40 3 THE ROLE OF TRADITIONAL HEALERS IN THE TREAMENT AND PREVENTION OF HIV/AIDS 3.0 HIV/AIDS: A challenge to urban development Prevention must be the No 1 component of our strategy. We need, firstly, to ensure that those individuals who are not infected stay that way, and that secondly, we prevent the spread of HIV (Mbazima Shilowa, Star Newspaper, November 30, 2005). o said the Gauteng premier on the eve of world AIDS Day 2005. The premier was referring to the Gauteng AIDS Programme?s annual report which was compiled by the Gauteng AIDS Council, which he also heads. This report, which bases its prevalence rates on 2004 antenatal survey, shows a statistically significant increase in HIV prevalence nationally, with Gauteng at a prevalence rate of 33 per cent (Star, 30 November, 2005). Unfortunately, the report only provides provincial HIV prevalence rates and not specific data on HIV/AIDS in individual urban centres. But there is usually a tendency for urban centres to have higher than average provincial prevalence rates (von Donk, 2003). It is estimated that out of 2 883 226 people living in Johannesburg, 287 000 of these are living with HIV/AIDS, making up 10.4 of the population (Gauteng Department of Health, 2003). At Johannesburg hospital about 30 per cent of pregnant mothers tested are HIV-positive. Of the children tested on admission to the paediatric wards, 40 per cent are HIV-positive, and 75 per cent of paediatric deaths, mostly under the age of two are AIDS related (Johannesburg News Agency, 2004). The current mayor of Johannesburg, Amos Masondo, has recognised the severity of the impact of the HIV/AIDS pandemic on the city, which will be in his own words ?an enormous threat to the development of Johannesburg into a world class city? (Sunday Times Newspaper, 3 December, 2000). As a result the fight against HIV/AIDS is one of the Executive Mayor?s Six Mayoral Priorities. In the light of this priority the City is working in close cooperation with the Gauteng Health Department and NGOs to develop and implement comprehensive prevention, community mobilisation and workplace plans, which seek to prevent new infections, while also taking care of those who are already infected. The launching of the Integrated S 41 Strategic Health Plan 2002/03 is one example of such plans. It seeks to ensure that resource allocation in all regions is a planned and coordinated process. Councillor Prema Naidoo (member of the mayoral committee responsible for health) believes that, ?these initiatives, coupled with widespread health awareness programmes, will make an important contribution to the overall quality of life of the people of this city? (Annual Report on the City of Johannesburg 2002/2003). As part of the Integrated Strategic Health Plan, a comprehensive AIDS strategy is being implemented in all eleven regions through the regional AIDS committee. One of the key components of this strategy is that the city is collaborating across sectors and building partnerships to fight HIV/AIDS. This collaborative strategy is in line with NACOSA AIDS Plan discussed in the literature review and suggests that the Johannesburg City Council is finally taking cognisance that HIV/AIDS requires the involvement of all sectors of society. Partners in this plan include government departments, PLWA, faith organisations and traditional healers. The involvement of traditional healers by the Johannesburg City Council in HIV/AIDS prevention plan is worth noting since the new health care system in South Africa is based now on PHC (Pretorious, 1999). In this approach, which focuses strongly on preventative health service delivery, people?s basic needs are met at the district level where community can participate in the planning and provision of services in line with the NACOSA AIDS Plan. With proper support and training, traditional healers can become important allies in organising efforts to improve the health of the community. 3.1 The role of traditional healers in Primary Health Care Traditional healers are established health care workers within their communities. Their treatment is comprehensive and has curative, protective and preventive elements. In this regard, traditional healers could make an important contribution to primary health care. Moreover, traditional treatment appeals to many patients largely because traditional healing practices are linked to African belief in ancestors (Hammond-Tooke, 1989). Speaking of his special calling by ancestors, a 70-year old traditional healer who has been living in the Mai-Mai Bazaar since 1975 commented, Becoming a traditional healer was not an easy choice to make. I had terrible dreams, dreaming with snakes and drowning into the river. I later had to leave 42 school and to a far-away land for my training?I had to respond to this call from my ancestors. All of us have to go through this sacrifice before we can help our people?As traditional healers we are expected to identify the problem of our clients without anyone informing us about it? We diagnose illnesses, prescribe and prepare herbal treatment, provide counselling and also offer spiritual help? we are well established, well respected, accepted and trusted by our communities. Our medicines, combined with ritual can cure diseases such as STIs, pubic lice, headaches, skin infections and other problems such as nightmares and misfortunes We are a resource for the dissemination of basic health care, especially for poor people who don?t have access to private clinics ( Interview, traditional healer, July 2004) Notice how this participant responds to the question (why people consult healers) by first explaining why and how he became a traditional healer. This implies that a choice to consult a traditional healer has less to do with a particular healer, but it has more to do with the art of traditional healing itself. To describe his calling the participant uses the word ?sacrifice?, something that all traditional healers have to do before becoming legitimate healers, to describe how one becomes a traditional healer. Another female healer commented, I had to leave my husband and children behind. My mother-in-law took care of them while I was away training as a sangoma?I remember when my daughter died and I was not allowed to attend her funeral?It was very painful?It?s the rule. You can?t go to your house until you finish your training? It was in winter and I had to wake up at three o?clock in the morning to wash myself in the river. This was done so that I may become very strong (Interview, traditional healer, 2004). This participant uses the phrase ?respond to this call from my ancestors? to describe how she became a healer. Ancestors are treated with respect among Africans and must be obeyed at all costs (Schuster, 1998). Failure to do so may cause a misfortune, the worst being death as yet another healer commented, ?I became very ill. After I have done all sorts of medical tests and X-rays the doctors told me they did not know what was going on and so they could not help?I went to a sangoma and he told me that I had a choice: become a sangoma or die (Interview, traditional healer, July 2004). Obedience and sacrifice is what makes a traditional healer spiritually powerful. The strength of a traditional healer is in being able to ?identify the problem without anyone informing him or her about it? (Interview, traditional healer, July 2004). This cannot be achieved unless one sacrifices and undergoes rigorous training. Patients also recognise the sacrifice that traditional healers had to make and they also appreciate traditional healers? obedience to the call from ancestors. Accordingly, ?people don?t want a person who guesses. They want somebody who can 43 communicate with ancestors and then tell them what the problem is and how it can be solved? (Interview, traditional healer, July 2004). Diagnosing the cause of sickness and misfortunes is not the only function of traditional healers; they are also masters of medicines and have a vast knowledge of an array of plants, roots and animal portions. A walk in the Mai-Mai complex shows various animal parts (like python skins, skulls and bottles with fats) and plant herbs. All these are capable of, ?making a patient strong and immune to bad spells and other misfortunes? (Interview, traditional healer, July 2004). Traditional medicine can be applied in many forms such as washing the body, smearing the patient?s body and inhaling. Other forms of medicine are designed for complex uses such as regurgitating (ukuphalaza), enema (ukuchatha) and steaming (ukugquma). The participants frequently raised the point that traditional medicine is used in combination with ritual. It is this ritual aspect that serves to repair the misfortunes encountered, such as unhappy ancestors or an evil spell. It follows then that traditional healers deal with the person in their entirety and not as a series of disorders affecting parts of them. This definition of health is remarkably similar to what Norman (1996) describes as a more holistic approach to health. Commenting on this approach to health one healer said, ?We (traditional healers) diagnose illness, prescribe and prepare herbal treatment, provide counselling and also offer spiritual help? (Interview, traditional healer, July 2004). This counselling and spiritual help given by healers is important in dealing with patients, especially those living with HIV/AIDS. From the moment that a person discovers they are HIV positive until the time of their death, there is a need for psycho-social support for that person. Yet counselling has not received the attention it deserves in policy cycles. Where it is offered by the medical fraternity, usually only doctors, nurses and psychologists are viewed as competent. However, traditional healing and western counselling are based on different philosophical assumptions. The African approach is symbolic, intuitive, and integrally part of traditional African beliefs and cosmology, while western counselling is based largely on scientific principles, which have no direct link with symbolism (Uys and Cameron, 2003). Accordingly, when counselling cross-culturally, counsellors should avoid being seen 44 as patronising. They should also explore and acknowledge their own prejudices, stereotypes and cultural assumptions (Evian, 2000). Most of the time, however, counsellors do not take these cultural considerations into account at all. This has an effect on patients as one worried healer noted, The staff at clinics and hospitals is not sensitive to patients. They have no manners. How can you tell a patient to go home and prepare to die? ?Just like that?? Without even offering a prayer for that person?. These nurses don?t do their work properly. They don?t do pre-test counselling and when they tell the patient that they are HIV positive, these patients become very, very frightened and believe they will die soon. They worry and can?t even eat or take care of themselves. When these patients come to me I have to undo this hurt caused by nurses (Interview, traditional healer, August 2004). On the contrary, the counselling provided by healers includes a spiritual dimension and performing of rituals, which connects the patient with their ancestors. It is similar to the one done by the Freedom Hospital in Kwa-Zulu Natal. Counselling also helps them adjust to safer sexual practices (Evian, 2000). Traditional healers interviewed have no doubts about the legitimacy and the efficacy of their medicines. But they also freely admitted that in certain cases, modern medicine is preferable and can cure diseases which they cannot. Expanding on this, one healer commented, ?We (healers and doctors) each have our specialities, our weaknesses and our strengths. It?s high time to stop saying ?I can? to a patient when I know I cannot? (Interview, traditional healer, July 2004). This refers to cases such as cancer, surgery, and blood transfusion. Traditional healers in Jeppestown are also fairly knowledgeable about HIV/AIDS, how it is transmitted and how to avoid contracting it. All ten traditional healers interviewed mentioned that HIV/AIDS is difficult to transmit except by sex or other direct contact with bodily fluids such as the blood of an infected person. When traditional healers were asked to mention the major modes of transmission, all ten traditional healers gave the answer as unprotected sexual intercourse. Only three went on to mention the re-use of contaminated syringes by injecting drug users, and only one mentioned the mother to child transmission. 45 There is a general consensus among healers in Jeppestown that HIV/AIDS is sexually transmitted; hence when asked how people can avoid contracting HIV/AIDS, the answers given had a lot to do with modifying one?s sexual behaviour. This is exactly what the IEC programmes are trying to achieve. Undoubtedly, this response by healers does promote public health and awareness about HIV/AIDS. This finding is also in line with what the ATICC is doing in Natal (see table 4). Even though the contact between healers and nurses in Jeppestown is minimal, traditional healers have shown themselves competent in promoting the modification of people?s sexual behaviour and addressing some of the areas relating to HIV/AIDS. Six areas where healers can play a major role were highlighted. 3.1.1 Promoting condom usage To date, the major emphasis of HIV/AIDS in South Africa has been the use of condoms. According to Beeker (1998) these have turned out to be effective only 95 per cent of the time due to incorrect usage and the poor quality of the available products. Examples of studies on condom usage (given in the literature review) also suggest a great resistance to using condoms on the part of African men. Traditional healers in Jeppestown, however, have had some success in promoting the use of condoms by men. Talking about the usefulness of condoms a male healer said, ?I trust condoms. If we want to stop the spread of HIV/AIDS we must talk about it and put on condoms. I tell all my clients to use condoms all the time? (Interview, traditional healer, July, 2004). Eight healers distribute condoms to their clients and one healer has a dildo in her consultation room, where she demonstrates to her clients how to use a condom properly. ?I am able to indicate on the dildo where there are sores and other symptoms, rather than try to describe them in vague terms? (Interview, traditional healer, August, 2004). She believes that ?knowledge alone is not enough; people must get hands-on experience on how to use condoms. In this case we are really empowering them and giving them necessary skills to negotiate safer sex? (Interview, traditional healer, August, 2004). Interventions, such as the one where the use of a condom is demonstrated and people are given a chance to experiment with condoms using a dildo, can result in substantially more behavioural change than knowledge alone, as one healer commented, ?It is not enough for people to know that using 46 condoms can prevent the spread of HIV/AIDS, but they must actually know how to use them? (Interview, traditional healer, September, 2004). According to traditional healers, many of their clients, who are mostly men, are sceptical at first. They don?t want to talk about their sex lives and ?they don?t want to hear a thing about condoms? (Interview, traditional healer, August, 2004). These men claim that using condoms reduces the pleasure of sex. They say ?they can?t eat sweets with papers on. They also believe that obtaining condoms from clinics implies that they are sexually active, which many of them don?t want to admit openly? (Interview, traditional healer, September, 2004). Adding to this reluctance by men to use condoms is the fact that, ?at clinics some of these nurses are hostile to their patients and the clinic is not a good environment to demonstrate condom use? (Interview, traditional healer, July 2004). This harassment and unsympathetic behaviour of health care staff has also been identified as a barrier to condom usage in many parts of Natal (Tillotson and Maharaj, 2001). Healers in Jeppestown, therefore, are in a better position to promote and distribute condoms because their consultation rooms are private, unlike in clinics where people sit in a big waiting room and condoms are placed in this waiting area for people to help themselves. The result is that people do not take these condoms because, ?people are very sceptical about use of condoms and one needs to explain to them why and how they should use them. Otherwise they don?t even take them? (Interview, traditional healer, July 2004). Healers did, however, indicate that with proper counselling, there is an increase in the usage of condoms by men, as one of them pointed out, I tell them that if they do not protect themselves they will get sick again with STIs. I show them how to use a condom and ask them if they would like to take some home. They do take them and some even come back for more or to take for their friends (Interview, traditional healer, August 2004). The important thing to note here is that healers establish a rapport with their clients before advising and explaining to their patients why they should use condoms and then demonstrating how condoms are used. The clinic, on the other hand, does not take this approach. 47 Even though there has been an increase in the number of men taking condoms from healers, there are two major challenges. One of these challenges is how to make sure that healers? clients continue using condoms. Healers have found that, Most of our patients use condoms as part of the treatment for STIs rather than as part of their daily life?As a result we have people who always come back with the same problem (Interview, traditional healer, August 2004). Many people associate using condoms with being HIV/AIDS positive. As a result wanting to use a condom shows/signifies lack of trust between two people (lovers). People ask themselves why she insists on using a condom if she trusts me?. If there is no trust then there is also no love (Interview, traditional healer, July, 2004). In this case the concept of love is used to manipulate people into having unprotected sex. The idea of trust and intimacy is used here to maintain a relationship or to prove that a relationship is monogamous, although this is not usually the case. The above quotations clearly show that the use of condoms (or lack of) continues to be a challenge. While using a condom during STI treatment is fairly successful, there needs to be more programmes aimed at ensuring that men use condoms on a continual basis, with both their casual partners and their wives. The second challenge pertains to a lack of infrastructural support on the part of government: We would like to help lower the spread of HIV/AIDS but we don?t have resources. We don?t get any help or support from the government?? My son helps me by bringing condoms from his school and sometimes they run out and I have nothing to give to my patients. We would like government to help us with free condoms and lifelike ?erect dildo with veins? as well as books that provide photographs of STIs (Interview, traditional healer, September 2004). We don?t have enough resources. I always struggle to go and collect plant herbs from Mpumalanga since I don?t have a car. The money I get from my patients is not enough and I can?t charge them more. My ancestors will not allow this. Our consultation rooms are not in good conditions and many times my patients have to wait outside and this becomes very difficult when it is raining. A little help from government will be appreciated (Interview, traditional healer, July 2004). This suggests that the discrepancy in terms of health expenditure is not only at provincial level but also at local level. In Johannesburg all the money budgeted for health is used to fund clinic-run activities and campaigns. This shows a contradiction 48 in the part of Johannesburg Council?s Health Department: their policies stress the multi-sectoral approach to HIV/AIDS, and yet they fund only one sector. 3.1.2 Breaking gender stereotypes Gender inequality and female subordination are a major driving force behind the spread of HIV/AIDS. Despite the call by the Human Rights Commission for gender equality, the reality is that many Africans still adhere to traditional values and practices. Some cultural or traditional norms include a double standard, which gives men freedom to be sexually active while restricting female sexuality (Boerma, 1997). This does not mean that women do not have sexual needs and desires. What it means is that different norms are applied to women and men, with men having greater decision-making power regarding sexual and reproductive matters. According to the CHSD (2002) report, deeply entrenched inequalities in sexual relationships are aggravated by the fact that it is common for a man in South Africa to be unaware of his HIV/AIDS status. Traditional healers agree with this statement as, ?Men have a bad attitude. They prefer not to know their HIV/AIDS status. This is despite the fact that many of them engage in sexual behaviours that put them at risk? (Interview, traditional healer, July 2004). Men are further inclined to refuse testing even when they fall ill. Even those men who know that they are infected may hide this from their partners (Boerma, 1997). In many communities it is more or less taken for granted that men need to have sex regularly and that they should be dominant, deciding when, how and with whom they will have sex. By contrast, women are expected to remain faithful, do whatever their partners want and not question their behaviour (Campbell, 2003). The result of these expectations regarding male and female behaviour is that the ability of women to engage in protective sexual behaviour is reduced. During the interviews, one healer recalled a case where one female client was forced by her husband to take a course of tablets without being told the reason. When this woman asked her husband as to why she had to take the pills, she was not given any answer but told to take the pills and ask no questions. Later this woman found out that her husband had infected her with gonorrhoea. 49 Some healers made a connection between sexual violence and the number of informal settlements and beer halls in Jeppestown. According to these healers, ?it has become difficult for the police to enforce the law in the area. The Wolhuter Men?s Hostel has become a ?no go area? for the police? (Interview, traditional healer, August 2004). It is reported that in 2003, 15 police officials were killed in the hostel while on duty?. These healers believe that, ?The hostel is the place where people hide their guns, for they know that the police won?t search the area? (Interview, traditional healer, August 2004). As a result, the hostel and its surrounding areas have become very dangerous, especially for women. Women staying or just walking close to the hostel are always in danger of being raped. One traditional healer recalled an incident where a woman who was walking on the street along the hostel was abducted and gang- raped by a number of hostel dwellers. The following morning she was found dead and nobody even bothered to report the matter to the police. As mentioned in the literature review, there is little research on men and their perceptions on HIV/AIDS transmission and prevention. A survey conducted by Scalway (2001) has also shown that resources directed at providing HIV/AIDS information, education and services to young men do not correlate with their impact on the transmission of the virus. There is therefore a need for programmes that help men explore their values. Traditional healers expressed a concern about men?s lack of involvement in HIV/AIDS awareness campaigns. Whenever there is a talk or workshop on HIV/AIDS in Jeppestown, few men attend?This poor attendance by men is problematic since in many cases their behaviour (having many sexual partners) results in STIs and therefore perpetuates the spread of HIV/AIDS (Interview, traditional healer, July 2004). We need to get more men involved in HIV/AIDS awareness campaigns as this will help them (men) recognise that they play a big role in transmitting HIV/AIDS. They should stop blaming it on women but should rather acknowledge that stopping HIV/AIDS is everybody?s responsibility (both men and women). Blaming it on one party is not going to help (Interview, traditional healer, August 2004). Traditional healers therefore seem to believe that getting more men involved in HIV/AIDS campaigns will help break gender stereotypes. Furthermore, the close interaction and trust between traditional healers and men put healers in a better position to change men?s perceptions of women. The powerful influence that healers ? Jeppestown Station Commander, September 2004 50 have over men has been useful in encouraging the majority of men to use condoms and in encouraging them to talk about sex (as is discussed below). This same power could be used to break gender stereotypes. This however, is a very complex issue since on the face of it traditional healers do have the power to change the way society treats women. But many times traditional practices (such as virginity testing) serve to reinforce the way men see women. Perhaps this is an issue that needs to be addressed in the training of traditional healers. 3.1.3 Encouraging people to talk about sex and to confront their fears Linked to the role of healers in breaking down gender stereotypes is the issue of talking about sex. Much to the healers? surprise, when introducing the topic of HIV/AIDS, people open up and discuss their own sexual experiences. The fear and concern engendered by HIV/AIDS has, to a certain extent, broken down the barriers to discussing sex (Preston-Whyte, 1995). Traditional healers gave many examples where they managed to get their patients to open up and talk about their sex lives. One female healer recalled an incident where: When he arrived here he was sick to the point of death?He was scared of dying with AIDS?He has not done an HIV/AIDS test and I advised him to go to the clinic and do one as soon as he could and he told me he was scared?I asked him if he practised safe sex and he answered no?he later told me about his unfaithful girlfriend, his two other girlfriends he has back at home and his involvement with another man?s girlfriend?I persuaded him to do an HIV test and it came back negative?He promised to use condoms all the time (Interview, traditional healer, August, 2004). Here is a man opening up and talking about his sexual life to a woman. According to Preston-Whyte (1995) this openness to discussing sex can be put to good use in intervention. Traditional healers could use these discussions of sex as a strategy to influence and alter people?s attitudes to sexual behaviour. The traditional healer quoted above also succeeded in persuading the patient to go for an HIV test and the patient promised to use condoms each time he has sex. This demonstrates the traditional healers? power to console and give courage as well as get people to talk openly about HIV/AIDS and sex which, according to Evian (2000), is central in the fight against HIV/AIDS. Talking about sex involves, in a way, talking about gender. Healers mentioned that at first men are sceptical about HIV/AIDS and preventive measures such as condom 51 usage. But through continual interaction and the building of trust, changes begin to occur. Moreover, traditional healers voiced a need for men to interact with each other and with women in workshops and focus group meetings, and in so doing learn from each other. Healers believe that ?being able to talk about sex in groups (of both men and women) helps break down barriers which have made it impossible for men to discuss sex with their partners? (Interview, traditional healer, August, 2004) and moreover, ?sexual risk reduction requires that people talk about sex? (Interview, traditional healer, August 2004). Caution should be taken here, as talking about sex may simply mean that people voice stereotypes. However, studies done in Natal have shown that with appropriate methodological inventions, it is possible to get people to talk about issues such as gender, sex and HIV/AIDS at a deeper level (Tillotson and Maharaj, 2001). With proper programmes such as workshops, traditional healers could do the same in Jeppestown. 3.1.4 Breaking the myths surrounding HIV/AIDS The 2000 loveLife survey indicated that 40 per cent of participants believed that traditional medicine could cure HIV/AIDS (ECI, 2001). Furthermore in their study, Tillotson and Maharaj (2001) also found indications of a belief in AIDS-curing ability of traditional healers. There are many traditional herbs in the market, which are actively ?pronounced? as a cure for HIV/AIDS. This has serious implications since many people might not practise safer sex with the belief that when they get HIV/AIDS infected, some concoction will cure them. In addition, many traditional healers are also actively propagating the message that having sex with a virgin can cure a man with HIV/AIDS and also protect this man from contracting the virus in the future (Swanepoel, 2001). This ?ignorance? about HIV/AIDS is one of the crucial reasons why the HIV/AIDS epidemic has run out of control (CHSD, 2002). Scepticism and reluctance, when it comes to the use of condoms, is also a result of misconceptions and myths, such as if one uses a condom his erection cannot grow, and condoms are contaminated with the germs that spread HIV/AIDS (CHSD, 2002). Some traditional healers also believe that they can offer preventive medicines which ?block? an STI from entering a person as, ?drinking a mixture of manyazini (potassium permanganate) before sleeping with a woman will kill any dirt from that woman that might have caused a disease? (Interview, traditional healer, August 52 2004). This belief then makes the use of condoms unnecessary since a man thinks that he is immune from getting an STI. Traditional healers, therefore, have a big role to play in breaking down these misconceptions and communicating the ?truth? about HIV/AIDS and condom usage to their patients. The THO tries to impress upon its members that there is no cure for HIV/AIDS and that traditional healers should rather be preaching or employing conventional ways of dealing with the disease- such as awareness, abstinence and prevention, We have not found the cure for HIV/AIDS but our members are capable of treating the symptoms and opportunistic infections such as diarrhoea and low appetite?? Sometimes people come to us thinking they have been bewitched while they have not, they just have an STI and they must recognise this and then take proper measures (Interview, THO leader, October, 2004). The THO further organises many workshops where traditional healers learn about HIV/AIDS and how to prevent it. Healers highlighted that they would like to attend more of these workshops and would like to have more biomedical professionals coming to facilitate these workshops. They even raised their desire to conduct workshops themselves and thereby empower other healers as, ?The knowledge I learnt at the workshop is not only for me. It is to help everyone. I would like to pass it onto other traditional healers? (Interview, traditional healer, August 2004). Two sangomas reported that part of their training as a sangoma involved learning about HIV/AIDS, how to protect themselves from contracting it, and how to communicate with their future clients about HIV/AIDS. 3.1.5 Traditional healers as community health care workers In an attempt to deal with HIV/AIDS and its impact, South Africa has placed some effort to developing community-based care structures such as community health care. According to Pretorious (1991), community health care is care by the community for the community. It involves a sense of belonging and ownership within the community and as such, community health care programmes can lead to community empowerment. This approach to health also implies a cheaper, more attainable, more accessible and often a more appropriate and more effective form of health care. Furthermore, the involvement of communities in health, especially HIV/AIDS prevention, is one of the NACOSA AIDS Plan?s priorities. In an area such as 53 Jeppestown it is traditional healers who can help to achieve greater community participation in HIV/AIDS intervention programmes as, People are more likely to listen to us (traditional healers) as opposed to nurses and doctors. We have much in common with the people here in Jeppestown. We speak the same language, come from the same homelands, live with our patients and share the same struggles. We interact with them all the time. We also have the same cultural beliefs, customs and traditions (Interview, traditional healer, August 2004) This close involvement within communities puts traditional healers in a unique position to be involved in community health care programmes. According to Scheider (2000) these programmes have been shown to reduce the incidence of hospitalisation and length of hospital stay. They also reduce the burden on the primary health care system as a result of increased education and awareness about minor illnesses, nutrition and general wellness advice. Traditional healers can achieve such a state in Jeppestown as, ?our medicines are effective in treating cases such as diarrhoea, and shingles??the African Potato also boosts the immune system? (Interview, traditional healer, July 2004). One woman healer also runs a soup kitchen in the area. She gets fruits and vegetables from the City Deep Vegetable Market that is located within a walking distance from Jeppestown. She believes that, ?eating healthy food keeps people from getting sick. It also help fights diseases from those who are sick? (Interview, traditional healer, August 2004). Another learned healer from Mpumalanga commented that, We have to be realistic about this situation. When a patient discloses his or her status, that of being infected with an opportunistic disease, I start counselling them by promoting the use of a condom, advise them to go for an HIV test, eat healthy foods and join groups with awareness of HIV/AIDS (Interview, traditional healer, August 2004). But the most important aspect of community health care is that it allows patients, family and community to come to grips with HIV/AIDS. By so doing mutual support is enhanced, leading to openness and understanding of the disease and thereby promoting awareness of HIV/AIDS which leads to acceptance and risk behaviour reduction (Evian, 2000; Uys & Cameron, 2003). ? Herpes Zoster-a common viral infection (characterised by blistering of the skin) among people with HIV/AIDS. 54 3.1.5a The need for a Continuum of Care in HIV/AIDS prevention One of the reasons why the community-health care approach is important in dealing with HIV/AIDS is that it gives room for the continuum of care. WHO stresses the need for a continuum of care because it addresses a range of needs, from diagnosis through to death and bereavement, and it also creates effective referral linkages between all actors in meeting these needs (Van Praag, 1995). The continuum of care includes emotional support such as counselling and social support such as housing and medical nutrition. Limited human resource in the medical health care sector makes it difficult to provide for a continuum of care. On the contrary, traditional healers have the numbers and distribution needed to provide such care, as one healer emphasised, We (traditional healers) are more close to the community then the clinic. We are able to give more support to HIV/AIDS. Our herbs are also able to treat opportunistic diseases such as TB and lack of appetite (Interview, traditional healer, July 2004). It is evident from empirical data from other studies that community care and support strategies within a continuum of care can have a positive impact on mitigating and decreasing the spread of HIV/AIDS (Schneider, 2000). This is because community- based services are more accessible to clients and their families. Patients that are being taken care of by traditional healers may live longer; experience a better quality of life and an improved health status. This may reduce the burden on clinics and hospitals as people learn to cope with minor symptoms and address them before they become complicated. Four healers mentioned they have been involved in community-based projects. Of the collaborative programmes that were mentioned by traditional healers, the one that stood out is the one Kwa-Hlabisa, in Natal. 3.1.5b Case Study: Integrating traditional healers into a TB control programme in Kwa- Hlabisa. Kwa-Hlabisa health district is located Kwa-Zulu Natal, about 300km north-east of Durban. In order to cope with the increasing numbers of TB patients in Kwa-Hlabisa, a community-based DOTS programme was established in 1992. In this initiative patients may choose their treatment supervisor, who may be a layperson or a community health worker, or may choose to be treated at a clinic. Since traditional healers are spread throughout Kwa-Hlabisa, and are widely consulted by the community, a study was implemented to assess the acceptability and effectiveness of traditional healers as supervisors of TB treatment. Traditional healers attended 55 training workshops on the management of TB and they were then integrated into the existing community-based TB DOTS programme, where options for supervision now consist of the local health clinic, community health workers and traditional healers. The Medical Research Council later published the results of this study. The study found that between 1999 and 2000 in Kwa-Hlabisa district, 53 patients (13 per cent) were supervised by traditional healers and 364 (87 per cent) were supervised by clinics and community health workers (Colvin, et al, 2001). Overall, 89 per cent of those supervised by traditional healers completed treatment, compared with 67 per cent of those supervised by the clinic and community health workers. The mortality rate among those supervised by traditional healers was six per cent, whereas it was 18 per cent for those supervised by the clinic and community health workers The above-mentioned case study and numerous others, show that traditional healers are a potentially important resource to integrate into primary health care. Integrating traditional healers in this TB programme was a huge success. The same model can also be used in Jeppestown as Government health services are inadequate. Today South Africa provides free Anti-Retroviral (ARV) treatment to HIV/AIDS patients. This is potentially an area where traditional healers can get involved as supervisors to make sure that patients take their medication properly, just as healers in Kwa-Hlabisa did with TB patients. 3.1.6 The Role of Traditional Healers in STI Management One root of the current AIDS epidemic can be identified with the intersection of migrant labour and urbanisation (Walker et al, 2004). The socially constructed masculine identities make migrants vulnerable to HIV/AIDS infection. The need for multiple partners, the desire for the pleasure of flesh-to-flesh sexual contact and the living conditions in Jeppestown all inevitably place men at high risk of contracting STIs and HIV/AIDS. For example, a study that was conducted by the Wits Reproductive Health and Research Unit (RHRU) in the inner city clinics in 2002 showed that 50 per cent of patients who contact STIs also test positive for HIV (Johannesburg News Agency, 2004). This high incidence of STIs in the inner city poses a serious threat to public health, largely because STIs are important co-factors in driving the HIV epidemic. 56 Yet the approach that the Johannesburg City has taken to addressing STIs has paid little attention to the way in which the social construction of sexuality undermines the likelihood of behaviour change by migrants in the inner city, even though they are aware of sexual health risks. The City?s biomedical response has taken a form of the provision of STI clinics run by trained medical experts. In doing so, Johannesburg City has made little attempt to understand the fact that migrants? understandings of HIV/AIDS and the way in which they seek treatment for STIs is often not consistent with the biomedical model. The other exacerbating factor that contributes to the continuing spread of STIs is that many of STIs display no or minimal symptoms, particularly in women, and hence many infected individuals do not seek health care and so remain infected and infective (Colvin, 2000). Even when symptoms are apparent, there is evidence that individuals, particularly men, do not seek appropriate health care, especially with mild symptoms. People may either not seek treatment or let the symptoms abate or self-treat (Ngungi, 1994). Even those who do seek medical help often do not visit the clinic immediately but delay the visit. These untreated individuals remain infectious and, if they continue having unprotected sex, will further spread the infection. Hence a critical aspect of HIV/AIDS prevention is the management of STIs (Green, 1996; Colvin, 2002; Gilbert, 2002) and traditional healers are a critical component of any STI management plan since they treat a number of clients with STIs and have a special relationship with the people they treat. Previous research on HIV/AIDS in Jeppestown has shown an interesting relationship between STI patients and traditional healers. Table 6 shows the health services offered at the Jeppestown clinic. Comparing the results in table 6 with table 7, (which shows the services offered by traditional healers), it is evident that traditional healers treat more STIs than the clinic does. 57 Table 6: Health services offered at the Jeppestown Clinic and average number of treatments/week. Services offered at clinic Average no. of treatments (women) Average no. of treatments (men) TB 60 10 Sugar Diabetics 60 3 High Blood Pressure 70 10 Asthma 40 15 Child-related 100 0 Family Planning 90 0 STIs 50 10 Table 7: Services offered by traditional healers, average charges and number of treatments /week (This is the average of the ten that were interviewed). Type of complaint No. of treatments (women) No. of treatments (men) Cost Involved Various STIs 50 100 Up to R50 Mental illness 100 100 +R100 Epilepsy 50 50 +R100 High Blood Pressure 100 75 Up to R50 Midwifery 35 0 + R50 Witchcraft/sorcery 75 75 + R100 Infertility 25 75 +R50 Impotence 0 75 Up to R50 Contrary to the belief that people consult traditional healers because the don?t have enough money to go to doctors (Pretorious, 1991; Pillay, 2000), table seven shows that the cost of traditional medicine is relatively high, especially if one considers the fact that cases such as STIs, high blood pressure and epilepsy are treated free of charge at the clinic. Evidence such as this suggests that the choice to consult a traditional healer has less to do with money but more with a cultural belief and cultural acceptance. Traditional healers? response to the question why their services were preferred reflected a diversity of opinions. There is, however, substantial thematic overlaps between responses, all of which are orientated towards a single broad finding i.e. traditional healers are skilled in dealing with STIs and people (especially men) trust 58 them more than they do with nurses/doctors, as is demonstrated by the following extracts: I myself have been to the Jeppestown clinic many times. Each time I went there I never saw a male nurse. You only find female nurses?Since many STIs affect the man?s penis, it becomes very difficult for men to show their private parts to a woman they don?t know?One day this young man came here suffering from ?drop?. By the time he came here he could not even walk. I then advised him to go to the clinic to get some pain killers and he refused, saying that he has been to the clinic and the nurse put his penis on a ?plank? and hit it with a rubber hammer. This is not a way to treat a patient (Interview, traditional healer, August, 2004). Men are by nature not willing to have a woman telling them what to do. They fear being examined and taking orders from female nurses. They know that having an STI means that have ?misbehaved? and that they like going after women, and nurses at clinic condemn them. We (traditional healers) are gentle with our patients. We administer herbs that go inside and take out the disease from the inside. Our treatment procedure takes place over a long time. You first have to vomit after drinking herbs, then we give you an enema, then follows the steaming session and finally we make incisions to make you strong. All of this is done to clean your reproductive system (Interview, traditional healer, August 2004). The first theme to emerge from the above extracts is that in clinics there are no male nurses. Men do not feel comfortable having a woman examine their genitals. Moreover, it is culturally unacceptable for a man to strip naked in front of a woman who is neither his wife nor girlfriend. However, when it comes to traditional healers, men can choose to go to or male or female healer and most female healers have a male helper who can help these men in a ?dignified manner?. Secondly, some female nurses are judgemental and have a negative attitude towards men with STIs. They assume that every man contracted STIs through promiscuous behaviour. This is because, ?just like with HIV/AIDS, there is a stigma attached to someone with an STI? (Interview, traditional healer, August 2004). One male healer commented that, ?these educated women (nurses) have no respect for men. They shout at them in front of other patients. This is unacceptable? (Interview, traditional healer, August 2004). Such treatment from nurses is bad for patients because, When a person feels neglected and marginalised, they may resort to bad behaviour. They may become abusive and continue to practise unsafe sex as a form of revenge to women?(whom many men blame for their HIV/AIDS status)?as well as a means of releasing stress (Interview, traditional healer, August 2004). 59 This insensitive behaviour of some of the nurses is common, not only towards STI patients but to HIV/AIDS patients as well. According to traditional healers, doctors and nurses are famous for chasing away HIV/AIDS patients from hospitals and clinics and wishing them away to ?go and die at home?. In the quest for dignity, many of these patients and their relatives resort to alternative medicine such as traditional healing. One healer recalled an incident where, When this man arrived here he was a walking skeleton. His family brought him here?I asked, why don?t you take him to the hospital??and as is always the case, he has been refused admission at the hospital (Interview, traditional healer, August 2004). Traditional healers believe that staff from clinics and hospitals must be more sensitive to patients. This attitude from nurses makes the job of traditional healers difficult because, ?now these patients come to me and I have to undo the bad experience caused by nurses. I must build back their confidence because this worry can kill them. ?I tell them not to blame anyone, not even themselves but to remain positive and continue living their lives. They must also avoid unsafe intercourse to prevent infecting others and being re-infected (Interview, traditional healer, August 2004). Again, this demonstrates healers? ability to console and offer support, as discussed in chapter four. As indicated by the above-quoted healer, counselling helps patients feel they can overcome bad feelings and face the world with confidence and dignity again. Spiritual counselling is also important in dealing with uncertainties (such for how long I will live or when will I become ill) and healers interviewed demonstrated that they could deal with anxious and fearful patients. All healers who participated in the study have treated cases of STIs. Treatment involves drinking a herbal mixture or taking a herbal enema. One healer boasted, I have treated both rich and poor people, educated and those who are not educated?I give three types of medicines: for energy, for purifying/cleansing the blood and for healing the sores/wounds. I am well known here in Jeppestown. Most people come to me (Interview, traditional healer, August 2004). The confidence that healers and patients have of traditional medicine deserves comment. It speaks of the important role those healers play as primary health care providers in their societies. This health care is not only physical but also involves the ritual dimensions of health. Five healers commented that they also tell their patients 60 to bring their partners for treatment. This is a very important and effective treatment plan since treating only one partner can result in re-infection. Traditional healers also gave detailed accounts of other STIs they treat. The most common STIs are gonorrhoea (drop); syphilis (gcunsula); genital sores and genital warts. The following is an extract from one of the participants, The two most common STIs in Jeppestown are drop (gonorrhoea) and gcunsula (syphilis). Gonorrhoea is characterised by a pus discharge from the penis and pain during urination. A woman can also have drop and the symptoms are a vaginal inflammation and sores?this illness is caused by having sex with many partners and having sex with a person with an unclean blood?it is treated with a herbal tea and enema?I prefer to treat both partners if one came to me? Syphilis on the other hand is characterised by a hot, burning, painful urination. Both men and women can suffer from this illness. The genital sore caused by gcunsula makes it difficult for people to walk properly?the illness is caused by a husband or lover who treats his wife/girlfriend with medicines to ensure her fidelity?treatment includes washing the sores with a special medicine and drinking a herbal mixture (Interview, traditional healer, July 2004). Traditional healers thus have complex nosologies based on distinctions between symptoms. This implies considerable skill in observation and diagnosis. It is because of these skills that men consult traditional healers when they have STIs. They also affirmed that STIs could be prevented. As for the means of prevention, traditional healers mentioned sticking to one sexual partner, abstinence, thigh sex and condom usage. This is in line with the ?traditional? preventative measures being emphasised by the South African Department of Health. Hence empowering healers will mean that even if people chose not to go to the clinic, they can still get this information from traditional healers. 3.2 Conclusion In the absence of a cure, prevention remains the only strategy to curb the spread of HIV/AIDS and so is the treatment of HIV/AIDS related illnesses. Government sponsored IECs seek to achieve such prevention. Yet despite the widespread availability of government IECs, HIV/AIDS continue to kill thousands of South Africans. Clearly something is missing in these IECs that has rendered them ineffective. This chapter has argued that for IECs to be effective, more stakeholders should be involved, including traditional healers. They can help by passing culturally sensitive information to their male clients. The need to look at the role of healers is strengthened by the commitment of government to incorporate traditional healers in 61 the provision of PHC. This is largely because their medicines are used widely by the South African population. But besides that, traditional healers have also shown themselves competent in addressing some areas relating to HIV/AIDS such as promoting condom use, providing counselling and support, encouraging people to talk about sex and STI management. Since health-care providers and planners are fully aware of the activities of traditional healers, they should take them into account when designing health messages and other health promotion initiatives.