Efforts to improve the care and treatment of South Africans with HIV/AIDS are often hampered by misunderstandings and poor relations between Western healthcare workers, and the community-based African traditional healers (or sangomas) that many people first turn to when they have a medical complaint. However, a new project launched in the Nelson R. Mandela School of Medicine/University of KwaZulu-Natal (UKZN) in Durban is trying to build bridges and improve collaboration with traditional healers caring for people with HIV/AIDS.
African health care Systems
It has been estimated that 80% of South Africans see traditional healers or `sangomas` on a regular basis and that there are around 200,000 sangomas in the country, but efforts to test and treat people with antiretroviral therapy often leave the community sangoma `out of the loop.` This can have disastrous consequences, leading patients to disregard their doctor’s advice, or take `muthi` (herbal remedies) that sometime have dangerous interactions with pharmaceuticals they are taking. However, working closely with traditional healers could reduce workload, improve patient care, and give the treatment programme key stategic allies and counsellors who live within the patient’s own community.
Speaking at a satellite conference prior the 2nd South African AIDS Conference, Dr. James Hartzell, an adjunct lecturer at the school of medicine said: “The medical school has long had a strategy to develop a focus on complementary systems of medicine including African Health Care Systems (AHCS), Indian Systems of Medicine (such as Ayurvedic), Chinese Systems of Medicine (Traditional Chinese Medicine, Japanese, etc.), and other traditional, complementary and alternative systems.” The Department of Family Medicine has lectures on complementary systems of medicine for undergraduate and graduate medical students, and has a number of research initiatives under development.
One of the first to be approved by the faculty is the African Health Care Systems (AHCS) Research Network. In October 2003, a MOU was signed between the school and the KZN Traditional Healers' Council (including the Ethekwini (Durban) Traditional Healers' Council), Mwelela Kweliphesheya, and the Umgogodla Wesizwe Trust. An HIV/AIDS task team was established from KwaZulu Natal’s eleven health districts; and the US State Department funded two workshops to discuss future directions for collaboration.
These discussions generated the first major AHCS proposal: The Saving Lives: Biomedical and Traditional Healing Collaboration on HIV/AIDS, which received funding last year from the US Presidents Emergency Plan For AIDS Research (see link).
The Project is in the process of training 350 traditional healers (in five one-week long trainings) on HIV/AIDS awareness, voluntary counselling and testing, home-based care and antiretroviral therapy awareness.
“This is a select group, we don’t just take anybody from off the street. Each participant has to be registered with one of the councils,” said Dr Hartzell.
Project components
Guidelines development: The project is also working to develop joint HIV/AIDS clinical guidelines using Family Medicine guidelines (which Dr. Hartzell says has lots of similarities with the traditional healer approach), the Ethekwini health guidelines, KwaZulu Natal’s Department of Health guidelines as well as traditional healer guidelines that ACHS has been helping to formalize (based upon informal, unwritten guidelines that already exist).
Two-way referral system development: To an extent an informal system of referral already exists between sangomas and health care facilities. But, said Dr. Hartzell, “Traditional healers complain that it is largely in one-direction (from the sangomas to the clinics).”
Frequently, patients move back and forth from the sangoma to the clinic, especially when they want to hear an `alternative` diagnosis after testing positive for HIV, but the traditional healers don`t know what is happening at the clinic. “Traditional healers already send referral letters to clinics and are just asking for at least basic information back from the biomedical team (which is often hostile to them) such as what were patients given in terms of treatment”, said Dr. Hartzell.
Forming better two-way communication could be vital to a patient’s health. Dr. Hartzell suggests that “traditional healers can make big impact on patient compliance and OI management with good collaboration from the biomedical team."
However, confidentiality issues must be clarified before doctors will feel free to share patient information with the traditional healers. and the project is working with the Department of Health on these issues.
Medical kit supply: Most traditional healers work in resource-constrained settings, seeing an average of five HIV-positive patients a day, and yet most of them don’t even have rubber gloves. The project is working to supply them with a modified version of KZN DOH Home-based Care Kit.
Introduction of record keeping systems: “This underlines the success of the entire project”, said Dr. Hartzell, “but is a brand new concept to most traditional healers.” Even so, it has already been agreed to and advocated by the traditional healer councils.
However, this is one of the project’s greatest challenges because of the issue of illiteracy, which means systems have to use pictograms and check boxes. Dr Hartzell said they may experiment with tape recordings as well.
If succesful, these systems, according to Dr Hartzell, should deeply and broadly improve our understanding of traditional healer practices, and should dramatically improve the chances of success for the long-term collaboration between practitioners of the two systems.
Voluntary Counselling and Testing (VCT) strategy development: Traditional healers are expert counsellors, and are already involved in pre- and post-test counselling, but they are not currently allowed to legally test in South Africa. Many other African countries, though, allow healers to perform the test. Giving sangomas this right could greatly increase access and acceptance of HIV testing in the communities.
Development of more effective prevention messages and behavioural counselling: According to Dr Hartzell, “Patients listen well to what healers tell them. Healers affirm that they can work together with us to develop more effective behavior change strategies, and healers are available 24 hours a day like real old style family and community doctors."
Healers care for patients while they are on the waiting list for ART: Dr Hartzell noted that healers can advise patients on good nutrition and positive living, and encourage behavioural changes. There are many good herbal remedies for strengthening the immune system, increasing appetite, treating oral thrush, skin rashes, sexually-transmitted infections and diarrhoea. According to Dr. Hartzell: “Traditional healers are already doing a lot of these things, providing a lot of these services within the community. We’re just helping them formalise it.”