AIDS action Issue 46 Page 1 2
Issue 46 October - December 1999
Working with traditional health practitioners
'Western' or 'modern' medicine can reduce levels of HIV in the body and treat HIV-related opportunistic infections, but many people with HIV have no access to even the most basic western medicines. It is estimated that in many developing countries, particularly in rural areas, four out of every five people visit traditional health practitioners and use traditional treatments.
Traditional healers already treat large numbers of people living with HIV and AIDS. It is important to look at approaches to working with traditional health practitioners that can improve HIV prevention and care services, while continuing to advocate for improved access to western medicines and treatment.
Some programmes have trained traditional health practitioners in HIV/AIDS and other sexually transmitted infections (STIs). Appropriate training encourages traditional health practitioners to replace harmful practices or myths about HIV with safer practices. It can also help them to diagnose HIV and other STIs and encourage increased collaboration with biomedical or 'western' health services. This collaboration can have a number of advantages and biomedical health practitioners also need education in the benefits of working with recognised traditional health practitioners. For example, traditional health practitioners often have an approach to healing that takes into account the whole person - their mental, emotional, spiritual and physical health. Initial research into a variety of traditional treatments also suggests that some of these treatments offer potential relief from HIV-related infections; although like western medicine, none of these treatments is a cure for HIV.
This issue of AIDS Action looks at some successful approaches to working with traditional health practitioners and using traditional health practices to improve HIV prevention and care.
Traditional health practitioners and traditional medicine have an important role to play in HIV prevention and care.
Healers as educators
Respected traditional health practitioners see many clients and they can be very powerful educators. They have influence in the community, as well as with other healers through their professional networks. They understand local belief systems and can explain illness and misfortune in ways that people understand. It is important that they have correct information about HIV/AIDS and other sexually transmitted infections (see page 3).
Care for the whole person
Many people with HIV approach traditional healers even when they have access to other health services. One reason is that traditional healers usually treat the 'whole' person, not just the disease. They take into account a person's mental, emotional and spiritual as well as physical well-being. This can include contacting the spirits for help.
Traditional health practitioners often see their patients together with other family members and can play an important role in family counselling and in reducing stigma and discrimination against people with HIV/AIDS.
'You are not complete without the spirits guiding you - whether in diagnosing an illness or in selecting the appropriate medicinal plant'.
EI-Hadj Sara Sagne, Malango Healers Association, Senegal.
Traditional medicines and health practices can help reduce symptoms (such as pain), strengthen the immune system, and treat opportunistic infections. The preparation and use of herbal medicines often varies greatly, even from village to village and from healer to healer. To ensure quality of service, some people promote institutionalised training and licensing of healers, but many healers do not see licensing as an answer. Their concerns include the differences between types of traditional healers and the fact that they often have to be literate to qualify for a license. Some groups, such as PROMETRA in Senegal (see page 8), have developed internal systems to ensure the quality of services their members provide.
Clinical research is needed to develop guidelines on the preparation, use and side effects of particular traditional medicines - and their use with biomedical treatments. A number of studies are taking place. These suggest that various traditional medicines can be effective against opportunistic infections or can be used to help strengthen the body's immune system. In Thailand, for example, studies are being carried out into the use of a paste of greater gangalal (a member of the ginger family) to treat oral thrush, acupuncture to help people with nerve damage (neuropathy), and the herb slippery elm to relieve diarrhoea. Promotion and improvement of traditional medicines and heath practices should go hand-in-hand with improving access to biomedicine and biomedical services.
Biomedicine refers to a health system that has built on evidence from clinical trials. It is also called western or modern medicine. Most national health systems are based or biomedicine.
Traditional medicine refers to a wide range of traditional medical systems such as Chinese, Ayurvedic and folk medicine. It also includes traditional practices that heal or reduce the symptoms of disease, for example, acupuncture, traditional massage, meditation and yoga.
Complementary/Alternative medicine (CAM) refers to traditional and other non-biomedical health practices that are either used together with biomedical practices or on their own, as an alternative to biomedicine.
Involving traditional healers in HIV prevention programmes can significantly improve the effectiveness of these programmes.
There is increasing recognition of the role that traditional health practitioners can play in preventing and treating STIs including HIV/AIDS. Traditional practitioners already see and treat most of the STIs in Africa and clinical research is needed into herbal medicines used for STIs.
Since the late 1980s, a number of HIV/AIDS prevention programmes in Africa have involved traditional healers. Evaluations of these programmes have shown how they improve the way traditional health practitioners diagnose, treat and counsel clients with HIV/AIDS and other STIs.
For instance, an evaluation of a South African AIDS prevention programme found that a year after training, healers were able to:
define and describe HIV accurately
describe three or more AIDS symptoms correctly (and not give incorrect symptoms)
accurately describe three or more means of HIV transmission and prevention.
Almost all healers reported providing correct HIV/AIDS preventive advice and demonstrated the correct way to use condoms. Many of the healers also provided condoms.
The following are some policy and programme recommendations to consider when planning work with traditional healers:
Be fair and democratic in selecting healers for training - use clear criteria to select participants. Find a balance, for example, between: types of healers (such as herbalists and diviner-mediums), male and female healers, and rural and urban healers.
Try to identify and train motivated healers who are respected in their home communities. They need not be literate but they should possess leadership skills and be able and willing to train other healers.
Do not make membership of a traditional healer association a requirement for participation in HIV/AIDS training. Selection through such associations may make the process easier for planners, but this often brings its own set of problems due to rivalries between or within associations.
Encourage healers to promote sexual abstinence among youth, and fidelity within marriage among adults. Such values often agree with traditional beliefs about the causes of STIs and other illnesses, and it is now recognised that reduction in the number of sexual partners is a powerful factor in reducing HIV transmission.
Edward C Green, 2807 38th St, NW, Washington, DC 20007, USA. E-mail: [email protected]
Training on HIV/AIDS
Training on HIV/AIDS Traditional and bio-medical health workers need training on HIV/AIDS and other STIs. A study in Zambia showed that only half of the bio-medical health workers and even fewer traditional healers had received any training on HIV.
Trained traditional healers can help:
provide STI/HIV information
increase awareness around HIV/AIDS issues community
promote and distribute condoms report and register deaths in the register orphans in the community
support tuberculosis (TB) therapy
provide traditional treatments give spiritual and psychological support
help people tell their HIV status to partners and family (disclosure)
provide home-based care counsel and encourage people to adopt safer sexual behaviour
improve referral to biomedical health services
identify training needs before developing a training curriculum.
Training in STIs/HIV for traditional health practitioners can include:
general facts about HIV/AIDS
information about the local HIV/AIDS situation
identification of harmful practices and safer alternatives
diagnosis of STIs and other HIV-associated illnesses such as TB
condom use and promotion
counselling, including talking about sex to people of different ages
collaboration with biomedical health practitioners and facilities, including referral where appropriate.
In Uganda, THETA (Traditional and modern health practitioners together against AIDS and other diseases), is promoting collaboration between traditional and biomedical health workers
THETA is a non-governmental organisation, which is recognised and supported by the Ministry of Health, Uganda, and the National AIDS Commission. It aims to promote collaboration between traditional healers and biomedical health workers, in the prevention and care of STIs including HIV.
The first THETA project involved collaboration in clinical trials to study the effectiveness of herbal treatments for the treatment of opportunistic infections. The healers found it difficult to talk to their clients about AIDS because it was seen as a terminal diagnosis. So a second project was started to empower traditional healers to offer counselling and education on STIs/HIV. As HIV was prevalent among women at that time, the project focused on women's information needs and cultural practices affecting women.
A training curriculum was developed in collaboration with The AIDS Support Organisation and with the participation of healers and local women. It included information on STI/HIV care and prevention, use of medicinal plants, infection control, tuberculosis and HIV, the law, ethics and traditional medicine, gender and HIV, and community development. Healers used the training differently. Some became involved in community education, others in counselling and others started HIV-support groups. Healers designed their own training materials. They used story telling, personal testimonies of HIV-positive people, and music, dance, poetry and drama to convey their messages. The community education and counselling increased understanding about HIV and resulted in some behaviour change, including an increase in condom use. THETA gained the trust of the traditional healers by respecting their knowledge, experience and beliefs, such as their right to keep their herbal medicines secret.
The THETA initiative was expanded to cover about 210 traditional healers in seven districts of Uganda. THETA also runs community workshops. These help improve patient management and community health by facilitating referral and meetings between traditional and biomedical health workers.
Teopista Nakyanzi, THETA, PO Box 21175, Kampala, Uganda.
Tel: +256 41 530619 or 532930.
E-mail: [email protected]
Rachel King, 172 Lone Tree Ave, Mill Valley, CA 94941, USA.
Tel/Fax: +1 415 381 6256.
E-mail: [email protected]
When a young man in his late thirties fell ill in a small village near Lusaka, everyone knew what was happening. The symptoms were obvious, and yet his mother, walked many miles in search of traditional medicines and healers to save her son. Traditional healers told her all sorts of stories, including the extraction of a bird beak from his stomach as a sign of witchcraft in the neighbourhood.
HIV is killing our brothers and sisters. They will continue to visit traditional healers so we need a positive approach, such as THETA's, to involve traditional healers in main-stream strategies for combating this pandemic.
Luke Kwamya, 74 Harp Island Close, Neasden, London, NW10 0DQ, UK.
E-mail: [email protected]
Adapted from AF-AIDS E-mail list
Regional task force
THETA is the Secretariat for a task force for east and southern Africa, which will coordinate activities around traditional medicine in HIV prevention and care. The task force is made up of NGOs from the region, observers from West Africa, and international organisations, including UNAIDS. It will share information, generate an inventory of activities about traditional medicine, document and distribute best practices, promote research in traditional medicine, and mobilise resources. The Global Initiative for Traditional Systems (GIFTS) of Health is developing a network of researchers and institutions to build a research programme that will identify, assess, and develop safe and effective local treatments for HIV-related illnesses, while protecting the intellectual property rights of local healers.
Gerard Bodeker, GIFTS of Health, Green College, University of Oxford, Oxford, OX2 6HG, UK. Website: http://www.users.ox.uk/~gree0179
Offering traditional medicine and biomedicine as part of a complementary care package can improve treatment options for people with HIV/AIDS.
The Tanga AIDS Working Group (TAWG), based in Tanga, Tanzania, is an alliance of traditional healers, biomedical health workers, botanists, social scientists and people living with HIV/AIDS. Its goal is to bridge the gap between traditional medicine and biomedicine in order to improve HIV care and prevention. TAWG is active in three regional towns and cares for over 400 people living with HIV/AIDS.
TAWG provides pre-test, post-test and family counselling. Its office in the regional hospital dispenses traditional medicines and biomedicines for the treatment of symptoms of opportunistic infections. People come from outside Tanga - even outside Tanzania - to obtain these medicines. TAWG makes home visits to very sick people. For people who want to remain anonymous, these same traditional medicines are also available from the local healer affiliated with TAWG.
Most of the treatments TAWG provides are plant medicines gathered and processed by one traditional healer who has worked closely with TAWG for seven years. TAWG's standard treatment is a combination of four plant medicines. These treat symptoms of opportunistic infections, including weight loss and diarrhoea, fungal infections (such as oral thrush), and skin diseases (such as Herpes Zoster). TAWG gives the medicines in powder form. Patients prepare them as teas or apply them topically to affected areas.
Researching new remedies
TAWG provides any treatment - traditional or biomedical - that improves a patient's quality of life. TAWG has worked with selected traditional healers for nine years to identify potentially useful herbal remedies. These are plant medicines that healers perceive are non-toxic and which appear to improve or reduce patients' symptoms. When possible, TAWG supplements these findings with literature reviews and laboratory tests. TAWG provides these plant medicines to people with symptoms of opportunistic infections - at the doses prescribed by the healers - and monitors the results. When patients improve without experiencing side effects, TAWG health workers continue the treatment and recommend it to others.
'All patients require their own treatment. When a patient requires a drip, for example, that's a job for modern medicine. However, AIDS-related opportunistic infections respond well to traditional medicine.'
Mohamed Kasomo, TAWG's primary traditional healer.
'Working with TAWG has been a very good experience. We refer patients to each other. We work well together and whenever a problem arises, we solve it quickly. Collaborating with modern medical practitioners is very useful since we combine special skills to treat people with HIV/AIDS. We really help each other. Our relationship ha a bright future.'
TAWG holds seminars with local traditional healers and traditional birth attendants. Topics include basic facts about HIV/AIDS, transmission, diagnosis and prevention, plus when and where to refer people to biomedical facilities.
Heather McMillen and David Scheinman, TAWG, PO Box 1374, Tanga, Tanzania.
Tel: + 255 53 42266.
E-mail: [email protected] or [email protected]
Starting to work together
TAWG encourages traditional healers and biomedical health workers to work together to improve HIV prevention and care. One way to accomplish this is to first identify healers and health workers in your area who would like to work together, and then arrange a time and place to meet. During the meeting:
Agree on an agenda based on respecting each other and sharing ideas freely.
Ask participants to identify diseases or conditions that they feel will respond well to traditional medicine and can be monitored easily (for example, skin conditions).
Ask traditional healers to identify plants that they use to treat these diseases.
Use local names and explanations of the diseases identified and ask people to bring leaf specimens of medicinal plants. If the plant is rare, use a picture or photograph.
Develop an action plan of what to do next. This should include finding out more about the plants identified. For example, do other communities or cultures use the plant, and if so, for what? Are any of the plant parts or preparations poisonous? Are there existing laboratory or clinical studies on these plants?
Marketing herbal medicines
In Thailand, HIV-positive support groups, together with hospital pharmacists, are fighting the high cost and lack of access to pharmaceuticals by producing and distributing herbal medicines.
Herbs have been an important part of Thai medicine for centuries, and people in northern Thailand use herbal preparations from a variety of traditions, including Chinese, Ayurvedic (Indian), and ethnic highlander medicines. The Ministry of Public Health has a National Institute for Thai Traditional Medicine that promotes the discovery and use of Thai herbal medicines. The Royal Institute of Thai Traditional Medicine supports work with herbal specialists to identify potentially useful herbs for people with HIV.
In Theung district, Chiang Rai province, members of the local support group for people with HIV produce their own, low-cost, herbal medicines. Thai traditional herbs grow easily and can be harvested from the wild, but many are bitter and HIV-positive people do not like using them. Pulverized herbs in capsule or tablet form are tasteless and easier to swallow, so the group applied to the AIDS Division in the Ministry of Public Health for money to purchase a pulverizing machine. People who bring in their own herbs can use the machine for free, and the group also sells herbal medicines at a low price (about US$1.25 for 70 capsules). These herbs include fah talai jon (Andrographis paniculata), which eases colds, fever, nausea, sore throat, and diarrhoea, and boraphet (Tinospora crispa), which stimulates the appetite, reduces fever, and relieves stomach ache. Since these herbs are helpful for common illnesses, using them does not identify the user as HIV positive as other HIV medications do. While none of these herbal preparations provides a cure for HIV/AIDS, they do offer relief for some of the symptoms of opportunistic infections.
Preparing the herbs
The herbs are prepared by the group members under the supervision of the pharmacy department at the district hospital. Members must clean and dry the herbs to remove fungus and other impurities that can cause illness. The herbs are clearly labelled and this label has become a sort of brand name among HIV-positive people in the province who seek quality herbal preparations.
Local people judge the effectiveness of herbal remedies by hearing testimonials from pe9ple who have witnessed an improvement in symptoms (see quote). These folk trials may not be scientifically accurate, but they prove very useful to local people wondering which therapy to try. Several HIV-positive groups such as the Clear Skies group in Doi Saket have developed skills in growing and trying out different herbal treatments, and they share their findings with a broad network of HIV-positive groups. Families are also becoming directly involved in herbal production. For instance, in Mae Sai, a group of mothers have collected money to buy a herb pulverizer.
In the northern provinces of Thailand, several AIDS NGOs - including the AIDS Counselling Center and Education Support Services (ACCESS), the Center for Ethnic Studies and Development, and the AIDS Network Development Foundation - have encouraged networking among HIV-support groups and with monks, herbalists, and public health officials.
In response to the popularity and effectiveness of herbal medicines. the Ministry of Public Health has approved plans to sell products derived from local herbs in the pharmacies of government hospitals.
Margery Lazarus, Department of Anthropology, History and Social Medicine, University of California, San Francisco, Box 0850, San Francisco, CA 94143, USA.
Tel and fax: + I 925 449 9344 . E-mail: [email protected]
Adapting traditional healing practices
Traditional healing practices can be effectively adapted for use in HIV counselling and education.
Indigenous people in Canada (also called Aboriginal people) have experienced much discrimination, violence and abuse (including self-abuse through alcohol or drug addiction). This directly contributes to low self-esteem and therefore greater risk of HIV. Two traditional healing practices are being used effectively to help Aboriginal people avoid HIV infection, and to live more healthily and positively if they are infected.
The Medicine Wheel
The Medicine Wheel is a traditional model used to explain ideas. It is based on the understanding that any circle, as a whole, is more than just what it contains. In many Aboriginal cultures, this Wheel is used to represent the complex inter-relationship among all living things and shows how life itself is an ever-turning cycle where endings become beginnings.
The Wheel is a circle divided into four quarters by North-South and East-West lines. Each quarter represents ideas which, when considered together, form an inter-dependent whole. For instance, starting at the right, each quarter in turn stands for: the four directions (East, South, West, North), the four seasons (Spring, Summer, Autumn, Winter), the four races (yellow, red, black, white), the four stages of life (child, youth, adult, elder), and the inner parts of a person (physical, emotional, mental, spiritual).
Leonard Johnston, of the Cree Nation in Canada, adapted the Medicine Wheel to educate Aboriginal communities about HIV and the various stages of infection as they progress in a person (see illustration).
Many Aboriginal AIDS Organizations are now using this 'AIDS Teaching Wheel' model. Counsellors and others use it to help people under-stand how their immune system is physically affected by their emotions and worries, and so how getting counselling can improve their physical health. Educators use it to deliver prevention information in a culturally-relevant way.
People seated in a circle have no leader; all have equal power. Traditional Sharing Circles give participants a sense of support and a means for expression without stigma or judgment. All can share how they feel without having to respond to other participants' problems. Some Circles are only for people with HIV, while others are for family or caregivers. Sometimes these are combined to provide a larger sense of 'community'.
Rules include talking as long as one wants, if one wants, but only in turn. People cannot interrupt; they only speak about themselves rather than addressing others' concerns. Whatever is heard inside the Circle is kept confidential.
Circles provide an environment where people feel safe to talk about HIV and to share their feelings and fears without having to worry about other people's reactions. Participants often discover other people with similar feelings and situations. They can find healing and empowerment in realizing they are not alone and in having their personal experiences witnessed and valued.
As a result, many people who attend HIV Circles begin to take better care of themselves (and others). Gaining confidence in communicating their needs and feelings leads to improved self-esteem, which in turn usually leads to safer behaviour practices and better self-care.
Judy Weiser, Counsellor/Director, PhotoTherapy Centre, Suite 205-1300 Richards Street, Vancouver, B.C., V6B 3G6, Canada.
Tel/Fax: + 1 604 689 9709.
E-mail: [email protected]
For further information on Aboriginal AIDS organisations in Canada contact: Canadian Aboriginal Network, 409-396 Cooper Street, Ottawa, Ontario, K2P 2H7.
Fax + 1 613 5674652.
E-mail: [email protected]
AIDS action Issue 46 7 Page 8
News / Letter / Resources
Update on mother-to-child HIV transmission
Early findings from a joint Uganda-United States study known as HIVNET 012 suggest that the antiretroviral drug nevi rapine may be a practical drug treatment for preventing mother-to-child HIV transmission. Early results from the study suggest that if one oral dose of nevaripine is given to an HIV-infected mother in labour and another to her baby within three days of birth, the rate of mother to child HIV transmission is cut by half.
Treating peripheral neuropathy
I read AIDS Action 41 on caring for people who are very sick and wanted to share my experience of treating peripheral neuropathy. This is numbness or loss of feeling in the arms, legs, hands and feet. It can be due to HIV infection, but in Uganda, it is usually a side-effect of drugs, particularly drugs for the treatment of tuberculosis.
Treatment depends on the symptoms and cause. Pain can range from a numbness or pins and needles, to a burning sensation or feeling like an 'electric shock'. I've found that the burning sensation and pins and needles tend to respond well to a low dose of an antidepressant, like amitryptilline, whilst 'burning' pain responds to an anticonvulsant such as carbamazepine. However the dosages used to treat peripheral neuropathy are very different from the usual dosages for these drugs. Most people will respond well. but occasionally drugs need to be combined. Emotional support and complementary therapies like massage and aromatherapy are also useful. If a drug you are using seems to be causing the peripheral neuropathy then ask your doctor to give an alternative.
Catherine Sozi, AIDS Treatment Centre, PO Box 24985, Kampala, Uganda. Fax: (+ 256) 41 200861.
E-mail: [email protected]
Collaboration with traditional healers in AIDS prevention and care in sub-Saharan Africa: A literature review. Available free from the UNAIDS Information Centre, 20 Avenue Appia, 1211 Geneva 27, Switzerland.
Tel: + 41 22 791 4651
Fax: 41 227914165.
E-mail: [email protected]
AIDS Organisations Worldwide 1999/2000 is a directory with contact details and service profiles for over 850 key AIDS agencies in over III countries.
Available free from nam publications, 16a Clapham Common Southside, London, SW4 7AB, UK.
E-mail: [email protected]
The database is also available online in English, French, German, Italian, Spanish and Portuguese.
WHO's Model List of Essential Drugs, 11th edition (December 1999), including explanatory notes is now available on the WHO website at: http://www.who.int/medicines/edl.html
The Association for the Promotion of Traditional Medicine (PROMETRA)
PROMETRA is a Senegalese non-governmental organisation, that promotes research and collaboration on traditional medicine and HIV/AIDS. In 1999, it organised an international conference on the subject, which resulted in an international network of traditional medicine organisations.
PROMETRA's policy and advocacy work comes out of a history of practical experience. In 1985, PROMETRA set up Malango, an association of around 450 traditional healers (22 per cent of whom are women) based in the Fatick region of Senegal. In 1989, it started the Experimental Centre for Traditional Medicine (CEMETRA). The Centre has central offices as well as one care unit in the county town of each rural community in the region. When researchers from USA and UK studied some of the Malango healers' treatments for symptoms of opportunistic infections (including thrush, skin disorders, diarrhoea and wasting), they found that the treatments were successful for nearly two-thirds of the patients.
PROMETRA has also developed a participatory, train-the-trainer curriculum for traditional healers; it is responsible for managing an international e-mail list on traditional medicine, and it produces a quarterly newsletter on research in traditional medicine called Medicine Verte (available in French and English).
For more information contact: Erick V. A. Gbodossou, President, PROMETRA, BP 6134 Dakar Etoile, Senegal.
Tel: +221 832 2850. Fax: +221 832 5749.
E-mail: erickg@ codata.refer.sn Website: http://www.prometra.org
Editor Christine Kalume
Design and production Ingrid Emsden
Special advisor for this issue Gerard Bodeker
Editorial advisory group Calle Almedal, Dr Sandra Anderson, Kathy Attawell, Dr Rachel Baggaley, Dr Nina Castilio-Caradang, Nancy Fee, Susie Foster, Peter Gordon, Dr Sam Kalibala, Dr Elly Katabira, Dr Ute Küpper, Philippa Lawson, Dr Simon Mphuka, Dr Arletty Pinel, Dr Eric van Praag
Aids Action Publishing partners HAIN (the Philippines) KANKO (Kenya) SANASO Secretariat (Zimbabwe) ENDA (Senegal) ABIA (Brazil) Colectivo Sol (Mexico) Consultants based at University Eduardo Mondlane (Mozambique)
AHRTAG's AIDS programme is supported by CAFOD, Christian Aid, DfkF/JFS, HIVOS, ICCO, Irish Aid, Misereor, Norwegian Red Cross, SIDA.
The International Newsletter on AIDS Prevention and Care
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