Lupine Publishers | Open Access Journal of Complementary & Alternative Medicine
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Abstract
Native people in West Timor Indonesia have been exposed to malaria
since long time ago. Because of this experience, it is
believed that this community has developed their local concept about
malaria, and how to manage it. This research was intended
to document and analyze local knowledge and practices of malaria
prevention and treatment developed by Tetun ethnic people in
West Timor. The research was a field study, conducted through some
interviews, discussions and observations. The results of this
study showed that this community has long been developing various
methods to prevent and threat malaria. The prevention and
treatment of malaria in traditional medicine of Tetun ethnic people
consists of both herbal and non-herbal methods and supported
by some prohibitions and restrictions. The results also showed that the
practice of traditional medicine for prevention and treatment
of malaria by Tetun ethnic people can be explained scientifically.
Medicinal plants that widely used like Strychnos ligustrina, Carica
papaya, Momordica sp., Cleome rutidosperma, Physalis angulata, Alstonia spectabilis, Alstonia scholaris and Melia azedarach have
been proven to have antimalarial activities as anti-plasmodial, antipyretic, analgesic, anti-inflammatory and immunostimulant.
Introduction
Traditional communities in ancient times developed their local
knowledge about the prevention and treatment of a disease based
on their experience interacting with the disease for a long time. This
local knowledge was then become a guidance for them to establish
strategies to prevent and treat the disease, which were practiced
widely in the community, and become their traditional medicine
[1,2]. Traditional medicine is a term imposed on pre-scientific
medical systems, and defines as a sum total of knowledge, skills
and practices based on theories, beliefs and experiences of different
cultural customs used in health care, disease prevention and
increased physical and mental performance, which have been used
for generations from one generation to the next [3,4]. Malaria is an
ancient disease that has not been fully eradicated until this time
[5]. Since long time ago, malaria was the main infectious disease
that often attacks Timorese people, especially in Belu and Malaka
Districts in West Timor (Indonesia). Several old manuscripts noted
that Timorese people in early of 19th century were suffered from
malaria which caused many deaths [6,7]. Until this time, Belu and
Malaka Districts are still hyper-endemic areas of malaria. According
to the Global Fund report, in 2014, Belu and Malaka Districts were
classified as high malaria endemic areas, with the Annual Parasite
Insidence (API) of 12.87o/oo and 11.58o/oo respectively, higher
than Indonesian average API 1.38o/oo. Various programs for
malaria prevention and eradication sponsored by the Indonesian
Ministry of Health and World Health Organization such as
insecticide-impregnated net, fogging, mass blood survey for early
diagnosis and prompt treatment, and treat malaria patient using
Artemisinin Combination Therapy (ACT) have been implemented,
but decreasing of the API value is still not too convincing [8].
Cultural factors that influence public attitudes and acceptance on
the programs of prevention and treatment of malaria are estimated
to be one of the obstacles to the success of these programs. The
implementation of various disease control programs and strategies
often faces major challenges stemming from the social and cultural
situation of the community. The social and cultural situation of
a community in a particular place can negatively influence the
choice, acceptance and use of interventions in disease control.
Many programs of disease control and eradication are unsuccessful
because of these social and cultural barriers. Therefore, it is very
necessary to understand the local knowledge of the community,
including an understanding of the health-illness concept that
they believe in. An understanding of this can help policy makers
in designing a sustainable and more effective disease control
programs [9]. The Tetun ethnic is one of native communities
that inhabit territories from the central part of Timor island (in
Belu and Malaka districts, Indonesia) to the east (in Republic
Democratic de Timor Lester, RDTL). Tetun people are still using
traditional medicines to date, and often running various traditional
medication rituals [10]. Because of their long-time interaction with
malaria, it should be assumed that they have developed their own
local knowledge about malaria and methods to prevent and treat it.
Therefore, this research was intended to study the local knowledge
of the Tetun ethnic people regarding malaria and the methods they
have developed for the prevention and treatment of this disease.
Introduction
Study Design
This study is a kind of research in the field of medical
anthropology. This study was conducted as a qualitative exploratory
research, with a field study as main technique, supported by a
literature study.
Profile of Study Site and People
This research was conducted in Belu and Malaka Districts
located in the central part of Timor island. These areas are located
at 9°15’ S-9°34’ S and 124°40’ E-124°54’ E. Belu and Malaka are
two of Indonesian territories that border directly with the Republic
Democratic Timor Leste (RDTL). The topography of Belu Districts
is mainly hilly, while Malaka is generally a stretch of flat land. Some
areas of Malaka at the south part meet the rainy season twice in
a year, while the areas of north part and also Belu areas are only
have one rainy season. The main rainy season takes place between
November-March due to wind that brings rain from the Indonesian
Ocean. This rain occurs evenly in Malaka and Belu regions. The
additional rainy season in April-June, which is limited in some
areas of Malaka, is affected by wind from Australia that carries
moisture from the Timor Sea. Based on the ethnolinguistics, there
are four indigenous ethnic groups that live in Belu and Malaka
Districts, namely Tetun, Dawan, Kemak, and Bunaq (Marae). Tetun
ethnic is the majority ethnic group in Belu and Malaka, consists of
approximately 80% of the population. They scaterred in almost all
sub-districts of Belu and Malaka [11].
The Informants
The informants of this study were people of Tetun ethnic who
have lived for long time in Belu or Malaka Districts. They were people
with good knowledge and experiences of traditional medicine
practices. The informants were selected through the purpossive
and snowball tehniques. A total of 94 informants (42 men and 52
women) with the age of 40-90 years old were involved in this study.
They came from 15 vilages of five sub-districts in Malaka (Wewiku,
Malaka Barat, Weliman, Malaka Tengah and Kobalima Timur Subdistricts),
and 14 vilages of ten sub-districts in Belu (Raimanuk,
Tasifeto Barat, Nanaet Duabesi, Tasifeto Timur, Lasiolat, Raihat,
Lamaknen, Kakuluk Mesak, Atambua Barat and Atambua Selatan
Sub-districts). These informants consist of traditional public
healers, home healers, and traditional medicine users.
Data Collection
Data were collected through several interviews, discussions,
and observation. Interviews were conducted with a semi-structured
questionnaire. Interviews were intended to collect informations
about local knowledge on health-illness concept, symptoms, signs
and causes of malaria, traditional methods for the prevention and
treatment of malaria, and medicinal plants used for the prevention
and treatment of malaria. More deep questions were developed
spontaneously based on the answers given by the informants to the
previous questions. Interviews and discussions were conducted in
Tetun (local language) and Indonesian. We recorded the contents
of every interview by wrote a detailed essence of the conversation,
but not fully word by word. Several interviews were recorded with
audio and video recorder. In this field study, we were assisted by
several local guides to search for informants, accompanied in the
interviews, to interpreted specific local terms that strange for
us, and help us to search, document and collect plant specimens.
All plants mentioned by informants were collected in-situ and
documented by making photographs and herbaria for taxonomic
identification. This field study was conducted from April 2017 to
December 2017.
Data Analysis
Data obtained from interviews, discussions and observations
were analyzed qualitatively, and presented in narrative or
qualitative descriptions [12]. The steps of qualitative analysis are
as follows:
a) Transcription of data: first of all, the interview data,
discussions and field observation records were well-transcribed
in a neat text.
b) Data reduction: transcripts were analyzed to marked
meaningful parts, and then grouped based on the same
characteristics into certain categories, i.e. the local knowledge
about health-illness, local concepts about malaria, methods for
the prevention and treatment of malaria, and plants used for
the prevention and treatment of malaria.
c) Presentation of data: data that has been grouped were
arranged regularly according to each category to make them
easy to understand. Data of plants used in malaria prevention
and treatment were presented in a table.
d) Verification and conclusion: determined the meaning of
the data presented.
Local Concepts about Health-Illness
The concept of health and illness in Tetun community is very
simple. Tetun people define health as a condition of normal, good
and not sick. Illness is interpreted as a condition in which someone
feels unwell or sick or has a disease in the body. Tetun traditional
people state a condition as health or ill by seeing physical signs.
A person is said to be health if he/she looks physically strong,
fresh, agile, has a bright face and good appetite; and vice versa, if
the physical performance seems weak, lethargic, pale face, lack of
appetite, then the person is said to be sick or has an illness in the
body. Someone is said to have recovered from illness when showing
physical signs such as being able to get up, not feel dizzy anymore,
being able to walk quickly and to work again, and his/her appetite
is back and improved. The concept of Tetun people about health
and illness is also associated with the ability to carry out daily
life activities. Someone who is still able to work or move without
feeling bad or pain in his body, then that person is not said to be
sick. People who are clinically suffering from a certain disease but
not feel sick and still able to carry out daily activities without being
disturbed by the disease, then that person is not considered sick.
WHO and Indonesian Ministry of Health define health as a state of
complete physical, mental and social well-being, and not merely
the absence of diseases or infirmity [13]. Comparing the concept
of health according to Tetun people’s understanding with this
official definition, it can be concluded that the concept of health
of Tetun ethnic people is inadequate to describes whole condition
called health, because for this community, health and illness are
more related to physical performance than psychological and social
performance.
Local Concept about Symptoms and Signs, and Causes of Malaria
The indigenous people of Tetun know malaria as is in mana’s
(hot body, fever) with primary signs and symptoms are high fever,
shivering, intermittent fever, headache, muscle and joint pain, pale,
yellow eyes, and abdominal pain and/or diarrhea. Many informants
did not know that swollen spleen (splenomegaly) is also one of
the signs of malaria that is already severe, but they assumed that
the swollen spleen can cause fever (they say “malaria”). In general,
almost all the informants assumed that malaria is a common, mild
and not serious disease, only a sick of hot body or fever. This local
concept seems to greatly influences people’s perceptions of the
danger of malaria and result in reduction of their alertness on
malaria and the seriousness of managing this disease. In the local
knowledge of Tetun ethnic people, the causes of malaria are: sweet
food and drink, chilled, sunburn, fatigue, presence of other disease
in the body, magic, cold food and drink, lack of sleep, inadequate
post-natal care, spicy food, alcohol, and oily or fatty food. Tetun
ethnic people assumed that sweet food and drink, sunburn, magic,
spicy food, alcohol, and oily or fatty food cause an excessive heat
in the body, and as a result, someone will get high fever malaria.
Chilled, cold food and drink, lack of sleep is assumed to cause cold
entering the body, and as the result, someone will get shivering
malaria. The fatigue, presence of other disease in the body and
inadequate post-natal care for mother and infant are assumed
to destroy the equilibrium of hot and cold in the body and result
in malaria with high fever and/or shivering. According to some
informants, mosquito as malaria transmitter was a new knowledge
that coming from outside, introduced by the Catholic missionaries
from Europe. According to Foster dichotomous on causes of disease
[14], the causes of malaria in the local concept of Tetun people are
naturalistic, not personalistic. Factors such as sweet foods or drinks,
long time in rain, water or cold places, long working under the hot
sun, fatigue and the presence of other diseases in the body are
naturalistic properties that cause heat-cold balance in the human
body to be disrupted, and then causes someone to get malaria.
Many Tetun people do not consider mosquito as carrier of malaria,
causing them to have low awareness of the threat of mosquitoes.
This may be one of the causes of the still high endemic of malaria in
Belu and Malaka until this time [15].
Methods for The Prevention and Treatment of Malaria
The Tetun ethnic people have their own patterns or habits of
life that they do for generations to prevent malaria attacks. The
methods that are considered effective in preventing attacks of
malaria are: luli or hale’u, drink medicinal concoction of bitter
herbs, eat bitter food, and drink tua moruk. Luli or hale’u means
avoiding things that can cause malaria (according to their local
concepts about the cause of malaria), which are: not eating sweets
frequently, not working for long time under the rain or hot sun,
and not too tired at work or physical activities. Eating bitter foods,
especially papaya and bitter melon, and drinking bitter palm sap
tua moruk are also considered effective to prevent someone from
being attacked by malaria. Some informants who previously linked
malaria with mosquitoes stated that repelling mosquitoes using
smoke of burned aromatic plants and sleeping under mosquito
nets are effective for malaria prevention. The treatment of malaria
in traditional medicine of Tetun ethnic consists of herbal and
non-herbal methods. Herbal method consists of drinking herbal
concoction, inhaling the vapor of boiled medicinal plant, massage
with paste of medicinal plant, bath with water of boiled medicinal
plant, and attach the paste of medicinal plant as a cataplasm on the
swollen spleen. A non-herbal method is sunu kok, that is burning
the waist above the swollen spleen using a piece of coconut shell
coal or a heated metal. The results of the interviews showed that
most traditional medication for malarial patient usually combine
two or more methods. It was found also that the role of traditional
healer in the treatment of malaria patient is not so important.
Tetun ethnic people assumed that malaria is a common and not a
serious disease, thus the treatment of malaria does not require a high
competency healer. Several informants stated that they usually
conducted self- and home-medication for malaria complaint. In
the traditional medicine of Tetun ethnic people, the treatment of
malaria is a simple treatment for reducing heat or fever [15]. The
assumption of malaria as a common, mild and not a serious disease
results in lack of awareness about dangers of malaria. It was found
that in many cases, health workers often complain of disobedience
of patients who stop taking antimalarial drugs immediately after
they feel cured (being able to get up, not feel dizzy anymore, being
able to work again, and the appetite is improved), even though
Plasmodium in their blood has not been completely eliminated. As
the result, the success of the malaria eradication program in this
area has increased very slowly [8].
Plants Used for The Prevention of Malaria
Tetun ethnic people believe that consumption of bitter food or
drink can prevent someone from malaria attacks. Therefore, small
children are often forced by their parents to eat stew and drink
decoctions of flowers, leaves and young fruit of Carica papaya, or
young fruit of Momordica sp. (M. charantia or M. balsamina). Some
informants gave information that if they feel tired, achy and lack
of appetite, they will drink decoction of Carica papaya leaves, fruit
of Momordica charantia, Melia azadarach leaves, Alstonia scholaris,
Alstonia spectabilis or Strychnos ligustrina stem bark. Consumption
of these plants’ decoction is believed to restoring body freshness,
increasing appetite, eliminating fatigue, and thus, preventing from
malaria attack. Some informants also believed that drinking tua
moruk is effective in malaria preventon. Tua moruk is a traditional
drink made by fresh tapped palm sap soaked with the stem bark of
Alstonia scholaris, Alstonia spectabilis or Strychnos ligustrina soaked
in it. Several publications of other previous studies showed that the
bitter plants used by Tetun people to prevent malaria has been
shown to have pharmacological activities as antiplasmodium and
immunostimulant [16-18].
Plants Used for The Treatment of Malaria
In this study, we recorded a total of 96 species from 39 families
used by Tetun people in various formula for drink, massage, bath,
inhalation and cataplasm (Table 1). Strychnos ligustrina, Carica
papaya, Cleome rutidosperma, Physalis angulata, Alstonia spectabilis,
Alstonia scholaris and Melia azedarach are some of the most widely
plants used in various formula for drink. For massage, Garuga
floribunda, Jatropha curcas, Acorus calamus, Allium cepa, Drynaria
quercifolia, Ocimum sp. and Ruta graveolens are common. For
bathing, people use Tamarindus indica, Psidium guajava, Melicope
latifolia and Blumea balsamifera. Leaves of Brucea javanica, Annona
muricata and Annona reticulata are used in inhalation method.
Root of Moringa oleifera and leaves of Ficus hispida are used as
cataplasm to reduce the swollen spleen [19]. Several plants were
found in various formula for more than one mode of application.
Several previous publications showed that most of these plants
are also used in other traditional medicine for the same purpose
in many areas of Indonesia and the world [16,18], and have been
scientifically proven to have pharmacological activities as true
antimalarial (antiplasmodial) and/or indirect antimalarial such
as antipyretic, analgesic, anti-inflammatory and immunostimulant
[20].
Table 1: Plants used by Tetum ethnic people for the treatment of malaria.
Conclusion
The practice of preventing and treating malaria in the traditional
medicine of Tetun ethnic people is a direct implementation of their
local knowledge about malaria. The local concept of signs and
symptoms and the causes of malaria encourage traditional people
to create methods to prevent and treat malaria. The local concept
of the Tetun ethnic people about malaria is the main reference in
the creation of rules regarding prohibitions and restrictions, and
recommendations for preventing attacks of malaria. The local
concept of the causes of malaria determines the choice of plants for
the treatment of malaria. Scientifically, these plants have been proven
to have activities as true antimalarial and indirect antimalarial. The
local concept of malaria as a common, mild and harmless disease
causes that the role of traditional healer is not always needed in the
treatment of malaria. Methods for the prevention and treatment of
malaria developed by Tetun ethnic people consist of both herbal
and non-herbal methods and supported by the implementation
of several prohibitions and restrictions to provide healing for the
sufferers of malaria.
Acknowledgement
We thank to Indonesian Ministry of Research, Technology and
Higher Education, for financial support (Research Contract No.
0668/K8/KM/2018).
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