Traditional medicine plays an impor

COMPLEMENTARY AND ALTERNATIVE MEDICINE

AFRICAN TRADITIONAL HEALERS: Cultural and religious beliefs intertwined in a holistic way Ilse Truter Drug Utilization Research Unit (DURU), Department of Pharmacy, Nelson Mandela Metropolitan University

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African traditional healing is .... intertwined with cultural and religious beliefs, and is holistic in nature. It does not focus only on the physical condition, but also on the psychological, spiritual and social aspects of individuals, families and communities.

raditional medicine plays an impor tant role in primary health care in many developing countries.1 There were approximately 200 000 traditional healers practising in South Africa in 1995, compared to 25 000 modern doctors.1,2 In SubSaharan Africa, the ratio of traditional healers to the general population is approximately 1:500, while doctors trained in “Western” medicine have a 1:40 000 ratio to the rest of the population.3 It is estimated that 70% to 80% of the population in Africa makes use of traditional medicine.1,4,5 Also in South Africa, it is estimated that between 60% and 80% of people consult a traditional healer before going to a primary health care practitioner,1,6,7 and it is estimated that traditional birth attendants deliver approximately 60% of all babies born.1,8

DEFINITION OF TRADITIONAL MEDICINE Traditional medicine is defined in the Traditional Health Practitioners Act9 as: “… an object or substance used in traditional health practice for – (a) the diagnosis, treatment or prevention of a physical or mental illness; or (b) any curative or therapeutic purpose,

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including the maintenance or restoration of physical or mental health or well-being in human beings, but does not include a dependence-producing or dangerous substance or drug”.

Traditional health practice9 means “the performance of a function, activity, process or service based on a traditional philosophy that includes the utilisation of traditional medicine or traditional practice and which has as its object – (a) the maintenance or restoration of physical or mental health or function; or (b) the diagnosis, treatment or prevention of a physical or mental illness; or (c) the rehabilitation of a person to enable that person to resume normal functioning within the family or community; or (d) the physical or mental preparation of an individual for puberty, adulthood, pregnancy, childbirth and death”, but it excludes the professional activities of a person practising any of the professions contemplated in the Pharmacy Act, the Health Professions Act, the Nursing Act, the Allied Health Professions Act, or the Dental Technicians Act, and any other activity not based on traditional philosophy.

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COMPLEMENTARY AND ALTERNATIVE MEDICINE African traditional medicine is defined by the WHO Centre for Health Development as5,10: “The sum total of all knowledge and practices, whether explicable or not, used in diagnosis, prevention and elimination of physical, mental, or societal imbalance, and relying exclusively on practical experience and observation handed down from generation to generation, whether verbally or in writing”. African traditional healing is therefore intertwined with cultural and religious beliefs, and is holistic in nature. It does not focus only on the physical condition, but also on the psychological, spiritual and social aspects of individuals, families and communities. Western medicine (or biomedicine) is often contrasted with the approach taken by traditional medicine practitioners. The former is usually associated with diseases of the physical body only, and is based on the principles of science, technology, knowledge and clinical analysis developed in Northern America and Western Europe.5 Yet, modern allopathic medicine has its roots in ancient traditions of healing, and some aspects of those traditions are still relevant and complementary to modern medical practice. Biomedical literature refers to the use of traditional medicines as phytotherapy.5 Traditional medicine and traditional healers form part of a broader field of study classified by medical anthropologists as ethnomedicine.5 In South Africa, most people associate traditional medicine with the herbs, remedies (or muti) and advice imparted by sangomas or inyangas, and with strong spiritual components.

TRADITIONAL HEALERS’ APPROACH TO HEALING The theory underlying traditional medicine in many Black ethnic groups of South Africa is essentially similar1, namely that disease is viewed as a supernatural phenomenon governed by a hierarchy of vital powers beginning with the most powerful deity followed by lesser spiritual entities, ancestral spirits, living persons, animals, plants and other objects. Traditional medicine has at its base a deep belief in the interactions between the spiritual and physical well-being. Traditional healers therefore use a holistic approach in dealing with health and ill-

ness. This implies that the healer deals with the complete person, and provides treatment for physical, psychological, spiritual and social symptoms. Healers do not separate the natural from the spiritual, or the physical from the supernatural. The traditional healing process follows different stages1,8: • Identification of the cause or discovery of violation of established order through supernatural divination. • Removal of the hostile source by neutralisation of the sorcerer or seeking of the ancestors’ forgiveness with sacrifices and rituals to appease their anger or by prescription of certain medication. Patients are treated as integral components of a family and of a community at large rather than as isolated individuals. Family members are almost always involved and the healing process is facilitated by the broader involvement of members of the community. Traditional health practitioners basically follow three principles1,2: • Patients must be completely satisfied that they and their symptoms are taken seriously, and that they are given enough time to express their fears. • The healer studies the patient as a whole and does not split the body and mind into two separate entities. • The healer never considers the patient as an isolated individual but as an integral component of a family and a community.

TYPES OF AFRICAN TRADITIONAL HEALERS Traditional healers do not all perform the same functions, nor do they all fall into the same category. Each of them has their own field of expertise, with their own methods of diagnosis and their own, particular medicine. Different types of African traditional healers can be identified as discussed below.1,8,11,12 Although each type has its distinctive features, their roles do overlap considerably. A comparison between selected types of traditional healers is given in Table 1.

Sangoma (diviner) A sangoma or diviner is the most senior

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of the traditional healers. She is a person who defines an illness (diagnostician) and also divines the circumstances of the illness in the cultural context (diviner). Diviners are usually (in approximately 90% of cases) female, although the calling is open to people of any gender, age or status. They are highly respected in their community for their leadership and mystical powers. Diviners are known by different names in the different South African cultures (for example, amagqira in Xhosa, ngaka in Northern Sotho, selaoli in Southern Sotho, and mungome in Venda and Tsonga). Most South Africans, however, generally refer to them as sangomas (from the Zulu word izangoma). A diviner may or may not have knowledge of medicinal herbs. A diviner’s speciality is divination where she operates within a traditional religious supernatural context and acts as a medium with the ancestral spirits. Diviners concentrate on diagnosing the unexplainable. They analyse the causes of specific events and interpret the messages of the ancestors. Although the focus is on divination, they often also provide medication for the specific case they have diagnosed. Training to become a sangoma is not a personal choice but is a calling bestowed by ancestors (usually a woman) to a person who then gets apprenticed to a qualified diviner for several months. During this time, she learns to throw the bones and to control the trance-like states where communication with the spirits takes place. On completion of training she undergoes the ukuthwasa process (a culturally accepted form of ancestral spirit possession when she is called by ancestors to become a diviner). There is no fixed training period (it may take anything from six months to 10 years), since qualification depends on two factors.11 Firstly, the teaching sangoma only qualifies a pupil once a final fee is paid, and secondly, the sangoma retains territorial exclusivity, where allegiance is paid by the pupil to the teacher.

Inyanga (traditional doctor or herbalist) An inyanga (inyanga in Zulu, ixhwele in Xhosa, and mganga in Swahili) specialises in the use of herbal and other medicinal preparations for treating dis-

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COMPLEMENTARY AND ALTERNATIVE MEDICINE ease. He possesses an extensive knowledge of curative herbs, natural treatments and medicinal mixtures of animal origin. He does not receive a calling, and chooses to become an inyanga. Approximately 90% of inyangas are male. Their comprehensive curative expertise includes preventive and prophylactic treatments, rituals and symbolism as well as preparations for luck and fidelity. Some treat only one disease and become renowned experts on that disease. These include rainmakers and specialists in diseases of specific organs (for example heart, kidney or lung disease consultants). Inyangas generally spend a few years as an apprentice and do not profess to have divine powers. This results in patients having to physically visit the inyanga and have a case history taken (unlike the sangoma where the patient does not have to be present). Inyangas generate their business through referrals and often have “shops” where herbs and remedies are sold.

Umthandazi or umprofiti (faith healer or prophet) A faith healer (umthandazi in Nguni, and muProfiti in Sotho) is usually a professed Christian who belongs to either mission or African independent churches. They heal mostly through prayer, laying hands on patients, or providing holy water and ash. They believe that their healing power comes from God through ecstatic states and trance-contact with a spirit (uMoya), or sometimes a combination of both Christian Holy Spirit and ancestral spirit. They use a combination of herbs, remedies and holy water in their treatment. Their healing system is moulded on the sangoma group pattern whereby the afflicted live for months and sometimes years at the prophet’s residence. Their period of training is not prescribed since the “student” is prayed for, goes through purification rites, and is in close contact with the healer. Faith healing is sometimes favoured because the doctrines used seem to integrate both Christian and African traditional beliefs. They interpret sickness in terms of the patient’s world view and perception. The vigorous display of emotions in rhythmic movements and dances which are common practice in faith healing follow the same

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Table 1: Comparison between selected types of traditional healers8 Inyanga

Sangoma Skills

Spiritual Healer

• “Called” by spirits • Individual choice to Trances and contact become one with spirits • Apprenticed to an ex• Apprenticed to an expert • Medical skills acpert quired as an inyanga

Method of service

• Essentially diagnostic • Knowledge of symp- Essentially diagnostic • Throws and reads toms and patient’s history necessary “bones” • Divination through • Contact with patient trance necessary • Contact with patient not needed for diagnosis • History, symptoms and nature of problem not revealed by patients

Nature of service

• C o m p r e h e n s i v e , Lays on hands, prays, • Conflict resolution curative, prophylac- provides holy water and • Confirms patient’s tic, ritualistic and other symbols beliefs symbolic • Revelation of misfortune and illness • Recommends solution • Provides expertise and leadership

Accessibility

Depends on grades Freely accessible (relatively few high grade, whilst lower grade much more accessible)

patterns of the ceremonial dances of sangomas.

Traditional midwife/birth attendant Traditional birth attendants (ababelithisi) are usually elderly women who have been midwives for many years and are highly respected for their obstetric and ritual expertise. They focus their attention on pregnancy problems and assist pregnant women at deliveries. They are responsible for duties such as the teaching of behavioural avoidance among pregnant women, ritual bathing of the mother, ritual disposal of the placentas, provision of healing medicine and traditional massage after delivery. They also give advice on postpartum and cord care and provide important support for breastfeeding as well as advice on marriage, contraception and fertility. The inyanga or diviner acts as a consultant in case a difficult labour or complication occurs. Women who aspire to become traditional birth attendants must satisfy certain cri-

Freely accessible

teria. For example, they should have had two babies in order to be able to appreciate the joys and agonies of childbirth. Training entails 15 to 20 years of apprenticeship before assuming the title. Traditional birth attendants do not charge for their services but donations in the form of gifts are usually given. They may also be invited to be guests of honour when the baby is named. There are also other types of traditional healers, such as traditional surgeons (ingcibi) who perform circumcision as part of an African cultural initiation ceremony.

THERAPEUTIC PROCESS AND METHODS USED BY AFRICAN TRADITIONAL HEALERS Traditional diagnosis is both an art and a method of seeking to discover the origins of the disease and determining what it is. The diagnostic process not only seeks answers to the question of how the disease originated (immediate

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COMPLEMENTARY AND ALTERNATIVE MEDICINE causes), but who or what caused the disease (efficient cause), and why it has affected this particular person at this point in time (ultimate cause).7 Diagnosis comprises a combination of information, namely observation (noting physical symptoms), patient self-diagnosis (reporting by patients of their symptoms) and divination. Three methods of divination include the casting of divination objects, mediumistic ability (clairvoyance or telepathy) or dreams, and visions. If necessary, the impressions of other family members regarding the patient’s illness may also be obtained. Herbal medication is the most common therapeutic method used by African traditional healers – some are used as placebos, others for sympathetic magic, but many have definite medicinal value. Other methods include psychosocial counselling, simple surgical methods, rituals and symbolism. The types of medications used by African traditional healers can be classified into three categories8: •

Preventive and prophylactic medication Most of the work of traditional healers concerns protecting patients from possible afflictions. This can be achieved in various ways, for example by performing ceremonial acts, using medicine against disequilibrium, or wearing totemic objects. Among the Zulus, for example, medication for self-fortification is called amaKhubalo. IzinGqunda or IziNtelezi is sprinkled around and about the kraal to ward off lightning or to cause the umthakathi (witch) discomfort in his bad endeavours. • Treatment for ailments These are prepared in different forms such as cold and hot infusions, decoctions, powders, poultices and lotions, and a variety of earthy ointments that comprise animal fat, clay and sometimes ashes. These formulations are made into different medicine mixtures (umuthi or imbiza). The recipes are usually a secret and are part of the knowledge that the healer will pass onto his apprentice. •

Medications used to destroy the power in others These medications target specific indi-

viduals. A concoction can, for example, be placed in the enemy’s path and it is then believed that when the enemy passes by, he will contract a fatal disease. Sacrification, blood-letting and cupping are the commonest surgical procedures performed by African traditional healers and these are sometimes performed in full view of onlookers. The letting of blood is sometimes used as a way of casting out the illness. If the cause of the sickness is perceived to be bewitchment, a number of rituals may be performed in order to cast out the spell. These may include the induction of vomiting, enemas, blood-letting, whistling or elaborate rituals such as animal sacrifices. Rituals play an important role. Many Africans believe that if the ancestors withdraw their protection and gift of good fortune, the descendant is left vulnerable to all sorts of misfortunes and diseases. The wrath of the ancestors is usually evoked by discord in the home, the violation of customs and traditions or non-observance of certain taboos. Traditional medicine’s rituals aim to restore balance and harmony in terms of the beliefs and values of its culture. These rituals reduce patients’ anxiety and serve to relieve feelings of guilt. Completion of the rituals often has a calming effect on the patient. A large part of the African traditional healer’s practice is also devoted to counselling individuals. Treatment is comprehensive and has curative, protective and preventive elements. It can either be natural or ritual, or both, depending on the cause of the disease. It includes among others, ritual sacrifice to appease the ancestors, ritual and magical strengthening of people and possessions, steaming, purification (for example, ritual washing, or the use of emetics or purgatives), sniffing of substances, cuts (African mode of injection), wearing charms, and piercing (African acupuncture). A variety of treatment methods are used in the administration of herbal medications, for example8: • Sucking of hot medicated liquid from fingertips – unkuncinda. • Inhalation of powdered medicine in its dry form as snuff – ukubhema. • Induction of vomiting via the use of an emetic – ukuphalaza. • Rubbing of powdered medication into

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•

• • • •

incisions – ukugcaba. Steaming or use of a vapour-bath (ukugquma), whereby a patient covered with a large skin or blanket to keep out the cold air crouches over a boiling pot of medicaments. This induces perspiration and reduces fever. Use of enemas for stomach complaints – ukuchatha. Use of fomenting treatment for aching feet – ukuthoba. Burning of incense which is said to appease the ancestors. Use of an amulet manufactured from animal skin to ward off evil spirits.

Traditional healers also deal with traditional ailments. These culture-bound syndromes usually do not respond to Western medicine and must be treated by traditional healers (Zulu: ukufa kwabantu). There are five such culturebound syndromes: spirit possession, sorcery, ancestral wrath (esinyanya), neglect of cultural rites or practices (amaseko), and defilement.

REASONS WHY PEOPLE VISIT TRADITIONAL HEALERS Traditional healers’ availability and accessibility, their familiarity with culturebound syndromes and traditions, their relationships with patients and their families place them in a position to serve as an alternative to mainstream health providers. 13 Reasons that are given why people go for traditional healing are13,14: • Know healers quite well. • Visits are not only for health problems but also for other problems. • Belief that illness arises from supernatural causes and indicates the displeasure of ancestral gods or evil spirits or is the effect of black magic. • A firmly and irrevocably established health care system throughout the whole continent of Africa. • Forms part of the culture and custom. • Traditional medicine and the various African cultures go together. They cannot be separated. • Lack of satisfaction with treatment. • Lack of trust in the ability of Western medical practitioners to effectively treat psychosocial problems. • Lack of knowledge of Western medical practitioners in the treatment of culture-bound syndromes.

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COMPLEMENTARY AND ALTERNATIVE MEDICINE REGULATION OF AFRICAN TRADITIONAL MEDICINE It has been said that traditional healers existed in South Africa before the Dutch colonised it in the 17th century.1 Various pieces of legislation (such as the Witchcraft Suppression Act of 1957 and the Witchcraft Suppression Amendment Act of 1970) explicitly prohibited diviners from practicing their trade (as early as 1891 in colonial Natal).5 Although the majority of the African population utilises traditional medicine services, in many African nations traditional medicine technically remains illegal. 15 The WHO’s 2001 survey of the legal status of traditional and complementary/ alternative medicine revealed that of the 44 African nations surveyed, only 61% had legal statutes regarding traditional medicine and not all national policies have necessarily been implemented.16 Increasing efforts have been made regionally and internationally to formally include traditional healers in primary health care, as well as in HIV/AIDS care and prevention. The WHO formally recognised the importance of collaborating with traditional healers in 1977.5 In South Africa, a “Traditional Health Practitioners Bill of 2003”, was drafted. Certain sections of the Traditional Health Practitioners Act, Act 35 of 2004, came into operation on 13 January 2006. Efforts are furthermore ongoing to develop a pharmacopoeia of traditional medicines.8 An extensive project is underway to document all traditional medicines derived from indigenous medicinal plants, but this is no easy task. The concentration of active ingredients in medicinal plants is, for example, said to vary according to the season. This constitutes a potential danger of overdose during drier seasons when the concentrations of active ingredients are higher.

IN CONCLUSION … Traditional healers hold an esteemed and powerful position in southern African societies.17 Their role is that of physician, counsellor, psychiatrist and priest, and people visit a traditional healer for problems ranging from social dilemmas to major medical illnesses. They there-

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fore have a role to play in building the health system in South Africa. In a country where the needs are great and the resources inadequate, traditional healers can play an important and valuable role in helping communities to improve their health and quality of life.
REFERENCES: 1. Setswe G. 1999. The Role of Traditional Healers and Primary Health Care in South Africa. Health SA Gesondheid, 4 (2): 56-60. 2. Kale R. 1995. South Africa’s Health: Traditional healers in South Africa: a parallel health care system. British Medical Journal, 310 (6 May): 1182-1185. 3. Richter ML. 2004. Traditional healing and human rights in South Africa. XV International AIDS Conference, Bangkok, 11-16 July (Abstract no.: MoPeE4200). 4. WHO Traditional Medicine Strategy 2002-2005. 2002. Geneva: World Health Organization. 5. Richter M. 2003. Traditional Medicines and Traditional Healers in South Africa. Discussion paper prepared for the Treatment Action Campaign and AIDS Law Project. Available on the web: http://www.tac.org.za/ Documents/ ResearchPapers/Traditional_Medicine _briefing.pdf (date accessed: 10 July 2007). 6. Healers licensed in South Africa. 2004. BBC News. Available on the web: http://news. bbc.co.uk/2/hi/africa/3640270.stm (date accessed: 9 July 2007). 7. Pretorius E. 1999. Traditional Healers. Chapter 18. South African Health Review. Available on the web: http://legacy.hst.org.za/sahr/99/ chap18.htm (date accessed: 10 July 2007).

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Abdool Karim SS, Ziqubu-Page TT & Arendse R. 1994. Bridging the Gap: Potential for a health care partnership between African traditional healers and biomedical personnel in South Africa. Project report prepared for the South African Medical Research Council. South African Medical Journal, 84 (December, Supplement): 1-16. Republic of South Africa. 2004. Traditional Health Practitioners Act, Act 35 of 2004. Pretoria: Government Printers. Planning for cost-effective traditional medicines in the new century – a discussion paper. WHO Centre for Health Development. Available on the web: http://www.who.or.jp/tm/research/bkg/ 3_definitions.html (date accessed: 10 July 2007). Moskovitz S. 1996. Traditional healers in modern medicine. The SA Retail Chemist, August: 2. Troskie R. 1997. The role of health care workers in collaborating with traditional healers in primary health care. Part 1. Health SA Gesondheid, 2 (1): 29-35. Kgoatla P. 1997. The use of traditional medicines by teenage mothers in Soshanguve. Health SA Gesondheid, 2 (3): 27-31. Stanhope M & Lancaster J. 1988. Community Health Nursing: Process and Practice for Promoting Health. St Louis: Mosby. Gbodossou EVA, Floyd VD & Katy CI. Aids in Africa: Scenarios for the future. The role of traditional medicine in Africa’s fight against HIV/ AIDS. Available on the web: http:// www.prometra.org/Documents/AIDSinAfricaScenariofortheFuture.pdf (date accessed: 10 July 2007). WHO Report: Legal Status of Traditional Medicine and Complementary/Alternative Medicine: A Worldwide Review, 2001. Geneva: World Health Organization. Hewson M. 1998. Traditional healers in Southern Africa. Annals of Internal Medicine, 128 (12): 1029-1034.

OSTEOPOROSIS DAY : 20 OCTOBER 2007 International speaker to address the importance of calcium supplementation in teenagers to ensure lifelong bone health

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t is estimated that 40% of women will suf fer an osteoporosis fracture in their lifetime. The cost of osteoporosis exceeds $30 billion worldwide. The only cost-effective approach to osteoporosis is prevention. To raise awareness around Osteoporosis Day 20 October 2007, Wyeth Consumer Healthcare will host the internationally renowned Professor Connie Weaver, together with South African specialists, on a lecture tour addressing the South African medical fraternity. Prof Weaver is a distinguished Professor and Head of the Foods and Nutrition Department at Purdue University in the United States and has conducted several groundbreaking research studies on calcium metabolism, including a landmark study finding that calcium absorption peaks in young girls near the onset of menses. The research provided insight into factors affecting development of peak bone mass during growth, which determines the risk of osteoporosis in women. The results of Prof Weaver and her research team’s studies are being used to determine recommendations for calcium supplementation around the world. South African specialists, including Dr Stanley Lipschitz, Prof Stephen Hough and Dr Aslam Amod will present various topics rang-

ing from the importance of Vitamin D and Calcium supplementation in the treatment of osteoporosis to an update on the latest treatment options in osteoporosis. Members of the medical fraternity and medical media are invited to attend these seminars. Prior booking is essential. Date: 16/10/07 City: Johannesburg Venue : The Venue, Melrose Arch Date: 17/10/07 City: Cape Town Venue : The Table Bay Hotel Date: 18/10/07 City: Durban Venue: 1on1 Events & Conference Centre, Gateway, Umhlanga Time: 18h30 for 19h00 Drinks and food will be served following the lectures. Application for CPD points has been submitted. To book for any of the events please fax your details to Marieta Ferreira on 0865246965 or e-mail your details to [email protected]. Please include your contact details.

SA Pharmaceutical Journal – September 2007