PYGMIES' IN THE 1990s, CHANGES INFORESTLAND TENURE, SOCIAL IMPACTS & POTENTIAL HEALTH HAZARDS, INCLUDING HIV INFECTION

Executive Summary

In the African Equatorial rain forest region, Pygmies are known by various names but all share the same history of dependence on forest resources . In Uganda, Pygmies number about 3000 persons. The forest resources have been gazetted for other purposes and are now considered "protected areas". Furthermore, socio-cultural, environmental and political changes have teamed up and denied Pygmies' access to forest resources. Agriculturists and nomads have taken up more land for cultivation and grazing, and conservation movements have restricted the Pygmies from utilising forest resources. Thus , the Pygmies' response to non-forest based livelihood could expose them to life- threatening activities and situations, including the construction of STDs and HIV.

Most Pygmies in Uganda do not have access to modern health care facilities, and yet they indulge in
" unprotected" sexual activity because of general lack of health/sex education. The Pygmies still adhere to the deep rooted custom of widow inheritance, and polygamy is socially accepted. Sex- working has penetrated the Pygmy communities , mostly in urban and trading centres. "Drinking a friend's blood " is also common among Pygmies. This is a means to cement the relationships between friends. Pygmies ' incomes are dismally minimal and can not afford medical services which are also relatively not accessible to many Ugandans. There is conspicuously excessive alcohol consumption among the Pygmies, and this is a pre- disposing factor for HIV transmission.

Health workers' attitude has been observed to be a disincentive and distracting the Pygmies to visit and consult the bio-medical health services. Even the Pygmies do not trust anyone with their lives. They have a mistrust towards their neighbours. The Pygmies tend to share the medical drugs with sick relatives contrary to the doctor's prescriptions. The use of herbs and strong belief in the existence of ancestral spirits are considered supreme to medical health care services by Pygmies. Thus the Pygmies do not attach much importance to bio-medical practices. They attribute sickness and death to displeasure of ancestors, hence the practice of a number of rituals of appeasement are therefore important --the work of herbalists and traditional priests.

There are still a number of prejudices heaped on herbalists by Christians and medical personnel. Herbalists are considered as backward, uncivilised and witch doctors, and yet many people still "flood the market" of herbalists. It is observed that inspite of the bad history and other shortcomings, the ethnomedical practices and remedies are increasingly becoming popular. Literate persons have started joining the profession of traditional healers.
TABLE OF CONTENTS
Executive Summary ……………………………………………..……………………
Background information ………………………………………………………………
Pygmies’ Traditional Lifestyles and Recent Forestland Tenure Changes……….
Section I: Pygmies Population at Risk for STDs…….………………………….
1.1.0 Estimating HIV/AIDS among the Pygmies of Uganda…………………………
1.1.1 Condom Use ……………………………………………………………………
1.1.2 Widow inheritance and susceptibility to HIV infection ……………………….
1.1.3 Commercial Pygmies-Sex-workers and the Risk of STDs …………………….
1.1.4 Blood Relationship ……………………………………………………………..
1.1.5 Pygmies’ employment, poor working conditions and increased health hazards …….
1.1.6 Pygmies and alcoholism …………………………………………………………….

Section II: Pygmies’ Access to Biomedical Health Care Facilities ………………….
2.1 Pygmies and Sexual Taboo ………………………………………………………….
2.2 Pygmies access to health education …………………………………………………..
2.3 Weakened Social Ties and Weakened Access to Healthcare ………………………..
2.4 Lack of money and poor access to biomedical health care facilities ………………..
2.5 Pygmies’ Attitude to and of Medical Personnel ………………………………………
.
Section III: Herbal Therapies and Alternative Healthcare among the Pygmies ……..
3.1 Pygmies’ Interpretation of Ill-health, Disease and Reliance on Herbal Therapies …
3.2 Pygmies’ Health Seeking Behaviour, and Self Medication ………………………..
Additional “assaults” to the Pygmies traditions ……………………………………
3.3 Prejudices about Herbal Medicine ……………………………………………………..
3.4 Recent developments in the traditional/ herbal medicine …………………………..

Concluding Remarks ……………………………………………………………..
References …………………………………………………………….
PYGMIES' IN THE 1990s, CHANGES IN FORESTLAND TENURE, SOCIAL IMPACTS & POTENTIAL HEALTH HAZARDS, INCLUDING HIV INFECTION

Background information

Pygmies’ Traditional Lifestyles and Recent Forestland Tenure Changes

Within the African Equatorial rain forest region, the Pygmies people are known by various names. For example in Cameroon some are called Baka, Aka, or Tikar. In Burundi and Rwanda they are either Batwa, Impunyu or Twa. In Democratic Republic of Congo, some are called Mbouti, Cwa, Sua or Efe. In Uganda the Pygmies population types comprise of the Sua, Mbouti, Abayanda and Batwa. Without exception, the majority of each group of Pygmies in the region live within or at least around a once forested area (Kabananukye & Wily, 1996).

In Uganda, the Abayanda (who are the Pygmies majority, over 70%) and the other Pygmies groups number about 3000 persons, and have traditionally had a hunter-gatherer lifestyle. Their economy and mode of livelihood depend(ed) on forested lands. They hunt(ed) wild animals, gathered fruits, nuts, roots, and collected honey, insects, mushrooms in the forests’ diverse ecology. Some of these forest resources were traditionally bartered for agricultural produce, such as bananas, tobacco, local brew and meat from domestic animals. In this way, both the forest dwellers and their neighbours, traditionally had an important interaction with the forest resources. Through a reciprocal interaction with nature, the forested lands have been significant providers of local communities' subsistence. Pygmies groups are believed to have traditional systems (indigenous knowledge) of natural resource management that reflect centuries of adaptation in the search for a sustainable livelihood.

Recent (early 1990s) socio-cultural, environmental and political changes (MPED, 1991) have teamed up to undermine many local communities’ including traditional forest dwellers’ habitation and dependence. Some of these factors are of a national character, others take up the international dimension. For example:

¨ Population pressure in Uganda is one of these factors. Agriculturists and nomads have increased in numbers and this also increased the need for more cultivable and grazing land. Forested areas were opened up for these needs. In this process, forest dwellers and other forest dependant communities were displaced. Unlike some of the local communities that owned land communally, the “new comer” agriculturists and nomads privatised the land. Individualisation of land crippled the traditional forest dependant communities’ access to their traditional hunting, grazing and gathering grounds.

¨ Also during the early 1990s, conservation movements affected Uganda’s land tenure. Some forests, especially Mgahinga, Semliki, Echuuya forest reserve, and Bwindi impenetrable forest in western Uganda were gazetted as protected areas and turned into national parks. For example, Echuuya forest attained a new status as a forest reserve. This status greatly limited the Pygmies’ traditional form of forest habitation and utilisation: ie hunting and gathering. As forested lands were gazetted, the Pygmies and other forest dependant communities were detached from forests, and found themselves in non-forested environments. The non-forest environment has posed diverse challenges. Among others, it requires them to establish ‘permanent settlements’ as part of their new non-forested culture. Implications for this are numerous. It necessitates getting land on which to settle and perhaps put up "permanent" houses, as well as establishing some agriculture or any other cash paying economic activity. Acquisition of land, agricultural tools and implements require cash, which calls on the Pygmies to have at-least some ‘seed money’. Unfortunately this seed money has not easily been available to the Pygmies.

¨ Having stated that the Pygmies are essentially a forest centred people, the gazetting of their forests was not a welcomed move. Indeed when the Pygmies were losing their forests in Uganda, like most other developing countries, was undergoing major social and economic transformations that included the structural adjustment (SAP[1]) programs. Concern over the impact of SAPs on the populations of developing countries is not new. SAPs involve, among others currency devaluation, strict control of money supply and credit, cuts in government spending[2], (especially on the provision of social services), harmonised tariff regimes, removal of trade and exchange controls and de-regulation of prices of goods and services. Unfortunately the impacts of these measures later translates into severe impacts on local community concerns, such as major cuts in the education and the health sectors.

Given this context of economic changes and changes in forestland tenure, a fundamental concern arises from the Pygmies inaccessibility to forest resources in Uganda. As many forested areas are converted into cultivated or pasture lands, while others assume new status as "protected areas" or national parks, the Pygmies' response to non-forest based livelihood could expose them to life threatening activities and situations, including the development of STDs and HIV infection, given that this is a community with perhaps the lowest, if any, access to health care facilities.

This paper explores specifically the challenges to the health of Pygmies population. Section (1) looks at the Pygmies’ risk for STDs, including AIDS. Section (2) and (3) examine the Pygmies’ poor access to bio-medical health services and their reliance on traditional health services and healing systems, both of which are factors constituting additional health hazards.

Section I: Pygmies Population at Risk for STDs

1.1.0 Estimating prevalence of HIV/AIDS among the Pygmies of Uganda

Uganda Government's response to HIV/AIDS prevention among the Pygmies has been limited (Kabananukye 1995). The Uganda government’s focus has been on prevention rather than care, treatment and support services for people already infected. Although sexual activity with more than one partner has been singled out as one of the risk factors for HIV transmission, it has also remained a common practice among the sexually active adolescents[3] and adults in Uganda (Olowo & Barton, 1992).

There is a high incidence of HIV/ AIDS among the rural population of Uganda (UNICEF, 1996). The area along the main district highways and trading centres have been identified as high transmission areas. There is a high incidence of high risk sexual behaviour eg people having multiple partners. In some districts (including districts which host the Pygmies) the true picture of HIV/AIDS incidence is not known because there are no proper records and most affected people do not report to health units.(Asingwire, 1992).

It is observed that the number of adolescents with Sexually Transmitted Diseases (STDs) which include the fatal developments of AIDS, has been increasing over the years in Uganda (STD/AIDS Control Programme - Ministry of Health 1996). Other studies indicate that the numbers of adolescents engaging in early sexual activities is increasing (Kaharuza, 1991, and Barton and Wamai, 1994) and with multiple sexual partners (Turyasingura, 1989, 1991, Ssamula et al, 1991 and Uganda Demographic and Health Survey (UDHS), 1995). For instance, 70% of adolescent mothers had their first sexual encounter, (mostly “unprotected”) between the ages of ten to fourteen years (Agyei et al, 1991, and Bagarukayo et al, 1993). This has been associated with early puberty, economic hardships, urbanisation, and the weakening of traditional structures that informed on and regulated adolescents' sexual behaviour (Zirembuzi, 1991).

Sexual relations with prostitutes are cited as a probable source of infection by 50 to 90% of STD patients in Uganda (Asingwire, 1992). In this scenario, it may be plausible to estimate an even higher percentage of infection among Pygmies prostitutes and their clients. This is especially so considering the fact, that over 90% of all Pygmies in Uganda do not have access to modern health care services (Kabananukye, 1998).

1.1.2 Condom Use

In Uganda, nonuse of condoms is associated with a wide range of explanations. According to Rwabukwali and Kirumira, (1990), a number of people reason that condoms are cumbersome, unsatisfying, insulting to a partner, mistrustful, depriving, very expensive, rupture and may “stick into the uterus”, cause death and are deterrent to child bearing. For example, among the Baganda, proper sex must involve vaginal penetration by the penis, skin-to-skin contact and mixing of vaginal and seminal fluids (Rwabukwali & Kirumira, 1990). To some persons, especially girls and married women and men, condoms are rejected because, to them, their use signifies mistrust of the partners' fidelity (Kisekka, 1989). In addition, young girls and women often shy away from discussing with their partners issues related to infidelity or preventive measures like condom use either for fear of severing the relationship or because men threaten or use actual violence to compel them into unprotected sex (Maposhere (cited in Mpungu, 1997).

“Unprotected” sexual activity, highly exposes adolescents sexually transmitted infections (STIs)’ unwanted pregnancies leading to among others, abortions, dropping out of school etc. All these have negative health and social implications for individual adolescents, their families and the community. In addition adolescents may be emotionally unstable and financially incapable of looking after themselves and their babies. Babies born to adolescent mothers are not only high risk births from the perspective of both the mother and child, but they are also high cost births considering the associated negative effects on women’s quality of life and their role in society.

Desire for marriage, remarriage, and child bearing is common especially among adolescents and young adults. Ideological dogma derived from religion, particularly Catholicism, and imagined displeasure of protected sexual intercourse tends to discourage people from using condoms (Olowo-Freers & Barton, 1992). Apart from urban areas and townships, the remote areas of Uganda are under served in terms of condom distribution and worsened by high unemployment and poverty. Thus, a number of individuals who may wish to protect themselves during intercourse using condoms are constrained by condom shortage and lack of money to purchase any (Ssekatawa & Kiirya, 1997).
Uganda is one of the Sub-Saharan countries with the highest prevalence of STD/HIV transmission. The hetero-sexual contact constitutes about 90% of HIV infections. To tackle this wide transmission, Uganda has three options. Abstinence, faithfulness and condom use. It is evident that to break the chain of transmission, the sexual active population have to change its sexual behavior (pattern). Behavior change per-se has proved very difficult and slow. However, on the other hand the use of condoms to prevent transmission of STD/HIV has proved to be both effective and easier to adopt than other options of behavior change. It is however observed that in a community with low access to public health information, and knowledge about condom use, if they engage in unprotected sex they are susceptible to HIV infection.
Soucre: Kabananukye, 1998









1.1.2 Widow inheritance and susceptibility to HIV infection

It has been observed, that the Pygmies' adherence to the deep-rooted custom of widow inheritance may also increase their risk for STD and HIV infection. When a man dies, his brother is expected to "cleanse" the death by having sexual intercourse with the widow and to take full responsibility of both her and the children. A similar potential risk occurs where there are multiple partners, especially so among polygamous marriages. Polygamy is a socially acceptable phenomenon among the Pygmies and other communities in Uganda.
For example, polygamy is also commonly practiced by the Banyankole, Langi, Basoga and Madi. Ntozi & Kabeera, (1991) found that about 27 - 30% of the married men in Ankole and Lango are polygamous (; Curley, 1973), while among the Madi, about 20% of the married men and 33% of married women are in polygamous unions (Schopper, 1991). According to Olowo-freers & Barton (1992), barrenness, poor marital relationships and religious customs are key determinants of polygamy in Uganda. Treatment of barrenness is commonly practiced by inserting herbs in vagina through direct sexual contact (using the penis) with the traditional healer. And among the Karamajong of Jie ethnicity, sisters of the deceased often chose the person to sexually inherit the widow (Lamphear, 1973).

It is also common for the husband to take another wife when his wives are pregnant, practising post partum abstinence and or when women fail to bring forth children, especially male children. In this regard polygamy becomes a potential risk for STDs if one of the spouse engages in extra marital relations.

1.1.3 Commercial Pygmies-Sexworkers and the Risk of STDs

With the increased restrictions (as some forests attained a National Park/game/forest reserve status) in the use of forest and their resources, the Pygmies find themselves with nothing to sell so as to meet other demands of life. Some females resort to take up commercial sex as a means of earning a livelihood. Many STDs for men and women tend to be asymptomatic and hard for females to recognise. This is aggravated by the fact that female Pygmies do not seek modern treatment the reasons being lack of money to meet health service charges (in a cost sharing system for medical services). The health unit are also distant and lack equipment and drugs. It is within this context that women Pygmies are not only likely to infect their husbands, but also infect their clients, both women and men.


According to a study, the mean age for first sexual intercourse was 16.6 years for males and 16.2 for females in Uganda. In the 15-19 year age group, 43% of the males and 48% of the females are sexually active. There is a noticeable increase in the proportion of 15-19 year age group delaying to have sex. 18.8% of the respondents currently-married were having regular sexual partners other than their spouses. There are more females than males in marriage relationship in the younger groups (15-24 years). Enabling situations for having sex for the first time were; schools (49.9 males, 50.1 females); wedding (3.05 males, 69.5 females); disco dance (53.2 males, 46.8 females); funeral rites (49.1 males, 50.9 females); drinking place (60.0 males, 40 females); others (30.5 males, 69.2 females).
Source: Kabananukye, 1998







Further studies such as Lubega (as cited in Olowo-Freers and Barton, 1992) found that many sex workers in Uganda are adolescents and young adults, who entered this trade to exchange sex for income to meet their shelter and nutrition requirements. He further found that prostitution is an addittional source of income for a number of low paid workers such as bar maids. Meanwhile, widows, especially those who already know that they have HIV/AIDS adopt prostitution as a strategy for obtaining material and financial support for their children (Vander, 1990).

It has been observed that more Pygmies’ women are becoming involved in the commercial sex trade (Personal observation, 1999). Thus rendering them vulnerable to sexually transmitted diseases (STDs) and HIV/AIDS infection. The problem is further exacerbated by the lack of access to health care facilities and information.

1.1.4 Blood Relationship

Among the Pygmies, there is a strong tradition of establishing blood relationships. The process involves what is called “drinking a friend’s blood”. Friends are tied in a blood relationship by allowing each person to taste (lick) each other’s blood. With the use of a razorblade, one’ stomach, (especially the part under the belly button), is cut so that some blood can ooze out. A roasted potato is used to pick some of the blood, and eat it. This is done to cement the relationship. This practice is high risk for HIV transmission.

1.1.5 Pygmies’ employment, poor working conditions and increased health hazards

An analysis of labour rewards among Pygmies shows that in Kabale district,Uganda, out of the total population (600 Pygmies), only 2 people are employed on a monthly basis. Only these can expect an income at the end of each month. The rest of the Pygmies are engaged in occasional and marginal employment, such as transportation of other peoples’ agricultural products from farms to markets; fetching water and fuel wood; collecting vines and handcraft materials from forests. Prostitution and begging are also taking up a considerable percentage of Pygmies’ females activities. Available data shows that 95% of 600 Pygmies in this area are landless. They even do not own farm tools and this is why for example, for a days labour, each of them is paid 300/= to 500/= per working day. This amount is 1.5 times or almost half the amount that other labourers who own farm tools earn per day (Pygmies are paid less as the balance is deducted to cater for wear and tear, depreciation of farm tools that land lords lend them). In general terms therefore, in the absence of education and training, and specialised bargaining skills, coupled with the problem of landlessness, the Pygmies livelihood appear to render them vulnerable to absolute poverty has a significant impact on their health and wellbeing.

Because of the poor economic situation among the Pygmies, and in an attempt to meet financial demands, it is becoming increasingly common for Pygmies men (especially because they do not have bargaining skills) to take up employment far away from home. It may at times necessitate one staying away from home for several days and months. This destabilises the family, since the man is usually the one supposed to be catering for the family’s sustenance. It may require the woman to return to her family.

1.1.6 Pygmies and alcoholism

Excessive alcohol consumption among Pygmies appears to be on the increase, and an important predisposing factor for HIV transmission in Uganda. Sale and use of alcohol is mainly in bars/pubs, alcoholic beverage shops and hotels. Individuals who are involved in this business often prostitute with the frequent alcohol consumers as a side source of income. Malamba (as cited in Olowo-Freers and Barton, 1992) found that a majority of people involved in brewing and selling alcohol are women while the biggest consumers are men. A study conducted among Makerere University students, cited in Barton and Wamai (1994) shows that three quarters of undergraduates consume alcohol, and of these, at least 90% begin consuming alcohol at an early age. According to Hooper (l987), it is an increasingly common behaviour for people under the influence alcohol to buy sexual favours from barmaids. Sometimes unprotected sex is practiced with a lack of awareness of the implications ie transmission of STD. Wallman (1996) found that men and women (especially married) often visit bars, pubs and hotels to have extra marital sex. Truck drivers and other persons often use these places as meeting points with their partners, while bar maids, engage in prostitution to get extra income to supplement monthly wages.

The lack of regular income as well as, the general instability of their situations lead some Pygmies to resort to alcoholism, and to engage into multiple sexual relations. It appears that some Pygmies work for two to three days in the week, where they are remunerated with 5-litres of Urwagwa or Umusururu (local brew). This condition has bred apathy and appear not to be easily overcome. This could partly explains why over 90% of all the Pygmies; men, women and children smoke and at times chew Enjaga Hemp[4], cannabis gigantea sativa (Kabananukye, 1998). In addition, it has also been observed that Pygmies poor dietary habits predispose them to the malnutrition[5], and therefore expose them to high disease prevalence in the community.

Section II: Pygmies’ Access to Biomedical Health Care Facilities

2.1 Pygmies and Sexual Taboo

Among Pygmies inUganda, matters regarding sex are never discussed between children and their parents. It is a taboo for adults to talk about sexual matters when children are listening. Besides, at the time of marriage, girls are sent to their close relatives, especially aunts to be coached on matters regarding sex. It is understood that, among other things, girls are taught how to respond to her husband's sexual demands. The bride to be is also taught how raise the "husband’s” children and told never to say no to her husband's sexual demands. The allegedly supreme role of a man in a household, coupled with the Pygmies communities low regard for a woman's role in society, lead Pygmies women to develop low expectations for themselves. This further leads to lowered self-esteem and aspirations. According to Pygmies women, (Kabananukye, 1998) these are issues that may render them more vulnerable to a diverse spectrum of environmental and health hazards including STD/HIV infection.

2.2 Pygmies access to health education

Educational[6] attainment among Pygmies is still extremely low (Kabananukye & Wily, 1996). Educational attainment among the Pygmies show that for instance, out of 600 Pygmies from Kabale district, only 5 people have received formal education lasting longer than 4 years. This implies that in the absence of education and training, most Pygmies here may not be accessing health education, including HIV/AIDS messages. Yet some of these HIV/AIDS information- education, and adoption of safer sexual behaviors such as sex avoidance, delayed sex and marriage, condom use, and non-penetrative sex or non-sexual-fluids exchange which have been widely advocated as ways for reducing HIV transmission in Uganda (UNICEF, 1996).

2.3 Weakened Social Ties and Weakened Access to Healthcare

The “weakening social ties” have also been observed to be contributory to the Pygmies’ health care. The Pygmies have been pressurised and dispersed to come out of the forests. They are now living in scattered settlements as squatters on other peoples land. They work most of the time for their landlords. As one elderly Pygmy, Munyagasozi puts it, some of the land lords deny the Pygmies time and opportunity to attend to each other, especially in times of health care. Since most of them still cling to relatives, friends and traditional birth attendants for treatment than modern health care, a break or disruption in their traditional social relationships greatly affects their health access and delivery systems. The Pygmies people suffer discrimination where they live, every effort is made by their employers and landlords to admit the inferiority of their culture. This is to the extent that their culture has now been condemned to secrecy.

2.4 Lack of money and poor access to biomedical health care facilities

The ongoing anthropological study of Pygmies and their communities (Kabananukye, forthcoming) suggests that the Pygmies do not usually attend medical health care services because they lack money to pay for the services (user charges) and awareness about the advantages of modern health care services as compared to the traditional healing techniques. This lack of access to health care services also facilitates the transmission of STDs and HIV.

Access to health care services and ‘cost sharing scheme’[7] has proved too expensive for the Pygmies to afford. This is unlike the services of herbalists. There is more room to negotiate the terms of payment. It is observed that the traditional herbalists were not expected to refuse treating a patient if he (the patient) had no material wealth, and indeed their remuneration were expected to be minimal and within the patients’ reach and affordability. The mode of payments in medical service delivery systems is cash on delivery of the services. This could even be in terms of agricultural produce, bundles of firewood, meat that has been hunted or some quantities of honey collected. Forest resources were used as a medium of exchange. This is considered as a convenient mode of payment considering the fact that markets in the rural areas may not be easily accessible.

Even when the Pygmy is sick, (except in extreme conditions), one has to go on a begging or search for work, in order to be able to get some money to pay for medical services. The Pygmies have a very limited culture of saving (and investment) for ‘the rainy days’. It is what one works for that constitutes for the day’s meal. Moreover, in the process of moving from place to another in search of food, there are more chances of forgetting to take the drugs as per the doctor’s prescriptions.

2.5 Pygmies’ Attitude to and of Medical Personnel

The poverty level among the Pygmies is generally high. They cannot afford to raise money to meet costs for the medical health services. Due to poverty they are in most cases poorly dressed in rugs and dirty clothes. This makes them feel shy and therefore fear to approach medical personnel who are better clothed. This aggravates the Pygmies’ discrimination and shying away from accessing medical services. Furthermore, most Pygmies do not have access (in terms of distance)

Nalwanga Sebina et.al (1988), NCC (1994), UNICEF (1989), Koblinksky et al (1993), Kirumira et al (1993) elaborated that transport has been a problem when seeking health care. Indeed, Koblinsky et al. (1993) noted that long distances are obstacles to prenantal care. Ninety six percent of mothers in Nigeria, South Asia, Central America and among Navanjo Indians of New Mexico cited inability to use health services due to long distances. Similarly, studies in Uganda indicated that it is approximately 2 hours to walk to the health centre and the nearest health unit for majority of sick women was more than 2kms away. UNICEF (1989), NCC (1994) noted that because of limited public transportation in rural areas and some urban areas. Wheel barrows, bicycles and sometimes cars are used but only when a patient has money. In most parts of the country, there are no ambulances going to collect the sick, private transport is very expensive or not available in rural areas. In fact, the problem is compounded by poor distribution of women oriented health facilities Kirumira et al (1993). These findings do not explain whether the situation has been worsened by SAPs.
Kanyesigye, J. Oct. 1995













to medical health care services because the health centres are far from their local residences, and there is poor communication network.

The health service management system in Uganda is limited in delivery, and most of these are located in urban centers. This is because the necessary infrastructure (roads, buildings, laboratory services and manpower) is not in place. Thus hindering the efficient and effective functioning.

In IYECA's preliminary findings, it is observed that the terrain of these districts (Kabale inclusive) is characterized by high hills. Infrastructure facilities, such as roads are in a poor state. Considering the uneven distribution of public health centers, and the very few NGOs operating in the field of AIDS control, a number of problems have been identified: Lack of knowledge about condom use; lack of condom distribution outlets and lack of trained counselors. The situation is worse in and around Bwindi Forest, Mgahinga Gorilla National Parks and Echuuya Forest Reserve where health units are inaccessible and the road-networks are in a sorry state. The rural people in these areas have been observed to be very poor in terms of little parcels of fragmented land, and with no reliable cash crop, hence no regular income and saving. If the AIDS epidemic is to be defeated, there is need for a comprehensive AIDS control program that adopts a participatory approach, so as to reach the such rural poor communities.














Health workers' attitude has been observed to a form of disincentive and distracting the Pygmies to visit and consult the medical health services (Kabananukye, op cit). Although the medical personnel are mandated to visit household in their area of operation, a visit to the Pygmies’ household is something uncommon. There is essentially a clear lack of encouragement on the part of medical personnel who offer them services to the Pygmies. Even in the cases where the Pygmies have visited medical health units, they are not given encouragement to come back for regular or further treatment and follow up treated cases to evaluate the success or failure of the service. There are no Pygmies trained medical practices who would have encouraged them to take up the medical services. Thus the Pygmies do not see the need to go back to the health centres for further follow up. There is therefore no quality assurance in the services provided.

The generally poor attitude of medical staff towards Pygmies, coupled with Pygmies’ low literacy makes some of the Pygmies fail to trust anyone with their lives. They believe that non Pygmies cannot have good intentions for the Pygmies. As one Kanyarutookye puts it: "How can a non -Pygmies look between the legs of my wife ?". Kanyarutookye is one polygamous Pygmies who has resisted even taking any of his three wives for medical treatment. This demonstrates the level and extent of mistrust the Pygmies have towards their neighbours.

Finally, if one Pygmy gets the medical drugs, the chances of sharing it with relatives that are sick are very high (80%). The chances of taking the drugs contrary to the doctor’s prescriptions are also very high (85%) (Kabananukye, 1998).

Some of the Pygmies socio-cultural barriers and traditional beliefs are also observed as a contributory factor to their inability to access health care services. The use of local herbs and existence of ancestral spirits are considered supreme and superior to medical health care services. Even in the cases where the Pygmies use medical services, it is believed that some specific diseases can only be healed locally using herbal medicine (among Pygmies) and other healing systems. For instance they believe that back-aches can be healed through sexual relationship with a fellow Pygmy, hence low response to health care services. Sexual intercourse with Pygmies cures (one becomes immunised) backache. This belief holds true among the Pygmies and their neighbours alike. Other diseases that can be treated using herbal medicine include asthma, malaria, diabetes, rheumatism, conjunctivitis, and diarrhoea.

Section III: Herbal therapies[8] and alternative health care among the Pygmies

3.1 Pygmies’ Interpretation of Ill-health, Disease and Reliance on Herbal Therapies

A recent Survey (Kabananukye, 1999) showed that most Pygmies (90%) strongly believe in the use of herbal therapies. They deal with illnesses themselves, or seek the professional help other known Pygmies herbalists. The herbalists’ treatment, care and explanations are understood and are in accordance with known views of how sicknesses should be dealt with. Peoples’ illnesses are thought to be the responsibility of the displeased ancestral spirits and gods. Pygmies believe that every sickness and every death has a cause. The main cause of sickness is attributed to angry and displeased ancestral spirits. The gods’ displeasure manifests itself in such case of sicknesses and other misfortunes. It is in their extreme annoyance, that may lead to the death of the patient, or striking a series of misfortunes on the whole community. Thus, to this extent the Pygmies do not attach much importance to biomedical practices. They thus resort to herbal therapies.

Pygmies have their traditional herbalists, who still access herbs from the protected areas. Although there is no official permission to allow them to harvest herbal plants, soils, and insects from government reserves, some Pygmies herbalists have established good neighbourliness with the forest and game park guards. This is for purposes of soliciting permission to access the forests. This is particularly true in Echuuya reserve and north Bwindi Impenetrable forest national park. In Nyakabande, Kisoro district, Mzee Majwi has established a medicinal herbal garden. However, he argues that certain herbs require to grow in a forest environment, so he has to continue getting them from the forests.

The Pygmies’ health care management practices (Kabananukye, 1998) show that, from their perspective, reliance on traditional therapy for health-care is still commanding a considerable (75%) respect. The Pygmies’ traditional healers remember and administer a lot of herbal remedies to a multiplicity of illnesses. This is illustrated with the central role of traditional birth attendants (TBAs or Abazarisa) which is strongly believed in among the Pygmies. The Abazarisa are specialised with skills and medicine which other women do not know. In cases of child birth complications such as prolonged and abstracted labour, amenorrhea, retention of the placenta, among others. The Pygmies feel the role of Abazarisa in their community is indispensable which indeed may be true. Even when a mother visits a medical center for child delivery, there is still need to consult such people for post natal attention (care) and healing the ‘woman’s womb after delivery’. They fill the herbal medicine heals better and faster than the modern medicine.




3.2 Pygmies’ Health Seeking Behaviour, and Self Medication

Regarding the herbal healing therapies, the Pygmies reveal (Kabananukye, forthcoming) that they have traditionally been practising self medication. In the words of Hooshabarama, -a Pygmy mother of four: ‘When we are sick. We visit a herbalist. The herbalist at times advises you to keep harvesting and administering specific herbs over a certain time period. For us mothers, once you do it (treatment) once or twice, you do not have to visit the herbalist at every time that your child is sick. You only go when the sickness is severe or when the sickness is unknown’. This is a form of self-medication –using herbs. This practice is stretching from the herbal medicine also to include, medical health therapies. It is shown that there is a high sharing concept among the Pygmies. So even when one falls sick, they seek drugs from neighbours. To some Pygmies (70%), ‘medical medicines ought to work like magic.’ One type of medicine is thought all round therapy for a number of illnesses. Sharing of drugs for such an illiterate community without technical expertise may indeed lead to drug abuse with adverse consequences on their lives.

The Pygmies’ relocation and settlement outside the forests is also believed to greatly affect their traditional social structures, which again has multiple effects of herbal knowledge and practice. Whilst still in the forests, Pygmies’ traditional community living structures were defined in clusters of friends and relatives. Each group of close friends and relatives lived near each other. This was important for it served many functions including health issues. The community bands were also an important institution for social support and lending a hand in times of need - happiness or sorrow. Through these institutions, Pygmies would express their emotional succour, as well as attend to each other in times of sickness. Herbal medicine specialists would be consulted in close vicinity. With their eviction, and there having been no system in place to resettle them in community structures they were used to-a replica of their forest based systems, has furthermore contributed to the erosion of Pygmies’ health management practices. This may give way to opportunistic infections that promote HIV.

Since the idea of seeking medical assistance is anathema to some Pygmies, they deal with illnesses themselves, or seek the professional help of one or other known Pygmies’ herbalists. Example, the causes of childlessness, child-sickness and death are an indication of displeasure on the part of the ancestors who feel neglected. Rituals of appeasement are therefore important, and allegedly an important part of the herbalists work. This generally involves the offering of a sheep or pot of local brew. As is common among traditional societies, cures administered are often through the practice of leaching, cutting of ones skin and sucking out the poisoning agent (okurumika).
The Okurumika can be compared to the, male circumcision practiced by the Bakonjo, Bamba, Bagisu, Sabiny and Samia, and which is used as ritual to initiate boys into manhood, sex and symbolize courage (Kisekka, 1989). According to Pande (1995), individuals who undergo circumcision have wounds that provide good grounds for HIV infection, especially if it is done one after the other or if the knife is not sterilized. There is opposition to use of separate or sterilized circumcision knives due to the belief that it is anti-culture and dulls the blade respectively. Meanwhile, female genital cutting (FGC) which is practiced by the Sabiny is usually done in small groups using the same knife (Vaizey, 1995). A number of girls and women who brave this practice encounter excessive bleeding, genital ulcers and complications during labor, and painful penetrative sexual intercourse. These situations also facilitate infertility and transmission of HIV/ STD (Kakuba, 1997; McNamara, 1995).

Like in many indigenous cultures, knowledge about medicinal plants has survived in its purest form through complex rituals of passing it over from generation to generation. A lot of irreplaceable knowledge of the healing properties in medicinal plants is dying out with elder generations without being recorded for future record purposes. Furthermore, some important rituals are no-longer taking place. Totems and myths nolonger hold since most of the traditional institutions that upheld them have been eroded, especially after the relocation of the Pygmies from the forests.

Additional “assaults” to the Pygmies traditions

Some local initiatives (Bwindi-Mgahinga gorilla TRUST, Adventist Development and Relief Agency, (ADRA), CARE Uganda, and Church of Uganda) are attempting to alleviate Pygmies' plight. These initiatives include sustained effort to integrate them into contemporary society. A lot of these efforts also aim to eradicate what is thought to be "backward and unsustainable activities", or what anthropologists would rather label as Pygmies culture itself. To downplay the Pygmies’ rich indigenous knowledge and practices, including herbal practices, there are various attempts to bring these people ‘into the main stream of development’. This is put into better perspective by looking at CARE's work on Multiple-use model. In this model, local communities are "consulted" and given identity cards and timetable, spelling out when (time of the day, day of the week) one may visit the forests (to collect herbs, vines, fuel-wood, etc). The compatibility of this arrangement with the Pygmies’ traditional forest utilisation is unclear, especially considering the fact that the Pygmies need for the forest resources is a continuous process that may not stick to specific time schedules.

3.3 Prejudices on Herbal Medicine

Like in many traditional societies, the Pygmies’ traditional healers have in the recent past not been fairly treated by policy and decision makers. This is in-spite of the fact that the traditional healers in general have been attending to a very big (conservative estimate put it at 80 % ) proportion of the population. There are still a number of prejudices heaped on the herbalists. They are considered as backward, uncivilised, equated to witch-doctors. Medical personnel also regard traditional healers arrogantly. It is appreciated that herbalists earn their living from such traditional knowledge. Their source of income, prestige and community respect would be at risk if their herbal secrets become common knowledge. This is why most of them are reluctant in having their knowledge recorded for reference purposes. “Some people will flood our market, by freely reading and practising what we are doing.” Kabananukye, (1998) quotes one respondent-herbalist.

Kabananukye, (op. cit) makes reference to how Christian religion[9] has recently worked against traditional healing practices of the Pygmies. When some of Pygmies herbalists converted into Christianity, they were instructed to destroy their herbal plots as a manifestation to turning to the right faith. This went as far as demanding that their converted believers should bring their medical equipment and tools and burn them before the church congregation in order to demonstrate the real depth of their Christianity. In this scenario, plants of medicinal values no longer grow in the neighbourhood of the converted Christians. This fact together with the population pressure, deforestation and draining of wetlands, herbal plants have greatly been reduced which renders the Pygmies access to herbal therapies more difficult.

Increased demand for traditional healing systems

Importance of traditional health practices was stressed further by the fact that at times the patients do not get the necessary drugs at the health centers. The patients are requested to bring their own papers for prescriptions. In Bundibugyo, The BaSua Pygmies showed me exercise books, that they have to buy so that the medical workers could have where to write the prescriptions. It was observed that once the book is lost, they usually harassed and scolded. This attitude makes the Pygmies detest the whole exercise of going to the health units.

There are usually long lines-queues in the health centers. Even when the Pygmies are queuing up, the Bafumbira, a neighbouring tribe, usually displace them from the queue, so they end up delaying on the queues. “Accessing medical services is tedious and time consuming”. Said Uwayezu Babona, a mother of three from Kisoro district.

Increasing demand for herbal therapies has been attributed to a number of factors. For example, the traditional healers better future as medical health is hit by problems . In a study of maternal health care in south western Uganda, Neema, 1992 has shown that only 20% of the women deliver at the health unit, 34% are delivered by traditional birth attendants 46% by a relative or alone. This further emphasises the role of the traditional healers. She attributes this to uneven distribution of the few health facilities located just at the main road thus less access to the rural majority population. It is further observed that dissatisfaction with biomedicine has led people, even in developed countries, to seek alternative therapies.
Kabananukye, 1998:34






















3.4 Recent developments in the traditional/ herbal medicine

It is observed that inspite of the bad history and other shortcomings, ethnomedical practices and remedies are increasingly becoming popular. A conservative estimate show that a substantial proportion of the rural population (over 80%) still depend on herbal therapies. And as a result of a number of problems that characterise most rural medical health institutions, there is a good future for herbal therapies. In many tropical African countries where there are rudimentary and strained network of modern health facilities there has been emphasis on the use of traditional medicine. Emphasis of traditional medicine has been made because of a number of reasons:
§ It is an integral part of every culture developed over many years. Thus it is effective in curing certain cultural health problems.
§ It is socially acceptable
§ It has the widest spatial coverage ; each community has its own healers. It is thus the surest way of moving towards attaining health for all by the turn of the century.
§ It is holistic in approach. It views diseases and illness to be in equilibrium social groups with the total environment.
§ Traditional healers charge affordable fees
§ The compelling reason in the use of traditional herbs is its ability to meet the four criteria of accessibility, availability, acceptability and dependability (Nchinda, (1976 :134), Sindiga, 1995) .

Furthermore, it is observed that literate persons have started joining the profession. As a result, some of the herbal plants and knowledge and practices are being recorded for reference purposes. Most important, the negative attitude (e.g. There is usually the misconception that all traditional healers are witch hunters practising black magic.) towards the biomedical practitioners towards the traditional healers is being reversed. Encouraging the public and demystifying the negative picture that it is the illiterate and evil people that visit herbalists is also being positively changes in society. So is the recent thinking that consulting herbalists is unchristian, therefore the churches are changing attitude. There are indications that government is positive and promoting the traditional practices.

Discrimination against the AIDS infested persons impairs the nation's ability to limit the spread of the epidemic. Fear, ignorance and denial about AIDS could lead to reactions which have tragic effects on individuals, families and communities. These reactions take the form of exclusion of individuals and groups of people from social events, functions, cherished activities, valued roles as well as avoidance and denial of HIV which are more difficult to identify and obviate and create discriminate towards those affected. In areas where AIDS/HIV messages are easily accessible, many of these reactions have been counteracted by the provision of information about how HIV is and is not transmitted, and through increased contact with those affected. Nevertheless, discriminatory behaviour and practices remain common in many places, especially where there is inadequate information about the disease.

Since stigma is applied by the society through rules and sanctions towards the affected individual or group, it may give rise to behaviour which is discriminatory and where the affected person or group may be blamed. By assigning blame to an individual, group or institution, society can to an extent absolve itself from responsibility and ignore or isolate in one form or another those with the disease or at risk of getting AIDS/ HIV infection. Like in most other communities, in most communities of the study area, the AIDS/ HIV infection has been conceptualised as a disease of foreigners and not a concern of local communities. Ignoring the existence of HIV and those most at risk of HIV infection or failing to respond to the urgency of growing epidemics, are the forms of denial which have been commonly reported. And it is this behaviour which may act to further isolate and discredit the needs of the affected. This kind of response may result in the individual's perception of a lack of risk and vulnerability to HIV or refusal to acknowledge the risk of transmission to others.

The Pygmies are often times referred to as an endangered species of human beings. They suffer discrimination where they live. Every effort is made by their employers and landlords to admit inferiority of their culture. This is to the extent that their culture has now been condemned to secrecy. They are now living as squatters on other people's land. They work most of the time and the landlords deny them time and opportunity to attend to each other, especially in times of health care. There are a growing number of instances in which people are denied their enjoyment of their right to work, or to pursue education or other rights essential for their survival, dignity and well-being. While people continue to get support and care, there is continuous and bitter isolation, rejection and neglect experienced from other people neighbouring the Pygmies.



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[1] For a period of about 20 years, Uganda had been through civil wars that had brought devastating economic and social disruption. Some 15% of the health units in the North have been destroyed by war while the majority in the country needed repair MOH, (1993). Faced with the above problems plus deteriorating terms of trade, dwindling external finance, a weak and external hostile environment, Uganda was forced to adopt Structural Adjustment Program (SAPs)Museveni,(1992).

[2] As part of the World Bank policy agenda for financing health services, Uganda was forced to reduce expenditure on health by 50% MOH, (1993); which has resulted in underfunding health services. The reduced budget was already small and since 1982, the health budget declined from 4.8% to 2% in 1987. In spite of a promising rate of economic growth and further resource mobilization through borrowing and tax increases, the funding gaps are likely to continue widening. In 1989/90, the health budget was 0.5 of GDP and 0.6% of GDP in 1990/91 World Bank, (1993).

[3] The youth comprise a large proportion of Uganda's total population. According to the 1991 Census, one third of the population (33%) were young people aged between 10-24 years while, one quarter (24%) were those aged between 10-19 years. Adolescents are a neglected but a high-risk and vulnerable group.

[4] This could explain the presence of virtually all their households which have this risonous drug grown within their homesteads.
[5] Some households (figures yet to be established) depend on 3 to 4 days of their "meals" comprising of dredges (ebikanja) from the local brew. Even children and infants of 6 months are fed on this substance -ebikanja of 'Urwagwa (dredges of some local brew).
[6] Recent studies show that school-going adolescents tend to delay sex contact, while non school-going ones often initiate sex earlier, thus explaining why close to 71% of adolescents aged 19 are mothers or pregnant with their first child (DHS, 1995).
[7] While examining the impact of SAP on health services and treatment patterns, Malest Afro (1980), NCC (1989), Banugire (1989), UNICEF (1989), Otim (1993), Jonker (1988), World Bank (1983), World Bank c (1993(a) cited that the majority of the people relied on self-medication and traditional healers. In comparison studies carried out in Ethiopia, Peru, Zambia, Uganda showed that women are the majority involved in self-medication and traditional medicine.


[8] In Uganda, it is estimated that there is one traditional health practitioner for every 200-400 people as compared with 1:20,000-40,000 for modern medical practitioners. As urban populations have grown and as liabilities of medicinal plants have decreased. Protected areas have become a major source of supply of medicinal plants for the protected areas nexus communities. They also serve urban communities whose medicinal plants, brought in nearby markets, originate in large quantities from protected areas.

[9] As Nyine-Bitahwa (1996:6-14) observes, in spite of the drawback that hit the herbal medicine and practices over the years (especially during colonisation) the traditional medicine “as a system did not die out, but rather operated underground”. “With liberalisation of policies regarding traditional healing systems, however, healers have come out of the underground and individual initiatives to preserve plants as raw materials are gradually emerging”.