Elizabeth Kafaru's herbal clinic -- a four-bedroom apartment in a dusty complex of small buildings located off a busy road in the noisy Ogba neighborhood of Lagos, Nigeria -- doesn't exactly say state of the art. Inside, as two ceiling fans creak, 16 people wait in hard-backed chairs to see the "doctor" -- the matronly Kafaru, 55, a former secretary who left the world of shorthand to take up healing full time. Even though traditional taboos discourage female participation, Kafaru has built a reputation as one of Nigeria's most celebrated healers; she has a weekly natural health column in the national Guardian newspaper and is a regular on Nigerian TV. Every HIV positive patient who comes calling gets the same treatment -- an herbal formula made from the roots and bark of six local trees, processed into tea, syrup or capsules; they're told to take it for up to eight months. She also offers what she calls a "psychotherapy session," counseling patients to stop all "unnatural habits," from smoking and drinking to hatred and jealousy.
Kafaru -- and most of her patients -- claim that this regimen provides relief from many symptoms of HIV; other healers go so far as to assert that they can even cure the disease. Obviously, Africa's catastrophic AIDS death rate gives the lie to the latter belief. But even Westerners who scorn the widely respected Kafaru's methods as having little or no scientific basis acknowledge that traditional medicine has an important role to play in combating opportunistic infections (OIs), especially given the acute shortage of antiretrovirals. The challenge ahead for healers of every paradigm is how to integrate traditional approaches safely into established efforts to help African PWAs.
To some extent, this integration is already taking place, due to the urgency of the crisis. Healers like Kafaru, time-honored fixtures in African cultures, are busier than ever on a continent that last year witnessed an estimated 2 million AIDS deaths. The drugs and tests of Western-oriented health care -- the first, and often only, choice of most African governments -- are "far too expensive or simply out of reach of our populations," says Erick Gbodossou, MD, a Western-trained physician who heads the Association for the Promotion of Traditional Medicine (PROMETRA).
In Nigeria, Africa's most populous nation, there are, for example, only 20,000 doctors and 13,000 hospitals for 118 million people. With few other options, Nigerians must turn to the country's estimated 700,000 traditional healers, many of whom practice in rural areas where up to 70 percent of Nigeria's 4.5 million people with HIV live. Many of the nation's physicians are wary of traditional healers' herbal remedies and holistic approaches -- some of which they say have no benefit at all. But others concede that abuses could be avoided and benefits optimized if these healers were part of official AIDS campaigns. "Our government leaders keep talking about drugs, drugs and more drugs," Kafaru says. "They neglect the herbs that our ancestors have been using to treat infections for centuries."
In March, a groundbreaking gathering in Dakar, Senegal, focused attention on traditional medicine as an essential tactic in any African strategy to treat HIV. Organized by PROMETRA, the International Conference on Traditional Medicine and HIV/AIDS brought together more than 200 healers and 250 medical doctors, researchers and funders from 28 countries to lay the foundation for collaboration, in particular around HIV.
Advocates showcase the Center for Experimentation in Traditional Medicine (CEMT), a village in Senegal's Fatick district, about a four-hour bus ride from Dakar. A cluster of 15 round red-brick huts in a large forest clearing, the center was built by PROMETRA in 1971 as part of a study of the ability of traditional healers to cure infections. For the next 14 years, PROMETRA staff undertook the immense task of identifying those traditional healers in Fatick's 264 villages who were legitimate. "First we had to distinguish between real healers and charlatans," says Gbodossou, CEMT's director. "If you send out a call for healers and get 100 answers, you will find only one true healer among them."
Gbodossou's team looked for obvious improvement in a significant number of a healer's patients suffering from the same illness. In the end, they identified 450 healers (20 percent women), who were then hired and organized into a health system called Malango (meaning "what is needed and appropriate"). The center, financed by the Senegalese and foreign governments, also employs a small number of biomedical scientists, including doctors.
The process that patients undergo at CEMT is a mix of modern and traditional. First, they go to a Western-trained doctor for a diagnosis and lab analysis. Then they consult a team of four healers, who make their own diagnosis and prescribe treatment. (If the first group of healers cannot diagnose or treat a patient's illness, other healers examine the patient until they determine who is most expert in that condition.) Finally, when the healers declare the treatment complete, a biomedical doctor examines the outcome.
Traditional diagnostic techniques are elaborate: Besides extensive interviews, healers read the patient's pulse and examine skin, hair, eyes, tongue, mouth and urine. They do incantations, entering a state of altered consciousness in which they say they contact a spirit realm. El-Hadj Sara Sagne, head of the Malango Healers Association, says that this nonrational component is by no means peripheral to the process: "You are not complete without the spirits guiding you -- whether in diagnosing an illness or in selecting the appropriate medicinal plant."
The spiritual, Gbodossou notes, is what most dramatically alienates this holistic approach from Western medicine, with its view of the patient as primarily a physical entity. "Biomedicine treats psychology as its dustbin, dismissing ailments it cannot understand as psychosomatic," he says. Traditional healing focuses on the culture's entire definition of personhood -- the physical, emotional and moral. Patients may be asked, for example, if they have offended anyone recently, or if anything unusual has happened in their household. They may be counseled against "impure" thoughts or habits, which in traditional African belief can cause illness. Rituals are also used to activate "guiding spirits" that can heal broader community malaise. By Western lights, it is more religion than science.
Each Malango practitioner specializes in a particular set of ailments. Because healers are selected based on experience, most are elderly -- over 60; their medical knowledge and skills have been developed and transmitted orally over many generations. Practitioners come from all over Senegal for training with the Malango elders (one's lineage dates back more than 700 years). Although less than 2 percent of Senegal's population is HIV positive, healers in Malango are trained in the science of the disease and claim to be able to treat most OIs.
Western-trained physicians tend to discount these healers' diagnosis and treatment advice, long lineage notwithstanding. They argue that relying on such scientifically unproved methods only distracts from efforts to promote more effective, and rigorously tested, treatments -- Western ones. Scarce resources that could be allocated toward improving access to other therapies, such as antiretrovirals, should not be squandered on traditional healers, they say.
At the heart of this debate, of course, is a radical disagreement over the efficacy of traditional medicine as practiced in Africa. Over the past 12 years, CEMT has worked with several Western institutions to try to evaluate if and how the herbs used by its healers work. In 1987, a team of U.S. researchers found quantifiable improvement in more than 90 percent of patients suffering from a wide range of ailments, including certain AIDS-related OIs. Among the conditions treated were thrush, skin disorders, diarrhea and wasting. A European research team later found that the lowest recovery rate was 65 percent.
Papa Amadou Sow, president of Resad, a PWA association in Senegal, says he was successfully treated for OIs. "I had been ill with AIDS for 12 years," he says. "I had lost 12 kilos (26 pounds) and had vision problems. But then I went to Malango and came back fit and healthy. I have regained my lost weight and can read without glasses." Unlike many traditional practitioners in Africa, however, those at Malango are careful to distance themselves from any claim to cure AIDS. CEMT's Sagne explains that a central tenet of most traditions is that nature has a cure for every disease, but he adds, with an understatement that even David Ho could appreciate; "Disease is like a child: When it is growing up, it is difficult to control. It is easy to say 'I can cure AIDS,' but to actually do so is a very difficult thing indeed."
Cure or no, in a continent with rampant infections and even more poverty, traditional healers are often the only way to go. A major argument for the CEMT experiment is the reasonable price for its services. An average visit is 3,000 CFA francs (less than US$6) -- far less than the cost of Western antiretrovirals. Due to its high favor and relative low price, the Malango approach is an integral part of Senegal's formal health care system. Traditional healers have been tapped to disseminate information about natural methods of birth control and remedies for infant diarrhea, and to help with epidemiological studies of HIV-transmitting sexual behavior. In the Fatick region, Malango's base, healers' consultation huts have been built next to clinics. Here, seven out of 10 medical doctors report referring patients to their traditional peers. This development goes hand-in-hand with tiny steps toward increased drug access: The Senegalese government recently set aside 250 million CFA francs to purchase antiretrovirals at a discount for 55 PWAs.
Across Africa, healers are pressuring officials to adopt the Senegalese model. They complain of being routinely excluded from HIV work by health officials -- usually biomedical scientists steeped in Western orthodoxy. And when allowed, their participation is often restricted. In South Africa, the government has limited healers' application of their skills and remedies to prevention, according to Merci Manci, a longtime advocate with Nyangazezigwe, a traditional medicine association.
There are many reasons given for such restrictions. One argument put forth by some governments' health ministries is that traditional medicine can actually be harmful to those whose immune systems have weakened. There is also deep distrust among health officials of treatments that they do not consider part of serious medicine, including practices based on superstition, unseen forces and spiritual concepts.
Healers themselves are readily aware of this wariness. Kaiya Montaocean, director of the Washington, DC-based Center for Natural and Traditional Medicine, says, "Many Western doctors refuse to accept techniques like spiritual healing that can't be tested by placebo-controlled, double-blind studies." Yet more than 150 studies of one design or another have found benefits for PWAs using various traditional healing methods, Montaocean says. While these were mostly based on observations and lab work of patients treated by healers without any control group, some were controlled trials of particular traditional herbs. It took intense lobbying, she says, to get organizers of international AIDS conferences to authorize sessions at which this research could be presented. Advocates also defend traditional healing's legitimacy by pointing out that many common Western treatments are derived from analysis of herbal remedies long used by healers. The active ingredient in aspirin, for one, comes from the bark of the willow tree.
Since the founding of Senegal's CEMT village more than a quarter of a century ago, international health agencies have come to a more enlightened view of traditional healers, at least on paper. The World Health Assembly urges countries to incorporate traditional practitioners into health services, and the World Health Organization has established a Program on Traditional Medicine to offer governments technical assistance in training traditional healers and identifying medicinal plants -- a service that few African nations have used.
Yet 20 years of AIDS on a continent desperate to find cheap alternatives to antiretrovirals is uprooting resistance. Training programs and research collaborations are springing up; in South Africa, for instance, an estimated 500,000 healers and 650 traditional healers associations joined forces with the AIDS Foundation of South Africa in 1995 to develop a formal training program. "Before training, 75 percent of the healers claimed they could cure AIDS," an independent evaluation reported in 1997. "After training, none believed this. However, a strong belief remains that traditional remedies can alleviate symptoms and slow the progress of the disease."
In Tanzania, an alliance of traditional healers, biomedical physicians, botanists and social scientists formed the Tanga AIDS Working Group (TAWG) in 1990 as an HIV prevention and herbal treatment project. TAWG has since added a discovery program for medicinal plants, says spokesperson David Scheinman. With the help of foreign grants, TAWG obtains local herbs -- provided by healers paid on a monthly retainer -- and sends them out for toxicity tests to Shaman Pharmaceuticals, a small Washington, DC, company. Once lab tests verify safety, they are dried, processed and offered at highly subsidized prices to TAWG's 100 PWA members.
TAWG's research, Scheinman says, has identified promising remedies for a number of AIDS-related conditions, including herpes zoster and simplex, wasting, diarrhea and oral thrush. "Selected traditional medicines work," he says. "Patients often specifically request certain treatments."
At the March Dakar conference, "mutual respect" was the mantra from all camps. The confab produced a proposal to include healers on the boards of UNAIDS (the Joint United Nation's Program on HIV/AIDS), next July's World AIDS Conference in Durban, South Africa, and other groups.
Post-Dakar, many traditional practitioners, and a few biomedical doctors and scientists, are energized by the hope of a true global collaboration -- one that offers to Africans with HIV the best of what's available in both worlds. "Modern medicine has been tried and tested in many fields and remains an inescapable pillar in fighting AIDS," says Gbodossou of PROMETRA. "Traditional medicine can be the second pillar needed to offer a more optimistic and confident life for people with this disease."