For most people in the developed world, the words ‘traditional healer’ conjure up the image of a figure cloaked in beads, animal pelts and an air of impenetrable mystery. Someone, in short, whom Western-ers find difficult to understand or trust, and who has rejected biomedical science in favour of mysticism and magic.

This kind of distrust is problematic anywhere, but especially so in African countries struggling with the HIV epidemic. South Africa, the worst affected, is home to an estimated 5.5 million HIV-positive people, many of whom visit traditional healers, or sangomas as they are known locally. Many sangomas have earned themselves a bad reputation among doctors for not referring their HIV patients to clinics for testing and treatment. For their part, many traditional healers fear that Western medicine will harm their patients.

Amid this welter of misunderstanding, there is one sangoma who finds herself in the unique position of being able to understand and relate to both sides of the divide. She is finding ways to reconcile the two and to build bridges of trust between doctors and sangomas. And now, her efforts are enriching and informing a pilot project to improve the health and quality of life of HIV patients in South Africa.

British born and bred, Jo Wreford is a doctor of social anthropology and a research fellow for the AIDS and Society Research Unit at the University of Cape Town. She is also one of a small number of white people in South Africa who have qualified as sangomas, and is known to her sangoma colleagues and clients as Thobeka, which means 'she who can be trusted because she is grounded' in the Xhosa language. This training, which involved undertaking a spiritual journey with a sangoma mentor, makes it easier for other healers to trust her as one of their own. Her training in anthropology and Western cultural background reassures doctors that she understands and appreciates scientific method.

Body and soul: to Jo Wreford (centre and right), clinics and healers are both needed to fight AIDS in Africa. Credit: N. BOLOGNESI

Different vision

Wreford wears beads, throws the bones, burns the herb imphepho to invoke the guidance of the ancestors, and experiences visions. She says that unlike many of her colleagues, she is comfortable with reconciling her traditional beliefs with science, arguing that biomedicine can treat the body, while traditional healing can help treat the soul. “Neither cures,” she says. “We must therefore use the best of what both systems have to offer to alleviate the AIDS burden, which is both physical and psychological.”

Most doctors still feel that traditional healers do more harm than good in patients with organic illness. Del Kahn

Wreford wants to see doctors and traditional healers working harmoniously side by side. “Both play vital roles in healing the majority of AIDS-afflicted South Africans,” she says. “ARVs (antiretrovirals) are the only medical intervention available to alleviate the physical effects of AIDS. The traditional healer, in addition to using herbs, also works on the spiritual level, which is an essential part of the African healing process that Western medicine does not address.” But this will be a huge challenge. Del Kahn of the department of surgery at the University of Cape Town explains the obstacles: “Most doctors still regard sangomas with suspicion because they don't have training in treating serious organic disease, and the general feeling is that traditional healers do more harm than good in patients with organic illness.”

Sangomas are just as wary of Western physicians. Phillip Kubukeli, founder and president of the Western Cape Traditional Healers and Herbalists Association based in Cape Town, says that during the apartheid regime in South Africa many sangomas believed that doctors administered poison instead of medicine to black patients in the hope of killing them off. “This fear persists today,” says Kubukeli, “although it is not as prevalent as it was.”

Kubukeli adds that traditional healers strongly believe that physicians are out to get their hands on herbal remedies to sell to drug companies. “Many Western medicines are derived from indigenous plants,” says Kubukeli. “This makes traditional healers very suspicious. For example, when I am trying to bridge the gap between sangomas and doctors, the sangomas will often accuse me of trying to sell their remedies to the physicians.”

Driving a deeper wedge between this mutual medical divide is the South African government's perception that natural remedies can treat AIDS — a view it vigorously promotes. At the International AIDS Conference in 2000, South African President Thabo Mbeki caused an international uproar when he questioned the link between HIV and AIDS. And at this year's AIDS Conference in Toronto — where South Africa's stand, covered in beetroot, garlic and lemons, seemed seriously out of place — the South African health minister Manto Tshabalala-Msimang further discredited her government's AIDS policy by saying people must have a choice between ARVs and traditional remedies (see Nature 443, 134–135; 2006).

“As a result of this persistent denial, even at the highest government levels,” says Monika Esser, a paediatrician at Tygerberg Academic Hospital in Cape Town, “Western medicine of predominantly white origin continues to be met with an element of suspicion by black patients and traditional healers.”

It is here, into the turmoil of the AIDS healing conflict in South Africa, that Wreford hopes to throw a lifeline, in the form of a willingness to share her acceptance of both scientific and traditional beliefs with doctors and sangomas. Her hope is that by trusting Thobeka, the one who can be trusted, they can learn to trust each other.

Wreford qualified and practised as an architect in London before deciding to explore the spiritual aspect of her life more, and use this to help people through spiritual healing in Africa. Before leaving London, she embarked on a course of jungian psychotherapy, which emphasizes exploring the unconscious through the use of visualization and dreams. Wreford says it helped to prepare her for the intense spiritual demands made on her during her sangoma training.

What Western medicine needs to understand, says Wreford, is that many Africans believe that their ancestors live in a separate realm and carry with them answers to the deep questions about the cause of illness. “This knowledge is accessed by the sangoma through ritual, visions, dreams and herbs, and communicated to the patients, who then feel they have redressed the situation, which prompts more complete healing,” she explains. “Like psychotherapy, it can also help people cope with stigma and emotional strain in the face of a disease such as AIDS.”

Spreading HOPE

Wreford plays an equally vital role in explaining to her sangoma colleagues the importance of biomedicine in fighting AIDS. “Here my role is specific,” she says. “Sangomas believe that the disappearance of symptoms through the administration of a herb means that they have cured the patient of AIDS. I have to explain to them that this is not so and that the application of ARVs, which do not cure either, at least enables the patient to live life normally.”

But alone, her efforts are a drop in the ocean. According to the Western Cape Traditional Healers and Herbalists Association, there are more than 200,000 sangomas in South Africa — vast numbers spread over a vast country.

So Wreford was invited to join forces with HIV Outreach Programme and Education (HOPE), a non-profit, non-governmental organization based in Cape Town. HOPE is currently running a pilot study in five townships outside Cape Town to build mutual trust and acceptance between sangomas and doctors. It aims to encourage them to collaborate on HIV/AIDS intervention, to avoid disruption of ARV treatment through mistaken herbal administrations and to persuade more male clients to volunteer for HIV testing.

Wreford uses herbs, visions and ritual to access spiritual knowledge for clients.

The project operates on a cross-referral system between nine traditional healers and primary-health-care clinics in the townships. The healers, having been taught to recognize the symptoms of HIV infection and the importance of ARVs, refer these patients to a clinic for testing, counselling and treatment. The patients then come back for traditional spiritual counselling from the healer.

It is difficult for healers to refer patients to hospitals, which in Africa carry a strong association with death. Nocawe Frans

HOPE's recruitment and training of sangomas for the pilot study in October 2005 sparked misgivings at first. According to HOPE training officer Pauline Jooste, one healer said: “We were very scared — the facilitator was a white person.” Now the response seems more positive. Nomsisi Stefans, a practising sangoma from Mfuleni township outside Cape Town, says: “I am happy with HOPE and, if I think they should, my clients are happy to go to the clinic to be tested, especially if I go with them.”

The project is closely monitored and aided by Wreford. She participates in a monthly support and supervision day for all participants, regularly visits the clinics and sangomas to ensure commitment and quality, and lectures medical students and doctors on the need to recognize and respect the value of spiritual healing.

Much help is necessary if the project is to work. Nocawe Frans, a HOPE member and social worker at Tygerberg hospital, points out that many traditional healers are reluctant to spread HOPE's message because they resent Western interference in African traditional medicine. “It is also difficult for sangomas to refer patients to a hospital because in African culture the hospital carries a strong association with death — parents often take their children out of hospital and to a sangoma instead,” she says.

Despite these challenges, the five-month-old project is beginning to show a slight increase in patient referrals to clinics from traditional healers, although exact numbers are hard to come by, says Esser, who is also a HOPE management member. Patients tend to go to clinics outside their community owing to the persistence of an enormous AIDS stigma in South Africa.

Also encouraging are signals from both camps that Wreford's and HOPE's efforts are working. “I think we underestimate the spiritual needs of patients — the 'healing' rather than the management of treatment and cure that we are familiar with in Western medicine,” says Helena Rabie, a specialist in HIV/AIDS in children at Tygerberg hospital. “If we can succeed in tapping into the traditional healers' influence as a resource to fight the spread of HIV, it would be wonderful.”

Confidence is rising among sangomas too, according to Kubukeli. “Thobeka is truly great,” he says. “She has helped my colleagues understand Western medicine. We want to see the HOPE project grow.”

HOPE chairman, Reverend Stefan Hippler, is optimistic that, if the project succeeds, it could inform HIV policy in other African nations as well. “Traditional health practitioners are important role models and leaders in their communities,” he says. “They are indispensable for all national efforts in the fight against HIV and AIDS.”