IK Notes Indigenous Knowledge and HIV/AIDS: Ghana and Zambia I t has always been difficult to reach poor people with development aid, particularly in health where most loss of indigenous knowledge regard- ing traditional medicine, which forms part of the cultural heritage of local resources benefit the middle classes communities and is usually transmit- in urban hospitals. For the rural poor, ted orally. This knowledge is often and increasingly also for the urban undervalued by the younger genera- poor, often the only affordable and tions, at least in part because tradi- accessible form of health care is pro- tional medicine seldom brings high vided by traditional healers. Zambia economic returns to the practitioner. with an estimated 20-25 percent of In recognition of the importance to the population HIV-positive has only preserve and protect this 900 western- educated doctors (600 ethnomedical knowledge, and the of whom are foreign) but has 40,000 plant species on which it is based, the registered traditional healers for a governments of Zambia and Ghana, population of 10 million. Ghana, with with support from the World Bank, 5 percent of the population being are in the process of establishing a HIV-positive, has 1,200 western edu- bridge between environment and cated doctors but an estimated health in fighting HIV/AIDS. In Zam- 50,000 traditional healers for a popu- bia the executing agency is the Tradi- lation of 20 million. Thus, the ratio of tional Health Practitioners Associa- doctor to traditional healer is 1:44 in tion of Zambia (THPAZ) through the Zambia and 1:42 in Ghana. Given the Environmental Support Program central cultural role of traditional (ESP) under the Ministry of Environ- healers in communities, they provide ment and Natural Resources. In No. 30 one of the best hopes for treating and Ghana, the effort will be part of the March 2001 stemming the spread of AIDS. But healers rely on medicinal plants and there has been a significant decrease IK Notes reports periodically on Indigenous Knowledge (IK) initiatives in the abundance of many important in Sub-Saharan Africa. It is published medicinal plant species as their habi- by the Africa Region’s Knowledge and Learning Center as part of an evolving tat are lost through deforestation, IK partnership between the World cultivation, overgrazing, burning, Bank, communities, NGOs, develop- droughts, desertification, etc. This ment institutions and multilateral organizations. The views expressed in problem has been exacerbated by the this article are those of the authors World Bank unmanaged local and international and should not be attributed to the World Bank Group or its partners in demand for medicinal plants. Fur- this initiative. A webpage on IK is thermore, traditional healers have available at //www.worldbank.org/afr/ identified as an important issue, the ik/default.htm 2 Northern Savanna Biodiversity Conservation Project botanic gardens, forest reserves for medicinal plants, and (NSBCP) under the Ministry of Land, Forestry and Mines. a herbarium with medicinal plants. Some of the seeds, cut- Basically, the two projects have the same approach al- tings and tubers for planting will come from Spiritual For- though they differ in design: in Zambia the initiative has ests, which have considerable biodiversity and contain rare been retrofitted into an already existing program while in species of plants and trees, which have been preserved be- Ghana the activities will be part of on-going project de- cause of the traditional rules, norms, and taboos associ- sign. What follows is first a short description of the AIDS ated with them. The second activity “Training and Capac- component involving traditional healers under the Zam- ity Building” is directed towards the traditional healers bian ESP; second, a comparison of the sociocultural find- and includes a long list of topics from behavior modifica- ings particularly concerning gender differences related to tion in relation to HIV/AIDS, understanding ecosystems, traditional medicine in the two countries; and third, some nutrition, toxicology, basic virology, epidemics, and immu- of the difficulties experienced during the process of estab- nology. In addition to the environmental and medical as- lishing this cross-sector initiative involving agriculture, pects there will also be legal training so that healers do environment, health, and rural development. not infringe the law, such as the Witchcraft Act, and get a Under the Zambian initiative, “Protection and Sustain- better understanding of human rights. The third activity able Use of Biodiversity for Medicinal Value: An Initiative “Dissemination of Information/Knowledge on Biodiversity to Combat HIV/AIDS” there are three main activities. The and HIV/AIDS” will set up a communication strategy to be first activity, “Conservation of Biodiversity for HIV/AIDS implemented through newsletters, radio programs, TV, Prevention and Treatment” includes the establishment of drama/plays and leaflets. This activity will also include an electronic database on medicinal plants and publication of a handbook for traditional healers to be used in their prac- IK Notes would be of interest to: tice. All training materials, programs, and publications will be in the major local languages and a basic literacy program will be added to make the (often) -illiterate heal- ers capable of registering their patients, and documenting Name their indigenous knowledge. Institution Whereas gender analysis has been essential for project design in both Zambia and Ghana the role of women are Address very different in the two countries. Generally the gender division of labor has been stronger in Ghana than in Zam- bia. This has had an effect on the position of female tradi- tional healers as well as their ability to participate in project activities. Some of the sociocultural differences are analyzed here. In Zambia, traditional healers have re- Letters, comments, and requests for publications ceived donor help to be organized on a national basis, and should be addressed to: 60 percent of the registered traditional healers are Editor: IK Notes women. The number of women healers is even said to be Knowledge and Learning Center Africa Region, World Bank growing in response to the increasing number of AIDS pa- 1818 H Street, N.W., Room J5-055 tients. People call HIV/AIDS “Kalaye noko,” meaning “go Washington, D.C. 20433 and say goodbye to your mother,” because most people die E-mail: pmohan@worldbank.org in their villages in their mothers’ homes. Although women in Ghana are also the ones to care for the ill, the contrast 3 is striking when it comes to practicing healing. In Ghana, family. Healers in Ghana were also reluctant to teach their there is no functional national traditional healers’ associa- daughters traditional medicine, but little girls also have tion, and the three northern regions have less than one- eyes and ears, and many women practice medicine, al- fifth of the estimated healers’ registered. Of these (few) though not openly. That obviously had a negative influence registered members, less than 10 percent are women ex- on women’s options for income generation through their cept for one minor sub-region where an active healer has practice. Only traditional birth attendants (TBA) were al- managed to raise the figure to 49 percent. However, the most exclusively women, and most TBAs received some re- low figure in Ghana is more a reflection of local beliefs muneration for their services. But most traditional heal- than of the actual number of women healers. Also, the ers earn their main income from farming and remunera- Bank-assisted initiative might have unintentionally ce- tion for healing was in farm products. In Zambia, the de- mented already existing gender bias by, for example, only clining economy had forced many healers to give up pay- training the registered healers, who are overwhelmingly ment in kind, and healers had increasingly turned to male. According to one female healer in Ghana, women, if (their individual) standard payments for each disease. The they openly practice traditional medicine “are termed highest price was always a cure for infertility, which had to witches and every misfortune is blamed on them; in most be paid at the arrival of an infant son. The strong division cases these women are disowned and sent out of their soci- of labor in Ghana gives a unique opportunity through the eties. For this reason it is only the queen of witches who is project to support women and families in HIV/AIDS pre- known to heal, because she is so powerful that it is impos- vention and poverty reduction, thereby enhancing the sible for any member of the society to challenge her.” prospects of success for the project as a whole. The long- In both countries it was extremely rare to find tradi- term goal of biodiversity conservation could seem abstract tional healers who cultivated medicinal plants, and when to communities suffering from food shortages and hunger; it did happen, it was almost exclusively funded by donors. however, short-term income generation through the culti- In Zambia, women healers often referred to a spirit guid- vation and selling of medicinal plants and vegetables lead- ing them to the medicinal plants, which they collected and ing to improvements in, particularly, children’s health prepared for medicine themselves. In Ghana, there was could have a catalytic effect on the success of the project. substantial gender bias related to the collection of plants, Traditional healers, both male and female, expressed an preparation of medicine, and even to sexuality, which had eagerness to be trained to improve their practice. In a positive influence on males but a negative influence on Ghana, the mass communication program on HIV/AIDS women. Fewer female healers in Ghana were married than had succeeded in disseminating information on transmis- were male healers, which one female healer explained by sion of the disease from one person to another via blood, saying that she would not be able to heal if her husband sexual intercourse, infected needles, and so forth. But was living with her. Neither would healers, who used tradi- communities’ knowledge on how it is transmitted was not tional African religious rituals in the healing process, send always complete or accurate. Some communities referred their daughters into the bush to get the plants, because to the danger of eating or bathing together with an AIDS- “people would think they were witches.” And husbands infected person; even shaking hands or using the same would not let their wives help to make the medicine “be- clothes was mentioned as a possible way to be infected. cause the medicine would not work” if prepared by a None of the communities admitted that there were any af- woman. An obvious rationale for this taboo was patrilineal fected individuals in their village, and in both Zambia and location and succession which meant that a woman at Ghana, severe stigma was attached to a person with AIDS. marriage would move to her husband’s house, and the Thus, people were less likely to admit infection and treat family’s secret knowledge on plants and its medical use, HIV/AIDS as a common, but serious, disease. Poverty and would thereby be in danger of being uncovered by another cultural norms also make Africa the continent with the 4 highest proportion of women to men infected with AIDS. conservation of medicinal plants and has acknowledged In the fight against AIDS, traditional healers need training traditional healers by passing a Traditional Medicine Prac- as they provide health care for about 70 percent of the tice Act in 2000. In Zambia, on the other hand, it was population. And TBAs, according to the World Health Or- when more than one-fifth of the population became in- ganization, deliver 95 percent of babies in the rural areas, fected with AIDS that traditional healers were invited to which makes them particularly critical care-givers but also become part of the Technical Committee on Natural Rem- renders them more vulnerable to HIV/AIDS. In the long edies for HIV and Other Related Diseases, placed directly run, the health infrastructure provided by the traditional under the Head of State. The Ministry of Environment and healers and their organizations could provide the distribu- Natural Resources, under which the ESP is located, was tion network for AIDS medicines when they become avail- initially very reluctant to involve civil society in natural able at a reasonable price. Traditional healers have a resource management, and particularly THPAZ, which is unique position as educators and potential distributors of the country’s largest NGO. Traditional healers were con- AIDS medicine—for example in handling patients’ doses. sidered to be irrelevant to modernity and therefore to be No African government has the resources or health per- excluded from development. A similar reluctance was ini- sonnel in the numbers needed to fight the AIDS epidemic. tially found in the World Bank where traditional healers’ Governments in Ghana or Zambia do not support tradi- practices were often perceived as lacking scientific valida- tional healers financially as they do their (modern) medi- tion, and hence legitimacy. This view was also widespread cal associations, and in neither country is traditional among western doctors, although traditional health prac- medicine part of the curriculum at medical faculties. In tice predates modern medical practice just as the use of this respect, African countries are far behind countries herbs and medicinal plants predates the present pharma- such as China and India where alternative medicine is an cological practice. Gradually, however, this attitude has integrated part of modern medicine practiced at hospi- changed and today it is acknowledged that initiatives like tals. However, Ghana and Zambia both have staff in their the ones in Zambia and Ghana are benefiting the poor di- Ministries of Health to coordinate policies to traditional rectly and have considerable potential in treating AIDS-re- healers, and both governments want healers to be regis- lated diseases. tered. Ghana has shown a positive attitude towards the This article has been written by Maja Naur, Ph.D. in sociology, consultant to the World Bank. The projects referred to are: Zambia: Environmental Support Program, report no. 16239-ZA, and Ghana: Northern Savanna Biodiversity Conservation Project, project document on a proposed grant from the Global Environmental Facility Trust Fund. The author wants to thank the concerned Task Managers, Yves Prevost and Hassan M. Hassan and not least John Lam- bert for his work on medicinal plants. The social studies for the projects have been undertaken by the author and funded by the Danish Trust Fund. For more information, e-mail: MAJANAUR@msn.com