Carolyn Audet, Vanderbilt University; Mosa Moshabela, University of KwaZulu-Natal, and Ryan G Wagner, University of the Witwatersrand

There are around two million traditional healers in sub-Saharan Africa. More than 200,000 live and work in South Africa.

Traditional healers are frequently exposed to bloodborne pathogens such as hepatitis B and HIV. In particular, they are exposed through the widespread practice of traditional “injections” by incision. This is when the healer makes small cuts in a patient’s skin using a razor blade to rub herbs directly into the bloodied tissue with their bare hands. They are also exposed to airborne pathogens such as COVID-19 and tuberculosis (TB) when treating patients.

Education and awareness campaigns have led to greater understanding among traditional healers about the causes and treatments for HIV, TB and other conditions for which effective treatment can be found at public health facilities. However, many people seek treatment from traditional healers before definitive diagnoses have been made, placing the traditional healer at risk of occupational infection.

Traditional healers can and should benefit from efforts to protect people caring for the sick from bloodborne and airborne pathogens. The correct use of personal protective equipment is an evidence-based practice that prevents infection by creating a barrier between the patient’s body fluids and the health provider. But protective equipment is only effective if used correctly and regularly.

Our research in a rural South African town found that traditional healers are open to using gloves and masks, and many regularly do so. But they do not have access to formal training in putting on, taking off, and disposing of personal protective equipment. They also don’t have regular access to government-funded gloves or masks. Leaving aside any question about the efficacy of traditional methods for diagnosis and treatment, traditional healers should be made as safe as possible.

Occupational hazards

The practice of “injections” by incision can increase a healer’s risk of HIV infection. An average healer in the rural South African town where our research was done is exposed to blood in this way about 1,500 times over their working life.

Most exposures on unbroken skin do not result in infection. But the risk of infection varies by the pathogen involved, the type of exposure, the amount of blood involved, and the amount of virus in the patient’s blood at the time of exposure. The average risk of HIV infection after a needle stick or cut exposure to HIV-infected blood is 0.3%, and after exposure to eye, nose or mouth is estimated to be 0.1%.

“Injections” result in substantial blood exposure, which is in contact with a healer’s bare skin. The exposure is primarily on the hands and arms. But, as people touch their faces 23 times per hour, exposure to the mucous membranes (mouth, nose and eyes) is possible.

We partnered with the Kukula Traditional Healers Association in Mpumalanga to understand the risks of occupational acquisition of HIV in rural South Africa. From December 2017 to May 2018, we randomly selected 229 traditional healers to complete a survey assessing HIV risk behaviours (sexual activity, receiving a tattoo with an unclean needle, and occupational exposure during traditional treatments) and complete HIV testing.

We found that healers have an HIV prevalence of 30% compared to 19% in the general population. HIV prevalence is 28.3% in men who have sex with men and 58.6% among female sex workers. Our findings suggest that traditional healers are also a high-risk population for HIV acquisition. Specifically, healers who reported exposure to patient blood have an 2.4-fold higher risk of being HIV-positive than those with no exposure, after other exposure risks (gender, age, number of sexual partners) are taken into consideration.

We found that the use of personal protective equipment among traditional healers is acceptable and most healers understand that blood exposure can result in infectious disease transmission. Despite positive attitudes, consistent glove use remains low due to financial constraints, glove availability, and distance to clinics and pharmacies (where they can be acquired). Of those we studied, only 10% of healers were willing to pay for their own gloves to ensure that they were protected.

These healers were motivated by four things:

• a belief that personal protective equipment is effective,
• a trust of, and feeling of partnership with, the allopathic health system,
• a fear of contracting disease, and
• a belief that they are responsible for their own health.

Recommendations

The emergence of COVID-19 will likely lead to increased glove and mask use among traditional healers, at least in the short term. Healers are becoming more educated and concerned about disease transmission – whether it be HIV or COVID-19. Personal protective equipment is slowly becoming more accessible (now being sold at local shops, instead of only large pharmacies) and socially acceptable in nonclinical situations. While we expect to see some improvements, proper use will likely remain a barrier to protection.

In the long term, we propose two strategies.

The first is engaging traditional healers who use personal protective equipment consistently to train those who do not. We believe these healers can be respected role models who can appreciate the challenges of protective equipment use among traditional healers and provide effective training and strategies to put on, take off, and dispose of it safely.

Secondly, improving access to personal protective equipment among healers and their patients. Healers either acquire protective equipment from select health facilities (for free) or purchase them from pharmacies. While free personal protective equipment is preferable (to the healer), many clinics do not provide this service and travel times to those that do can hinder uptake.

Purchasing personal protective equipment is made difficult by the sale of gloves and masks in bulk at large pharmacies, and the limited availability of some of these items because of COVID-19. Access to readily available personal protective equipment is essential to protecting traditional healers.

Carolyn Audet, Assistant Professor in the Department of Health Policy at the Vanderbilt Institute for Global Health , Vanderbilt University; Mosa Moshabela, Deputy Vice-Chancellor of Research and Innovation (Acting), University of KwaZulu-Natal, and Ryan G Wagner, Research Fellow, Wits School of Public Health, University of the Witwatersrand

This article is republished from The Conversation under a Creative Commons license. Read the original article.