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Thirty first of every August is ‘African Traditional Medicine Day’ but how many know about it?

Over a span of about 150 years three members of my family have practiced medicine. My grandfather, my brother and I have all at one time or another provided medical care to the needy, all of us receiving acknowledgements from our patients and society. However, that is about where the similarities cease, for with the coming of the colonial power to our lands my grandfather’s practice became severely restricted and despised. Generally, he practiced in secrecy from then on. On the other hand, in the case of my brother and I who were trained in ‘scientific medicine’ by the colonials, our practices were legitimised by stints in the ‘motherland’ as well as being registered by professional regulatory authorities.

 African traditional medicine

In all countries of the world there exists traditional knowledge related to the health of humans and animals. The World Health Organization (WHO) defines traditional medicine as “the sum total of all the knowledge, skills and practice, based on the theories, beliefs, and experiences indigenous to different cultures,whether explicable or not, used in the maintenance of health as well as in the diagnosis, prevention and elimination of physical, mental or social imbalance and relying exclusively on practical experience and observation handed down from generation to generation, whether verbally or in writing”[i].

This definition applies to all traditional systems of medicine whether in Europe, India, China or Africa. Yet whereas European missionaries and colonial administrators left alone, sometimes even encouraged, traditional medicine in India and China, they almost violently discouraged African traditional medicine. In particular, the intricate relationship between African medicine and African religion[ii] made traditional medical practices key targets of attack by early European Christian missionaries, who considered many African traditional religious rites and rituals to be against Christian teachings and morals. Traditional healers were regarded as heathens because of their participation in African Traditional Religion.

The medicine my brother and I practice derives from the germ theory of disease (see below) while my grandfather’s traditional African medicine is based on concepts that are much broader and holistic. In traditional African societies it is believed that good health, disease, success or misfortune are not chance occurrences but arise from the actions of individuals and ancestral spirits according to the balance or imbalance between the individual and the social environment. African traditional understanding was that sickness was a kind of punishment by the spirits of the ancestors to those who do not observe the rules of good social behaviour, from whom the ancestors withdraw their protection leaving them exposed to the whims of evil spirits who cause physical and mental dysfunctions. Traditional healers use plants in a variety of ways, depending on the illness to be cured. Parts of plants can be applied directly to wounds and cuts or, if necessary, prepared as powders, infusions, or even used in the form of smoke or fumes. African herbal medicine is often associated with magic[iii], for example the prescription of amulets and charms as prevention or treatment of diseases.

Today, many Africans including some self proclaimed Christians, and especially politicians, consult a traditional healers for advice on various issues, including health-problems. The African traditional ‘doctors’ have skills in both herbal remedies as well as in spiritual healing, the latter involving various traditional religious rites and rituals. In this regard, African medical practice is holistic- it takes into account all of patient’s physical, mental, and social conditions in the treatment of illness.

The Germ Theory of disease

The Germ Theory of disease is the foundation of modern (western) medicine and was an important basis for innovations such as antibiotics and hygienic practices. Germ theory was validated in the late 19th century, thanks to the works of Louis Pasteur (1822-1895) and Robert Koch (1843-1910). It proposes that microorganisms are the cause of many diseases. Hence management of the disease is focused on establishing which microorganisms are responsible and applying specific drugs (antibiotic) for their elimination. Modern medicine is also referred to as Allopathy, which is defined as the treatment of a disease by using remedies whose effects differ from those produced by that disease. This is the principle of mainstream medical practice, as opposed to that of homeopathy– a complementary disease-treatment system in which a patient is given minute doses of natural substances that in larger doses would produce symptoms of the disease itself.

There is no doubt that introduction of antibiotics (e.g. Penicillin), revolutionised medicine and remains one of the most important milestones in the history of medicine. However, as observed by some critics, the concentration in modern medicine on fighting germs using antibiotics has tended to ignore the “soil upon which the bacteria flourish[iv]” In other words modern medicine tends to focus on the disease not the whole person, as is the case in traditional systems of medicine. “Modern medicine seems too grounded in the study of disease [pathology] and in its eradication and not enough in studying health and how to create and sustain it”. This in fact, is where the great divide exists between modern medicine and African traditional medicine.

 

Preparing and drying out freshly picked mutis

Bridging the divide- Integration of traditional medicine in national health systems

The World Health Organization estimates that 80% of the populations of Asia, Africa and Latin America use traditional medicine to meet their primary health care needs. For many people in these countries, particularly those living in rural areas, this is the only available, accessible and affordable source of health care. In scenarios such as these African governments should have no option but to ensure there is collaboration between conventional and traditional health practitioners. To this end, Ministries of Health need to set up mechanisms for the regulation and integration of traditional medical practice in national health systems.

The 50th Session of the WHO Regional Committee for Africa which took place in Ouagadougou, Burkina Faso, 28 August to 2 September 2000 recognized the importance and potential of traditional medicine for the achievement of health for all, and set 31st August of every year as African Traditional Medicine Day[i], [ii]. The Regional Committee adopted a regional strategy for the promotion of the role of Traditional Medicine in national health systems, including establishing structures, programmes and offices in Ministries of Health to institutionalize traditional medicine. Currently 39 countries (including Kenya) have set up such offices, and a few training institutions have established departments of Herbal Medicine[iii]. Other examples of collaboration between traditional medical practitioners and modern medical practitioners are to be found in Uganda and South Africa. In Uganda the Traditional and Modern Health Practitioners against HIV /AIDS (THETA[iv] ) have demonstrated the positive impact traditional medical practitioners can make on health care delivery. In South Africa research conducted by AMREF shows that traditional practitioners can play important roles in integrated HIV/AIDS/STI/tuberculosis programs[v].

Conclusion:

As we look forward to this year’s African Traditional Medicine Day it cannot be lost on us that the ongoing WHO-led collaboration appears to focus solely on herbal medicine, yet traditional African medicine is a broader concept than that, incorporating (beside use of herbs) divination and healing of physical, emotional and spiritual illnesses. In any case, a large proportion of herbalists also engage in divining causes of illness and providing various solutions to spiritually or socially-centered complaints, in addition to use of plant and animal products. To this extent herbal medicine and spiritual healing act as mutually reinforcing systems of African traditional medicine. Accommodating the holistic approach in the proposed integrated health systems remains a critical challenge for all involved including WHO.

[i] http://www.afro.who.int/en/fiftieth-session.html

[ii] African Traditional Medicine Day, 31 August, Special issue, African Health Monitor, World Health Organization Regional Office for Africa).2010

[iii] The Kwame Nkrumah University of Science and Technology in Kumasi, Ghana, established a Bachelor of Science Degree in Herbal Medicine in 2001 to train Medical Herbalists.

[iv] Initiated in 1992 through a partnership between The AID S Support

Organization (TA SO) Uganda Ltd and Medicines Sans Frontières (Doctors without Borders), an international humanitarian organization.

[v] Melusi Ndhlalambi:Strengthening the Capacity of Traditional Health Practitioners to Respond to HIV/AIDS and TB in Kwa Zulu Natal, South Africa AMREF Case Studies 2009.

 

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How Kenya’s New Constitution is likely to impact on access to safe abortion services

Background:

The aim of this presentation is to contribute to the understanding of the provisions in the New Constitution as they relate to access to safe abortion services in Kenya, and to analyse areas of particular concern in the implementation of the Constitution. In order for Kenya to achieve Millennium Development Goal 5 on Improving Maternal Health, it is imperative that the issue of unsafe abortions is addressed, since this is a major contributor to the high maternal mortality rates in the country. In addition, complications resulting from unsafe abortion contribute to serious sequelae for women’s reproductive health such as chronic pelvic inflammatory disease (PID) and infertility.

 

The incidence of unsafe abortion generally reflects the magnitude of unwanted pregnancies in a particular community. Hence, the only sure way of effectively minimizing unsafe abortion is to ensure women have easy access to contraceptive information and services, backed up by positive legislation that decriminalizes abortion. According to UN data[ii], in most so-called developing countries like Kenya, there was a trend towards enactment of more restrictive abortion laws in the period between 1999 and 2007 (Figure 1). Whereas in nearly all countries abortion is permitted to save a mother’s life, only 60 percent and 57 percent respectively of the countries permit abortion to preserve a mother’s physical and mental health. Rape or incest, and fetal abnormalities are respectively considered in 37 percent and 32 percent of the countries; and in only 19 percent are economic or social considerations entertained. Abortion is available on demand in some 15 percent of developing countries.

 

Figure 1: Grounds on which abortion is permitted – percentage of countries

Source: (World Abortion Policies 2007 )

Constitutional provisions that are relevant to abortion services in Kenya

The new Constitution of Kenya, while maintaining the longstanding restrictive stance towards abortion[i], it nevertheless, does provide opportunities for enhancing the reproductive health and rights of Kenyan women, which if adequately implemented can significantly contribute to the reduction of the high maternal mortality rates prevailing in Kenya today, and the achievement of MDG 5. In particular, the Constitution of Kenya:

  • Is committed to nurture and protect the well-being of the individual, the family, communities and the nation[ii].
  • Guarantees reproductive health care as a right for all Kenyans[iii]
  • Commits the government to implement international conventions, and regional commitments that Kenya has pledged to support such as CEDAW[iv] and the Maputo[v] Plan of Action[vi],
  • Guarantees that every person has inherent dignity and the right to have that dignity respected and protected[vii], and
  • Guarantees equality and freedom from discrimination for every Kenyan[viii]

 

The Constitution of Kenya is explicit in the chapter on Bill of Rights regarding circumstances when abortion may be legal. Article 26 (4) states: Abortion is not permitted unless, in the opinion of a trained health professional, there is need for emergency treatment, or the life or health of the mother is in danger, or if permitted by any other written law. In other words, abortion can be permissible if in the opinion of a trained health professional there is need for emergency treatment (as in cases of severe pre-eclampsia and eclampsia), or the life or health of the mother is in danger (as in the case of severe cardiac disease, or complicated diabetes mellitus that is not adequately responding to treatment).

 

To a certain degree Article 26 (4) has widened access to safe abortion in Kenya through the inclusion of danger to ‘health’ as a ground for abortion in addition to danger to ‘life’, of the mother previously provided in Section 240 of the Penal Code[ix]. As it stands today, the Code of Professional Conduct and Discipline published by the Medical Practitioners and Dentists Board mentions, in addition, the health of the baby: “There is room, however, for carrying out termination when in the opinion of the attending doctors it is necessary in the interest of the health of the mother or baby”.

 

Restrictive medical practices

The Code of Professional Conduct and Discipline (see above) goes on to provide guidance on how medical practitioners should proceed in cases where there is ground for termination of pregnancy (TOP): “In these circumstances, it is strongly advised that the practitioner consults with at least two senior and experienced colleagues, obtains their opinion in writing and performs the operation openly in hospital if he considers himself competent to do so in the absence of a Gynecologist”. This guideline can present a serious access barrier, for example for the solitary medical worker in rural areas, where a second opinion may be a considerable distance away. Similarly restricting performance of abortion procedures to hospitals is not only restrictive but may also be unnecessary, considering that modern techniques for TOP can safely be carried out on an outpatient basis.

 

In addition, quite often in order to establish the risk to the life of the woman, a psychiatric assessment is required. This is not only discriminative to those living far from urban centres where psychiatrists are to be found. In addition, it is a process that gives the woman a label of psychiatric illness, besides being expensive, time consuming, and in many respects completely unnecessary. It is an invasion of the inherent dignity of the woman (see above). In many respects these practices serves to discourage rather than facilitate access to safe abortion services.

 

Provision of Safe abortion services[x]

The World Health Organization defines ‘unsafe abortion’ as “a procedure for terminating an unwanted pregnancy either by persons lacking the necessary skills or in an environment lacking the minimal medical standards, or both”[xi]. ‘Safe abortion’ services, on the other hand, imply the services are provided by well-trained health personnel and supported by policies, regulations and a health systems infrastructure, including equipment and supplies.

 

Almost all the deaths and complications from unsafe abortion are preventable through application of safe abortion practices. Termination of pregnancy (TOP) is a safe medical procedure when performed by trained health care providers using proper equipment, correct technique and ensuring infection prevention standards.

 

Regrettably, in many circumstances where women are legally entitled to have an abortion, safe services are not available to them due to a range of reasons, which include the following:

  • Provider associated problems and biases: a lack of trained providers (recruitment constraints; poor deployment and distribution); negative provider attitudes; stigmatization and other sanctions; conscientious objection among health workers.
  • Medical policies and practices: insistence on hospitalization; insistence on use of unnecessary or outdated techniques including use of general anaesthesia; opposition to task-shifting, and other regulatory bottlenecks.
  • Lack of knowledge of the law or lack of application of the law by providers; lack of public information about the law and women’s rights under the law.
  • Lack of awareness about facilities providing abortion or the need to obtain abortion services early in pregnancy.
  • Lack of awareness among health workers of their ethical and legal obligations to respect women’s rights, and to provide women in need with adequate information on where and how safe abortion services can be obtained.

 

Prevention of unsafe abortion and its complications

The Africa Union’s Maputo Plan of Action for the Operationalisation of the Continental Policy Framework for Sexual and Reproductive Health and Rights (2007-2010) aimed to reduce the incidence of unsafe abortion, through the following strategies:

  • Enacting policies and legal frameworks to reduce incidence of unsafe abortion;
  • Preparing and implementing national plans of action to reduce incidence of unwanted pregnancies and unsafe abortion;
  • Training service providers in the provision of comprehensive safe abortion care services where national law allows;
  • Providing safe abortion services to the fullest extent of the law;
  • Educating communities on available safe abortion services as allowed by national laws;
  • Training health providers in prevention and management of unsafe abortion

 

On the whole, there is consensus that to effectively reduce the incidence of unsafe abortion women must have easy access to contraceptive information and services, backed up by positive legislation that decriminalizes abortion. Table 1 shows a suggested three-tier scheme for the prevention of unsafe abortion and the related morbidity and mortality.

 

Table 1: A three-tier scheme for the prevention of abortion related morbidity and mortality[xii]

Conclusion 

 

This review has shown that the new Constitution of Kenya, despite the restrictive stance on abortion, does at the same time provide opportunities for enhancing the reproductive health and rights of Kenyan women. Hence, to be effective in the provision of safe abortion services, it is imperative that health care providers do familiarise themselves with these provisions in the Constitution. This will avoid the introduction or continuation of unwarranted access barriers to what should be legally availed to women in need.

Unsafe abortion remains an important contributor to the unacceptably high levels of maternal morbidity and mortality that prevail in Kenya; it is a key challenge to the achievement of MDG 5, as well as attaining the health targets set out in Kenya’s Vision 2030. In addressing the issue of unsafe abortion particular focus should be on ensuring equity in access to health care, especially for the poor and marginalised communities. Despite the paucity of supportive data, it is highly possible that considerably more induced abortions occur among the wealthier and more mature women than among the poor young single women that are often reported from public institutions. However, it is the latter that protract Kenya’s high maternal mortality rates, and who create the stiffest challenge to the attainment of national and international goals, if they are left ‘out of the loop’. In any case, the Constitution guarantees equality and freedom from discrimination for everyone.

 

Related Links


[i] Japheth Mati, New abortion law is still bad for women. STAR Thursday 29 April 2010

[ii] Preamble to the Constitution of Kenya

[iii] Article 43 (1) (a) Every person has the right to the highest attainable standard of health, which includes the right to health care services, including reproductive health care

[iv] CEDAW, the Convention on the Elimination of All Forms of Discrimination against Women, is an international agreement that affirms principles of fundamental human rights and equality for women around the world. It was adopted by the UN General Assembly in 1979 through Resolution 34/180.

[v] Maputo Plan of Action for the Operationalisation of the Continental Policy Framework for Sexual and Reproductive Health and Rights 2007-2010

[vi] Art. 2 (6) Any treaty or convention ratified by Kenya shall form part of the law of Kenya

[vii] Article 28 Every person has inherent dignity and the right to have that dignity respected and protected

[viii] Article 27 on Equality and freedom from discrimination

[ix] “A person is not criminally responsible for performing in good faith and with reasonable care and skill a surgical operation upon an unborn child for the preservation of the mother’s life if the performance of the operation is reasonable having regard to the patient’s state at the time, and to all the circumstances of the case” Section 240 of the Penal Code, Laws of Kenya.

[x] World Health Organisation. (2003) Safe Abortion: Technical and Policy Guidance for Health Systems. Geneva, World Health Organisation

[xi] World Health Organization. (1992) The prevention and management of unsafe abortion. Report of a Technical Working Group. Geneva, World Health Organization. (WHO/MSM/92.5)

[xii] Source: Mati JKG J. Adolescent reproductive health in the era of HIV/AIDS: Challenges and Opportunities. Obstet. Gynecol. East Cent. Afr. (2005); 18: 1-18


What if the HIV epidemic first manifested in poor countries?

By Japheth Mati

The first WHO report on neglected tropical diseases[i] highlights the importance of a class of diseases which though medically diverse, are grouped together because all are strongly associated with poverty, all flourish in impoverished environments and all thrive best in tropical areas, where they tend to coexist. Most are ancient diseases that have plagued humanity for centuries. These diseases remain largely silent, as the people affected or at risk have little political voice. As a result, they have traditionally ranked low on national and international health agendas, allowing them to continue causing massive but hidden and silent suffering, and frequently kill, though not to the same extent as in the case of HIV and AIDS, tuberculosis or malaria.

The response to the continuing presence of the neglected tropical diseases (NTDs) in most countries in the Tropics stands in sharp contrast to the unparalleled achievement in addressing the HIV epidemic. The first case of AIDS was diagnosed in 1981. Two years later, in 1983 the HIV virus was identified, and in 1985 the FDA approved the first HIV antibody test, making it possible to diagnose the disease more precisely and to screen individuals (and blood) for the infection. In 1987 the FDA approved the first antiretroviral drug AZT (ziduvidine). Thus, despite remaining a serious global challenge, HIV had changed within a period of less than a decade from being essentially a fatal condition to become a chronic illness, thanks to the unprecedented global cooperation and commitment of massive resources for HIV research and development (R&D) activities.

Source:Working to overcome the global impact of neglected tropical diseases, First WHO report on neglected tropical diseases, 2010

Funding for Research & Development (R&D): HIV and AIDS versus NTDs

From the 1990s until 2009, funding for the HIV epidemic increased substantially[ii]. In 2008, an estimated $15.6 billion was spent on HIV and AIDS compared to $300 million in 1996. These funds mainly derived from donations from national governments, multilateral funding organisations, and private funding. In 2009 the United States of America was the largest donor in the world, accounting for more than half of disbursements to HIV R&D by governments. DFID is the world’s second biggest bilateral donor for HIV/AIDS.

On the other hand, R&D of drugs for NTDs has been very significantly under-funded. The first comprehensive survey of global spending on R&D for neglected diseases[iii], showed that in 2007, nearly 80% of the global investment into R&D of new medical products[iv] was consumed by three diseases- HIV/AIDS, TB, and malaria. Many NTDs, responsible for killing millions of people in developing countries, shared the remaining 20%; each received less than 5% of global funding. These diseases include Filariasis, Schistosomiasis, Onchocerciasis, Sleeping sickness, Leishmaniasis (kalar-azar), Chagas disease, Guinea-worm, Dengue, diarrhoeal illnesses, worm infestations, Pneumonia, Meningitis, Leprosy, Buruli ulcer, Trachoma, Rheumatic fever, Typhoid and Paratyphoid fever, and Rabies.

What is peculiar about the HIV epidemic?

AIDS as a disease entity was first reported in 1981 among homosexual men in the United States, and for some time the disease was considered peculiar to homosexuals, being variously labeled “the gay cancer”, “the gay plague” and “the gay-related immunodeficiency disease [GRID]”). These first cases involved highly educated men, many from the upper echelons of the American society. They soon realized their plight and, through a strong well organized lobby movement, fought hard for public attention and support of the search for ‘cure’. No wonder, within less than a decade, several drugs had already received FDA approval. Since then, HIV disease has engulfed the world, and the majority of the cases now live in developing countries. Nevertheless, it is possible that the conscience and momentum built up in those early years continue to play a significant role in sustaining international support for HIV activities.

What is peculiar about the neglected tropical diseases?

The nature of NTDs differs in several respects from HIV[v]. Generally, although these diseases affect the poor and marginalized populations living in rural and urban areas, they are almost exclusively limited to the tropics. These are people that cannot readily influence government decisions that affect their health, and often seem to have no constituency that speaks on their behalf. Also, unlike HIV, most NTDs generally do not spread widely, since their distribution is restricted by climate and its effect on the distribution of vectors and reservoir hosts; in most cases, there appears to be a low risk of transmission beyond the tropics. Consequently, not much is spoken about the impacts of the NTDs, nationally or internationally.

The neglected tropical diseases, also dubbed the ‘ancient companions of poverty’, have an enormous impact on individuals, families and communities in developing countries in terms of disease burden, quality of life, and loss of productivity aggravating poverty, as well as the high cost of long-term care. They constitute a serious obstacle to socioeconomic development and quality of life at all levels. WHO estimates that these diseases blight the lives of 1 billion people worldwide and threaten the health of millions more[vi]; they are a serious obstacle to the achievement of health-related Millennium Development Goals.

These diseases can, at relatively low cost, be controlled, prevented and possibly eliminated using effective and feasible solutions, such as the five strategic interventions recommended by WHO[vii].

What if the HIV epidemic first manifested in poor countries?

The answer to this philosophical question may never be known. However, going by the example of the dilatory international response to NTDs to date, it is worrying to imagine what the status of the HIV epidemic would be if it first manifested in poor countries.

[i] World Health Organization (2010) First WHO report on neglected tropical diseases 2010: working to overcome the global impact of neglected tropical diseases WHO, Geneva 

[iv] Total investment was about $US 2.5 billion.

[v] World Health Organization (2010) First WHO report on neglected tropical diseases 2010: working to overcome the global impact of neglected tropical diseases WHO, Geneva

[vi] World Health Organization (2010) First WHO report on neglected tropical diseases 2010: working to overcome the global impact of neglected tropical diseases WHO, Geneva

[vii] These are: preventive chemotherapy; intensified case management; vector control; the provision of safe water, sanitation and hygiene; and veterinary public health.

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