Building on Traditional Medicinal Plant Knowledge and Home-based Health Care Efforts in Rural Malawi NotesKI M alawi remains one of the world's investigated local women's knowledge least developed countries, with and use of home-based plant medi- more than 65 percent of its cines. An attempt was also made to un- population of over 11 million below derstand women's particular contribu- the poverty line. As in most countries tion to the relevant decision-making in the region, biomedical health facili- processes at the household level. Gen- ties and services are in very short sup- der-sensitive qualitative and participa- ply, especially in the rural communi- tory research methods, including focus ties of Malawi--about 85 percent of its group discussions (FGD) and semi- population. The HIV/AIDS epidemic structured key informant interviews has exacerbated the already strained were employed. The study recom- scarce resources available within the mends specific ways in which the World http://www.worldbank.org/afr/ik/default.htm national health delivery system. In the Bank-supported Malawi Social Action absence of adequate biomedical health Fund (MASAF III ) might effectively tar- services, most rural Malawians con- get its community demand-driven tinue to rely on traditional, largely (CDD) development efforts in support plant-derived treatments for their pri- of local women's knowledge and skills mary health care needs. in this area (MASAF, 2003). Someofthe As observed by one researcher, virtu- main findings are highlighted below. ally all rural Malawians can be viewed as practising herbalists, as they typi- No. 73 cally know of a variety of herbs to treat October 2004 common ailments (Morris, 1986). In- deed, while traditional healers un- IK Notes reports periodically on doubtedly occupy an important posi- Indigenous Knowledge (IK) initiatives tion in health care delivery throughout in Sub-Saharan Africa and occasionally rural Africa, it is increasingly appreci- on such initiatives outside the Region. It is published by the Africa Region's ated that ordinary local people and Knowledge and Learning Center as women in particular, are often among part of an evolving IK partnership the main custodians of much tradi- between the World Bank, communi- ties, NGOs, development institutions tional knowledge. and multilateral organizations. The Through support provided by views expressed in this article are those of the authors and should not be World Bank GENFUND1, a field-based study carried attributed to the World Bank Group out in three rural communities2 in the or its partners in this initiative. A Central, North and South regions of webpage on IK is available at // Malawi respectively (April-May, 2004) www.worldbank.org/afr/ik/ default.htm 2 Ongoing activities in support of traditional health der. It is noteworthy however, that local women reported knowledge and practices that they are generally the first to diagnose symptoms of ill- nesses in children. There was also one notable exception: There are, currently, four registered associations of special- men generally demonstrated little knowledge about the ist traditional health practitioners in Malawi: the Herbalists women's health problems and their appropriate traditional Association of Malawi (HAM, based in Kasungu); the Yohane treatments, pointing to the need for targeted health educa- Herbalists Association of Malawi (Lilongwe); the Interna- tion interventions in raising awareness and understanding tional Traditional Medicines Council of Malawi (ITMCM, among local men regarding such conditions. The importance Blantyre); and the Chizgani Ethnomedical Association of this becomes all the more compelling when considering (Mzuzu). Thus far, the Ministry of Health's (MOH) efforts that local women, despite considering themselves as the related to traditional medicine have focused mainly on pro- prime decision-makers on health matters at the household viding support to traditional health specialists, through level, often depend on their husbands for money for biomedi- these associations, e.g., through training workshops on HIV/ cal or specialized traditional care. AIDS prevention and care. The ministry has also supported On the whole, both male and female study participants the provision of basic supplies and ongoing training for tradi- generally demonstrated considerable appreciation for their tional birth attendants (TBAs), although the findings of this local heritage of traditional health knowledge and skills, study suggest that resource constraints have limited both the which they value both as a modest source of income and so- reach and consistency of such programmes (Smitt, 1994). cial esteem. The skills for preparing and administering most Two major challenges faced by national decision-makers home-based plant-derived medicines are often learned from were noted by key informants: the persistence of negative parents or close relatives. Specialist ofunamankwhala, re- perceptions of traditional health practices among biomedical portedly acquire and develop their herbal recipes through professionals; and the current `policy vacuum' surrounding more extensive exchanges with other knowledgeable persons the use of traditional therapies. Despite the lack of a clearly (often encountered while travelling to distant areas), while defined national policies regarding the development of tra- the sing'anga interviewed claimed that they attained their ditional medicine, various national organisations, non-gov- divinatory powers and plant knowledge through `spiritual in- ernmental organizations (NGOs), and individual researchers tervention'. have pursued work on traditional health practices and Focus group discussions revealed considerable local appre- Malawian medicinal plant use, albeit with limited apparent ciation for the need to systematically document traditional coordination of their efforts. health knowledge as a whole, and particularly herbal prepa- rations commonly used at the household level. However, a The knowledge base: local distribution of medicinal perceptible culture of secretiveness surrounding the knowl- plant knowledge edge and use of traditional herbal remedies may render this a particularly challenging area for intervention. Given the Local people generally distinguished between: (a) knowl- prevailing preference among local people for recording tra- edge held by ordinary men and women pertaining to widely ditional herbal recipes at the household level rather than available medicinal plants used as home-based treatments through a concerted communal effort, it was suggested that for common ailments; (b) special herbal recipes restricted to support for community literacy programmes may represent a individual families; and (c) the knowledge and practices of vital strategy for safeguarding traditional health knowledge. specialists: community `herbalists' known as ofunamankhwala, generally viewed as distinct from the sing'anga (spiritual diviners/healers), the azamba or TBAs The main health problems: local views of traditional and herbal vendors at local markets (often themselves prac- therapies and biomedicine tising sing'anga). The study affirmed that inhabitants of the three communi- At the household level, knowledge and skills pertaining to ties continue do routinely make use of home-based tradi- plant identification, collection, preparation and administra- tional herbal remedies as the first line of treatment for most tion of most commonly used traditional herbal treatments common ailments. Such treatments appear to be used more generally do not appear to be clearly differentiated by gen- frequently than the services of local traditional specialists or 3 biomedical health facilities. Many informants reported hav- (often consulted for conditions believed to be caused by ing used a traditional herbal treatment as recently as a few witchcraft) were also cited as a drawback. days or weeks ago. Biomedicine's diagnostic capabilities, the specificity of There was considerable similarity in the range of the most modern drugs and the generally rapid recovery after treat- pressing health problems identified by FGD participants in ment are perceived as its key advantages. Distances to health the study communities. In addition to leading health prob- facilities and the associated costs of transportation, consulta- lems recognized at the national level, i.e., malaria, HIV/ tion fees and purchase of medication, were cited as the main ADS, acute respiratory tract infections, diarrhoea and peri- drawbacks. The difficulties experienced particularly by non- natal complications, a range of other commonly experienced literate community members in following written prescrip- ailments were recorded, including,, common dermatological tions correctly were also noted. conditions, symptoms associated with gastro-intestinal infec- tions, various forms localized pain and bilharzia. Key findings relating to the major health problems are The plants: classification, supplies and use patterns summarized below. The local names, corresponding scientific designations3 and Malaria: stands out as the single largest health problem in specific applications of 70 plant species (representing 44 all of the study communities. A local wild shrub cited as an families) of medicinal value were recorded by this study. This effective mosquito repellent, is used to varying extents is indicative of the wide range of plants in use among the among the study communities. Biomedical treatment is study communities. It is notable that all of the treatments deemed the most effective solution by local people for se- mentioned are derived from plants viewed as being readily vere malaria. Participants were generally well-informed available in the local area. about the mechanisms of malaria transmission, but there The majority of locally-valued medicinal plants occur natu- were indications of uncertainty about the symptoms indica- rally in nearby uchire (uncultivated wooded grasslands). How- tive of cerebral malaria in particular. ever, in some cases, smaller patches of natural vegetation HIV/AIDS: Study participants generally demonstrated re- around the homestead, often flanking farm-plots appeared to markable appreciation regarding HIV/AIDS modes of trans- be the main sources of medicinal species. mission. There were no traditional treatments which were Many of the most popular remedies are derived from na- expressly cited as remedies for secondary infections associ- tive trees. The continued availability of such species is in- ated with HIV/AIDS. However, the need for support for those creasingly endangered by ongoing land-clearing, deforesta- households caring for HIV/AIDS orphans was repeatedly tion and in some cases, over-harvesting. The most frequently brought up in discussions about pressing community health cited therapeutic plant parts were the roots and bark. Some concerns. highly valued medicinal tree species appear to be threatened Diarrhoea: Some home-based herbal preparations be- by unsustainable (bark or root) harvesting practices. For ex- lieved to be effective for childhood diarrhoea are reportedly ample, `mwavi' (Erythrophleum suaveolens) a tree noted as administered, notably with plenty of water and fluids. ORS being `scarce' and valued as a source of several medicines were seldom reported as the first resort for managing diar- among the study communities, is known to have disappeared rhoea in children. from certain forest reserves elsewhere in Malawi (FRIM, Perceived advantages/disadvantages of traditional 2003). medicine and biomedicine: Local people generally view bio- medicine as complementary to both specialized and home- based traditional forms of health care. Among the perceived Way forward: seeking community-demand-compatible advantages of traditional medicines, are that they are acces- strategies sible and often cost nothing (especially home-based treat- ments). Among the disadvantages reported were that many The study concluded that despite local people's continued traditional treatments are relatively slow to take effect, are reliance on, and high regard of traditional forms of therapy, at times not specific to the particular illness being treated, project proposals aimed exclusively at the improvement of and that their dosage is not always well measured. The very traditional medicines and health practices per se are unlikely high fees that can be charged by some specialist sing'anga to naturally emerge as the most pressing among the many 4 competing community demands for support by social fund References projects such as MASAF. Among the study communities, sup- port for the construction of boreholes and community health FRIM.(2003). Developing biometric sampling systems and centres consistently took precedence. optimal harvesting methods for medicinal tree bark in In light of this, projects such as MASAF III would need to Southern Africa: A FRIM research project. Forest Research adopt a variety of proactive and indirect strategies for har- Institute of Malawi (FRIM). nessing and strengthening traditional health knowledge and MASAF(2003). Malawi Social Action Fund Phase III - Com- practices through its various programs. The key recommen- munity Empowerment and Development Project (MASAFIII dations made to MASAF in shaping its strategic approach to /CEDP): Operational Manual (OM). Government of this area of work are: (a) foster coordination of the wide ar- Malawi. Office of the President and Cabinet (OPC). ray of ongoing efforts in the field of traditional health knowl- Morris, B. (1986). Herbalism and divination in southern edge and practices, through inter alia, encouraging collabo- Malawi. Soc. Sci. Med. 23(4): 367-77 rative efforts at the community level; (b) devise multi- Smitt, J.J (1994). "Traditional birth attendants in Malawi". sectoral approaches, in supporting traditional health knowl- Curationis 17(2): 35-8. edge and practices, through, e.g. the establishment of herbal gardens and afforestation schemes targeting threatened me- dicinal plants as adjuncts to diverse projects; (c) incorporat- ing gender and culturally-sensitive health education efforts on key topics (e.g. reproductive health, malaria prevention and treatment), with a view to building critical symptom rec- 1 Norwegian Trust Fund for Mainstreaming Gender ognition skills and supporting health care efforts and deci- (GENFUND). sion-making at the household level; (d) exploring innovative 2 Chala Group Village, Malili, Lilongwe Rural (Central Re- ways of disseminating vital health information, e.g. through gion); Nation Nhelma Group Village, Nthwalo, Mzimba indigenous networks, with a view to improving the beneficial (Northern Region); and Group Village Kantukule, Somba/ aspects of traditional health knowledge and affecting posi- Blantryre Rural (Southern Region). tive change in those practices identified as problematic or no 3 The botanical identities of most species could be deter- longer useful. mined with reasonable confidence by experts at the Na- Finally, it should be noted that while the importance of tional Herbarium and Botanical Gardens (at least to the traditional medicinal plant knowledge was well-acknowl- genus level) using photo images of the plants collected edged in all the FGD sessions, invariably, other pressing is- throughout the fieldwork.; further work, including collec- sues both directly and indirectly related to health were tion of voucher specimens, would be needed to confirm raised. Not surprisingly, subsistence and food-security con- taxonomies. cerns consistently outweighed the priority given to health care. This is illustrated by the following pointed remark made by a local woman at the end of a FGD session: "How can we even worry about health or walk to the health center ... if we are already so weak because we do not have enough to eat? Hareya Fassil, MPH, PhD, Consultant, Knowledge and Learning Centre, Africa Region, World Bank hfassil@worldbank.org or hareyafassil@yahoo.com