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African Journal of Traditional, Complimentary and Alternative Medicines, Vol. 5, No. 4, 2008, pg. 419-420 Research PaperTraditional healers and nurses: a qualitative study on their role on sexually transmitted infections including HIV and AIDS in Kwazulu-Natal, South Africa Nolwandle Mngqundanisoa and Karl Peltzerb aHuman Sciences Research Council, Pretoria, South Africa, aIn memory of an altruistic scientist, bSocial Aspects of HIV/AIDS and Health, Human Sciences Research Council, Pretoria, South Africa & Department of Psychology, University of the Free State, Bloemfontein, South Africa. Email: kpeltzer@hsrc.ac.za Code Number: tc08052 Abstract The aim of this study was to investigate the role of traditional healers in sexually transmitted infections including HIV/AIDS and collaboration between the traditional and biomedical health care systems as seen by nurses and traditional healers. A convenient sample of 15 professional nurses and 15 traditional healers were interviewed using a semi-structured questionnaire. Qualitative analyses identified the following themes: (1) attitude and respect, (2) collaboration between traditional healers and nurses, (3) control/regulation of (traditional) health practices, (4) training needs of healers and nurses. The main results indicated that the professional nurses had mixed attitudes towards traditional healers, mostly negative (e.g. lacked training, used expired medicines, gave improper dosages, and kept poor or no records), but, also positive, such as contributing to the management of opportunistic infections (STIs). The traditional healers also had mixed attitudes towards nurses. The traditional healers believed that nurses undermined their work (did not accept their efficacy in treatment and consequently did not refer patients). Notably, most of the traditional healers were willing to learn and refer patients to clinics and hospitals, while this was not true for the nurses. Key words: Attitudes, traditional healers, nurses, collaboration, sexually transmitted infections, HIV/AIDS, KwaZulu-Natal, South Africa Introduction Traditional healers who practice in South African can broadly be grouped into three types: the traditional doctor or inyanga who is typically male and uses herbal and other medicinal preparations for treating disease (or herbalist); the isangoma (Zulu) or diviner, usually a woman who operates within a traditional religious supernatural context and acts as a medium with the ancestral shades; and the faith healer who integrates Christian ritual and traditional practices (Freeman and Motsei, 1992). Many South African patients consult traditional healers as a first effort to remedy ailments (Louw and Pretorius, 1995). For example, Peltzer (2000) found that among 104 black Africans sampled from the general public in Limpopo Province, South Africa, 68% sought medical treatment for their last illness, followed by the herbalist (19%) for minor and chronic conditions, the diviner (9%), and faith healer (4%). Traditional healers seem to be consulted often for the treatment of sexually transmitted infections (STIs) such as Tshofela/drop (gonorrhea), Thosola (syphilis), and assumed HIV/AIDS (Peltzer, 1998, 2001). In a community survey, Peltzer (2003) found among rural adult South Africans that, of those who reported to have had a STI in the past 12 months, 36% had consulted traditional healers for treatment. Wilkinson and Wilkinson (1998) found that, among 360 patients presenting with STIs in a primary care clinic in KwaZulu-Natal, 14% had sought care for their previous illness from a traditional healer. Persons may consult traditional healers for the treatment of STIs because they provide client-centered and personalized health care that is tailored to meet the needs and expectations of their patients, paying special respect to social and spiritual matters (King and Homsy, 1997). The South African HIV prevalence amongst adults (15–49 years) is estimated to be 16% nationally and 21% in KwaZulu-Natal province (Shisana et al., 2005). In areas of high HIV prevalence traditional healers often play a role in STI and HIV prevention, care and treatment. According to the (South African) Department of Health (2004) the continuum of care developed for the HIV and AIDS care and treatment program should involve traditional health practitioners as an essential and irreplaceable component of the comprehensive care provided. Moreover, traditional health practitioners can enhance the implementation of the antiretroviral therapy component of this plan by mobilizing communities, drawing patients into testing programs, promoting adherence to drug regimens, monitoring side effects, sharing their expertise in patient communications with biomedical practitioners, and vice versa, and continuing their acknowledged mission in improving patient well-being and quality of life. Traditional health practitioners tend to adopt a more holistic approach to health promotion and disease management, an approach that is more appropriate to the problem of immune deficiency wherein virologic assaults upon the immune system are compounded by immune exhaustion from concomitant infections, psychological stress such as that due to social isolation, under-nutrition, alcohol abuse, and behaviours that compromise immune recovery such as repeat exposure to HIV and sexually transmitted infections. A holistic approach to living with HIV and AIDS is known to be a key factor for success in living a longer, healthy life with the syndrome (ibid.). Due to the role of traditional healers in the care and treatment of STIs, including HIV/AIDS, it has become apparent that healers should be involved in referral and treatment, as well as in the promotion of behaviour change (Green, 2000; Munk, 1998; Peltzer, 2000, 2003; Wilkinson and Wilkinson, 1998). King and Homsy (1997) found that experiences across African countries show that modern and traditional care systems are not incompatible. Collaborations among traditional and modern providers can create complementary systems that are of greater benefit to patients and communities. Collaborative HIV/AIDS programmes involving traditional healers have been initiated in a number of sub-Saharan African countries indicating that the different paradigms of health beliefs and practices do not preclude collaboration. At the base of cooperation is that each system recognizes and respects the other (Stuargard, 1985). If the medical profession accepts traditional healers as part of the same team, much more can be achieved in the fight against HIV (Lachman, 2000).Traditional medicine is often mistrusted because it is considered not to be science based. ’Other people’s quackery appears worse than one’s own,’ argues Leslie (1980). It is usually considered redundant or may be even culture imperialistic to provide healers with counselling skills because one anticipates that there is already a valid discourse inherent in the traditional healing system (Munk, 1998). The argument against traditional healers’ practice is that it is not empirically based, however, is not valid. For example, not all Western medical interventions in the United Kingdom hospitals for example, are supported by scientific evidence (Ellis et al., 1995). Nurse practitioners in rural Limpopo Province, South Africa, were asked about their attitudes towards traditional healing (Peltzer and Khoza, 2002). They expressed a low regard for traditional healing. Nurses practiced low rates of referrals to traditional healers (14%) but 55% said they got referrals from traditional healers, and if it was done, it was done so mainly in the patient’s interest and not as a last resort for chronic or terminal illness. The five most common problems they would refer to the traditional healer were HIV/AIDS, cancer, bereavement, psychosocial problems and depression. Most did not discuss with a patient, benefits of traditional healing but 71% discussed the possible harmful effects. Among urban traditional healers, Peltzer (2001) found that they hardly referred or got referred any patients in the last 4 weeks. The most commonly referred conditions to biomedical health care were: AIDS, diabetes, asthma, tuberculosis, mental illness, sexually transmitted disease, epilepsy, stroke, bone fracture, high blood pressure and others (Peltzer, 2001). On the other hand, traditional healers would like to have referrals from the biomedical sector for the following conditions: (1) bewitched, (2) Lekone (red spots on back of neck), (3) Sefolane (feet problems associated with stepping on “placed” medicines), (4) epilepsy, (5) painful legs, and (6) infertility. Generally, traditional healers refer patients with infectious, chronic and neurological disorders to the biomedical sector and made suggestions to receive referrals for the psychosocial and spiritual management of patients. Urban healers (about 90%) seem to refer patients to the modern health sector more often than rural healers (about 20%) in Limpopo Province (Peltzer, 1998). Among the rural healers, referrals were made mainly for physical disorders such as TB, plastering and operations. When asked to express their views on collaboration with the modern health sector, the answers pivoted around the following: provision of material resources (bonds, building of facilities, provision of telephones, tablets, etc.) (86%), and referring patients to them (61%) (Peltzer, 1998). Hopa et al., (1998) found that traditional healers felt that they should be allowed to issue sick-leave certificates, while medical doctors were against that and were overall mostly negative towards traditional healers. Referrals are mostly expected from traditional healers to the biomedical health practitioners (Green, 2000; Upvall, 1992) but also HIV/AIDS patients are referred to the traditional healers (Homsy et al., 2004). The aim of this study was to investigate the role of traditional healers in sexually transmitted infections including HIV and AIDS and collaboration between the traditional and biomedical health care systems as seen by nurses and traditional healers. Method Sample and procedure This study was conducted between February 2004 and October 2005 in KwaZulu-Natal, South Africa. A convenient sample of 15 professional nurses and 15 traditional healers were interviewed using a semi-structured questionnaire (including biographics, attitudes and collaboration on sexually transmitted infections including HIV/AIDS between traditional healers and nurses). The participants were between the ages of 22 and 84 years, mean age being 45 years (SD=12.8 years). The nurses were all registered professionals from selected primary health care clinics in KwaZulu-Natal. The traditional healers were both those registered with the healer’s council and those who were not registered. They were accessed through the healer’s council. All participants were Zulu or English speaking Africans and were interviewed in Zulu or English by the first author (NM) after informed consent was taken. The interviews lasted about 45 minutes, were audiotaped and detailed notes were also taken. Audiotapes were then transcribed and those in Zulu were then translated into English. The study protocol was approved by the Human Sciences Research Council ethics committee. Data analysis The transcripts and notes from the interviews were translated from Zulu to English, and then analysed using content analysis by means of a set approach according to guidelines given by Krueger (1988) and by Stewart and Shamdasani (1990). At the first step of the analysis, the transcripts and notes were reordered to the topics addressed by the discussion. At the second step of the analysis, issues that were brought forward repeatedly or were discussed at length by the participants, and relevant parts from each interview and notes were ordered by these issues, using a ‘cut and paste’ method. The third step was to make a summary of the results for each interview, based on the issues that were addressed in the discussions. The summaries were reviewed by an external expert to test whether the summaries were good representations of the interviews and the summaries were then revised based on her comments. Finally, an overall summary of the discussions was made. Results Qualitative analyses identified the following themes: (1) attitude and respect, (2) collaboration between traditional healers and nurses, (3) control/regulation of (traditional) health practices, (4) training needs of healers and nurses. Attitude and Respect Most traditional
healers felt undermined by the nursing staff. Some nurses undermined the traditional
healers and this made it difficult for the patients to even tell them that they
have been to a traditional healer The following quotes reflect above attitudes: “These traditional healers can’t even tell you what they gave the patient. It’s worse when they say some herbs are more useful when they are rotten.” (Nurse) “Many nurses undermine us, sometimes they even scold patients once they tell them they have been to a traditional healer. I think it will take time before they respect us. Many people still need our help.” (Traditional healer) A well known 84 year old herbalist in KwaZulu-Natal said “I know that many of the izangomas? don’t like me because I said they cannot register with the association as izangoma but only as herbalists. I said this because I know they know herbs but they failed to prove ubungoma to me. They claim they can foretell, so I gave them a test and I told them if they pass it they could register as izangoma. My test was easy. I had R10, R20, R50 and R100 notes in my hand. I asked them to tell me how many of the individual notes I had and they all failed to tell me. I believe they can mess up the nation if they lie by telling people who bewitched who.” One nurse said: “I wish these traditional healers can tell us their secret of talking to their patients. They can be very influential. They must take action and give good advice to their clients.” A female traditional healer said: “Our people like and trust us because we understand them. We speak the same language and most of all we are easily accessible. In a hospital or clinic they wait for long hours before they can be attended to, whereas with us they get attention sooner.” One respected traditional healer in his early fifties said: “I don’t like the fact that some health care workers say our people come to us first then to the hospital. In other words they are saying that we are failures. I say our people go to the clinics or hospitals first, then after not getting any help they come to us. Usually we refer our people to hospital if we see that it’s something we can’t handle.” Collaboration between nurses and traditional healers Some traditional healers note that they have been to clinics and showed interest of learning more about Western ways of treating the patients. Most nurses felt that collaboration with the traditional healers will help in many ways as the healers are closer to the people. The nurses emphasized that the traditional healer must refer clients to the clinic even if they have already given them something especially in cases of tuberculosis or cholera. They feel that without working hand in hand with the traditional healer nothing positive will be accomplished. They went on to say that now it’s even better that traditional healers use referral letters to send clients to the clinic. The nurses pointed out the fact that it is still difficult for them to refer clients to the traditional healers as they are not officially authorized to do so yet. They acknowledged that they refer clients to traditional healers with the conditions known to be commonly cured by them. When doing this they don’t write anything on paper so as not to implicate themselves. Some nurses also pointed out that if all the traditional healers can keep records of their patients, know which medicine they gave the client. This can help when the client goes to the clinic with complications as the nurses and doctors would know what the client had taken. When recording, the traditional healer will know if the client keeps coming back with the same problem without getting better so that he/she can change the medicine or quickly refer the client to the clinic. A traditional healer in his late fourties said: “We traditional healers do refer patients to clinics or hospitals, but the nurses never refer patients to us. Those patients whom they can’t help should be referred to us as we have a gift of curing even what has been declared incurable with Western medicine. We are prepared to work hand in hand with them.” However, one nurse in her early fourties had this to say: “Some traditional healers do not want to refer patients to clinics and or hospitals because they think they’ll lose their profit.” Another nurse who felt collaboration with TH was impossible and needless said: “How can we collaborate with these clumsy people?” A few nurses felt that nothing could be a barrier to collaboration if there is respect and cooperation between the two health providers. One nurse said that: “The barriers were there because doctors did not want this collaboration”. Other nurses say that when some HIV positive clients come to them, they tell them that they are already using some medication from the traditional healer. In this case the nurses say they do not discourage them from using these but they further advise them on how to take care of themselves. One nurse made an example of a traditional healer in her village that specializes in abnormal rash. She said: “One child came to the clinic and had been tried with different types of medication without success. The nurse then referred this child to the traditional healer and the healer managed to cure the rash of that child.” Nowadays the problem with some doctors is that they quickly give up on certain clients once they know they are HIV positive. It is for this reason that nurses are taking it upon themselves to refer to traditional healers who will never turn the clients away. The nurses advised that the traditional healers must come together as health providers so that they can voice out their opinions. The nurses emphasized the importance of being patient with each other and that the healers must be prepared to listen to the nurses’ advice. One nurse acknowledged the traditional healers by saying: “We know that some of their muthi (medicine) works. In my years of nursing I have seen a patient being saved by traditional healers after the Western medication has failed. The one example is that of a diabetic patient who came with her glucose levels very low. The doctor was surprised and asked the patient what she took and the patient told the doctor about the traditional healer’s medication. She was given a bottle with medication to take for the whole month. The bottle was taken to the laboratory for analysis but they could not find the ingredients of that medication in the bottle even though it was helping. More patients were referred to that traditional healer and were helped. Even with HIV/AIDS and some other STIs we know that traditional healers can be of great help”. Control/regulation of (Traditional) Health Practices Nurses noted that they have the Nursing Council as their professional body. No nurse is allowed to practice without registering with the council. On the other hand there is also a Traditional Health Practitioner’s Council which should regulate the practice of traditional health practitioners. At the moment there are no strict rules for those who practice without registering but the government will be looking into this now that the Traditional Health Practitioners Bill has been passed. It is said that most of the accusation to traditional healers are because of malpractice by the unregistered traditional healers. The practice of traditional healers needs quality control and enforcement of good practice. The main fear expressed by the nurses is that of malpractice, hygiene, infection control and lack of record keeping by traditional healers. The other concern is the dosage given by the traditional healers. It seems as if they overdose their patients most of the time. The fact that their medication is sometimes not well prepared and not sterile is also of great concern by nurses. Some nurses are concerned about the healers who tell their clients to stop any other medication and only use theirs. “How can one handle people’s lives if he/she doesn’t have binding rules and regulations? This is why some of the traditional healers do anything for money because they cannot be held accountable for any of their wrong doings.” (Nurse) A nursing sister who has worked in nursery for a number of years said: “Most of the babies brought to hospital have gastro-enteritis from the herbal medicine that had been administered to them. The medication given to pregnant women by traditional healers to speed up the process of delivery can be detrimental to the unborn baby. One example is that of an HIV positive patient who attended the antiretroviral clinic. This woman was already weak with a CD4 absolute count of 127. She understood very well how she had to take care of herself as they are counselled. The boyfriend decided to take the woman to a traditional healer, after taking the traditional healer’s medicine the woman became weaker, mentally disturbed, renal problems and died. The clinic staff was not sure what medication the traditional healer gave to her. If the traditional healer had recorded down everything, this could have helped.” Another nursing sister in one of the rural clinics in KwaZulu-Natal said: “Their herbs are not modified which makes me worry about the hygiene part of it. The traditional healers do not investigate the cause of the disease. The medication of the traditional healers has no expiry date, so people can use it even if it’s no longer safe to use. It is also worrying that some traditional healers believe that when the herbs are rotten, it is only then that they are useful. This can cause further infections to the patients. The traditional healers must know how far they can go with their treatment; they should not force matters when they are not sure.” Training needs of healers and nurses Nurses indicated that the lack of knowledge and understanding of the diseases concerned (i.e. HIV/AIDS, sexually transmitted infections (STIs), tuberculosis (TB)) by the traditional healers is a problem. For this reason, traditional healers need to be trained on HIV/AIDS/STIs/TB and safety precautions when handling patients. Many healers noted that they want to be partners with the department of health. They are also very grateful to be trained on HIV/AIDS/STIs/TB. They admit that they have lost many of their patients by not referring them to the hospital because they didn’t know the symptoms they had. This will be rectified by the HIV/AIDS/STIs/TB trainings in place. It is also important that the professional health workers be trained about the ways traditional healers work. The following are some sexually transmitted diseases that are known to the traditional healers. This can be a problem if the nurses don’t understand them. Ukubhajwa: whereby the infected person cannot walk properly because of the sores in his/her genital part. This usually refers to syphilis and gonorrhoea. Ilumbo: Any man-made disease is referred to ilumbo. There can be many different kinds of this. In some cases the man will prepare ilumbo for his wife, in this case when the wife has sex with someone else other than the husband so that other male sexual partner gets the disease. Isisende: This is one example of ilumbo, when a man has had sex with a woman whose husband has done something on her. The man’s testes get swollen and very painful. The woman doesn’t get the infection even though she transmits it to the other man. Iqondo: This is the same as ilumbo but has a specific way of doing it. This whereby the man uses herbs with the worms of a puffader to infect his wife so that she transmits the disease to her lover and not her husband. Isipatsholo: Gonorrhoea Ugcusula: This refers to any venereal disease, sometimes refers specifically to syphilis Isichitho: This is also a sexually transmitted disease whereby a woman or a man has difficulty in having sex with someone else. Izintwala zengulube: Pubic lice. These may be sexually transmitted or may not be sexually transmitted. Discussion This study investigated the perceptions of nurses and traditional healers on the role and collaboration between nurses and healers in sexually transmitted diseases including HIV/AIDS. It was really important to look at the perceptions of the traditional healers and health care workers so as to know what information they need. In addressing traditional healers one should bear in mind that they are of different origin and practice. The main results indicated that the professional nurses had mixed attitudes towards traditional healers, mostly negative (e.g. lacked training, used expired medicines, gave improper dosages, and kept poor or no records), but also positive such as contributing to the management of opportunistic infections (STIs). The traditional healers also had mixed attitudes towards nurses. The traditional healers believed that nurses undermined their work (did not accept their efficacy in treatment and consequently did not refer patients). Notably, most of the traditional healers were willing to learn and refer patients to clinics and hospitals, while this was not true for the nurses. Kaboru et al. (2006) interviewed community members in Zambia on their views on prerequisites for collaboration between modern and traditional health sectors in relation to STI/HIV/AIDS care in Zambia, and also found as important improvements in healers’ qualification, organisation and good practice, education for both groups of health care providers. This study further found a variety of terms used by consumers and traditional healers to identify sexually transmitted diseases. The information can be used as a point of departure in their health education. It is recommended that guidelines for designing a module for teaching health professionals about indigenous sexually transmitted diseases be formulated (Mulaudzi and Makhubela-Nkondo, 2006). It is interesting to note the different opinions between the two parties. With the nurses, one could see that even though some do believe that the traditional healers play an important role, they didn’t want to say that openly. One could sense this from some of their comments. As an example, one nurse was complaining about traditional healer’s ways of practising but the same nurse narrated how one healer helped her brother who was mentally disturbed. On the other hand, the traditional healers are more willing to work with nurses. The lack of trust between the traditional healers and nurses can hinder progress in patient care. It is important that the two parties understand each other so as to be able to trust each other. If there is a proper collaboration between these two parties, the patient referral system can be strengthened. Looking at the results, it is clear that there is more to be done between the traditional healers and the nurses to enhance collaboration and improve understanding of each other’s approach to patient management (Morris, 2001). Government has acknowledged traditional healers as important partners in the mitigation of the HIV/AIDS epidemic. However, lack of policies for the effective implementation of such plans delay collaboration, thus creating a sense of despondency among traditional healers. Unequivocally delineated policies at a national, provincial and local levels are necessary to guide and facilitate collaboration between traditional and biomedical health practitioners. In addition, joint workshops should be conducted for traditional healers and nurses (and other biomedical health workers) towards demystifying traditional healing methods. The nature of the workshops should be such that practitioners of both health systems are allowed to interact and clarify misconceptions and myths related to each profession, and traditional healers should be educated about basic principles of biomedicine. References
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