Ukugcaba - A South African Traditional Medicine Procedure: Proscription or Regulation?

Ukugcaba – a South African traditional medicine procedure by incising the skin to introduce traditional medicines: Proscription or regulation?

SUMMARY

South African legislation, the Traditional Health Practitioners Act, Act 22 of 2007, makes provision for establishment of an Interim Traditional Practitioners Health Council and for the registration of persons practising certain professions of traditional medicine, namely the categories of diviner, herbalist, traditional birth attendant and traditional surgeon. Despite the promulgation of this legislation some sixteen years ago, this statutory health council is not yet fully operational legally.

Certain unregulated practices within the South African traditional medicine medico-legal paradigm are cause for concern, in particular the practice of ukugcaba, where incisions, termed izingcabo, are made into the skin for the purposes of introducing traditional medicines into the incised tissue. This practice is believed to be a remedy to redress pollution of the person resulting from actions by persons of evil intent, but research estimates a more than twofold higher set of odds of practitioners in becoming HIV-positive by repeated exposure to patient blood; contribution to the spread of hepatitis B and C, as well as other blood-borne agents is also increased. Apart from the introduction of traditional medicines into incised skin, the use of elemental mercury similarly introduced, ostensibly to protect against violence and for ostensible use in pregnancy, is deleterious to the health of the patient, and especially to the unborn.

This practice is also reported as being used on the genitalia of women for the sexual enhancement of men. In public health terms, an urgent action plan by the national and provincial departments of health is required, both in terms of an informational campaign, but also legal action by the promulgation of legal scopes of practice to regulate ukugcaba. Since it is held that proscription will not eliminate the practice, the mandatory completion of a course of education and training regarding this practice is also regarded as essential.

1. Introduction

South African traditional medicine is a system of medicine original to Africa and is practised from a perspective of indigenous philosophy, ideology, possibly even religion, and with a specific pharmacopoeia and usage of medicines from a symbolic perspective or otherwise – it is actively extant in South Africa with a significant number of practitioners and adherents, but the current regulatory body, the Interim Traditional Health Practitioners Council, established in terms of The Traditional Health Practitioners Act, Act 22 of 2007, is yet not fully operational legally. An assessment of the relevant regulatory framework[1] makes recommendations, but a cardinal recommendation is that legal scopes of practice for practitioners of South African traditional medicine, which do not exist, now need to be promulgated and that registration of the categories of practitioners of traditional medicine, namely that of the diviner, herbalist, traditional birth attendant and traditional surgeon, now commence by the formal opening of the relevant registers.[2] An appraisal of the causes of illness[3] in this indigenous system of medicine, the sources of healing power and the treatment of disease,[4] together with acts specially relating to this system of healthcare (including diagnosis by divination), akin to the conventional medical terminology of ‘clinical practices’,[5] has educed incisive reflection of the treatment of ukugcaba. This clinical act is a traditional medicine treatment where incisions, termed izingcabo, are made into the skin over joints in order to introduce imithi, traditional medicines, or other substances directly into points where the body is believed to be most at risk.[6] Graphically ukugcaba may be described as a process where the practitioner performs dozens of subcutaneous incisions using a razor blade to rub herbs directly to bloodied tissue.[7] This procedure is used in the treatment of umnyama, or darkness, attributed to pollution and where the cause of illness may be ascribed to ecological factors, but where it is perpetrated by persons with evil intent,[8] but also in some other cases, such as to promote sexual enhancement or as a protection mechanism against violence, and in pregnancy.

2. Pollution as a state of umnyama

In terms of Zulu belief, both birth and death are viewed as a continuum – a continuum akin to a state from which humankind originates at birth to that state into which humankind transcends at death. There exists, however, an intersection or overlap, namely a marginal state between life and death. This is between the state of life on the physical plane and the spiritual plane of the deities, spirits and the ancestors, and is termed umnyama – the literal meaning of which is ‘darkness’.

[1] Mullinder An assessment of the regulatory framework pertaining to traditional medicine in South Africa (PhD thesis 2023 UP) v.

[2] Section 1, The Traditional Health Practitioners Act. 

[3] Mullinder 43.

[4] Mullinder 61.

[5] Mullinder 102.

[6] Mullinder ix.

[7] Audet et al “Traditional healers use of personal protective equipment: A qualitative study in rural South Africa” 2020 BMC Health Services Research 655.

[8] Ngubane Body and mind in Zulu medicine: An ethnography of health and disease in Nyuswa - Zulu thought and practice (1977) 22.

When used metaphorically to symbolise death, the term may be translated as ‘pollution’: Pollution, then is viewed as a marginal state between life and death.[1]

3. Ecological causes of illness: pollution

Zulu belief holds that there is a particular relationship between persons and their respective environments, and that plant and animal life also influence those environments. Different regions therefore require different adjustments by the inhabitants and travel to another region may be a factor in the causality of illness. Also, the Zulu idea of imikhondo – tracks or traces, visible on the ground or invisible, but able to be detected by tracking animals – can cause disease. Imimoya – inhaled traces or spirits, souls or dispositions of persons can also cause disease – and are seen as significant in the causality of illness. Uhabula imimoya means inhaling imimoya, whereas weqa imikhondo refers to stepping over imikhondo. Imimoya may, however, also mean spirits, air, wind, soul, as well as an amicable disposition of persons and it may be appropriate to use imikhondo for all tracks, whether in the air or on the ground.[2] Pollution by persons of evil intent, who, by using undesirable tracks or discarded material substances to contaminate loci causing persons to contract a disease by stepping over dangerous tracks, is known as umeqo.[3]

4. Ukugcaba as a clinical act within traditional medicine treatment principles

It is believed that the joints of the human body are the most defenceless parts through which evil may enter the body. To redress this, ukugcaba involves incising the skin over the joints by making small cuts made with a razor blade into the patient’s skin to introduce imithi, or traditional medicines, directly at the place of most risk to the person.^[4] Treatment involves not only the clinical act of ukugcaba, but also correcting and removing the illness source and in certain types of disease may be removed from a patient and discarded elsewhere, encompassing then definite discarded material substances which may remain in the atmosphere or be discarded in another specific locus, then afflicting another person with this disease, seemingly a paradox. A popular place for disposing of such dangerous material substances is said to be at cross-roads (enhlanganweni yezindlela) and on the highways (endleleni yomendo), given that travellers frequent such places. The intention behind disposal in such loci is that these substances would then be carried away from the geographical locus.[5]

5. Ukugcaba in the context of HIV, Hepatitis B and C: the risk to patient and practitioner

An extraterritorial study in the Zambézia province of Mozambique, among 236 traditional health practitioners, offers the statistic that 75% of these practitioners conducted ukugcaba on at least four patients in the months preceding the study, that a new razor was used on an average of three occasions, but that practitioners almost never used gloves and most traditional health practitioners were exposed to patient blood repeatedly, and since there was a high prevalence of HIV, hepatitis B and C, together with other blood-borne agents, the practice of ukugcaba was an occupational
[1] Ngubane (1977) 77.

[2] Ngubane (1977) 24.

[3] Ngubane (1977) 26.

[4] Ngubane, 25.

[5] Ngubane (1977) 26. 

hazard and the re-use of razors was a risk to the patient’s health. ^[1] Another study, by the same researchers, posited that South African traditional health practitioners are frequently exposed to various viral diseases, such as those caused by the same viruses as in the Mozambican study and a qualitative study was conducted among 30 traditional healers in the Bushbuckridge sub-district in Mpumalanga to establish the use of personal protective equipment: the use of gloves worn during treatments where the practitioner is exposed to patient body fluids. It was established that while 90% of the traditional health practitioners reported the use of latex gloves, the use was irregular. Furthermore, where latex gloves were not available, items such as plastic shopping bags, bread bags, paper and even sticks were used to prevent exposure to patient body fluids, with the integrity of the item also being compromised. This study concluded that traditional health practitioners experience approximately 1 500 occupational blood exposures over the course of their lifetime, but, of extreme concern was the finding that the study group was reported to be infected with HIV at a prevalence of 30% compared to 19% in the general population, meaning a 2.4-fold higher set of odds of becoming HIV-positive than persons with no exposure.[2] While traditional health practitioners in the Mpumalanga study ostensibly display an understanding of the danger of exposure to patient body fluids and have adopted various protective strategies, the use of personal protective equipment is both inadequate and inconsistent from a health and safety perspective and recommended training and messaging strategies, and increased availability of gloves – at low cost or free – is seen as cardinal.[3]

6. Ukugcaba as a prophylactic sexual health procedure

Zulu traditional health practitioners reportedly employ the practice of ukugcaba to make incisions not only on the joints, but also on the head, abdomen, breasts and in the genital area near the labia. Herbal substances are then introduced into the izingcabo to attract men and sustain their sexual satisfaction. This practice has been classified by some as ‘injections’ or ‘immunisations/vaccinations’, since the aim of the practice is to introduce imithi, or traditional medicines, into the body. The statistic offered is that 42% of the women in the study were aware of genital incisions, but only 3% had submitted to this procedure and another conclusion of the research is that while reports are not to be found about this particular practice in and around the genital area in traditional literature, it is posited that since southern Africa an area in which genital mutilation is not traditionally practised, this variant of ukugcaba has not been considered by researchers of genital mutilation;^[4] other authors cited in this study confirm that these practices have been linked with increased transmission of STDs, including HIV.[5]

[15] Audet et al “Occupational hazards of traditional healers: Repeated unprotected blood      exposures risk infectious disease transmission” 2016 Tropical Medicine & International  Health 1476.

[15] Audet et al “Traditional healers use of personal protective equipment: A qualitative study in          rural South Africa” 2020 BMC Health Services Research 655.

[16] Audet et al  2020 BMC Health Services Research 655.

[17] Scorgie et al ‘”Cutting for love”: Genital incisions to enhance sexual desirability and commitment  in KwaZulu-Natal, South Africa’ 2010 Reproductive Health Matters 64.

[18] Chersich et al Association between intravaginal practices and HIV acquisition in women:  Individual patient data meta-analysis of cohort studies in sub-Saharan Africa: Abstract number:  TUAC 204, 5^th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention, July 2009; Hilber AM et al “Intravaginal practices, vaginal infections and HIV acquisition: Systematic review and meta-analysis” 2010 PloS One e9119.

7. Ukugcaba and the use of mercury

Another statistic offered in a study about the use of mercury as an umuthi, or ‘medicine’, in the practice of ukugcaba with this neurotoxic metal then being introduced directly into the incisions, is the confirmation by 59% of the participants in the study group that mercury was indeed used. Some 90% of the study group indicated that its use was for childbirth, not however indicating for which purpose it would be administered during childbirth, for example, inducement of labour or pain relief, an easier birthing process, or other issues. Since elemental mercury readily crosses the placental barrier and may also be present in breast milk, this practice is considered deleterious to the foetus and the suckling child.[1] Another ostensible application of mercury administered by ukugcaba is protection from harm caused by weapons used by persons involved in the local minibus taxi industry, and although this study involves a non-random sample, the assumption was made that this indicated an established cultural practice.[2]

8. Ukugcaba – a purposeful approach[3] at verifying the practice in South African traditional medicine

The assessment into the regulatory framework applicable to the practice of South African traditional medicine also encompassed stakeholder interaction, in particular then a request for affirmation or denial by practitioners of traditional medicine regarding the clinical practice of ukugcaba.[4] This clinical practice was denied as being used in Gauteng, but affirmed as being in use in KwaZulu-Natal; it was denied, however, in the latter locus, as being used introduce imithi into the izingcabo on the head, abdomen, breasts and joints, but also in the genital area near the labia, to attract men and sustain their sexual satisfaction.

9  Conclusion

Taking into consideration the explanation of the practice;[5]  the research conducted in Mozambique that 75% of the study group had carried out the practice on at least four patients in the month preceding the study;[6] the research in Bushbuckridge, Mpumalanga, which concluded that the traditional healthcare practitioner study group is reported to be infected with HIV at a prevalence of 30% compared to 19% in the general population, together with the inadequate use of personal protective equipment, thus presenting a danger to the practitioner and patient; [7] not to mention the research concerning the ostensible practice of ukugcaba on the head, abdomen, breasts, but also near the labia to attract men sexually,[8] it is concluded, unequivocally
[19] Street et al “Metallic mercury use by South African traditional health practitioners:            Perceptions and practices” 2015 Environmental Health 72.

[20] Street et al 2015 Environmental Health 72.

[21] Palinkas et al “Purposeful sampling for qualitative data collection and analysis in mixed method implementation research” 2015 Administration and Policy in Mental Health and Mental Health      Services Research 533; J Bantjes et al ‘"Our lifestyle is a mix-match": Traditional healers talk about suicide and suicide prevention in South Africa’ 2018 Transcultural Psychiatry 77.

[22] Mullinder 237.

[23] Ngubane, 26.

[24] Audet et al  2016 Tropical Medicine & International Health 1476.

[25] Audet et al  2020 BMC Health Services Research 655.

[26] Scorgie et al 2010 Reproductive Health Matters 64.

so, that this practice is egregiously deleterious to the health of the South African traditional medicine practitioner and patient alike and that there exists extreme cause for concern specifically for unborn children where this practice is employed in the treatment of pregnant women. It is not believed that proscribing this clinical practice will be effective, but it is imperative that the national and provincial departments of health launch an urgent action plan to inform all persons practising ukugcaba of the dangers inherent in the practice, namely the increased risk of transmission of HIV, and hepatitis B and C, together with other blood-borne agents; proscription of the sale, purchase or use of elemental mercury for ostensible use in any clinical practice purposes is also essential. This proposed action plan should not only be confined as an exercise in information, but be translated into legal action by promulgating of legal scopes of practice, calling also for the practice only to be permissible to registered practitioners where such persons have undergone a supplementary course of education and training through an approved institute of education and training as may be approved by the Minister of Health. A draft of such a legal scope of practice, developed for diviners, but applicable to any other South African traditional medicine practitioner involved in this treatment practice, might read as follows:[1]

TRADITIONAL HEALTH PRACTITIONERS ACT, 2007

DRAFT REGULATIONS RELATING TO THE CONDITIONS UNDER WHICH A PERSON MAY PRACTISE IN THE REGISTRATION CATEGORY OF AN ISANGOMA 

….

SCHEDULE

Definitions

1. In this Schedule any expression defined in the Act bears that meaning and, unless the context otherwise indicates:

“amakhambi” means herbal medicines;

“amakhubalo” means symbolic medicines;

“basic substance” in relation to the pharmacopeia of an isangoma means any substance from which or out of which a dilution or mixture is prepared or manufactured, or any stronger concentration of such substance for the purposes of making a medicine, specifically umuthi wendabuko (traditional medicine), including, but not limited to amakhambi, amakhubalo, or imithi classified as ebomvu, emhlophe or emnyama, or imithi yenyamazane, but only for the purposes of making an umuthi wokwelapha (medicine for healing), and specifically excluding the making of any umuthi wokubulala (medicine for killing);

“Biodiversity Act” means the Biodiversity Act, 2004 (Act 10 of 2004) and includes the regulations made thereunder;

“blood-dripping” means the insertion of insekane into the vagina towards the cervix in any female person to induce bleeding;

“bloodletting” means the removal of blood from a patient for whatsoever purpose by whatsoever means, except in the case of the procedure of “ukugcaba”;

 
[27] Mullinder 293.

“compound” means the combining or mixing of any basic substances to create an umuthi wokwelapha used in the profession of an isangoma;

“council-accepted” or “accepted by the council” means that the recommendations of the Interim Council have been accepted by way of due process;

“dispense” means the issuing, interpretation and evaluation of a prescription, or the selection, manipulation, preparation, recording or compounding of an umuthi wokwelapha used in the profession of an isangoma for therapeutic purposes, the labelling and supplying of such an umuthi wokwelapha or substance in an appropriate container and the provision of information and instructions to ensure its safe and effective use by a patient;

“formulate” for the purpose of making an umuthi wokwelapha, whether used alone or in combination, means to calculate or determine any umuthi or substances and the quantities and strengths of such umuthi wokwelapha, including the process of preparing or combining such umuthi wokwelapha, and the calculation or determination of the dosage of such umuthi wokwelapha or substances;

“herbal monograph” means an Interim Council-accepted reference standard that is compiled in order to define identity, quality and safety criteria, as well as therapeutic information on any particular umuthi wokwelapha;

“imithi ebomvu” are red medicines;

“imithi emhlophe” are white medicines;

“imithi emnyama” are black medicines;

“imithi yenyamazane” are medicines derived from wild animals;

“isangoma” means a person who is a practitioner registered as such under the Act;

“isangoma esichitha amathambo” means an isangoma who diagnoses using the ‘throwing of the bones”;

“isangoma sekhanda” means an isangoma who is a ‘head’ or ‘ecstatic diviner’;

“materia medica” means any Interim Council-accepted publication in which the properties or the physical character of an umuthi wokwelapha, the natural history of the effect of umuthi wokwelapha on the body in health and disease, the collective symptoms obtained from experimental study of an umuthi wokwelapha or the therapeutics relating to the application of an umuthi wokwelapha in disease, are described;

“Medicines and Related Substances Act” means the Medicines and Related Substances Act, 1965 (Act No 101 of 1965) and includes the regulations made thereunder;

“prepare” means any act pertaining to the making or changing or adaptation or manipulation of an umuthi wokwelapha, substances or ingredients and the preparation of substances or imithi for the purposes of compounding, formulating or dispensing;

“substance” means anything which, whether used alone or in combination in either its original or natural state or in compounded, manipulated or prepared form, constitutes an umuthi wendabuko or forms part of an umuthi wendabuko or which is a basic substance;

“the Act” means the Traditional Health Practitioners Act, 2007 (Act No 22 of 2007);

“ukugcaba” means the procedure where incisions are made into the skin over joints in order to introduce imithi directly into points where the body is believed to be most at risk;

“ukulumeka” means the process of blood-cupping;

“umuthi wendabuko” or traditional medicine is a principal class of medicine used in the process that involves the diagnosis or treatment of a physical or mental defect, illness, disease, deficiency or abnormality in any person, or in the promotion and maintenance of health by the administration or in the prescription of an umuthi wokwelapha, substance or preparation, which may be prepared, manipulated, formulated, or compounded and dispensed by an isangoma;

“umuthi wokubulala” is medicine used for killing; and

“umuthi wokwelapha” is medicine used for healing;

Acts specially Pertaining to the Profession of an isangoma

2. The following are Acts specially pertaining to the profession of an isangoma:

(a)  The diagnosis of any defect, illness, disease or deficiency in any person by divination by any person who has undergone ukuthwasa and is recognised after this process as either an isangoma esichitha amathambo or an isangoma sekhanda;

(b)The treatment or prevention of any defect, illness, disease or deficiency in any person by means of:

(i) any umuthi wokwelapha or substance in accordance with and based on traditional medicine principles or procedures or any other symbolic means of treatment without the use of an umuthi wokwelapha;

(ii) any other umuthi wokwelapha or substance permitted to any isangoma in terms of any applicable legislation;

(iii) health promotion and preventative interventions, including but not limited to nutritional and lifestyle advice; and:

(iv) advising any person on his or her physical or mental health, but excluding:

(I) blood-dripping;

(ii) bloodletting;

(iii) ukulumeka or blood-cupping;

(iv) the practice of ukugcaba unless the isangoma has undergone a supplementary course of education and training through an approved institute of education and training as may be approved by the Minister from time to time by publication in the Government Gazette; or

(v any other act as may be proscribed by the Minister from time to time by publication in the Government Gazette.

3. Subject to the provisions of the Medicines and Related Substances Act, 1965 (Act No 101 of 1965) and the Biodiversity Act 2004 (Act No 10 of 2004), a practitioner registered as an isangoma may, for the purposes of his or her practice:

(a) possess or have under his or her control: 

(i) any umuthi wokwelapha, substance or preparation pertaining thereto;

(ii) substances that are not scheduled or scheduled under the Medicines Act No. 101 of 1965, or substances listed in any Annexure to these regulations;

(iii) substances that are not proscribed for purpose under the Biodiversity Act No. 10 of 2004 or substances listed in any Annexure to these regulations;

(iv) substances, including scheduled substances, that are used as basic substances in the preparation, formulation, compounding and dispensing of umuthi wokwelapha, substances or preparations;

(v) those scheduled substances which are recorded in a council-accepted herbal monograph, herbal materia medica, herbal pharmacopoeia or in any other equivalent umuthi wokwelapha standard, in quantities and concentrations that do not exceed what is reasonably necessary for this purpose;

(vi) such scheduled substances, other than those contemplated in subparagraph (iv), as are determined to be necessary for the practice of umuthi wokwelapha by the Council, at the recommendations of the professional board, and published in the Gazette;

(vii) ethanol, glycerol or other permitted solvents used in the preparation of umuthi wokwelapha; and

(b) prescribe for, administer to, or dispense to, a patient: 

(i) any umuthi wokwelapha, or preparation or mixture of substances, or imithi or substances containing umuthi wokwelapha substances, in any umuthi wokwelapha dosage;

(ii) basic substances and preparations or mixtures of umuthi wokwelapha substances whether they include scheduled substances or substances not scheduled under the Medicines and Related Substances Act No. 101 of 1965;

(iii) other medicines, substances, preparations and mixtures of substances that are scheduled or unscheduled substances including any other scheduled substance or medicine that may be prescribed for the purpose identified in the Schedule.

(c) formulate, prepare, manipulate or compound and dispense: 

(i) any substance, preparations and mixtures of substances that are recorded in a council-accepted herbal monograph, materia medica or umuthi wokwelapha pharmacopoeia or any unscheduled substance for the purpose of making an umuthi wokwelapha;

(ii) substances referred to in paragraph (a) (i) – (vi);

(iii) substances referred to in paragraph (b) (i), (ii) and (iii); and

(iv) any umuthi wokwelapha or a preparation or mixture of substances containing an umuthi wokwelapha, in any umuthi wokwelapha dose or strength.