Paulo Peter Mhame(1)
Ossy MJ Kasilo(3)
1. Traditional and Alternative Health Practice Council, Ministry of Health
and Social Welfare, Dar es Salaam, United Republic of Tanzania
2. West African Health Organization
3. WHO Regional Office for Africa
Paulo Peter Mhame
In African traditional medicine, the curative, training, promotive and rehabilitative services are referred to as clinical practices. These traditional health care services are provided through tradition and culture prescribed under a particular philosophy, e.g. ubuntu or unhu. Norms, taboos, tradition and culture, which are the cornerstones of clinical practice of traditional medicine, are the major reason for the acceptability of traditional health practitioners in the community they serve. The philosophical clinical care embedded in these traditions, culture and taboos have contributed to making traditional medicine practices acceptable and hence highly demanded by the population. This paper discusses the different traditional health care services, such as curative services, general traditional healthcare, mental healthcare, midwifery, bone setting, rehabilitative and promotional services that increases health awareness and developing positive attitudes and behaviour towards healthier living).
Dans la médecine traditionnelle africaine, les services de traitement, de formation, de promotion et de réhabilitation sont considérés comme des pratiques cliniques. Ces services traditionnels de soins médicaux sont dispensées en tenant compte de la tradition et de la culture qui sont préconisées en vertu d'une philosophie particulière, par exemple, « Ubuntu». Les normes, les tabous, la tradition et la culture, qui sont les pierres angulaires de la pratique clinique de la médecine traditionnelle, sont les principales raisons de l'acceptabilité des praticiens de santé traditionnels dans la communauté qu'ils servent. La philosophie des soins cliniques étant intégrée dans ces traditions, la culture et les tabous ont contribué à rendre les pratiques de la médecine traditionnelle acceptables et donc très demandées par la population. Cet article examine les différents services traditionnels de soins médicaux, tels que les services de traitement, les soins généraux traditionnels, les soins de santé mentale, de sage-femme, de rebouteux, les services de rééducation et de promotion qui sensibilisent sur les problèmes de santé et développent des attitudes et des comportements positifs envers une vie plus saine.
Na medicina tradicional africana, os serviços curativos, de formação, promotores e de reabilitação são referidos como práticas clínicas. Estes serviços tradicionais de cuidados de saúde são prestados por tradição e cultura e prescritos ao abrigo de uma filosofia particular, por exemplo ubuntu ou unhu. Normas, tabus, tradição e cultura, que são as pedras basilares da prática clínica da medicina tradicional, constituem a principal razão para a aceitabilidade de praticantes de saúde tradicional na comunidade que servem. Os cuidados clínicos filosóficos embebidos nestas tradições, cultura e tabus contribuíram para tornar as práticas de medicina tradicional aceitáveis e, assim, procuradas pela população. Este documento discute os diferentes serviços tradicionais de cuidados de saúde, tais como serviços curativos, cuidados de saúde tradicionais gerais, cuidados de saúde mental, obstetrícia, endireita, serviços de reabilitação e promocionais que aumentam a sensibilização para a saúde e o desenvolvimento de atitudes e comportamentos positivos no sentido de uma vida mais saudável.
Awofeso (1) defines health as "a dynamic state of well-being characterized by a physical and mental potential, which satisfies the demands of life commensurate with age, culture, and personal responsibility", while Saracchi defines health as "a condition of well being, free of disease or infirmity, and a basic and universal human right" (1). For the Australian Aboriginal people "…health does not just mean the physical well-being of the individual but refers to the social, emotional, spiritual and cultural well-being of the whole community". This is a holistic view of life and includes the cyclical concept of life-death-life (1).
However, the most commonly quoted definition of health is that given by the World Health Organization (WHO) over half a century ago. It defines health as ''a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity" (2,3). The WHO Constitution states that "the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being". Overall health is achieved through a combination of physical, mental, emotional, and social well-being, which, together is commonly referred to as the health triangle.
Clinical practice is the process of evaluating conditions of ill health of an individual and its management. The treatment guide used by traditional health practitioners (THPs) in general and diviners in particular, varies greatly and depends on the THP's own knowledge and skills, as well as the nature of the patient's illness. Satisfactory healing involves not merely recovery from physical symptoms, but also the social and psychological re-integration of the patient into his/her community.
In African traditional medicine clinical practice, THPs personally assess patients in order to diagnose, treat, and prevent disease using their clinical judgement. The THP – patient relationship typically begins with interrogations through case-history taking and recourse to basic diagnostic procedures such as divination to determine the cause of the patient's complaint. Once the primary causes of the ailment are determined, the THP then prepares medicines, which may be derived from medicinal plants, animal parts or minerals (4, 5).
The THP's own experience, added to the accumulated knowledge handed down by their ancestors, allow the THPs to offer cheap, but effective remedies for treating the main ailments that afflict the populations of the African Region, such as malaria, stomach infections, respiratory problems, rheumatism, arthritis, sexual dysfunction, anaemia, parasitic infections, mental problems, bone fractures and conditions requiring midwifery services (5).
In African TM, health care delivery includes curative, apprenticeship (training), promotional and rehabilitation services. These services are being provided through tradition and cultural philosophy for example ubuntu philosophy. The philosophy requires a THP to provide health services under a "humanity-first" consideration and not for material gain. There are many philosophical terminologies in African culture, used to describe a THP as a person of high standing in a community, open and available to serve others, when they need health care services.
Traditional health care services are practiced in accordance with ubuntu philosophy (an African ethical or humanist philosophy focusing on people's allegiances and relations with each other).. It is believed that THPs, who uphold this principle throughout their lives will, in death, be united with the living.
Ubuntu philosophy requires THPs not to provide services for material gain. THPs are therefore obliged to provide health care services to their patients without demanding any charges. This taboo imposes on the practitioners a strong code of ethics in the provision of health care services to which they should always abide. This places a huge responsibility on the THP/individual to demonstrate a high sense of "professionalism" and integrity in the discharge of their work. A THP, who believes in ubuntu strives to provide health care services according to the tenets of the taboo.
There are several types of African traditional medicine practices in the Region, however, and not all of them are recognized by communities and governments. According to the Regional Strategy on Promoting the Role of Traditional Medicine in Health Systems, which was adopted by the Fiftieth Session of WHO Regional Committee for Africa in Ouagadougou in 2000 (7), recognition of traditional health services, by communities and governments is a prerequisite for integrating traditional systems of medicine into national health care services.
Examples of African traditional medicine practices that are recognized by almost all communities in the African Region include general traditional health services, traditional midwifery, bone setting and mental healthcare. Traditional health services that are not often recognized by all communities and governments include divination and circumcision..
Diagnosis is a key part of African traditional medicine. This entails a systematic quest for answers to the origins (immediate cause) of a particular disease to determine, who or what caused it (efficient cause), and why it has affected a particular person at a particular time (ultimate cause). In situations where divination is utilised, diagnosis may comprise of a combination of observation, where the patient's physical symptoms are noted, and patient self diagnosis, where the patient reports their problem to the THP. Where necessary, the impressions of other family members regarding the patient's illness may also be obtained. The process of divination will then involve such techniques and beliefs as the casting of divination objects, extra-sensory perception or ability (clairvoyance/ telepathy) or interpretation of dreams and visions.
In African traditional medicine, practitioners treat all age groups and all health problems, using and administering medicines that are readily available and affordable. The treatment guide used by THPs in general and diviners in particular, may vary greatly and depends on the THP's own knowledge and skills, as well as the nature of the patient's illness. Satisfactory healing involves not merely the recovery from physical symptoms, but also the social and psychological re-integration of the patient into his/her community. Treatment is comprehensive and has curative, protective and preventive elements. Moreover, treatment can be either natural or ritual or both, depending on the cause of the disease. The mode of administration of medications includes, among others, oral ingestion, steaming, sniffing of substances, cuts (the African traditional medicine form of injection) and/or body piercing (the African traditional medicine form of acupuncture).
Another aspect of clinical practice of African traditional medicine are norms and taboos. These belief systems account for the widespread acceptability of THPs in the communities they serve.
In the African context and traditional medicine practices in particular, food taboos are a set of rules developed to control the dietary habits of humans. They ensure that people abstain from consuming certain foods and drinks for reasons, which may be religious, cultural or hygienic. They also give directions as to how certain foods may be prepared. The origin of these prohibitions or restrictions varies from one community to another.
Food taboos include abstention from the consumption of meat of certain animals. These may be mammals, rodents, reptiles, amphibians, bony fish, or crustaceans. Some taboos are specific to a particular part or excretion of an animal, while other taboos restrict the consumption of certain plants, fungi, or insects.
To date, many antenatal and postnatal cases are still handled by traditional healers and midwives in many parts of Africa. In Tanzania, for example, 97% of all pregnant mothers attend antenatal clinics, but only 47% attend modern health facilities during delivery, and 53% of all deliveries occur at home with the assistance of either traditional midwives or relatives. As a result, some taboos have evolved to control maternal health. For example, intake of some foods is prohibited during gestation as a way of controlling abnormal weight gain of unborn babies, which could cause harm to mothers during labour (7).
In countries of WHO African Region, 60-80% of people rely on African traditional medicine for their primary health care. Traditional medicines are used to treat most non-acute illnesses that do not need emergency intervention. Even today, because of the limited access to antiretrovirals (ARVs) many people living with HIV/AIDS (PLWAs) rely totally on African traditional medicines for treatment. Also, several cases of bone fractures and psychiatric disorders are treated by THPs using traditional medicines. In respect of curative services, the efficacy and potency of herbs are very real in traditional health services provisions.
THPs also provide preventive health care. The experiences they accumulate, are transferred to their successors from one generation to another through apprenticeship.
Some African countries are locally producing traditional medicines used for various diseases such as chronic diarrhoea, liver disorders, amoebic dysentery, constipation, cough, eczema, ulcers, hypertension, diabetes, malaria, mental health and HIV/AIDS in order to improve people's access to medicines. This will enhance the process of integrating traditional systems of medicine into the healthcare services (6).
Traditional health services cover many areas including general traditional health services; bone setting; traditional midwifery and traditional mental health services.
General clinical practices are services provided to clients by non-specialised healthcare providers. The general THP manages conditions such as malaria, stomach infections, respiratory problems, rheumatism, arthritis, sexual dysfunction, anaemia and parasitic infections.
The African concept of disease and medicine is the foundation of traditional medicine treatment. Unlike the situation elsewhere, in countries of the African Region, medicines have a personality and potent living force. For example, the management of neurosis is markedly different in Africa than elsewhere. African THPs make use of divination to unravel the mental and psychological problems of their patients. Divination therefore plays a significant role in the treatment of neurosis and helps re-trace a patient's life from its metaphysical past to how it interplays with the present and future.
The THP provides for a link between a patient and the patient's own social, cultural and intellectual environmental background.
Studies have shown that the number of common mental disorders recorded among patients consulting THPs is twice as great as that recorded for those attending a primary health care clinic. The most common symptoms presented in both settings, were fatigue, obsessions, worries about physical health and depression. However, people who seek traditional medicine treatment are more likely to have chronic complaints and to have seen several doctors. These results suggest that THPs are a last resort for patients with long-term health problems, who may be unhappy with the outcome of biomedical treatment. In general, primary health care consultations are free, but very short, with little time to discuss symptoms or their causes (8).
Midwifery is a health care profession in which providers give prenatal care to expecting mothers, attend the birth of the infant, and provide postpartum care to the mother and her infant.
Midwives are autonomous practitioners who are specialists in a low-risk pregnancy, childbirth, and the postpartum stage. They generally strive to help women have a healthy pregnancy and natural birth experience. Midwives are trained to recognize and deal with deviations from the norm (9).
A midwife may practice in any setting including in the home, the community, hospitals, clinics or health units. Many traditional midwives live in rural, and often isolated communities. They may work at considerable distance from health facilities and are often older mothers; many are post-menopausal. Many midwives are also herbalists, or specialize in other traditional healing practices.
In the past 30 years, several efforts have been made in Africa to improve the skills and practices of traditional midwives, often referred to as Traditional Birth Attendants (TBAs). However, most of these training programmes failed to give attention to the working environment of the TBAs. For traditional midwives to be able to provide optimal care, an enabling environment has to be provided and their collaboration with nurses and doctors in health facilities strengthened. Moreover, they must have access to basic medical equipments, such as gloves, scissors, etc. They must also have a reliable means of transportation to be able to have timely access to their patients (10).
In the United Republic of Tanzania, in the Kilombero and Hai districts (Morogoro and Kilimanjaro regions respectively), TBAs have become partners in a programme for the prevention of mother-to-child transmission of HIV/AIDS (PMTCT). This programme is being implemented by the district health authorities with technical assistance of Axios and funding from the Elizabeth Glaser Paediatric AIDS Foundation, UK. About 400 TBAs have been mobilized and trained in the provision of HIV/AIDS education to clients, in the mobilization of women for voluntary counselling and treatment (VCT), in the provision of directly observed treatment (DOT) to HIV+ mothers who are on Nevirapine treatment who deliver at home, and postnatal referral of these mothers to health facilities to allow their infants to receive Nevirapine syrup (11,12).
This initiative is in line with the Regional Strategy on Promoting the Role of traditional medicine in health systems that calls for integration into health systems of traditional medicine practices and medicines for which evidence on safety, efficacy and quality is available and the generation of such evidence when it is lacking (4).
A bonesetter is a practitioner of joint manipulation. Before the advent of chiropractors, osteopaths and physical therapists, bonesetters were the main providers of this type of treatment. Bonesetters would also reduce joint dislocations and re-set bone fractures.
Another aspect of bone setting is spinal adjustment, which is a variation of a procedure known today as spinal manipulation. Records show that this form of treatment has been in existence since the time of Hippocrates and ancient Egypt and was passed down through the ages by families of bonesetters. The modern form of spinal manipulation techniques have characteristic biomechanical features, and are usually associated with an audible "popping" sound. In countries of WHO African Region, traditional bonesetting (TBS) has been practised for centuries (14).
Apprenticeship is a system of training a new generation of practitioners to acquire some skill. Most of this training is done on the job while working for an employer, who helps the apprentices learn their trade, in exchange for their continuing labour for an agreed period of time after they become skilled. Theoretical education may also be informally involved, via the workplace (14).
Although years of colonial rule repressed African traditions, culture, norms and taboos, African traditional medicine has survived to date. Traditional medicine practices have since been passed from one generation to another through training and apprenticeship. Grooming trainees to understand diseases, diagnostic procedures, medicinal resources and preparation of the required prescription and administration of the medications, requires appropriate theoretical and practical training methods.
The training and promotional aspects of African traditional medicine prepare practitioners to be responsible, accommodating, hardworking, good listeners, as well as having a sense of pride of themselves and their tradition and culture – the ubuntuphilosophy.
In the African context and ubuntu philosophy, rehabilitation is carried out as a family or community duty. Traditionally and culturally there is no system of skills development for disabled people leading to employment. Instead, the family and the community are responsible for the rehabilitation of the disabled person. This situation gives the disabled a sense of belonging, creating an accommodating way of living through tradition, culture, norms and taboos. Every disabled person is regarded as part of the family or community and is supported to lead a functional life.
Future perspectives in this area include:
Traditional medicine and its practitioners should be formally and explicitly recognized by all countries in the Region through policy and regulatory framework development and implementation. This will ensure the establishment of systems for the qualification, accreditation or licensing of THPs that respect their traditions and customs, and to assist them to upgrade their knowledge and skill in collaboration with relevant health providers. Effective implementation of the policy and regulatory frameworks will also provide for the protection of traditional medical knowledge and access to biological resources.
Available structures should be strengthened and an enabling environment provided for addressing the traditional health services in the context of policy formulation, capacity building, research and development, local production of traditional medicines, and capacity building in African traditional medicine;
Collaboration between THPs and conventional health practitioners (CHPs) should be strengthened, particularly in the case of traditional medicine research into priority diseases such as malaria, Tuberculosis, HIV/AIDS; sickle cell anaemia, hypertension and diabetes
A forum is needed for sharing country experience, service development, policy and regulatory frameworks.
The African philosophical clinical healthcare practice is the bridge between people's well-being and life. It is the practice that is embedded in the tradition, culture and taboos that are still relevant to the way of life of Africans. In order to maximize health care coverage there is a need for formalization of traditional health services through the integration of traditional medicine into health systems. This calls for enhanced collaboration between practitioners of conventional medicine and traditional medicine for the benefit of the people in the WHO African Region. This realization is in line with the principles of the Regional Strategy. The aim of the Strategy is to contribute to the achievement of health for all in the Region by optimizing the use of traditional medicine and one of its principles is institutionalization of traditional medicine. This includes the development of mechanisms for collaboration between CHPs and THPs in areas such as patient referrals and information exchange at local level.
The future of African traditional medicine is bright if viewed in the context of service provision and increase of health care coverage, economic potential and poverty reduction. The increase of health care coverage will be achieved through collaboration and partnerships between THPs and CHPs which is already happening, particularly in the area of traditional medicine research. When a large number of scientifically evaluated traditional medicine s become available, local production will be scaled up and this will improve access to medicines for the population. This in turn would reduce the cost of imported medicines, increase countries' revenue and employment opportunities in both industry and practice. In addition, the African Region will be able to grow medicinal plants on a large scale as resources for research and local production. Industrial processing of locally produced medicines will require packaging and marketing thus contributing to poverty reduction.