Integration of traditional healers into primary eye care
In Africa, doctors, nurses and traditional healers have to share the burden of health care services. It is inconceivable and impossible to disregard the role of traditional healers in culturally bound rural communities. Traditional healers are not only important but crucial in primary eye care in developing countries.
Additionally, in the face of economic restructuring and health care systems on the brink of collapse, traditional healers represent an under-utilised resource. Set against this socio-economic background is the huge burden of suffering from ocular disease and visual disability, with which the current health systems cannot cope. It is vital that modern practitioners and health care planners cooperate with traditional healers to meet the needs of rural populations.
Important lessons in my involvement as a field worker in rural Africa for almost two decades have been that:
Everyone has some special knowledge to contribute to development
No one person is superior to another.
With this in mind, a model of practical and successful rapport and dialogue has been established between traditional herbalists (called n’nangas in Zimbabwe) and ‘Hippocratic’ modern paramedics. Among the many components of this exercise, a strategy was drawn up to integrate them into primary eye care.
Traditional healers are directly involved with individual health problems within the community. Their success relies upon simplicity, and they are easily accessible and accountable to the rural communities. The n’nangas are recognised and respected by the communities. They understand their beliefs, as well as the cultural, social and religious organisation of rural populations. Well-patronised, the n’nanga is the first line of medical attention.
The practice of ophthalmology in many developing countries is challenging, and sometimes the detection of disease aetiology is masked by harmful eye practices. These include instillation of herbal concoctions directly into the eyes.
Whereas the service provided by traditional healers has had beneficial effects in the fields of psychiatric and AIDS counselling, irreversible damage to eyes has been recorded due to treatment with herbs (Figs. 1 and 2).
In Zimbabwe, extensive information on the methods and remedies used by n’nangas has been painstakingly gathered and presented in various publications. This information is open to vast scientific research. However, the n’nanga’s perception of health care is based on mystical concepts.
The dialogue: incorporation of traditional healers into primary eye care
Phase One: Workshops. A series of joint workshops were planned with the senior n’nangas to obtain their approval on future work in the field of eye care and to share experiences and review ways of coordinating ophthalmic practice.
Phase Two: Exchange Programme (1). At the hospital: training of traditional healers in eye anatomy and the knowledge of basic eye care. The district representatives spent a week training, observing outpatient clinical examinations, theatre procedures and attending ward rounds to see the postoperative cataract surgery results. Restoration of sight by a simple surgical procedure was educational and inspiring for the n’nangas. It is important for them to differentiate a corneal scar from a cataract which may receive similar treatment by the n’nangas, often by scraping with a razor blade.
Phase Three: Exchange Programme (2). Visits to the clinics of the n’nangas: examining their patients, observing their techniques and discussing the patients (Fig. 3). Never criticise their approach, but discuss.
Phase Four: Discussion at District Level. At the district levels, bilateral discussions take place. Under close supervision, unlabelled chloramphenicol eye drops are provided to the healers who see most eye patients. This approach maintains their integrity and the confidence of their patients in them – as if these were the concoctions prepared by the n’nangas. If an eye condition does not improve in a day or two, the n’nangas must refer the patient to the eye unit.
A joint strategy for the future of eye care activities, including eye health education and a referral network is planned and already documented.
Develop a good rapport with the traditional healers.
Recognise that everyone has some special knowledge to contribute.
Appreciate that no one person is superior to another.
Special thanks to my colleagues Professor Volker Klauss, Larry Schwab MD and Ralf Buhrmann MD for their relentless inspiration.