Traditional healers in prevention of blindness
A number of ophthalmologists will be sceptical, if not frankly hostile, to the notion of involving traditional healers in prevention of blindness activities. Some will agree with the words of an ophthalmologist working in pre-independence Zambia: “… in the sphere of ophthalmology the African herbalist can only be described as a ‘blinding menace’.”1
Indeed, there is evidence to demonstrate that traditional eye medicines (TEM) can cause corneal damage and blindness.2-4 We know that couching, practised in West Africa and parts of Asia, can lead to blindness. However, the magnitude of these problems is not known. There are no population-based estimates of TEM use or couching, nor data comparing the frequency of a good versus poor outcome. For every interaction between a patient and traditional healer that leads to a poor outcome, there are many more that do not. Data from Malawi indicate that there may be up to 4,500 visits made to a traditional healer for eye disease for each case presenting to the ophthalmic medical assistant with corneal disease. Patients managed successfully by a traditional healer do not come to the attention of the ophthalmologist. Seeking treatment from a traditional healer, the patient may be cured or the disease may resolve spontaneously. The failure to balance the ‘disasters’ seen in the eye clinic (such as those described by Musa Goyal and Margreet Hogeweg in this issue) with the successes, which occur in the field, may well lead eye care providers to dismiss traditional healers as a blinding menace.
We suggest that this is a mistake. Traditional healers have long been a part of most cultures and will remain so. If this were not enough, consider the fact that, unlike ophthalmologists, or even medical assistants, healers live and work even in the most rural villages; they are already in place. Furthermore, healers are already salaried and have been practicing fee-for-service medicine for centuries. Involving them in prevention of blindness does not require hiring additional health staff.
In Zimbabwe, Malawi and Nepal it has been demonstrated that traditional healers can be a positive force in prevention of blindness.5-8 Successful programmes in these countries have several common elements:
- They do not necessarily discourage the treatment of eye disease by healers but have aimed to help change specific practices that may be harmful and encourage those that are not. All of the programmes have tried to improve the ability of healers to recognise and refer patients with cataract.
- They build upon the existing respect given to healers by the community. Community-based healers are usually the moral core of the community and actions or behaviours promoted by healers are more likely to be received favourably than if they were promoted by a health worker from a nearby health post.
- African programmes have not attempted to co-opt healers to be primary eye care providers (using the Western model); instead programmes collaborate with healers, using their pre-existing knowledge and skills. These programmes have been built on the concept that we, from the Western model of eye care, must be willing to adapt and, most importantly, to empower others to provide eye care.
- A long-term approach is taken with an attempt to maintain interaction between healers and eye care providers continuously. Establishing collaborative activities with healers must be more than a simple process of conducting a few workshops and expecting the healers to continue on their own.
There are, of course, considerable differences in programme activities among the Zimbabwe, Malawi and Nepal programmes, which developed independently of one another. While there are some general elements in developing collaborative eye care programmes, the local environment will determine details of how these programmes evolve. Although we use the term traditional healers or traditional practitioners, there are, in fact, many different types of healers with different roles and positions in society. Furthermore, traditional eye medicines, used throughout the world, vary tremendously; classification is sorely needed. Awareness of the common elements, however, may help create a foundation for further efforts in this area.
Many questions remain unanswered: how much TEM related corneal disease is due to healer preparations and how much is due to home concoctions? Can traditional healers be involved in community education? What is the minimum amount of interaction necessary to maintain programmes? What is the potential role of female healers in reducing childhood blindness and low vision? These questions, and many more, should be addressed.
Activities in Zimbabwe, Malawi, and Nepal are first steps to creating eye care programmes with traditional healers. Much remains to be learned. The 10th-12th September 1997 INGDO Task Force-sponsored symposium in Malawi (see page 16) aims to pull together experiences and create guidelines to help field personnel establish collaborative eye care programmes with healers. Through these efforts and others there is the potential to reach well beyond existing eye care programmes to the most rural poor in developing countries.
1 Phillips CM. Blindness in Africans in Northern Rhodesia. Central African Journal of Medicine 1961; 5: 153-8.
2 Yorston D, Foster A. Traditional eye medicines and corneal ulceration in Tanzania. J Trop-Med Hyg 1994; 97: 211-5.
3 Courtright P, Lewallen S, Kanjaloti S, Divala DJ. Traditional eye medicine use among patients with corneal disease in rural Malawi. Br J Ophthalmol 1994; 78: 810-2.
4 McMoli TE, Bordoh AN, Munube GMR, Bell EJ. Epidemic acute haemorrhagic conjunctivitis in Lagos, Nigeria. Br J Ophthalmol 1984; 68: 401-4.
5 Chana HS, Schwab L, Foster A. With an eye to good practice: traditional healers in rural communities. World Health Forum 1994; 15: 144-6.
6 Courtright P, Lewallen S, Kanjaloti S. Changing patterns of corneal disease and associated vision loss at a rural African hospital following a training programme for traditional healers. Br J Ophthalmol 1996; 80: 694-7.
7 Courtright P, Lewallen S, Kanjaloti S. Traditional healers in primary eye care. Br J Ophthalmol 1995; 79: 506.
8 Newlin S. Traditional healers join new ways with old. Ophthalmology World News 1995; 1(8): 25.