INTEGRATING TRADITIONAL HEALERS INTO A TUBERCULOSIS CONTROL PROGRAMME IN HLABISA, SOUTH AFRICA Mark Colvin,1 Lindiwe Gumede,1 Kate Grimwade,2 David Wilkinson3 1Medical Research Council, 491 Ridge Road, Durban, South Africa; 2Hlabisa Hospital, Hlabisa, South Africa; and 3Adelaide University and University of South Australia, Australia. BACKGROUND community-based DOTS pro- study to assess the acceptabili- South Africa is experiencing gramme (CB-DOTS) was ty and effectiveness of tradi- 4 explosive twin epidemics of established in Hlabisa in 1992. tional healers as supervisors of HIV/AIDS and tuberculosis In this successful initiative TB treatment. (TB). In the rural district of patients may choose their treat- Hlabisa, admissions of adults ment supervisor, who may be a METHODS with TB increased 360% lay person or community health Hlabisa health district is located between 1991 and 1998, with 1 worker (CHW), or may take in the province of KwaZulu- 65% of them being HIV-infect- place at a clinic. Overall, from Natal, about 300 km north-east 2 ed in 1997. The prevalence of 1992 to 1998 approximately of Durban on the east coast of HIV among pregnant women in 80% of patients completed South Africa. It is home to KwaZulu-Natal in 1999 was treatment under direct observa- about 215 000 predominantly 32.5%.3 tion, and the CB-DOTS pro- Zulu-speaking people. In order to cope with the gramme was shown to be Since there has been only 5 increasing num- highly cost-effective. limited co-operation between bers of TB Since traditional mainstream health services patients, a healers are spread and traditional healers in South throughout rural Africa and because of sensitivi- 6 areas and are ties with regard to such, care widely consulted,7 was taken to ensure that there we implemented a was full consultation with all levels of health authorities and with representative organisa- tions of traditional healers about this project. Once support was No. 4 December 2001 secured it was decided to conduct the study in three sub-districts of Hlabisa. Twenty-five traditional healers volunteered to participate in the study and attended two 1-day training workshops on the management of TB. These traditional healers were then integrated into the existing community- based TB DOTS pro- gramme, where options for supervision now consist of the local health clinic, CHWs and lay people (usual- attitude and enquired about the general RECOMMENDATIONS ly shop keepers), and traditional healers. well being of the patients they supervised. •There should be formal discussions In order to determine the acceptability One patient stated: “They love their nationally and locally between organisa- of the traditional healers as DOTS super- patients and treat them like family”. This tions representing traditional healers and visors, patients who completed treatment, caring approach was further demonstrated those representing the health authorities defaulted or transferred were traced and by 3 traditional healers doing regular with the aim of developing a better briefly interviewed by one of the authors home visits to 18 patients in the early understanding between the groups and (LG). phase of their treatment because the fostering a closer working relationship. patients were at times too ill to leave their RESULTS homes. A further 3 patients reported regu- •Existing community-based DOTS pro- Between 1999 and 2000 in the three larly receiving food from their supervisor grammes in Southern Africa should con- study sub-districts, 53 patients (13%) when attending for treatment. sider recruiting traditional healers as were supervised by traditional healers and DOTS supervisors. 364 (87%) were supervised by clinics, DISCUSSION CHWs or lay people. Our findings suggest that traditional heal- •Health care authorities should consider Overall, 89% of those supervised by ers are a potentially important resource to integrating traditional healers into other traditional healers completed treat- integrate into TB control programmes. In aspects of health care including volun- ment, compared with 67% of those Hlabisa alone there are 290 traditional tary counselling and testing for HIV and supervised by others (P = 0.002). The healers across the district. In Africa south for home-based care for people with mortality rate among those supervised of the Sahara the ratio of traditional heal- AIDS. by traditional healers was 6%, whereas ers to the population is approximately it was 18% for those supervised by 1:500, in contrast to the doctor to popula- •The potential health benefits of traditional 7 others (P = 0.04). Interestingly, none of tion ratio of 1:40 000. medicine should be explored in conjunc- the patients supervised by traditional Perhaps the greatest hurdle to over- tion with traditional healers in a manner healers transferred out of the district come in developing a closer working rela- that produces good science but avoids during treatment, while 5% of those tionship between traditional healers and exploitation. supervised by others did. health authorities is the level of distrust By the end of March 2001, 51 patients that still exists between some members of •The potential of closer co-operation had completed treatment or defaulted and the two groups. It has also been our between health care authorities and 41 interviews had been done. Ten people impression from meetings with other traditional healers should be nurtured were not interviewed: 1 died soon after researchers and health care providers in medical schools. completing treatment and 9 had left the from Africa, that there is substantial reluc- area. tance to accept the idea of working with Generally high levels of satisfaction traditional healers. were expressed by patients supervised These attitudes will take time to by traditional healers, and all patients change, but studies such as this that believed that traditional healers should demonstrate the scientific rationale for be DOTS supervisors. A major advan- better co-operation may help to overcome tage commonly reported was easy what may be unfounded prejudice. access to traditional healers, who typi- cally live near to patients, and short waiting times when attending for treat- ment. Other reasons for satisfaction were that traditional healers typically had a caring REFERENCES 1. Floyd K, Reid RA, Wilkinson D, Gilks CF. Admission trends in a rural South African hospital during the early years of the HIV epidemic. JAMA 1999; 282: 1087-1091. 2. Wilkinson D, Davies GR. The increasing burden of tuberculosis in rural South Africa — impact of the HIV epidemic. S Afr Med J 1997; 87: 447-450. 3. Department of Health. National HIV sero-prevalence survey of women attending public antenatal clinics in South Africa 1999. Summary report. Pretoria: Health Systems Research and Epidemiology, DOH, 1999. 4. Wilkinson D. High compliance tuberculosis treatment programme in a rural community. Lancet 1994; 343: 647-648. 5. Floyd K, Wilkinson D, Gilks C. Comparison of cost effectiveness of directly observed treatment (DOT) and conventionally delivered treatment for tuberculosis: experience from rural South Africa. BMJ 1997; 319: 1407-1411. 6. Wilkinson D, Gcabashe L, Lurie M. Traditional healers as tuberculosis treatment supervisors: precedent and potential. 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