Hareya Fassil hfassilsph'emory'edu

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Extraordinary Balancing Acts Local health
knowledge and survival strategies in rural Malawi
Hareya Fassilhfassil_at_sph.emory.edu
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Knowledge Learning Group, Africa Division,
World Bank Consultancy study under GENFUND
provision (2004)
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Overview

• I. The study
• Objectives and research questions
• Study communities and methods
• II. The big picture at national level
• III. Local realities
• Home-based practitioners vs. specialists vs.
  herb vendors
• Balancing the old vs. new
  modernization and biomedicine
• The gender balance
• The plants use patterns and sustainability
• Imbalances poverty vs. deforestation
• Local views and initiatives
• Field notes on malaria and HIV/AIDS
• Hypotheses revisited lessons learned
• IV. Proposals for MASAF action striking
  balances
• V. Way forward

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I. The Study objectives research questions

• To elucidate local womens knowledge and reliance
  on traditional health protective and restorative
  plants in meeting household health and nutrition
  needs and their contributions to relevant
  household decision-making
• To inform MASAF Phase III how to integrate/
  build on womens local health knowledge/resources

1. How is knowledge distributed and
transmitted/acquired? (knowledge in the
public domain vis-à-vis knowledge of
specialist traditional healers and herb
vendors) 2. What types of plants are used as
home remedies? supplies? use patterns?
sustainability? 3. Overall significance of
home-based traditional knowledge and use of
medicinal/food plants?
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Study communities

• 3 rural villages
• Central, Northern Southern Regions
• Selection criteria
• regional representation
• distance from urban-center 25 km
• ongoing/ past MASAF involvement
• 1. Chala, Malili, Lilongwe Rural (27km south of
  Lilongwe) MASAF Materezi Maize Mill Project
  (since 2002)
• 2. Jombo Nation Nhelma, Mzimba (40km N. Mzuzu)
  MASAF under-5s health unit
• 3. Mpemba, Kantukule, Somba Blantyre Rural
  District (25 km SE Blantyre)

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Qualitative methods six components
1. Focus group discussions (FGD)

• MIXED GROUP FGD
• data verification
• key gender differences
• participatory needs/priorities ranking
• possible initiatives for MASAF support

WOMENS FGD
MENS FGD
2. Key informants
3. Village TBAs
SEMI-STRUCTUREDINTERVIEWS
4. Traditional healers
5. Village elders
6. Herb vendors at local markets
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II. The big picture at the national level

• Diverse efforts and interests - but lacking
  national-level coordination
• Some community-based efforts but not
  community-driven per se
• Policy vacuum persistent negative views
  among biomedical community
• 4 traditional medicine associations
• Herbalists Association of Malawi (Kasungu,
  Central)
• Yohane Herbalists Association of Malawi
  (Lilongwe, Central)
• Intl Traditional Medicines Council of Malawi
  (Blantyre, Southern)
• Chizgani Ethnomedical Association (Mzuzu, North)
• Integration as a single national organisation
  remains a challenge
• Women represented in associations
• Home-based medicinal plant knowledge and use
  largely disregarded

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Ofunamankwhala(herbalists) vs. singanga
(spiritual healers) vs. others
III. Local realities
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At the market healthcare vs. livelihoods
Doctor Mateyu singanga (spiritual healer)
herb vendor (15 years) High demand fertility
STD treatments (trees) Most scarce muowani
tree Likuni Market (Central)
Mai Nezia Peliaz ofunamankhwala herb vendor
(12 years) High demand good fortune
treatments Most scarce mwavi tree
Likuni Market
(Central)
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Village child-delivery room vs. urgent hospital
care
I got TBA training at Likuni Hospital I also
delivered all my children there.. All I tell
pregnant women is to go to the hospital to get
advice they should also eat green vegetables
(pumpkin leaves, ntambe, fruits) But our
main problem is transport especially when we
have delivery problems in the night time, we have
no way of taking the mother to the hospitalwe
need an ambulance at night or at least a bicycle
to send a messengeralso a proper delivery room
for our village People always come and
ask questions, questionsbut nothing happens,
nothing is done
Tereza Chipe Traditional birth attendant (TBA)
(15 years) Chala Village (Central) Cited only 2
birth-related herbal remedies both fertility
treatments
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Old vs. new mpungabwi chitukuko

• mpungabwi traditional herbal
  mosquito-repellent, deemed effective but
  increasingly viewed as a thing of the past
• chitukuko Tumbuka i.e. modernization
  development

mpungabwi (Ocimum sp.)
Jombo (North) Womens Focus Group

• Dynamism of local health knowledge practices

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The gender balance health knowledge/skills

• Symptom recognition/ diagnosis
• consultation (adult household members
  neighbors)
• women often the first to notice symptoms in
  children
• unambiguous symptoms often treated promptly
• Plant identification/ growth habit/collection
• men women generally know similar range of
  plants
• elders generally cited more plants
• Processing/ preparation of plant treatments
• womens remit of food processing grinding/poun
  ding, infusions, etc food-based medicines
• knowledge of remedies for womens problems
  largely limited to women

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The gender balance healthcare decision-making
...Of course, we decide !...
We decide, the men provide!
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The gender balance

• Vital in-depth understanding womens health
  problems and home-based treatments
• Sensitizing/educating men about womens health
  problems

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The plants main types

• Total 70 medicinal species used as home-based
  remedies recorded
• Majority native tree species occurring in nearby
  uchire(uncultivated grasslands/ bush)
• Some shrubs and herbs
• To date, afforestation schemes have not
  prioritized medicinal species

mvunguti (Kigelia africana)
chipembere (Catunaregam spinosa)
mbula (Parinari curatellifolia )
naphini (Terminalia sericea)
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The plants health restorative vs. health
protective

• several traditional vegetables cited
  semi-domesticated/ wild leafy greens (likely
  vitamin/ mineral-rich) used as relishes
• some viewed as famine foods largely, taken for
  granted
• variety of native fruit species

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The plants use patterns

• over-harvesting threatens sustainability of
  supplies

• subsistence use significant medicinal plant
  trade in all town centers
• markets wide array of root parts and bark
• harvesting increasingly monitored in protected
  areas

Last muowani tree (Cassia sp.) in Jombo (N.
Malawi) Effects of bark over-harvesting
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Imbalances poverty vs. deforestation

• poverty
• ever-increasing demand for fuel wood
• loss of indigenous trees
• destruction of habitats of other useful wild
  species

Uphill ! - En route to Mzuzu (North)
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Local views multipurpose
I learned medicines from my fathervillage
people now often come to me with problems and
give me what they can for medicinesI find most
medicines in the uchire We hear MASAF does
good things but our village has not benefited
What we need is help planting multipurpose
trees hardwood and medicinal we know which
trees and we need carpentry training and
toolsthat way people will stop cutting trees for
charcoal
"...I guess you can say I am ofunamankhwala..."
Makray Fundeni Farmer, carpenter,
ofunamankwhala Cited treatments for gt 10
health problems (ranging cough diarrhea
gonnorhea) Mpemba (South)
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Local initiatives Secrets Eunices prized
notebook
I started writing them down years ago so I
wouldnt forget
Eunice Qongwani Jombo (North)

• openness about widely
• known home-based herbal remedies
• but reluctance to disclose special family
  medicines
• from which small, in-kind
• compensation can be derived
• documentation of knowledge at the community level
  viewed as extraneous

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Malaria balancing prevention vs. treatment

• perceived as the major health problem
• use of modern anti-malarials essentially part of
  home-based strategies and local health
  knowledge
• BUT notable ambiguity in symptom recognition

e.g. kugnu (epileptic seizures ) sila
(acute fever/ convulsions) vs. cerebral malaria
symptoms

• Training building on womens diagnostic skills
  
• better detection timely home treatment
• culturally-sensitive IEC use of bed-nets

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HIV/AIDS awareness/knowledge vs. attitudes/
behavior

• ongoing education/prevention programs appear to
  have made in-roads ? considerable HIV/AIDS
  awareness/ understanding among communities
• yet a fatalistic attitude prevails
• no traditional treatments for secondary
  infections cited
• need to address cultural practices which increase
  HIV and STD risk
• need for funding/program support for care of
  HIV/AIDS orphans was key among the priorities
  identified by all the study communities

Edzi irrimufa!... AIDS is in the maize
flour!
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Hypotheses revisited

• Local knowledge/practices
• understand
• document
• enhance
• strengthening the beneficial
• changing the harmful
• building on economic benefits

• Medicinal plants
• sustainable supplies
• protect, conserve/cultivate

EMPOWER COMMUNITIES
women
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Lessons learned local actions and proposals

• Local knowledge/practices
• understand
• document
• enhance
• strengthening the beneficial
• changing the harmful
• building on economic benefits

• The power of basic literacy
• documenting secret knowledge
• Home-based efforts
• strengthening malaria diagnosis/treatment
  prevention
• HIV/AIDS risk-related cultural practices
• Alternative livelihood strategies building
  skills/ community funds for
• averting deforestation
• Multipurpose tree species
• aforestation

• Medicinal plants
• sustainable supplies
• protect, conserve/cultivate

EMPOWER COMMUNITIES
women
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Lessons learned leverage of the borehole

• Clean water significant and direct health
  gains
• Convenience allocation of womens labour to
  productive/income generating activities
• Empowering women

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Lessons learned stark realities
How can we even worry about health or walk to
the chipatala to get treatment if we are
already so weak because we do not have enough to
eat? What can MASAF do to help us with that?...
WOMENS FGD PARTICIPANT MPEMBA (SOUTH)
poverty health

• chronic food insecurity
• maize crop failure/ looming threat of hunger

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IV. Proposals for MASAF action striking balances

• Inter-packaging looking outside the health
  box
• medicinal plant gardens as adjuncts of
  infrastructure projects health units, schools,
  village child-delivery units
• alternative livelihood strategies building
  skills/ community funds for averting
  deforestation
• Health infrastructure vs. services
• More staff for health units training
  appreciation of home-based efforts and local
  health knowledge/practices
• TBA training reform under discussion
• Culturally/gender sensitive IEC in all health
  initiatives
• Malaria prevention balanced with hands-on
  training for detection/treatment
• HIV/AIDS risk
• Empowering women disseminators of IEC, e.g.
  through local organizations
• Upholding CDD by leveraging projects with strong
  community support
• Community-based HIV/AIDS Orphan care programs
• Boreholes and roads

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V. Way forward more leveraging

• Opportunities and challenges for MASAF
• Catalyzing coordination of diverse efforts
• Raising awareness (balanced messages
  beneficial vs. harmful cultural practices)
• Diverse partnerships biomedical community, MOH,
  NGOs, Universities, CBOs

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Dzanja limodzi silikumba mankhwala One hand
alone cannot dig up medicinal herbs A popular
Chichewa proverb
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Acknowledgements
Zukomo !

• Malawi
• Participating members of the
• study communities
• Chala, Jombo, Mpemba
• Field research partner Ms. Lexa Kawala (Nurse/
  Lecturer Kamuzu College of Nursing, Lilongwe)
• All MASAF Staff
• Ms. Juliana Lunguzi (Dept. of Reproductive
  Health, Lilongwe)
• World Bank
• Mr. Reiner Woytek The Knowledge Learning
  Group
• Dr. N. Mungai Lenneiye
• Dr. Khama Rogo
• GENFUND - Norwegian Trust Fund for Mainstreaming
  Gender