The ethnomedicinal use of vultures by traditional health practitioners in KwaZulu-Natal, South Africa

African traditional medicine contributes to greater healthcare coverage by providing primary healthcare to rural dwellers, who often have limited access to modern medical services. However, the prevalence of traditional medicine use has been reported to put pressure on biological resources upon which it relies. Indigenous people have identified many wild animals as possessing curative properties. The use of animals and their body parts as ingredients in traditional medicine is often poorly regulated and therefore represents a major challenge for biodiversity conservation. We investigated traditional health practitioners’ ethnomedicinal use of vultures in KwaZulu-Natal, South Africa. In-depth interviews were conducted with 26 traditional health practitioners from two district municipalities. Data collected were analysed through qualitative and quantitative methodologies. We documented seven parts of the vulture that traditional health practitioners used in KwaZulu-Natal. When the Use Value (UV) index was calculated for each part, the head obtained the highest (0.92). Consensus on parts and their uses was generally low across the study group. Of the 21 uses reported for vulture parts, 71% were spiritual-based. The participants were aware of the hunting of vultures through the use of poison but demonstrated different views about the risks associated with using such material. Overall, our findings confirm the increasing use of African vultures in traditional medicine. Raising awareness and upscaling the active involvement of traditional health practitioners in natural resource management may benefit vulture conservation and that of other species commonly used in belief-based practices.


Introduction
Over the years, many cultures of the world have developed their own healthcare systems to help overcome physical, spiritual and psychological maladies (Benedict 2014). The World Health Organisation (WHO) defines traditional medicine as "the sum total of knowledge, skills and practices based on the theories, beliefs and experiences indigenous to different cultures, whether explicable or not, that are used to maintain health, as well as to prevent, diagnose, improve or treat physical and mental illnesses" (World Health Organisation 2004: 06). Traditional medicine indigenous to African cultures is known as African Traditional Medicine (Mothibe and Sibanda 2019), muthi in some indigenous languages. One of the distinctive characteristics of African traditional medicine is the inherent consideration of natural and supernatural forces in etiologies of illness. African traditional health practitioners employ a holistic approach to disease management, where well-being is examined from spiritual, cultural, physical and psychological dimensions (Ozioma and Chinwe 2019). According to Abdullahi (2011), traditional medicine was the main source of primary healthcare for the majority of the African population before the introduction of modern healthcare to the continent. Despite significant development and increased access to modern healthcare, evidence indicates that the use of traditional medicines remains prevalent in most African communities (James et al. 2018).
Although traditional medicine is often described as affordable, accessible, and culturally acceptable (Kamsu-Foguem et al. 2013;Kasilo et al. 2019), a large proportion of its use derives from the pluralistic nature of healthcare systems common in most African countries, where modern medicine is appreciated but used simultaneously with traditional medicine (Nxumalo et al. 2011;James et al. 2018). The role played by African traditional medicine in contributing to greater healthcare coverage is well recognised by the World Health Organisation (Kasilo et al. 2019). Nonetheless, issues of efficacy, safety concerns, and the integration of traditional medicine into formal healthcare systems lead to debates within the domain of traditional medicine (De Roubaix 2016;Zuma et al. 2016;Mutola et al. 2021).
The majority of the population in sub-Saharan Africa resides in rural areas (Crush and Fayne 2010;De Brauw et al. 2014). These areas are the most marginalised settings in the sub-continent, as they persistently fall behind in terms of economic progress (Darkoh 2009;Saghir and Santoro 2018). Consequently, service delivery in rural southern Africa has considerable shortcomings, one key example being the provision of conventional primary healthcare services. Rural residents are therefore driven to rely, alternatively, on traditional medicine as an easily accessible option (Sato 2012;Saghir and Santoro 2018). In recent decades, the region has been experiencing rapid rural-urban migration, with countries like Namibia, Botswana, Angola and South Africa now having over half of their populations occupying towns and cities (World Bank 2021). City occupants' reported increasing use of traditional medicine is indicative of cultural diffusions, characteristic of migration processes. The strong belief in African healing practices has been the primary factor in choosing African traditional medicine, especially in KwaZulu-Natal, South Africa (Cunningham and Zondi 1991;Zuma et al. 2016).
The predominant reliance of traditional medicines on wild-sourced biological resources has attracted considerable controversy because of increasingly unsustainable use patterns that contribute to biodiversity loss Williams et al. 2017). In addition to the many plant species used for medicinal purposes, within their local environments, indigenous people have identified a number of wild animals as possessing curative properties (Soewu 2008;Vats and Thomas 2015;Izah and Seiyaboh 2018;Nieman et al. 2019). However, evidence on the pharmaceutical effects of faunal resources used in traditional medicine is limited. Only a few studies exist; for example, Dinesh et al. (2013) demonstrate that the coelomic fluid of the African Nightcrawler Earthworm (Eudrilus eugeniae) is cytotoxic (i.e. it can kill cancer cells). Traditional knowledge and cultural belief systems remain the fundamental basis for the widespread ethnomedicinal use of fauna (Vats and Thomas 2015;Borah and Prasad 2017). If the popularity and demand for animals in traditional medicine increase, there is an expected increase in activities such as illegal hunting and trade. Most animals used in traditional medicine are wild-sourced (Soewu 2008;Alves et al. 2013;Soewu and Sodeinde 2015;Loko et al. 2019), often with little to no adherence to regulatory mechanisms put in place to ensure sustainability (Djagoun et al. 2013;Adhikari et al. 2020). Both local and international markets drive the demand; with regards to local trade, sales generally occur in open markets across cities and within local community networks (Atuo and O'Connell 2015;Williams and Whiting 2016;Williams et al. 2017;Nieman et al. 2019). Trade in wildlife resources for traditional medicine often represents an important source of income for those involved in it, especially the economically marginalised McKean et al. 2013). Finding equitable trade-offs between socio-economic obligations and biodiversity conservation outcomes poses a challenge.
Some argue that traditional medicine may not always represent an immediate threat to wildlife species (Ferreira et al. 2013;Williams et al. 2014). However, species differ in their vulnerability to stressors. Some species may have a limited capacity to withstand consistent offtake. This is true for cultural keystone species, which are usually large-sized or long-lived, charismatic, peculiar and strong characters often preferred by traditional medicine practitioners (Williams et al. 2014;Durojaye and Olufemi 2015). Generally, most large-sized species occur in relatively low densities, are slow reproducing, have long life histories, and often face multiple anthropogenic threats (Whiting et al. 2013). Such species are highly vulnerable to offtake, especially under uncontrolled harvesting regimes, as is often the case with traditional medicine use. Ethnographic studies provide valuable insights into the value of species in traditional therapies of various ethnic groups (Williams et al. 2014. These studies may help highlight species whose populations may be compromised as a result of use in traditional medicine. Historically, vulture species have been used in traditional medicine in parts of South Africa, but research demonstrates that there has recently been an increase in their demand (Cunningham and Zondi 1991;McKean et al. 2013;Whiting et al. 2013;Nieman et al. 2019;Mashele et al. 2021). Most vulture species are highly threatened, owing to multiple stressors, including habitat modification, electrocutions, collisions, direct hunting and poisoning (Ogada 2014;Krüger et al. 2015;Botha et al. 2017;Rushworth et al. 2018). Out of seven resident vulture species in South Africa, four are regionally listed as Critically Endangered, two are categorised as Endangered, and one is listed as Least Concern (Geldmann et al. 2013;Allan 2015a, b, c;Krüger 2015;Taylor and Peacock 2018). Poisoning has been identified as one of the techniques hunters use to acquire vultures for trade and use in traditional medicine (Botha et al. 2017). The impact of poison on wildlife, including vultures, is often catastrophic, with overarching implications for biodiversity conservation (Groom et al. 2013). From a human health perspective, there may be risks stemming from using poisoned material, although this needs further investigation. There is a possibility that traditional health practitioners are not aware that some of the vultures traded for use in traditional medicine may be contaminated with poison. We conducted a study in KwaZulu-Natal to solicit traditional healers' perspectives on the present dynamics of the use of vultures in traditional medicine, including parts used, conditions treated, and perceptions concerning the use of poisoned vultures and their body parts as ingredients in traditional medicine.

Study sites
Our study involved traditional health practitioners residing in KwaZulu-Natal Province, South Africa, particularly within uThukela and Zululand district municipalities. Sampled areas were in or adjacent to the towns of Pietermaritzburg, Estcourt, Ladysmith, Vryheid, Nongoma, Mtubatuba, Mkhuze and uPhongolo ( Fig. 1).

Data collection and analyses
We followed a mixed-method approach comprising of qualitative and quantitative research techniques. We adopted a mixed sampling method consisting of purposive and snowball sampling. Purposive sampling is a qualitative technique used in studies involving homogenous individuals based on characteristics, knowledge, and experiences (Brancati 2018;Cohen et al. 2002). This technique was suitable as the study intended to solicit the knowledge held specifically by traditional health practitioners in KwaZulu-Natal (Albuquerque et al. 2014). One of the main advantages of purposive sampling is the optimum use of time and resources (Albuquerque et al. 2014). Local traditional health practitioner societies serving as representatives for traditional healers were identified and contacted by the lead researcher. Several meetings were held between the lead researcher and leaders of the selected societies, during which the study purpose and requirements were discussed. Outcomes from the meetings were shared with the rest of the members. From this phase, the researcher was given a list of traditional health practitioners (with their contact details) who were willing to participate in the study. The traditional healers who volunteered to participate in the study were contacted and visited for interviews. Subsequently, the snowball sampling technique was used to obtain additional participants. The snowball technique is particularly convenient when conducting research involving hard-to-reach populations (Albuquerque et al. 2014;Chang et al. 2017). Indeed, traditional healers are not easily approachable to people who are not seeking to use their services. In addition, early in the study, it was established that most local traditional health practitioners were not keen on participating in research studies because they believed researchers solicit knowledge from traditional health practitioners to use for their own commercial gain (pers. comm.).
A semi-structured interview guide was formulated and used to guide the interview process. The first section of the research instrument was designed to obtain demographic attributes of the study participants. The second section was dedicated to questions concerning the ethnomedicinal use of vultures. The interviews were conducted in July 2019 and again from September to December in 2020. Interviews were conducted in isiZulu (the participants' home language), and lasted from 30 to 45 min. The University of KwaZulu-Natal Humanities Ethics Committee granted ethical clearance for the study (reference number: HSS/1089/108D). Verbal consent was obtained from each participant before the interviews were administered. The consent statement indicated that the interview was for research purposes and that the research aimed to contribute knowledge that would help address the decline in vultures. In addition, participants were informed that their responses would be recorded as anonymous. No personal information was obtained by the interviewers except for a few respondents who requested feedback when the study was finalised.
Free-listing was adopted, and participants were (for some questions) at liberty to give multiple responses (e.g. ailments known by the participant that were treated by a particular part). Qualitative data were coded and prepared for thematic analysis which allows for a systematic arrangement of data into patterns of meaning (Braun and Clarke 2012).

Use value
The Use Value (UV) index was computed for all vulture parts reported using the formula from Phillips et al. (1994). The formula for this index is often used to indicate species' ethnomedicinal importance in a given community (Albuquerque et al. 2006). It has, however, also been used in previous studies to demonstrate the value of different body parts of species used in traditional medicine (Boakye et al. 2019(Boakye et al. , 2021. Similar to the latter, the UV index was used in the present study, and computed as follows: where: Up represents the number of times a particular part was cited as being used and n, the total number of respondents.

Informant agreement ratio (IAR)
Homogeneity in knowledge is one of the main indicators of the cultural importance of resources (Hernandez et al. 2015). To demonstrate the level of consensus among the study participants regarding parts and ailments that these parts were reported to treat, we used the Informant Agreement Ratio (IAR) (Boakye et al. 2019). This index is alternatively known as the Informant Consensus Factor (ICF) (Loko et al. 2019). The following formula was used to compute the index: where: nr represents the total number of times a specific part was reported and na the total number of conditions reportedly treated with this body part. The IAR results vary from 0 to 1. One represents the highest level of agreement between respondents. Zero and values closer to zero indicate the absence and lowest levels of consensus among respondents regarding parts and ailments for which they are used and a high variation in uses for the part in question (Heinrich et al. 1998;Boakye et al. 2019;Loko et al. 2019).
Uses were categorised as either medicinal or spiritual. From these two categories, uses or ailments of physical nature were classified using the International Classification of Diseases 10 version 2019 (ICD 2022). Spiritual ailments/uses were classed according to what the treatment was intended to achieve (e.g. intelligence for learners was classified under Acts of enhancing).

Study composition and participant information
The study involved 26 participants, 15 (58%) males and 11 (42%) females. Twenty-four of the respondents participated as interviewees, while two contributed as key informants. Analyses of data were thus based on 24 respondents (Table 1). The youngest participant was 29 years old, the oldest was 70 years, and the average age of respondents was 54 years. In this study, we identified three main types of traditional health practitioners, namely, diviner (59%), herbalist (21%) and faith healer (8%) (Zuma et al. 2016 provide a detailed description of traditional health practitioners' typology and their different roles, e.g. faith healers mainly use prayer, sometimes holy water and candles but fewer herbs and, are highly unlikely to include animal parts in their healing practices.). Other participants identified as more than one type of healer [i.e. faith healer + herbalist (8%) and diviner + herbalist (4%)]. Participants provided healing services to people of all races, gender and age groups; presenting general physical illness, sexual reproductive health-related issues and mental illness. Some of the study participants also furnished spiritual healing services such as protection against acts of witchcraft. Moreover, respondents helped people build and maintain good relationships with their ancestors. It was indicated

Vultures in traditional medicine
Participants fell into two categories; they were either vulture users (83%) or non-vulture users, who were aware of the use of vultures in traditional medicine (17%). All the diviners in our study used vultures in their healing practices. All participants who identified as faith healers did not use vultures.

Vulture parts
Seven vulture parts were identified as of use for a range of ailments and conditions in traditional medicine (Tables 2  and 3). Ithuko, a fluid-like substance (as described by the participants) found in the vulture brain, was reportedly the main product that traditional healers required. However, because of the perception that this substance disappears as soon as the bird dies, it was challenging to harvest as this had to be done while the bird was still alive. Most healers resorted to using the vulture's head or brain. The head and brain were thus combined into one part, namely the head, as these parts were often mentioned as one by the respondents, and their uses overlapped. The head had the highest number of use reports (n = 22, 92%), followed by bones (n = 6; 25%). Body parts with the lowest use citations were eyes (n = 2) and eggs (n = 1). Similarly, the UV for the head was highest, at 0.9, while bones demonstrated a UV of 0.2 ( Table 2). The vulture head was predominantly used as an ingredient in concoctions for umhlahlo, the ability to foretell, which was, overall, the most reported use for vulture parts  in traditional medicine (72%). The head was also used as an ingridient in treatment for izizwe, a spiritual malady that manifests in mental disorientation and uncontrollable wailing. Enhancing intelligence in learners and curing headaches were among other uses of the head. Vulture bones were linked to 24% of the uses reported, including fractured bones, stroke, izizwe and protection against unwanted spirits. Parts were not exclusive to just one condition or ailment; for example, the head, bones and heart could all be used in concoctions for clairvoyance. The Informant Agreement Ratio (IAR) was calculated for each part in relation to the uses for which they were reported (Table 2). Although the level of agreement among the participants was generally low, vulture wings obtained the highest IAR (1.00). The head and heart followed, each obtaining consensus levels of 0.38 and 0.33, respectively ( Table 2). Due to our small sample size, respondent consensus for eggs, and eyes could not be computed.

Ailments or uses
We identified a total of 21 uses for vultures and their parts in traditional medicine and further classified them as either spiritual (i.e., matters concerning the supernatural) or physical (i.e., Diseases of the body) ( Table 3). Matters of spiritual nature constituted 71% of the reported uses for vulture body parts.
Only 29% of the cited uses for vultures and their parts in traditional healing practices were for physical well-being (Table 3). All ailments and conditions were further divided into sub-categories. For spiritual conditions, the majority (53%) of uses were associated with "acts of bringing forth"; where vultures and their parts were used to retrieve or obtain something. Other acts included enhancement of abilities (27%) and protection against unwelcome spirits and misfortunes (20%). Pertaining to physical ailments, vultures and their parts were mainly used to treat the nervous system and neurological disorders, including epilepsy, headaches, and strokes. These ailments accounted for 50% of the conditions cited. Other ailments were associated with the circulatory system (heart palpitations), the visual system (poor eyesight) and injuries (bone fractures) ( Table 3).

Preparation and perceptions about the use of poison to harvest vultures
Preparation for vulture parts such as bones, head and claws consisted of drying, crushing into powder and mixing with other material, mainly from plants. The concoctions were administered through smoking/inhaling or ingestion (with food). Most respondents (94%) revealed that one vulture could last them a year. The justification for this was that a small (approximately a quarter of a teaspoon) portion of the powdered material is added into a concoction. Healers also reported that cases where their patient or client would require that they use a vulture part.
The use of poisoned baits by hunters to kill vultures for trade was well-known to our study participants. However, views regarding risks associated with using possibly poison-contaminated products in healing practices differed (Table 4). On the one hand, there were traditional health practitioners who were against the use of poisoned baits, as vultures killed in this manner were deemed unsafe to use. On the other hand, we found participants who believed that parts were safe to use after removing the internal organs from the carcass and also by leaving them out to dry out before use.

Study composition
Four types of traditional healers are recognised in South Africa, namely diviners, herbalists, faith healers and birth attendants (Sodi et al. 2011). Three were identified in the present study, and they include diviners (59%), herbalists (21%) and faith healers (8%). This composition is comparable to an exploratory study conducted in KwaZulu-Natal in which the authors identified the same three types of healers (Zuma et al. 2016). The absence of birth attendants from both studies and other local literature (i.e. Abdullahi 2011; Laher 2014) could likely signal an increased reliance on western doctors for childbirth in KwaZulu-Natal. In addition, the study constituted more diviners compared with other traditional health practitioner types. Evidence suggests that divination is presently the most prominent practice of indigenous healing in the province (Zuma et al. 2016).

Vultures in traditional medicine
In addition to the treatment of physical and mental ailments, animals hold symbolic meanings, and are sacrificed for ritualistic and religious purposes based on beliefbased and mythological premises unique to different ethnic groups (Vats and Thomas 2015;Borah and Prasad 2017). All respondents who identified as diviners used vultures in their healing practices, while neither faith healer used vulture parts. Divination is predominantly associated with foretelling, and vultures are largely perceived by traditional health practitioners as good carriers of the knowledge of events to happen (Cunningham and Zondi 1991;McKean et al. 2013;Mashele et al. 2021). The relationship between healer type and vulture use was significant. The main reason for non-use was the belief underpinning the nature of one's work, training and calling. Other respondents did not believe in animals having healing properties, and one of them was of the view that this practice was abnormal. They posited: "It is plants that heal human ailments, the tendency of involving animals in traditional healing practices is the reason why some people use human body parts in traditional medicine" (thp09).
We identified seven vulture parts that were used by the study participants in their healing practices (i.e. head, bones, claws, wings, heart, eyes and eggs). Other studies have noted the use of feathers, beak, blood and intestines (Boakye et al. 2021;Mashele et al. 2021). The head had the highest number of citations and, consequently, the highest Use Value (0.9). This indicates that this part is an important ingredient in traditional remedies (Alves et al. 2012). Most studies on the use of vultures in traditional medicine have made similar observations about the importance of the head (McKean et al. 2013;Saidu and Buij 2013;Boakye et al. 2019). The head was linked to 15 out of 21 uses reported for vultures in traditional medicine. Previous studies have shown that in parts of Africa, the vulture head is believed to possess clairvoyant powers and may be used to increase success during gambling, betting, and contests (Cunningham and Zondi 1991;McKean et al. 2013;Chigunta 2017). According to Cunningham and Zondi (1991), this derives from the vultures' perceived great sight and ability to locate carcasses from vast distances away when scavenging. Moreover, vultures are believed to possess the ability to discern when an animal is about to die.
Similarly, foretelling, also referred to as clairvoyance in other studies (Cunningham and Zondi 1991), was the most cited use for the vulture head in the present study. However, this use was predominantly associated with the practice of divination. Umhlahlo, was the most cited rationale for the overall involvement of vultures in traditional medicine. Divination allows the healer to enter the supernatural domain where they can interact with ancestral spirits. In this realm, healers can access information that is beyond the reach of the rational human mind (Ozioma and Chinwe 2019). Traditional healers use this supernatural skill in diagnosis as well as in explaining illness causality and determining suitable treatment (Laher 2014;Zuma et al. 2016). Through clairvoyance, traditional healers can see events before they happen and devise protection measures if the events foreseen are to cause harm to either themselves or their patients. In addition, the vulture head, bones and, in some cases, the heart, were reportedly used in training prospective diviners (amaThwasa). Inhaling smoke from the powdered vulture head mixed with dried plant material and parts from other animals (e.g., eagle or hyena) was believed to assist in introducing initiates into divination. The ability to foretell is one of the key determinants that one is ready to take on the role of a diviner within the greater practice of traditional healing.
According to our knowledge, the information on the number of traditional health practitioners presently operating in KwaZulu-Natal is not available. However, in 2007 there were 25,000 traditional health practitioners in the province, according to Gqaleni in Zuma (2016). Over the years, this number has likely increased significantly. Due to the growing levels of youth unemployment and deteriorating socio-economic conditions, young people, especially in rural and peri-urban areas, are driven to seek opportunities Table 4 Participants' responses regarding the risks of using poisoned vultures and their by-products in traditional medicine (n = 10) thp traditional health practitioner Participant response (s) Reference People are using poison to kill vultures. Poison is harmful to patients. Even when the parts are dried, poison remains in the veins. It is like alcohol in your system. That is why I do not use vultures very often. I would rather go inside the reserve than buy from traders #thp13 Poison is bad, that is why I avoid using them (vultures). Using poisoned birds is adding to sickness #thp19 We are careful about what we buy; we always ask before we buy because we cannot risk using poisoned birds #thp21 We cannot use vultures killed through poison. I do not buy from the muthi market because I have no idea of how the birds would have been obtained #thp22 Poisoned vultures are harmless; we dry the parts before we use them thereby eliminating the fluids that carry the poison. The poison evaporates #thp14 Poison has no negative effect if you discard the internal organs #thp16 Patients could die because of the use of poisoned products #thp10 Poison is bad, we must find out how the vulture was killed before we buy it #thp08 Poison is very dangerous. Our aim is to heal people and not the opposite. Sometimes it is difficult to tell if poison was used to kill a vulture because someone would come selling a few parts. Using poisoned products can ruin your practice and reputation #thp11 Vultures are difficult to find, poison works faster and better. But it is wasteful, several vultures die but not all of them are taken #thp07 in the informal sector (Graham and Mlatsheni 2015;Thompson and Blackmore 2020). In recent years, there has been a growing number of young people training as traditional healers, particularly diviners (Ngobese 2020 pers. comm.). In addition, the intensifying economic insecurity has resulted in greater socio-psychological stress, causing people to seek explanations and solutions from traditional health practitioners, thus increasing the demand for such services. These factors could partly explain the prevailing illegal use of vultures and other biotic resources in traditional medicine.
Izizwe was frequently mentioned as one of the conditions for which the vulture head was used. Izizwe (directly translated as nations) is a spiritual illness that manifests in auditory hallucinations, screaming and disorientation. This malady is administered through a mixture with the same name (Izizwe), which is made from plant and animal-derived materials from around the African continent. The ingredients must be sourced from different countries for the concoction to be effective. When taken, this mixture evokes spirits that alter one's behaviour for good or bad, depending on the intention. Izizwe is often used for bad intentions, including manipulating people into adhering to your will. Laher (2014) provides an example of a suitor who used izizwe to cause a lady to run to his home on her "own" after she turned down his marriage proposal. It is believed that specific body parts of an animal with peculiar and/or superior behavioural traits, such as the African vulture (Gyps spp.) or lion (Panthera leo), are fused in a concoction and used to counteract the bad spirit and relieve the affliction.
We found that uses for vulture parts in traditional medicine and associated practices were relatively diverse. The IAR was generally low regarding conditions for which each part was reportedly used. The wings obtained the highest IAR of 1.00 for strength. We suggest that this finding be interpreted with caution as the high IAR demonstrated for the heart may not reflect respondents' true consensus, considering the study sample size. The head obtained an IAR of 0.38, which was relatively low. Although the reported uses for the head were numerous, most were single reports, indicating high heterogeneity in knowledge amongst the respondents. Ozioma and Chinwe (2019) posit that traditional healers often lack coherence on ingredients, preparation procedures and dosage of traditional medicines. Low consensus on what parts are used for, especially those of high value, may signify high versatility and cultural significance (Durojaye and Olufemi 2015). Low consensus could also be attributed to limited resources causing traditional healers to use whatever part is available in their time of need.
We identified a total of 21 ailments (or conditions) that were managed using vulture parts in this study, the majority of which were spiritual (71%). These uses were further categorised into Acts. Many uses (53%) were concerned with bringing forth; some examples include foretelling, winning dice games, business success and bringing back lost lovers. Evidence suggests that in African traditional medicine, vultures are predominantly used to manage spiritual ailments (McKean et al. 2013;Saidu and Buij 2013;Boakye et al. 2019;Mashele et al. 2021). One of the participants in a qualitative study conducted by Mashele et al. (2021) defines the role of vultures in traditional medicine by stating; "Vulture muthi (medicine) does not cure any illnesses, but it does cure curses". The use of vultures and other threatened species in traditional medicine, especially for spiritual ailments, is likely to continue since there are no known explicit clinical alternatives for spiritual afflictions (Boakye et al. 2019;Nieman et al. 2019).
Respondents claimed that one vulture per healer was sufficient to last for a year. This is comparable with what was reported by traditional health practitioners of the Kruger to Canyons Biosphere Reserve, who required 1-2 vultures per year (Mashele et al. 2021). The drying of parts facilitates preservation, representing a sustainable use strategy by healers. In addition, only a small portion of the powdered parts is used at a time. According to traditional health practitioners, this portion is mixed with other products from plants, other animals, and abiotic materials; therefore, only a hint is needed. Unfortunately, these inferences might be ineffective in the case of southern Africa, considering that vulture populations have sustained considerable declines to allow for any offtake. The legislation does not allow for any harvesting of the birds except under special circumstances such as research, law enforcement and or conservation (Geldmann et al. 2013;Williams and Whiting 2016).
Nonetheless, law enforcement remains inadequate, and the illegal hunting of vultures for use in traditional medicine represents a serious threat. Traditional health practitioners propose the domestication of vultures, while traditional leaders recommend the adoption of strategies that consider the socio-economic importance of vultures to local people. From the conservation perspective, opportunities to provide birds that have died from natural causes, collisions with energy infrastructure and electrocutions may exist. In addition, feathers from live birds may also be made available to traditional health practitioners. However, these proposals require in-depth deliberation between all parties concerned. There is also a need to understand people's perceptions of spiritual illnesses and consider alternative management of such conditions. A range of options should be explored and integrated into efforts to reduce the illegal use of vultures and other threatened species in traditional medicine.
The study participants were well aware of the use of poison to capture vultures for use in traditional medicine. Traditional health practitioners expressed conflicting opinions about using vultures that had been killed through poison. On the one hand, poison was perceived by many to be dangerous. Vultures and parts were carefully selected to avoid buying poisoned ones. Notably, other healers had decided to stop using vulture parts because of the increase in their poisoning. On the other hand, some healers reported that vultures had become difficult to find, and options were limited. The traditional health practitioners reportedly avoid poison consumption by drying the parts they need and discarding internal organs before use. Williams and Whiting (2016) indicate that modes of administration such as burning and sniffing or inhaling (which are relevant to vulture use) may reduce exposure if poison was used as a hunting method. However, there is concern that the effects of poison consumption may take a long to manifest, thus making it nearly impossible to trace the affliction back to traditional medicine use. Generally, most toxic substances used to kill vultures in South Africa are derived from agricultural pesticides (McKean et al. 2013;Mashele et al. 2021). Rani et al. (2021) report that human exposure to pesticides can result in various health problems, including cancer, respiratory disorders, neurological disorders, and reproductive syndromes, inter alia. Therefore, we propose further research on the long-and short-term health implications of secondary poison ingestion and suggest that traditional healers are educated about the possible risks of using poisoned products in their healing practices.

Conclusions
This work presents an assessment of the ethnomedicinal use of vultures in KwaZulu-Natal from traditional health practitioners' perspectives. Diviners were significantly the most common type of traditional health practitioners in the study and whose practices were largely associated with the use of vulture parts as ingredients in traditional medicine and practices. We identified seven vulture body parts that were used for a range of ailments and conditions. Although the head was the main part that healers required, seemingly all parts were used, possibly because of the limitations in access. The use of vulture parts in traditional medicine was primarily connected to spiritual dimensions of well-being. Results derived from this study are comparable with the existing body of literature highlighting the established belief-based use of vultures and their body parts in traditional healing practices, especially in Southern and Western Africa. Moreover, our study participants were aware of the hunters' use of poison to kill vultures. This, however, was not an adequate deterrent to some healers who had found ways to navigate using possibly poison-contaminated products. Balancing conservation outcomes and socio-economic requirements of local communities remains a major challenge. In light of the results presented here, supplementary to the institutionalisation of traditional medicine, we suggest a wide-scale establishment of collaborative conservation initiatives mainly involving traditional healers and conservation practitioners. The initiatives must focus broadly on safe and reliable resource supply, sustainability, and effective conservation of biodiversity resources. People who rely on natural resources should be invited to actively participate in the conservation of these resources to safeguard their livelihoods and indigenous knowledge.