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Introduction
Indigenous communities worldwide have historically been devastated by various pandemics, with some populations halved and others almost completely destroyed. This devastation has been seen, for instance, in the waves of smallpox, chickenpox, measles, scarlet fever, sexually transmitted diseases and tuberculosis introduced to communities by external visitors1. Among many other reasons, Ghio2 and Haring et al3 state that these communities were more genetically prone to these infections and were also immunologically naïve. The impact of pandemics and epidemics on these communities, however, is similar: cultural loss, breakup of interdependent relationships and generational gaps that impact the transfer of their health knowledge systems3,4.
The most recent pandemic, COVID-19, changed the world as we knew it5. Many countries followed the WHO guidelines for the pandemic and closed their borders, instituted social distancing, wearing of masks, lockdowns, and constant handwashing and hygiene5. To monitor and mitigate the impact of the pandemic, the Africa Taskforce for Coronavirus Preparedness and Response was created by a joint committee of the African Union Commission, Africa Centre for Disease Control and the WHO Regional Office for Africa, in partnership with African governments and various relevant stakeholders6. In addition to this taskforce, the importance of ensuring community ownership and local action within the processes of support provision was promoted. Rosenthal et al posited that every country is different and unique, and that guidelines should be implemented – taking note of the cultural and contextual locations within different spaces7.
Narratives on the experiences of this pandemic from African Indigenous communities are still inadequately represented. The focus has mainly been more within urban global spaces rather than rural Indigenous contexts8, and the multifaceted and dynamic experiences of the pandemic within these communities. Therefore, in this article, we aim to contribute to current literature, presenting an African Indigenous community’s experiences of the pandemic, how they understand health and wellbeing and what actions they took to protect their health and wellbeing in the face of the COVID-19 pandemic. We argue that societies and governments must gain an understanding of how to tap into these Indigenous care practices to influence plans for future health crises within communities, for sustained wellbeing9. Including the voices of Indigenous communities can contribute to resilience-building where the pandemic guidelines are adhered to, while at the same time maintaining the spiritual and cultural practices that inform their wellbeing.
Spirituality practices and their impact on coping during life's traumatic experiences, including the experiences of loss and death, have been well documented in the literature10-12. The connection between spirituality and the benefits of various rites, rituals and sacred scriptures in advancing health and wellbeing have long been established10,11,13,14. A recent study by Sen et al indicated religion and spirituality have a significant influence on how individuals and families view and interpret negative events, including within the pandemic context14. Findings by Ozcan et al suggest that a faith-based and spiritual approach helps interviewees feel grounded, calm, resilient and present in difficult environments15. Literature is replete with evidence from various religions and faith practices, including the Christian, Islamic, Jewish, Buddhist and Hindu belief systems, revealing the positive and healing impact of positive emotions on our immune system and wellbeing10,13,14. Thus, the practice of our spirituality contributes to our wellbeing.
These historic and structural inequities create certain vulnerabilities and health conditions16 that are better understood by the communities that live and exist within these contexts. For example, Gxamza reported that some communities identified culturally congruent and contextually relevant means of addressing the pandemic through individual isolation and sequestering of their community1. Airhihenbuwa et al17 and Zhang et al18 both agree that a collaborative approach is better than an imposition on these communities, which could quickly become unsustainable and lead to adverse health outcomes.
Linked to this, the aim of this study is to explore how the Indigenous Xhosa people of Thamarha, in the Eastern Cape Province of South Africa, sustained wellbeing during the COVID-19 pandemic.
Study context
In South Africa, Indigenous people are mainly situated in rural parts of the country. There are four villages within the Xhosa community of Thamarha in the Eastern Cape of South Africa, and all four were involved in the study. In this tightly knit Xhosa community, spirituality is foundational to their belief system, supporting social cohesion and wellbeing. Some people go to church, some practice Indigenous spirituality, but many more practice both Christian and Indigenous belief systems. These belief systems influence their health-seeking behaviour as they often straddle both biomedical and Indigenous healing methodologies.
Demographic and geographical context
Thamarha is a small rural community situated in the Amathole District Municipality. It is under the authority of the Ngqushwa Local Municipality within the Eastern Cape province of South Africa. The population is about 68,300 residents, with a fairly even gender distribution: 47.8% male and 52.2% female residents11. The community is predominantly Xhosa-speaking and relies on subsistence farming and small-scale agriculture.
The region is characterized by its dispersed settlements, with few urban facilities within reach. One notable feature of the population is the high percentage of young people attending educational institutions. A significant 79.7% of individuals aged 5–24 years are enrolled in schools, indicating a strong focus on education and the community's dedication to supporting its youth. The majority of households in the region live in formal dwellings, with 89.4% residing in such structures19. This suggests that most residents have access to secure and stable housing, which is essential for their wellbeing and growth.
Despite the prevalence of formal housing, access to basic services like piped water remains a challenge for inhabitants in this region. Only 29.1% of households have piped water within their homes, highlighting the ongoing need for improved infrastructure to ensure all residents have access to clean and reliable water sources11.
Thamarha is situated within the wider Xhosa cultural area, characterized by a deep-rooted history and vibrant cultural practices. The community maintains a strong bond with its ancestral land and upholds traditional customs and ceremonies. The historical narrative of Thamarha is closely linked to the broader history of the Eastern Cape, encompassing the effects of colonialism and apartheid on the Indigenous inhabitants.
Like many rural communities in South Africa, Thamarha was impacted by the COVID-19 pandemic. The community faced difficulties in accessing healthcare services and controlling the spread of the virus. The pandemic brought attention to pre-existing vulnerabilities, such as inadequate healthcare infrastructure and resources. The region saw a rise in mortality rates due to the pandemic, worsening existing health inequalities19.
Thamarha is confronted with numerous environmental challenges, such as the effects of climate change, lack of food security, and water scarcity20. The area encounters fluctuating rainfall patterns, resulting in droughts and water deficits. Climate change has worsened these problems, impacting agricultural output and food security. A significant number of households in Thamarha depend on rainwater collection and shared water supplies, which are frequently inadequate to fulfil their requirements.
The community has restricted access to formal healthcare facilities, with the closest healthcare centres situated in neighbouring towns: Peddie, at a distance of about 38 km, and King William's Town, approximately 25 km from Thamarha. This necessitates residents to travel long distances to receive medical care. The community depends on a mix of traditional healers and public health clinics for healthcare services. The absence of nearby healthcare facilities presents difficulties in addressing both regular health requirements and emergencies.
This sense of being straddled between two ideologies of wellbeing informed how these communities responded to and navigated the COVID-19 pandemic, providing insight for more suitable and inclusive health support systems for these communities in case of future pandemics.
Policy context, guiding frameworks and study methodology
The policy grounding of this study was informed by the human rights framework of the South African Constitution, and the Sustainable Development Goals (SDG) 2030 Agenda21. The study is anchored specifically in SDG 3 (relating to good health and wellbeing), SDG 10 (relating to reducing inequality within and among countries) inequalities and SDG 17 (relating to establishing partnerships).
The study is influenced by Ubuntu (humanity to others) and resilience theory within the social justice paradigm8,20, utilising a postcolonial Indigenous framework. Resilience theory informed this study in three ways in terms of risk mitigation: adverse circumstances experienced by a collective; vulnerability in terms of history, practice or circumstance that heighten risk; and protection, which includes all factors that reduce risk or reduce its effects2 and impact on the social determinants of health and wellbeing. The key tenet of resilience positioned within this study is spirituality. Spirituality harboured within resilience also exists within cognitive, social and environmental justice, and postcolonial discourses. It is a unifying concept that supports a re-existence in the face of dire health crisis for marginalized communities, and facilitates collective health and wellbeing for the community22,23.
The postcolonial Indigenous framework as positioned within this study is aligned with Ubuntu and a resilient spirituality. It is about decentring and disputing eurocentric health and wellbeing knowledge as the only ‘valid’ episteme, acknowledging the health narratives that exist and are practiced within Indigenous communities; it is about resilient wellbeing, cultural identity, and ethical and culturally congruent practice, as espoused within Ubuntu. The foundational concept of spirituality is found within resilience theory and Ubuntu22,24. This is the focus within the discussion of resilience in this study.
Ubuntu advocates the recognition and acknowledgement of the ‘other’. While in disagreement with the dominance of Eurocentric knowledge, Ubuntu does not eschew this knowledge, but rather invites it into a conversation. It is a sharing of epistemic space, but led by knowledge on the ground – the relevant contextual knowledge that, similar to cognitive and social justice, refers to a spiritual entanglement between people and community, that contributes to faith and hope, an authenticity of person and space and connectedness that supports resilience13,23. This is because, as Dreyer states, truth and authenticity is found in our connectedness, moving from 'I’ to 'we'24. This spiritual connectedness to the ‘other’ as given within Ubuntu – the ‘we’ – is where we position resilience in this study22.
Beyond acknowledging the trauma of colonialism and the impact of ongoing coloniality within Indigenous communities, the postcolonial theory notes the competing discourse that currently still exists within these communities. We agree with the notion of resistance, or re-existence – where communities resist, but still live side by side with the impact of coloniality and the resultant competing discourses. Therefore, cognitive justice as an aspect of postcolonial theory acknowledges the power dynamics that exist, while equally espousing resistance and co-existence13.
In this way postcolonial theory enabled this study to align with the lived experiences of the people who live within these communities. They have ‘lost’ their utopia and are on a journey but still seeking to grasp what their re-existence may become, as they re-imagine and retake/assert their identity. But the process of re-existing requires certain resources that are located within both the individual and the collective spirituality in this case13,22.
Here, postcoloniality supported the positioning of the study within these dual movements or transitory spaces, where we see the impact of historical subjugation and the inherent power dynamics, but also witness the push to craft a re-existence – of themselves and their communities. Straddled between their own knowledge and the imposed healthcare knowledge, the communities aimed at a re-existence that supports their worldview.
Methods
The study employed a qualitative, exploratory, interpretivist approach aligned with the Indigenous paradigm7. The qualitative paradigm is identified as appropriate because it is an interpretative, naturalistic approach that was used to study the health belief systems of the Indigenous communities within their context8. The study is exploratory because it seeks to better understand health and wellbeing practices that the communities carried out in response to the COVID-19 pandemic20. Meanings are therefore subjective. The postcolonial Indigenous framework supports a participatory approach that advocates for Indigenous voice and autonomy in research methodology, respect, and creation of a shared space for knowledge and co-existence7. These processes were adhered to in order to better understand how the pandemic influenced cultural resilience and continuity25.
The consent form was translated into the local language of isiXhosa, explained in detail to the participants and a signed copy given to the participants. Data-gathering tools included semi-structured interview guides developed and informed by the research objectives and literature review findings, while allowing flexibility for participants to express their perspectives freely. These guides were piloted and refined to ensure cultural relevance and clarity.
The sample size was determined by data saturation, the point at which no new themes emerged, rather than by statistical representation. This is a recognized principle in qualitative inquiry, prioritizing richness of data over quantity. Each interview and focus group discussion (FGD) was conducted in isiXhosa, the local language preferred by participants, in order to ensure comfort and authenticity of responses. The duration of interviews was approximately 45–60 minutes, while FGDs lasted approximately 90 minutes, allowing sufficient time for participants to share their experiences in depth.
Participants were recruited through purposive and snowball sampling method14 by first approaching the Paramount Chief. A trusted member of the immediate local community, (one of the chief’s administrators) also gave ‘informal’ research assistance, helping with essential support for building rapport and facilitating respectful engagement from us with the community and with the participants.
The second author was the formal research assistant, and there were informal ‘co-researchers’ from the surrounding community. Within the Indigenous framework of Ubuntu, hierarchy is dismantled and there is proximity between all research collaborators. The co-researchers gave support by:
- brokering trust with the community, and providing local knowledge and acceptable ethics guidelines for research engagement with the community
- identifying and visiting key stakeholders in the community with the researcher during all phases of the study
- liaising with participants to coordinate interview and FGD schedules based on availability and geographic location within the study area
- organizing accessible venues as arranged and agreed with participants
- supporting logistical arrangements to ensure smooth facilitation of data collection sessions.
Their involvement was critical in creating a safe and welcoming environment for participants, which contributed to the quality and depth of the data collected. Their presence helped bridge cultural and linguistic nuances, ensuring that participants felt understood and respected throughout the process.
Participants were asked to refer us to other potential participants in the community who may potentially participate after the interviews. Additionally, we approached local traditional leaders and councillors at the Thamarha Great Place – the ancestral residence of the Paramount Chief – to refer us to potential participants. Participant types and numbers are shown in Table 1. There were 27 participants who took part in the study, but only 25 participants contributed data to the study. Ten interviews and two FGDs were conducted with participants within each of the community grouping and institutional categories included in the sample.
Role type was assigned as ‘community member’ where a participant played a leadership advisory role within the family. Both the ‘chief assistant’ and the ‘community secretary’ were those offering supportive roles to the chief.
Inclusion criteria for participants were residence in the community during the pandemic lockdowns and aged 18 years or more. Participant groups included community/cultural leaders, family/clan elders, religious leaders and Indigenous healers. We interviewed 25 people: traditional/spiritual healers, church leaders, ward councillors, initiation teachers/leaders (ikhankatha and ingcibi; see Table 1), community members who played a family leadership role, rehabilitation care workers and local police officers. Participants were all from the amaXhosa, from the Eastern Cape of South Africa, and included people from these clans: AMabamba, ooDlomo, AmaXesibe, AMamntlane, AMacethe, OoLeleke, OoNcuthu, Amazangwa, OoNcilashe, OoGxarha, Siyoyo, Potwana, AMamZangwa, OoKhwalo, OoNcuthu and nooMlanjana. Ten in-depth individual interviews (IDIs) and two FGDs were carried out with seven and eight participants respectively in each focus group. A total of 13 participants were female while 12 were male. Gender was not used as a selection criterion.
Participants were asked questions related to their beliefs about wellbeing, and their experiences of the pandemic and their coping strategies.
Both authors were involved in the data-gathering process and played complementary roles. The second author conducted most of the in-depth interviews, meeting online with the first author after each interview to discuss and reflect on the process and emergent discourses. Both the first and second authors co-facilitated the FGDs and member checking sessions for all interviews, ensuring that participants’ voices were accurately represented and that preliminary findings were validated through collaborative reflection. The first author, although African, did not speak the local language, hence it became very important to cross-check every translated document through an independent consultant, to ensure rigor.
This co-facilitation approach supported methodological rigor by integrating multiple perspectives during data gathering and enhancing reflexivity throughout the research process. Field notes were taken by the researcher and co-researcher during each individual interview and FGD. The notes were compared and discussed by the researchers immediately after each interview. These notes captured non-verbal cues, contextual observations and emerging themes to complement the audio data.
Table 1: Study participant community roles
| Community role | Number |
|---|---|
| Traditional healer | 4 |
| Spiritual healer | 1 |
| Church leader | 2 |
| Ward councillor | 1 |
| Ikhankatha (guardian in charge of youths undergoing the initiation rite of circumcision) | 2 |
| Ingcibi (traditional surgeon) | 3 |
| Community member (family leadership role) | 6 |
| Rehabilitation care worker | 4 |
| Chief assistant | 1 |
| Community secretary (to the chief) | 1 |
| Police officer | 2 |
Recording, transcription and translation
All interviews and FGDs were audio-recorded with participants’ consent. Recordings were transcribed verbatim in the original language of the interviews to preserve the authenticity of participants’ voices and ensure accuracy in analysis.
The transcripts were translated from isiXhosa to English for analysis. Translations were cross-checked by an independent consultant for consistency and meaning retention.
Data analysis
Thematic analysis was employed, following Braun and Clarke’s six-phase framework, and affirmed by the community through three collaborative workshops (Table 2). Transcripts were coded manually and iteratively, allowing patterns and themes to emerge inductively. Reflexivity and peer debriefing were integrated throughout the process to enhance credibility and reduce researcher bias.
The communities gave feedback for each phase of analysis, which was incorporated into the next phase, until the final document was agreed upon by the community. Two textual evidences as advocated within postcoloniality emerged from the study: an Indigenous resource and response strategy for crisis guideline (in English and isiXhosa) and a policy brief. The community was involved from the start to the final publication of the two documents. The methodological processes of the study have been published in a case study series25.
Table 2: Thematic analysis phases of the study
| Phase | Description |
|---|---|
| Familiarising ourselves with our data | Actively reading and re-reading data to obtain an overall understanding |
| General initial codes | Noting important aspects of data |
| Searching for themes | Identifying codes and forming codes into themes |
| Reviewing themes | Relating the themes to codes and the entire dataset |
| Defining and naming themes | Producing clear definitions and names for themes |
| Producing the report | Final analysis and write-up of themes relating to the initial research question |
Ethics approval
The study was implemented in line with the principles of the Declaration of Helsinki. The Ethics Committee of the University of Stellenbosch Human Research Ethics Committee granted approval (reference number N20/11/071_COVID-19).
Results
The study results are represented in Table 3.
The study findings report on the participants’ experiences of wellbeing and resilience during the pandemic. We first discuss the perceptions of health and wellbeing that emanated from the context, then highlight the implications of this understanding for cultural and spiritual continuity during the pandemic. Next, we present the coping strategies used, and how the community responded with expressions of the community spirit of Ubuntu. Lastly, we highlight the relevance of creating spaces of engagement that are respectful of stakeholder culture, as narrated by the participants. After the findings identified here, we discuss what these findings mean for Indigenous community engagement during a health crisis or future pandemics.
Table 3: Study themes and subthemes
| Theme | Subtheme | Description |
|---|---|---|
| Perceptions of health and wellbeing | The presence of peace | Wellbeing is relational and linked to peace with oneself and others, including conversations between people |
| The absence of fear | Fear and uncertainty. Restricted freedom and broken connections heightened fear, which adversely impacted wellbeing | |
| Implications for cultural and spiritual continuity | Cultural disruptions | COVID-19 forced the cancellation of key cultural and spiritual ceremonies, causing stress |
| Coping strategies | Finding faith and strength | Faith in God and prayer were vital coping mechanisms during the pandemic |
| Leveraging dual belief systems | Mutual support between Christian and traditional spiritual practices helped maintain spiritual continuity | |
| Expressing the communal spirituality of Ubuntu | Communal care and support | People supported one another by sharing resources and helping their neighbours |
| Creating spaces of engagement that are respectful of stakeholder culture | Respectful engagement between all government and the community is paramount | |
| Collaboration is critical | Collaboration between Western and Indigenous healthcare was seen as beneficial |
African Indigenous perceptions of health and wellbeing
The first theme relates to participants’ understanding of health and wellbeing, which is relational and directly linked to a peaceful state of being, without fear.
The presence of peace
The participants explained that wellbeing is not just a biological or physical experience but is about the relationship of the self to others around that self. Wellbeing is associated with the feeling of peace, being at peace with yourself and with others. Participants stated that wellbeing begins with the state of a person and connects to the people around the person – when we are anxious or lose our peace about any situation, sickness begins from there, then impacts the environment around us, be it human or otherwise. Wellbeing is an individual’s state of health in relation to the ‘self’ and everything else in the person's life. ‘The state of wellbeing in an African context includes an individual’s state of health and relationship with everything else around the person. One cannot live well with others when you yourself are not well’ (IDI 4).
Participants stated that when people are peaceful, the words that emerge from their mouths give hope, unlike during COVID-19 when there were few hopeful words to support wellbeing. ‘People living together in peace, harmony and being patient with one another, so your words can carry meaning to those around you and bring hope’ (IDI 8). The speeches given by the president of South Africa to the nation during the pandemic were given as an example of words that carry meaning and brought encouragement to the people. ‘The president strengthened me by encouraging us on how to live during the pandemic in order to save our lives, encouraging us to stay safe by staying home. Listening to him saved us from being infected’ (IDI 1).
The absence of fear
Fear was one of the most used words reflecting participants’ experience of COVID-19. They agreed that the presence of fear – and fear that COVID would spread – does not augur well for wellbeing, which for them was one of the most unique and deleterious effects of the pandemic. They believed that the fear and uncertainty carried by the pandemic were the main contagions of the pandemic, as the fear people carried made them sick – and, even worse, it spread faster than the biological contagions. ‘The presence of fear through COVID and lockdown was believed to have played a big role in affecting wellbeing through sickness, death and keeping people separated from others’ (FGD 2). ‘We no longer live freely and at peace together but in fear which in turn does not help our health’ (IDI 5).
The fear was facilitated by the forced separation and broken connection between families and communities, the loss of freedom to connect or restrained freedom to connect.
A state of freedom which we did not have during lockdown, being stuck in one place which is not the way people live. As Africans we live together but that was not possible, we were just living under a lot of stress during lockdown. (FGD 1)
Implications for cultural and spiritual continuity
Several participants stated that the pandemic impacted negatively on their ability to continue to observe their Indigenous spiritual practices.
Cultural disruptions
Participants described the frustration of going through a sudden and complete change in their way of life. This frustration was especially exacerbated by the immediate and indefinite cancellation of already-planned religious events and traditional ceremonies, which usually involve financing. Far more important than the financial implication was the uncertainty of wellbeing, stemming from the spiritual health implications of not completing traditional ceremonies that are mandatory for families to perform.
I remember during lockdown we had already planned a traditional ceremony at home. Everything was bought and we had just emptied our pockets to get that out of the way and suddenly, we had to stop as the president instructed … now what do we do? … we had to enquire from the elders what to do as it was an unusual situation to just stop the process that had already started. (FGD 2)
An Indigenous healer and community leader discussed how they could not assist with certain ceremonies because of the shutdown, which was also a stressor for them.
Only a few numbers of people were allowed to be here at a time. Certain events like umhlwayelelo [an initial stage of a ceremony in the initiation of a diviner] that need people in an enclosed environment were on hold and mainly slaughtering [of animals ceremonially] went smoothly. So, I had to decline those. (IDI 5)
Coping strategies
Participants discussed some of their most relevant coping strategies, identifying spirituality as key.
Finding faith and strength
Despite these cultural and spiritual health disruptions, participants explained how they have a positive mindset, and found peace despite the challenges. ‘I know that I cannot control everything, but I am well and happy with my life’ (IDI 6).
Putting their faith in and connecting with a higher power was perceived as a fundamental strategy for combating life’s stressors during the pandemic. Many participants discussed how their faith and belief in God sustained them through the pandemic and lockdown restrictions. Prayers and being part of the church were identified as the most impactful coping strategies through hard times of the pandemic and trying, now, to find their ways through the ‘new normal’. ‘Prayer and faith became my pillar as the bible says that all things will pass but not his word’ (FGD 2). ‘Prayer. This gave me strength and courage; I believe in prayer to solve everything. Knowing the president was going to talk always brought hope and encouragement of hearing something new and that change was about to happen’ (IDI 1).
Leveraging dual belief systems
Many participants practiced both Christian and traditional belief systems. Despite the existence of this dual belief system, there seemed to be mutually beneficial cooperation between the various religious leaders during this time. A church leader and an Indigenous healer gave examples of the kind of support they employed to address the necessity of spiritual continuity. This included the use of technology when relevant. ‘We had to make virtual sermons and kept in touch. Initiation schools closing was also very hard, but we listened to our leaders’ (FGD 1). ‘People knew that they could go into their kraal to pray and praise their ancestors and request patience from them until the pandemic is over’ (IDI 4).
Expressing the communal spirituality of Ubuntu
Participants referred to a communal spirituality that encouraged and ensured that they care for and ask about one another. In this way people were encouraged to know that they were not alone or isolated.
Communal care and support
People devised ways of keeping in contact to check on each other’s safety during the lockdown. Almost everyone used telephones to keep in touch with friends and family members, which provided a means of social support and communication about community matters. People checked on their elderly neighbours who were living on their own. People prayed together. Those with transportation offered to drive sick people to the hospital. Generous community members shared fresh vegetables from their gardens with those without food. People did not think of themselves as alone but thought of ways to show care to others.
We were all going through a crisis with COVID and scared not knowing the right thing to do because many people were dying. I was also sick from COVID so with the experience I realised it is important to follow regulations so as not to put others at risk of being infected ... finding our ways through that time not knowing what is right or not but doing what we could. So, for me it was important to take care of ourselves in caring for others. (IDI 5)
A participant explained, ‘I was very scared but … I made sure to visit my elderly neighbours next to me and opposite my house. I made sure I had their cell phone numbers’ (FGD 2).
Creating spaces of engagement that are respectful of stakeholder culture
A number of participants mentioned instances where they felt that the government could have intervened better by engaging communities in managing situations at a community level respectfully and jointly. For instance, alcohol is utilised within certain religious ceremonies for healing. When alcohol was prohibited, police would just get rid of any alcohol they saw without talking with the family first. The police often act without being unaware there is a sick person who needs the alcohol for a healing ceremony, ignoring the spiritual health significance of not holding this ceremony for the person and family concerned.
In our culture, imbeleko [a ceremony that is conducted to introduce the baby to the ancestors for them to protect the baby] is very important and a matter of life and death, it cannot be stalled … and does not even need a lot of people as it is a family event. Government is a person [consists of humans], and in such cases provision needs to be made for it. (FGD 1)
A similar incident was referenced in a different interview. ‘We had a case of a very sick child that needed a ritual to be performed, and we got stuck not knowing what to do with police intervening in the process’ (IDI 9). A second participant stated that the role of the government and police:
… is to listen and not to undermine people’s cultures. Communication is important when dealing with crisis but when you do not listen to others’ views, you miss out and we all learn from one another … So, we just need not to undermine peoples’ cultural beliefs. (IDI 5)
Reflecting on themselves as the community, participants shared proud moments that, in a way, encouraged them to appreciate each other and what they had. For some, it was helpful to rediscover existing local knowledge and skills around natural herbs and home remedies that they found to be helpful. The following comments echo the shared views.
We became patient, lost a lot and our lives were turned upside down but it’s a lesson learned and now we need to build together moving forward. We must not shy away from using traditional medicines, and conversations like we are having are important. (FGD 2)
During COVID we learned about caring for our health more and have carried this with us even after the pandemic. We know the difficult place we are coming from; it has even made our children wiser, and they have not forgotten what happened. (IDI 11)
Collaboration is critical
Other lessons that participants felt were important for the community and government to consider include a crisis management strategy that supports spiritual and cultural continuity rather than suspending initiation schools.
Yes, a lot of our traditions and celebrations were put on hold. We could not slaughter for our ancestors nor send our young men to initiation schools, as tradition requires. We were kept in the dark and only heard how severe the next stage was without any helpful intervention medically. (IDI 11)
The participants further highlighted that the pandemic has shown the need, more than ever, for collaboration between Indigenous healthcare systems and the more formalised government healthcare system. The lack of cooperation could mean loss of lives, while collaborating could help address the burden of an overloaded healthcare system.
It’s important that before going to initiation school a person is physically fit. Some come with pre-existing conditions or chronic diseases without disclosing them and end up getting sick. This is where we really need to work together more with government. (IDI 2)
Another participant referred to the need for open communication to protect wellbeing and avoid health complications when performing rituals
Your father or uncle needs to know your medical history and it needs to be shared with us to avoid any problems in initiation schools. (IDI 1)
Parents need to be transparent in order to assist young men going to initiation schools. Also, they [the initiates] need to know what traditional medications can be used for each ailment that they currently have and encounter from time to time. They [the initiates] should involve an elder to avoid any problems in initiation schools, to avoid unnecessary pressure on the healthcare facility. (IDI 4)
Participants did not let go of their own cultural healing practices. Participants were led by their Indigenous spiritual health ideologies and understanding of wellbeing to find ways to sustain wellbeing during the pandemic, while implementing government guidelines.
Discussion
Losing collectiveness is ill health
In his article ‘Crisis of utopias and the four justices’26, Porto states:
Although despised by the materialistic science, the pragmatic spirituality of different peoples is the basis of the wisdom that produces meanings and builds bridges between the outer and the inner sides, the immanent and the transcendent, the thought and the affection.
The heading and quote reflect one of the most critical outcomes of this study, which informs the cultural understanding of health that is prevalent within the contexts of this study. Culture is a complex phenomenon, and every culture has its own understanding of health and illness systems, and how they engage with them17. Culture is a pervasive, powerful phenomenon that informs worldviews and understandings, practice and outcomes for its adherents27, and therefore it cannot be ignored within any discussion of health and wellbeing. Among many Indigenous people of Africa, health is understood as the spiritual balance of the relationship between individuals, families, communities, the divinity and the natural environment9. When these relationships are broken, illness results. Therefore, to maintain good health, the self and all the other areas of life in the community, both physical and spiritual domains, must remain in equilibrium. This speaks to a collective spirituality. French et al assert that healing occurs within the collective4. The physical companionship, and the performance of various ceremonial rites and engagements that support wellbeing, are carried out as a collective. Gathering as a collective gives mental, spiritual and physical resilience to address the negative stressors of life4, which in turn support cultural continuity and contribute to resilient wellbeing for Indigenous communities.
This collectiveness is what participants allude to in relation to the pandemic. What these communities identify as the most uniquely troubling and threatening aspect of the pandemic lies in the isolation and separation of people from each other. They believe that this separation or disconnect causes susceptibility, a weakening of the individual. This weakening greatly influenced the severity of the illnesses that people experienced during the pandemic and the resultant deaths. If people have access to each other, then they can cope better and feel supported. Various studies support this assertion20,28.
The accepted protocol of social distancing and minimised interaction equally threatened this relational foundation of health within Indigenous communities of Africa, posing a challenge to the Indigenous concept of health. The idea of social and physical distancing is more aligned to the more individualistic lifestyle of the urban context, not the collectivist structure of African Indigenous communities. Rural communities uphold culture and exist in community and familial clusters, which further makes physical contact mandatory20. The community observances and ceremonies needed for cultural continuity to support resilience for wellbeing are performed as a collective28.
Therefore, urban communities seemed to adjust and conform to the social distance mandate with some level of efficiency during the pandemic, albeit with issues of loneliness and mental wellbeing noted. Indigenous communities, on the other hand, experienced the pandemic beyond personal challenges of loneliness and mental health challenges, to existential and broader issues of culture and wellbeing. We align with the definition of culture in this study as ‘a collective sense of consciousness that influences and conditions perception, behaviours, and power and how these are shared and communicated’1. This understanding of culture should influence health messages and conversations held with communities to ensure buy-in and local ownership – but, as evidenced in this study, this collaboration was not primary in supporting communities through the challenges of the pandemic.
A dual approach to healthcare management
Participants advocate for a more collaborative process between Indigenous healthcare and the more formalized government healthcare system. It is critical for public health practitioners to be both aware of and to access existing cultural perceptions11,29. This is so that local interventions encourage participation of local communities through education and local engagement to avoid stigmatisation of groups or populations11,30.
The understanding and processes of cultural healing are reflected in this study, as an area that healthcare practitioners and government agents, including police need, to become more aware of. Cultural healing encapsulates the totality of the understanding given to healing within any context31. Evidence of the postcolonial engagement, the push for cognitive justice, is reflected here. We find participants referring to their religious and cultural leaders when having to make a specific choice between their belief systems and government mandates about the pandemic. Participants felt that the enforced guidelines were dismissive of their belief systems, and that the guidelines should have been better implemented to respect their beliefs. Participating in Indigenous spiritual rites and rituals is a determinant of health within Indigenous communities across the globe30.
Participants put forward the notion that both Indigenous and the more formalised western healthcare systems were beneficial during COVID-19. Studies conducted within some Indigenous communities have revealed a narrative and belief from these communities, that the solution to an illness or health condition is often located within its source, where it emanated from13,23. If an illness emanates from their context, they have the cure within that same context. However, if the source of ill health is external, then the remedy must first be sought from this external space and then contextualized within their beliefs for healing13. Therefore, this community saw COVID-19 as a Western disease, and therefore there was a mediated response. This is why the authors, in reporting the community’s responses in this article, did not present a tone of militant resistance, but one of a more mediated resistance, because that was what the community did, in responding to COVID-19. The re-existence made room for both, but was contextualized and led by their Indigenous health and wellbeing practices as understood within a postcolonial engagement.
The community saw the Western context as responsible for looking for a COVID remedy, but that did not discount their belief systems, as all remedies, while being implemented, must be grounded within their spirituality, be it Christian or Indigenous or both. Hence, the community complied and cooperated with government, re-imagining a re-existence that asserted their identity, belief systems and sense of knowing, while reflecting their current reality in terms of the pandemic, its source and its related remedies.
The realism within this accommodative stance is not only supported by the postcolonial approach. As Porta states, ‘The postcolonial approaches open a wide range for deconstructions and alternatives for social struggles to incorporate the epistemological dimension and indicate new possibilities and processes of emancipation, copresence and coexistence’22. This stance of co-existence is also espoused by the Indigenous framework of Ubuntu, which posits a shared space of understanding, agitating for a shared humanity and ecology of knowledge with the ‘other’13,23. On the other hand, Ubuntu is knowledge in the blood, imbued with contextual, cultural, spiritual communal and ancestral meanings that inform the lived experiences of peoples and communities within this context. Ubuntu as a spiritual philosophy is not dormant24, but eschews subjugation of any kind and agrees with a strong resistance to ‘othering’ of people and knowledges.
In addition, the Indigenous healthcare strategies are more holistic, more available, affordable and sustainable for them, and are aligned to their sense of cultural healing. Indigenous healers are not only important for spiritual and physical wellbeing, but they often play the multiple roles of counsellors, social workers, psychotherapists and physiotherapists all in one4,30. They also live within the communities and are reachable at any time they are needed. All of these roles encompass the notion of cultural healing.
In philosopher Kleinman’s analysis of cultural healing, the relevance of the multiple roles of the Indigenous healer begins to make more sense as he further explains the concept32. He asserts that cultural healing involves both the personal and social understandings of the illness. One can then argue that the ontological and epistemic understanding given to the concept of healing affect a patient’s experience of illness and consequently shape the cultural context of the healthcare strategies the patient will seek32. When we relate this understanding of illness as personal and social, we begin to immediately see the influence of the multiple roles the Indigenous healer embodies. Hence, with participants wanting to connect with their Indigenous healers, it was not just about medication, but about a connection to support holistic wellbeing. Their need for Indigenous healers is directly related to the earlier discussion on an ontological and epistemic understanding of health and wellbeing as holistic, something more than mere medication. This holistic wellbeing approach is in opposition to biomedicine’s focus on mainly the physical aspects of illness, which is a violence to the Indigenous patient and an area of major concern8. Kleinman agrees with the argument above and emphasizes the need for orthodox Western medicine to learn from folk medicine, arguing for an approach that centres a patient’s personal, social and cultural experiences of ill health when treating illness32. Thus, the fragmented approach to western healthcare practice, and its time pressures, emanates from its colonial settler history and is not congruent with holistic care within the Indigenous understanding of health and wellbeing19.
The integration of Indigenous and Western medicine is a possibility within the South African context. It is, however, fraught with challenges28. Until this happens, people continue to straddle both systems, which was even more challenging to do during the pandemic. This straddling and push could be related to the fight for cognitive justice, for their sense of cultural healing, which the community refuse to give up, seeing the health and life that it sustains for them. As Muchenje puts it, ‘Therefore, the proposal of cognitive justice can be assumed as the search for recognition, legitimacy and the right to coexist of the enormous variety of knowledge systems that exist among different peoples and cultures. This search implies the criticism of the dominant paradigm of modern science that assumes itself as superior and sole criterion of truth, rejecting and making other knowledge systems invisible’22.
Therefore, although participants welcomed the information provided by the formal healthcare system, there was a resistance as they applied this information through their lens of cultural healing. Participants advocate for a more participatory decision-making process11 during a health crisis, which is more helpful. Additionally, Indigenous people live in communities that have operational Indigenous understandings of health and wellbeing11,25. There is a need to take these definitions and understandings into context when devising health management strategies for these communities25.
A study carried out in Sierra Leone reflects the importance of adopting collaborative approaches within a health crisis. Researchers discovered that the use of methods that aligned to Indigenous divination processes elicited more responses, participation and understanding from their study population. The authors advocate that public health practitioners should identify and include methods that align to relevant cultural belief systems and practices when engaging with communities regarding the COVID-19 pandemic22,28. The outcomes of this study align with those of Ohajunwa28 about aligning public health practices with Indigenous healthcare. Participants insist that there did not have to be a total shutdown of all their Indigenous institutions if their continued use had been properly discussed and negotiated.
The assertions of the study participants about the integration or, at the very least, consideration of both healthcare systems, have implications for policymaking during any pandemic. Health policies implemented within Indigenous communities should have their buy-in, and their worldviews and their current realities considered during the development process. The health experiences of rural Indigenous communities are uniquely informed by their histories, positionalities and belief systems; therefore, assuming a ‘one size fits all’ policy and neglecting Indigenous voices will create ill health rather than wellbeing. For instance, in advocating for social distancing, cultural matters should be considered1.
Findings revealed how even the funeral ritual space has been affected by the pandemic. Amongst the amaXhosa people it is believed that, when a family member dies, they move on to the spiritual realm to join their ancestors. If the deceased person’s spirit is not properly assisted to join the ancestors, then that spirit will not be at rest and may inevitably become a force of destruction and bring illness upon the family11. To prevent this, certain sacred funeral rites must be performed before, during and after the burial. These rites form a crucial part of the grieving process among Indigenous Xhosa people and require the participation of the entire family, the relatives, fellow clan members and community members. The pandemic protocols as reinstated by the South African government interrupted these critical cultural rites. Furthermore, the presence of heavy policing by the South African Police Service and the Department of Health inspectors added an extra element of confusion and discomfort for the bereaved in their process of grieving their departed. Although the community does not discount these enforcements, they believe that some more engagement between government and community would support a space of mutual respect and understanding, contributing to the promotion of health and wellbeing.
Limitations of the study
Some limitations were experienced within the study process. The primary researcher did not speak the local language, therefore all documents had to be translated. An independent cross-checking process was put in place, but there is still opportunity for some meaning to be lost in translation of data. The researcher encountered some previously existing internal political challenges on ground with one of the communities, which impacted access to participants for data-gathering purposes. This meant that fewer participants came from this community and more from the other three communities, affecting the study aim of achieving equal representation across all communities.
Conclusion
Indigenous health practices are grounded within spirituality expressions, for Indigenous communities globally. The African cultural expression and belief system is enshrouded by the lived experience of their spirituality, which supports resilient wellbeing for Indigenous communities in the face of a health crisis. The understanding and insight into the African Indigenous experiences of this pandemic, and how people mitigated the stipulations of the pandemic within their cultural, spiritual belief systems to support wellbeing, is important. Participants stipulated that a more consultative process would have been beneficial, and the immediate shutdown of spiritual spaces like initiation schools and healing rituals and observances created even more challenges. They stated that the imposition of the government guidelines – which they observed, and saw as necessary – could have been implemented within a more inclusive approach. There is a need to ensure buy-in from the communities as part of authentic collaboration to sustain wellbeing.
Despite these challenges, the communities reflected a push for cognitive justice by ensuring they grounded all wellbeing practices within their Indigenous spirituality. They used various herbs and home remedies to sustain wellbeing during the pandemic, sustained faith and hope through their spiritual practices, and looked to their traditional leaders and healers for support.
These outcomes have certain implications for sustainable health policies to address both current and long-term impacts of future pandemics and health crises beyond Africa to other global Indigenous spaces. Further studies could explore the concept and attributes of inclusive policymaking and what this currently means within Indigenous practices and knowledge systems.
Acknowledgements
The authors would like to acknowledge all study participants. We thank community members, families and local traditional leaders and councillors at the Thamarha Great Place for supporting the study activities in Thamarha.
Funding
The authors thank the South African Medical Research Council Self-Initiated Grant and the National Research Foundation Innovation Post Doctoral Grant for the financial support received for the research.
Conflicts of interest
The authors declare no potential conflicts of interest with respect to the research, authorship and publication of this article.