program to train traditional healers essentially to implement a science-based program of counseling and basic health care while also using them to funnel patients to modern health treatments. In addition traditional healers could be trained how not to interfere with modern treatments – for example by not giving herbs that might reduce the effectiveness of anti-HIV drugs. Also they will need to be educated so that they do not spread myths and misconceptions, and in fact so that they can help to counter them. Until such an education program is in full swing, however, the policy of using traditional healers is likely to be counter-productive. As one report notes:

According to the 2006 survey by THPAZ, only 13 percent of the traditional healers in the country had been in contact with modern medical doctors or facilities.

In essence the goal is to use an existing infrastructure of trusted primary care providers (traditional healers) to get them to help the HIV/AIDS program, rather than hinder it. The only alternative strategy would be to replace this infrastructure with a modern science-based medical system – ideal but not realistic. These two strategies are also not mutually exclusive – efforts can be made to maximize the availability of modern health care in the region, while using traditional healers to fill the gap, or at least make sure they are not working against the system.

But there are significant pitfalls to using traditional healers. I have already stated some – most have had no contact with modern medical doctors. By all accounts traditional healers in the region rely upon treatments that are worthless at best, and may even be harmful. There is every likelihood that despite some modern medical education, many traditional methods will be retained.

The biggest pitfall of a partnership is that it will be used as a sign of validation of traditional healing methods, whether or not they are safe and effective. Already there are attempts to validate herbal treatments for HIV/AIDS in Africa. Dr Sekagya Yahaya Hills is a dentist and traditional healer who is promoting herbal remedies as effective in treating HIV/AIDS. Not surprisingly we are seeing the same pattern as elsewhere with the promotion of herbs as drugs – preliminary small studies of poor design being used to justify unlikely treatments. Many herbs are, in fact, drugs but they contain a mixture of chemicals that are not purified, are not quantified, and have unknown bioavailability (as well has half-life and other pharmacological properties). This makes them very poor drugs. The experience in the US is likely to be typical – herbs that seemed promising in preliminary studies have almost all been useless when studied in large well-controlled trials.  In addition they have drug-drug interactions and potential side effects and toxicities that were not apparent before being carefully studied.

Treating HIV is very challenging, and it is also a recent plague on humanity. It seems very unlikely that any traditionally used herb would be safe and effective against HIV. Despite the low probability, it is reasonable to test candidate herbs (as long as it is done ethically) but only well-controlled studies should be performed.

A more plausible research program would be to screen hundred of candidate herbs for in vitro activity – demonstrating that there is some biological activity that could plausibly fight HIV. Then follow up with animal testing of those herbs that seem promising on the screening test. And finally conduct preliminary then definitive testing in humans – and once you have a product that is proven safe and effective, recommend it for usage. This, of course, all s0unds suspiciously like pharmacognacy and drug development. But this is not what is happening. Rather, the preliminary research is bypassed and we have only preliminary and unreliable clinical studies.

What is very likely to happen is that traditional healers, propped up by an alliance with the WHO, will stick to their traditional methods, supported by those like Dr. Sekagya Yahaya Hills, who will use bad science as a rubber stamp to endorse traditional treatments.

It is a real dilemma – a devil’s bargain. It seems necessary and potentially useful to enlist the help of traditional healers, given the realities on the ground in Africa. But the potential to do more harm than good is extreme. The WHO should therefore go into any such collaboration with their eyes wide open, and not naive to the power of cultural belief, the highly sophisticated anti-scientific propaganda of the CAM movement, and the potential for reliance upon bad science. The WHO should therefore focus on regulation, which is an admitted problem:

The other concern is a weak regulation of traditional medicine, leaving people living with HIV open to abuse by unscrupulous healers who promote cures for AIDS or persuade their patients to cease life-prolonging drugs such as the antiretroviral treatment.

Therefore any such partnership should be contingent on careful scientific scrutiny and improved regulations.

Conclusion

Given the cultural and health care realities in Africa, it does seem necessary for the WHO to partner with local traditional healers in order to implement any widespread public health program. The endorsement of traditional healers may be necessary to achieve public acceptance of “Western” medicine. It is also necessary to counter myths and misconceptions about HIV/AIDS, and this must begin with the locally recognized health authorities – the traditional healers.

But the WHO should resist pressures to “respect” local traditions themselves as if they are acceptable alternatives to science-based medicine. In the promotion of health, which is the WHO’s mandate, utilizing treatments that are safe and effective is the only ethical option. Promoters of unscientific treatments, however, often resort to an appeal to cultural sensitivity and a false dichotomy between “Western” science and the beliefs of other cultures. Whether or not Dr. Hill’s herbs are an effective alternative to proven anti-HIV drugs will be determined by objective science, not culture, and bad science should not be excused with appeals to cultural sensitivity.

Without maintaining a strong dedication to science-based medicine this WHO program will likely become an epic example of the axiom that the road to ruin is paved with good intentions.

Posted in: Public Health, Science and Medicine

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23 thoughts on “WHO Partnering with Traditional Healers in Africa

  1. windriven says:

    “In addition traditional healers could be trained how not to interfere with modern treatments – for example by not giving herbs that might reduce the effectiveness of anti-HIV drugs. Also they will need to be educated so that they do not spread myths and misconceptions, and in fact so that they can help to counter them. Until such an education program is in full swing, however, the policy of using traditional healers is likely to be counter-productive.”

    You seem to assume that traditional healers will be willing participants in an endeavor that displaces traditional healing practices with modern medicine. I suspect that this will not be altogether common. By deferring to modern medicine the traditional healer is denigrating the power of the techniques and remedies s/he has used for years thereby diminishing his or her standing. More people than fewer put their own power and prestige above the needs of their community.

    How, precisely, are these healers persuaded to act against their own interests?

  2. WilliamLawrenceUtridge says:

    How, precisely, are these healers persuaded to act against their own interests?

    It would be nice if you could appeal to a desire to actually help people. I would say it’s unjustly prejudicial to assume that because they are traditional healers they will put ego and tradition before the health of their patients, but the experience of “traditional healers” in the West (i.e. CAM) makes me wonder if this is a universal stupidity.

  3. windriven says:

    @WilliamLawrenceUtridge

    I cannot claim to have made a careful study of the persistence of folk beliefs and I am well aware of the dangers of anecdotal evidence. That said, I have traveled broadly and have been regularly startled by some of the bizarre beliefs that are clung to by otherwise educated and urbane individuals.

    If we were all – or even mostly – a species of rational and altruistic actors, ours would be a much different world. The requirement then, if we are to aspire to a future world better than our own, is to draft policies and take actions that coldly recognize our shortcomings and, to the extent possible, use them to advance the agenda.

  4. weing says:

    I think it’s utterly stupid to expect people to not act in their own interest. Yes, there is the example of Jonestown. But even there not everyone drank the Kool-Aid willingly. If you want to use the traditional healers, you have to introduce some science-based medicine that they can utilize. They will quickly see its efficacy and use it to gain prestige and followers. Word will spread to others who will also adopt it.

  5. squirrelelite says:

    Evidently, THPAZ may be a cooperative partner in this effort.

    They have already condemned some traditional practices that are ineffective and might contribute to the spread of HIV/AIDS.

    http://cc.bingj.com/cache.aspx?q=THPAZ&d=4990172301821417&mkt=en-US&setlang=en-US&w=a7c16ba5,f82867c1

    They are also one of the partner organizations that the International HIV/AIDS Alliance is already working with in Zambia through the Antiretroval Community Education and Referral Project (ACER).

    http://pdf.usaid.gov/pdf_docs/PNADL431.pdf

  6. Windriven has an excellent point.

    We also must not take for granted how much our educations matter. We have a very reductionist understanding of cause and effect that is far from universal and may be very difficult to achieve. Thirty years ago when I was in West Africa I heard that police in the US were in possession of a special powder that they could shake into the footprints of a criminal which would cause the criminal to appear before them. They were very impressed with the strong american magic. I was fascinated to hear how fingerprint powder can change as it crosses the Atlantic.

    I also met a traditional healer who demonstrated how to heal a broken leg by smearing it with python fat and by breaking a chick’s leg. If the chick’s leg healed straight then the person’s leg would heal straight too.

    Our night watchman was feared because he could turn into a snake. Some of the other watchmen had caught him at it and he hadn’t denied it.

    Bongi’s take on traditional healers and hiv and South African government policy:
    http://other-things-amanzi.blogspot.com/2007/04/powerful-horn.html
    http://other-things-amanzi.blogspot.com/2009/08/savages.html (read the comments too)

    Also, more generally:
    http://other-things-amanzi.blogspot.com/2007/02/flogging-dead-horse.html
    http://other-things-amanzi.blogspot.com/2007/11/one-of-aims-of-this-blog-is-to-touch-on.html
    http://other-things-amanzi.blogspot.com/2010/01/in-dead-of-night.html
    http://other-things-amanzi.blogspot.com/2007/07/madness.html
    http://other-things-amanzi.blogspot.com/2007/06/balance.html

    Traditional medicine in africa is much broader than just herbalism.* In Tanzania you can buy medicines made from (human) albino body parts. I imagine we all know of the practice of men ridding themselves of the hiv they contracted from an infected woman by having sex with uninfected women — virgins (preferably albinos in some areas). The way to ensure that a woman is a virgin is to get her when she’s young, of course; under ten will usually do it.

    Many of these practices would be regarded as vile by most of the population. That doesn’t mean people don’t believe they work. If you have some understanding of what a virus is, you wouldn’t believe that hiv is something that can be gotten rid of by giving it to someone else. The fact that (at least some people) believe it is, is evidence that the concept of a microorganism is far from universal.

    If you want people who are everywhere, try pharmacists. My understanding is that in most (all?) african countries you can go to a dispensary in the market and buy antimalarials, oral contraceptives, antibiotics and lomotil without a prescription. It shouldn’t be as hard to train a pharmacist as a practitioner of traditional medicine.

    Belief in magic is not specifically african, but disbelief in magic is less widespread there than in countries where science is well-established. I am always surprised talking to (american) evangelical christians just how much magic they often believe in. Psychosis is possession by demons. “I don’t believe in necromancy” means “I believe the dead can be brought back to life but I think it’s bad.” Astrology works but is a devil’s gateway. Sometimes it’s just poor education; they have literally not been exposed to a medical model of psychosis, so if you provide them with one the demon model can be abandoned (until the next difficult phenomenon needs explaining). Sometimes it’s a commitment to an understanding of the world as battling forces of good and evil, where the physical realm is an illusion and temporary testing ground until we die and are reunited with christ in the second coming, or until we die and go to heaven. I would not preferentially select prominent members of american apocalyptic cults for medical training — these are people who have chosen a non-material model for understanding the world when they have the option of an alternative model, and are likely to be unreliable in applying material methods. By the same token I question the selection of traditional doctors in africa for additional training when pharmacists are also present.

    ___________
    *The herbalism component can of course be valuable, though probably not against hiv. There are some medicines that are used by all traditional doctors in an area for the same condition; nobody would seek out a different treatment when it’s so obvious that one is effective and superior.

    *** *** ***
    Sorry for rambling. This is a very difficult topic. And I know I haven’t said anything about Zambia in particular, but it borders both Tanzania and southern africa (which I have mentioned), and some of the problems are generalizable to humans, broadly.

  7. windriven says:

    squirrelelite’s link deserves reading. I have excerpted a part of the news article below.

    THPAZ= Traditional Healers Practitioners Association of Zambia. Its president is Rodney Vongo.

    “It is unfortunate that some traditional healers are still encouraging their clients to do sexual cleansing and defilements to young ones as part of curing the HIV/AIDS.

    Sexual cleansing and defilement should not be condoned because the pandemic is real and needed to be discouraged because this trend was there sometime back,” Dr Vongo said.

    At the same meeting, Eastern Province Aids coordination advisor Emmanuel Chama told traditional healers to work hand in hand with health personnel in the fight against HIV/AIDS.

    Mr Chama said he was aware that because of the greediness of some traditional healers, many people had died because of not referring serious cases to hospitals.

    “You should work hand in hand with health officials, what we do not want from you traditional doctors is to be greedy because many people are dying because of your greediness,”he said.

  8. Jurjen S. says:

    A thing to bear in mind concerning the WHO is that, as a UN organization, it’s subject to political pressure from the member states (very likely to the chagrin of many of its personnel). Any time the WHO makes a pronouncement on something, or embarks on a certain course of action, it helps to ask “whom would saying/doing the opposite piss off?” For example, the WHO’s reluctance to dismiss TCM is readily explained by the likelihood that the Chinese government would be severely honked off.

  9. Halycon says:

    Interesting perspective on HIV/AIDS, especially concerning Africa provided by Hans Rosling and the Gapminder tool. http://www.ted.com/talks/hans_rosling_the_truth_about_hiv.html

  10. Toiletman says:

    I like to be somewhat polemic so:
    This cooperation plan with treaditional healers is just plain nonsense that will not work. Where does the HIV denial, the myths about contraceptions and the other mentioned come from? Right from those healers they want to cooperate with. They belong to the problem and cannot be part of the solution. It’s like working with germ denialists in order to get more people vaccinated. It’s a dire and hopeless situation. We cannot solve the situation as long as there are cleptocracies at power in those countries. Already a USSR or China like dictatorship would be a progress. Not even to mention real democracy. The only useful thing Western nations can do is directly founding schools, which also include health education curriculums.

  11. squirrelelite says:

    Hans Rosling had an interesting comment about 5 minutes into the presentation:

    “It’s very good that what is being done is being done.” I think he was referring to treating those that we (or their countries) can afford to treat and reach to make those treatments options available.

    I am taking a wait and see approach and look forward to further information. But, since THPAZ is already assisting in discouraging counterproductive traditional therapies, I still think they are a useful ally in both the educational and treatment aspects of addressing this problem.

  12. Toiletman – There’s this color between black and white, it’s called grey.

    hypothetically, say 5% or 10% or 20% or more of the healers are not the equivalent of germ denialist (who have had access to education and tools to know better) but are just people who are looking for the best tools available to do their job. If they change their practice, do the people they help not count?

    That said, It all comes down to whether the money you put into training would get better results with another method. It seems to me, it’s kinda hard to tell until you’ve at least run some pilot programs to get an idea of the results.

  13. micheleinmichigan,

    Sure, I can go with that. What if 20% or 30% or 50% or more of dispensing pharmacists are not the equivalent of germ theory denialists either? What’s the compelling argument for seeking out traditional healers when dispensing pharmacists are right there?

    Perhaps the WHO has already done a great deal of work with dispensing pharmacists to reach people all over Zambia and the traditional healers are just the next group on the list to reach out to. That could certainly be a fair experiment. I’d be interested to know the background.

  14. Alison Cummins – on dispensing pharmacist vs traditional healers.

    Agreed, comparing the results with traditional healers to other tactics (such as dispensing pharmacists) that might result in the same or better results (cost, benefit, risk) is what I was trying to address in my second paragraph.

    I don’t know much about Africa, but my experience in Kazakhstan suggests that the pharmacist often serve as an ad hoc medical expert to those who don’t have the money for a doctor’s visit.

    Hard to make an educated guess at which would be more appropriate without looking into the nitty gritty of what’s been tried, tested, etc. Wish I had more time.

  15. And I hope that WHO is providing pizza or the local equivalent at the traditional healer training luncheons. Perhaps some branded key chains and pens would be appropriate. Brownies are important.

  16. weing says:

    “And I hope that WHO is providing pizza or the local equivalent at the traditional healer training luncheons.”

    Great point. That should work well on them. After all the pharmaceutical companies have been influencing our docs here like this. Maybe WHO can send them out to resorts to influence them too.

  17. NicholasTurnbull says:

    The WHO’s approach in this circumstance is fundamentally broken due to the conflict of interest between the traditional practioner’s beliefs on treatment and the approach taken in evidence-based medicine. Instead it hopefully relies on the part that *doesn’t* have a conflict of interest at least amongst those practitioners who are sincere, the hope that the practitioner shares the intent to make the patient well.

    Unlike science-based medicine, however, traditional medical practices require faith on the part of the practitioner in order to practice them. Yes, that was not a mistake; one can practice science-based medicine without needing to *believe* that it works, simply because one can *demonstrate* it can. Where practitioners are of course used to the state of affairs of their belief in traditional practices, what will their first response to a patient presenting HIV/AIDS symptoms, I wonder?

    I find it extremely unlikely, no matter what their training, that their first thought will be to refer to science-based medicine. On the contrary, they will first wish to explain away the diagnosis, and secondarily convince the patient that they know how to cure them (whether or not they believe the patient actually has HIV/AIDS, or whether or not they believe the disease actually exists). This means they will effectively be talking patients out of needing antiretroviral therapy under colour of the WHO’s initiative, I need not add, is nothing short of suicidal for improvement in access to HIV/AIDS treatment. This is nothing short of putting the lunatic in charge of the asylum.

  18. squirrelelite says:

    For a little perspective on the current situation in Zambia, I exchanged emails with my aunt who was a nurse in a hospital in Zambia for many years and recently visited there. She noted that the hospital has trained hundreds of nurses to work all over Zambia in the 50+ years it has been in operation. They do not work much with traditional healers but have been involved in providing ARV drugs to HIV patients.

    My first link to the sexual cleansing story appears to be broken, but this one should work.

    http://allafrica.com/stories/200910090420.html

    Note that THPAZ wasn’t chosen by WHO out of the blue. They were already involved in education and referral programs.

    In 2009, THPAZ “condemned traditional healers who promote sexual cleansing and defilements as part of curing HIV/AIDS”.

    And they have been involved in the ACER project at least since 2006.

    A report on the ACER project which has been ongoing since 2004 describes the role of THPAZ thusly:

    “THPAZ:
    • Educated traditional healers and traditional birth
    attendants about HIV prevention, HIV counseling
    and testing, ART, and prevention of mother-to-child
    transmission (PMTCT).
    • Referred healers and birth attendants to HIV-related
    services.
    • Used traditional ceremonies to educate and sensitize
    people about HIV and ART.
    • Discussed ways to reduce the risk of HIV transmission
    during traditional practices such as cutting
    and circumcision, and distributed gloves and clean
    razors.
    • Distributed condoms and information on HIV prevention
    and ART at market stalls.
    • From January to December 2006, THPAZ in Lusaka
    reported reaching 3,471 people (1,899 women;
    1,572 men); in Ndola they reported reaching
    10,059 people (6,754 women, 3,305
    men).”

    Like many other African countries, Zambia suffers from a weak economy and poor populace (many people subsist on less the $2 a day). There is also a severe shortage of trained medical personnel to implement this effort.

    A good discussion of the history of the fight against HIV/AIDS in Zambia can be found here:

    http://www.avert.org/aids-zambia.htm

    As it states,

    “The crisis stems from a variety of factors, most notably a large-scale emigration of trained professionals to other countries in Africa and abroad, where salaries and conditions are more favourable. Zambia is now trying to recruit as many health workers as it possibly can, and has implemented a variety of initiatives to retain health staff, expand the workforce, and improve the wellbeing of doctors and nurses.50 ‘Task-shifting’ is a strategy that has been introduced to delegate certain health-care duties to lay people or community workers to reduce the workload of doctors and nurses. ”

    Under these circumstances, continuing to use traditional healers to provide education and referral services may not be an ideal option but it seems to be a practical and useful choice.

  19. Thanks squirrelelite, this is very helpful.

  20. Very good summary, squirrelelite, Thanks!

  21. Very good overview, squirrelelite, Thanks!

  22. red rabbit says:

    The main advantage of the traditional healers: they’re cheap.

    I suppose my main issues with using the traditional healers are twofold. First: these practitioners are first and foremost orators and showmen. They tend to be a lot like politicians, in my experience. Very smooth. Very easy to talk to. Very easy to trust.

    If they think participating “as directed” will be useful to their profession and will increase the trust people have in them, then great; if they think it in any way undermines what they do, there will be trouble. If only there was a way to get them to have the advantages of full medical training along with their social talents.

    Which brings me to my second issue: I know that the perfect is the enemy of the good, and that when starting from such a spot it is best to use the resources already on the ground, but using the sang’anga in such a way smacks of the imperialist attitude that the best need not be provided for mere Africans. And it burns, you know?

    I remember the frustration. So many people assumed there was no point of protecting themselves… HIV was everywhere and they were surely going to die. I remember writing on a chalkboard in my classroom in Malawi: “9 out of 10 Malawians are HIV ______”

    My kids said positive, and seemed genuinely surprised when I emphatically wrote NEGATIVE. I had to reinforce, over and over, that there was lots and lots of hope.

    Things are improving, ART is available now as it wasn’t then.

  23. squirrelelite says:

    @Red Rabbit,

    Thanks for your input.

    Since Zambia and Malawi are bordering land-locked African countries that share a similar ethnic, religious and political background, it seems they also share some of the same problems.

    As you have been on the ground in Malawi and I haven’t been to Africa, I will defer to your judgment of the traditional healers.

    I looked over the AVERT web page on Malawi (at the same site as the Zambia page I linked to earlier) and a lot of it sounds like it could have been written about Zambia.

    The general poverty of the populations, the high cost of medications and the difficulties in providing access to services and distributing resources are similar.

    At least both countries have current political leaders who accept the problem and are making an effort to use modern medicine to combat it.

    I hope they are successful.

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