SICOT e-Newsletter

Issue No. 49 - October 2012

Articles by SICOT members

Traditional Healers - How can we improve their treatments?

Geoffrey Walker 
SICOT Emeritus Member - London, United Kingdom

It is generally accepted that the great majority of fractures in low and middle income countries (LMIC’s) are treated by Traditional Healers. Only a very small percentage of injured patients will have contact with any form of conventional modern medical attention, and even when this is available it will often be given by doctors or health workers with little if any specific orthopaedic training.

Some patients with fractures may never even see any form of ‘Healer.’ Hip fractures are a good example. When these occur the patient will simply rest until pain has subsided sufficiently to allow walking using a stick or pole. They will never have been X-rayed so that there will be no differential treatment between a trochanteric fracture which will unite with deformity and eventually allow walking without support, and those of the femoral neck which particularly when un-united may continue to cause pain and necessitate some permanent form of walking aid.

A substantial proportion of injured people may be unable to reach a recognised health facility and will simply ‘soldier on’ allowing their fractures to heal with deformities and probably with local joint stiffness. However many are very likely to be seen by a local Traditional Healer who may previously have treated the patient or other members of his or her family.

These Healers often have considerable experience in towns and cities and may even have access to radiology. They will have time to listen to the patient and to touch them before starting treatment; they also charge fees and these three features are themselves important therapeutically as we all appreciate. Among treatments they use are manipulation, splints, massage, application of ‘magic’ oils, and scarification with cupping. In addition to helping with orthopaedic and trauma problems, many of these Healers also manage the entire range of medical, surgical and psychological conditions.

It is unfortunate that visiting orthopaedic teachers tend to form a poor impression of the work of Traditional Healers as they usually only see bad results following ‘too tight splints’, ‘the poor treatment of open fractures’, and occasionally ‘the use of ferocious medicines taken internally or applied externally’. Healers unfortunately may not appreciate the dangers of the swelling associated with fractures which may lead to vascular and neurological impairment when circumferential splints have been applied. These are often made of split bamboo (Fig. 1) but fortunately rarely include the joint above as well as the joint below the fracture. The child may then present with a gangrenous hand or foot (Fig. 2) for which the only possible management is amputation; or if they are relatively lucky with ‘only’ a Volkmann’s ischaemic contracture. It is hard to imagine the agony that the child must have experienced and which could so simply have been avoided by the use of a splint of ‘gutter type’, by simple longitudinal ‘splitting’, or by early removal of the whole splint.

Traditional Healers tend to be secretive people who have learned their practice from a father, mother or other relative. They work in a competitive field and are loath to reveal the methods of management that they use, or to allow ‘foreigners’ to observe their work. In all the years that I have spent in low and middle income countries and even after making great efforts to gain contact I have only managed to see three healers at work.

The first of these was in Dhaka, Bangladesh, where I was introduced to a ‘Healer’ of great repute (Fig. 3). He ran a clinic with several assistants and treated each day about thirty new patients many of whom had arrived from distant parts of the country. Displaced fractures were reduced by manual manipulation and then supported with simple wooden splints. There did not seem to be any attempt at anaesthesia or analgesia but the Healer’s personality and experience went a long way to replacing these adjuncts to treatment. Patients who had been treated at the orthopaedic hospital often found their way to his practice and appreciated the healing oil which was poured into plaster casts, or applied after these had been ‘prematurely’ removed to allow massage.

The second Healer that I was lucky enough to encounter worked in a large village in rural Indonesia. I saw him treat several patients either with fractures, other limb problems or of course ‘backache’. He had great manipulative skills and when using one of his feet was able to produce very satisfactory and loud ‘cracks’ when treating patients. It was not until I had seen him manage three or four patients that I realised that this impressive noise came from his own foot and not from any part of the patient. However, his patients seemed to be improved by his treatment, were happy to pay his fees, and would return when indicated.

The third Healer that I know works in Addis Ababa, the capital city of Ethiopia. He specialises in orthopaedics and says that there are probably about eight others in that metropolis of about four million who only treat bone and joint problems. There are many other ‘Healers’ (known in Ethiopia as ‘Wugeshas’), of whom about 400 are in a rather inactive association which seems to have a somewhat distant connection with the Ministry of Health. This interesting and very cooperative Healer speaks reasonable English and has addressed the local Orthopaedic Association as well as giving a presentation to a recent meeting of World Orthopaedic Concern held during a SICOT conference. He is very anxious to increase his knowledge and to cooperate with formally trained orthopaedic personnel. He says that others among his colleagues would also be interested in learning more of modern modes of management.

Before considering how the knowledge and skills of Traditional Healers could be improved mention must be made of the very excellent scheme for training Orthopaedic (and indeed other specialty) Clinical Officers in Malawi. Ed Blair was responsible for the orthopaedic component and created a training program lasting about eighteen months for experienced government employed Health Assistants and Senior Nurses. After qualification these clinical officers work in most of the smaller regional hospitals where often there may not be any trained surgeons, and where orthopaedic clinical officers are capable of dealing with the great majority of orthopaedic trauma as well as many other bone and joint problems. They are content to live with their families in the areas from which they come, and their qualification currently is not recognised in other countries. A few will remain in major centres helping with clinical work as well as with training. Attempts to copy this excellent training program in other low and middle income countries (LMIC’s) have never really succeeded, and it is sad to say that there is often considerable resistance from doctors and their organisations. There is no doubt that properly trained orthopaedic clinical officers can be worth their weight in gold.

Similarly Traditional Birth Attendants who have been appropriately trained are an effective resource and this has been described in a recent major article in the British Medical Journal (Ref. 1): "They save babies' lives and potentially save their mothers' lives too. In many LMIC’s the majority of Caesarean Sections are performed by trained nurses and clinical officers".

Returning to the exposure of Healers to more formal orthopaedic training, it has been shown by Mekonnen Eshete (Ref. 2) when working a very long distance from Addis Ababa that with care, diplomacy and the cooperation of local government and other organisations training can be arranged for, then given to and appreciated by Traditional Healers. His work resulted in a major decrease in the number of amputations performed for gangrenous limbs in a district hospital which had resulted from the use of ‘too tight splints’. So it can be done, but how to encourage this very worthwhile activity seems to be beset by all sorts of problems.

As ‘foreigners’ making teaching visits – often of very short duration – it is almost impossible to make contact with, and then help, Traditional Healers and this means that involvement with Traditional Healers and then their instruction has to be the responsibility of indigenous colleagues. Some of these will have already tried to establish worthwhile contact, but only too often and for a host of reasons have found this difficult if not impossible to do. Traditional Healers may be seen as competitors rather than potential colleagues and in LMIC’s the level of pay for doctors is often so low that private practice is essential both to allow a family to live in a big city, as well as to find and then fund appropriate schooling for their children. When a visitor, even those with a considerable track record of teaching in LMIC’s raises the possibility of cooperating with Traditional Healers he or she will be told that this has been attempted but failed. A host of reasons may be given, sometimes expressed forcefully, but most of our colleagues will listen to rational reasons, especially if these can be supported with appropriate evidence. It may be a long and rather uphill task, but with patience, diplomacy and the passage of time it should be possible to instil the idea of closer contact and ‘not competition’ with Traditional Healers.

At present there is very considerable interest in encouraging and spreading the use of the Ponsetti management for clubfeet. This requires dedicating time for the actual treatment of relatively large numbers of children (and their families), and with medical cover being in such short supply in many LMIC’s it might well be helpful to all concerned if appropriate Traditional Healers could be taught this technique. I have suggested this on various occasions and in various countries and while interest is expressed I do not know of anywhere that this has yet been tried. But I’m not going to give up, and I hope that others will think and act along these lines.

   
References:

1. Ellen Hodnett. Traditional birth attendants are an effective resource. BMJ 2012; Page 9; volume 344:e365
2. Mekonnen Eshete. The prevention of traditional bone setter’s gangrene. Journal of Bone and Joint Surgery (Br) 2005; B:102-3

Fig. 1: A gangrenous hand from too tight splintage

Fig. 2: Maggots performing their antiseptic debridement

Fig. 3: A Traditional Healer managing a tibial fracture

  
Acknowledgements:

Fig. 1: Is reproduced and adapted with permission and copyright © of the British Editorial Society of Bone and Joint Surgery (citation), and with that of Dr Mekonnen Eshete.

Fig. 3: This photograph was taken in Bangladesh about 35 years ago and the ‘Healer’ has since died. The picture is reproduced with the kind agreement of his ‘Grand Nephew’ who is continuing the Practice in Dhaka, although advertising by Traditional Healers has now been banned by the Government.