Module 6: Integrative Medicine: Incorporating Traditional Healers into Public Health Delivery

Introduction to Traditional Medicine

The World Health Organization (WHO) defines traditional medicine as “the sum total of knowledge, skills, and practices based on the theories, beliefs, and experiences indigenous to different cultures that are used to maintain health, as well as to prevent, diagnose, improve, or treat physical and mental illnesses”.(1) Traditional medical practices can include plant, animal, and mineral-based medicines, massage, spiritual therapies, and a variety of other techniques unique to different regions and cultures.(2) Traditional medicine is typically contrasted with conventional medicine, also referred to as allopathic, modern, orthodox, or Western medicine, which is based on biochemical theories of illness.

In countries with limited access to allopathic medicine, traditional medicine is often the main source of health care. In some countries in Asia and Africa, 80% of the population uses traditional medicine for primary health care needs.(3) In many developing nations, there are more traditional healers than there are allopathic practitioners, and the population of allopathic practitioners is often concentrated in urban areas, further reducing rural access to medical care. In Uganda, the ratio of biomedical practitioners to the population is approximately 1:20,000, while the ratio of traditional healers to the population can be as low as 1:200.(4) Other studies report that Uganda has at least one traditional healer per village, and four out of five Ugandans seek care from traditional healers.(5) In regions of Ethiopia where modern public health services are limited or not accessible, 80% of the population relies on traditional medicine for primary health care. Traditional medical services are also sought in urban areas of Ethiopia, where allopathic services are more readily available, and contribute considerably to the public health care system in Addis Ababa, the capital city.(6) 

Traditional medical practices vary among geographic regions and cultures, and traditional health care is sought for a variety of reasons. Ethnographic studies often describe traditional healers’ ability to explain illness in a way that is culturally relevant and understandable. For instance, Lemelson (2004) reports that Balinese traditional explanations for illness may provide an “understandable and integrated system of meaning for [psychological] disorders” that can be highly valuable to the patient, even if the traditional treatment does not relieve the patient’s symptoms.(7) In addition, traditional medicine is the most accessible form (and sometimes the only form) of health care in many areas. In Edo State, Nigeria, childbearing mothers reported that they sought care from traditional birth attendants (TBAs) instead of from biomedical practitioners because TBA services were more available and less expensive than clinic-based care.(8) Likewise, women in Kwame Danso, a village in Ghana’s Sene District, tended to seek traditional care during childbirth, instead of seeking supervised delivery at the regional health center, because of the costs associated with treatment and travel to the clinic. Jansen (2006) emphasizes that many of the Ghanaian women made use of the allopathic health center’s antenatal services, and thus they did not universally reject allopathic care, but chose traditional care during childbirth for logistical and economic reasons.(9)

The Need for Integrative Medicine

Despite the important role that traditional medical practitioners play in many communities, their services are often unregulated and unaccepted by the modern health care sector. In Edo State, Nigeria, questionnaires, in-depth interviews, and focus group discussions conducted with 48 TBAs, 309 childbearing women, and 34 medical professionals (clinic-based doctors, nurses, and midwives) revealed conflicting attitudes towards traditional medicine. Although 100% of the TBAs reported that the quality of care they provided was adequate, 53% of childbearing women and 100% of the medical professionals reported that the quality of care provided by TBAs was inadequate.(10)

The divide between traditional and modern health care systems is also demonstrated by a lack of collaboration. Kaboru et al. (2006) argue that in Zambia, where traditional healers are considered a useful potential resource to scale up HIV/AIDS prevention and care efforts, an effective response to the HIV/AIDS crisis “requires consideration of the collaboration between traditional and biomedical health providers”. The authors conducted a cross-sectional study in two Zambian urban areas, Ndola and Kabwe, interviewing 152 biomedical health practitioners (BHPs) and 144 traditional health practitioners (THPs). Structured questionnaires revealed a “very low” level of collaboration between BHPs and THPs; only 24% of BHPs and 13% of THPs reported contact with the other sector within the previous six months. Although THPs identified many factors impeding collaboration, (e.g. “the lack of formal collaborative mechanisms, their own ability to treat, and resistance from BHPs”) a large majority of both groups of practitioners “acknowledged the potential role of THPs” in HIV/AIDS prevention and care efforts.(11)

The need for collaboration between traditional and biomedical practitioners is also highlighted when traditional practices negatively affect public health delivery efforts. For instance, childhood vaccinations have significantly decreased childhood morbidity and mortality rates from preventable infectious diseases such as tuberculosis, diphtheria, pertussis, tetanus, measles, and polio. However, vaccination services are severely under-utilized in many developing nations. In Haiti, for instance, about 140,000 children die of preventable diseases each year, and only 30% of children aged 12 to 23 months are fully vaccinated. Muula et al. (2009) studied a sample of 720 mothers of children five years old or younger in Pont-Sonde, Haiti to investigate the relationship between traditional medical care and child vaccination status. Children of women who often or always sought care from traditional healers were 53% less likely to be fully vaccinated than were children whose mothers never used traditional healers. The researchers concluded that these results highlight the importance of collaborating with traditional healers to encourage them to support biomedical interventions that improve the health of their communities.(12)

WHO Recommendations(13)

Recognizing the widespread reliance on traditional medicine and the central role it plays in many communities, the World Health Organization (WHO) has worked with its Member States to promote the use of traditional medicine in health care delivery. The WHO lists the following goals for the integration of traditional medicine into the modern health care system:

• Support and integrate traditional medicine into national health systems in combination with national policy and regulation for products, practices and providers.

• Ensure the use of safe, effective, and quality products and practices, based on available evidence.

• Acknowledge traditional medicine as part of primary health care, to increase access to care and preserve knowledge and resources.

• Increase the availability and affordability of traditional medicine, as appropriate, with an emphasis on access for poor populations.

• Ensure patient safety by upgrading the skills and knowledge of traditional medicine providers.

Integrative Medicine

Case Study: Makewe Hospital, Chile(14) 

In Chile, efforts to develop integrative health care began in the 1980s, when the Ministry of Health recognized a governmental initiative for “intercultural health”. Chile’s Makewe Hospital offers one example of an intercultural health program. The hospital is managed by the Mapuche, an indigenous community, who established the Indigenous Health Association Makewe-Pelale in 1999 to save the hospital from closure. Currently, half of the hospital workers are Mapuche, the other half are non-Mapuche, and the Indigenous Health Association works to facilitate cooperation between biomedical treatment and Mapuche beliefs. For instance, the Indigenous Health Association organizes committees to enable interaction between the hospital administrators and the Mapuche community. The hospital also employs a team of Mapuche community members, including machis (Mapuche traditional healers) and a gutamchefe, a specialist in treating fractures and dislocations, and the non-Mapuche staff is taught about Mapuche culture and medicine.  

In 2009, Torri (2012) conducted 42 semi-structured and open-ended interviews with Mapuche patients, doctors, and nurses at Makewe Hospital to evaluate the hospital’s intercultural health care model. The majority (60%) of patients used both the Mapuche and the biomedical systems, 30% used only biomedicine, and 10% sought care exclusively from Mapuche healers, suggesting that the hospital’s intercultural emphasis was successfully promoting the use of biomedical care while still respecting Mapuche practices. However, interview responses revealed that the nationally entrenched inequality between Mapuche and Chilean people could not be resolved simply by combining the two types of health care. Torri concluded that “effective and equitable intercultural health practices will not take place unless there [is] an integral valorization of the Mapuche culture”, highlighting the importance of integration and regulation of traditional medicine on a national scale.

Case Study: The School and Community Health Project, Kavrepalanchowk, Nepal(15)

Many integrative medicine programs have focused on training traditional healers in basic features of Western medicine to improve the prevention, recognition, and treatment of infectious diseases. In Nepal, which has an estimated 400,000 to 800,000 traditional healers but only 3,500 biomedical doctors, traditional healers can play a central role in scaling up community health care. Poudyal et al. (2003) evaluated the effectiveness of a biomedical training model developed by the School and Community Health Project (SCHP) for traditional healers in a rural area of Kavrepalanchowk, Nepal. Following the SCHP training model, instructors from the SCHP or the Nepalese Government trained 50 traditional healers and provided the healers with a first aid kit containing iodine tincture, cotton and bandage rolls, oral rehydration solution, and condoms, in addition to other basic medical supplies.

One year after training, semi-structured interviews were used to compare 48 trained traditional healers with 30 untrained traditional healers. Compared to the untrained healers, the trained healers had significantly better knowledge of allopathic medicine. For instance, trained healers had significantly better knowledge of prevention of malnutrition, acute respiratory infection, diarrhea, and HIV/AIDS, and were better able to identify the symptoms of those illnesses. In addition, the trained healers were more likely to refer patients to government health workers, and 52% of the trained healers used both modern and traditional treatment methods following the provision of the first aid kit. Although these results suggest that the biomedical training was effective, other studies emphasize that unidirectional training, in which conventional medicine is taught to traditional healers, does not promote intercultural collaboration and respect as fully as do programs that emphasize a mutual sharing of knowledge.(16)

Infectious Disease Initiatives

Numerous public health initiatives focus on incorporating traditional healers into health initiatives to prevent and treat infectious diseases, such as tuberculosis and HIV/AIDS. Colvin et al. (2003) explored the possibility of incorporating traditional healers into an established tuberculosis treatment program in Hlabisa, Kwa-Zulu-Natal, a rural health district in South Africa. Due to high numbers of tuberculosis (TB) cases, a community-based directly observed treatment, short-course (CB-DOTS) program was established in Hlabisa in 1992. Following discharge from the hospital, the patients’ treatment was overseen by a supervisor of their choosing: a layperson, community health worker, or clinic-based nurse. Patients starting the CB-DOTS program between 1999 and 2000 were offered the additional option of choosing a traditional healer as their supervisor. The 25 traditional healers who volunteered for the study attended two one-day training sessions on TB management. Supervisors directly observed patients’ treatment twice per week, kept a record of patient visits, and were visited monthly by the TB control program field worker.

There were no significant differences in treatment outcomes (e.g. treatment completion rate, death rate, etc.) between the 48 patients who selected traditional healers and the 227 patients who selected the other supervisor options. This suggested that traditional healers were equally as effective in supervising TB treatment as the supervisors in the established program. With nearly 300 traditional healers in Hlabisa, incorporating traditional healers into TB management programs may help scale up infectious disease management by providing a culturally sensitive way to increase adherence to treatment regimens.(17)

Other integrative health delivery programs, such as Uganda’s Traditional Healers and Modern Practitioners Together Against AIDS (THETA), Tanzania’s Tanga AIDS Working Group (TAWG), and Zimbabwe’s National Traditional Healers Association (ZINATHA), have used traditional healers to assist in the prevention and care of HIV/AIDS patients.(18) For instance, Furin (2011) performed a qualitative study of traditional healers’ involvement in a community-based HIV/AIDS treatment program rolling out antiretroviral therapy (ART) in two rural communities in Lesotho, South Africa. The program, Rural Health Initiative (RHI), is a “collaborative, community-based model” that was launched in 2006; it enrolled 4,521 patients in HIV care and started 2,354 patients on ART in its first 2.5 years of operation.(19)

Interviews, focus groups, and participant observation sessions with 17 traditional healers were conducted three months prior to and during the first two years of RHI’s implementation. Interviews with traditional healers prior to the start of RHI implementation revealed that all of the healers “expressed deep concerns” over introducing ART to their communities; their main concerns were the side effects of ART (88.2%), loss of income for traditional healers (76.4%), loss of community (58.8%), and their distrust of allopathic practitioners (33.5%). To address these concerns, the RHI strove to integrate traditional healers into the ART rollout effort by including healers at planning meetings, training them to participate in HIV prevention and treatment activities, and paying healers a referral fee for HIV-positive patients referred to the clinic. Interviews during the first two years of the program revealed that the integration efforts were largely successful; all of the healers who participated reported they actively monitored patients on ART, referred patients to the allopathic clinics for evaluation, and continued to provide the social and emotional support they had always offered to patients. Fourteen of the seventeen healers participated in joint conferences with the biomedical practitioners designed to offer opportunities for mutual education, and 14 of the 17 healers viewed the RHI project positively, suggesting that the adjustments RHI made to the program (based on responses from the traditional healers) helped promote intercultural collaboration and mutual satisfaction with the program’s results.(20)

Efforts to incorporate dhami-jhankris, Nepalese traditional healers, in the HIV/AIDS program of the United Nations Development Programme (UNDP) in Nepal’s Doti district also had promising results. Poudel et al. (2005) used a structured questionnaire and focus group discussions to assess 61 traditional healers’ knowledge of HIV transmission and preventive measures immediately prior to and 9-12 months after training. The training curriculum included the history of HIV/AIDS, facts and misconceptions about transmission, prevention strategies, diagnosis, importance of early treatment, prevention of other sexually transmitted infections (STIs), condom promotion, care and support of people living with HIV/AIDS, and the role of traditional healers in prevention and control of HIV/AIDS and other STIs.(21)

Prior to training, 80% of the healers had heard of Aidas, a local term for HIV/AIDS. Follow-up 9-12 months after training revealed that training was associated with significant improvement in traditional healers’ knowledge about the transmission and prevention of HIV. For instance, prior to training, 40.8% of healers who had heard about HIV/AIDS believed that HIV could be transmitted by shaking hands with an infected person; following training, only 8.3% of healers (incorrectly) identified hand shaking as a mode of transmission. Prior to training, 53.1% and 44.9% of healers correctly identified blood transfusion childbirth as possible modes of HIV transmission; following training, 100% of the healers correctly identified both as modes of transmission. Focus group interviews one year after training revealed that the trained traditional healers “provided culturally acceptable HIV/AIDS education to the local people, distributed condoms, and played a role in reducing the HIV/AIDS-related stigma”, an important development in Nepal, where talking about sexual issues and STIs is largely taboo.(22) 

Although more rigorous and quantitative research is needed on the integration of traditional and biomedical health care systems, the largely unmet need for global health care, the high availability of traditional healers, and the successes of early integrative medicine programs suggest that integrated health care systems will be essential to effective public health care delivery efforts.

Footnotes

(1) World Health Organization (WHO). 2008. “Traditional Medicine”.

(2) World Health Organization (WHO). 2005. “WHO Traditional Medicine Strategy”.

(3) World Health Organization (WHO). 2008. “Traditional Medicine”.

(4) World Health Organization (WHO). 2005. “WHO Traditional Medicine Strategy”.  

(5) Aboo, C. (2011). Profiles and outcomes of traditional healing practices for severe mental illnesses in two districts of Eastern Uganda. Global Health Action, 4:7117-7131.

(6) Birhan, W., Giday, M., Teklehaymanot, T. (2011). The contribution of traditional healers’ clinics to public health care system in Addis Ababa, Ethiopia: a cross-sectional study. Journal of Ethnobiology and Ethnomedicine, 7:39-45.

(7) Lemelson, R.B. (2004). Traditional healing and its discontents: efficacy and traditional therapies of neuropsychiatric disorders in Bali. Medical Anthropology Quarterly, 18(1): 48-76.

(8) Imogie, A.O., Agwubike, E.O., Aluko, K. (2002). Assessing the role of traditional birth attendants (TBAs) in health care delivery in Edo State, Nigeria. African Journal of Reproductive Health, 6(2): 94-100.

(9) Jansen, I. (2006). Decision making in childbirth: the influence of traditional structure in a Ghanaian village. International Nursing Review, 53:41-46.

(10) Imogie, A.O., Agwubike, E.O., Aluko, K. (2002). Assessing the role of traditional birth attendants (TBAs) in health care delivery in Edo State, Nigeria. African Journal of Reproductive Health, 6(2): 94-100.

(11) Kaboru, B.B., Falkenberg, T., Ndubani, P., Hojer, B., Vongo, R., Brugha, R., Faxelid, E. (2006). Can biomedical and traditional health care providers work together? Zambian practitioners’ experiences and attitudes towards collaboration in relation to STIs and HIV/AIDS care: a cross-sectional study. Human Resources for Health, 4:16-23.

(12) Muula, A.S., Polycarpe, M.Y., Job, J., Siziya, S., Rudatsikira, E. (2009). Association between maternal use of traditional healer services and child vaccination coverage in Pont-Sonde, Haiti. International Journal for Equity in Health, 8:1-8.

(13) World Health Organization (WHO). 2008. “Traditional Medicine”.

(14) Torri, M.C. (2012). Intercultural health practices: towards an equal recognition between indigenous medicine and biomedicine? A case study from Chile. Health Care Anal, 20:31-49.

(15) Poudyal, A.K., Jimba, M., Murakami, I., Silwak, R.C., Wakai, S., Kuratsuji, T. (2003). A traditional healers’ traditional model in rural Nepal: strengthening their roles in community health. Tropical Medicine and International Health, 8(10): 956-960.

(16) Kaboru, B.B., Falkenberg, T., Ndubani, P., Hojer, B., Vongo, R., Brugha, R., Faxelid, E. (2006). Can biomedical and traditional health care providers work together? Zambian practitioners’ experiences and attitudes towards collaboration in relation to STIs and HIV/AIDS care: a cross-sectional study. Human Resources for Health, 4:16-23.

(17) Colvin, M., Gumede, L., Grimwade, K., Maher, D., Wilkinson, D. (2003). Contribution of traditional healers to a rural tuberculosis control programme in Hlabisa, South Africa. Int J Tuberc Lung Dis, 7(9): 586-591.

(18) Kayombo, E.J., Uiso, F.B., Mbwambo, Z.H., Mahunnah, R.L., Moshi, M.J., Mgonda, Y.H. (2007). Initiating collaboration: Experience of initiating collaboration of traditional healers in managing HIV and AIDS in Tanzania. Journal of Ethnobiology and Ethnomedicine, 3:6-14. 

(19) Furin, J. (2011). The role of traditional healers in community-based HIV care in rural Lesotho. J Community Health, 36: 849-856.

(20) Ibid.

(21) Poudel, K.C., Jimba, M., Joshi, A.B., Poudel-Tandukar, K., Sharma, M., Wakai, S. (2005). Retention and effectiveness of HIV/AIDS training of traditional healers in far western Nepal. Tropical Medicine and International Health, 10(7): 640-646.

(22) Ibid.