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Traditional healers, HIV/AIDS and company programmes in South Africa David Dickinson Published online: 11 Nov 2009.

To cite this article: David Dickinson (2008) Traditional healers, HIV/AIDS and company programmes in South Africa, African Journal of AIDS Research, 7:3, 281-291, DOI: 10.2989/AJAR.2008.7.3.5.652 To link to this article: http://dx.doi.org/10.2989/AJAR.2008.7.3.5.652

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African Journal of AIDS Research 2008, 7(3): 281–291 Printed in South Africa — All rights reserved

AJAR

ISSN 1608–5906 EISSN 1727–9445 doi: 10.2989/AJAR.2008.7.3.5.652

Traditional healers, HIV/AIDS and company programmes in South Africa David Dickinson

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Wits Business School, University of the Witwatersrand, PO Box 98, Wits 2050, Johannesburg, South Africa Author’s e-mail: [email protected] This paper explores the organisational structures of traditional healers, outlines their explanations of HIV/AIDS, and discusses how they can be integrated with company programmes. The South African Traditional Health Practitioners Act seeks to register, regulate and promote traditional healers, but its ability to do this depends on strong, formalised associations of traditional healers. The different forms of traditional healer groupings in South Africa are described along with the implications that their organisational structure has for knowledge, competition and service standards. Traditional healers’ diverse and fluid beliefs about HIV and AIDS are explained together with ways in which cooperation between companies, allopathic medicine and African traditional healing practices could be promoted in workplace responses to HIV/AIDS. It is suggested that such collaboration should focus on ‘windows of compatibility’ rather than on overall agreement. Moreover, it is argued that any response to HIV/AIDS must be embedded within a wider set of agreements, the most critical being a genuine process of referral between the traditional and allopathic healthcare systems. Companies are in a strong position to initiate such reforms, and this would support the professionalisation of traditional healers as well as help coordinate a wider and more effective response to the HIV epidemic in South Africa. Keywords: cultural beliefs, health services, indigenous practitioners, integrated services, professional associations, traditional practices

Introduction In the face of continued incidence of HIV infection (Rehle, Shisana, Pillay, Zuma, Puren & Parker, 2007), along with people’s continued reluctance to test or access available antiretroviral therapy (ART), a wide range of social agents need to be mobilised in response to the HIV epidemic. While some people remain optimistic about the eventual success of pedagogical efforts based on a scientific, biomedical, or allopathic understanding of the disease (e.g. Ashforth & Nattrass, 2005), the limited impact of over 20 years of HIV/AIDS education points to the need for re-evaluation. Traditional healers are increasingly recognised as a potential ally in responding to HIV and AIDS in South Africa. Even though precise figures are lacking, traditional healers are widely utilised within a de facto plural healthcare system by many South Africans, and there have been some attempts to involve traditional healers in HIV/ AIDS programmes (Wreford, 2005a). However, the acceptance of traditional healers’ influence remains partial and often grudging.1 Consequently, even when collaboration is attempted, projects frequently duplicate the tried, tested, and repeatedly failed strategy of imposing the biomedical explanation of HIV/AIDS onto existing cultural understandings of health and disease (Wreford, 2005a; UNAIDS, 2006).

The paper first outlines key features of African traditional healing and then explores three interlocking issues: 1) traditional-healers’ structures and the current process of regulation in South Africa; 2) traditional healers’ approach to HIV/AIDS and the implications of this in a plural healthcare system; and 3) ways that effective cooperation between the allopathic and traditional healthcare systems can be encouraged. Building on this exploration of traditional healing within a contemporary context, I suggest that the way companies choose to respond to these issues could have a beneficial impact on the wider processes of the organisation, professionalisation and regulation of traditional healers in South Africa. Methods The paper draws on a range of contacts and collaboration with traditional healers in South Africa, primarily ones based in the Kathorus (Katlehong, Tokoza and Vosloorus) townships of Ekurhuleni, Gauteng Province. I was first introduced to traditional healers several years ago by a traditional practitioner leading the NEPAD2 Moral Regeneration (Nemore) Traditional Doctors Movement. In 2006 and 2007, I workshopped a ‘Professional Guidelines and Code of Ethical Conduct: HIV/AIDS’ with 60 members of Nemore, and in December 2007 I administered a

Note on the peer-review process: Anonymous peer-review of this article was independently managed by the AJAR Managing Editor, since the author was a guest editor of this issue.

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questionnaire to 22 members of that group. In early 2008, I formalised my contact with a number of traditional healers affiliated with the Katlehong Traditional Healers Association (Katha). Through that meeting I also made contact with the Ekurhuleni Metropolitan Municipality Traditional Health Practitioners Forum and attended an induction workshop. I spent one day at the consulting room of a Nemore member, conducted a group interview with eight traditional healers affiliated with Katha, and conducted in-depth interviews with four healers, of whom one was the Chair of Ekurhuleni’s Traditional Health Practitioners Forum. Additionally, in August 2007, I had attended a Free State provincial hearing on the then Traditional Health Practitioners Bill. And, in April 2008, I conducted an interview with the HIV/AIDS programme coordinator at a mining company in the North West Province (which incorporates traditional healers into its programme). My understanding of traditional healing has also been assisted by inquiry into the topic within research on workplace peer education (see Dickinson, 2007). Finally, contact with several families in Katlehong (a township near Johannesburg) has provided me with direct exposure to the plural healthcare system accessed by much of South Africa’s population. Although I write this as an individual who does not utilise African traditional healing, I recognise that millions of other South Africans do. My explanations and explorations of traditional healers and their calling are addressed to those who are considering how they can work with traditional healers in response to HIV. African traditional healers The extent to which African traditional healing is used is not known. The South African Department of Health (2003) estimated (although it is not clear how) that there were 200 000 traditional healers in South Africa. The World Health Organization (WHO) (2002) has estimated that up to 80% of Africa’s population make use of traditional healers: for many people it is the only health system available to them. Ashforth (2005a) cogently argues that the estimates should be regarded with caution. But regardless of the margin of error, there are clearly significant numbers of traditional healers and clients in South Africa. Appreciating how traditional health practitioners and users understand traditional healing requires placing them within an African cosmology that operates according to very different world view to than that of scientific inquiry. To put this in perspective, few, if any, people anywhere in the world rely purely on the realm of scientific understanding in regard to their own health, as they are likely to draw on a range of non-scientific practices, such as prayer or a positive attitude. Hammond-Tooke (1989) identifies South African traditional healers, in line with other writers describing traditional healers in other parts of Africa (e.g. Evans-Prichard, 1977), as part of the traditional African world view that includes a belief in ancestors, witchcraft, and the polluting nature of certain objects and practices. These elements of the traditional African world view constitute — as do all world views — an attempt to “make intellectual sense of the world and of life, so that in the broadest sense it involves theories

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of explanation” (Hammond-Tooke, 1989, p. 33). Operating within this traditional world view, African healers are often divided first into the group called diviners who, though a range of rituals, such as ‘throwing the bones,’ seek to establish the underlying cause of a client’s problem, and secondly into the group called herbalists, who specialise in treatment. In practice, apart from a small number of specialised herbalists, most traditional healers appear to combine divination and treatment.3 Treatment can include: herbal medication, rituals to allow a patient to communicate with ancestors, holding appropriate cultural events that may have been neglected, protection against witches, emotional empathy, and advice or coaching on a wide range of problems. Overall, traditional healing is much more holistic in its approach to the client/patient than what occurs in allopathic medical practices. The wide range of problems dealt with by African traditional healers is illustrated by the responses of 22 surveyed traditional practitioners belonging to Nemore, surmised in Table 1. Operating alongside traditional African beliefs are more recently introduced religions, notably Christianity. As rival cosmologies, they compete over constructions of meaning. However, the relationship between traditional African beliefs and Christianity is, in practice, complex. Although some churches strongly oppose traditional African beliefs, individual church members may practice traditional beliefs in (concealed) defiance of church practice or with tacit acceptance. In addition, a large number of African churches openly synchronise traditional and Christian beliefs and operate their own parallel healing practices. Western medical science is another introduced world view that traditional African beliefs engage with. In contrast to the relatively more malleable beliefs of the Christian churches (allowing the possibility of synchronisation), the custodians of Western medicine have largely refused to contemplate any role for traditional healing as a legitimate health system. Thus, the South African Medical Council successfully lobbied the government for the closure of non-allopathic medical colleges in the 1960s (WHO, 2001), and traditional healing practices are currently unregulated, aside from some relatively weak voluntary associations of healers. Because of the fragmented and diverse nature of traditional healing, there have been a range of responses to potential collaboration with Western medical practitioners and institutions (Ingstad, 1990). One (not surprising) response is suspicion of such collaboration due to traditional healers’ fear that they will be kept in a subservient position or that their own knowledge will be stolen from them. This resonates with the colonial and racial history of South Africa and provides arguments for maintaining separate institutions and practices. However, there is also a strong desire by traditional healers to access legitimacy and resources. This can only come through accommodation with the dominant Western medical establishment. Essentially then, African traditional healing and Western medicine represent rival healing (or treatment) systems in which the latter dominates publicly, through an alliance with the state and employers, although the former system privately retains considerable sway within large sections of the population.

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Table 1: Frequency of patients’ problems as stated in a questionnaire, in December 2007, answered by 22 traditional healers belonging to the NEPAD Moral Regeneration (Nemore) Traditional Health Practitioners Movement (n = number of healers reporting) Frequency that this problem is presented (%) Patients’ problem:

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‘Extremely often’ Physical health problems 61 Mental health problems 22 Problems with family and relationships 77 Problems with work and study 79 Witchcraft 41 Dreams 26 Bad luck 53 Stolen or lost property 12 Note: Rows may not total 100% due to rounding

‘Very often’

‘Quite often’

‘Sometimes’

‘Never’

n

17 0 24 5 18 32 32 12

11 6 0 5 6 5 5 12

11 50 0 11 0 31 11 24

0 22 0 0 35 5 0 41

18 18 17 19 17 19 19 17

The training, structure and associations of African traditional healers Three forms of association among African traditional healers can be distinguished: 1) ‘organic’ structures made up of vertically organised training-based ‘clans,’ and the horizontally structured geographic networks that supplement these; 2) the many ‘modern’ voluntary associations of traditional healers; and 3) evolving structures that are preparing for the interim Traditional Health Practitioners Council to be established under the Traditional Health Practitioners Act (Republic of South Africa, 2007). The typical training process for traditional healers in South Africa creates a vertical structure of students and teachers or trainers (Green, Zokwe & Dupree, 1995). Via an ancestral calling, a student locates a traditional healer to act as a trainer or principal. When training is complete, typically between six months and a year (but longer for herbalists), the student sets up his or her own practice. Students are expected to remain in contact with their trainers (who are responsible for their conduct) and to attend events such as the graduation of other students. As students become trainers a vertical clan-like structure is created, with members referring to each other as children, parents or grandparents, as appropriate. In addition to these clans of traditional healers, contact between traditional healers in close proximity to one another extends the practitioner’s network of contacts, typically through the invitation of nearby traditional healers and other members of an individual’s own clan to the graduation ceremonies of new students. Ngubane (1992) described these networks in a rural Zulu setting and estimated that a traditional healer could meet with as many as 400 other traditional healers over a three- to five-year period. Such networks create structures of contact, referral, knowledge, and ethical standards within traditional healing practices. The vertical component of such structures, based on the intense relationship between student and teacher, is clearly the strongest component, while the horizontal links, based on geographical proximity, provide a wider but weaker structure of mutual support and information-sharing. During the research, such traditional healer networks were observed in the urban areas of the Kathorus townships, but

in general they seemed not as robust as those described by Ngubane (1992). While some students do remain in contact with their teachers after graduation it is also not uncommon that contact will be lost. In some cases this can be linked to the mobile, anonymous and faster pace of urban life — especially in informal settlements and new housing projects where mobility is high. There is also ambiguity about which traditional healers constitute neighbours. In some cases the geographic networks, like those described by Ngubane (1992), appear to be replaced by smaller friendship networks. These ‘organic’ structures of traditional healers are often overlooked. Consequently, it is not clear how these structures will be incorporated into the regulatory environment of the Traditional Health Practitioners Act. Yet, these organic structures provide the dominant mechanism by which traditional healing practices are reproduced and self-regulated as a health system in South Africa. Moreover, the survival of African traditional healing, despite centuries of repression, bears testimony to the resilience of this form of professional reproduction. A large number of relatively modern, voluntary associations of traditional healers exist in South Africa — some local and others national in scope. Some organisations date back decades and others are new. In the Kathorus townships of Ekurhuleni I noted perhaps four significant organisations, each with different, sometimes changing, membership and with different geographical reach. However, there were clearly many more than four associations with members in these townships, and many healers who are not members of any association. The associations serve a range of purposes, including the value of mutual association, information-sharing, accreditation (most issue some kind of certificate of membership), and representation. Besides the internal conflicts that may lead to splits and re-alignments, it is accepted that a lack of organisational skills (largely due to the low level of literacy in many groups of traditional healers) bedevils these organisations. The Traditional Health Practitioners Act, Act No. 22 of 2007 (Republic of South Africa, 2007), which has had a long and complex gestation, provides for setting up a 22-member interim Traditional Health Practitioners Council (hereafter, the Council) that will include traditional healers from each of South Africa’s nine provinces. This has motivated a

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necessary, but difficult, process of establishing structures that can nominate the appropriate representatives from each province. This presents a dilemma because the Traditional Health Practitioners Act is largely devoid of specific content in regard to the practice of traditional healing; rather, the Act specifies establishment of a Council, which will then regulate matters of traditional healing, such as training, codes of conduct, fees, and methods. As a result, preparatory organisation has not been based on agreed principles and practices, but rather on getting representatives into the Council who will eventually help establish the principles and practices. This presents challenges given the plurality of the already existing associations and the legislatively-neglected organic structure of traditional healers’ organisations. The formalisation of traditional healing in South Africa faces further difficulties. In addition to setting up the Council, the other main element of the Traditional Health Practitioners Act is to empower the Council to establish a process for registering traditional healers. Without such registration traditional healers may not practice for gain. However, while there is a need to register as a traditional healer with the Council, there is no stipulation that healers must be members of any association. Thus, it is possible that traditional healers may register directly with the Council in order to practice (without being a member of an association) or they may be part of an association that does not participate in structures linked to the Council. This raises questions about how the regulations and guidelines developed by the Council can be communicated, explained and enforced — if the majority, or at least critical mass, of traditional healers is not incorporated into a clear structure of organisations linked into the Council. Knowledge and competition among African traditional healers There are two features of the complex matrix of structures of African traditional healers that can be highlighted. One concerns the nature of the knowledge at their disposal, and the other the nature of the professional relationships between traditional healers — something that impacts on the healer-patient relationship. In contrast to Western medical science, African traditional healing has no shared repository of knowledge to which trainees or practitioners can refer. In South Africa, the most widely shared information is that which exists within clans. Some trainees are required to write down treatments during training — text that they can add to and pass on to their own students. Such information is often closely guarded as the property of the clan. This custom is overlaid by a pervasive fear that their knowledge of herbal treatments will be stolen from them. As one traditional healer said, ‘The universities are full of books that we have written.’ The pharmacological value of their herbal treatments needs to be taken seriously; however, as Ashforth (2005b) outlines, current efforts at evaluating and protecting the intellectual property rights associated with indigenous knowledge systems are far from straightforward. Moreover, while knowledge about treatment is recorded or passed down (more extensively among traditional healers specialising as herbalists), much

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treatment is highly individualised. In addition to the oftencited problem of dosage, many traditional healers operate according to ancestral advice in regard to what measure of treatment should be given, and some operate according to personal inspiration. The latter situation is often grounded on ‘sympathetic magic’ that “draws upon ethno-pathological notions of homeopathy whereby ‘like produces like’” (Leclerc-Madlala, 2002, p. 93). Scientific opinion should remain receptive to the possibility of herbal treatments being effective in treating particular diseases and conditions. However, as a rival health system, traditional healing is clearly at a disadvantage compared to allopathic medical practices because of its fragmented and secretive approach to knowledge, which impedes the flow of information within the profession. But, traditional healing is at much less of a disadvantage (or sometimes has an advantage) in other elements of its holistic approach to the client/patient. Many of the skills of ‘bedside manner,’ psychological support, facilitating domestic or social peace, counselling and coaching are largely tacit in nature. Such skills can be codified only to a limited degree and are, rather, largely learned on the job by the various practitioners in any healthcare system. Thus, outside of providing medication, traditional healers can equal or be superior to allopathic medical practitioners, who focus on bodily illness, are frequently resource-constrained regarding time for clients, and often operate across vast social divides. The fragmented and complex way that traditional healers organise themselves has profound implications for their professional relationships. This of course stems from the historic suppression of traditional healing, which has prevented it from developing forms of regulations that can function in contemporary South Africa, especially where traditional, rurally derived forms of regulation have limited efficacy in urban communities. Clearly, the Traditional Health Practitioners Council can eventually move towards regulation of traditional healing practices, though this will undoubtedly take time. For the moment, its envisaged powers remain limited compared to those of other established professions. Thus, for example, it is currently not possible to limit entry into practicing traditional healing, and there is no explicit mechanism to remedy this under the Traditional Health Practitioners Act. Yet, restriction on entry into a profession is critical for controlling the standards of professionalism and the level of services provided. Because entry into traditional healing practices in South Africa is not yet regulated, traditional healers are often in competition with each other. Without regulation concerning what can and cannot be offered, any traditional healer is vulnerable to clients defecting to other healers. While some traditional healers may make large sums of money, more typically they manage to just make a living. This heightens competition and has implications for professionalisation, which will inevitably cost money. Given this, charlatans are resented especially by those traditional healers who regard themselves as devoted to the care of their clients. Even so, without regulation, what constitutes either an unscrupulous healer or a genuine healer remains considerably subjective.

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African traditional healers and HIV/AIDS

patient seeking assistance because of employment problems requested a remedy that did not involve burning herbs5; the (unspoken) context of this was concern for the suspicions that might be raised by his neighbours should he start burning muti in the building that they shared.6 While bewitchment is put forward as an explanation of HIV/AIDS, this may serve a range of purposes (Ashforth, 2005a; Wreford, 2008). The traditional healer’s role of ‘witch-finder’ (Hammond-Tooke, 1989) supports the idea that traditional healers may explain HIV or AIDS by means of witchcraft. Yet, the traditional healers I spoke with expressed a more complex position: they saw their role not as witch-finders but as healers helping to ease accusations of witchcraft within communities, regarding these as socially disruptive and unhelpful.7 In one consultation I observed the initial suspicion of witchcraft as a cause of a patient’s problem was re-interpreted by using a second ‘throw of the bones,’ which subsequently faulted the patient for neglecting an ancestor. Most of the healers I interviewed clearly asserted that they did not believe that HIV or AIDS could be sent by witches.8 The tension between popular beliefs and traditional healers’ opinions about witchcraft and HIV/AIDS is instructive. MacCormack (1986) pointed out that the legitimacy of traditional healers rests exactly in their ability to draw on the authority of tradition. Obviously, those who consciously seek to modernise by unambiguously embracing new ideas (such as those originally brought by colonialists, including allopathic medicine), will view traditional healers as illegitimate. But for those who believe that traditional African ways have value, then the custodians of such practices — as traditional healers position themselves — have legitimacy. However, this legitimacy locks in and limits the manoeuvrability of traditional healers. If their influence and authority depends on resonance with popular beliefs, which in turn are legitimated by tradition, then traditional practitioners can only side step those beliefs to a limited degree.9 Wreford (2008) explores how this legitimate, if limited, space might be utilised to allow an individual’s HIV-positive status to be addressed. Notwithstanding such options, the traditional healer’s limited manoeuvrability contrasts with that of Western doctors who have more freedom to impose a diagnosis. The power of allopathic medical practitioners is derived from a scientific body of knowledge that is independent of the majority of the population. Moreover, the patients of allopathic medicine can be controlled to a greater degree as a result of doctors’ (legal) monopoly, which is exercised in practical terms through institutions such as hospitals. One question pursued in the research (following the approach of Ingstad, 1990) was whether traditional healers saw HIV/AIDS as a new disease (which would require a new approach) or as an old disease (i.e. as a new label applied to something they were already familiar with). Within the population at large there is a range of theories on the origins of HIV which identify it as a new disease (Schoepf, 2001). Many of these theories link to racial, often conspiratorial, narratives, and many incorporate elements of scientific explanations of AIDS illness. At the same time, there are a range of theories to explain the origin of HIV in terms of the breakdown of traditional social and sexual

African traditional healers offer diverse explanations of HIV and AIDS (Mills, 2005). This is not surprising given the limited extent to which they share information and the multiple and separate channels of communication among them. Moreover, the lack of regulation among traditional healers makes it easy for fakes to put forward unproven claims, which further complicates the plurality of their explanations. Importantly, this is not a static situation, as conceptualisations of HIV/AIDS continue to evolve among traditional healers. This part of the discussion attempts to outline the different, often overlapping, and changing strands of thought about HIV/AIDS which circulate among traditional healers. As a subjugated element of South Africa’s plural healthcare system, traditional healers are generally ready to accept that their clients will access Western medicine as well as their own services. Indeed, most healers will refer clients to Western doctors, clinics or hospitals, in regard to a range of conditions that they feel is beyond their competency to treat or is a condition that would benefit from ‘dual therapy.’ Acceptance of dual therapy is not simply pragmatic acceptance that the dominant healthcare system cannot be excluded, but it links to various conceptions about the duality of sickness. The most commonly understood duality is that of separating the illness itself (as a biological disturbance) and the underling cause of the illness — finding an explanation for ‘Why me?’ rather than ‘What?’ In this regard traditional healers may oftentimes accept that Western medicine deals better with the biological problem while their own diagnoses and treatments can attend to the patient’s underlying spiritual or social imbalance.4 In Africa, one underlying or traditional variant of illness is identified as the neglect of ancestors and/or social behaviour that offends the ancestors who are constantly concerned with the behaviour of the living. While few traditional healers actually suggest that ancestors have sent a disease, the physical symptoms may be interpreted as the ancestors’ demands for attention, while continued neglect of the ancestors may forfeit their normal protective role, making the individual more vulnerable to infection and sickness. Such an interpretation allows traditional healers to utilise their strong socio-cultural understanding of a client’s situation as well as their often highly developed intuitive personalities. It also highlights African healers’ belief in a ‘traditional moral order,’ a point discussed later. Some writers have stressed witchcraft as an explanation put forward by South African traditional healers for HIV/AIDS (e.g. Ashforth, 2005a). Belief in witchcraft is widespread in African society and it clearly figures into the range of problems presented to traditional healers. This belief is not always immediately discernible because witchcraft is a subject that Africans are frequently reluctant to talk about to outsiders, and since understanding among Africans is often implicit rather than explicit. While observing consultations at a traditional healer’s workplace there was only the occasional open referral to witchcraft; yet, when discussing what had taken place within the consultations, implicit understanding about witchcraft was often detectable. For example, one

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orders (Sandile, 2006). These latter theories are able to incorporate the current HIV pandemic both as something old, but also new in its scale, as a result of social changes that have brought about the destruction of traditional ways of life and the associated moral orders. Such theories can also incorporate narratives of racial oppression and the role of poverty in fuelling the epidemic in South Africa. Traditional healers belonging to Nemore were asked whether they thought HIV/AIDS is a new illness or an old illness that has existed for a long time. Their responses (Table 2) indicate that despite their ability to apply the term HIV/AIDS,10 most did not believe in HIV and AIDS but in older illnesses that have only now been labelled as such by Western science. The respondents were then asked to proceed on the basis of their answer to state what the name of this older disease was, or what the cause of HIV/AIDS is if it is a new disease. The 20 traditional doctors who thought that HIV/ AIDS is an old illness provided a total of 28 names for the disease, and these names could be grouped into 10 distinct terms. This plurality was in part a result of the use of Zulu and Sesotho in the responses. Nonetheless, the range of responses indicated that there is no consensus, at the level of terminology, among traditional healers. This finding was supported by the in-depth interviews, which added more terms used by healers to describe what Western science calls HIV/AIDS.11 A closer look indicates three features of the disease are implied in the range of terms used by the healers: 1) a progressive disease that can start with relative minor sores, for example, before progressing into a more dangerous illness; 2) a disease originating from pollution when cleansing or protective processes have not been followed (for example, after the death of a spouse, after an abortion, not taking precautions when medicating for another disease, etc.); and, 3) a sexually transmitted disease, with a strong correlation to promiscuity and adultery. These attributes indicate that an alternative system of explanation, with a fair degree of internal logic, circulates among traditional practitioners and, one assumes, their patients. None of the three attributes of the disease stands in opposition to another. In fact, they can be easily woven into a coherent narrative. Much of this can be regarded in parallel to Western-based understandings of HIV/AIDS. The critical difference between them is their explanation of the origin of the disease. In some cases clear disagreement between Western and traditional explanations can be located (e.g. abortion as a cause of HIV-related illness). In other cases there is a degree of compatibility: traditional healers may regard a particular behaviour as the cause of the disease (e.g. sex without ‘purification’ after the death of a spouse), while Western medicine regards this behaviour as a potential mode of HIV transmission only. These observations were

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also supported in in-depth interviews with the traditional healers.12 In regard to prevention, many traditional healers agreed that condoms would prevent infection of sexually transmitted diseases, but they generally argued that this was not the best approach. Rather they felt the best response was a return to traditional values — in which young people’s sexuality was more closely controlled, wherein individuals remained faithful, or where polluting events were avoided through appropriate behaviour.13 The traditional moral order put forward by traditional healers critiqued the impact of colonialism and apartheid on African society. But such purported morality was also frequently critical of the new South African Constitution, which many traditional healers regarded as accelerating the breakdown of social values, because, in their view, it legitimated sexual (and other) freedoms (such as for children, or in relation to abortion and prostitution), or by assisting the prioritisation of rights over respect — all of which contributed to HIV/AIDS, or at least their understanding of the disease. The compatibility of Western medicine and African traditional healers’ understanding of HIV/AIDS Despite educational projects with traditional healers in South Africa, since the early 1990s (Green et al., 1995), Western medicine and traditional healers appear to have maintained different understandings of HIV/AIDS. While Western science understands HIV transmission at a biological level, beyond its success in stopping mother-to-child transmission of HIV, it is ill-equipped to prevent sexual transmission, which is embedded in social and emotional relationships, and over which science has little influence. Traditional healers’ understandings of HIV/AIDS are much more diffuse, less clarified and remain in flux, and they draw on spiritual and social rather than biological understanding. Although healers’ understanding is influenced by Western explanations of the disease, this remains partial and is likely to remain so. As with Western medicine, traditional healers have no cure (despite claims by some to the contrary); and while some traditional practices can undoubtedly improve patients’ general health and tackle some opportunistic infections associated with HIV, none can directly suppress the virus. Nevertheless, traditional healers are widely consulted on a range of health, sexual, social and other matters, all of which have relevance to HIV transmission and prevention, as well as the care of those who are infected or affected. In many ways, traditional health practitioners are far closer to large sections of the population than most allopathic doctors can ever hope to be. While there is a need for collaborative responses to HIV, two approaches to a partnership between traditional and allopathic medicine are likely to fail. One focuses on

Table 2: Traditional healers’ responses to whether they thought HIV/AIDS is a new or an old disease

‘HIV/AIDS is a new illness’ ‘HIV/AIDS is an old illness that has existed for a long time’

‘Yes’ 2 20

‘No’ 19 2

‘Not sure’ 0 0

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converting traditional healers to the allopathic explanation of HIV and AIDS; the other approach is to insist that traditional healers do not have a cure for HIV or AIDS. A common starting point for plans to involve traditional healers in HIV/AIDS programmes is to teach them the Western biomedical understanding of HIV and AIDS. This approach is likely to result in one of two outcomes. First, traditional healers may refuse to participate if they feel they are about to be led down a path that will require them to accept a different world view, abandon much of their intellectual and emotional framework, and become merely assistants to allopathic doctors. One traditional healer interviewed said, ‘What we don’t want is education [on HIV/ AIDS] which means we must throw away our bags [of muti].’ Second, they may respond in a way similar to many lay people with limited formal education in the natural sciences; they may learn key phrases, repeat them when appropriate, perhaps attempt to integrate some instruction into their traditional understanding, and then proceed with not much having changed other than having acquired a slightly larger vocabulary.14 The first outcome is more likely when the traditional healer has no real need to cooperate with Western medicine. That is, the healer may have a viable practice and can happily continue seeing patients without an alliance with allopathic doctors. The second response is likely from traditional healers who seek to access more of the economic and intellectual resources currently held by Western doctors and who see no other way in which partnership can be established but to ‘play along.’ Insisting that traditional healers cannot cure HIV is not as simple as those steeped in science might think: if anything, it motivates and calls attention to those traditional healers who claim to have a cure for AIDS. Demanding scientific proof has little sway among those who base their own healing practices on non-scientific principles. Wreford (2005b) has outlined some of the complexities of defining what a cure means in the context of HIV/AIDS and traditional healing. As well, traditional healers can point to examples in their own communities where antiretroviral therapy has failed or they can cite the fact that Western medicine itself does not have a cure. In such a context, setting up a confrontation about who does or does not have a cure is hardly helpful. ‘Moderate’ traditional healers will likely respond to such provocation with measured counter claims of ‘therapeutic parity,’ while less responsible healers may find a platform for making spectacular claims, which, given the unregulated nature of traditional healing, they may profitably succeed with for some time. Then, if these approaches are to be avoided, what alternative would constitute a viable approach to a partnership between traditional and allopathic health systems? As in any genuine partnership, each side should look to the strength of the potential partner (rather than their weaknesses) and endeavour to have these aspects brought to any joint endeavour. What follows considers which aspects of traditional healing might benefit a joint response to HIV/AIDS. The discussion does not suggest a comprehensive weaving together of the Western scientific and traditional healing approaches to HIV/AIDS. (From what has been outlined in this article, this is probably not possible.)

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Rather, we should be looking for ‘windows of compatibility’ connecting the two systems. In terms of HIV prevention, despite differences in understanding between the two health systems, there are clear areas of compatibility, especially related to traditional moral codes espoused by many traditional healers. Whether traditional healers have sufficient influence to (re)establish such values across modern-day South Africa is doubtful. But support for key aspects of such a code could provide a viable model of behaviour that would, among other things, slow the spread of HIV among those who sought to adhere to it with pride in their African heritage. Within this code, specific rules of behaviour make sense in the era of HIV. Thus, for example the practice that after the death of a spouse there should be a period of sexual abstinence (usually, one year) accompanied by rituals of cleansing, is alone far from adequate in preventing HIV transmission, yet it could clearly assist prevention and can be built upon. Traditional practices can also be used to introduce specific HIV-prevention methods. Thus, the view that men taking certain traditional medicines should not have sex because of the danger of them transferring the discharging pollution to partners provides a means to introduce condom use.15 Also, integrating HIV testing into traditional cleansing rituals and processes would be especially valuable; as described below, this could be a fairly uncontroversial addition to traditional practices. Traditional healers care for many people who are HIV-positive. The 22 Nemore practitioners surveyed were each dealing with an average of 3.8 patients, and a historic total of 8.8 patients, who they believed were HIV-positive or had AIDS.16 While these represent small case loads in comparison to many Western doctors dealing with HIV-related illnesses, the total number of patients nationally who in the view of traditional healers are HIV-positive or have AIDS can be very approximately calculated using the total estimated number of healers. If this is 200 000, then we currently have 760 000 people who are either HIV-positive or sick with AIDS and in contact with traditional healers. The idea of integrating traditional healing within a wider healthcare system is not new but has had limited success so far (Feierman, 1985). Possibly the best option for a genuine partnership between Western and traditional medical systems over HIV/AIDS treatment would be a patient-centred approach within an open and coordinated plural medical healthcare system. If there was two-way referral between the traditional and allopathic health systems then a division of labour providing the best of both systems to the individual patient could emerge. Allopathic medicine could provide medical testing and antiretroviral treatment while traditional healers could help strengthen patients’ immune system, treat certain opportunistic infections, give counselling and psychological support, and help HIV-positive patients normalise their situation within family and community. This may not be as problematic as it may first seem. The idea of using three methods of diagnoses simultaneously in regard to HIV-positive patients — divination, assessment of physical symptoms, and a clinical HIV test — was put forward without controversy by the traditional healers

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in the Nemore workshops. Since most traditional healers accept that they are part of a de facto plural health system, they recognise that Western medicine has technologies that they do not. The ability to make a diagnosis from a patient’s blood is one of them, and this presents a significant opportunity for cooperation. As mentioned, HIV testing could be added to a number of traditional processes (such as cleansing) that traditional healers could be trained to administer (as has been done in the HOPE Pilot Traditional Healers Project; see Wreford, Esser & Hippler, 2008). It also offers possibilities to cooperate by giving traditional healers, via referrals, notice that a patient is HIV-positive and so should be appropriately supported. Of course, this does not happen in the current context, as Western medical practitioners never refer patients to traditional healers. While many traditional healers do refer patients to the allopathic system, such referrals are often simply advice to ‘go to the clinic,’ since they have no prescribed relationships, and usually with the subtext that ‘it’s best not to tell’ the nurses that they have first seen a traditional healer. By contrast, a VCT counsellor with one-year’s training as an auxiliary nurse is equipped with a pro-forma letter to refer to local clinics or doctors. Such a system of mutual referral17 has the potential to dampen pointless debates and to prevent either side from operating outside the realm of its main strengths. However, it obliges traditional healers to provide individuals with an equally predictable, if different, service as offered by the allopathic system. This brings the discussion back to recent attempts to regulate traditional healers; the next section looks at how companies can help develop a genuine referral system and division of labour between traditional healers and allopathic medical practitioners. Companies and traditional healers: Wait for the Act, or act now? The relationship between traditional healers and companies is currently no more substantial than their relationship with allopathic practitioners. While a number of companies have projects with traditional healers linking them to their HIV/ AIDS programmes, the general relationship with traditional healers remains limited; notably this affects the acceptance of sick-leave notes and claims to medical aid providers. Lack of cooperation or collaboration is the consequence of various factors, including: negative managerial attitudes to traditional healing; the dominating strength of (allopathic) occupational health practitioners within companies; illiteracy among traditional healers; problematic experiences with individual traditional healers; employees’ reluctance to present a sick-leave note from a traditional healer; and the relative ease with which sick-leave notes can be got or bought from doctors. 18 Given this, from a managerial perspective, there is little pressure to alter the current system of managing employees’ health and sickness, despite ongoing concerns for HIV and AIDS. The Traditional Health Practitioners Act may alter the balance of these calculations in South Africa, but change will likely take time. One option is to simply wait for the Act to take effect and then respond as needed. Alternately,

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companies could choose to act now in ways that would benefit their HIV/AIDS programmes, their employees, and the professionalisation of traditional healers. The Act will require the registration of traditional healers but not association. But without strong associations the proposed Traditional Health Practitioners Council will struggle to convey its legitimacy and hence the regulations it is tasked with establishing. Moreover, without extensive association it is difficult to envision how traditional healers might professionalise themselves by excluding charlatans, guaranteeing standards of service, and improving the quality of training and practice. Therefore, in contrast to the relatively weak powers of the Council,19 companies have significant power to promote formalised associations of traditional healers. The acceptance of notes for sick leave and claims to medical-aid providers from traditional healers need not wait for the Act to take its course, but can be introduced pro-actively and incorporate agreements that suit the company while promoting formal organisation among local traditional healers. Such collaboration would allow traditional healers to write employees notes for sick leave and claim for their services from medical aid schemes on the basis that they had registered with the Council and were members of good standing in a traditional health practitioners’ association (that had entered into an agreement with a given company). This arrangement would also assist with the creation of single organisations of traditional healers in particular geographical areas. For some large companies cooperation or collaboration could be achieved independently; for smaller companies it could be accomplished through coordination with chambers of commerce, or by following the example of a larger nearby company. Where municipalities like Ekurhuleni have started a process of regional association, this would provide the obvious structure to partner with. The advantage for companies would be to deal with only one provider network of traditional healers with which it can agree on important specifics, such as standards and procedures; the advantage for traditional healers would be the establishment of an association that can provide real benefits, for members of good standing, and would create possibilities for raising the standards and quality of services. The process of picking one association may result in winners and losers among existing, rival, traditional healer groups. Overall, however, such an endeavour will support a national process of consolidating traditional healer associations, which will allow the establishment of a legitimate national Traditional Health Practitioners Council and a viable means to establish regulations and standards to be disseminated and enforced. Significantly, an agreement on standards between a company, or group of companies, and traditional healer associations needs to encompass more than a response to HIV/AIDS. Thus, it should include agreements about particulars such as time-off for illness or charges for healers’ services, and it may entail developing (low-literacy level) documentation for submitting to human resources departments or the company’s medical aid provider. This would be facilitated (as it is for current allopathic treatment) by the parameters of sick leave entitlement and medical aid limits.

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Where companies do not have their own medical services, referral processes should to be coordinated with the public health sector and traditional healers.20 Company HIV/AIDS programmes need to insert their own particular concerns within this wider framework of agreement. This should take cognisance of how windows of compatibility linking allopathic and traditional approaches to HIV and AIDS can be used and expanded. For instance, this may include: training traditional healers to conduct VCT for HIV; agreeing on which services are appropriate for traditional healers to provide to HIV-positive patients; suitable processes of referral to allopathic medical practitioners; training traditional healers to professionalise their practice; and responding to training needs as articulated by traditional healers and as are compatible with the company’s HIV/AIDS programme. Conclusions Many South Africans experience a de facto plural healthcare system. While allopathic medicine dominates, traditional healers are a significant source of health-related advice and treatment. Thus, the HIV epidemic and the limits of our current responses call attention to the importance of traditional health practitioners. South Africa’s Traditional Health Practitioners Act is a long-overdue attempt to establish processes of registration and regulation of the services provided by traditional healers. There are relatively few examples of coordinated attempts to pull together traditional healers’ different structures and organisations into a formal structure that will support the interim Traditional Health Practitioners Council as envisaged by the Traditional Health Practitioners Act. Given this, the problem of a formal association presents major challenges to the objectives of the Act, which the process of registering traditional health practitioners alone will not resolve. The limited professional self-regulation that currently exists among healers highlights the issue of internal competition, which can seriously compromise attempts to professionalise and improve service provision. Establishing inter-health-system cooperation over HIV and AIDS needs to assess each system’s perspectives on the disease. Traditional healers’ perceptions of HIV and AIDS are complex and still in flux. While some traditional perceptions are incompatible with biomedical understanding of the disease, cooperation will not be achieved through attempts to resolve (or win) such differences. Rather, it is suggested that windows of compatibility should be looked for, and company interventions that promote cooperation between allopathic practices and traditional healers concerning HIV and AIDS should aim at a mix of initiatives, rather than attempt (unrealistically) to draft a comprehensive, joint master plan. Attempting this with a narrow focus on HIV and AIDS is unlikely to be successful, since the broader problems of association within traditional healing practices and the tensions between the traditional and allopathic health systems will remain. Thus, this response to the HIV epidemic must be embedded in a broader set of reforms — which companies are in a strong position to implement.

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At the heart of this would be the creation of a genuine system of referral and communication between companies and allopathic and traditional health practitioners. This would have the advantage of allowing each health system to contribute in terms of its own strengths, while providing resources to traditional healers to help them professionalise and improve their services. Since this cannot be done without quality controls in place on both sides, it is imperative to have strong associations of traditional healers, which currently do not exist. By carefully working with agreed services providers (e.g. creating policies on notes for sick leave and claims for medical aid), companies could assist selected traditional healers’ associations in achieving quality control; doing this would help with the overall process of professionalisation envisaged by the Traditional Health Practitioners Act. Collaboration between companies and traditional healer associations would need to deal with all relevant health concerns, with particular issues around HIV and AIDS recognised and built into a wider agreement. Notes 1

2 3

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6

7

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Not least because tensions over responses to HIV/AIDS are embedded within a much wider, and far older, set of tensions (within South Africa, and other African countries) involving the role and position of traditional healers. NEPAD (New Partnership for Africa’s Development). Cf. Devenish’s (2005) account of herbalist and diviner organisations in KwaZulu-Natal Province, South Africa. In addition to this spiritual–biological duality of illness there are other ideas around the dual nature of disease: namely, that one disease can emanate from two different sources (Wreford, 2005b). This may take different variations, but while one variation may be treatable by Western doctors, the other can only be dealt with by traditional healers (Ngubane, 1977). In addition to the prepared mixture that was eventually given, the traditional healer’s ‘treatment’ involved substantial practical advice, personal coaching and support in regard to the client’s employment problems. There are seemingly never-ending levels of complexity that are not necessarily clear to the participants in such situations. For instance, is the patient afraid that his neighbours will think he is trying to bewitch him, or are the neighbours actually bewitching him and will they be alerted by the incense? And how should the neighbours’ intentions be interpreted if they then burn their own muti? They were also conscious that identifying a witch could land them in trouble if the ‘witch’ ended up being attacked or harmed in some way and then the police became involved. Though this explanation was once caveated. A traditional healer reconsidered her view that witches could not send HIV to suggest that it was possible that a witch’s familiar (an entity under the control of a witch) might themselves be infected with HIV and then could infect the witch’s victim through sex. An issue further complicated by the role of ancestors within the world view of Africans and traditional healers. Indicated by their having gone through an extended process of drawing up Nemore’s ‘Professional Guidelines and Code of Ethical Conduct: HIV/AIDS’ (Author’s workshops for NEPAD Moral Regeneration [Nemore] Traditional Doctors Movement, 2006 and 2007). These names did not include popular euphemisms in circulation for HIV/AIDS (which generally incorporate a trinity symbol, such

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12

13

14

15

16 17

18

19

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as an ‘African three-legged pot’ or the [BMW] Z3, of some sort) nor did they include descriptive names that have been popularly coined for the disease, such as the Sesotho term mokakallane wa letekatse (‘the disease of promiscuity’), though the term is also interpretable as the disease of an alien invading (virile) plant. The latter idea is more explicit in the term mokakallane wa setlabotha (‘the disease of new [alien] plants’). Though, outside the restrictions of a questionnaire, the responses tended to be more nuanced, with several of the previously discussed explanations woven together. Another feature suggested in some of the in-depth interviews (including one original respondent to the questionnaire), was that the disease was new and had arisen as a result of the mixing of different sexually transmitted diseases that widespread sexual contact had facilitated. This is a variation on an early (1980s) allopathic medical explanation of AIDS among gay communities in American cities. It is also one explanation of HIV and AIDS (among affluent rather than poor Africans) put forward by Thabo Mbeki (see Gevisser, 2007, p. 733). What these responses do not take into account it the extent to which any cultural structure (traditional or otherwise) can be accepted in public, but undermined privately. See, for example, Kempton (1987) and McCloskey (1983) for the construction and resilience of folk theories. Some peer educators are already making use of this technique in relation to a similar practice among Zionist Christians who are prohibited from having sex with a menstruating wife, but who wish to do so, for example, when making short-term visits home as a migrant labourer. Range 0–10 for current patients and 1–50 for historical totals. The AMREF/KZN Department of Health project in KwaZuluNatal Province has gone some way in developing such referral mechanisms. The HOPE Pilot Traditional Healer Project in the Western Cape Province has also established systems of referral between traditional healers and medical clinics (Wreford et al., 2008). Whether for convenience, fraud, or to provide cover for a genuine visit to a traditional healer. Short of it being provided with a powerful inspectorate, which is currently not being contemplated. Again, local state involvement (as in Ekurhuleni) can greatly assist here.

Acknowledgements — This research is based on fieldwork that was possible only with the assistance of a number of traditional healers. I am particularly grateful to the following traditional practitioners: TDrs Hlahatse (Nemore), Matsebe (Katha Centre), Mbele (Ekurhuleni Traditional Health Practitioners Forum) and Ndaba, who have all assisted me in accessing other traditional healers as well as providing direct information. Many members of Nemore participated in the research. I would particularly like to thank traditional healers TDrs Radebe, A. Moloi, L. Moloi, Sitole, Thibile, Jele and Dladla. TDr Gilbert Martin (Tshwane Traditional and Faith Healers Forum) drew my attention to the value of having traditional healers trained to conduct VCT for HIV. Additionally, I am grateful to all the officials and office bearers of the Ekurhuleni Metropolitan Municipal Traditional Health Practitioners Forum, Gauteng Province, and to Webster Diale of Impala Medical Services, Rustenburg. The author — David Dickinson is an associate professor of HIV/ AIDS in the workplace at Wits Business School. He was co-chair of the 2nd Wits HIV/AIDS in the Workplace Research Symposium. His research focuses on the mobilisation of social agencies in response to the HIV epidemic.

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