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Traditional Healers in South Africa: Knowledge Without Power

Though technically classified as a ‘middle-income country’, health services in South Africa are characterised by polarities, particularly within mental health services (Lund et al. 2010). Much of the country continues to struggle for access to basic amenities, including electricity and running water, and is categorised as one of the most unequal in the world (Coovadia et al. 2009).

The rural community at the heart of this case study is located in the province of KwaZulu-Natal, just south of the Mozambique border. The province is one of the most underserved in terms of mental health services, marked by high levels of mental illness risk factors including a large proportion of individuals living below the poverty line (Burns 2010). It is marked by high rates of HIV/AIDS (Welz et al. 2007) and high levels of unemployment (Statistics South Africa 2006). Mental health services are delivered using a primary care approach (Department of Health, KwaZulu-Natal 2003) within a district health model. The catchment area of focus is a rural sub-district with a population of just over 106,000 individuals (Department of Health, KwaZulu-Natal 2010).

Flows of power and resources traverse multiple tiers of care. The ‘community’ is found at the base of the pyramid, who play a monitoring role, responsible for referring individuals up through the medical sectors (Department of Health, KwaZulu-Natal 2003, p 11). The ‘community’ is comprised of multiple actors: NGOs, police officers, social workers, teachers, community- based organisations, community leaders, and spiritual and traditional healers. A larger case study completed by the first author featured a brief ethnographic study of this service model (See Burgess 2013b for details). Semi-structured interviews with actors linked to the various communities engaged with mental health services in the subdistrict were conducted. The subsequent discussion refers to data collected during life history interviews with traditional and spiritual healers, exploring their contributions to ‘community’ mental health services in the area.

South African healing traditions are linked to notions of spirituality and reverence to ancestors (Berg 2003; Parle 2007). The role of the healer is to help restore balance between the self and various aspects of the individual’s social world. In KwaZulu-Natal, illnesses are divided into natural conditions (linked to biomedical concerns) and those linked to ancestral discord. Typically, natural conditions are initially treated by herbalists (Izinyangas).

Long-term illnesses are believed to have roots in ancestral disharmony, and as such, for chronic illnesses, such as mental health conditions, an Izangoma (spiritual healer) is often sought for support (Flint 2008; Urbasch 2002).

In this study, despite healers’ description of mental illnesses along the traditional lines outlined above, their discussions also acknowledged that there were social and relational issues at the heart of distress. Two healers noted that in contemporary society mental distress was linked to causes that they didn’t understand fully. As noted by one healer:

During ancestral times it (mental illness) was there and it was caused by bewitchment—enemies bewitching people ... But today we don’t know because a lot of sicknesses today can cause mental illness. (Izangoma, Female 1)

A long-standing body of research presents a discourse that positions traditional healers’ involvement in mental health services as largely problematic. For example, Sorsdahl et al.’s (2010) recent study cites a high number of deaths linked to traditional healers and notes the problematic use of potentially lethal combination of herbal medicines and toxic additives such as methane.

Healers’ interviews included descriptions of differential diagnosis process. They clearly parsed out differences in which those suffering from issues linked to more common mental disorders such as poverty and familial discord were supported versus those with more severe conditions. Approaches to common mental health disorders did not include any of the more potentially harmful interventions that are critiqued by biomedical practitioners. As one healer described:

Patients will often talk about things that are not well at home ... like if someone can’t sleep because they are having nightmares, or they don’t have a job ... this can all be caused by evil spirits. I take them outside for baths to cleanse away the evil spirits. (Izangoma, Male 2)

Other treatment approaches included wrapping patients in ‘blessed’ pieces of cloth, as well as the process of ‘throwing the bones’ to explain the meaning behind clients’ experiences.

Despite plans to include traditional healers as partners within the delivery of mental health services from as early as 2003, in practice this process has been fraught with difficulty given conflicting knowledge systems that drive traditional and formal health systems. This has often been linked to the negative attitudes held by many biomedical practitioners towards the methods and practices of healers (Urbasch 2000). Despite current policy stipulations that call for partnerships with healers (Department of South Africa 2013), engagement between the two groups remains limited and is shaped by continuing imbalances in power between the two groups. Healers in this study spoke of their experiences in partnering with formal health sectors, usually nurses, for training sessions. None of these engagements were for mental health (all had attended training on HIV/AIDS and TB). Their accounts noted unbalanced relationships with health services, attending sessions where they were told to explain how they made their medicines, with promises of further meetings with guidance on new treatments for their patients that never materialised. As noted by one healer:

We registered (with the doctors) and they told us that we will meet and talk about cases and treatment. We learned new things but they don’t learn things from us—they asked us to cook our traditional medicine, and to tell them how we treat patients—but nothing has happened since then, because they take us for granted. We send patients to them when we cannot help them, but they don’t send patients to us. (Izangoma, Male 1)

Accounts from healers in this community highlight that the main aim of the partnership remains—the use of traditional healers as extensions of the medical system—with little desire to engage in mutual frames of understanding and action. Healers’ participation, and thus the success of these partnerships, is influenced by dimensions of power and recognition (Burgess 2014). When biomedical systems are criticised by community members as ‘brief or ineffective’ by patients and family members, traditional healers can provide a seemingly positive alternative (Read et al. 2009). This means that in many cases, pluralism in service use is the prevailing norm—with patients utilising both traditional and biomedical services in tandem (Swartz 1998) or sequentially (Read et al. 2009). Accounts from healers in this study highlight that where partnerships with the health sector threaten the power of healers, or are interpreted as disrespectful to healer’s training and knowledge, traditional healers will be reluctant to engage at all—limiting the utility of partnerships for both healers and formal practitioners. The result is a missed opportunity to increase the availability of support to communities through capacitating local healers to build on their existing set of responses to distress, as well as the alienation of key routes to access within local communities.

The second case study presents an example of a combined partnership between communities and the formal health sector. The approach is informed by a rights-based framework, attention to community empowerment, and increasing access to biomedical services for people with severe mental distress.

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