Traditional healers play a great role in the health care delivery systems in the developing countries. In some parts of Africa, Asia and Latin America traditional healers are far more in number than the modern medicine practitioners and are widely accepted in the society as the first level of contact and trusted health care providers. The World Health Organization (WHO) (2002) has estimated that up to 80% of Africa’s population makes use of traditional healers: for many people it is the only health system available to them. With increasing threat of HIV epidemic and critical shortage of human resources for health it is essential that traditional healers are included in the HIV/AIDS prevention and control program.
Traditional Healers are consulted first
In developing world, cultural practices, social attitudes and economic conditions facilitate the spread of HIV/AIDS and complicate prevention. Social stigmas surrounding sexual transmitted diseases (STDs) and AIDS keep many from turning to the public health system for testing and treatment. And as a result many people in developing countries continue to consult traditional healers when afflicted with STDs. Many people still believe that AIDS is due to witchcraft and a fetish conspiracy against the infected person and traditional healers may be one of the principal sources of care utilized by people suffering from HIV/AIDS.
Bangladesh has made significant progress in recent times in many of its social development indicators particularly in health. A major constraint identified towards reaching the MDGs and other national health goals is the issue of shortages in the health workforce and the uneven skill mix. Bangladesh has a pluralistic health system and issue of particular concern is the role of non-state health workforce. Like most transitional societies, a wide range of therapeutic choices are available in Bangladesh, ranging from self care to traditional and western medicine. Traditional healers in Bangladesh are very often the first medical contact, particularly in the rural area and sometimes the only source of treatment. There are several types of healers according to their means of practice, like spiritual healers, faith healers, herbalists, bonesetters, kabiraj, practitioners of folk medicine and traditional birth attendants. Some herbal practitioners and traditional birth attendants (TBA) are recognized by the government, after receiving training from an approved institution. Other traditional methods are widely practiced in the country, though not acceptable by law. It is estimated that 70-75% population of the country still use traditional medicine for management of their different health problems where there are only 2 doctors for 10,000 population compared to 70 traditional healers (The State of Health in Bangladesh, 2007).
Common misunderstandings and myths
In Bangladesh, about 30% of STD clients do not have any STD symptoms and perceive themselves as having other Sexual Health problems (Chowdhury et al). The traditional healers in Bangladesh, primarily focuses on treatment of sexual dysfunction and illnesses as due to greater acceptance by the people who believe that traditional healers can help men become sexually stronger and cure impotency. Treatment for both male and female is mainly in the form of traditional and herbal remedies, often combined with homeopathic and other methods, primarily based on common misunderstandings and myths propagated by literature that is used to advertise the services of traditional healers and common beliefs. These messages are widely and freely available in the country, which constructs the perception on STDs among the people of Bangladesh.
Advertisements on different daily newspapers on traditional medicines mostly accounted for the conditions related to sex and sexuality. Claims on increasing sexual power, enlargement of male sexual organs and beautification of female breasts were quite common in most of the advertisements. The most commonly cited medicament in the herbal advertisements was some all-in-one power oil found in various brand names such as Special HP Power Oil, Special SP Genital and Erection power Massage Oil. Other remedies offered in these advertisements include various tablets, creams and lotions prepared from assorted herbs and plants. Many of those manifestations were nothing but common myths or beliefs on sex and sexuality such as nocturnal emission, side effects of masturbation, deformity of penis, thinning of semen and others. Study indicated that the anxiety related to sex and sexuality may be reinforced by ignorant individuals and malpractices of Traditional Healers. Apart from these, choice and use of words in these advertisements were provoking and appealing in most of the cases. One such example from the herbal system can cited for instance as follows:
“A single course (seven days) use of the special massage oil can make the male genitalia as strong as iron rod and as thick as the wrist. It causes instant erection of the genitalia to defeat the sexual partners easily. Even a 60 years old man can be as young as 25 years and will get complete satisfaction in coitus. This power oil provides the stamina for love making several times a day. Both married and unmarried people can apply it. This remedy is tested and appreciated by millions of people. This is entirely devoid of side-effects and makes the skin of genitalia fairer. Success is 100% guaranteed.” (Islam/Farah 2008)
Sexual myths abound, but the facts still remain lesser known. As sex continues to be deemed as taboo in the society, not to be talked about overtly, nagging doubts about sex is what makes people inquisitive as they end up picking up myths from random sources. These pervasive myths can act as the biggest wreckers, ruining the fun of a sexual act and leading to traditional healers. While nobody knows where the erroneous beliefs originated from, these myths still make their way into people’s bedroom. 7 out of 10 patients with impotency and premature ejaculation issues attribute their problem to the masturbation habits. Most men associate their value with their organ size and also with their macho personality, thus they erroneously believe that the dimensions of their penis are of great importance for sexual techniques and gratification.
The common complaints that bring patients to them are sexually transmitted diseases (STDs) and so called “sexual weakness”. Providing correct information about HIV transmission and prevention are the fundamentals for HIV/AIDS prevention. It is not much known about the knowledge among traditional healers concerning STDs and HIV/AIDS although a number of them are involved in advising laboratory investigations and using antibiotics and vitamins for treatment.
UNDP initiated a Health Pilot initiative in the Chittagong Hill Tracts to improve the health status of the people in the region through community health programs, mobile medical teams and partnership building. Although the incidence of HIV/AIDS is low in the region, the high rates of STDs, illiteracy, ignorance, availability of commercial sex workers, injecting drug use and bordering with India and Myanmar posses threat to a raising epidemic in the region. Considering the immense role of the traditional healer within the community, UNDP health unit collaborated with traditional healers for preventing HIV/AIDS in the region.
Study on perception and knowledge
Between February-May 2007, 165 traditional healers were interviewed with a semi-structured questionnaire and face-to-face interview to gather information on their perception and knowledge about STDs and HIV/AIDS and prevention. The findings were analyzed using both qualitative and quantitative methods. The findings showed that 68% of traditional healers could mention at least one mode of transmission correctly, 31% answered about symptom of AIDS while 56% mentioned condom as means for prevention of STD/HIV. None of the traditional healers prescribed condoms to clients. However 41% said using herbal also could prevent AIDS. The concern for STDs is diffused by physical and psycho sexual myths. According to the 65% traditional healers all sexual problems are linked with the two most commonly known STDs, i.e. gonorrhea and syphilis, which leads to misconceptions. Interestingly, a few traditional healers could identify HIV/AIDS as a potential threat to human being and believed that being faithful and maintaining a monogamous relationship would prevent from getting this deadly disease.
The study concluded that while many people in the region had still faith on the traditional healers, it is important that medical team of UNDP coordinate with the traditional healers for better access to health service and HIV/AIDS prevention program. One possibility is incorporating their influence and skill in the primary health care at community level, after providing orientation on modern medical system.
The project collaborated with the government health departments, hospitals and NGOs to begin the training of Traditional Healers with the goal of harm reduction and improving safety measures within their practice. A consultative meeting was organized at the district level for stakeholders to develop strategies to include the traditional healers within the health systems. With the help of an experienced consultant, UNDP designed a program on HIV/AIDS Prevention.
A three-day residential workshop was organized in collaboration with UNAIDS and Christian Hospital, Chandraghona for 131 traditional healers who participated in the survey. Training program included orientation on STDs and HIV/AIDS, symptoms, safe sex behaviors, prevention methods, health education messages, HIV/AIDS counseling and responsibilities of traditional healers. The health education message was targeted to clear the common myths regarding sexuality and HIV/AIDS and gain better understandings of the real situation which can be conveyed to the patients. Different adult learning methodology was adopted for the training sessions. Participants were provided with a handbook in local language and supply of condoms that they would distribute freely to clients. At the end of the training session, it was noted that a new willingness on the part of traditional healers to demonstrate and offer condoms.
Follow-up meetings were organized quarterly between health professionals and traditional healers at the district hospital. The impact of the training on the Traditional Healers had great impact on their practice. For most of them this was a first time they came in contact with qualified medical practitioners and they felt they were valued and part of the medical team. Most of them had no problem learning from medical practitioners although a fraction of them regarded their practice were safer and more effective. The traditional Healers considered working with the medical doctors as a prestige for them in the society and with the expectation that this would increase their acceptability in the community. It was noted that those who had received training were more likely to have changed their practices and initiated community public health activities. They reported conducting community education, promoting condoms and referring patients to medical treatment to district hospitals.
Conclusions and lessons learned
The role of traditional healers in the fight against HIV/AIDS is of great importance. Traditional healers, even when illiterate, are vital to disseminating information about the prevention of AIDS. Because of their position in the community as trusted health care providers, they are free to speak about sensitive topics, such as sex. Although there are differences in different tribal societies regarding the religion, the traditional healers practiced in almost a similar fashion. For example, faith healers used different types of prayers to cure diseases and herbal medicine was a common practice. More than 75 % of Traditional Healers were Males compared to females. But, as the traditional healers were mostly (83%) aged more than 40 years and coming from the same community they were at ease to speak on sensitive issues like sex. In a developing country like Bangladesh, many STD patients strongly believe that they can be cured by traditional healers. Due to the limitations of qualified doctors it is important to establish a collaborating mechanism between the traditional practitioners and modern medicine to minimize harm and prevent spread of the epidemic among the vulnerable people. However, there is also a strong desire by traditional healers to access legitimacy and resources that can be achieved through collaboration with modern medicine.
Training of traditional healers on STDs and HIV/AIDS prevention methods including condom promotion is necessary as they are the major service provider to the large number of population. It is important to know about the provider’s conception of disease and HIV/AIDS. Training materials should be customized so that the receivers can understand the basic message. Cultural appropriate health education message that deals with common myths should be developed. The take home message is important because this is what they will impose upon the people. We should remember that HIV/AIDS prevention is not solely based on biomedical explanations but require an integrated approach involving the socio-cultural dimension as well. Referral for STD cases is essential in order to incorporate the traditional healers with interventions linking STD/HIV prevention in Bangladesh. Consequently, HIV programs and STD testing and treatment programs should develop stronger linkages with traditional healers providing treatment of STD's, secondary infections, pre and post counseling for the individual and family and referral.
The Way Forward
With the critical level of health workforce shortage, ineffective health systems and increased threat of emerging and reemerging diseases in the developing countries, bolder thinking is necessary - how can the vast majority of the informal providers be most appropriately used? These providers are deeply rooted in their localities and will not go away. We can not keep pretending that they do not exist but need to think creatively about how to deal with this reality and both the positive and negative aspects of their practice. Traditional healers need to be mainstreamed into the formal health systems, giving them some sort of recognition, training and certification would help to reduce the harmful practice and involve them in providing appropriate level of care to the people who needs it the most.
* by Dr. S. M. Shariful Islam is Programme Officer with Partners in Population and Development in Dhaka, Bangladesh. Contact: drsislam@gmail.com
Amadou Moreau is Programme Officer with Partners in Population and Development, Dhaka, Bangladesh. Contact: amoreau@yahoo.com
References
M. S. Islam & S. S. Farah: How Complementary and Alternative Medicine (CAM) is promoted in Bangladesh?: A Critical Evaluation of the Advertisements Published in Local Newspapers . The Internet Journal of Alternative Medicine. 2008 Volume 5 Number 2- Health Workforce in Bangladesh: Who Constitutes the Healthcare Systems?: Bangladesh Health Watch, 2007.
