ORIGINAL ARTICLES Approaches of South African Traditional Healers Regarding the Treatment of Cleft Lip and Palate DANIELLE DAGHER, B.A. ELEANOR ROSS, PH.D. Objective: Due to the large number of Black South Africans known to consult with traditional healers and the influential role they play in the developing world, this study investigated the approaches of a group of 15 traditional healers toward the treatment of cleft lip and palate. Design: An exploratory-descriptive, qualitative research design was employed, which involved the use of standardized, semistructured interviews, conducted with the assistance of an interpreter who was fluent in several African languages. Setting: Interviews were conducted outdoors in places in which traditional healers usually consult with their patients. These areas were in the fields close to the traditional healers’ homes or under a highway bridge in the Johannesburg inner city. Participants: Individual interviews were conducted with 15 African traditional healers who had been practicing in their callings for at least 1 year. Results: Traditional healers interviewed had treated one to six persons with a cleft lip, cleft palate, or both. Most informants believed that clefts were caused by the ancestors, spirits, and witchcraft. A variety of plant and animal products were used to treat these conditions and were augmented by spiritual resources from the ancestors. All except one healer had undergone formal training, although they had received no specific training relative to cleft lip and palate. Most participants reported referring patients to Western health care practitioners who were referred to as modern doctors but did not receive reciprocal referrals from these professionals. Patients generally consulted with traditional healers because this approach was part of their culture. Conclusions: These findings have important implications for health care professionals as well as traditional healers in terms of cross-cultural consultation, collaboration, and information sharing with regard to cleft lip and palate; the potential use of traditional healers in primary health care and education; and further research. KEY WORDS: cleft lip and palate, South Africa, traditional healer

In South Africa, the treatment of craniofacial conditions such as cleft lip and palate often depends on the type of healer or health care professional who is consulted (Tomoeda and Bayles, 2002). In the developing world, there are two main

types of health traditions, the modern approach that is located within a Western medical paradigm and the traditional approach that is based on indigenous belief systems. The traditional healers of Africa have been using ritual in combination with herbal and animal remedies to treat Africa’s people for generations. Several of these medicines seem to be effective where modern medicine has failed to find a cure. Until recently many Western-trained health practitioners have tended to regard these traditional healers as primitive witch doctors and have tried to discourage people from consulting with them. However, traditional healers are able to reach far more people than medical doctors because of the fact that they are a trusted source for health information and treatment. It is currently estimated that there are 150,000 to 200,000 traditional healers in South Africa, and 8 out of every 10 Black South Africans are

Ms. Dagher is a speech and hearing therapist and Dr. Ross is an Associate Professor in the Department of Speech Pathology and Audiology, School of Human and Community Development, University of the Witwatersrand, Johannesburg, South Africa. Presented at the South African Cleft Lip and Palate Society Bi-Annual Conference; Magaliesberg, South Africa; October 22, 2003. Submitted November 2003; Accepted April 2004. Address correspondence to: Eleanor Ross, Ph.D., Department of Speech Pathology and Audiology, School of Human and Community Development, University of the Witwatersrand, Johannesburg, Private Bag 3, P.O. Wits, 2050, South Africa. E-mail [email protected]. 461

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reported to rely on traditional medicine only or a combination of traditional and Western medicine (Foster, 2000; Gilbert et al., 2002). The African traditional medical practitioner or traditional healer is defined as ‘‘someone who is recognized by the community in which he lives as competent to provide health care by using vegetable, animal, or mineral substances and certain other methods based on the social, cultural, and religious backgrounds as well as the prevailing knowledge, attitudes, and beliefs regarding physical, mental, and social well-being and the causation of disease and disability in the community’’ (Oyebula, 1986; p. 222). Traditional healers can be men or women; they do not all perform the same functions, nor do they all fall into the same category. Although diviners are known by different names in the different South African cultural groups (e.g., amagqira in Xhosa, ngaka in northern Sotho, selaoli in southern Sotho, and mungome in Venda and Tsonga), most South Africans generally refer to them as sangomas (from the Zulu word izangoma). Each group has its own field of expertise. The groups employ their own methods of diagnosis and have their own medicines. Africans may choose between two main categories of indigenous healers (i.e., diviners and herbalists), although many of their roles overlap. A third type of healer is the prophet or faith healer that divines and heals within the framework of the African independent churches. Other categories include traditional surgeons (ingcibi), and traditional midwives or birth attendants (ababelithisi) (Spogter, 1999). Diviners are the most important intermediaries between humans and the supernatural. Unlike herbalists, no one can become a diviner by personal choice. The ancestors call them (more usually women), and they regard themselves as servants of the ancestors. Diviners concentrate on diagnosing the unexplainable. They analyze the causes of specific events through communicating with the spirits or from the reading of thrown bones and interpret the messages of the ancestors (Kellerman and Thindisa, 1998). Their vocation is mainly that of divination, but they often also provide the medication for the specific patients they have diagnosed (Van Rensburg et al., 1992). Herbalists, however, are ordinary people who have acquired an extensive knowledge of magical technique and do not typically possess occult powers. They are expected to diagnose and prescribe medicines for everyday ailments and illnesses, to prevent and alleviate suffering or evil, to provide protection against witchcraft and misfortune, and to bring prosperity and happiness to people. In the healing practices of herbalists, empirical knowledge plays an important role because they are able to diagnose certain illnesses with certainty and to prescribe healing herbs for those illnesses. In general, magical techniques also have a decisive role to play because virtually all medicines can contain ingredients that are endowed with magical powers. The medicine often carries a strong symbolic meaning (i.e., Tswana herbalists often use the skin of a water iguana or crocodile that symbolizes coolness, to ‘‘cool off’’ the patient). The third type of healer, known as a prophet or faith healer, diagnoses and treats patients by prayer, candle-

light, or water. Sometimes, on being cured, a patient automatically becomes a member of the church to which the faith healer who cured him belongs (Van Rensburg et al., 1992). Although the approach taken by the faith healers is fundamentally different from that of the herbalists and diviners, within the African context, they are generally grouped under the rubric of traditional healing. The treatment used by traditional healers varies greatly and depends on the healer’s knowledge and skills as well as the nature of the patient’s illness. Satisfactory healing involves not merely the recovery from bodily symptoms but also the social and psychological reintegration of the patient into his or her community (Hammond-Tooke, 1989). This approach is in line with the African philosophy of Ubuntu, which is enshrined in the maxim, ‘‘a person is a person through other persons,’’ and is consistent with the fact that many African cultures are collectivistic rather than individualistic in nature (Teffo, 1994). In many traditional cultures, illness is thought to be caused by psychological conflicts or disturbed social relationships that create a disequilibrium expressed in the form of physical or mental problems. Psychological or spiritual factors or both may cause disequilibrium that relates to African cosmology and ‘‘threaten the intactness of the person’’. In traditional cultures, healing emphasizes righting this disequilibrium (Kleinman et al., 1978). In contrast, Western medicine rests on the axiom of separation of mind and body, which holds that healing is a process of correcting disease by using appropriate medical and surgical procedures. The primary concern of medical science is healing the body and eliminating physical suffering (Cassel, 1991). Traditional healers occupy an esteemed and powerful position in South African society. Their roles include that of physician, counselor, psychiatrist, and priest, and people visit traditional healers for problems ranging from social dilemmas to major medical illnesses (Hall, 1994). Pretorius et al. (1993) maintain that the World Health Organization acknowledges the potential effectiveness of traditional healers as primary caregivers and the potential efficacy of their treatments in the fight against HIV/AIDS, sexually transmitted disease, and other infectious conditions. However, there appears to be a paucity of literature with regard to the treatment and beliefs that traditional healers hold concerning craniofacial conditions such as cleft lip and palate. Beliefs with regard to causation of clefts are not always grounded in empirical science. Instead, sociocultural views play an important role in people’s belief systems concerning etiology. Culture implies meanings, ideas, and values that constitute a way of life that pervades relationships, systems of beliefs, and behavior (Fenalson, 1992). It may therefore be assumed that cultural factors are likely to influence attitudes toward cleft lip and palate as well as the etiology and treatment of these conditions. Hammond-Tooke (1989) maintained that in many ethnic communities, health status, disease causality, and health care treatment may be defined or explained through traditional or folk models. These models may differ from conventional explanations in that illness may be attributed to in-

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juries, environmental factors, interpersonal conflicts, witchcraft, sorcery, spirits, or the result of violating cultural, religious, spiritual, or traditional norms. For example, Patel and Ross (2003) interviewed a group of 20 South African adults with repaired cleft lip, cleft palate, or both and found that some individuals attributed the cause of their clefts to being cursed by a sangoma, and others mentioned that their mothers had handled sharp objects during an eclipse. Belief systems not only affect people’s conceptions concerning the etiology of craniofacial clefts but also are likely to impact on treatment approaches. For example, within the Western medical paradigm, treatment tends to occur within a multidisciplinary framework. Members of the cleft palate team usually include plastic and reconstructive surgeons, orthodontists, pediatricians, speech and hearing therapists, social workers, psychologists, nurses, and dietitians. However, traditional healers are seldom, if ever, included as part of the treatment team. Studies on African traditional healers and their role in communication disorders seem to have focused on the areas of stuttering (Platzky and Girson, 1993) and hearing impairment (De Andrade, unpublished data, 2000). However, there would appear to be little if any research investigating African traditional healers’ views on craniofacial disorders. Because of the large number of people who consult with these healers, it seemed important to study the role of African traditional healers in the management of cleft lip and palate. The main assumption underpinning the study was that health care professionals could learn from, as well as assist in, the training of traditional healers. Second, it was anticipated that the information obtained from this research project would be useful for facilitating professional collaboration between Western health care professionals and traditional healers and could potentially foster a stronger referral system, thereby improving prognoses in respect of persons with cleft lip, cleft palate, or both (Abdool Karim et al., 1994). Finally, it was envisaged that the study might have potential implications for the use of traditional healers in primary health care and community education. METHODOLOGY Aims

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laboration with other health care professionals in the management of cleft lip and palate. 6. Explore traditional healers’ views relating to the reasons why persons with craniofacial clefts seek their services over, or in addition to, those offered by Western health care practitioners. Research Design An exploratory-descriptive, qualitative research design was employed, which involved the use of individual interviews. Participant Sampling A purposeful, nonprobability sample of 15 participants was used. This number was based on the fact that qualitative research usually employs smaller sample sizes than quantitative research because the focus is on obtaining descriptive information (Sarantakos, 1998). Participants were recruited from various traditional healers who train others for this role. A lady in charge of various training schools for traditional healers granted permission to conduct the study with her past pupils. Other participants were recruited via snowball sampling whereby existing participants acted as informants to identify other members of the target population (Doehring, 1996). The only participant selection criterion was that the traditional healers were required to have been practicing for at least 1 year to have gained some experience in this field. Description of Participants Participant demographic information is shown in Table 1. Participants included the various categories of traditional healers (i.e., diviners, faith healers, and herbalists). Although some of the participants were originally from rural areas, they were all practicing their calling within the urban area of Gauteng, which is one of the most densely populated regions in South Africa. A limitation of the nonprobability sampling procedure was that no Xhosa speakers were represented despite the fact that they constitute a large proportion of the Black South African population.

The goals of this study were to: Research Instrumentation 1. Obtain information concerning the number and types of cleft lip, cleft palate, or both seen by the group of traditional healers who were interviewed. 2. Probe traditional healers’ opinions on the causes of cleft lip and palate. 3. Elicit information on the traditional healers’ treatment of cleft lip and palate. 4. Obtain information on traditional healers’ training, with particular reference to cleft lip and palate. 5. Ascertain traditional healers’ perceptions with regard to col-

The interview schedule was adapted from an earlier study by De Andrade (2000) and included demographic information on age, sex, number of years practicing as a traditional healer, category of healer, ethnic group, current place of residence, and languages spoken. Information was also sought on the number and types of clefts seen, opinions on etiology and treatment of clefts, collaboration with other health care professionals, and perceptions why people tended to use their services.

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TABLE 1 Description of Participants (N 5 15) Demographic Factor

Age, y

Sex Number of years practicing as a traditional healer

Category of traditional healer

Ethnic group

Current place of residence

Languages spoken

Data Analysis

Subcategory

Number

21–30 31–40 41–50 51–60 61–70 Male Female 1–10 11–20 21–30 31–40 Inyanga (herbalists) Isangoma (diviners) Umthandazi (faith healers) Zulu Swazi Sotho Ndebele Pedi Katlehong Soweto Johannesburg (inner city) Northcliff Natalspruit Zulu Northern Sotho English

2 5 5 2 1 5 10 3 5 6 1 11 2 2 7 3 3 1 1 6 4 2 1 2 10 4 1

Closed-ended questions were analyzed using descriptive statistics, and open-ended items were subjected to thematic content analysis. According to Babbie (1995), content analysis is a technique that allows researchers to highlight the common themes and categories expressed by participants and describe responses in a systematic and quantified mode. This process involved the researchers immersing themselves in the data to capture and discover the meanings therein. Thereafter, themes and motifs were extracted. Where necessary, these themes and motifs were then categorized into further subthemes and submotifs. In view of the subjective nature of content analysis, the analyzed data were reviewed by an independent, objective researcher to establish the trustworthiness of the analysis (Neuman, 1997). The person who performed this function was a university lecturer with experience in this area. Once agreement had been reached between the independent rater and the researchers concerning the categorization of themes and subthemes, the analyses were quantified. RESULTS Number and Types of Clefts Seen by Traditional Healers Who Were Interviewed

Research Protocol The research instrument was pretested on a small subsample of persons who met the selection criteria but were excluded from the final study. Following the incorporation of amendments arising from the pretest, the interview schedule and research proposal were submitted to the relevant university Ethics Committee for Research in Human Subjects. Thereafter, individual interviews were conducted in locations that were convenient for participants, including Katlehong, Soweto, downtown Johannesburg, and Northcliff. Most interviews were conducted outdoors in places in which traditional healers usually consult with their patients. These areas were in the fields close to the traditional healers’ homes or under a bridge in the Johannesburg inner city. Although the researchers originally intended to tape-record interviews, participants tended to be suspicious of and resistant to this procedure. For this reason, detailed, handwritten notes were made of all the responses provided by the traditional healers. At the beginning of the interviews, participants were shown an illustration of the different types of clefts to ensure that they recognized the craniofacial conditions referred to by the researchers. The services of an interpreter were used to assist in conducting the interviews with those participants who were not proficient in English. To enhance validity and reliability of the responses, the interpreter was briefed regarding the content of the interview schedule and the need for accurate translation of responses provided by participants.

Before being asked any questions on cleft lip and palate, participants were shown an illustration of babies presenting with various types of clefts. Analysis of the results revealed that the traditional healers had been consulted regarding one to six persons with clefts, with an average of three. In terms of incidence, cleft lip and palate represents the second most frequently occurring congenital anomaly after clubfoot. Nevertheless, in their survey of birth anomalies among Black South Africans, Kromberg and Jenkins (2002) obtained a percentage rate of only 0.30 facial clefts per 1000 births. The relatively infrequent occurrence of this condition was reflected in the following statement by one of the participants: ‘‘This is a very serious, rare, not your average illness.’’ Of the total number of 48 clefts seen by the traditional healers, 30 presented with a cleft lip and palate, 10 presented with a bilateral cleft only, and 8 patients presented with a unilateral cleft lip only. Traditional Healers’ Opinions on the Cause of Cleft Lip, Cleft Palate, or Both Table 2 illustrates the participants’ beliefs regarding the etiology of the cleft. The most frequent cause of cleft lip, cleft palate, or both mentioned by 8 of the 15 participants was that of ancestral spirits that expressed their thirst for blood and utshwala (sorghum beer) through the baby’s sickness. ‘‘Your amadlozi (ancestral spirits) ‘remind’ you that a sacrifice for them is overdue, and the sickness is the result of the punishment.’’ Another healer explained, ‘‘You have to make an umsebenzi (ancestral sacrifice; i.e., you will slaughter a beast or

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TABLE 2 Traditional Healers’ Opinions Regarding the Cause of Cleft Lip and Palate Perceived Causes of Cleft Lip and Palate

Ancestral spirits (amadlozi) Evil spirits Curses from jealous people Bewitched by umkhakathi (witches) Eating rabbit meat that was poisoned The mother’s attempt to abort the child failed but caused harm to the fetus, or the mother was being punished by the ancestors for her wrongdoing by giving birth to a child with facial abnormalities Being in the vicinity of a skunk

TABLE 3 Traditional Healers’ Treatment of Cleft Lip, Cleft Palate, or Both (N 5 15) Type of Treatment

Number

465

Number

Percent*

7 6 5

60 40 33

3 13 3

20 20 7

2

14

Percent

8 5 3 3 2

53 33 20 20 13

2 1

13 7

a goat for them, give them their fair share of the sacrifice (the gall is sprinkled in the cattle kraal and the amadlozi are presented with an ukhamba (clay pot) full of blood and one full of beer, which is put for them into the umsamo (crescentshaped area in the back of the main hut of the kraal) to quench their thirst).’’ Three participants believed that the ancestors were singling out the baby with a craniofacial condition because this child was blessed with supernatural powers. Such an experience was seen in a positive light. However, another healer viewed the condition negatively, stating that ‘‘the mother was punished as she tried to steal another woman’s child because she thought she was unable to fall pregnant.’’ Another participant explained that angry ancestors had caused the baby to be born with a cleft because the family had held a ritual ceremony in the wrong place. These responses were consistent with African beliefs in terms demonstrating that ancestors are held in high esteem. They have the power to prevent evil and also help the living in solving their daily problems. They are interested in the behavior of their descendants and may punish them for misbehaving. Five of the 15 traditional healers informed the researchers that they believed in evil spirits (imimoya emibi). ‘‘When possessed by the evil spirit, one usually speaks in a strange voice answering the questions asked and is indeed in an abnormal frame of mind’’ was an explanation offered by one of the participants. A related cause of cleft lip and palate was attributed to bewitchment. For example, one person explained that he became a witch because he became angry when one of his clients (a pregnant woman) did not pay her fee to him, and he therefore punished the mother by making the baby’s face ugly when the infant was born. He had experienced a vision of the baby’s face and insisted that it was just like the one with the complete bilateral cleft in the picture shown to him. Curses from jealous people were cited by three of the participants as the reason for the cleft lip or palate. Eating poisoned rabbit meat was regarded by two individuals as a possible cause of the cleft. It is believed that the poison (uroyi) enters the body at one spot and circulates to other parts, causing pain in the spot in which it eventually

Ritual sacrifice to appease the ancestors Herbal treatment Perform spiritual cleansing Animal horns filled with magical powders to protect the family Animal products Prayer There is no treatment to cure the child or one should not try to cure the condition because the child had special powers and had been chosen by the ancestors to become a traditional healer

* Percentages do not add up to 100% because some participants mentioned more than one method in their answers.

settles. It could also be mentioned in passing that the term harelip used to be associated with cleft lip, cleft palate or both because the cleft lip resembles the slit-like mouth found on rabbits. One participant thought that the cause of the cleft was due to the mother being in the vicinity of a skunk. Another two persons ascribed the cleft lip and palate to the mother attempting abortion. They believed that in the process of trying to abort the fetus, the baby’s face was destroyed. They also believed that the baby became infected when foreign objects were used in the abortion attempt. Celfand (1964) explained that within African cultures, termination of pregnancy may link the woman concerned with witchcraft and she may be labeled as a witch. Traditional Healers’ Treatment of Cleft Lip and Palate Table 3 shows the different methods used to treat craniofacial conditions such as clefts. It can be seen that the healers who were interviewed in this study treated illness mainly with plant products and some animal products and used spiritual resources to augment their healing powers. Six of the participants used herbal remedies to treat cleft lip and palate. They did not mention the names of specific herbs but explained that they used their own secret mixture compiled with the help of the ancestors. Their most commonly used medicines were made from plants, herbs, and powders of bones, seeds, roots, juices, leaves, and minerals. Treatments included the use of thorns, bleeding, incantations, needles, asking for the sacrifice of a goat or chicken, or avoiding certain foods such as meat from a rabbit. In this respect, HammondTooke (1989) noted that many herbalists have a very good knowledge of many natural substances that have a real remedial effect. Animal fat was a popular ointment that was used to rub on the cleft as a protective as well as healing remedy. Several of the participants believed that using the hoof of a piglet, calf, or sheep as a dummy for the child to suck on strengthened the muscles in the mouth and therefore assisted with the development of speech. Many believed that using a certain animal fat that was requested from the ancestors helped

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ear infections. Others combined the melted fat with plant extracts to make an effective eardrop. One healer mentioned that a woman came to see her and brought along her baby who had a cleft. At first the healer could not make any sense of the infant’s cleft and did not know what treatment was required. ‘‘Every day I got up before sunrise, washed with herbs, put on my ceremonial clothes, and beat the drums. I sometimes took muti (medicinal potions) so that I could talk to the ancestors. My patient participated in these ceremonies. Then I would go alone to the bush to hunt for herbs to make muti for him and other patients. I collected herbs that I learned about in my training.’’ A popular way of determining the type of herbs that was needed for treatment was through dreams. Celfand (1964) explained that the healers usually dream about medical matters, and in their dreams, they see the dead relative teaching them their art. If the healers are shown particular herbs, they look for them the next day and use them for the specified ailments. Five of the participants believed that spiritual healing and cleansing need to be implemented as part of the treatment for cleft lip and palate. Many attributed the cause of the cleft to evil spirits that had possessed the mother and her child. Spiritual healing is a process that dispels the evil spirits and cleanses the patient by removing impurities and restoring equilibrium to the patient’s mind and body. All the traditional healers who were interviewed mentioned only one treatment consisting of the application of the chirumiko (cupping horn). An incision was made on the patient’s forehead and the blood allowed to gather in the horn. Another cleansing process that was recommended by one of the participants was to scatter muti (medicinal powders) all around the room. If such procedures failed, the healers called the ancestral spirits, and sneezing signaled their arrival. The ancestors needed to be reverently welcomed by the whole family with their title of honor, ‘‘Makhosi! Makhosi! Makhosi!’’ Through inspiration from the ancestral spirits, the traditional healer will then be able to ukubula (smell out) the source of the evil and as a result heal the patient. Seven of the 15 participants mentioned that a ritual sacrifice was needed to appease the ancestors before any medication was given to the patient. ‘‘Your amadlozi (ancestral spirit) reminds you that a sacrifice for them is overdue.’’ Participants believed that the baby was born with the cleft because of the family forgetting the sacrifice. In the case of a minor illness, a chicken would be sacrificed. However, a cleft is perceived as a significant problem; one participant suggested sacrificing a goat as a way of asking for forgiveness. Three of the traditional healers believed that the most common charm for protecting the whole family from witches consisted of an animal’s horn filled with certain powdered medicines that was hidden in the house. One participant believed that one needed to soak pegs in the medicine and place them at each corner of the house. The pegs would make the house look like part of the landscape and prevent the witch from recognizing the home at night during her errands. Other views regarding treatment included the belief that

there was ‘‘a need for healing, which included both the physical and the spiritual. Modern doctors don’t take the spiritual side in healing patients with these facial damages (cleft lip and palate) into account.’’ However, most of the participants acknowledged that they had no real knowledge of anatomy or physiology. Another participant felt that modern doctors should not perform any surgery on the child with a cleft because it meant that the ancestors had chosen these children to be different. He believed that the child had supernatural powers and was selected to serve the community as a traditional healer when he or she became an adult. The implication of this finding was that if the family accepted this explanation, it might be potentially harmful in the holistic sense to repair the anomaly. However, most of the participants referred their patients to modern doctors because they felt that surgery was needed at a later stage in the recovery process. It was felt that these children would have serious psychological problems if they did not undergo surgery. One individual commented, ‘‘If the child does not get his face fixed, the community will not understand and mistake the child for being a witch and reject that person.’’ General Training Received as Traditional Healers and Specific Training Concerning the Treatment of Cleft Lip and Palate The type of training received by the traditional healers varied significantly. For example, one healer reported being trained for 3 years and another trained for 6 years and yet another had received no formal training. None of the participants had received specific training with regard to the treatment of cleft lip and palate. Fourteen of the participants all highlighted the fact that they had been required to go through the cleansing process to become a traditional healer. The cleansing process included not being able to see a spouse or children, abstaining from sexual contact, and often living under harsh conditions. All the participants reported being called on by the ancestors to become traditional healers. The callings from the ancestors differed. Five of the traditional healers suffered an illness and had to become a healer to be cured, and six knew that they had to serve their communities because the ancestors spoke to them in dreams. The remaining five became healers because their parents and forefathers were traditional healers, and they inherited this role. From the interviews it emerged that anyone who is given the powers to serve the community as a traditional healer can do so. The procedure can occur at any age. The trainees stay at the home of the traditional healer until they are fully trained. Each trainee then receives a packet of bones to take home. After they have graduated and are ready to heal others, the traditional healers are expected to know the various herbs and animal products that they can use, where to find the various remedies, and how to collect them as well as how to prepare and store them to maintain their healing properties.

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Perceptions of the Traditional Healers Concerning Collaboration With Other Health Care Professionals Eleven of the traditional healers who were interviewed expressed a keen interest in learning from Western medicine, which suggested that they were open to alternative ways of thinking. These same 11 participants reported that they were collaborating with modern practitioners at the time of the study, especially when surgery was needed or when their medicine was not perceived to be healing one of their patients. For example, ‘‘I am good at healing mental problems. Sometimes my medicine does fail. I then refer back to the ancestors. If they tell me to refer to the modern doctors, I do, and if they ask me to try another herb mixture, I have to follow their instructions.’’ Another participant stated, ‘‘We refer our people to Western doctors if we can’t help them, for example, to use penicillin. I hate the stuff, but I still advise people to see a Western doctor. There is no use trying to compete with one another.’’ One of the concerns raised was that Western doctors did not treat patients holistically. They maintained that modern doctors were generally in a hurry and did not give the patient enough care and attention. The healers also felt that they performed a far more difficult task. For example, they believed that the ancestors caused some diseases to occur, whereas Western medicine did not subscribe to this viewpoint. The healers used old types of healing methods such as the throwing of bones, whereas Western-trained doctors used modern methods. They believed that Western doctors obtained most of their information by questioning patients before examining them, whereas traditional healers relied mainly on throwing of the bones and then confirmed their findings with their patients. However, four of the traditional healers were adamant that they would not consider collaboration with Western doctors. A typical response included, ‘‘Why should I collaborate with them? White doctors know how to use medicine, but they don’t know where it comes from. Somebody else has to make it for them. They will never accept that they are having a problem when somebody is not healed. They are not worried and that is a problem. I prefer to use my own instincts and the help from my ancestors to heal my people.’’ All the healers who were interviewed agreed that Western medicine was unable to cure ancestrally caused diseases. For example, ‘‘Western medicine does not have all the answers. Witchcraft does exist and Western medicine can never cure them.’’ Traditional Healers’ Views Concerning the Reasons They Are Consulted in Connection With Cleft Lip and Palate Table 4 highlights the reasons given by the traditional healers that people seek their services over or in addition to those offered by Western medical practitioners. The issue of culture was strongly emphasized by all of the participants. According to Wolpe (1990), traditional healers are the guardians of culture. They are the most trusted and respected members of the

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TABLE 4 Perceptions With Regard to the Reasons People Consult With Traditional Healers (N 5 15) Common Themes

Number

Percent

Cultural beliefs, the trusted way The ancestors sent them to the healers They deal with supernatural causes They view their patients holistically, spend more time with them, and give them explanations for their conditions

15 9 6

100 60 40

6

40

* Percentages do not add up to 100% because participants provided more than one reason that their patients consulted with them.

community and serve as the links between the living and the ancestors and people of all ranks, including chiefs. One participant stated, ‘‘Our people have believed and trusted in our healing powers for generations. It has worked for so many years, I personally know they choose us over the modern doctors.’’ Six of the healers believed that people consulted with them because they treated them in a holistic manner. As one participant put it, ‘‘There are times when Western medicine does not cure the disease properly, from the inside. Injections and surgery do not take out the root of the problem.’’ Another healer mentioned, ‘‘Western doctors heal differently to us. I feel they are in a hurry and do not give their patients all the support, care, and attention they need.’’ Green (1988) maintained that the holistic perspective of the African healers led to considerable insight and success in treating a wide variety of illnesses, particularly those that have a psychosomatic component. Six of the participants felt that Western doctors did not deal with supernatural factors and they did. This viewpoint was reflected in the following responses, ‘‘The ancestors are the supernatural, and they guide us. They send you supernatural powers to heal your patients. The herbs that I use have supernatural powers as the ancestors help me through the healing process.’’ Campbell (1998) explained that supernatural belief systems are distinctly alien to and not easily comprehended by many Western practitioners. Green (1988) elaborated on this point by stating that one of the reasons that traditional healers have not been incorporated into the modern health care system up to now is the inherent conflict between the scientific and the magico-religious paradigms of Western-trained and traditional practitioners, respectively. More than half (i.e., nine) of the traditional healers who were interviewed believed that the ancestors had sent their patients to them. According to Morris and Levitas (1984), the traditional religions of the African black population do not view death as the end of life; instead, during death spirits of the ancestors continue to live and take an interest in the lives of the living. Most of the healers who were interviewed believed that failure by the living to maintain their traditions was likely to upset the ancestors, who then brought misfortune on their descendants. However, other participants explained that the ancestors did not always bring misfortune to people. There were other causes for illness, and the ancestors were some-

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TABLE 5 Issues of Concern to the Traditional Healers Who Were Interviewed (N 5 15) Examples of Comments Reflecting Themes

Theme

● We are not practicing witchcraft or promoting evil. ● People who kill a child, mutilate another human being, or steal from others can definitely not call themselves healers. They are definitely evil— witchdoctors. The vital role they play in using nat- ● We have a deep knowledge of the ural substances to heal patients medical properties of our indigenous plants to share with the rest of the world. ● We are constantly learning because there are more than 500 varieties of medicinal plants available to us in southern Africa to heal our patients. The need for mutual referrals ● I refer my patients to modern doctors, but they never refer their patients to me. ● We acknowledge that there are alternatives to healing people. We are open minded. The modern doctors laugh at us, not taking our beliefs and power into account. ● We know a lot about the spiritual world. Modern doctors do not. Doctors need our help on this issue because if the spiritual world is not considered, no medicine will work. . . I realize I need their help (e.g., we have no access to anesthetic or penicillin, but the modern world does). ● We need to refer because if the child does not get his face fixed, the community will not understand and mistake the child for being a witch and reject that person. The power of their medicine ● The ancestors give us powers that are unbelievably amazing.

The need for traditional healing to be accepted by western medical practitioners and not confused with witchcraft

times instrumental only in leading the patient to the traditional healer to be healed. Issues of Concern Raised by the Traditional Healers Table 5 illustrates the issues that participants felt needed to be addressed. DISCUSSION In evaluating the study, consideration needs to be given to the methodological weaknesses in the research design and analysis. First, the language issue was a major limitation in terms of communication with the participants. Seven of the 15 healers were unable to speak English, and consequently interviews were conducted with the help of an interpreter. At times it was not clear whether participants understood the questions the way they were intended, and it was necessary to probe further. Second, a sense of mistrust was experienced in some instances. Some of the participants appeared to be reluctant to

furnish information with regard to the type of herbal and animal treatments that they used. Despite reassurances regarding confidentiality, they seemed to fear that their secrets would be divulged to other traditional healers or pharmacists or that the findings from the study would be presented on a television program and that they would be accused of malpractice. These apprehensions seemed to be based on a television program screened at the time of the study in which traditional healers had been depicted in a very negative light. Furthermore, despite efforts to conduct the study in a culturally sensitive manner, it is possible that cultural differences between the researchers, who were white, and the participants, who were black, may have caused some misunderstandings. A third limitation related to the issue of sampling. The small sample size and the disproportionate representation of the different types of healers from the various categories precluded generalization of the findings to the broader population of traditional healers in South Africa. Nevertheless, in spite of these methodological limitations, the study has important implications. The fact that 73% of the participants acknowledged that they needed input from Western medicine when they were unable to help patients presenting with certain disorders and that they referred people to modern medical practitioners suggests that there has already been some movement in the direction of collaboration. However, issues such as Western doctors not acknowledging or respecting the participants’ beliefs and capabilities were emphasized. There is therefore a need for greater collaboration between traditional healers and Western-trained practitioners and recognition of the strengths and weaknesses of both approaches, which could potentially result in a complementary and holistic system that incorporates both physical and spiritual dimensions. The fact that all the traditional healers who were interviewed had been consulted with regard to cleft lip and palate underlines the need to share information on these craniofacial conditions. Furthermore, by giving traditional healers information relating to cleft lip and palate, the rehabilitation process could potentially be managed in a more effective manner. Although the researchers used the interview as an opportunity to answer questions posed by the participants, the wide range of issues raised highlighted the need for workshops to be held with this section of the population targeting areas such as the etiology of cleft lip and palate from a modern medical perspective, basic care issues such as feeding and nutrition, and the overall treatment program encompassing the roles of all professionals involved in the cleft lip and palate team. Moreover, sharing information on cleft lip and palate needs to be done in a culturally sensitive manner. It is important that the process of information sharing be perceived as mutual and reciprocal. Western health care practitioners need to be open to learning about the beliefs and practices of traditional healers and not only see themselves in the role of experts imparting scientific knowledge and understanding of these conditions. Some of the participants also expressed concern with the way their people were treated by modern doctors. They felt

Dagher and Ross, SOUTH AFRICAN TRADITIONAL HEALERS

that their patients often leave the modern doctors not understanding exactly what is wrong with them or how to use the medicine that has been prescribed. One healer stated, ‘‘My people leave the modern doctors being more confused than ever. They fear answering questions that they wish to answer.’’ Hence, it is recommended that traditional healers and modern health care professionals spend more time with each other, learning about their different cultural beliefs and practices. Findings from the study suggest that traditional healers could be used to great benefit in primary health care, which forms the cornerstone of health policy in South Africa (White Paper for the Transformation of the Health System in South Africa, 1997). The provision of primary health care also includes community education. Traditional healers are held in high esteem in most black communities, and they are consulted by vast numbers of people. They therefore represent a valuable resource for educating people about cleft lip and palate and need to be incorporated into the health care system. Finally, in view of the small nonrepresentative sample utilized in the present study, it is recommended that the research project be replicated with a larger sample size comprising the different types of healers from the various provinces in South Africa. It is also recommended that future researchers explore the views of Western doctors with regard to traditional healers and their potential role within the cleft lip and palate team. Other fruitful areas for research include the experiences of families of persons with cleft lip and palate that have utilized the services of traditional healers. CONCLUSION In conclusion, the purpose of this study was to draw attention to the various approaches to cleft lip and palate as well as the barriers to communication between modern and traditional healers. In this respect the remarks made by Adams as long ago as 1963 would still appear to be relevant: ‘‘The ethnocentrism of developed societies has led their members to regard those who fail to act in accord with their own practices as being ‘ignorant’ and ‘superstitious.’ This has led even specialists to try to contrast the ‘knowledge’ that is to be derived from scientific work with a thing they call ‘ignorance,’ which characterizes most of the world’s peoples. . . . Although the practices of some societies are clearly more efficacious, as measured in terms of mortality, morbidity, and life expectancy, that which people in those societies ‘know’ about how their own practices work, and how they may react to new practices is quite another matter. So it is that ‘folk knowledge’, and in the present instance, folk medicine, has mistakenly been thought to be peculiar to some ‘ignorant’ segments of the world’s population when in fact it is a kind of knowledge which characterizes in one way or another almost everyone in the species’’ (Adams, 1963 cited in Read, 1966, p. 110).

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