The New York Times - November 21, 2006
Elisabeth Rosenthal

But the very next week, the proud parents took their baby to the father's village in the south of Cameroon, to take part in a traditional birth and naming ceremony. Custom required the new mother to nurse little Innocent, so she did. And she continued for two weeks.

"Why would you risk his health in this way?" scolded Dr. Suzie Tetang Moyo, sighing deeply in frustration when she saw the parents recently at her clinic on a dirt road here in this rural district north of the capital, Yaounde.

As researchers spend more time studying Africa's overwhelming pediatric AIDS problem, they are finding that the routes of transmission may be different than in the industrialized countries, and that strategies for preventing the disease's spread must be adapted to local realities.

In developed countries, the only real risk factor for children is that they can get H.I.V. from their mothers at birth.

But here, researchers have come to agree, a host of traditional ceremonies and practices is creating transmission routes unique to Africa - dangers that have, up to now, been ignored.

There are naming ceremonies, like Innocent's, that require nursing. But there are potentially even more hazardous moments, such as when body fluids of different people are mixed.

In scarification ceremonies for ethnic identification and cutting for ritual healing, blades are used in sequence again and again. There is also the practice of communal breast-feeding a single baby by numerous women, common in many tightly knit villages.

In a country like Cameroon, where more than 5 percent of the population and 11 percent of pregnant women are infected with H.I.V. - the vast majority unknowingly - such practices could lead to a wildfire spread.

"If we are only biology, biology, biology, then we are only doing half of our mission," said Marcel Manny Lobe, director of the new International Reference and Research Center for H.I.V.-AIDS in Yaounde. "We need also to do the sociology and anthropology and then make biological interventions."

Researchers here and elsewhere in Africa are just beginning to study the role of these common traditional practices of rural Africa, to determine if they account for a small or large portion of H.I.V. transmission. "We don't know enough about this important topic, but there is no doubt that traditional practices are spreading H.I.V. It's a growing concern," said Dr. Edward J. Mills, an epidemiologist at McMaster University in Hamilton, Ontario, who has done extensive work in South Africa.

"Unaids has been ignoring it," he said, referring to the United Nations agency that deals with the disease. "I think it's because people think it's culturally insensitive to talk about. Even if it turns out to be only a minor amount, it's a preventable amount so we really need to address it."

In Batie, a village three hours from Yaounde, most people go to both traditional healers and medical doctors, and traditional treatments often involve blades to cut the skin.

On a recent afternoon, Berlin Simeu, a villager, visited the darkened hut of Sop Kamtchewo, a healer, in a ceremony intended to ward off illness and witchcraft.

With a razor blade that had been wrapped in a sheet of paper, the healer made three short cuts on his patient's body - one each on his wrist, back and shoulder. A fruit was placed on the wounds to draw out any bad influences.

It was unclear whether or how the blade would be cleaned before its next use.

Yves Moumbe, a doctor in Batie, said that almost all of his patients with H.I.V. went to traditional healers before they saw him.

"It is not clear if they are using any sterile technique at all," Dr. Moumbe said. "They don't have much knowledge of H.I.V. and how it is spread. So it could be a serious problem."

An estimated 70 percent of Africans use traditional healers as their primary source of health care, a function of tradition and availability.

In Africa, there is one medical doctor for every 40,000 people, but one traditional healer for every 500.

In one small survey, 50 percent of ritual healers were H.I.V. positive, doctors at the International Reference and Research Center for H.I.V.-AIDS in Yaounde said.

"We're used to saying this is all about sexual intercourse, but now we have to remind people it can be elsewhere in the body, and there are other dangers as well," said Bertrice Mabule, who started the Children's Education and Health Foundation to promote H.I.V. awareness in Batie.

A 2004 study in the journal Tropical Doctor by Dr. Etete J. Peters at the University of Calabar in southeastern Nigeria concluded that there was "a serious risk inherent in the practices of Nigerian traditional healers" because of "the continuous usage of unsterilized instruments and cross contamination of patients' blood and body fluid in their practices."

Though Dr. Peters has continued to work with the healers, he said there was little financing to carry out H.I.V. sensitization campaigns directed at this group, so "such awful practices persist in Nigeria and Africa in general."

In much of rural Cameroon, tiny scars are made to identify members of different ethnic groups, with large numbers of children scarred simultaneously.

"You see them everywhere, three lines on a cheek, on the forehead - the Pygmies make slashes between the eyebrows," said Serge Florent Moudt, an H.I.V. educator who works at the center in Yaounde as well as in the West Province, his home. "It's a real worry."

If just one child in a village had H.I.V., a common blade could spread the virus to dozens who come after him. The same is true for group circumcisions.

"There are traditionally African aspects of this fight," said Jean Stephane Biatcha, executive secretary of African Synergy, an AIDS prevention group. "We're taking the message to rural areas where traditions are very strong, and you have to work carefully and slowly."

Another traditional practice that government officials acknowledge could be spreading H.I.V. is communal breast-feeding, the norm in many rural villages.

Polygamy is legal in Cameroon, and a chieftain might have 30 or 40 wives, Mr. Biatcha said, because wealthy men routinely marry the wives of male relatives who have died. It is common for the wives - or even friends - to help out by nursing each other's infants. In fact, it is an essential service if a mother has to go to work or take a trip into the city.

But again, in a country where studies have found that 11 percent of women of child-bearing age are infected with H.I.V., the practice presents an open conduit for childhood infections.

Mr. Biatcha said people were generally unaware of such risks, so the first step was information.

In the last few years, an increasing number of medical doctors have warmed to collaborating with the traditional healers, to encourage safe practice and to use them as AIDS educators.

"We have to open a dialogue with the traditional healers," said Dr. Mills, the epidemiologist. "They may well be spreading H.I.V., but instead they could be part of the solution."

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