Dr. Prozac, Meet Dr. Vodou
WHY YOU SHOULD CARE
Because the line between hokum and science can be thinner than old gabardine.
For decades, scientists have dismissed traditional healing as hokum. Shamans are shams and leaf doctors are frauds, goes the conventional (Western) thinking. That bias is not without merit: Snake oil has long profited hand over fist in poor countries, where physicians are scarce and psychologists might as well be a myth. So much so that you’d think there’s no mental illness in the Global South.
But that’s blatantly untrue, and in the face of a massive treatment crisis, the Prozac nations are little by little changing their tune. A small but growing rebel cadre of researchers is looking to herbalists, acupuncturists and even Vodou priests for help in addressing mental health problems in developing countries. The new idea, which is new only to Westerners: to integrate traditional approaches and modern care for a saner population round the world.
Pairing dudes in stethoscopes with the practitioners they usually mock as wack jobs is a potential game changer, says Akwatu Khenti, an assistant professor of global health at the University of Toronto. Khenti is training Haitian clergy, and yes, that includes the aforementioned Vodou priests, in cognitive behavioral therapy (CBT) while also investigating how the traditional healers “engender confidence in their clients,” he says. “We’re not creating a one-way street.”
Nor is this a one-off — rather, it’s the latest sign of a major health care shift. In 2013, the World Health Organization released its Traditional Medicine Strategy, with a focus on complementing Western medicine with traditional approaches, replete with strategies to improve the safety and quality of the latter. October brought a nifty-sounding thing called the Nagoya Protocol: It aims to fight biopiracy — that’s where Big Pharma rips off traditional medicine — and require companies that profit from natural products to compensate the indigenous communities that have cultivated and used them for generations.
Don’t flush that prescription antipsychotic yet, please. Most traditional mental health remedies are well beyond the bounds of regulation, and some are, indeed, snake oil. Best case? It’s hard to assess the efficacy of traditional methods because measurement requires gauging patient beliefs. Even so, traditional healers have a leg up on Western ones. For starters, there are many more of them in poor countries. While Ethiopia and Ghana each have fewer than 10 psychiatrists per 100,000 people (there are about 135 per 100,000 in the U.S.), sub-Saharan Africa has one traditional healer per 500 people. And patients tend to comply with treatment, even if a “prescription” means daily prayers. Kwame McKenzie, a professor of psychiatry at the University of Toronto, wonders what would happen if his community could “get traditional healers to do not exactly what we want, but get them to do a bit,” adding that we’d “hugely expand” the number of people doing mental health work.
And where DSM-schooled providers exist, their services may carry a serious stigma. Mental illness is seen as a sign of weakness the world over but perhaps especially in poor countries, says Khenti. Psychologists are a last resort. More important than all of that: In many instances, traditional mental health treatments seem to work. They’re closely aligned with local cultural beliefs, including understandings of mental illness as supernatural — the result of an evil spirit or a strained relationship with God, for example.
When faced with emotional problems, most Ethiopians first consult with Christian pastors, Muslim imams, herbalists or spiritual advisers called awaki, says Dawit Wondimagegn, a psychiatrist at Addis Ababa University. He and psychiatrists from Mount Sinai Hospital in Toronto want to fold these healers into a network of local health workers, whom they’ve trained in interpersonal psychotherapy. Nurses will identify and refer patients undergoing spiritual distress — who feel guilty about not praying enough, for example — to traditional healers. And traditional healers are trained to recognize patients who might benefit from psychiatric services.
Christian monasteries are a linchpin in Wondimagegn’s plan. Family members of those with schizophrenia or other psychotic disorders often ditch them at monasteries. If for no other reason than safety, the monks and nuns put these should-be patients in chains and shackles. Hello, Middle Ages. But in 2013, Wondimagegn taught the nuns which medications to prescribe based on the symptoms they observed — in addition to offering their usual spiritual guidance. Six months later, not one of the 26 patients was shackled; some were even helping with fetching water and other chores. Wondimagegn plans to publish these preliminary data later this year.
In Haiti, Khenti has adapted CBT to Haitian culture based on his work with Haitian immigrants in Toronto. Providers translate lingo like goal setting and skill consolidation into lay-friendly Creole words and don’t assign written homework due to literacy issues. Khenti recently launched the first phase of a project to test his model’s efficacy in Haiti and is gearing up to teach the model to Haitian spiritual leaders in July.
So what if the positive effects of a traditional remedy can be traced to a placebo effect? That just further underscores the “trustworthiness, integrity and respect for traditional healers,” says Khenti. They’re the same factors, he says, that characterize positive relationships with the men and women in white coats with prescription pads.