Should Traditional Healers be Regulated by Modern Medicine?

Ebola, as many Americans learned during the recent outbreak in West Africa that claimed over 11,000 lives, is a horrific disease. Yet no matter how frightening it may seem, it's actually fairly easy to contain, so long as a country has a sufficient healthcare system. But when Ebola struck a rural Guinean village in December 2013, it found itself in a catastrophically facilitative environment—a nation with few doctors per capita, low popular trust in the healthcare system, and cultural practices around sickness and death that facilitated its transmission. Medical interventions were at times stymied by wariness of strange foreigners who dropped in, started taking people away, and tried to meddle in local cultural practices. This chronic mistrust might have extended the crisis much longer if it weren't for the intervention of traditional healers.

Part of a broad, malleable field, traditional healers sometimes rely on idiosyncratic mixes of religious-to-magical powers and local remedies to treat physical and metaphysical illnesses (like curses) in local communities, where they are often embedded into local culture and enjoy deep trust from their constituents. In Guinea, up to 80 percent of the population relies on these healers—and usually them alone. But when it became clear to healers that they could not cure Ebola, and to health workers that these healers were a vital point of contact with at-risk populations, a crucial alliance emerged: Many healers undertook training to detect, initially treat, and contain Ebola, and encouraged patients to seek mainstream Western medical treatment, allaying their fears and mediating culture clashes. The collaboration was so successful that medical groups in Guinea are now coordinating deeper, long-term alliances to detect and treat other major illnesses.

This intersection of traditional and mainstream Western medicine may seem like a surprising new lesson of the Ebola outbreak to some. But numerous global medical bodies have long recognized the value of working with healers, who are a main source of care for the majority of people in Africa and Asia due to the same embedded cultural legitimacy and low trust in doctors as is at play in Guinea. These medical groups have been advocating some form of alliance for decades.

Yet many countries have yet to build any official framework for coordinating with healers. And those that have, says Maylin Meincke, a researcher at the University of Helsinki who has studied the intersections of Western and traditional healthcare in Namibia, have opted for radically different and usually vague, half-implemented policies. "This is still a rather contentious topic," says Manoj Mohanan of Duke University's Global Health Institute and the Duke University Sanford School of Public Policy, who has also studied this intersection. "We need a lot more robust evidence before we are able to agree upon best practices or policies to address this issue."

It's even possible that no consensus approach to coordinating traditional and mainstream healthcare alliances will ever emerge, given the complexity and variability of traditional healing. There are almost infinite variations by which a medical system can try to work or coordinate with traditional healers. Many have cooperated with healers across Africa to detect and control the spread of HIV, like health officials did with Gambian healers and Ebola. Some have gone further, trying to turn informal healers into licensed and trained, if restricted, frontline caregivers for national healthcare systems until nurses and doctors can be deployed into remote areas in the future (a notable example of this has unfolded over recent years in West Bengal, India).

South Africa has taken another tack, advocated in several African nations, in some cases by healers themselves: creating traditional healers' councils to delimit what healers can do and regularize their training and license their practices, limiting the potential for conflict and fostering a sense amongst those using their services that they are one spiritual side of a two-pronged world of trustworthy healthcare. In America, where many indigenous, immigrant, and religious groups still value traditional healing and feel slighted by or suspicious of allopathic medicine, there's been a movement to try to integrate some healers or practices into medical facilities, allowing the practice of limited rituals and dispensing restricted remedies to alleviate that cultural friction.

Beyond their clear benefits to overall public health, all of the system could be appealing to traditional healers, says Mohanan. They offer legitimacy; in many nations traditional healers, outside of an official collaboration scheme, are subject to criminal punishments if something goes wrong in their practice. So although they may already have local legitimacy, official legitimacy can bring them greater security—perhaps even greater visibility. And restrictions placed upon them are often deemed acceptable, as many healers genuinely want to learn and help their patients, and acknowledge the dualistic value of mixing spiritual and allopathic treatments.

Of course, every form of cooperation comes with its risks. Public health officials sometimes worry that partial alliances or stopgap training to turn healers into frontline allopathic healthcare providers risks simultaneously granting medical legitimacy to what they see as traditional risky practices or to healers who did not opt into cooperation. "Many medical regulatory bodies… push for strict punitive measures against informal providers," Mohanan says. "Medicine, like any profession, would feel threatened by measures that [appears to relax] entry requirements."

Integrating healers directly into hospitals or forming self-policing councils might make it easier to monitor and enforce the nature of an alliance between traditional and mainstream Western medicine. But, Meincke explains, any such system involves standardizing, controlling, and limiting the practice of traditional medicine. That's a problem for many healers, whose practice depends on flexibility and perpetual evolution rather than any one set of principles and techniques they can nail down. Even when healers themselves define traditional healing, as in South Africa's council, some kinds of healers may be boxed out by others, creating an intra-healer political clash. "Standardizing traditional healing," she stresses, "can only be done by excluding and rendering 'incorrect' or labeling some [traditional] practices as 'non-traditional' healing practices."

"Many traditional healers would also not welcome" integration into a medical system, she adds, "as they would be made into second-class medical practitioners" next to doctors. Communities might also lose some trust in those who shift too rapidly and dramatically from old practices.

The incredible variability in the modes and methods of traditional healing, the flaws or limitations of allopathic healthcare systems, and the attitudes of local communities towards both from region to region makes it impossible for anyone to select one least-flawed method and double down on it, hammering out as many kinks as possible. In communities where traditional healing homogenized over time into a cohesive system with little room or local trust for variation—like Indian Ayurveda or iSangoma practices in parts of South Africa—Meincke says, a council system of self-governance and coordination could work well. In areas with dire need for mainstream healthcare providers, especially where traditional healers recognize that need and their own limitations, it might be most necessary and beneficial to turn them into frontline healthcare providers, no matter the risks of legitimizing their other, uncontrolled practices.

Instead of finding best practices, both Meincke and Mohanan suggest that healthcare workers or state officials at the local level should devote time and resources to assessing their needs and the dynamics of local healers. From there, they can tailor idiosyncratic collaborations for the local situation—based on mutual interests in best serving a community and mutual respect for each other's services. Operating on the most local level possible would allow for flexibility in tune with that of traditional healing and creates a good basis for healer buy-in and self-policing.

Unfortunately it's hard to mandate that every medical body, at every relevant level, engage in situational dialogue with local healers—or to secure the funding and support to facilitate that. "Usually cooperation… depends on whether people are motivated to reach out," Meincke says.

But the benefits of local cooperation between mainstream and traditional medicine are clear and strong—as when they helped to stem the tide of Ebola, saving hundreds, if not thousands, of lives. It'd be more than worth the time and money to at least try to incentivize and facilitate local collaborations. Someone's just got to find the resolve to deal with this squidgy state of affairs.

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