integrating traditional healers into a tuberculosis control by sdsdfqw21


                          TRADITIONAL HEALERS INTO A
                            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-
                      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
                      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
                      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-
                                                                     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
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-
   Other reasons for satisfaction were that
traditional healers typically had a caring

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. Int J Tuberc Lung Dis 1999; 3: 838-842.

7. Abdool Karim SS, Ziqubu-Page TT, Arendse R. Bridging the Gap: Potential for a health care partnership between African traditional healers and biomedical personnel in
South Africa (supplement). S Afr Med J 1994; 84: s1-s16.

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