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Emerging Infectious Diseases * Volume 2 * Number 4 * October-December 1996
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Commentary

Traditional Healers and Global Surveillance Strategies for Emerging
Diseases: Closing the Gap

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A recent position paper by the Centers for Disease Control and Prevention
(CDC) stresses that surveillance is critical to an effective defense
against new and reemerging infectious diseases and indicates that current
international monitoring of such diseases is fragmentary and inadequate
(1). Other major studies have also recorded the weaknesses in the present
disease reporting system (2-4).

The concept of "global surveillance" implies the coordination of existing
networks as well as the addition of state-of-the-art electronic networks to
ensure close monitoring of and rapid response to outbreaks, even in the
most remote locations (1,2,5-8). Plans for strengthening current
surveillance efforts include a global consortium with specialists in
epidemiology and infectious diseases working in close collaboration with
international agencies, ministries of health, universities, and research
laboratories (1,2,6,9-11). Existing programs at the World Health
Organization, CDC, the Pan American Health Organization, and elsewhere will
be reconfigured to work as a more cohesive system (1). Secure networks will
be developed for 1) the transmission of sensitive information; 2) automatic
reporting from physicians' offices, hospitals, and laboratories; and 3) the
integration of existing and planned information systems. The field
application of computer technology, satellite imagery that allows
geographically oriented information to be visually and analytically linked
to images of the environment, and the development of new statistical and
mathematical modeling methods are under discussion (1,3,12).

As medical anthropologists, we note the absence in current plans for global
reporting systems of "traditional" or non-Western health care providers,
who in communities worldwide are usually the first, and often the only,
health specialists to see patients with new or reemerging diseases. These
local health specialists, called traditional healers, may have a role to
play in the early identification of new or reemerging diseases and could
assist in coordinating responses to outbreaks and providing public health
education at the local or regional levels.

Most people around the world have little access to modern medical systems
(13-15). Even though immunizations and antibiotics increasingly find their
way into indigenous systems, healers, midwives, bone setters, herbalists,
and other traditional health experts provide most or all medical care. The
more remote, indigent, or traditional the population, the greater the
likelihood that it will have little access to modern medical care (13,16).
If such care is sought, it will be only as a last resort, should
traditional healers prove unable to address the illnesses (16). In many
communities, modern medicine is not perceived as better than traditional
healing, and it is often more costly. Distance from modern medical
resources is another barrier. Medical care that is not sensitive to
cultural differences as well as the belief that some types of diseases are
not treatable by modern medicine are also prevalent. These beliefs are
particularly common in developing countries; however, traditional healers
also practice in many ethnic and minority communities in industrialized
societies throughout North America, Europe, and Australia (17-19).

A primary dependence on traditional healers continues in areas that, until
recently, were considered largely untouched by modern development. It is in
just such areas that much of the recent economic development has triggered
rapid ecologic change. These once sparsely populated areas, now being
pulled into the global economic sphere through logging, mining, and
agriculture, are precisely the areas where it is anticipated that many new
infectious diseases will originate, as increasing populations come in
contact with previously undisturbed vectors of infectious diseases. In such
areas, traditional healers are often in a unique position to identify new
and reemerging diseases. Whatever their specialty, traditional healers are
1) familiar with diseases commonly found locally; 2) aware of an increase
or decrease in the incidence of such diseases in their patient population;
3) among the very first to see
                             [end of page 351]

cases of new diseases; and 4) cognizant of the recurrence of a disease they
have not seen in some time. If traditional healers are not tied into the
global reporting network in a systematic and effective manner, their
knowledge of new or reemerging disease information may reach the outside
world late or in many cases, not at all. Traditional healers differ not
only from country to country, but often from region to region and from one
ethnic or minority group to the next. An adequate surveillance system must
ensure that in each instance the most appropriate traditional healers are
included in some type of timely warning system.

Including traditional healers into a global system does not mean that
scientists and clinicians must agree with indigenous explanations of the
causes or treatments of infectious diseases. Nor does it require that
traditional healers accept modern assumptions about the causes, presence,
or treatment of such diseases. However, a complete surveillance system does
require that participants cooperate and maintain professional respect and
courtesy. The goal is a surveillance system that is sensitive to cultural
differences and in which new or unusual medical events can be reported
quickly and accurately from the traditional healer to the local medical
officials in the hospital or laboratory linked to the global surveillance
system.

In recommending the inclusion of traditional healers in a global
surveillance network, we do not seek to minimize the differences, or the
animosity, between these healers and modern medical practitioners (14).
Moreover, the relevant strengths and weakness of traditional healing are
not the issue here. Critical time, however, may be lost unless all
resources are tied into a disease reporting system.

Lines of communication must be established between traditional healers and
local health care systems that serve as the "up-links" to the regional,
national, and international early warning systems. A system in which
traditional healers know whom to contact and how to establish contact
quickly is essential. Traditional healers must be taught why, what, when,
and how to report unusual symptoms in their patients to local officials.
Training for traditional healers must include explaining, (in terms that
are culturally relevant to their understanding of illness and health) why
scientists outside their communities need timely medical information from
their local practices. What to report is of equal concern. Healers must be
briefed in what is reportable. A checklist of specific symptoms, such as
new or unusual fevers, rashes, or lesions could be developed for reference.
Such a checklist could also include questions on the apparent mode of
transmission of the disease, (whether it is appearing in members of the
same household; in specific parts of a local area, such as households that
share a common water source or are located near a forested area; or in sex
partners). The development and circulation of a pictorial reference guide
of diseases found in an area might facilitate communication between healers
and local officials. Specific guidelines should ensure that reporting is
done quickly. Finally, a clear and workable reporting system, with specific
information about whom to contact at the local level should be established.

An effective surveillance program must include a systematic educational
component for local health officials, with specific discussion about the
need to include traditional healers, what information these healers are
asked to provide, and how this information, once conveyed to local health
officials, must be transmitted to the regional hospital, universities, and
ministries of health quickly and effectively. Because many local health
officials have heavy demands placed on their time, the more straightforward
this transmission link is made, the better for all concerned. The local
health official is the key "up-link" between the remote field and the
regional or national surveillance centers where a more careful and
systematic evaluation of the new or reemerging infectious disease should
begin.

Finally, training for both healers and those to whom they report must be
comprehensive, and its effectiveness must be evaluated often. A
communications bridge must be established and maintained if global warning
is to be truly effective.
                             [end of page 352]

Acknowledgment
We thank Mark L. Wilson, Infectious Disease Division, Yale School of Public
Health, for his helpful comments on this manuscript.

Nora Ellen Groce* and Mary Elizabeth Reeve
*Division of Health Policy, Yale School of Public Health and Division of
International Health, Yale School of Public Health

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