There is an AIDS epidemic in Africa, and efforts to fight it are hampered by the endemic social problems of that continent. Chief among them are the lack of sufficient modern health resources, the spread of destructive rumors and myths about HIV/AIDS, and even the persistence of HIV denial in Africa (although this last factor is better than in the past).
The World Health Organization (WHO) and the International HIV/AIDS Alliance are teaming up with the Traditional Health Practitioners Association of Zambia (THPAZ) to address the first problem – the lack of health services. Most Zambians use traditional healers for primary health care. The WHO has therefore decided to utilize traditional healers in the fight against AIDS. There are interesting pros and cons to this policy, but it must first be recognized that there is no ideal solution to the problem. The resources to provide optimal modern health care to treat and prevent HIV/AIDS (which would need to include a massive education program) in Zambia and the rest of Africa simply do not exist. One might argue that the world should provide those resources, but let’s put that issue aside and focus on what to do in the meantime.
The arguments given in favor of this WHO strategy are:
Traditional healers far outnumber biomedical workers in the rural areas.
They are consulted, not only because they are closer and more affordable than their Western-trained counterparts, but also because they are embedded, extensively and firmly, within Ugandan culture.
Traditional healers are highly respected and widely consulted by communities.
In the various articles I read discussing this issue, even those entirely favorable to the idea, conspicuously absent is any mention of whether or not the interventions provided by traditional healers are safe and effective. It’s not even an afterthought – it’s as if it is a non-issue.
However, if we are to focus on the potential benefits of such a policy we could envision a program to train traditional healers essentially to implement a science-based program of counseling and basic health care while also using them to funnel patients to modern health treatments. In addition traditional healers could be trained how not to interfere with modern treatments – for example by not giving herbs that might reduce the effectiveness of anti-HIV drugs. Also they will need to be educated so that they do not spread myths and misconceptions, and in fact so that they can help to counter them. Until such an education program is in full swing, however, the policy of using traditional healers is likely to be counter-productive. As one report notes:
According to the 2006 survey by THPAZ, only 13 percent of the traditional healers in the country had been in contact with modern medical doctors or facilities.
In essence the goal is to use an existing infrastructure of trusted primary care providers (traditional healers) to get them to help the HIV/AIDS program, rather than hinder it. The only alternative strategy would be to replace this infrastructure with a modern science-based medical system – ideal but not realistic. These two strategies are also not mutually exclusive – efforts can be made to maximize the availability of modern health care in the region, while using traditional healers to fill the gap, or at least make sure they are not working against the system.
But there are significant pitfalls to using traditional healers. I have already stated some – most have had no contact with modern medical doctors. By all accounts traditional healers in the region rely upon treatments that are worthless at best, and may even be harmful. There is every likelihood that despite some modern medical education, many traditional methods will be retained.
The biggest pitfall of a partnership is that it will be used as a sign of validation of traditional healing methods, whether or not they are safe and effective. Already there are attempts to validate herbal treatments for HIV/AIDS in Africa. Dr Sekagya Yahaya Hills is a dentist and traditional healer who is promoting herbal remedies as effective in treating HIV/AIDS. Not surprisingly we are seeing the same pattern as elsewhere with the promotion of herbs as drugs – preliminary small studies of poor design being used to justify unlikely treatments. Many herbs are, in fact, drugs but they contain a mixture of chemicals that are not purified, are not quantified, and have unknown bioavailability (as well has half-life and other pharmacological properties). This makes them very poor drugs. The experience in the US is likely to be typical – herbs that seemed promising in preliminary studies have almost all been useless when studied in large well-controlled trials. In addition they have drug-drug interactions and potential side effects and toxicities that were not apparent before being carefully studied.
Treating HIV is very challenging, and it is also a recent plague on humanity. It seems very unlikely that any traditionally used herb would be safe and effective against HIV. Despite the low probability, it is reasonable to test candidate herbs (as long as it is done ethically) but only well-controlled studies should be performed.
A more plausible research program would be to screen hundred of candidate herbs for in vitro activity – demonstrating that there is some biological activity that could plausibly fight HIV. Then follow up with animal testing of those herbs that seem promising on the screening test. And finally conduct preliminary then definitive testing in humans – and once you have a product that is proven safe and effective, recommend it for usage. This, of course, all sounds suspiciously like pharmacognosy and drug development. But this is not what is happening. Rather, the preliminary research is bypassed and we have only preliminary and unreliable clinical studies.
What is very likely to happen is that traditional healers, propped up by an alliance with the WHO, will stick to their traditional methods, supported by those like Dr. Sekagya Yahaya Hills, who will use bad science as a rubber stamp to endorse traditional treatments.
It is a real dilemma – a devil’s bargain. It seems necessary and potentially useful to enlist the help of traditional healers, given the realities on the ground in Africa. But the potential to do more harm than good is extreme. The WHO should therefore go into any such collaboration with their eyes wide open, and not naive to the power of cultural belief, the highly sophisticated anti-scientific propaganda of the CAM movement, and the potential for reliance upon bad science. The WHO should therefore focus on regulation, which is an admitted problem:
The other concern is a weak regulation of traditional medicine, leaving people living with HIV open to abuse by unscrupulous healers who promote cures for AIDS or persuade their patients to cease life-prolonging drugs such as the antiretroviral treatment.
Therefore any such partnership should be contingent on careful scientific scrutiny and improved regulations.
Conclusion: Ethical and safety concerns
Given the cultural and health care realities in Africa, it does seem necessary for the WHO to partner with local traditional healers in order to implement any widespread public health program. The endorsement of traditional healers may be necessary to achieve public acceptance of “Western” medicine. It is also necessary to counter myths and misconceptions about HIV/AIDS, and this must begin with the locally recognized health authorities – the traditional healers.
But the WHO should resist pressures to “respect” local traditions themselves as if they are acceptable alternatives to science-based medicine. In the promotion of health, which is the WHO’s mandate, utilizing treatments that are safe and effective is the only ethical option. Promoters of unscientific treatments, however, often resort to an appeal to cultural sensitivity and a false dichotomy between “Western” science and the beliefs of other cultures. Whether or not Dr. Hill’s herbs are an effective alternative to proven anti-HIV drugs will be determined by objective science, not culture, and bad science should not be excused with appeals to cultural sensitivity.
Without maintaining a strong dedication to science-based medicine this WHO program will likely become an epic example of the axiom that the road to ruin is paved with good intentions.