Introduction and background
Before going into the role of traditional health practitioners in AIDS control in Ethiopia, it would be appropriate to go through the history of traditional health practitioners in Ethiopia. The inadequacy and inaccessibility of modern health services have been partly responsible for the continued reliance of over 80% of the rural population on traditional medicine (Ministry of Health, 1980). Even in cities where the services for modern medicine are adequate, many people continue to go to traditional health practitioners for various reasons. Traditional medicine in Ethiopia is as diverse as its culture, but there are two most fundamental features common to the different traditional medicine systems. They are (a) the holistic approach to human problems and (b) the overlap between “mystical” and “empirical” medical beliefs.
Healing in Ethiopian traditional medicine is more than the curing of disease. It is concerned with the protection and promotion of human physical, spiritual, and material well-being (Bishaw, 1989).
The more recent contact with the industrialized world has also influenced Ethiopian traditional medicine. Because of the attraction that modern medicine has had for the people, traditional health practitioners have in some cases mixed the two and become more popular. Some have even become “injectionists”.
The first legal provision for traditional medicine in Ethiopia came with the 1957 penal code, which more or less remained on paper. It was only after 1979 that the Ministry of Health appointed a committee of experts to plan and coordinate the promotion of traditional medicine in the country. This was then followed by the opening of a coordinating office. The purpose of establishing the coordinating office was to (a) organize, train, and register healers; (b) coordinate and encourage research into traditional medicine and conduct seminars and workshops for both traditional and modern medical practitioners; (c) identify, describe, and register those traditional medicines and healers with actual or potential usefulness; (d) explore the possibilities of establishing herbariums and museums for traditional medicinal plants and artifacts; and (e) pave the way for the final integration of traditional medicine into the formal health care system.
These goals were sanctioned by the government, and international meetings and workshops were organized that brought together traditional health practitioners and modern medicine practitioners. The intention of promoting and utilizing traditional medicine was incorporated into the ten-year perspective plan. The reasons behind the need to promote traditional medicine were (a) traditional medicine was part of the culture, used by about 80% of the population; (b) many traditional medicines were known to be efficacious; (c) traditional medical practice is not expensive; (d) provision of adequate health services would take a long time, considering the country's economic resources; and (e) the utilization of traditional medicine would be a step forward in self-sufficiency.
Considerable achievements have been made since 1974 towards the promotion of modern health services; however, the lag in policy implementation in the promotion of traditional medicine is marked. There are only a few places where traditional healers have been organized, and in most of these cases the lack of support and guidance has become a source of serious misgiving among healers about the sincerity and intentions of the Ministry of Health. The organization and registration of healers, which began after the creation of the coordinating office, have met with problems. So far, over 6000 healers have been registered from various parts of the country. In a number of places, healers have formed their own professional associations. These associations, however, lack guidance, funds, and personnel needed to move forward.
One other important factor that has created resentment between the coordinating office and the traditional health practitioners is the exclusive emphasis that continues to be placed on research into herbal medicine. The coordinating office has expended its limited resources on getting traditional healers to provide detailed information on the medicines they use in the treatment of illness. Thus traditional health practitioners argued that no one had the right to take away an important means of their livelihood without any assurance of involving them both in the testing of their drugs and in the sharing of the possible benefits should these medicines be found useful enough for mass production and marketing.
Traditional health practitioners and AIDS control
In the last couple of years a tremendous effort has been made to involve traditional health practitioners in the control of AIDS. Traditional health practitioners came to the programme claiming that they could cure AIDS. The technical advisory committee to the national AIDS programme in Ethiopia discussed the issue thoroughly and was sceptical at first. Two of the most important questions in the discussion were “Is it ethical to send patients to the traditional practitioner without knowing anything about the content of the drug and its possible toxic effect?” and “Are we in a position to do even a crude toxicity study on animals?”.
While the issues are being debated and because of pressure from different sectors, a few patients (AIDS patients that satisfied both the clinical and laboratory diagnosis criteria) were sent to two traditional healers. These were patients at different stages of the disease. Whenever possible, blood samples were taken before and after the patient had completed a seven-day course of the traditional medicine. In a few of the patients who had diarrhoea, the diarrhoea stopped and they developed a voracious appetite and, as a result, a marked weight gain. Some of these patients relapsed and died, but others continued to survive. In all cases where we have managed to collect blood specimens before and after the administration of the traditional medicine, there was no change in the Western blot pattern and all were culture-positive. In the meantime, the AIDS control programme and one traditional health practitioner came to an agreement that the traditional health practitioner would be given access to a clinic where he could administer the drug while a toxicity study on mice would be done simultaneously.
An acute-toxicity study was carried out on a few mice, but the entire toxicity study had to be abandoned because the traditional health practitioner would not allow anything to be done to the medicine out of his sight. All attempts to reassure him that all benefits would go to him if the medicine turned out to be useful failed.
A number of other traditional health practitioners have approached the AIDS control programme since then. A research committee, formed to look into the problem after the first experience, made its primary task the drawing up of an agreement between traditional health practitioners and the Ministry of Health, which would stand in a court of law. This agreement, which clearly states what is required of the traditional health practitioner, the Ministry of Health, and the AIDS control programme, have been given to traditional health practitioners for comment. Some automatically rejected it on the basis of disclosure of the contents of the medicine. Others said they would be able to provide everything required. At present, the agreement is in the process of being delivered to the Council of Ministers for endorsement. Once that is done, meaningful research into traditional medicine for AIDS can be embarked on.
As was pointed out earlier in the introduction, one of the difficulties in dealing with traditional health practitioners has been the mystification of the entire traditional medicine issue. In the Ethiopian context, the skill of a traditional health practitioner is given by God, and it may only be transferred to a favourite (usually male) child. That being the case, a traditional health practitioner would find it very difficult to part with his/her knowledge to a researcher whom he/she does not trust. From the modern medical practitioner's side, very little effort is made to understand traditional health practitioners for that same reason. The modern health practitioner in Ethiopia thinks that there is no logic to whatever traditional health practitioners do. Hence, ignorance on both sides makes the effort almost impossible.
Despite problems, a lot of progress has been made towards utilizing traditional health practitioners in Ethiopia. With the adoption of primary health care and with 80% of the population still going to traditional health practitioners for various purposes, the Ministry of Health has been giving various types of short-term retraining courses in an effort to make traditional practice a little bit more modern. The best example of this is the 11 500 traditional birth attendants who have been trained by the Ministry of Health and who are being given refresher courses so that they can take care of themselves and, at the same time, teach the community about the transmission and control of AIDS.
Apart from providing treatment, traditional health practitioners could be used to take care of AIDS patients. As was mentioned earlier, not only 80% of the rural population, but also the urban population go to traditional health practitioners, even if they have access to modern medicine. It is for this reason that gaining the confidence of traditional health practitioners and establishing a good relationship with them becomes crucial. In many African countries, including Ethiopia, with the increasing problems of the disease, the existing health infrastructure will not be able to cope with the problem in a few years.
(a) In countries where primary health care is being practised, efforts to include traditional health practitioners have to continue at an accelerated rate and in an integrated manner.
(b) In cases where traditional health practitioners are involved in the cure of the disease AIDS, a clear indication has to be given of their legal right to the benefits emanating from their medicines. This would bring traditional health practitioners closer to researchers and modern health practitioners.
(c) The effort that has been made in retraining traditional birth attendants in many places in Africa and that of teaching reasonable care to both patients and traditional health practitioners when it comes to administration of medicine has to be emphasized so as not to contribute further to the spread of the disease.
(d) Health education efforts should be directed toward traditional health practitioners in a meaningful way, rather than in the derogatory manner that is practised at present.
Bishaw M. 1989. Ethiopian traditional medical beliefs and practices. (Paper presented at the 14th Medical Workshop of CRDA.)