Meaning...

The Power of Meaning.

I had the opportunity to meet with three Songomas, or traditional healers, last week. All were within a “city block” of Marion hill Clinic where I’m working this week. That’s more market share than Starbucks! Vusi, the clinics HIV workshop and support group coordinator, brought me to the healers’ homes. However, he was not able to come in with me as he is in a

wheelchair. You can imagine the extent of “handicap accessible” homes in this area. He was left paralyzed from the waist down from Pott’s disease (or Tuberculosis of the spine). The TB infiltrated his spinal cord, stopping the electrical instructions to his legs. This is a very difficult disease to treat, it requires 4 drugs, taken continously for 18 months, with little room for lapses in medication...Pushing the wheelchair was an awesome workout, given the wicked hills and gravel roads… of course, it was well worth it.

Prior to these visits my only connection with Songomas was through their patients. Who all too often suffer from kidney and liver failure secondary to traditional medicines. One of the most important questions to ask patients here is, “When was the last time you took “traditional or Zulu medicine?” Having seen some of the negative aspects of traditional medicine, I was somewhat skeptical of their work. However, my preconceived expectations about South Africa are often wrong, and it’s in the best interest of our patients to partner with traditional healers, rather than burning bridges with a major source of “healing” in the area.

The first Songoma I met came from Malawi, and moved to South Africa more than 20 years ago. His house and clinic are directly across the street from Marion Hill clinic. When I first entered the house the smell of the traditional medicine and smoke were readily apparent, although a completely new olfactory experience. The room was filled with old water and vodka bottles containing orange, red, and yellow substances of an unknown origin… Roots, clay, herbs, and what appeared to be rodent bones were all combined in something that looked like a frying pan. I later found out he uses this for fortune telling.

At first the Songoma didn’t appear interested in talking. Almost every question I asked was replied with an audible sigh, hands on his face and 1 or 2 word answers. I didn’t take it personally, and assumed it was either because he was tired or because I wasn’t paying for any healing, I just came to listen and discuss what he does. Perhaps he felt I was questioning his ability to heal his patients…After all, I came in with my stethoscope around my neck, looking very western “doctor like.” Which, to him may silently screams disbelief or at least inferiority of any benefit from his medicines and practices.

At this point I could tell he wanted me to go soon. But, then he offered what I think is the primary reason Songomas continue to be utilized in great numbers. Put simply, MEANING. They deploy medical information in a relevant way that has meaning to their patients. They relate the meaning of an illness in way that is harmonious with traditional beliefs, something western medicine can’t do. Western medical practice in South Africa, especially within language barriers, relies heavily on the pattern of very specific complaints and objective exam and lab findings. It is difficult to fully understand how the patient’s beliefs, background, culture and ethnicity affect their interpretation of their illness. Songoma’s give patients information via a story. For example, This songoma offers all of his patients a “fortune telling” (i.e. diagnosis based how bones land in the pan). He tells his patients why they got sick, what they can expect and how he is going to treat them. These stories or fortunes have meaning to the patient, while a clinical diagnosis may not. The patient’s understanding of their disease in terms of lab tests and exam findings fails to convey a “meaning” of that illness. Meaning is

important to all of us… we want to know why we are sick, how to get better and how to prevent it from happening again. More importantly, meaning can help patients heal. He can explain and treat illness in a way that “means” something to his patients. Helping patients understand why their disease is happening and how he is going to treat it is a very powerful way helping patients start the healing process. He also has authority entrusted by his ancestors, a blessing I lack.

The second Songoma I visited with was a wonderful, 97 year old (although she looked 75 at most) Gogo. This was an absolute wonderful visit. I started on the right foot by greeting and thanking her in Zulu, at which she gave me a curious grin. After which she said Ngyathanda, meaning, I love you… which I replied back with Nami Ngyakuthanda…which, I think means “I love you too.” First she showed me her treatment for Shingles, a painful blistering rash affecting one dermatome (the sensory distribution of one nerve) from a latent chicken pox infection most people my age had when they were children. The traditional cure involved three rubs of different root mixtures. The “active ingredient” was in the “Holy Root” which you also drank in addition to rubbing it on the affected area. One is supposed to leave the rub on for three days and then wash it off. She understood that we also have a treatment for Shingles and said she always told patients to go to the doctor if it doesn’t get better.

I asked her how she helps patients with HIV and AIDS. I had heard some traditional healers were claiming they could cure HIV, which concerned as it can undermine patient adherence to lifesaving medication. She encourages them to eat healthy, drink water, be faithful, wear condoms, and to always…. ALWAYS take their pills. Also, to see their doctor, if they are getting sick or weak. This was a great for me to hear! When patients get consistent messages from two sources it increase the likelihood those patients will go on to do well. The number one reason individuals “fail” treatment for HIV is not taking their medications. When medications are taken every day, without lapses, almost all patients can expect their viral load (a measure of infection, transmissibility, and treatment efficacy) to be undetectable within 6 months and can expect to live in good health. Patients stop taking their medication because of drug side effects, misunderstanding of the chronic character of the disease, or lack of transport to clinic or money. To start on Anti-retroviral medications one must complete 3 modules that explain the disease, its treatment, and common questions. As a side-note, in South Africa all HIV medications are free off cost as of last year.

I also asked her what advice she had for me. She said listen and understand your patients, and to “be tough” on them if they are not following your treatment plan… she laughs and states that if patients don’t do what she says the first time she tells them to “go away!” I told her I give my patients a few more chances, which she returned a nice grin and laugh ;).

The third, Songoma actually hosted a school for training Songomas. Songomas will train from 7 to 12 months depending on their ancestors. As some ancestors “prepare” Songomas for understanding traditional medicine faster. She charges a small fee for the training. This Songoma also tells her HIV patients similar advice and encourages her patients to see both traditional healers and doctors.

The clinic is located in Marion Hill Township and is run by the IMA (Islamic Medical Association), an NGO that runs several clinics in the townships and one-mobile clinic. The clinic’s spectrum of care is limited and similar to a “minute clinic.” Complicated and very sick patients are sent to the hospital, via public transport. Antibiotics, vitamins and cough suppressant are handed out like candy… which in a setting without a labs, X-rays, a high prevalence of HIV and TB and limited transport may be more appropriate than I first thought. The clinic is run by 1 to 2 that sees around 100 patients between 8 and 4! This is with a tea break 10 am and an hour lunch and prayer break at noon. Patients are run through very quickly, i.e. sometimes less than 2 minutes for a patient which is understandable given it is important to see all the patients and she wants to get home before 10pm.

Visiting the Songomas has given me a new perspective on understanding the patient and the importance of meaning.