Sot. Ser. ,Mcd. Vol. 32, No. I I, pp. 1183-l190. 1992 Primed in Great Bntain. All rights reserved
0277-9536~92 55.00 + 0.00 Copyright (: 1992 Pergamon Press Ltd
PLANNING HEALTH CARE IN SOUTH THERE A ROLE FOR TRADITIONAL M. The Centre
for Health
Policy.
and M.
FREEMAN
Department York Road,
AFRICA-IS HEALERS?
MOTSEI
of Community Health. University Parktown, 2198 South Africa
of the Witwatersrand.
7
Abstract-Developing health policies for the ‘post-apartheid’ era has become an urgent task of the early 1990s in South Africa. A neglected policy issue thus far has been the question of whether traditional healers have a role to play in future health care, and if so what this should be. Rather than developing positions on these questions, this paper sets out the main debates which need the consideration of health care planners. Arguments for and against traditional healers in health care are presented, and alternatives which could be chosen are outlined. Options adopted by countries on South Africa’s borders. Zimbabwe, Mozambique and Swaziland are briefly considered. Key words--traditional
healers,
South
Africa,
health
1990’s in South Africa has been a period of rapid change. The unbanning of the African National and Pan African& Congresses, and the government’s commitment to the removal of racial discrimination, have heralded a move away from the era of ‘classical apartheid’ to a period of ‘social transition’. One of the most important tasks for anti-apartheid forces during this period is to develop (realistic) policies for the future. Within health care this transitional phase offers the opportunity to debate and develop approaches which will provide, or at least move towards, adequate and appropriate health care for all. The period before 1990 saw the anti-apartheid health organisations inside South Africa [I], and the health departments of the liberation movements primarily involved in political activism, in service provision (such as treating ex-detainees or soldiers in the field) and in organising and educating for better health and health care. Health policy was given minimal emphasis. Now however, policy is high on the agenda of these groups and alternatives are being seriously debated and discussed [2]. One important area which has received very little attention thus far however is what role, if any, traditional healers will play in ‘post-apartheid’ health care. It is very likely that a majority government will review and reformulate policy around traditional healers after independence-as occurred in many other African states. Already certain traditional healer groupings have approached the African National Congress with demands for legislative change. When policy is reconsidered it is essential that the relevant debates, experiences and available knowledge are considered. While we do not claim that this article manages to do this in full, many of the more importarit issues for policy makers are presented. This article briefly sets out the present
policy
status and utilisation of traditional healers in South Africa; outlines options which may be chosen if greater linkages between traditional and the formal health system are to be made; puts forward arguments from both proponents of a relationship between the ‘formal’ health sector and traditional healers and those that are opposed to this; and looks (only briefly) at examples of policies adopted by three neighbouring countries and the consequences of these choices. While the article is predominantly a survey of the literature, additional arguments not commonly associated with the ‘traditional healers debate’ are introduced [3]. The intention of this article is not to argue for one position over any other, but rather to present the arguments as objectively as possible in order to facilitate and encourage further debate and clearer policy thinking.
The early
TRADITIONAL
HEALERS
IN SOUTH
AFRICA
There are broadly three types of traditional healers available to South African consumers [4]. First the traditional doctor or inpanga. This is generally a male who uses herbal and other medicinal preparations for treating disease. Second the isangoma (Zulu) (diviner), ding&z (Sotho) or amgqira (Xhosa). This is usually a woman who operates within a traditional religious supernatural context and acts as a medium with the ancestral shades. Third the umprofethi or umfhandazi (faith healer) who integrates Christian ritual and traditional practices. This latter group can be traced to the rise of the independent African church movement which broke away from the more Western oriented missionary churches. They are not ‘traditional’ in the commonly used sense of the word in that they did not exist before the development of western medicine [S]. They are nonetheless included as they share a common theory of health and disease
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M. FREEMAN and M. MOTSEI
with other traditional healers, divine in a similar manner to diviners and treat various diseases with traditional herbs and remedies. The divisions into these three categories is convenient, in reality however they are often not distinct. For example there may be traditional doctors who use ‘bones’ or a voice from the ancestors to diagnose disease, a ‘sangoma’ who treats with herbs and so on. In addition a number of traditional practices have undergone changes to suit modern and technological advancements [6]. Officially the use of traditional healers in South Africa is outlawed. In 1974 the Health Act forbade healers not registered with the South African Medical and Dental Council (SAMDC) from practising or performing any act pertaining to the medical profession. De facto however the SAMDC generally turns a blind eye to traditional healers, and a few co-operative ventures between traditional and modern health care practitioners occur [7]. For the most part however the modern and traditional systems of health care operate independently with consumers choosing whom to consult. Despite the official illegality, a number of organisations register and represent (or claim to represent) the interests of traditional healers. These include the Southern African Traditional Healers Council, the Association of Traditional Healers of Southern Africa, The Congress of Traditional Doctors of Southern Africa, the African Dingaka Association and the African Skilled Herbalist Association. The exact number of traditional healers in South Africa and their utilisation is very difficult to assess. Karlsson and Moloantoa have suggested however that there are probably in the region of 150,000 traditional healers [8]. This suggests a massive consumer base. Many of these consultations are carried out at the same time as the patient may be receiving modern health care, or either before or after consultation with the modern health care system [9].
WHAT OPTIONS MODERN
EXIST FOR LINKS BETWEEN THE HEALTH
TRADITIONAL
SERVICES AND HEALERS?
A number of authors have outlined options open to health planners [IO-141. In this section we present three alternatives which we consider the most important possibilities for linking modern and traditional health care systems. These positions are first presented without review and without discussion on their feasibility. Some discussion arises later in the paper. Option
1: Incorporation
In this option it is suggested that traditional healers are integrated into health care systems (usually within a primary care approach) as ‘first-line’ health practitioners. Their function is seen as primarily carrying out services researched and designed within the scien-
tific health-care system. The inclusion of traditional healers who would spread curative as well as preventive and promotive health care was suggested at the World Health Organisation Conference at Alma Ata in 1978 [I51 as part of a primary health care approach. The importance of traditional healers was emphasised because of their availability and influence in the community. The option is well illustrated by Matjila who identifies a role for traditional healers in the prevention of illness. He points to the UNICEF designed GOBI FFF (Growth monitoring, Oral rehydration, Breast-feeding, Immunisation. Family planning, supplementary Feeding, and Female education) programme for reducing infant and under 5 mortality and morbidity in developing countries, and says: Dissemination of knowledge to influential members of the community is essential to enlist their co-operation in modifying attitudes and in motivating people to carry out health promoting practices. Such influential members of the community include ministers of religion, teachers and, of course, Traditional Healers. Not only are Traditional Healers influential but they are acceptable to and utilised by a part of the African community [16].
In this model the traditional healer functions in a very similar role to that of a Village Health Worker. Both would be involved in preventing illness, promoting health and treating specific disorders-while referring others who require more specialised care. It is also possible within this option that certain practices of traditional healers are regulated, and if found to be harmful by the scientific community, are strongly discouraged or even banned. Programmes within this option have begun in South Africa. For example at the Madadeni hospital in Natal inyangas and sangomas have regular meetings with the doctors. This has resulted in patients with chronic diseases receiving their regular (western) medicines from the traditional healers in their district rather than having to make the trip to the hospital each time medication is needed. Option 2: Co-operation
Jcollaboration
In this option both the traditional and western health systems remain essentially autonomous and each retains its own methods of operation and explanation; however practitioners from the two systems co-operate through the recognition of the importance and health value of the other. In the first instance this co-operation may take the form of ‘mutual referral’. Practitioners from both paradigms would recognise the efficacy of the other in the treatment of particular disorders and would thus refer to each other in the appropriate circumstances. Practitioners would come to an agreement as to what disorders should be referred to whom. Alternatively, it may be felt that either treatment is insufficient on its own, and that it may be necessary to consult both a western and a traditional healer for the same illness. A patient may for example consult
Traditional healers in the ‘new’ South Africa a western trained health worker for curative treatment and a traditional healer for cultural explanations for the causes of the illness. Ben Tovim, a psychiatrist working in Botswana quotes a patient as saying “the (traditional) Tswana doctor tells me why I am ill. Your medicine cures the illness as it affects my body” [17]. At present in South Africa ‘dual treatment’ regularly takes place [9]. For most people in South Africa who cannot afford the ‘fee-for-service’ charges of private medical practitioners, the state provides and pays for health services-albeit often inadequate care. Payment for traditional healers are not subsidised, and the traditional healer operates outside the formal health setting and at the financial cost of the patient alone. If this option is decided upon it may be possible to have both traditional and allopathic medicine operating within the ‘formal’ sector. Option 3: Total integration This option would involve the evolution of a ‘new’ healing system through the blending of the two systems. People seeking help would usually not receive either a pure western or traditional treatment, but a combination of the two. This could in itself take various forms. For example the explanation of the illness may be a combination of traditional and western understanding. Taking TB for instance, a person may be informed of the existence of the tubercle bacillus, and be provided with a scientific explanation of how the disease has taken root in the biological system, but at the same time be informed why he/she of all people developed the problem with an explanation involving witchcraft, annoyance of the ancestors or other ‘supernatural’ reasons. Practitioners would in all likelihood carry both western and traditional medication and prescribe either or both depending on the diagnosis. A small example of such integration is the practice of certain Traditional Birth Attendants (TBAs) [IQ The unification of the two disciplines is clearly seen through the use of traditional herbs to induce labour and bathing the newborn infant in water treated with traditional remedies to ‘protect’ the child, but at the same time using western apparatus for cutting and treating the umbilical cord.
DEBATES FOR AND AGAINST THE INCLUSION OF TRADITIONAL
HEALERS AS A HEALTH CARE RESOURCE
A number of arguments have been put forward as to why traditional healers should or should not be included in health care services. Many of the most important of these are discussed here. Arguments in favour include the lack of health resources in developing countries and the availability and accessibility of traditional healers; that traditional healers
1185
are part of African culture and should thus be encouraged and accepted; that the process of traditional healing has advantages over western health care, and that many traditional healing practices are effective. The arguments against inclusion range from the outright rejection of traditional healing to practical problems of registration. Discussed here are the harmful effects of traditional medicine; its superstitious nature; that inclusion will mean a ‘colonisation’ of traditional medicine and a threat to traditional healer’s status and remuneration; that traditional healers ‘disempower’ their patients; that traditional explanations are ‘false consciousness’; and that inclusion will involve numerous practical problems which may be impossible to overcome. (a) Lack of adequate resources seming the ‘African’ population One of the major reasons for the resurgence of interest in traditional healing shown by many organisations and governments previously sceptical of anything other than scientific medicine has been the fact that there are inadequate conventional health resources to meet needs. It has been estimated that 70-80% of the population in lesser developed countries have little or no access to basic health services [14]. In the 1970’s many countries realised that one of the most effective means of achieving health care for all was to utilise resources already existing in communities-among which were traditional healers. Green in fact claimed that the scarcity of resources is such that “. . public health goals probably cannot in the foreseeable future be realised in Africa without some form of participation in goal attainment on the part of indigenous healers. The numbers are simply not there . . .” [ 191. Compared with other African countries however South Africa is fairly well endowed with health personnel, and the problem of the lack of adequate ‘modern’ care for the majority is (in certain categories of health worker at least) not so much the lack of resources, as much as a problem with distribution and approach to care. While it is very difficult to calculate the exact numbers of health workers practising in South Africa, estimates indicate reasonable practitioner to population ratios in many health worker categories. For example there is approximately one registered nurse and one doctor per 429 and 1811 population respectively [20]. This compares well with the World Health Organisation recommendation of one nurse per 500 population, and shows South Africa to be between ‘upper middle income economies’ and ‘high income oil producing countries’ as far as the number of doctors is concerned [20]. Nonetheless for the majority black population adequate care is not available and will not simply become available. While the desegregation of facilities for all race groups will, when achieved, go some way to equalising health care between race groups,
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M.
FREEMAN and M. MOTSEI
and a primary health care approach will improve the availability of health care considerably, comprehensive and adequate ‘modern’ health care in the rural areas and in the black urban townships is still a long way off. At present in remote areas and in urban ‘townships’ many people turn to traditional healers in times of sickness, and for them primary health care may be synonymous with traditional medicine. For the foreseeable future at least it would seem that traditional healers will continue to offer greater accessibility. (6) African healing for Africans ‘Culture’ is a further reason for developing the role of traditional healers. It is said that colonial rule has systematically eroded African life style to the detriment of the African people [2l]. Not only has people’s land been appropriated, Africans impoverished through colonial and capitalist development, but their very way of life ridiculed, taken away and replaced by ‘western’ modes of being. To undermine the role of traditional healers, who are an ‘outgrowth and expression’ of culture [14], is a part of this process. While few people would, we believe, argue that there is no place for western health care, many would say that this should not be at the expense of traditional care. More practically large numbers of African people, even in urban areas, use traditional healers because of the belief in the explanation and cure provided by traditional medicine. Even amongst people who generally use western medicine when they are sick there are particular instances when the illness is seen to have African experiential causes, and can therefore not be treated by allopathic medicine (personal communication with Mr Zungu, National President of the Southern African Traditional Healers Council). It seems that whether traditional healers are included in a health plan or not, consumers will continue to find the practitioners who they believe are the only people capable of healing them. (c) The process of traditional healing Western health care, it has been argued, has made major technological advancements, but with this the human quality of care has declined. This is reflected in the impersonal and often inconsiderate health workers, the inadequate explanation which is often given of the diagnosis and procedures performed and generally a concentration on the purely medical aspects of health care [22]. Traditional healing on the other hand, involves the whole person. Care is not only directed at the biological aspect of the person, but at the social, psychological and spiritual as well. Neumann and Lauro say that ‘many of the practices of traditional medicine practitioners are designed to preserve cultural institutions and to help the patient live at peace with family, clan, village, tribe and inner self’ [ 141.
Traditional healers are involved in prevention of illness or misfortune. This means that the traditional healer becomes a full part of the socio-cultural life of the members of the community as a whole. Unlike modern healers, traditional healers are not purely associated with ‘illness’ but very much with ‘health’. (d) EfSecticeness of traditional medicines Traditional medicines are often effective with illnesses such as diarrhoea, headaches and other pains, swellings and in sedating patients [I I]. Though the proportion of pharmacologically active properties of traditional herbs used in South Africa is uncertain [23], there are clearly medicines which are effective. Success in treating psychological problems is well known and often recognised. (e) Harmful effects of traditional medicines Counterbalancing the previous point is the argument that traditional medicines are harmful. Green and Makuba [I I] have pointed out four such practices carried out in Swaziland, each of which is also practised in South Africa. These are medicinal enemas to treat and prevent childhood diarrhoea; induced vomiting for patients with weak hearts, tuberculosis patients etc; traditional vaccinations done with an unclean razor; medicines given which are dangerous either by themselves or if taken at the same time as modern medicines. (f)
Traditional healing belongs to pre -cirilisation
Traditional healers, far from narrowing their focus to the merely technical (as in modern health care), are open to a wide range of mostly ‘mystical’ explanations. Hammond-Tooke points out that “much illness is explained in quite explicitly religious terms, not only as being caused by ‘spiritual’ entities, but also in terms of moral responsibility” [6]. For most western practitioners explanation of illness which falls outside the laws of natural science is pseudoscientific, primitive and simply wrong. This perception, which began with the first historical contacts with African culture, continues to have strong support. For example Dr Nthato Motlana, member of the influential Soweto Civic Association, reflected this position when he said recently “Most of it (traditional medicine) is based on superstition, meaningless pseudo-psychological mumbo-jumbo, which is positively harmful” [24]. Another argument put forward against traditional healers is that community disharmony may be caused because guilt for a person’s illness may be put onto kin, neighbours or consociates. In extreme cases this may lead to ostracism and even death of ‘innocent’ people. While in certain instances witchcraft accusations may be caused by community conflict, Hammond-Tooke points out that such accusations may in turn cause conflict if publicly articulated [6].
Traditional healers in the ‘new’ South Africa (g) ‘Colonising’
traditional medicine
It is not just the modern health sector but the traditional healers themselves who may not want closer relationships with the western health services. Traditional healers may argue that inclusion is only likely to benefit western medicine and not themselves. This can be illustrated through the examples of incorporation (the use of traditional healers as primary care workers) and through co-operation (mutual referral being the example used). Nzimande argues that incorporation may not simply be a spreading of health care but “may be a paternalistic way of making the clients of traditional healers available to western interventions” [21]. It is also argued that as the traditional healer becomes more involved in first-line health ‘on behalf of’ scientific medicine so the modus operandi and the ‘culture’ of traditional healing is likely to be undermined. Similarly, while the option of mutual referral appears fair, it is argued that the reality is likely to favour western medicine. At present in South Africa, referral which does occur is overwhelmingly from traditional healer ta western medicine and this is not likely to change. Reasons for this include the deep suspicion which most western practitioners have for traditional healing and their fear that their hegemony over health care (and perhaps their wealth too) may be threatened by traditional healing [19]. It may be argued then that the greatest potential threat to traditional healing practices may not be through being left out of formal health care structures but through being ‘brought in’ and ‘taken over’ by western medicine. The process of inclusion, it is argued, would be a slow but comprehensive ‘colonisation’ of traditional healing. Moreover it has been argued that traditional healers are tolerated only because they take a strain off the overworked modem health care system and are used as an excuse for not providing adequate formal care. (II) A threat to traditional healer’s status and remunerarion
The option of integration aside, the range of disorders that the traditional healer will attend to after inclusion is likely to decrease. It is argued that by acknowledging that western health care is able to deal with more, or more severe, illnesses, the infallibility on which much of the power of the traditional healer depends, will be eroded-and with it their status. Asuni points out that if traditional healers come under supervision and control and have to comply with certain written regulations “this will immediately diminish his (sic) image of omnipotence, and consequently his therapeutic efficacy” [IO]. Remuneration may also decrease. At present the rates of traditional healers are not regulated and many have very lucrative practices. If traditional
1187
healers were brought into a national health plan many may expect to lose this high income. (i) The political-economic
perspective
Health is never ‘apolitical’. From this point of view it is argued that the decision to either encourage or reject the use of traditional healers in health care must be taken in the light of political as well as ‘purely health’ considerations. It is argued here that traditional healers ‘disempower’ the patient and may obstruct the understanding of the political dimensions of health. Health care involves a relationship between a ‘healer’ and a ‘patient’. In both traditional and western medicine this involves a ritual in which cure is prescribed by the authority (the healer) to the passive and ignorant receiver (the patient), This relationship is said to reflect and reproduce the authoritarian social order in which each of these interventions take place. Werner, and indeed the WHO, have suggested that it is possible to practice ‘scientific’ medicine in a more democratic manner, in which the relationship between health worker and patient is equalised [25]. On the other hand, it is argued that there may be a contradiction between traditional healing and democratic health practices. It is suggested that traditional healing is inextricable from the power given to the healer. Listening to and believing what the authority says is a crucial and integral part of the healing process in a way in which the ritual and authority of western medicine is not. Thus while western medicine is at present still far from democratic, there is in principle no reason why it could not become more so. On the other hand it is argued that if the authority of the traditional healer were removed, a fundamental principle of the treatment would be undermined as the effectiveness of traditional healers lies precisely in their authority [6]. Another important argument is that the explanation of disease or ailment may mask the ‘real’ reasons for illness. In western health care, explanation is most often presented as being within the individual, and purely in biochemical terms [26], while in traditional medicine the explanation is often ‘micro-social’ (family or community) and/or supernatural. It may be argued that neither of these conceptualisations explains illness, or is able to intervene adequately, because neither addresses the socioeconomic forces that determine health status. Neither takes the step of seeing that social and economic conditions determine the health of the population and that changes in these conditions are essential for good health. However a significant trend has developed within western health care which satisfactorily merges ‘natural scientific’ explanation with that rooted in the political economy of health [26-281. This is best illustrated by example-TB is again used. It is reasonable to assume that a western trained physician may easily accept that although a bacillus
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M. FREEMAN and M. MOTSEI
is the causative micro-biological agent, TB will not spread except in the face of poverty, which renders individuals susceptible to infection. This poverty in turn can be understood in terms of Apartheid or even capitalism. A similar combination of supernatural and socio-political perspectives on the other hand would lead to absurd and illogical conclusions. For example it would suggest that the ancestors are most displeased with those in conditions of poverty, or that the afflicted are in conditions of poverty because their ancestors are displeased with them! (j) Practical obstacles to inclusion Inclusion of traditional healers into health care structures is an extremely difficult task [29]. For example if incorporation or co-operation were decided on, it would be necessary to ensure adequate standards of health care and control of tariffs through the registration of all health practitioners. But while registration of traditional healers is well under way in most African countries [19] this is a very complex process and has not been fully achieved anywhere in the world. Whereas in western medical circles there are guidelines for registration based on official qualification, and in some cases experience, there is no clear equivalent for traditional healers. For example, to gain membership of the Traditional Healers Council of Southern Africa applicants need to go through a ‘test’ to determine whether they are ‘genuine’ healers or not. This involves investigation into the healer’s training, length of practice, supervision etc. Applicants for registration also go through either an oral or a written examination. However it is questionable whether using this form of discrimination would be successful in eliminating the ‘undesirables’-and only the ‘undesirables’. Given the range and form of healers and the secrecy in which most operate, this registration process is dubious. Already in South Africa the various registering bodies conflict around who registers bona fide healers. Many of these organisations claim that anyone not registered with them, may be a ‘quack’ or a ‘witchdoctor’. Also, it would be necessary to include all ‘genuine’ healers. However, many traditional healers are unlikely to present themselves for registration as they would not see any advantage in this. It has in fact been found that traditional healers interested in registering are those especially interested in learning more about modern/western medicine [l9]. According to Fassin and Fassin “the stronger the traditional legitimacy, the less need for rational-legal legitimation” [30]. Registration could of course be enforced by law, healers could be enticed to join through government subsidisation of patients attending registered healers, or healers could be attracted to register by allowing only registered healers the authority to book employees off work etc. Whether any of these solutions would solve the problem is uncertain.
The problems of financing traditional healers is a further obstacle. At present traditional healers are paid on a ‘fee-for-service’ basis. This has been seen to be advantageous to the health care system as a whole as the more people who use traditional healers, the less burden there would be on the state to provide health care through the formal sector. However others have pointed to the fallacy and danger in this point of view [31]. It is argued that in reality those that make most use of traditional healers are those who can least afford to pay for their own health care. Thus if traditional healers are to be integrated into the health care system in South Africa it will be necessary (at some point) to shift the form of payment of traditional healers to one in which the State (or national cover of some sort) would pay. This may or may not be acceptable to the traditional healer, but more pertinent at this point is where the money would be found for incorporation. The health budget in South Africa is already stretched to the point where inadequate services are provided and staff are underpaid. It seems doubtful that an additional estimated 150,000 health workers could be accommodated within the health budget. The problem would be even worse if the option of consulting both a traditional and a western healer was adopted. Moreover it can be expected that planners would demand proof of efficacy before including traditional healers in the system. The rub here is that much of the traditional healer’s ‘cure’ is psychological and social, and therefore extremely difficult to measure.
LESSONS FR0.M NEIGHBOURING
STATES
Three different strategies used by countries on South Africa’s borders reflect possibilities and problems with different approaches. Zimbabwe took the policy of registration and inclusion of traditional healers into its national health service, Mozambique took the position of ‘ideological confrontation’ and Swaziland a policy of ‘improved co-operation’. It is significant that none of these policies have in fact resulted in the anticipated consequences. Zimbabwe In Zimbabwe, despite official recognition of traditional healers and a policy of inclusion, there has been both formal and informal resistance to the policy. For example though co-operation with and recognition of ZINATHA (Zimbabwe National Traditional Healer’s Association) occurred after independence, the official council which was to regulate integration under the Traditional Medical Practitioners Act of 1981 had, by 1989, never met [6]. ‘On the ground’ co-operation has also been far from comprehensive. This probably reflects opposition to
Traditional
healers
in the ‘new’ South
the policy from both modern and traditional practitioners for many of the reasons already discussed in this paper. It is worth adding at this point however a point made by Green [19] that many specifically African professionals see traditional healers as a threat to their professionalism, and this acts against greater co-operation. Not all traditional healers have registered with the association and refer=1 which does occur, although meant to be mutual, is often loaded in favour of referral to the modern health sector [32]. Mozambique
Mozambique’s effective ‘illegalisation’ of traditional healers on the grounds that “healers were, and potentially still are, part of the old ‘feudal’ system, unproductive, giving support to the chiefs, furthering ‘superstition’ and liable to exploit the poor in their need” [33] has not been successful. Despite the policy, over half the population continued and continues to use traditional healers. Moreover, the policy caused tension between the government and the masses of the people who felt their choice and their cultural expression were being interfered with 1341. The realisation that the policy had failed recently prompted the Frelimo government to recognise its error and change its approach. People now have a free choice of who they choose for health care, and associations of traditional healers are encouraged [35]. The government has not changed its ideological position but want to demonstrate the efficacy of modern health care through the provision of the services, rather than through a policy of official rejection of the traditional alternative 1341. Swaziland
Attempts have been made since the 1940s to recognise and register traditional healers in Swaziland [ 111. While as yet there is no formal recognition, the government have nonetheless encouraged links with traditional healers and have even participated in joint programmes. For example around 1983 healers received training in the use of oral rehydration therapy together with free UNICEF packets of rehydration salts. It was thought that this programme would be successful because for example healers had indicated in a survey that they wanted the means to prevent deaths of patients with symptoms of dehydration from cholera and other diseases, because the distribution of the packets was seen to constitute a gesture of trust and cooperation on the part of the government and so on [I I]. However a couple of years after the programme had started, it had been ‘stalled’ [19]. The reasons why the project did not reach its goals are unknown to the authors, though again sufficient reasons have been given in this article to indicate why ‘incorporative’ approaches may fail.
Africa
1189 CONCLUSION
In planning health policy for a new South Africa, decisions of crucial significance will have to take place, one of which is the role of traditional healers in health care. A range of options are open. These range from banning traditional healers and hunting them down so that their practices are stopped, through options such as the retention of the starus quo-where western health care occurs through the formal sector and traditional healing through the informal sector, with pockets of co-operation; to alternatives in which the state actively intervenes to achieve collaborative, incorporative or integrative programmes. We have been careful not to take sides on the issue and any bias detected towards one position is purely unconscious. One thing that we are clear on though and that is that policy on traditional healers must be taken with clear reasons and with due consideration of opposing arguments. We hope that this paper facilitates this process.
REFERENCES
I. For example the National Medical and Dental Association (NAMDA), the South African Health Workers Congress (SAHWCO) and the Organisation for Appropriate Social Services in South Africa (OASSSA). 2. Many of the most important current debates are summarized in Health and Welfare in Transition. Crirical Hlth 31132, August, 1990. 3. The additional points relate predominantly to the political economy of health. 4. Edwards S. D. Traditional and modern medicine in South Africa: A research study. Sot. Sci. Med. 22, 1273-1276, 1986. 5. Generally traditional healers are regarded as practitioners whose methods existed before the development of western medicine. See Bannerman R., Burton J. and Wen-Chieh C. Traditional Medicine and Health Corerage: a Reader for Healrh Administrarors and Practitioners. World-Health Organisation, Geneva, 1983. 6. For an insightful and in-depth exposition of the different forms of practices current in South Africa see Hammond-Tooke D. Rituals and Medicines. AD Donker, Johannesburg, 1989. 7. For example at Madadeni Hospital in KwaZulu and Itsoseng in Boputaswana. 8. Karlsson E. L. and Moloantoa E. K. M. The traditional healer in Primary Health Care-yes or no? Conrinuing Med. Educar. 2, 43-47, 1984. 9. Ferrand D. Is a combined Western and Traditional health service for black patients desirable? S. Afr. med. J. 66, (17). 779-780, 1984. 10. Asuni T. The dilemma of traditional healing with special reference to Nigeria. Sot. Sci. Med. 13B, 33-39, 1979. II. Green E. C. and Makhubu L. M. Traditional healers in Swaziland: Toward improved cooperadon between the traditional and modern health sectors. Sot. Sci. Med. 18, 1071-1079, 1984. 12. Dunlop D. W. Alternatives to ‘Modern’ health delivery systems in Africa: Public policy issues of traditional health systems. Sot. Sci. Med. 9, 581-586, 1975. 13. Pillsbury B. L. K. Policy and evaluation perspectives on traditional health practitioners in national health care systems. Sot. Sci. Med. 16, 1825-1834, 1982.
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14 Neuman A. K. and Lauro P. Ethnomedicine and biomedicine linking. Sot. Sci. Med. 16, 1817-1824. 1982. Alma Ata 1978: Primary IS. World Health Organisation. Health Care. World Health Organisation, Geneva, 1978. 16. Matjila J. The Role of the Traditional Healer in Community Health Care. Paper delivered to a workshop Public Health, Social Services and the Law. University of South Africa. Pretoria, 1988. * Psychiatry. Mental Health 17. Ben Tovim B. Development and Primary Health Care in Botswana. London, Tavistack Press, 1987. medicine 18. While it seems that western and traditional merge rather easily in the TBA, total integration is the least likely of the three options. As Green points out “perhaps syncretism can never develop very far due to a basic incompatibility between the two paradigms of illness and the supporting worldviews” Green E. C. Can collaborative programs between biomedical and African indigenous health practitioners succeed? Sot. Sci. Med. 27, 1125-I 130, 1988. programs between 19. Green E. C. Can collaborative biomedical and African indigenous health practitioners succeed? Sot. Sci. Med. 27, 1125-l 130, 1988. 20. Rispel L. and Schneider H. Setting the scene: human resource development for health in South Africa. Conference Health and Welfare in South Africa, Maputo, 1990. B. African life and the ‘hidden abode’ of 21. Nzimande mental health: some unmasked questions about ‘tradition’ and progressive social services in South Africa. In Mental- Health: Struggle and Transformation, OASSSA 3rd National Conference, Durban, 1988. 22. Ngubane H. Aspects of clinical practice and traditional organization of indigenous healers in South Africa. Sot. Sri Med. lSb, 361-365, 1981. found 5% of 23. The last study known to the authors traditional medicines to have pharmacologically active properties. This was however done nearly sixty years ago. Watt B. E. and Breyer-Brandwijk M. The Medical
24. 25. 26.
27. 28.
29. 30.
31.
32. 33.
34.
35.
and poisonous Plants of Southern Africa. Livingstone, Edinburgh, 1932. Motlana N. The Star Newspaper. Johannesburg, 9.2.89. Werner D. and Bower B. Helping Health Workers Learn. The Herperian Foundation. Palo Alto, 1987. de Beer C. The South African Disease: Apartheid and Health Services. Southern African Research Services, Johannesburg, 1984. Doyal L. The Political Economy of Health. Pluto Press, London, 1976. Savage M. The Political Economy of Health in South Africa. In Economics in Health Care in South Africa. Vol. I, Johannesburg, 1979. Bibeau G. New legal rules for an old art of healing. Sot. Sci. Med. 16, 1843-1849, 1982. Fassin D. and Fassin E. Traditional medicine and the stakes of legitimation of Senegal. Sot. Sci. Med. 27, 353-357, 1988. Other disadvantages of the ‘fee-for-service’ model in health care can be found in Price M. and de Beer C. Can privatisation solve the problems in the health sector? A National Health Set-rice for South Africa. The Centre for the Study of Health Policy, University of the Witwatersrand, Johannesburg. 1988. Similar arguments would apply to private payment to traditional healers. Freeman M. Mental health in Zimbabwe: are there lessons for South Africa? Psychol. Sot. 9, 2243, 1988. Last M. The professionalization of African medicine: ambiguities and definitions. In The Professionali-_ation of African Medicine (Edited bv Last M. and Chauunduka G. L.), pp. I-19. Manchester University Press, Manchester, 1986. Hayes G. The Maputo conference on health and its implications for mental health struggles. In Mental Health Carefor a New South Africa (Edited by Freeman M.), pp. 4455. The Centre for Health Policy. Johannesburg, 1990. Simao L. Meeting with Mozambiques Minister of Health. Health and Welfare in Transition. Critical Health Vols 31/32. Doornfontein, 1990.
0277-9536~92 55.00 + 0.00 Copyright (: 1992 Pergamon Press Ltd
PLANNING HEALTH CARE IN SOUTH THERE A ROLE FOR TRADITIONAL M. The Centre
for Health
Policy.
and M.
FREEMAN
Department York Road,
AFRICA-IS HEALERS?
MOTSEI
of Community Health. University Parktown, 2198 South Africa
of the Witwatersrand.
7
Abstract-Developing health policies for the ‘post-apartheid’ era has become an urgent task of the early 1990s in South Africa. A neglected policy issue thus far has been the question of whether traditional healers have a role to play in future health care, and if so what this should be. Rather than developing positions on these questions, this paper sets out the main debates which need the consideration of health care planners. Arguments for and against traditional healers in health care are presented, and alternatives which could be chosen are outlined. Options adopted by countries on South Africa’s borders. Zimbabwe, Mozambique and Swaziland are briefly considered. Key words--traditional
healers,
South
Africa,
health
1990’s in South Africa has been a period of rapid change. The unbanning of the African National and Pan African& Congresses, and the government’s commitment to the removal of racial discrimination, have heralded a move away from the era of ‘classical apartheid’ to a period of ‘social transition’. One of the most important tasks for anti-apartheid forces during this period is to develop (realistic) policies for the future. Within health care this transitional phase offers the opportunity to debate and develop approaches which will provide, or at least move towards, adequate and appropriate health care for all. The period before 1990 saw the anti-apartheid health organisations inside South Africa [I], and the health departments of the liberation movements primarily involved in political activism, in service provision (such as treating ex-detainees or soldiers in the field) and in organising and educating for better health and health care. Health policy was given minimal emphasis. Now however, policy is high on the agenda of these groups and alternatives are being seriously debated and discussed [2]. One important area which has received very little attention thus far however is what role, if any, traditional healers will play in ‘post-apartheid’ health care. It is very likely that a majority government will review and reformulate policy around traditional healers after independence-as occurred in many other African states. Already certain traditional healer groupings have approached the African National Congress with demands for legislative change. When policy is reconsidered it is essential that the relevant debates, experiences and available knowledge are considered. While we do not claim that this article manages to do this in full, many of the more importarit issues for policy makers are presented. This article briefly sets out the present
policy
status and utilisation of traditional healers in South Africa; outlines options which may be chosen if greater linkages between traditional and the formal health system are to be made; puts forward arguments from both proponents of a relationship between the ‘formal’ health sector and traditional healers and those that are opposed to this; and looks (only briefly) at examples of policies adopted by three neighbouring countries and the consequences of these choices. While the article is predominantly a survey of the literature, additional arguments not commonly associated with the ‘traditional healers debate’ are introduced [3]. The intention of this article is not to argue for one position over any other, but rather to present the arguments as objectively as possible in order to facilitate and encourage further debate and clearer policy thinking.
The early
TRADITIONAL
HEALERS
IN SOUTH
AFRICA
There are broadly three types of traditional healers available to South African consumers [4]. First the traditional doctor or inpanga. This is generally a male who uses herbal and other medicinal preparations for treating disease. Second the isangoma (Zulu) (diviner), ding&z (Sotho) or amgqira (Xhosa). This is usually a woman who operates within a traditional religious supernatural context and acts as a medium with the ancestral shades. Third the umprofethi or umfhandazi (faith healer) who integrates Christian ritual and traditional practices. This latter group can be traced to the rise of the independent African church movement which broke away from the more Western oriented missionary churches. They are not ‘traditional’ in the commonly used sense of the word in that they did not exist before the development of western medicine [S]. They are nonetheless included as they share a common theory of health and disease
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M. FREEMAN and M. MOTSEI
with other traditional healers, divine in a similar manner to diviners and treat various diseases with traditional herbs and remedies. The divisions into these three categories is convenient, in reality however they are often not distinct. For example there may be traditional doctors who use ‘bones’ or a voice from the ancestors to diagnose disease, a ‘sangoma’ who treats with herbs and so on. In addition a number of traditional practices have undergone changes to suit modern and technological advancements [6]. Officially the use of traditional healers in South Africa is outlawed. In 1974 the Health Act forbade healers not registered with the South African Medical and Dental Council (SAMDC) from practising or performing any act pertaining to the medical profession. De facto however the SAMDC generally turns a blind eye to traditional healers, and a few co-operative ventures between traditional and modern health care practitioners occur [7]. For the most part however the modern and traditional systems of health care operate independently with consumers choosing whom to consult. Despite the official illegality, a number of organisations register and represent (or claim to represent) the interests of traditional healers. These include the Southern African Traditional Healers Council, the Association of Traditional Healers of Southern Africa, The Congress of Traditional Doctors of Southern Africa, the African Dingaka Association and the African Skilled Herbalist Association. The exact number of traditional healers in South Africa and their utilisation is very difficult to assess. Karlsson and Moloantoa have suggested however that there are probably in the region of 150,000 traditional healers [8]. This suggests a massive consumer base. Many of these consultations are carried out at the same time as the patient may be receiving modern health care, or either before or after consultation with the modern health care system [9].
WHAT OPTIONS MODERN
EXIST FOR LINKS BETWEEN THE HEALTH
TRADITIONAL
SERVICES AND HEALERS?
A number of authors have outlined options open to health planners [IO-141. In this section we present three alternatives which we consider the most important possibilities for linking modern and traditional health care systems. These positions are first presented without review and without discussion on their feasibility. Some discussion arises later in the paper. Option
1: Incorporation
In this option it is suggested that traditional healers are integrated into health care systems (usually within a primary care approach) as ‘first-line’ health practitioners. Their function is seen as primarily carrying out services researched and designed within the scien-
tific health-care system. The inclusion of traditional healers who would spread curative as well as preventive and promotive health care was suggested at the World Health Organisation Conference at Alma Ata in 1978 [I51 as part of a primary health care approach. The importance of traditional healers was emphasised because of their availability and influence in the community. The option is well illustrated by Matjila who identifies a role for traditional healers in the prevention of illness. He points to the UNICEF designed GOBI FFF (Growth monitoring, Oral rehydration, Breast-feeding, Immunisation. Family planning, supplementary Feeding, and Female education) programme for reducing infant and under 5 mortality and morbidity in developing countries, and says: Dissemination of knowledge to influential members of the community is essential to enlist their co-operation in modifying attitudes and in motivating people to carry out health promoting practices. Such influential members of the community include ministers of religion, teachers and, of course, Traditional Healers. Not only are Traditional Healers influential but they are acceptable to and utilised by a part of the African community [16].
In this model the traditional healer functions in a very similar role to that of a Village Health Worker. Both would be involved in preventing illness, promoting health and treating specific disorders-while referring others who require more specialised care. It is also possible within this option that certain practices of traditional healers are regulated, and if found to be harmful by the scientific community, are strongly discouraged or even banned. Programmes within this option have begun in South Africa. For example at the Madadeni hospital in Natal inyangas and sangomas have regular meetings with the doctors. This has resulted in patients with chronic diseases receiving their regular (western) medicines from the traditional healers in their district rather than having to make the trip to the hospital each time medication is needed. Option 2: Co-operation
Jcollaboration
In this option both the traditional and western health systems remain essentially autonomous and each retains its own methods of operation and explanation; however practitioners from the two systems co-operate through the recognition of the importance and health value of the other. In the first instance this co-operation may take the form of ‘mutual referral’. Practitioners from both paradigms would recognise the efficacy of the other in the treatment of particular disorders and would thus refer to each other in the appropriate circumstances. Practitioners would come to an agreement as to what disorders should be referred to whom. Alternatively, it may be felt that either treatment is insufficient on its own, and that it may be necessary to consult both a western and a traditional healer for the same illness. A patient may for example consult
Traditional healers in the ‘new’ South Africa a western trained health worker for curative treatment and a traditional healer for cultural explanations for the causes of the illness. Ben Tovim, a psychiatrist working in Botswana quotes a patient as saying “the (traditional) Tswana doctor tells me why I am ill. Your medicine cures the illness as it affects my body” [17]. At present in South Africa ‘dual treatment’ regularly takes place [9]. For most people in South Africa who cannot afford the ‘fee-for-service’ charges of private medical practitioners, the state provides and pays for health services-albeit often inadequate care. Payment for traditional healers are not subsidised, and the traditional healer operates outside the formal health setting and at the financial cost of the patient alone. If this option is decided upon it may be possible to have both traditional and allopathic medicine operating within the ‘formal’ sector. Option 3: Total integration This option would involve the evolution of a ‘new’ healing system through the blending of the two systems. People seeking help would usually not receive either a pure western or traditional treatment, but a combination of the two. This could in itself take various forms. For example the explanation of the illness may be a combination of traditional and western understanding. Taking TB for instance, a person may be informed of the existence of the tubercle bacillus, and be provided with a scientific explanation of how the disease has taken root in the biological system, but at the same time be informed why he/she of all people developed the problem with an explanation involving witchcraft, annoyance of the ancestors or other ‘supernatural’ reasons. Practitioners would in all likelihood carry both western and traditional medication and prescribe either or both depending on the diagnosis. A small example of such integration is the practice of certain Traditional Birth Attendants (TBAs) [IQ The unification of the two disciplines is clearly seen through the use of traditional herbs to induce labour and bathing the newborn infant in water treated with traditional remedies to ‘protect’ the child, but at the same time using western apparatus for cutting and treating the umbilical cord.
DEBATES FOR AND AGAINST THE INCLUSION OF TRADITIONAL
HEALERS AS A HEALTH CARE RESOURCE
A number of arguments have been put forward as to why traditional healers should or should not be included in health care services. Many of the most important of these are discussed here. Arguments in favour include the lack of health resources in developing countries and the availability and accessibility of traditional healers; that traditional healers
1185
are part of African culture and should thus be encouraged and accepted; that the process of traditional healing has advantages over western health care, and that many traditional healing practices are effective. The arguments against inclusion range from the outright rejection of traditional healing to practical problems of registration. Discussed here are the harmful effects of traditional medicine; its superstitious nature; that inclusion will mean a ‘colonisation’ of traditional medicine and a threat to traditional healer’s status and remuneration; that traditional healers ‘disempower’ their patients; that traditional explanations are ‘false consciousness’; and that inclusion will involve numerous practical problems which may be impossible to overcome. (a) Lack of adequate resources seming the ‘African’ population One of the major reasons for the resurgence of interest in traditional healing shown by many organisations and governments previously sceptical of anything other than scientific medicine has been the fact that there are inadequate conventional health resources to meet needs. It has been estimated that 70-80% of the population in lesser developed countries have little or no access to basic health services [14]. In the 1970’s many countries realised that one of the most effective means of achieving health care for all was to utilise resources already existing in communities-among which were traditional healers. Green in fact claimed that the scarcity of resources is such that “. . public health goals probably cannot in the foreseeable future be realised in Africa without some form of participation in goal attainment on the part of indigenous healers. The numbers are simply not there . . .” [ 191. Compared with other African countries however South Africa is fairly well endowed with health personnel, and the problem of the lack of adequate ‘modern’ care for the majority is (in certain categories of health worker at least) not so much the lack of resources, as much as a problem with distribution and approach to care. While it is very difficult to calculate the exact numbers of health workers practising in South Africa, estimates indicate reasonable practitioner to population ratios in many health worker categories. For example there is approximately one registered nurse and one doctor per 429 and 1811 population respectively [20]. This compares well with the World Health Organisation recommendation of one nurse per 500 population, and shows South Africa to be between ‘upper middle income economies’ and ‘high income oil producing countries’ as far as the number of doctors is concerned [20]. Nonetheless for the majority black population adequate care is not available and will not simply become available. While the desegregation of facilities for all race groups will, when achieved, go some way to equalising health care between race groups,
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FREEMAN and M. MOTSEI
and a primary health care approach will improve the availability of health care considerably, comprehensive and adequate ‘modern’ health care in the rural areas and in the black urban townships is still a long way off. At present in remote areas and in urban ‘townships’ many people turn to traditional healers in times of sickness, and for them primary health care may be synonymous with traditional medicine. For the foreseeable future at least it would seem that traditional healers will continue to offer greater accessibility. (6) African healing for Africans ‘Culture’ is a further reason for developing the role of traditional healers. It is said that colonial rule has systematically eroded African life style to the detriment of the African people [2l]. Not only has people’s land been appropriated, Africans impoverished through colonial and capitalist development, but their very way of life ridiculed, taken away and replaced by ‘western’ modes of being. To undermine the role of traditional healers, who are an ‘outgrowth and expression’ of culture [14], is a part of this process. While few people would, we believe, argue that there is no place for western health care, many would say that this should not be at the expense of traditional care. More practically large numbers of African people, even in urban areas, use traditional healers because of the belief in the explanation and cure provided by traditional medicine. Even amongst people who generally use western medicine when they are sick there are particular instances when the illness is seen to have African experiential causes, and can therefore not be treated by allopathic medicine (personal communication with Mr Zungu, National President of the Southern African Traditional Healers Council). It seems that whether traditional healers are included in a health plan or not, consumers will continue to find the practitioners who they believe are the only people capable of healing them. (c) The process of traditional healing Western health care, it has been argued, has made major technological advancements, but with this the human quality of care has declined. This is reflected in the impersonal and often inconsiderate health workers, the inadequate explanation which is often given of the diagnosis and procedures performed and generally a concentration on the purely medical aspects of health care [22]. Traditional healing on the other hand, involves the whole person. Care is not only directed at the biological aspect of the person, but at the social, psychological and spiritual as well. Neumann and Lauro say that ‘many of the practices of traditional medicine practitioners are designed to preserve cultural institutions and to help the patient live at peace with family, clan, village, tribe and inner self’ [ 141.
Traditional healers are involved in prevention of illness or misfortune. This means that the traditional healer becomes a full part of the socio-cultural life of the members of the community as a whole. Unlike modern healers, traditional healers are not purely associated with ‘illness’ but very much with ‘health’. (d) EfSecticeness of traditional medicines Traditional medicines are often effective with illnesses such as diarrhoea, headaches and other pains, swellings and in sedating patients [I I]. Though the proportion of pharmacologically active properties of traditional herbs used in South Africa is uncertain [23], there are clearly medicines which are effective. Success in treating psychological problems is well known and often recognised. (e) Harmful effects of traditional medicines Counterbalancing the previous point is the argument that traditional medicines are harmful. Green and Makuba [I I] have pointed out four such practices carried out in Swaziland, each of which is also practised in South Africa. These are medicinal enemas to treat and prevent childhood diarrhoea; induced vomiting for patients with weak hearts, tuberculosis patients etc; traditional vaccinations done with an unclean razor; medicines given which are dangerous either by themselves or if taken at the same time as modern medicines. (f)
Traditional healing belongs to pre -cirilisation
Traditional healers, far from narrowing their focus to the merely technical (as in modern health care), are open to a wide range of mostly ‘mystical’ explanations. Hammond-Tooke points out that “much illness is explained in quite explicitly religious terms, not only as being caused by ‘spiritual’ entities, but also in terms of moral responsibility” [6]. For most western practitioners explanation of illness which falls outside the laws of natural science is pseudoscientific, primitive and simply wrong. This perception, which began with the first historical contacts with African culture, continues to have strong support. For example Dr Nthato Motlana, member of the influential Soweto Civic Association, reflected this position when he said recently “Most of it (traditional medicine) is based on superstition, meaningless pseudo-psychological mumbo-jumbo, which is positively harmful” [24]. Another argument put forward against traditional healers is that community disharmony may be caused because guilt for a person’s illness may be put onto kin, neighbours or consociates. In extreme cases this may lead to ostracism and even death of ‘innocent’ people. While in certain instances witchcraft accusations may be caused by community conflict, Hammond-Tooke points out that such accusations may in turn cause conflict if publicly articulated [6].
Traditional healers in the ‘new’ South Africa (g) ‘Colonising’
traditional medicine
It is not just the modern health sector but the traditional healers themselves who may not want closer relationships with the western health services. Traditional healers may argue that inclusion is only likely to benefit western medicine and not themselves. This can be illustrated through the examples of incorporation (the use of traditional healers as primary care workers) and through co-operation (mutual referral being the example used). Nzimande argues that incorporation may not simply be a spreading of health care but “may be a paternalistic way of making the clients of traditional healers available to western interventions” [21]. It is also argued that as the traditional healer becomes more involved in first-line health ‘on behalf of’ scientific medicine so the modus operandi and the ‘culture’ of traditional healing is likely to be undermined. Similarly, while the option of mutual referral appears fair, it is argued that the reality is likely to favour western medicine. At present in South Africa, referral which does occur is overwhelmingly from traditional healer ta western medicine and this is not likely to change. Reasons for this include the deep suspicion which most western practitioners have for traditional healing and their fear that their hegemony over health care (and perhaps their wealth too) may be threatened by traditional healing [19]. It may be argued then that the greatest potential threat to traditional healing practices may not be through being left out of formal health care structures but through being ‘brought in’ and ‘taken over’ by western medicine. The process of inclusion, it is argued, would be a slow but comprehensive ‘colonisation’ of traditional healing. Moreover it has been argued that traditional healers are tolerated only because they take a strain off the overworked modem health care system and are used as an excuse for not providing adequate formal care. (II) A threat to traditional healer’s status and remunerarion
The option of integration aside, the range of disorders that the traditional healer will attend to after inclusion is likely to decrease. It is argued that by acknowledging that western health care is able to deal with more, or more severe, illnesses, the infallibility on which much of the power of the traditional healer depends, will be eroded-and with it their status. Asuni points out that if traditional healers come under supervision and control and have to comply with certain written regulations “this will immediately diminish his (sic) image of omnipotence, and consequently his therapeutic efficacy” [IO]. Remuneration may also decrease. At present the rates of traditional healers are not regulated and many have very lucrative practices. If traditional
1187
healers were brought into a national health plan many may expect to lose this high income. (i) The political-economic
perspective
Health is never ‘apolitical’. From this point of view it is argued that the decision to either encourage or reject the use of traditional healers in health care must be taken in the light of political as well as ‘purely health’ considerations. It is argued here that traditional healers ‘disempower’ the patient and may obstruct the understanding of the political dimensions of health. Health care involves a relationship between a ‘healer’ and a ‘patient’. In both traditional and western medicine this involves a ritual in which cure is prescribed by the authority (the healer) to the passive and ignorant receiver (the patient), This relationship is said to reflect and reproduce the authoritarian social order in which each of these interventions take place. Werner, and indeed the WHO, have suggested that it is possible to practice ‘scientific’ medicine in a more democratic manner, in which the relationship between health worker and patient is equalised [25]. On the other hand, it is argued that there may be a contradiction between traditional healing and democratic health practices. It is suggested that traditional healing is inextricable from the power given to the healer. Listening to and believing what the authority says is a crucial and integral part of the healing process in a way in which the ritual and authority of western medicine is not. Thus while western medicine is at present still far from democratic, there is in principle no reason why it could not become more so. On the other hand it is argued that if the authority of the traditional healer were removed, a fundamental principle of the treatment would be undermined as the effectiveness of traditional healers lies precisely in their authority [6]. Another important argument is that the explanation of disease or ailment may mask the ‘real’ reasons for illness. In western health care, explanation is most often presented as being within the individual, and purely in biochemical terms [26], while in traditional medicine the explanation is often ‘micro-social’ (family or community) and/or supernatural. It may be argued that neither of these conceptualisations explains illness, or is able to intervene adequately, because neither addresses the socioeconomic forces that determine health status. Neither takes the step of seeing that social and economic conditions determine the health of the population and that changes in these conditions are essential for good health. However a significant trend has developed within western health care which satisfactorily merges ‘natural scientific’ explanation with that rooted in the political economy of health [26-281. This is best illustrated by example-TB is again used. It is reasonable to assume that a western trained physician may easily accept that although a bacillus
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M. FREEMAN and M. MOTSEI
is the causative micro-biological agent, TB will not spread except in the face of poverty, which renders individuals susceptible to infection. This poverty in turn can be understood in terms of Apartheid or even capitalism. A similar combination of supernatural and socio-political perspectives on the other hand would lead to absurd and illogical conclusions. For example it would suggest that the ancestors are most displeased with those in conditions of poverty, or that the afflicted are in conditions of poverty because their ancestors are displeased with them! (j) Practical obstacles to inclusion Inclusion of traditional healers into health care structures is an extremely difficult task [29]. For example if incorporation or co-operation were decided on, it would be necessary to ensure adequate standards of health care and control of tariffs through the registration of all health practitioners. But while registration of traditional healers is well under way in most African countries [19] this is a very complex process and has not been fully achieved anywhere in the world. Whereas in western medical circles there are guidelines for registration based on official qualification, and in some cases experience, there is no clear equivalent for traditional healers. For example, to gain membership of the Traditional Healers Council of Southern Africa applicants need to go through a ‘test’ to determine whether they are ‘genuine’ healers or not. This involves investigation into the healer’s training, length of practice, supervision etc. Applicants for registration also go through either an oral or a written examination. However it is questionable whether using this form of discrimination would be successful in eliminating the ‘undesirables’-and only the ‘undesirables’. Given the range and form of healers and the secrecy in which most operate, this registration process is dubious. Already in South Africa the various registering bodies conflict around who registers bona fide healers. Many of these organisations claim that anyone not registered with them, may be a ‘quack’ or a ‘witchdoctor’. Also, it would be necessary to include all ‘genuine’ healers. However, many traditional healers are unlikely to present themselves for registration as they would not see any advantage in this. It has in fact been found that traditional healers interested in registering are those especially interested in learning more about modern/western medicine [l9]. According to Fassin and Fassin “the stronger the traditional legitimacy, the less need for rational-legal legitimation” [30]. Registration could of course be enforced by law, healers could be enticed to join through government subsidisation of patients attending registered healers, or healers could be attracted to register by allowing only registered healers the authority to book employees off work etc. Whether any of these solutions would solve the problem is uncertain.
The problems of financing traditional healers is a further obstacle. At present traditional healers are paid on a ‘fee-for-service’ basis. This has been seen to be advantageous to the health care system as a whole as the more people who use traditional healers, the less burden there would be on the state to provide health care through the formal sector. However others have pointed to the fallacy and danger in this point of view [31]. It is argued that in reality those that make most use of traditional healers are those who can least afford to pay for their own health care. Thus if traditional healers are to be integrated into the health care system in South Africa it will be necessary (at some point) to shift the form of payment of traditional healers to one in which the State (or national cover of some sort) would pay. This may or may not be acceptable to the traditional healer, but more pertinent at this point is where the money would be found for incorporation. The health budget in South Africa is already stretched to the point where inadequate services are provided and staff are underpaid. It seems doubtful that an additional estimated 150,000 health workers could be accommodated within the health budget. The problem would be even worse if the option of consulting both a traditional and a western healer was adopted. Moreover it can be expected that planners would demand proof of efficacy before including traditional healers in the system. The rub here is that much of the traditional healer’s ‘cure’ is psychological and social, and therefore extremely difficult to measure.
LESSONS FR0.M NEIGHBOURING
STATES
Three different strategies used by countries on South Africa’s borders reflect possibilities and problems with different approaches. Zimbabwe took the policy of registration and inclusion of traditional healers into its national health service, Mozambique took the position of ‘ideological confrontation’ and Swaziland a policy of ‘improved co-operation’. It is significant that none of these policies have in fact resulted in the anticipated consequences. Zimbabwe In Zimbabwe, despite official recognition of traditional healers and a policy of inclusion, there has been both formal and informal resistance to the policy. For example though co-operation with and recognition of ZINATHA (Zimbabwe National Traditional Healer’s Association) occurred after independence, the official council which was to regulate integration under the Traditional Medical Practitioners Act of 1981 had, by 1989, never met [6]. ‘On the ground’ co-operation has also been far from comprehensive. This probably reflects opposition to
Traditional
healers
in the ‘new’ South
the policy from both modern and traditional practitioners for many of the reasons already discussed in this paper. It is worth adding at this point however a point made by Green [19] that many specifically African professionals see traditional healers as a threat to their professionalism, and this acts against greater co-operation. Not all traditional healers have registered with the association and refer=1 which does occur, although meant to be mutual, is often loaded in favour of referral to the modern health sector [32]. Mozambique
Mozambique’s effective ‘illegalisation’ of traditional healers on the grounds that “healers were, and potentially still are, part of the old ‘feudal’ system, unproductive, giving support to the chiefs, furthering ‘superstition’ and liable to exploit the poor in their need” [33] has not been successful. Despite the policy, over half the population continued and continues to use traditional healers. Moreover, the policy caused tension between the government and the masses of the people who felt their choice and their cultural expression were being interfered with 1341. The realisation that the policy had failed recently prompted the Frelimo government to recognise its error and change its approach. People now have a free choice of who they choose for health care, and associations of traditional healers are encouraged [35]. The government has not changed its ideological position but want to demonstrate the efficacy of modern health care through the provision of the services, rather than through a policy of official rejection of the traditional alternative 1341. Swaziland
Attempts have been made since the 1940s to recognise and register traditional healers in Swaziland [ 111. While as yet there is no formal recognition, the government have nonetheless encouraged links with traditional healers and have even participated in joint programmes. For example around 1983 healers received training in the use of oral rehydration therapy together with free UNICEF packets of rehydration salts. It was thought that this programme would be successful because for example healers had indicated in a survey that they wanted the means to prevent deaths of patients with symptoms of dehydration from cholera and other diseases, because the distribution of the packets was seen to constitute a gesture of trust and cooperation on the part of the government and so on [I I]. However a couple of years after the programme had started, it had been ‘stalled’ [19]. The reasons why the project did not reach its goals are unknown to the authors, though again sufficient reasons have been given in this article to indicate why ‘incorporative’ approaches may fail.
Africa
1189 CONCLUSION
In planning health policy for a new South Africa, decisions of crucial significance will have to take place, one of which is the role of traditional healers in health care. A range of options are open. These range from banning traditional healers and hunting them down so that their practices are stopped, through options such as the retention of the starus quo-where western health care occurs through the formal sector and traditional healing through the informal sector, with pockets of co-operation; to alternatives in which the state actively intervenes to achieve collaborative, incorporative or integrative programmes. We have been careful not to take sides on the issue and any bias detected towards one position is purely unconscious. One thing that we are clear on though and that is that policy on traditional healers must be taken with clear reasons and with due consideration of opposing arguments. We hope that this paper facilitates this process.
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