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Volume 11, No. 3—April 2001  
Table of contents for this issue  

It Takes A Village Healer
Anthropologists believe traditional medicine can remedy Africa's aids crisis.
Are They Right?
by Matthew Steinglass

ON A HOT SUNDAY EVENING, IN A MANIOC field near the village of Gboto in the small West African nation of Togo, a group of men in city clothes rustle through the brush, periodically stopping to look at bits of uncovered root. At the center of the group stands a stout, gray-haired man in an embroidered African shirt, giving directions. He doesn't seem to be finding what he's looking for. He stops to finger a bush with wide leaves.

"This is called ahonto," he says. "It's good for renal problems." But it isn't the plant he needs.

A few dozen yards further on, he pushes into a thicket and motions toward one of his companions, a muscular field hand carrying a machete. The field hand thrusts his machete into the ground, digs until he encounters a root, and then begins to slice away at it. It takes a few minutes of brisk whacking before he comes up with a length of smooth, tan tuber. The man in the embroidered shirt holds it up, examines it, and nods.

"This is hetsi," he says with satisfaction.

The man in the embroidered shirt is Dr. Kokou Coco Toudji-Bandje, an African healer who concocts herbal remedies for a variety of ailments. One of these remedies is something he calls Tobacoak's. He believes it is a "natural antiretroviral." More specifically, he says Tobacoak's "destroys HIV in the blood." Over the past ten years, Toudji-Bandje has used Tobacoak's to treat over three thousand AIDS patients. Most of them, he says, have gotten better—and some have been completely cured.

Toudji-Bandje is not the only herbal healer in Africa who claims the ability to cure AIDS, but he is one of the best known. Patients fly from as far away as Congo to see him. He has a large air- conditioned villa-cum-office in Togo's capital city, Lomé. He has a Mercedes and a white Toyota van. According to a few other doctors who have looked into his finances, he has tremendous amounts of money. The one thing Toudji-Bandje does not actually have is an M.D., but he doesn't seem to miss it much.

Most members of the Western intellectual community consider people like Toudji-Bandje part of Africa's AIDS problem, not its solution. The dimensions of that problem are by now depressingly familiar: HIV-positive rates in southern Africa run to 20 percent and higher. More than twenty-five million sub-Saharan Africans are already infected, and hundreds of millions more are at risk. No one knows what will happen to the social fabric in these countries when cumulative death rates climb into double digits. Under the circumstances, you might think that anyone who would distract attention from HIV education and prevention efforts by claiming to have cured the disease with an herbal concoction is not the kind of guy international organizations should be working with.

If so, you would have been surprised to see Toudji-Bandje at last December's crucial meeting of the Africa Development Forum, in Addis Ababa, where a continent-wide AIDS strategy was under development. Toudji-Bandje came with the official Togolese delegation, and the World Health Organization paid his way. He was representing a constituency that the WHO believes should be an integral part of the campaign against AIDS in Africa: traditional healers.

The WHO's support for collaboration between traditional healers and Western-style public-health systems in Africa actually dates back well before the AIDS epidemic. Public-health experts have advocated such collaboration since the 1970s, drawing on arguments that range from the practical (the crippling lack of M.D.s and trained nurses in the developing world) to the ideological (a refusal to privilege Western biomedical science over alternative systems of medical belief). And some of the most enthusiastic advocates of collaboration with traditional healers have been those Western academics whose job it is to study them: medical anthropologists.

MEDICAL anthropology's slice of the academic pie consists in studying different cultures' beliefs and practices relating to health and disease. A typical medical anthropologist might spend his time sitting in the homes of Bono healers in north-central Ghana, looking into how they deal with diarrhea: what diseases they associate with the symptom (ayamtuo, asonkyere), what they think causes the diseases (unclean substances, contagion), how they treat the diseases (herbal solutions, enemas), and how their disease typologies match up with those of Western medicine (malaria, food poisoning). An anthropologist studying the Manica of Mozambique would find a completely different conception of diarrhea than that of the Bono: The disease might be attributed to a disturbance of a child's "internal snake," to exposure to heat, or to a father touching his still-breastfeeding child after committing adultery and then failing to wash his hands. With its multitude of ethnic groups, who speak more than eight hundred different languages and construct who knows how many startlingly innovative theories of diarrhea, Africa provides medical anthropologists a never-ending supply of thesis fodder.

Back in the 1960s and early 1970s, some medical anthropologists claimed that African traditional healers were a vanishing breed in need of protection from the onslaught of modernity. Today, anyone who talked that way would be laughed out of the lecture hall. Modernity doesn't seem to be doing too well in Africa. Traditional healers, on the other hand, are going strong. There are quite possibly more than two million healers in Africa, and an estimated 80 percent of sub-Saharan Africans consult them. In some countries, these healers outnumber Western-style medical professionals by around forty to one.

If you go into an average village in Togo looking for biomedical health care, you're likely to find an almost empty dispensary, staffed perhaps one or two days a week by a poorly trained community health worker. The same village might have three or four traditional healers within easy walking distance, each ensconced in an attractive compound with flags flying from the roof. And while the community health worker often has a social standing equivalent to that of a cashier at Dairy Queen, traditional healers are generally among the most powerful and respected members of village society.

MEDICAL anthropologists typically divide healers into two main categories: herbalists and diviner-mediums. The healers' work ranges from administering herbal treatments to eradicating spirit possession to dream interpretation. When it comes to answering the obvious questions—Do the diseases diagnosed by traditional healers actually exist? Do the healers' practices help sick patients?—medical anthropologists are supposed to remain strictly nonjudgmental. And yet, they are typically Westerners, who share a basically biomedical understanding of disease etiology. Medical anthropologists handle this clash of worldviews the same way any of us handle conversations with people whose outlooks differ radically from our own: They finesse the issues. They try not to bring them up. They concentrate on areas of agreement.

The problem is that medical anthropologists' particular area of concentration happens to be one in which certain questions can't be finessed. When children are dying of diarrhea-induced dehydration, and you, as a Westerner, think you know how to save them, you can't sit back and watch a traditional healer apply a treatment you believe to be ineffective. You want to do something.

Starting in the late 1970s, some medical anthropologists began doing more than studying traditional healers—they started working with them. Some saw training traditional healers in Western-style biomedicine as a potential solution to Africa's drastic shortfall of trained health-care personnel. Others thought traditional healers might know things—about medicinal herbs, or about how to deliver care in a spiritually wholesome fashion—that Western doctors didn't. Twenty years later, these same medical anthropologists are spearheading the drive to include traditional healers in AIDS prevention and care. One of the first was Edward C. Green, an independent anthropologist whose 1994 book, AIDS and STDs in Africa: Bridging the Gap Between Traditional Healing and Modern Medicine, made the clearest case yet for bringing healers on board in the fight against AIDS.

Green's book drew on his experience in South Africa, where he had established a program that trained traditional healers as educators for AIDS prevention. Such programs, Green was convinced, could be crucial to stopping the spread of HIV. In fact, he wrote in his book, any successful effort to fight AIDS in Africa would have to include "some sort of collaborative action program involving traditional healers."

Traditional healers pervade African societies, Green stressed; instead of ignoring them, doctors and health educators should view them as an untapped resource. His research showed that while Africans rely on doctors and hospitals to treat many illnesses, most believe that traditional healers are better than doctors at curing sexually transmitted diseases. At least part of the reason is that unlike doctors, healers tend to take a "holistic" approach, treating the patient's spiritual and physical well-being together. With a terminal disease like AIDS, the spiritual side becomes very important. In any event, Green reasoned, patients consult traditional healers whether or not the healers have been educated in AIDS prevention. Untrained healers might spread inaccurate information or engage in harmful practices. Moreover, Green asserted, traditional healers are eager to learn about Western medical ideas, and they put what they learn to good use.

Green's controversial ideas largely stemmed from a single core belief: African societies are not a tabula rasa onto which Western biomedicine can simply be imposed. Traditional healers embody the indigenous African medical culture, which cannot be ignored. As Green would later write, "It is Western medicine that is 'alternative' for most Africans."

THESE IDEAS were surprisingly new to the debate on AIDS in Africa, but they weren't new to Green. He had been dealing with them for most of his professional career—a career that neatly parallels the history of medical anthropology's efforts to bring traditional healers into the public-health mainstream.

The WHO first declared itself in favor of increased collaboration with traditional healers in 1977. That same year, Green, then an assistant professor of anthropology at West Virginia University, got an offer from Population Action International to go to West Africa to research population growth in the Sahel region. At some point during the trip, he had "a moment of epiphany," he says. "I was in Niger, I think, and somebody said, 'You know, we have a terrible malnutrition problem among pregnant women, and we have one good source of protein: chicken eggs. But there's a taboo against pregnant women eating eggs. Now, if we could just get an anthropologist in here to figure out a way around that taboo.'" Green laughs. "...I thought, gee whiz, you know, I could be applying what I know to life-and-death issues on a grand scale, instead of teaching anthropology to recalcitrant students who are fulfilling a social-science obligation."

Green never did get around to tackling the egg problem, but later in the same trip he had a second epiphany. At a cocktail party in Ghana, he ran into Michael Warren, a medical anthropologist from Iowa State. Warren was setting up one of the first serious programs to train traditional healers in Western health-care techniques. Called Primary Health Training for Indigenous Healers Programme (PRHETIH), Warren's project eventually trained hundreds of traditional healers in a few simple biomedical health-care precepts: diagnosing and treating diarrhea, malnutrition, febrile convulsions, and the like.

BY THE EARLY 1980s, Green had transformed himself into a medical anthropologist, trading in his recalcitrant college students for eager witch doctors. Having completed a study of traditional healers' responses to Swaziland's first cholera outbreak, he worked with the United States Agency for International Development (USAID) to make recommendations for integrating traditional healers into the Swazi public-health-care system. "We did a survey, and we found that something like 99 percent of the healers wanted to learn Western medical techniques," he says. "So I showed these results to the medical association of Swaziland, thinking all these doctors would be so happy that the traditional healers want to learn! And I finished my presentation, and the questions from the doctors were: Why aren't these guys in jail? They're practicing medicine without a license. Why isn't someone arresting them?"

Nevertheless, Green and a Swazi colleague, Dr. Lydia Makhubu, managed to set up some workshops. "The first healers came in disguise, dressed as civilians," he says. "By the second or third workshop, they were coming in full regalia, dressed in feathers and beads, and waving their...paraphernalia. Out of the closet, as it were."

Through the rest of the 1980s and into the 1990s, Green worked all over Africa on projects related to traditional medicine—in Nigeria, Liberia, South Africa, and Mozambique. With another USAID grant, Green set up a program in South Africa in 1992 to train thirty healers as trainers-of-trainers in HIV prevention. These healers would each be expected to train thirty other healers, and so on, hopefully reaching twenty-seven thousand healers by the third generation. The training sessions described the etiology of AIDS in terms culturally meaningful to traditional healers. White blood cells were described as healers' apprentices who guard the master healers, T-cells. During sex, the enemy, HIV, sneaks in and kills the master healers, takes their places, and tricks the apprentices into thinking they are still taking orders from their superiors. The enemy orders the apprentices to let in more and more HIV, until finally the enemy takes over the whole body.

When Green evaluated the traditional healers who had completed the program, he found that their knowledge about AIDS had significantly increased. They were willing to recommend and supply condoms to patients. They were eager to counsel patients against sexual promiscuity, which many healers already considered dangerous. And they understood that AIDS could be transmitted by sharing the same razor for ritual scarification, but not by sharing a spoon.

By this time, Green was far from the only one running such programs. In 1992, a medical anthropologist named Rachel King, working with Médecins Sans Fronti'res in Uganda, had started a program called Traditional and Modern Health Practitioners Together Against AIDS (THETA). The program initially trained just seventeen healers, but it did so intensively: fifteen months of training, three days a month. Before the program, according to King, healers were "reluctant to discuss AIDS with their clients, because they feared losing them." After the program, healers promoted and distributed condoms to their clients, counseled them on "positive living," and staged AIDS-education performances using music and theater. Evaluators compared the rate of condom use in areas where THETA had been active with the rate in non-THETA areas. It was 50 percent versus 17 percent.

EIGHT YEARS later, THETA is still going strong, and Uganda is an unparalleled AIDS success story. In 1993, Uganda had an overall HIV-positive rate that reached 14 percent, one of the highest in Africa at the time. As of 2000, Uganda had cut that rate to about 8 percent. It is the only country in the world ever to have fought double-digit HIV-positive rates back down into single digits.

Of course, many things had to go right for that to happen: Uganda's AIDS prevention programs were strong in every sector, involving religious leaders from every major community, including both Christians and Muslims. (In 1989 the mufti of Uganda officially declared a jihad on AIDS.) Community AIDS education proj ects honeycombed the country, working in every demographic group from market women to bicycle-taxi boys. Uganda had sub-Saharan Africa's first voluntary and anonymous HIV testing program and its first nationwide, multisectoral AIDS prevention coordinating body. Most important, the country's president made a firm political commitment to stopping AIDS. Still, Green feels that THETA served as an invaluable model for other programs in Uganda. "I'm not going to say it's the thing that stopped AIDS in Uganda—there is no one thing, there never is," he says. "But I think it was significant."

Throughout the 1990s, local and foreign governments, as well as NGOs, set up collaborative programs with traditional healers in Botswana, Malawi, Mozambique, Tanzania, and Zambia. Medical anthropology's efforts to integrate traditional healers into the fight against AIDS appeared to be succeeding. But there was one problem: None of these other countries had actually managed to stop the spread of HIV. Green's program in South Africa did not prevent infection rates there from zooming up toward the 20 percent mark, and they're still climbing. In Botswana the rate has been estimated as high as 36 percent.

WHAT HAPPENED? In 1999, one of the grand old men of African demographic research, John C. Caldwell, a professor emeritus at the Australian National University at Canberra, presided over a conference on resistance to sexual behavior change in the face of AIDS. In a paper he delivered at the conference, Caldwell put the problem this way:

There is a mystery at the heart of the African epidemic, which urgently needs explanation.... Much lower HIV seroprevalence levels and AIDS deaths have led elsewhere to marked changes in sexual behaviour and to an early decline in HIV incidence.... In northern Thailand the first evidence of the arrival of the AIDS epidemic led to brothels closing as clients' numbers dwindled, even before government interventions were put in place....

There is now some evidence of the beginning of sexual behaviour change in Uganda and of declining HIV incidence and prevalence. Research elsewhere in sub-Saharan Africa shows no such change. ... At first it was thought possible to explain this lack of change in terms of inadequate information.... Over time, this explanation has become ever less tenable. The Demographic and Health Survey program had shown that among men, 98 percent knew of AIDS in 1991-92 in Tanzania and 99 percent in 1998 in Kenya. For women, levels of knowledge were 93 percent in Tanzania in 1991-92 and 99 percent in Zambia in 1992 and in Kenya in 1998. The great majority knew of the dangers of sexual transmission.

So why didn't they do anything to protect themselves?

ZEIDAN HAMMAD is an internal- medicine specialist at CHU-Tokoin Hospital, the main public hospital in Lomé. The Lebanese-born Hammad was trained in Cuba, and as he walks me through the hospital's rather decrepit white-stucco facilities, he grumbles about the staff's idea of a sterile environment.

"They spread the clean linen out on the ground to dry," he says, waving at multicolored sheets draped across the bushes and dusty grass in the hospital courtyard. "They like that it dries faster that way. You know, in Cuba, there was no money for anything, but they kept things clean!"

The first stop on Hammad's tour is the HIV testing lab, and for this, at least, he has nothing but praise. The lab's two machines, for performing the ELISA and Western Blot tests for HIV, are in perfect, spotless condition, and the staff is efficient and professional. The tests, which cost about three dollars each, are administered in strict privacy, and results are made available to no one but the patient. The lab processes hundreds of results every month.

Next stop on the tour is Ward 4, the long-term-care ward. Only eight of the ward's beds are occupied. That, explains Dr. Hammad, is because the hospital does not treat AIDS patients.

"There's nothing we can do for them here," he says. "If they're rich, they go off to Europe. If they're poor, we send them home to die."

It's not entirely true that the hospital can do nothing. Hammad can treat the opportunistic infections that attack AIDS patients in the early stages of HIV infection, and if their immune systems have not deteriorated too badly, he can prolong their lives. And this is where Hammad's frustration with traditional healers manifests itself.

"I have people come to me with problems that suggest they may be HIV positive, and I tell them, go get tested and then come back," he says. "And then they disappear for six months. I go to the test lab and ask, what happened to this person? And they say, yes, we tested him. Then suddenly six months later the person shows up in my office again, practically on the point of death. And he says, 'Oh, I tested HIV positive, so I went to the traditional healer, but it didn't work. So I went to another healer, but it didn't work either.' So now they're back, and now I can't do anything for them. It's too late. Educated people! And they go to these healers! It's crazy!"

IF HAMMAD AND Green were to discuss the value of traditional healers in African health care, they would probably have a hard time keeping their voices down. But sixty years ago, doctors and anthropologists were more united in their frustration with traditional African medical culture. In fact, one of the foundational texts of medical anthropology is E.E. Evans-Pritchard's 1937 classic, Witchcraft, Oracles and Magic Among the Azande. The book is essentially a limit case of a culture with which Westerners cannot collaborate. When Habermas or Rorty wants an illustration of a worldview that rests on axioms so different from our own that communication between the two cultures is virtually impossible, they turn to Evans-Pritchard's Azande. According to Evans-Pritchard, the reason the Azande worldview is so inimical to the Western one is that it considers diseases, and other misfortunes, to be caused by sorcery. Whether or not Evans-Pritchard thought the Azande believed all diseases to be caused by sorcery has been an ongoing argument in anthropology for sixty years now. Another ongoing argument has been the question of whether Evans-Pritchard's observations about the Azande hold for the rest of Africa as well.

Until fairly recently, most anthropologists felt that they do. G.P. Murdock, whose Africa: Its Peoples and Their Culture History is a seminal ethnography of the continent, wrote in 1980 that mystical retribution and sorcery are the main African explanations for disease. George Foster, whose 1976 paper "Disease Etiologies in Non-Western Medical Systems" is another classic of the field, wrote in 1983 that "personalistic" explanations of disease—that is, you get sick because someone, human or demonic, wants you to get sick—predominate in Africa. Most other anthropologists and social scientists, both Western and African, agreed.

Some social-science researchers have blamed the persistence of personalistic theories of disease causation for the failure of Africans to alter their sexual behavior in the face of AIDS. These scholars have hypothesized that Africans' failure to use condoms or limit their number of sexual partners stems partly from the belief that you don't get AIDS unless an enemy wants you to get it. The idea that personalistic ideas about disease are reducing the ability of ordinary Africans to cope with AIDS is even more widespread among doctors like Hammad. Doctors and public-health officials, both Western and African, widely blame the failure of HIV prevention in Africa on local belief in witchcraft, sorcery, and gris-gris (black magic).

But they are working with a previous generation's understanding of African traditional medicine. In recent years, anthropologists have reassessed the importance of witchcraft to the African view of disease. In the 1970s, Michael Warren, the founder of the PRHETIH project, began arguing that the Bono of Ghana actually saw most diseases as impersonally caused—that is, caused by environmental factors, whether natural or supernatural, rather than by the malign will of another human being or a deity. Over the years more and more anthropologists have made similar findings with other African ethnic groups.

Anthropologists such as Harriet Ngubane, Mary Douglas, Michael Gelfand, and David Hammond-Tooke reported that ideas of contagion and pollution were actually widespread among many African societies. Some Africans believed that diseases were caused by tiny, invisible insects, or that illness was transmitted by contact with impure substances such as feces or menstrual blood. Shona healers in Zimbabwe practiced variolation, the rubbing of fluid from an infected person's pustule into a cut on a non-infected person, to stimulate an immune response. Practices in other ethnic groups might not have been so obviously biomedically effective, but the important thing was that they were based on impersonal theories of disease causation: You contracted a disease because you happened to come into contact with someone or something, not because a person or deity was using magic against you.

Green ascribes the overemphasis on witchcraft by earlier anthropologists in part to "xenophilia"—an attraction to the more exotic and flamboyant elements of African medical culture. (Witchcraft Among the Azande is a much sexier title than, say, Pollution Beliefs Among the Azande.) He also thinks many researchers were not thinking clearly about how to classify beliefs. For example, African survey respondents, asked to explain the causes of certain diseases, may reply, "It's the will of God." This has often been classified by researchers as a "supernatural" or personalistic response. But does it have to be? A Western oncologist might utter the same words when asked why a child contracts leukemia.

There are, undeniably, traditional healers who believe AIDS can be caused by witchcraft. In one oft-cited case in Zambia, a community's devastation by AIDS in the early 1990s led it to consult a "witch finder," who allegedly poisoned some fifteen suspected witches. In a Liberian survey, 13 percent of healers, local leaders, and health workers interviewed named witchcraft as a cause of STDs. But that put witchcraft well behind promiscuity, stepping in urine, or sex with an infected person.

The witchcraft question is important because it bears on the possibility of collaboration. If traditional healers believe that diseases are caused by witchcraft, there is not much you can do with them, from a biomedical perspective. They belong, as one doctor who worked in a district hospital in Africa for thirty-three years put it, to "a system that is irreconcilable with our own." But if traditional healers do not ascribe diseases to sorcery—even if they think illnesses are caused by tiny insects, by imbalances in semimystical forces of heat, by interference with the body's "internal snake," whatever—then you can work with that. You can describe the AIDS virus as a variety of the tiny invisible insects many indigenous medical traditions describe. You can build on many medical traditions' belief that promiscuous or adulterous sex results in pollution. You can collaborate.

More or less. Some medical anthropologists feel that even if traditional healers believe in naturalistic theories of disease causation, working with them is an iffy proposition.

In 1991, Peter Ventevogel, a Dutch medical student working on a master's thesis in medical anthropology, went to Ghana to follow up on Warren's famous PRHETIH project. The project had shut down in 1983, and Ventevogel wanted to find out what the healers had retained from their training. His findings, published in 1996 as Whiteman's Things: Training and Detraining Healers in Ghana, were interesting: On the one hand, the healers seemed to retain what they had learned in the workshops to a remarkable extent. On the other hand, they didn't actually seem to be putting that knowledge to use. They had learned that diarrhea could result in dehydration, and often remembered the formula for mixing oral rehydration salts, but almost none of them were actually doing it. They continued to treat diarrhea with herbal enemas, which biomedicine considers actively harmful. "PRHETIH was a powerful force attempting to change healers by training them," Ventevogel wrote. "But the healers formed an intractable counterforce, resisting training by 'detraining' themselves."

"The healers don't write their knowledge down and systematically compare it with each other," explains Ventevogel, now a psychiatrist in Amsterdam, in an interview. "The terms and beliefs differ in every village, in fact even in the same village. Their way of thinking is different from ours. I respect traditional healers, but you can't just mix Western scientific medicine and traditional healers up in a soup and expect to get something that makes any sense."

Unlike Ventevogel, Green thinks traditional medical beliefs are largely consistent within ethnic groups and even across them. But there is one of Ventevogel's critiques with which few people on the front lines would disagree. "Training traditional healers," Ventevogel writes, "is no panacea for a failing Western health care system." And in this belief, Ventevogel is joined by one of the more flamboyant medical anthropologists working on AIDS today: Dr. Paul Farmer.

PAUL FARMER runs a free clinic in a desperately poor region of rural Haiti. He also teaches at the Harvard Medical School and consults on numerous international infectious-disease projects, largely dealing with AIDS and tuberculosis. He made his mark in the AIDS field with a 1992 book called AIDS and Accusation, based on his experiences as an anthropologist in Haiti during the 1980s. One of the book's chief arguments was that the spread of AIDS in Haiti had been misattributed to "cultural factors"—particularly the belief in voodoo—when in fact it stemmed from socioeconomic causes: the country's vicious poverty, its lack of an adequate biomedical health-care system, and its exposure to a sex tourism trade that catered to Americans. Farmer did find that local interpretations of AIDS hinged on allegations of sorcery. But he didn't think that belief in sorcery was what was making the villages vulnerable. He thought they were vulnerable because they were poor.

Farmer doesn't think the spread of AIDS in Africa can be blamed on African traditional medical culture. The very notion, in Farmer's view, is merely a smokescreen behind which the rich West can evade responsibility for Africa's AIDS catastrophe. At the same time, he thinks that the newer emphasis on working with traditional healers has also served as an excuse for the West's failure to provide the world's poor with decent scientific medical care. We could stop AIDS in Africa, Farmer is saying—but we don't, because we don't want to spend the money.

This argument has become all the sharper recently, as generic antiretroviral drugs from Brazilian and Indian companies have pushed the cost of treatment ever lower. The recent offer by the Indian pharmaceutical company Cipla to supply Médecins Sans Fronti'res with an antiretroviral cocktail treatment for $350 per patient per year puts certified antiretrovirals into the same price class as the herbal remedy of Toudji-Bandje, whose six-month course of treatment costs $430. If Farmer is right—if the barriers to stopping AIDS in Africa are about money, not culture—then the cheaper the drugs get, the greater the pressure on the West will be to intervene.

GREEN spots a problem with Farmer's thesis. "The richest countries in Africa have the highest HIV rates," he says emphatically. "And the richest people in each country have the highest HIV rates." This may be an exaggeration, but there does seem to be some positive correlation between HIV rates and a nation's income. Botswana and South Africa are among the countries with the highest HIV- positive rates in southern Africa. The highest rate in West Africa is in Ivory Coast. These are the richest countries in their respective zones.

Early in the epidemic, some studies showed HIV rates rising with markers such as education level and travel. AIDS often seemed to hit the richer, more urban classes first. It struck the men who had the money to employ prostitutes. And, of course, their wives. As the epidemic wore on, these correlations became far less pronounced. After all, some of the poorest nations in sub-Saharan Africa—Zambia and Malawi, for example—also have extraordinarily high rates of infection. Still, most anthropologists agree that many rich, educated Africans continue to use traditional healers, though sometimes in conjunction with bio-medical doctors and often in secret.

Whatever his differences with other anthropologists, Farmer agrees that collaborating with healers can be worthwhile. "I bet I work with them as much as anybody," he remarks. But he doesn't see healers as the repositories of a culture's accumulated medical wisdom."When they're sick, they don't often go to each other," he says. "They come to see me."

In fact, Farmer doesn't just think traditional healers are ineffective. He thinks they're not really traditional: "It may have been different in Central America, Africa, and Asia in the past, but now you see that most 'traditional' healers use antibiotics, and a weird amalgam of modernity and the products of a globalizing economy."

MANY anthropologists have noticed that "traditional" healers in Africa are undergoing a strange process of mutation as the continent modernizes. Lots of them still wear traditional robes, carry staffs with ivory heads, and preside over smoke-filled huts surrounded by mud fetishes. But more and more of them are putting on lab coats, hanging certificates on the wall, selling their products in labeled bottles, or even administering injections. Green has documented the common practice of adding mashed-up ampicillin pills to "traditional" herbal medicines.

A perfect example of this sort of "weird amalgam" is Toudji-Bandje, the inventor of Tobacoak's. Toudji-Bandje, the secretary general of Togo's National Association of Traditional Healers, learned his herbal lore from his aged traditional-healer uncle. He also calls himself "Doctor." He has applied for a patent for Tobacoak's. He sends samples of his patients' blood to a laboratory in France to be tested for viral load. He has a catchy brand name for his product. And he calls it an "antiretroviral." Since when is "antiretroviral" a traditional African medical concept?

Toudji-Bandje's patients don't appear to care whether his theory of disease etiology is autochthonous, import, or creole. If anything, the mixture of North and South enables him to claim authority from both sources. What really matters to his patients is simply that someone is telling them he can cure their illness. And they believe the treatment works. "It completely eliminates my fever," says one patient, who declines to give his name. "When I take the medicine, I can eat. Whether it will cure me completely, I don't know. I haven't been taking it long enough."

"I tested positive in 1992," says a Mr. Kpodar, who claims to have been Toudji-Bandje's second AIDS patient. "I told my wife, and she tested positive too. I begged her to take Toudji-Bandje's medicine, but her family wouldn't let her. She died in 1993. The product saved my life." Toudji-Bandje claims that his remedy is effective in 86 percent of patients. But no third party has examined Toudji-Bandje's data, let alone conducted an independent study of his patients.

IN TOGO, AIDS is not yet completely out of control. But it's about to be. Togo's current rate of infection runs to 5.98 percent of adults aged fifteen to forty-nine, and a UNAIDS official confirms that HIV rates are rising. There have been active AIDS education and prevention programs in Togo since the late 1980s. But they don't seem to have had much effect.

"I've been trying to get traditional healers involved," says Bridget McHenry, a Peace Corps volunteer working in a village called Yometchin, in Togo's southern Maritime Region. "Some refuse. Some are psyched to do it. But most healers don't believe AIDS can't be cured. And they diagnose a lot of AIDS cases as the result of gris-gris."

Peace Corps volunteers in Togo are fairly pessimistic about the possibility of changing local sexual behavior, and they ascribe much of the blame to belief in gris-gris. But few of them know anything about gris-gris. They give the impression of being lost in a culture they don't understand—precisely the situation Green thinks should be avoided. And if you ask them whether they think it would have been useful to have some training in traditional medical ideas before going into villages as AIDS educators, most say no.

"It's different in every village," says Kim Williams, a volunteer in a Plateau Region village called Akpakpakpe. "You have to really listen closely to understand it at all, and they think you're an idiot."

"And they know you're not one of them," adds McHenry. "They know you don't believe it. You'll always be yovo"—a foreigner.

Williams nods in agreement.

Each Peace Corps volunteer is paired with a homologue, or counterpart, from a local Togolese NGO or governmental agency. At a recent meeting, the homologues made it clear they're not interested in collaborating with traditional healers either.

"The healers say they can cure AIDS," says one homologue. "But of course they can't. They deceive people."

"They deny the disease exists," says another. "They say it's an old African sickness traditionally known as dikanaku. It's 'get-thin-and-die' in Ewe."

Although the WHO and UNAIDS are both developing programs directed toward traditional healers in Togo, the country's medical establishment regards traditional practitioners with ambivalence. On the one hand, there are doctors, like Hammad, who blame traditional healers for preventing Togolese from coming to terms with AIDS. But Messanvi Gbeassor, a biologist at Lomé's Université du Bénin, has good relations with healers. "We even work with their national association," he says. Gbeassor also carried out some tests on Toudji-Bandje's product, with tantalizingly positive results.

As for the Togolese government, its PNLS—Programme National de Lutte contre le SIDA—claims to have an active program for collaboration with traditional healers. If you try to find out more about this program, you will be directed to the PNLS headquarters, a spacious villa in a sleepy residential section of town. The building appears to be devoid of activity, other than the whir of air conditioners and a couple of boys out front listening to the radio. On the first floor, in a bare, grimy office, a small old man will deflect your questions repeatedly, and then, rummaging through the room's single cabinet, will at last come up with a copy of a statement of program goals from 1992, which announces the intention to hold training sessions with traditional healers.

If there is one single reason for Togo's lamentable performance in stopping HIV, it is illustrated in the condition of the PNLS. Unlike Uganda, Togo's government has not made an overwhelming political commitment to the struggle against AIDS. The president, General Gnassingbe Eyadema, has paid lip service to the cause, but he has not committed sufficient resources to it or made it a top priority. "What's lacking here," says Moustapha Sidatt, the WHO's resident representative in Togo, "is political will." Sidatt has an ambitious plan to establish a nationwide association of traditional practitioners, which would inspect their practices to determine that they are not harmful, and would issue membership cards backed by the government and the WHO.

Sidatt would also like to start testing the products of traditional healers who claim to treat AIDS or its associated opportunistic infections. "We're trying to approach them, to gain their confidence," he says. "We have some laboratories here at the university, and virology laboratories abroad, which can test their products. There are many things we would like to do. But that requires a political decision from the government."

IF YOU DRIVE east on the highway from Lomé, toward Aneho and Ouidah, you will see little flags fluttering along the roadside in various colors. The flags are advertisements for traditional healers, and the different colors—white, green, black—symbolize the different practices available: herbal solutions, traditional vaccination (herbs inserted directly into cuts in the skin), sorcery, exorcism. Just a few miles outside of Lomé, you'll come upon the freshly painted clinic of Madame Léocadie Ashorgbor.

Ashorgbor provides herbal remedies. She learned them from her husband, from whom she is now estranged. She does not know where her husband trained, but some of the remedies are probably time-tested elements of Togolese culture. Still, her husband's recipes aren't all Ashorgbor relies on. "You have to have the gift," she says. "The gift comes from God." Ashorgbor doesn't heal through prayer, but the formulas for some of her herbal remedies come to her in revelations.

What would a medical anthropologist like Green make of Ashorgbor? Well, he would probably find her very interesting, but also a bit confusing. Can Western medicine collaborate with people like her to fight AIDS? If not, why not? "I don't claim working with traditional healers is easy," says Green. "I just think, looking at the public-health benefits, it's a good thing to do."

Ashorgbor agrees. "I think it's a good idea," she says of the WHO's initiative to organize Togo's traditional practitioners. "Depending on how it's done. You know, we traditional therapists are hard people to work with. We get all those herbs up in our heads, and we get a little bit crazy."

Matthew Steinglass is a writer based in Lomé, Togo. His article "Voices Carry: One More Paradigm Shift, and You'll Be Able to Tell Your Computer Everything" appeared in the July/August 2000 LF.

Also: For more information on the role of traditional healers in the African AIDS crisis don't miss Matt Steinglass' recent Feed Magazine article, "Shaman or Sham?"

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