1 This country profile was prepared by Dr W.M. Kofi-Tsekpo, PhD., Chief Research Officer and Director, Traditional Medicine and Drugs Research Centre, Kenya Medical Research Institute, P.O. Box 54840, Nairobi, Kenya; Dr Kofi-Tsekpo was unable to attend the consultation.
AIDS was identified in 1981 by researchers at the Centers for Disease Control in the USA, in homosexual men (CDC, 1981). A review of the medical literature (D. Huminer et al., 1987), however, revealed that at least 19 cases had occurred between 1950 and 1981. In this review, AIDS was found to have occurred in people in North America, Western Europe, Africa, and the Middle East. It would be logical to assume that more than 19 cases of the disease could have occurred, but only these were found in the literature and hospital records.
If the AIDS disease had been around before the AIDS era, from 1981 to the present, it would also be logical to say that traditional health practitioners would have come across it and would have attempted to treat it. A recourse to the ancestral medical armamentarium may, therefore, reveal some preparations that could be of value in the management of AIDS.
This paper will be restricted to the role the African traditional health practitioner, in general, and the Kenyan traditional health practitioner, in particular, can play in the prevention and control of AIDS. This is because cultural practices as they relate to traditional medicine vary from place to place; however, it should be possible to adapt the concepts to other areas of the world.
Cultural concepts in the management of disease
I would like to mention very briefly the relevance of cultural concepts as they relate to the present discussion. Traditional African medicine has been defined as: “The sum total of practices, measures, ingredients, and procedures of all kinds, whether material or not, which from time immemorial had enabled the African to guard against disease, to alleviate his sufferings and cure himself” (WHO, 1978). Traditional medicine, therefore, is derived from a people's culture, and culture is defined as: “All the historically created designs for living, explicit and implicit, rational, irrational, and nonrational, which exist at any given time as potential guides for the behaviour of men” (Von Mering & Kasdan, 1970). The integrated nature of culture and traditional medicine is therefore evident. Society means people, and culture means the behaviour of people. Culture is dynamic and is constantly evolving; consequently, traditional health practices also undergo evolutionary changes. It is in line with these concepts that we shall examine the role of contemporary traditional health practices in the management and treatment of AIDS.
Traditional concepts of disease
In many African communities, disease causation is invariably ascribed to external and, indeed, supernatural forces. The disease AIDS is no exception. However, because modern science has ascribed it to sexual transmission, many traditional health practitioners equate the disease with either syphilis or gonorrhoea. This view is difficult to change, and it is against this background that the involvement of these practitioners will be discussed.
Traditional health practitioners
There are two main types of traditional health practitioners: (1) traditional medical practitioners, which include herbalists, diviners, spirit mediums, defenders, rain makers, etc., and (2) traditional midwives, who are often derogatorily referred to as traditional birth attendants. These people do in fact provide health care much more than child delivery, and the name birth attendant, which refers specifically to the act of child delivery, is inappropriate.
Both traditional health practitioners and traditional midwives are herbalists to various degrees. The extent of the use of herbs is determined by the specialization of the practitioner.
The role of traditional health practitioners in the prevention and management of AIDS
The traditional health practitioner can be useful in two major areas in the control of AIDS, namely: (1) the prevention of AIDS and (2) the management and treatment of AIDS.
1. The prevention of AIDS
The traditional health practitioner is an influential member of his/her community. His role in educating members of the community on the disease and its prevention cannot be overestimated. He is able to reach the people through the right medium (not necessarily language) to get the message across. In certain cases, even the highly educated can be reached this way much more easily.
Ethical decisions often have to be made when HIV tests are to be done, or have been done, on someone (Zuger, 1990). The traditional health practitioner would be most useful where counselling is necessary. In all instances, the fundamental requirement would be that the traditional health practitioner is himself adequately trained to provide the required service and information. This point will be further discussed later.
2. The management and treatment of AIDS
The traditional health practitioner would be most useful at the rural community level in the counselling of people who have either been found to be HIV-positive or who have developed HIV disease. Since it is sometimes difficult to convince such patients that they have not been bewitched, the message would be delivered better by a traditional health practitioner. In the use of currently available drugs, the practitioner would prove very useful in counselling and in giving instructions for their use in the rural setting. He may be able to explain why this medicine, rather than his own, should be used at this time; this may not, however, be easy.
The chemotherapy of AIDS with traditional medicines
Many agents, synthetic and natural products, for use against AIDS are currently under clinical study in many parts of the world. Notable among them is AZT (or zidovudine). This is the most commonly used drug at the moment. AZT has some limitations in terms of toxicity and high cost because the drug has to be taken over a long period. Soon to be introduced for clinical study is the new drug KEMRON, developed at the Kenya Medical Research Institute. It is used as a sublingual medication and has shown no side-effects so far. It is also expected to be reasonably cheap. Some other compounds of interest currently under study are TIBO derivatives, which are synthetic benzodiazepine derivatives (Pauwels et al., 1990). DITHIOCARB, which is a synthetic inorganic compound (Reisinger et al., 1990), a well-known alkaloid, PAPAVERINE (Turano et al., 1989), and CASTANOSPERMINE, an indolizine alkaloid from the seeds of Castanospermum australe (Ruprecht et al., 1989). A number of medicinal plants have also been mentioned as potential sources of agents for the treatment of AIDS (WHO, 1989).
It would be desirable to continue looking for medicines against AIDS from among the traditional cures of the traditional health practitioners. If, as has been noted above, HIV disease has been occurring in Africa and other parts of the world in the past, there could be some medications that would be worthy of investigation.
The involvement of the traditional health practitioner in the management and treatment of AIDS
The most practical way of involving the traditional health practitioner in this process of health delivery is on a collaborative basis. This collaboration must emphasize equality in health care delivery. However, it will soon become apparent that this collaboration will involve a kind of mutual learning. The traditional health practitioner must be made to understand and feel this mutual relationship. The following steps will be useful to take:
1. Establish a relationship that involves your own desire to understand the cultural values under which the traditional health practitioner carries out his practice.
2. Give him/her the opportunity to understand the nature of modern medical practice and its complementarity to the traditional practice.
3. The traditional health practitioner of today has a strong commercial angle to his practice. This should be recognized. No attempt should be made to buy information directly or indirectly; but the practitioner should be made to feel that the interaction would be beneficial to his practice.
4. It would be desirable to develop a project on the prevention and management of AIDS, and involve up to five traditional health practitioners. More than five may become unmanageable. The selection of traditional health practitioners in such a group should be carefully done, and people with similar age, same sex, and experience should be in one group. This is important from the African cultural point of view.
5. Continuing education on health matters and the disease should be informal and on an information-exchange basis; it should not be didactic.
6. Wherever possible, learning should come from actual examples, such as HIV/AIDS patients in the hospital setting or in the traditional health practitioner's clinic.
7. Whenever possible, the traditional health practitioner should be given an opportunity to talk about his/her own practice.
8. Whereas it is desirable to limit incentives of financial gain at the beginning, later token payments of transport, meals, and honorariums are essential benefits that should be considered.
9. Typical topics to be covered in learning activities should include:
- the causation and transmission of AIDS;
- the distinction between AIDS and other STDs;
- counselling of patients with AIDS: here the practitioner should be encouraged to suggest alternative methods of counselling;
- the drugs currently used in the management of AIDS and their limitations;
- methods of preventing HIV transmission.
10. If the traditional health practitioner feels that he has a drug for the treatment of the disease, every attempt should be made to have the medicine investigated.
11. In the development of the project with traditional health practitioners, a multidisciplinary team of “modern” health practitioners should be involved. Such people should themselves be adequately tutored in the traditional approach to dealing with elders in the African cultural environment.
The ultimate aim of the above process is to establish the traditional health practitioner as an integral part of the health team in the fight against AIDS. But, above all, such a health practitioner should have improved in all other aspects of health care delivery so that his/her role in the community would have been further emphasized, and his own traditional practice should have also improved in terms of modern health science. Such a traditional health practitioner would then become a valuable asset, especially in the delivery of primary health care in the rural setting, where modern health facilities may be scarce.
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