'As such, if we continue to encourage them and work with them, I see traditional healers as partners in the development of vaccines and treatments for AIDS' Nguma 2005 p 3, UN Office for the Coordination of Humanitarian Affairs.
Since the beginning of the AIDS epidemic, patients have consulted both biomedical doctors and traditional healers for all kinds of physical, emotional and spiritual ills [1
]. Attempts to bring biomedical and traditional healthcare together to people living with HIV/AIDS have been made, at least since the early 1990s, [2
], when WHO recommended that traditional medicine be included in national responses to HIV; and hence the idea of collaboration [1
To handle the HIV/AIDS epidemic requires a mobilization of existing and potential resources of two health systems for coordinated controlled effort from the grassroots to national level [3
]. Thus the need for the collaboration of two healthcare systems is now more important in Sub-saharan Africa due to the ever increasing burden of HIV/AIDS [1
]. It has been noted that in behaviour for seeking healthcare support, a patient may start with allopathic medicine; and then move to traditional medicine and vice versa depending on what has been perceived to be the cause of disease/illness [3
]. Nevertheless, the problem is that each health system works independently because they have different theories on causation of disease/illness and its management [3
]; even though all are focusing on patients' welfare. It is being acknowledged that, healthcare systems are socially and culturally constructed in any community; these constructions include beliefs about the causes of illness and norms governing choice and evaluation of treatment as well as power relations [2
], therefore the socio-cultural aspects need to be taken into account in any healthcare system, and especially when fighting against the spread of HIV/AIDS.
In the Regional Workshop [13
] African governments expressed a need for a concerted, systematic and sustained effort at both local and regional levels to support and validate African traditional medicine on several fronts including evaluation of traditional remedies, spiritual aspects of healing, HIV prevention and care, standardization of processing and packaging traditional remedies, as well as protection of indigenous knowledge and intellectual property rights [13
]. It is vital that all methods of healthcare delivery and prevention are explored in order to curb this epidemic [10
As a result of this Regional Workshop [13
] and also UNAIDS [1
] recommendations, several models of collaboration between biomedical and traditional health practitioners have been developed like that of Traditional Healers and Modern Practitioners Together Against AIDS (THETA) in Uganda, and Tanga AIDS Working Group (TAWG) in Tanzania and Zimbabwe National Traditional Healers Association (ZINATHA) in Zimbabwe. The groups and associations are examples where biomedical healthcare practitioners are collaborating with traditional healthcare practitioners [1
]. Not only are such collaborations happening in these countries but also in Mozambique, South Africa and Cameroon to mention a few; attempts are being made to collaborate with traditional healers on the management of HIV/AIDS [1
The idea is sound, but the problem relates to how collaboration is being initiated and carried out when biomedicine and traditional medicine differ in theories on causation of disease/illness and even in management of the health problem in question [7
]. For example, in traditional medicine, the key issues include the following; firstly, ill health and other forms of misfortune are believed to be caused by either social causes (witchcraft, sorcery or evil eye), or by supernatural causes (gods, spirits, ancestral spirits) or natural causes (accidents, weather, living environment, heritage, etc) [14
]. Secondly, divination is one of the main tools in identifying both illnesses/diseases and causes [4
]. Diviners, skilled in the process of divination, and supplemented with skilled history taking during interviews with patients/relatives can vividly see indicators for the type of illnesses/diseases and their causes [4
]. Thirdly, success in treating patient's illness/disease is measured by pragmatic results i. e. relieves suffering and allows harmonious living in the community [15
Nevertheless, traditional healers (practitioners of traditional medicine) have scanty information about AIDS because it is a new disease, and they lack standardized training [3
] in healthcare. In addition, herbal treatments have often never been rigorously evaluated, nor are they always properly prepared or standardized, are usually poorly packaged and preserved, limiting their usefulness and accessibility to the immediate production site [2
In biomedicine, on the other hand, key issues are; firstly disease is seen as deviation from normal values, accompanied by abnormalities in structure or function by body organs or systems. Secondly, pathological processes are firmly identified by blood tests, X rays, scans and other investigations usually carried out in specialised laboratories or clinics. Thirdly, the broad model of biomedicine is mainly directed towards discovering and quantifying physico-chemical information about the patient, rather than less measurable societal and emotional factors which are common in the community where the patient lives. The ideology instilled in many biomedical health workers has in turn led them to be prejudiced against traditional medicine and traditional healers [7
]. Further more, the impact of biomedical ideology of disease causation has led national governments and ministries of health to be less enthusiastic about co-operation with traditional healers [12
]. The question which we are asking when thinking about collaboration is: 'Have biomedical practitioners now changed their views on traditional medicine since the rise in incidence of HIV/AIDS?'
Documented systematic attempts at collaboration with the traditional health care sector have mainly involved organising traditional healers into national organisations, training programmes for healers, and laboratory testing of traditionally used herbs [2
]. Achievements in these programmes included willingness of hospitals and clinics in some countries, such as Kenya and Tanzania, to provide on-site practice facilities to traditional healers, combined with training programmes [20
]. But considerable challenges remain. For example, the process of actualizing collaboration is not transparent meaning it is possible for it to be dominated by one group (often biomedical practitioners) in the so-called 'collaboration process'. The sustainability of such collaboration is highly questionable. Any effective collaboration requires a mutual understanding through dialogue, an exchange of materials and technology and signing memorandum of understanding (MoU). MoU in this article is defined as freely negotiated agreement between parties in a collaborative undertaking. MoU contains intentions, obligations and mutual responsibilities between the collaborating parties. The role of MoU is, therefore, to bring into line functions and create more avenues for collaboration for the mutual benefits of each party. Furthermore, the question of who will receive which benefits from the collaboration remains.
Framework for collaboration with traditional healers
Collaboration, literally, consists of working together with one or more others on mutual understanding which may accompany signing a memorandum of understanding. Collaboration between traditional healers and biomedical practitioners in African countries south of the Sahara is ever more important now in improving healthcare because it is likely to widen the scope of sharing and collecting information and, allows for shared leadership, decisions, ownership, vision, and responsibility [1
] in the management of health problems and especially HIV/AIDS.
The proposed framework for collaboration between traditional healers and biomedical practitioners assumes that as an individual, group or community discovers health care solutions they also expand capacity within collaboration. Further when creativity, skills, self-sufficiency, and motivation, accompany collaboration, possibilities are extended, doors are opened, capacity expanded, and success realized in improving healthcare to the community.
However, this can only be achieved if some of the key elements proposed by King [2
] are included during the initiation of a collaboration program. These key elements are; building mutual respect between biomedical and traditional health practitioners through dialogue on matters of interest, signing a memorandum of understanding; stressing complementarities of both systems by referral from one health system to another. Other proposed key elements to cement collaboration are showing humility and respect during workshop regardless of level of education; cultivating transparency through dialogue and negotiation, eagerness to learn from one another. Consistent exchange of information on management of illnesses/diseases, materials and technology used in preparation and dispensing are also key to collaboration. But most importantly is the selection of genuine healers i. e recognised traditional healers in the community through competence in managing diseases/illnesses and trustworthiness.
Furthermore, involving community leaders and members in selecting traditional healers for collaboration by rating the traditional healers on the level of competence in managing claimed diseases/illnesses they are treating and trustworthiness on the basis of clients' views. This can be complemented by involving biomedical health workers listing traditional healers on the basis of informal referral cases noted in their respective catchments areas. All in all, there is a need of planning for a long-term collaboration which can be measured by willingness to participate on key issues like vaccination and prevention of infectious diseases. The number of collaboration meetings and number of attendances can also be used as a measure of collaboration.
In addition, discussing differences and conflicts in cosmologies, evolution and changes in both health systems can be assessed through openness in dialogue and exchange of information on issues. Forming a dedicated and caring team which can manifest itself through willingness in participation on how to care for patients and looking for best options to arrest the illness and prevention is another avenue for assessing the level of collaboration. Collaborating with local institutions in enhancing and acknowledging practices within healthcare; opening/running or advocating collaborative clinics can be measured by the number of collaborating clinics opened in an area; including herbal research and/or provision of herbal medicine through joint research on specific illnesses/diseases. This collaboration can further be consolidated by adopting a comprehensive training approach focussing on key areas of prevention and treatment including a strong monitoring and evaluation component [2
] with jointly accepted parameters.
The research team of this study critically scrutinized the key elements cited by King [2
] and attempted to operationalise them in a fieldwork situation. This article, thus, presents the experience learned by initiating collaboration between Institute of Traditional Medicine (ITM) of Muhimbili University College (with biomedical practitioners) and traditional healers using the proposed framework for collaboration in Arusha and Dar-es-Salaam Municipalities specifically focused on:-
- the entry point to access traditional healers
- Knowledge on HIV/AIDS
- Handling cultural aspect like rituals in healthcare
- What traditional healers want from the collaboration
The study was carried out in Dar-es-Salaam and Arusha Municipalities, Tanzania from July to November in 2003. The two areas were purposefully chosen because firstly, they have many traditional healers who claimed to be treating HIV/AIDS patients. Secondly, they were among the areas with high prevalence of HIV/AIDS when compared to other urban centres in Tanzania [22
]. Thirdly, due to their proximity to Institute of Traditional Medicine for the cases in the study which need laboratory work.
Arusha Municipality is in the northern part of Tanzania and also the head quarter of the Arusha region. It has a total population of 282,712, and of these 143,675 are females [23
]. The indigenous people in the region are the Wamasai, Wameru, Wairaqw and Waarusha ethnic groups. The main occupations of these ethnic groups are herding and farming. In recent years Arusha Municipality is receiving many migrants from all over the country because of the increasing number of manufacturing industries and mining. Also Arusha hosts international institutions such as UN-ICTR and an East African Community. With the increasing number of migrants and workers from international institutions there is a lot of social interaction which sometimes leads to HIV infection. The prevalence of HIV/AIDS infection in the Arusha Municipality is estimated to be around 11% [22
Dar-es-Salaam city on the other hand is on the eastern coast of Tanzania. Dar-es-Salaam is the regional headquarter and former capital of the country (now it is Dodoma). It is the centre of social services, communication and industries. Dar-es-Salaam has a total population of 2,495,940 and of these 1,236,863 are females [23
]. The indigenous people in the city are from the Wazaramo ethnic group; and their main activities are subsistence farming, fishing and petty business. Dar-es-Salaam like Arusha is receiving high numbers of migrants annually, coming mainly from other regions in Tanzania in search of better life and other business opportunities. Social interaction is pretty high and this explains the high prevalence of HIV/AIDS (18.8%) [22
Dar-es-Salaam city and Arusha municipality are served by private and public health services. Public health services where many people go for treatment do not have adequate health facilities and drugs for the patients they are supposed to serve. The only option for many people is to go to traditional healthcare practitioners for various treatments including HIV/AIDS. Even though there is a Traditional and Alternative Medicine Act in Tanzania which allows traditional healthcare practitioners to practice [24
] there is no provision for formal referral between modern and traditional healthcare practitioners.
Since the Institute did not know healers who were attempting to manage HIV/AIDS symptoms, the research team began with a consultative meeting with regional medical officers and leaders of traditional healers' associations in order to identify traditional healers that could be partners of collaboration. These were identified as people who were managing HIV/AIDS opportunistic infection in their respective areas. In the two study areas several consultative meetings were held before the gates could be opened to see traditional healers who were managing HIV/AIDS patients. Sometimes a break was called for recollection and consultation in order to proceed with the meeting. The research team used these consultative meetings as a way of cultivating trust and respect with traditional healers. When doors were opened the research team visited the traditional healers who were identified by either regional medical officials or traditional healers' associations.
A detailed open ended questionnaire was administered to each identified traditional healer providing healthcare to HIV/AIDS patients by the research team in a face to face interview. The questionnaire focused on four main areas; background information of a traditional healer, knowledge of HIV/AIDS, type of herbal remedy preparation procedures and rituals, remedies if any for arresting opportunistic infection, the willingness to collaborate in planned research and what they hoped to achieve by collaboration. Whereas, the criteria used to select traditional healers for participation in the project were based on: an average of more than five patients per day and some of them having HIV/AIDS related diseases, a score of more than one of the major clinical symptoms of HIV/AIDS as shown by WHO [3
]; and a willingness to disclose medicinal plants used to treat HIV/AIDS and other ingredients.
The questionnaires were completed during individual traditional healers' interview conducted by members of the research team. Additional data was documented in a notebook for detailed documentation and analysis. From the collected data, traditional healers who could participate in a traditional medicine HIV/AIDS project were selected. The selected traditional healers were registered to the ITM record book including addresses and telephone numbers as a way of communicating when the need arose. There was a one-day educational seminar for the selected traditional healers on how to run the project.
The field collected data and those raised during the educational seminar were screened and then transcribed from Kiswahili to English. The data collected were summarized and codes were identified for grouping the information according to issues raised in the introduction. The information from the questionnaires was quantified and put in tables to support the discussion. The information was grouped by code, re-summarized to create a final report of results. The summary of the results is presented below.