Treating HIV in South Africa–a tale of two systems
Article Info
As
South Africa prepares for round o of a landmark legal struggle on April
18, which has raised hopes of cut-price drugs, notably for HIV/AIDS
(see Lancet, March 10, p 775), the reality is that many
Africans cannot afford even transport to health facilities. Another
system exists—one that reaches some 80% of people across the continent,
and fulfils many criteria of an ideal public-health intervention:
generally efficacious, cheap, individualised, and culturally
appropriate. Despite colonial oppression, its practitioners outnumber
allopathic doctors by at least ten to one. Yet, particularly in South
Africa, this alternative service remains marginalised, poorly regulated,
and unsubsidised.
Peter Haselau runs the outpatient
HIV/AIDS clinic at Ngwelezane hospital, KwaZulu-Natal province. He
focuses on positive, healthy living and his patients receive all
available drugs, but he acknowledges that only “a handful” of his
300–400 HIV-positive patients would be suitable for anti-retroviral
medications—those that understand their disease and have the income to
attend regularly and buy sufficient food. What many of his patients do
benefit from are the scientifically researched plant remedies and
supplements supplied by University of Zululand ethnobotanist, Anne
Hutchings, which include unwele (Sutherlandia frutescens), a herbal immunomodulator which has proven anticachexia and anti-HIV actions.
Many
experts now accept that this second system—indigenous knowledge that
encompasses traditional healing and folklore remedies—is actually
bearing the brunt of HIV/AIDS care and support in Africa. Which is
perhaps why KwaZulu-Natal, one of the worst-affected areas in the world,
has been a forerunner in strengthening traditional health care, and
forging links between systems. Former provincial deputy minister of
health Lissah Mtalane, who supports increased recognition and
involvement of traditional healers, notes that sangomas (diviners) and inyangas
(herbalists) have already proven beneficial in spreading HIV prevention
messages, partly because “they fit the psychology of our people”.
KwaZulu-Natal established the country's first province-wide traditional
healers' council in 1999. Now, around 700 healers have sat formal
examinations. And in many informal partnerships, traditional healers are
seeking advice on herbal remedies that might prove useful in HIV/AIDS,
including unwele, which is donated free by the Phyto Nova corporation,
whose mostly unpaid board includes notable traditional healers.
Yet
despite the enormous potential benefits of such efforts in the face of a
mostly unchecked epidemic, indigenous health care has received little
obvious attention from the South African government. Hutchings, for
example, may not legally treat patients, so she provides her expertise
informally via the Ngwelezane patients' support group. Enthusiasm for a
traditional healers council seems to have waned. Without support, many
projects are easily derailed. And, despite advocacy for fast-track
development of phytomedicines, director Nigel Gericke explains that
Phyto Nova has had no investment and little interest from the Ministry
of Health, the Medical Research Council, or the President's office.
A
pilot trial of unwele will now be run in Nigeria under Charles Wambebe
(National Institute for Pharmaceutical Research and Development), with
WHO support for monitoring. Even then, the South African Medicines
Control Council will be able to review the data only when its African
Traditional Medicines Committee is operational.
One
reason for the slow progress is the many stakeholders with conflicting
agendas. The Parliamentary Portfolio Committee on Arts, Culture, Science
and Technology aims to rectify the destruction of indigenous knowledge
during apartheid, whereas the Health Ministry seems more concerned with
stamping out unsafe practices and toxic phytomedicines. Healers worry
that regulation will bring restriction without recognition of their
skills and protection of their rights, and many fear commercial
exploitation.
The tragedy of South Africa's failure to
reconcile these viewpoints is that, internationally, widespread support
exists for incorporating traditional practice into government-sponsored
health care. WHO and UNICEF adopted resolutions to that effect in 1978,
and over the past 3 decades, many organisations have developed resources
and policy to support such efforts, including UNAIDS, the Commonwealth
Working Group on Traditional & Complementary Health Systems, and the
Global Initiative for Traditional Systems (GIFTS) of Health, which
founded the HIV/AIDS Research Initiative on Traditional Healthcare in
Africa (HARITHAF; see Lancet 2000; 355: 1284).
“While
official endorsement for traditional medicines for HIV/AIDS may be
slow, there is a growing emphasis on research endeavour in this field
[eg, HARITHAF], which in turn will provide the evidence base for policy
decisions to be made”, notes Gerald Bodecker (GIFTS). WHO guidelines
state that if a traditional medicine is in customary use with no
reported side-effects, a fast-track toxicology regimen is sufficient to
start simplified, rapid, phase III clinical trials. However, research
and development need to be targeted to meet needs, says Gericke. And he
notes that although local commercial ventures to develop folk remedies
benefit communities directly through job creation, the compensation of
communities for their intellectual property remains a thorny issue. But,
“having witnessed many failed community projects, I prefer to talk when
things are a reality”, he adds.
Countries such as
Nigeria and Ghana are moving to fast track the integration of
traditional medicine into mainstream health care, notes Bodecker.
However, independent anthropologist Edward Green believes that
“integration” inevitably places traditional healers lowest in the
healthcare system. Rather, he emphasises “collaboration”, in which each
system is respected as distinct. The greatest barrier to this is the
attitude of allopathic health-care workers. Acceptance of indigenous
knowledge requires “a realisation that technology is not the exclusive
property of industrialised societies”, says Bodecker. Green's advice to
allopathic practitioners is: “Keep an open mind. Don't assume we have an
empirical basis on which to make a judgment.” After all, in South
Africa as elsewhere, “don't we have a public-health responsibility to
identify harmful traditional practices and replace them with something
more beneficial?”, he asks.