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Title Shamans and Apprentices Programme: Promotion and Integration of Traditional Medicine   Themes Botany, community health, cultural identity, diseases, education, health, health centres, self reliance, traditional medicine, training   Introducing the practice In Suriname (South America), traditional healing practices are being revived among the Trio Amerindians of the communities of Kwamalasamutu and Tëpu, in the far south of the country. Kwamalasamutu is the community most remote from the capital Paramaribo. It is accessible only by air. A Cessna charter flight to Kwamalasamutu takes two hours; a flight to Tëpu takes an hour and a quarter. The programme to breathe new life into traditional practices began at Kwamalasamutu in 1988, following recommendations from ethnobotanist Mark Plotkin, president of the Amazon Conservation Team (ACT). He lamented the fact that the old shamans were dying and taking with them all their knowledge, without having transferred any of it to younger generations. The traditional healers involved in the present programme are shamans of the Amerindian tribes of the Suriname Amazon. Shamans are inheritors of a great medical tradition that has its origins in the beginnings of civilization. In the social firmament of Amazonian tribes, shamans act as healer-priests, responsible not only for the health of their people but also for their spiritual welfare. In this capacity, shamans are the keepers of both tribal traditions and rites as well as the knowledge of medicinal plants. Over thousands of years, Amazonian tribes have accumulated a vast storehouse of knowledge of medically useful plants growing in the rainforest. Although a large number of important pharmaceuticals have been discovered from studying the traditional medicine of indigenous people, medicinal plants are just one component of traditional health systems. Ceremonies and rituals, songs and colourful dances, incense and invocations often accompany the use of medicinal plants in healing. It is customary for shamans to teach the next generation about medicinal plants, their belief systems, methods of diagnosis, and traditional concepts of illness. At Kwamalasamutu, this practice was greatly enhanced in July 2000 with the opening of a clinic for shamans and apprentices, and with the operation of a training facility where youngsters aged about 12 receive introductory training in traditional health care. The shamans and apprentices’ clinic operates in conjunction with the clinic managed by the Medical Mission, the agency responsible for providing primary health care in the interior of the country. The aim is to establish structural cooperation between the two clinics. At Tëpu, a similar clinic was opened in August 2001. Also scheduled to be part of the programme are medicinal plant gardens. The programme is ongoing. With the opening of the traditional medicine clinic at Kwamalasamutu in 2000, the programme entered a new phase of implementation. It has not yet been evaluated. The aim is to expand the programme to cover the entire interior of the country. International exchange is also envisioned to foster the programme’s further development. The clinic has been so successful that it was initially in operation seven days a week, mornings and afternoons. Eventually the shamans could be convinced that it is ‘against the law’ to work seven days a week, so that the clinic is now closed on Sundays although the shamans are still on call. The Trio themselves are fully in charge of both the transfer of knowledge and the treatment of patients in the clinic. The practice is efficient, cost-effective and manageable. It also plays a vital role in the cultural recovery of the tribe. Outside influence (missionaries) had discouraged the tribe from maintaining their traditional healing practices, persuading them that ‘the white man’s pill’ was superior. But it was also outside influence (ethnobotanist Mark Plotkin) that was instrumental in reviving those practices. By explaining to the tribe that certain of ‘the white man’s pills’ were derived from plants in their own forests, Plotkin made a valuable contribution to restoring the shamans to their rightful place within the tribe. He recommended setting up a shamans and apprentices programme and he helped the Trio to produce a handbook, in their own language, of medicinal plants and their uses.   Content and approach The purpose of the Shamans and Apprentices Programme is to improve health care in the community. Everyone involved in the programme is firmly convinced that the integration of traditional health care with western health care, as provided by the Medical Mission, will result in better health care for the community, and that the programme will eventually have a ripple effect, enhancing health care nationwide. The Shamans and Apprentices Programme is an essential component of an effort to recover and conserve tribal culture, which in turn is part of an overall effort to achieve sustainable development. Persons and organizations involved in the practice The community as a whole is involved in the practice. At Kwamalasamutu, the community has approximately 1500 members. There are three shamans, six apprentices and 20 youngsters (novices) directly involved. Their services are available to the entire community. The establishment of individual gardens where certain medicinal plants are grown will be promoted. The Medical Mission (MZ) provides free primary health care services to the approximately 50,000 people living in the interior of Suriname. The Medical Mission is a non-governmental organization and the product of cooperation between three religious groups and the Suriname Ministry of Health. The Medical Mission operates 45 health clinics distributed throughout the Interior and staffed by Community Health Assistants, trained health care providers who mostly originate from the communities they serve. Six physicians circulate according to an established schedule between the different clinics of the district for which they are responsible. The Medical Mission’s ability to penetrate and deliver primary care into the interior has recently been severely compromised because of the government’s inability to provide regular and timely funding. In 1999, delays in funding almost forced the Medical Mission to close its operations and clinics in the Interior indefinitely. Deferral of health sector payments has had a broad-ranging impact on most Suriname health care providers and hospitals and will certainly persist, if not escalate, in the foreseeable future. In the course of working with indigenous peoples, Medical Mission physicians and community health workers have observed that patients often respond well to traditional medicine and that certain Amerindian and Maroon remedies, such as treatments for leishmaniasis and setting bone fractures, are perhaps more efficacious than the pharmaceutical interventions and therapies they can provide. In addition, shamans have several seemingly effective medicinal plant treatments for gastrointestinal disorders, an important disease burden in these communities. Such treatments are cost-effective and give indigenous communities greater responsibility for their own health care. For these reasons, the Medical Mission is seeking to understand traditional medicine better by cooperating closely on a basis of trust and openness with traditional healers in Kwamalasamutu and Tëpu, as well as in the Maroon community of Kajana (where ACT has a third traditional medicine clinic under construction), and sharing in the responsibility of delivering quality healthcare to the communities. The method The components of the practice can be summarized as follows: transfer of knowledge, clinical skills and traditions from the traditional healers (shamans) to the apprentices and novices, related to medicinal plants and their uses; operation of a shamans and apprentices clinic; management of a medicinal plant garden; cooperation/coordination with the Medical Mission on the integration of traditional health care; exchange with other communities/tribes both national and international. A medical student from Yale University, and one from the University of Suriname Faculty of Medicine are providing guidance to the shamans and apprentices. To facilitate replication, they are also working on a scientific evaluation of the operation of the clinic and a research programme. German Zuluaga MD, ACT’s Colombia Programme Director, is an experienced doctor with considerable knowledge of indigenous medicine. He has been consulted on the development of the programme since its initiation. ACT makes a modest payment to the shamans and apprentices, as reimbursement for their services to the community. During this transitional period, efforts are being made to develop income-generating activities, in order to enable community members to pay for the services received at the clinic. Finally, ACT also provides support in the form of supplies for the clinic.   The role of Indigenous Knowledge The practice is all about indigenous knowledge in action. The Shamans and Apprentices Programme is managed entirely by the indigenous community itself. Cooperation with the Medical Mission is aimed at achieving integration of the two forms of health care. The support provided by ACT merely facilitates the practice. At the same time other efforts are undertaken to make the programme more sustainable. These are part of an overall effort to achieve sustainable development through such activities as mapping the lands of local communities, helping to solve the land rights issue and to protect forests, and helping local communities to generate income through the exploitation of non-timber forest products (such as sustainable harvesting of Brazil nuts). The practice plays a vital role in the recovery and conservation of tribal culture. This will help the indigenous community to deal better with the outside world. The partnership with the Medical Mission will enhance the indigenous population’s awareness that they have a valuable contribution to make, for their own benefit and for that of the outside world. This realization is expected to contribute greatly to their self-esteem, which in turn will encourage them to recover and conserve their own culture. Transfer of knowledge The knowledge of medicinal plants and their uses is vested in traditional healers, who have taken it upon themselves to transfer this knowledge to the next generation of both apprentices and novices (youngsters aged 12). This transfer is the programme’s most essential component. Training deals with various subjects: how to recognize plants in the forest, which parts of the plants to use, which plants should be used for which ailments, and how to prepare and apply the medicines. These communities, though traditionally self-sufficient and wholly reliant on what the forest has to offer, are increasingly being drawn into the monetary economy. People need money to buy all kinds of basic necessities, such as machetes and batteries. The shamans and apprentices are no exception. This is why ACT is initially paying them a modest amount, and why the aim is to develop income-generating activities to enable community members to pay for the shamans’ services in the future. An international exchange is scheduled which should help the Surinamese shamans to benefit from the experience of Colombian shamans who are members of UMIYAC (the Union of Yage Healers of the Colombian Amazon). This organization has made great progress with its own shaman and apprentice programmes, whose results include a code of ethics for traditional healers. The Shamans and Apprentices Programme was started out of concern that the shamans’ knowledge was being lost. Efforts are therefore being made to document this knowledge. One of the first activities was the preparation of a handbook on local medicinal plants and their uses, in their language, undertaken several years ago by ACT President, ethnobotanist Mark Plotkin. However, the knowledge of the paramount shaman of Kwamalasamutu, a Sikiyana from Brazil, has never been documented in text. During this programme, a medical student collaborated with him to document his extensive knowledge of medicinal rainforest plants. After numerous trips into the rainforest, they produced a preliminary draft of his pharmacopoeia. Over the course of the next year, this draft will undergo numerous revisions to ensure accuracy and completeness and will be translated into the Trio and Sikiyana languages for future generations within the tribe. Establishing a traditional medicine clinic enables the shaman’s clinical skills (including rituals and belief systems) to be preserved in practice and provides an opportunity for apprentices to observe and develop their own clinical skills. This is not dissimilar to the role of the university teaching hospital in undergraduate western medical education. In any effort to record or document their knowledge, due consideration has to be given to intellectual property rights, and protecting the interests of the indigenous peoples against charlatans, pirates, and the like. The knowledge contained within texts or utilized in the traditional medicine clinic belongs exclusively to the shamans and tribes of Kwamalasamutu and access to such texts will thus be restricted. ACT does not engage in bioprospecting.   Achievements and results The case described here is considered a best practice because it has proven to be successful and meaningful to the community. Besides the direct benefits to the community, there are the derived benefits (described earlier) related to cultural recovery and conservation and overall sustainable development. Currently an evaluation is taking place of the first year of operation of the traditional medicine clinic at Kwamalasamutu. Beyond its role in the evaluation of the present programme, the evaluation and research programme represents one of the most comprehensive documentations ever undertaken of a traditional health system in an Amazon indigenous community and will offer invaluable opportunities for scientific analysis. The activity is sustainable, cost-effective and locally manageable. ·           It is sustainable because it focuses on transferring knowledge from the shamans to the next generation. Judging from the enthusiasm of the apprentices and 12-year-olds, a continued supply of apprentices should not be a problem. The modest payments that ACT makes to the shamans and apprentices cannot be considered to threaten the programme’s sustainability. The support from ACT is merely extra encouragement for the programme; without it the practice would continue. The community is still primarily oriented towards mutual support. If monetary compensation for the shamans and apprentices were not available, they would still go about their business and accept compensation in kind. ·           Cost-effectiveness is not a major concern since the focus is on making use of what nature provides. Any necessary facilities can be constructed from locally available materials so that little out-of-pocket investment is required. ·           The programme is managed entirely by the indigenous peoples themselves. They cooperate with the Medical Mission on a partnership basis in order to integrate traditional and western health care.   Strengths and weaknesses, and room for improvement The strength of the practice is that it falls completely within the beliefs and experience of the community. Traditional healing practices can be highly effective, particularly for ailments where western medicine is deficient. A weakness could lie in attempts to cure ailments for which no effective traditional medicine is available; inability to provide a cure, or even a fatal outcome could undermine credibility, especially since what is taking place is actually a recovery (but not a rediscovery) of traditional medicine practices following the discouragement of its use under the influence of missionaries. However, in the case of Kwamalasamutu, this has proved to be just a theoretical concern, as the medicinal plant knowledge passed on through the generations is still intact. Moreover, the shamans are clinicians with years of training and experience and are aware of their limitations, particularly where introduced diseases and conditions that require surgical management are concerned. One thing should be clear: neither western medicine nor traditional medicine have all the answers to all the problems. There are cases where traditional medicine is more effective, as there are cases where western medicine may be a more appropriate therapy. Integration of the two will result in improved health care for the community. Expectations are that the practice can definitely be developed and improved, both by blending it with other indigenous knowledge as well as with modern science and technology. An example of the former is exchange with other cultures leading to an expansion of the medicinal plants used; at Kwamalasamutu there have already been cases in which visitors (shamans, doctors, herbalists) from overseas have informed the community of a medicinal use of certain plants which were present at Kwamalasamutu but were not being used by the community. Examples of improvement through blending with modern science and technology are: ·           Providing adequate follow-up treatment (city hospital/surgery for initial diagnosis and treatment in the community). ·           In the case of Kwamalasamutu, which is far bigger than traditional Amerindian communities, the shamans need to travel deep into the forest to collect medicinal plants; this has created the need for a solar-powered refrigerator for the storage of perishable medicines.   Source of inspiration It would be fairly easy to transfer the practice, although some adaptations might be necessary. Two preconditions, however, are that the practice is in the interests of the entire community and is managed by the community itself. An example of a situation where adaptations might be needed would be if in a particular culture shamans only pass their knowledge on within their own family. And obviously, if traditional and western knowledge are to be integrated, there is a need for a willing partner like the Medical Mission in Suriname. Scope for replication is the main reason why the clinic at Kwamalasamutu is being evaluated as a possible model. The results should be very useful for this purpose. The programme has already been replicated on a small scale. Following the opening of the clinic at Kwamalasamutu in July 2000, a clinic and training facility were built in the Trio community of Tëpu. These opened in August 2001. Another clinic is under construction in the Saramaka Maroon community of Kajana. These efforts are all part of ACT’s Suriname Programme, involving partnerships with the Trio Indians and the Saramaka Maroons. ACT is engaged in similar efforts (shamans and apprentices programmes) in Colombia, Brazil, and Costa Rica. If you think that this case could be useful in a different context than the one described here, please get in touch first with the contact person listed below (Administrative data). Intellectual property rights could be an issue.   Additional remarks and information The Trio communities of Kwamalasamutu and Tëpu, and the Saramaka Maroon community of Kajana, are pilot sites for a more elaborate plan that would target the interior of Suriname in its entirety. Besides the shamans and apprentices programmes, traditional medicine clinics and medicinal plant gardens in the three pilot communities, workshops are envisioned at all levels: local, national and international. All of these would include participants from the three communities as well as representatives of the Medical Mission. Unfortunately, ACT and the Medical Mission have not yet managed to secure funding for the expansion of the pilot programme. Nevertheless, in view of the programme’s importance for the communities, ACT will do what it can within its own budget to put these plans into practice.   Administrative data Organization involved Responsibility for the practice rests with the Trio community itself. The Amazon Conservation Team, within the framework of a broader partnership with the Trio Indians, is providing support. ACT is considering helping the community to establish its own website and thus its own direct links with the world. This will reduce ACT’s responsibility even further. But for the present, the organization to contact is ACT. Amazon Conservation Team (ACT) 4211 N. Fairfax Drive Arlington, VA 22203, USA Tel.: +1 703 5224684 Fax: +1 703 5224464 E-mail: info@amazonteam.org Website: www.amazonteam.org   Amazon Conservation Team Suriname (ACT Suriname) Gravenstraat 123 bov. Paramaribo, Suriname Tel.: +597 421770 Fax: +597 421751 E-mail: actsur@sr.net   Contact person Neville Gunther 3301 High Tide Ct Valrico, FL 33594, USA Tel.: +1 813 6530813 Fax: +1 813 6852359 E-mail: ngunther@amazonteam.org   Other partner(s) involved in the practice Medical Mission Suriname (MZ) Coordinator: Edward van Eer, MD Tel.: +597 499466 E-mail: Evaneer@medischezending.sr   Person(s) who have described this Best Practice Neville Gunther, Suriname Programme Director, ACT

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