A Brief QuAlitAtive Study of indigenouS trAditionAl Medicine Providers in TiMor-LesTe

: Providers of Traditional Timorese Medicine are an essential resource in rural communities, contributing greatly to the overall health of individuals in Timor-Leste. Th eir identity and role in healthcare has not been widely investigated and functions outside of the National Health System. Th e objective of this qualitative study is to describe the role of providers of Timorese Traditional Medicine in Timor-Leste and their practice of medicine. To perform this research, semi-structured interviews were performed with providers of Traditional Timorese Medicine in the rural district of Viqueque. Interviews took place at providers’ homes in Tetun and, after translation into English, interview content was analyzed and emergent common themes identi fi ed. Th e seven providers of Timorese Traditional Medicine interviewed mostly identi fi ed themselves as either a Liman Badain , Matan-Dook , or reported no title. Another identi fi ed himself by his political position as village chief, Xefe-Suku. Emergent themes from interview content included 1) Medical pluralism, re fl ecting that Timorese frequently use more than one medical system; 2) Spiritual sickness, re fl ecting illness and treatments commonly involving ancestral spirits or supernatural forces; and 3) Familial knowledge, re fl ecting healing practices and knowledge often kept within a family and passed down across generations. Generally, providers reported that the most common symptoms they treated in their practice were illnesses/misfortunes related to a woman’s gynecologic health and were obstetric in nature, especially concerns regarding reproductive health. Th is qualitative study provides information about the key role of select individual providers of Timorese Traditional Medicine and adds to the limited existing knowledge. Further qualitative and quantitative research must be done to further characterize the identities and role of di ff erent providers of Traditional Timorese Medicine.

introduCtion Traditional Medicine practices are visible worldwide and are the preferred option for patients across many countries, despite impressive technological advances in biomedicine. In some countries, these longstanding practices and providers are regulated and integrated into the national healthcare system (Regional Committee for Africa, 2013). In Timor-Leste, a small island country located in Southeast Asia, indigenous traditional medicine practices, and the individuals providing these services, remain unregulated and poorly understood.
Timor-Leste gained independence in 2002, after a 24-year occupation by Indonesia during which the population of the entire country was reduced by a third. During this time, indigenous traditional medicine practices were relied upon heavily (Collins, Martins, Mitchell, Teshome, & Arnason, 2007). Healthcare facilities were only provided for those who supported the Indonesian occupation, and guerillas did not have access to these facilities as they faced prosecution if found. Timorese soldiers relied on plants for food and medicine, practicing in secret (Cousins, 2019;Alonso & Brugha, 2006;Tulloch, 2003;Galvin, 2000). At the end of the occupation when Indonesian troops were withdrawing there was widespread destruction of nearly all medical institutions, equipment, supplies, and records. However, after gaining independence indigenous traditional practices continued to flourish. Even as the new country developed its own formal healthcare system, the maintenance of old practices persisted (McWilliam, 2008;Boarccaech, 2013Boarccaech, , 2019.
The system set up in Timor-Leste currently provides free universal healthcare to all citizens, so it may be surprising that many also seek care elsewhere. Some individuals pay a fee for care from private health facilities like pharmacies, outpatient clinics, laboratories, or providers of Traditional Timorese Medicine. Timorese providers of indigenous and traditional medicine still exist in rural areas functioning outside the bounds of formal healthcare, and despite their widespread presence in Timor-Leste little is known about the individuals providing these services. The objective of this qualitative study is to describe the role of providers of Timorese Traditional Medicine in Timor-Leste and characterize their practice of medicine.

mAteriALS And metHodS
Brief semi-structured interviews were performed in 2019 in a rural district in Timor-Leste, specifically the sub-district of Uatu Carbau. Conversations were audio recorded and conducted in Tetun by a local Timorese researcher, and were focused around asking providers the following three key questions: 1) Can you tell me about your practice of medicine?; 2) Why do people come to see you?; and 3) Which treatments and plants do you use the most? A convenience sample was used for this study and participants were identified through local leaders who referred individuals known to be providers of Traditional Timorese Medicine. Providers were approached at their homes and invited to participate and all those who were approached agreed to be interviewed. All participants signed an informed consent prior to participation.
Interviews were audio recorded and transcribed verbatim into English by a native multilingual Timorese. Thematic content analysis was used for identification of common threads across interviews, which involved labeling relevant words, phrases, sentences, or sections. Two researchers reviewed all the transcripts and identified the themes that emerged from the interview responses. Before data collection began, permission from the relevant village chief, or Xefe-Suku, was informally obtained.

Interviews
A total of seven Traditional Timorese Medicine providers, six females and one male, participated in this qualitative study. Providers reported utilization of a variety of spiritual and religious modalities as well as herbal medicines (see Table 1). The most common illnesses/misfortunes that providers reported treating were obstetric and gynecologic concerns, often related to a women's reproductive health. Preventative prenatal practices were common as were treatments for difficulty conceiving, breast cancer, and other common gynecologic issues. Providers offered a range of healing modalities including massage, herbal medicine, and various forms of spiritual healing. As patients' concerns were often both biological and supernatural in origin, many of the treatment regimens reported by providers likewise included several strategies that were both biological and supernatural. In examining the transcripts across providers there were three distinct themes that emerged multiple times: medical pluralism, spiritual sickness, and familial knowledge. These themes are described below.

theme i -medical Pluralism
This theme reflects that Timorese frequently use more than one medical system, rather than solely receiving care from the Timorese Traditional Medicine providers. Providers mentioned the overlap of patients' healthcare across systems, and in this pluralistic healing context, values did not seem to conflict. Generally, the attitude towards biomedicine as discussed in these interviews was positive. Providers discussed patients' use of traditional medicine after a failure or unsatisfactory treatment with conventional medicine, as reflected by one provider who stated that "When they are sick, they go to hospital and take medicine but when they are still sick, they come to me and I massage without using medicine, but only ointment, and they feel better." Another discussed a patient's previous care, stating, "When they go to hospital to get help to have children, but the hospital cannot help them, they come to me, and I help them." Relationships between providers in both systems appeared positive, with Traditional Timorese Medicine providers reporting treatment of patients who were themselves professionally trained providers of biomedical conventional healthcare; one provider pointed out that "Some nurses also come look for me to help them." Furthermore, midwives are part of the hierarchical structure of communities in addition to having a certain power and social status (Boarccaech, 2013). Midwives are generally more open to conversation and training compared to others, which is why the government and NGOs have sought to partner with midwives.

theme ii -sPiritual sicKness
This theme reflects that there is a highly developed process for utilizing Traditional Timorese Medicine products and healing techniques commonly involving ancestral spirits or supernatural forces. During the search to identify providers, multiple individuals brought up one provider known to practice powerful black magic, though using the phrase 'black magic' to describe certain traditional practices may reflect a Christian point of view on these practices. This was the only individual identified as a potential interviewee that was not contacted, because the research team was told they were prohibited from speaking to this individual out of fear of this individual's powerful black magic that could cause severe harm. Interviewed providers identified human causes of intentional illness such as ema halo (the literal translation is ema: "people" and halo: "do", which taken together is a concept similar to a curse or spell) and discussed how individuals may practice both good and bad magic/witchcraft. Intentions to heal or hurt were not always clear, with some providers being stigmatized and ostracized. Some providers expressed that their ability to heal was due in part to their extensive understanding of spirits and their supernatural ability to communicate with spiritual forces, usually ancestral.
Healing methods may include supernatural abilities or witchcraft, for which details are secret. One provider, not willing to disclose certain details of how he prepares his medicines, stated that "These medicines cannot be shared with other people because I have performed witchcraft before I make them." Offering spiritual treatments not available with modern medical practices and the ability to communicate with ancestors in the spiritual world has led some providers to uncover non-biomedical illness etiologies. There was fear that a "Parent's spirit was going to be mad," and providers described precautions that could be taken to avoid this type of sickness. Causes of horok, a Tetun modality related to spiritual sickness and not readily translated into English, were described as many: " horok ne barak, horok muluk tasi-laran, horok babora ne ida, horok fatuk-kadi, horok fatuk-belar."

theme iii -Familial Knowledge
This theme reflects healing practices and knowledge often kept within a family and passed down across generations. Healing knowledge is passed down from relatives and some interviewees mentioned that they could not share their family trade secrets (see Boarccaech, 2013Boarccaech, , 2019. Development of their knowledge and skills related to their practice if Timorese Traditional Medicine was taught by grandparents and parents; one provider reported they "helped to preserve tradition that only my family knows." As such these were considered sacred family knowledge and not to be shared as shown by the following response: "I am afraid to share these medicines with other people because my grandparents were the ones that taught me and the other generation. I am afraid my grandparents' spirit is going to be mad at me. Therefore, I am not brave enough to demonstrate." Generally, providers reported learning such knowledge from previous traditional healers in their family throughout their childhood years. However, another healer mentioned that their skills and knowledge were given to them naturally at birth. An individual may be chosen to have the gift of healing and understanding naturally given to them.

diSCuSSion
Traditional health is largely concerned with proper engagement with the spiritual realm and ancestors in Timor-Leste. A commonly held belief is that illness is the result of a transgression or from becoming estranged from one's ancestors (Wallace et al., 2018, Boarcaech 2013, 2019. Timorese traditional practices often honor deceased ancestors or aim to protect patients from a Buan (sorcerer or witch), and findings from the current study support these previous observations. This indigenous belief system in Timor-Leste also incorporates many beliefs from Christianity, though this was not so obvious in our findings. Non-biomedical disease etiology in Timor-Leste posits that disease often involves Christian and Traditional Timorese beliefs woven together. For example, Catholic graves are often the site for leaving a tribute or holding a ceremony for indigenous ancestorial spirits. Providers interviewed in the current study did not provide much detail regarding spiritual practices, perhaps due to the sacred nature of these ceremonies.
Factors in the Timorese understanding of illness include causes from ancestral, spiritual, customary, or natural factors, or from not fulfilling one's social obligations (McWilliam, 2008, Boarccaech, 2019. The church rejects indigenous Timorese spirituality and discourages the practices of this belief system, although this guidance is generally ignored, especially in rural areas where individuals see lulik (holy) beliefs as complementing rather than contradicting their Catholic faith (see Rose, 2020;Boarccaech, 2013Boarccaech, , 2019. However, many priests use traditional beliefs, encourage the use of herbs, and even present themselves as the Matan-Dook of the church because they have healing powers. Providers interviewed in this study had a positive outlook on the conventional medical system and its providers as well as healing withing the institution of the Catholic Church. One Timorese described traditional ancestorial spirits as "close to God," and another researcher described traditional rituals as essentially a form of prayer (Rose, 2020). Therefore, healthcare initiatives premised only on the empirical understandings of reality may not be utilized as much as other healing modalities based on traditional beliefs. Another report found that healing practices rooted in Timorese traditional culture and animism are used in parallel with Catholic beliefs (Pollanen, 2004;Rose, 2017, Boarccaech, 2013. The overlap of healthcare, traditional beliefs, and religion is highlighted by one report of doctors and nurses prescribing forms of prayer (Boarccaech, 2019).
There are various providers of Timorese Traditional Medicine, although there is overlap in some of their practices. One of the most reported on provider type is a Matan-Dook, though published reports use various spellings and descriptions (Matan Dok, Matan Doc). Matan-Dook is translated directly as "eyes far" and is described as a shaman, or diviner, who can function as a healer and mediator between the realms of the living and the dead. They are reported to have the ability to access information and messages about illness from deceased ancestors. This group is not homogenous and there is no standardized training (Boarccaech, 2019). As shown from our interviews, treatment modalities and practices vary between provider types and across individuals. One notable variance within the Matan-Dook provider class is regarding the acquisition of one's healing ability. In some cases, the healing ability is thought to be passed down from generation to generation, and in others the provider has been naturally gifted with healing abilities.
Another less understood provider type that was interviewed in this study was a Liman Badain (bone setter). This is an expression that designates a series of different skills. It can be for massage therapists, for physiotherapists, for nurses, or for home builders. They are people who massage or know how to stitch wounds or put a dislocated shoulder in place. They are usually women and men who by tradition cannot be a Matan-Dook -or men who are not yet recognized as Matan-Dook -(see Boarccaech, 2013Boarccaech, , 2019. These are providers that heal often using herbs and physical touch. Another interviewed individual that also functions as a provider of Traditional Timorese Medicine was a Xefe-Suku (village chief), who informed us that he was the descendant of a previous Liurai (king of the land) from whom his herbal knowledge was acquired. Their higher status in society is often reflected in their political title as well as their extensive knowledge of traditional practices. Being a village chief, or even a Liurai as in the past, is not related to knowing healing practices. They are different social functions. Knowledge of medicines, knowing stories, or occupying a position of midwife or healer is also associated with a higher status. Social positions dictate a complex hierarchical structure within communities and traditional medicine is a social function involved with these social power relations (Boarccaech, 2013).
Others in this spiritual landscape include fortune tellers, spirits related to Catholicism, familial ancestral spirits or Matebian sira, land custodians or Rai Nain, and nature spirits or Espiritu Natureza (Winch, 2017). One provider that we were made aware of but were advised not to contact was a Buan, or witch, and in Timor-Leste these providers are sometimes feared if it is believed they practice black magic aimed at taking retribution and causing illness.
Other providers not represented in the interviews conducted for this study include Ema Aimoruk Timor (herbalists), individuals healing with herbal preparations (Edmonds, 2005). The heterogenous group referred to as provi-ders of Timorese Traditional Medicine has also been reported to include those referred to as a Liman Urat (diviner) as well as a Kukun Na' in (ritual specialist) (Barnes & Palmer, 2021). Another study has reported on a provider titled a Ruin Tohar (bone setter) and on multiple classes of providers that function as Traditional Birth Attendants (TBAs) including Badaen Liman, Daia, Dukun, and Liman Loos (Zwi, 2009). The focus of a Liman Badain on female health is supported in our findings as well as other studies using alternative spellings including Liman Badaen, Liman Badein, and Badaen Liman (masseur; also traditional midwife) (Barnes & Palmer, 2021). Another report states that Birth attendants who administer massage and assist with deliveries and postpartum care may go by multiple names including Daya or Liman Badain (hand workers) (Edmonds, 2005).
Providers reported modalities often related to horok, and the specific terms found in this study that were unique to this study or minimally used in previously published literature are found in Table 1. Direct translation may be a little limited and not reflect the true meaning of the terms including the specific combination of words, and thus there may be more nuances. For example, Ran Mate translates literally to "blood dead", but can be used to describe blood clots or any type of thrombus or embolism as well as complications such as stroke, paralysis, varicose veins, and venous stasis. All uses of horok that have been published, based on conducting an in-depth literature review of English and non-English sources, are reproduced below: a) The term Tara Bandu (hanging of a prohibition) comes from the process by which temporary or seasonal prohibitions are enacted through the erection of a pillar (ai-to'os) or tying/hanging of a prohibitionary sign (horok) as a clear landmark. It is important to understand that Tara Bandu should not be viewed as an isolated action, but as a complex social process which culminates in the public marking of a prohibition. Those involved in the ritual part of establishing Tara Bandu are recognized representatives from within the community (often elders), who are perceived to have an ability to put curses on infractors. (Periera, Pinto, Mohan, & Atkinson, 2013). b) A substantive meaning sorcery in English, and also prohibition... horok is used mainly to state a prohibition in an iconic framework, at the spatial and social scale of a family property (Casquilho & Martins, 2022, p. 252). c) Locally enacted customary practices of ritualized prohibitions (Palmer & McWilliam, 2019). d) A hanging object marking specific restrictions of access to spaces or crops that reminds the passer-by of the prohibition at stake in a given place." And "Horok marks the existence of a ban or custom-based regulatory mechanism 'aimed at governing the relationships among humans and between human and non-human entities (spaces, objects, animals, crops, the state, the environment)'" (Alonso Población, Rodrigues, & Lee, 2016). e) Horok is a word used in Tetun, but each community with its different language variants has its own words for it. Horok is a spell that aims to prohibit access to something, such as an object, a tree, a plant, a fruit and so on. Generally used to protect objects (and plants, fruits, etc.) that are owned by someone (individual or family) and belong to a certain place or that must remain in a specific location. This helps to prevent someone from stealing, or inadvertently appropriating something. […] There are some formalities to be followed in order to practice the horok, such as the place where the ceremony will be held, the words to be pronounced (sometimes in the form of a poem) and the objects that symbolically represent (as a visual mark) to the ban imposed. In general terms, the horok has a legal, spiritual and social dimension when communicating to people that no one can take (or even approach in some cases) that object, tree, etc. Anyone who disrespects horok will be punished by the spirits of nature and the ancestors (can also be punished by local leaders and cause conflicts between families). (Boarccaech, personal communication, May 24, 2022).
The limitations of this brief study include the small sample size and the skewed male to female ratio, with only one participant being a male provider. In addition, the data collection was limited to the district of Viqueque. Researcher presence may have also influenced responses, resulting in more limited or socially desirable responses. Knowledge about the role of traditional providers is crucial to improve the treatment in rural communities. Although three common themes were identified, interviews of a broader range of providers might reveal additional themes/commonalities/scopes of practice.
Further studies could identify all providers to lead to an understanding that focuses on how to better integrate the services provided by these traditional providers and conventional medical providers. Further information is needed to identify approaches that will also support better communication between traditional and conventional providers. Further research on this topic might aim to characterize the services and limitations of both types of providers and quantify these human resources. The observations from this qualitative study add to the limited existing knowledge in Timor-Leste and provide an opening for future study.