MRC policy briefs to government

Integrating traditional healers into a tuberculosis control programme in Hlabisa,
South Africa

Mark Colvin¹, Lindiwe Gumede¹, Kate Grimwade², David Wilkinson<sup>3

1</sup> Medical Research Council, 491 Ridge Road, Durban, South Africa;
² Hlabisa Hospital, Hlabisa, South Africa; and
³ Adelaide University and University of South Australia, Australia.

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Background
South Africa is experiencing explosive twin epidemics of HIV/AIDS and tuberculosis (TB). In the rural district of Hlabisa, admissions of adults with TB increased 360% between 1991 and 1998,¹ with 65% of them being HIV-infected in 1997.² The prevalence of HIV among pregnant women in KwaZulu-Natal in 1999 was 32.5%.³

In order to cope with the increasing numbers of TB patients, a community-based DOTS programme (CB-DOTS) was established in Hlabisa in 1992.⁴ In this successful initiative patients may choose their treatment supervisor, who may be a lay person or community health worker (CHW), or may take place at a clinic. Overall, from 1992 to 1998 approximately 80% of patients completed treatment under direct observation, and the CB-DOTS programme was shown to be highly cost-effective.⁵

Since traditional healers are spread throughout rural areas⁶ and are widely consulted,⁷ we implemented a study to assess the acceptability and effectiveness of traditional healers as supervisors of TB treatment.

Methods
Hlabisa health district is located in the province of KwaZulu-Natal, about 300 km north-east of Durban on the east coast of South Africa. It is home to about 215 000 predominantly Zulu-speaking people.

Since there has been only limited co-operation between mainstream health services and traditional healers in South Africa and because of sensitivities with regard to such, care was taken to ensure that there was full consultation with all levels of health authorities and with representative organisations of traditional healers about this project.

Once support was secured it was decided to conduct the study in three sub-districts of Hlabisa. Twenty-five traditional healers volunteered to participate in the study and attended two 1-day training workshops on the management of TB. These traditional healers were then integrated into the existing community-based TB DOTS programme, where options for supervision now consist of the local health clinic, CHWs and lay people (usually shop keepers), and traditional healers.

In order to determine the acceptability of the traditional healers as DOTS supervisors, patients who completed treatment, defaulted or transferred were traced and briefly interviewed by one of the authors (LG).

Results
Between 1999 and 2000 in the three study sub-districts, 53 patients (13%) were supervised by traditional healers and 364 (87%) were supervised by clinics, CHWs or lay people.

Overall, 89% of those supervised by traditional healers completed treatment, compared with 67% of those supervised by others (P = 0.002). The mortality rate among those supervised by traditional healers was 6%, whereas it was 18% for those supervised by others (P = 0.04). Interestingly, none of the patients supervised by traditional healers transferred out of the district during treatment, while 5% of those supervised by others did.

By the end of March 2001, 51 patients had completed treatment or defaulted and 41 interviews had been done. Ten people were not interviewed: 1 died soon after completing treatment and 9 had left the area.

Generally high levels of satisfaction were expressed by patients supervised by traditional healers, and all patients believed that traditional healers should be DOTS supervisors. A major advantage commonly reported was easy access to traditional healers, who typically live near to patients, and short waiting times when attending for treatment.

Other reasons for satisfaction were that traditional healers typically had a caring attitude and enquired about the general well being of the patients they supervised. One patient stated: "They love their patients and treat them like family". This caring approach was further demonstrated by 3 traditional healers doing regular home visits to 18 patients in the early phase of their treatment because the patients were at times too ill to leave their homes. A further 3 patients reported regularly receiving food from their supervisor when attending for treatment.

Discussion
Our findings suggest that traditional healers are a potentially important resource to integrate into TB control programmes. In Hlabisa alone there are 290 traditional healers across the district. In Africa south of the Sahara the ratio of traditional healers to the population is approximately 1:500, in contrast to the doctor to population ratio of
1:40 000. ⁷

Perhaps the greatest hurdle to overcome in developing a closer working relationship between traditional healers and health authorities is the level of distrust that still exists between some members of the two groups. It has also been our impression from meetings with other researchers and health care providers from Africa, that there is substantial reluctance to accept the idea of working with traditional healers.

These attitudes will take time to change, but studies such as this that demonstrate the scientific rationale for better co-operation may help to overcome what may be unfounded prejudice.

Recommendations

• There should be formal discussions nationally and locally between organisations representing traditional healers and those representing the health authorities with the aim of developing a better understanding between the groups and fostering a closer working relationship.
• Existing community-based DOTS programmes in Southern Africa should consider recruiting traditional healers as DOTS supervisors.
• Health care authorities should consider integrating traditional healers into other aspects of health care including voluntary counselling and testing for HIV and for home-based care for people with AIDS.
• The potential health benefits of traditional medicine should be explored in conjunction with traditional healers in a manner that produces good science but avoids exploitation.
• The potential of closer co-operation between health care authorities and traditional healers should be nurtured in medical schools.

References

1. Floyd K, Reid RA, Wilkinson D, Gilks CF. Admission trends in a rural South African hospital during the early years of the HIV epidemic. JAMA 1999; 282: 1087-1091. Wilkinson D, Davies GR. The increasing burden of tuberculosis in rural South Africa — impact of the HIV epidemic. S Afr Med J 1997; 87: 447-450. Department of Health. National HIV sero-prevalence survey of women attending public antenatal clinics in South Africa 1999. Summary report. Pretoria: Health Systems Research and Epidemiology, DOH, 1999. Wilkinson D. High compliance tuberculosis treatment programme in a rural community. Lancet 1994; 343: 647-648. Floyd K, Wilkinson D, Gilks C. Comparison of cost effectiveness of directly observed treatment (DOT) and conventionally delivered treatment for tuberculosis: experience from rural South Africa. BMJ 1997; 319: 1407-1411.
2. Wilkinson D, Gcabashe L, Lurie M. Traditional healers as tuberculosis treatment supervisors: precedent and potential. Int J Tuberc Lung Dis 1999; 3: 838-842.
3. Abdool Karim SS, Ziqubu-Page TT, Arendse R. Bridging the Gap: Potential for a health care partnership between African traditional healers and biomedical personnel in South Africa (supplement). S Afr Med J 1994; 84: s1-s16.