Traditional healers as eye team members in Nepal
Nepal is a country where many people, at times of trouble and with all sorts of medical problems, consult local traditional healers for treatment and help prior to going to the hospital. They first visit the traditional healers in their area, even when medical facilities are available. It is estimated that there are 450,000 traditional healers in Nepal, whereas all health manpower, including doctors and paramedics, numbers 9,650.
The Nepal Blindness Survey of 1981 indicated that blindness is a problem of public health proportions. The prevalence of bilateral and unilateral blindness was found to be 0.84% and 1.66% respectively. The major causes included cataract, ocular injuries, trachoma, corneal scarring of uncertain aetiology, retinal disease, glaucoma and xerophthalmia. We know that 80% of the total blindness in Nepal is curable or preventable if detected and treated in time. An extensive system of eye centres has been developed to provide cataract surgery and preventive services. Yet, it is clear that to reach the majority of rural populations, creative partnerships must be forged with all available community resources, including traditional healers.
The traditional healer’s role in the community
In Nepal, blessing from the gods is sought before commencing any new venture. The concept of ‘atma’ (spirit or soul) is important to understand the work of traditional healers. If the atma is disturbed, the system will be spoiled with possible mental or physical disruption to the body.
Nepali people believe that success and failure, good and bad, all depend not only on one’s efforts, investments and labour, but also on one’s luck. People believe that good spirit or atma comes from the gods and that problems or sorrow come to them through devils, if they do not obey the gods. To solve human needs and problems, the gods have several alternatives. Among the alternatives is the giving of power through dreams to a few chosen people. In Nepal, these people are called traditional healers, ‘Dhami/Jhankri’. Many people are so deeply rooted within their tradition that at times of trouble they first consult with their nearest traditional healers. Without the healers’ permission, they will not go to others even when medical services are available nearby.
In keeping with these traditional help-seeking patterns, any patients with red eyes prefer to consult with one of the traditional healers of their area as their first attempt at cure. These healers are considered experts in treating red eyes by either chanting spiritual words or treating with traditional medicines. People come to the hospital only after they cannot be treated or cured by the healers. Often this delay in coming is too late for cure, and the eye must be enucleated or eviscerated. Although these severe cases are incurable, patients come with some hope and go back with a bad impression of the eye hospitals.
Our aim is not to undermine traditional healers’ practices or social status, but to provide additional techniques to make village healers effective rather than just popular. Therefore, the focus of training is to prepare traditional healers to identify and refer operable cataract and to recognise ocular emergencies, initiate treatment and refer the patient to the nearest eye care centre without delay.
There has been a tendency for health care personnel to tease or disregard these healers by saying that they are quacks and ineffective, whereas, these traditional healers are still respected by the community. This has created a serious communication gap between the healers and medical personnel. The training adopted in Nepal offers a compromise with traditional healers saying that they are the ‘doctors of god’, and we are the ‘doctors of disease’. Why not join our hands together to fight blindness? We do not tell them to stop their treatment methods, except that we discourage their use of traditional medicines in the eyes. This has been a happy compromise. The traditional healer receives the patient, determines whether the problem is due to a god or evil spirits, offers ‘something to please the god’ if that seems indicated, and then refers to the eye care centre for necessary treatment.
Our experience in training traditional healers
The National Eye Health Education Unit of Nepal Netra Jyoti Sangh (NNJS, Nepal’s Society for Comprehensive Eye Care) started this training during 1994 on an experimental basis. Originally, we planned a five day primary eye care training to expose traditional healers to the blinding problems in their area. However, we found that the training should not be for more than three days, as healers are in great demand and some reported that their god could get angry if they were absent for so long a period. Therefore, we adapted to a three day training programme:
Day 1: discussions on their way of treating eye patients, eye problems in their area and their important role in early diagnosis, education and referral.
Day 2: focus on childhood blinding problems including the needs of immunisation, nutrition, childhood health and eye problems. Emphasis is given to children’s needs because about 70% of the problems brought to them involve children under 10 years of age.
Day 3: discussions on cataract, trauma and other eye problems, motivation to discontinue the use of herbal medicine, and guidelines for referring patients to eye centres in time for treatment.
*VDC = Village Development Committee. This identifies political boundaries of one or two villages with a population of 3000 to 7000. VDC #50 denotes 50 Village Development Committees. There are 4000 VDCs in Nepal in 75 districts.
The NNJS Eye Health Education Unit has conducted traditional healers’ training in four districts: Dhading (population 278068, VDC#50)*, Nuwakot (population 245260, VDC#61) Jumla (population 75964, VDC#30) and Kalikot (population 88805, VDC#29) during 1994-1996. There is one healer among every ten houses in these communities and it is not possible to train all of them at once. Therefore, we selected the healers on the basis of their renown in the area, engagement with maximum community people and also by their area coverage; i.e., at least one from one village development committee with a population of about 5000.
Eighty-four traditional healers have already been trained in primary eye care from the above four districts.
After training, every traditional healer has been supplied with 5 tubes of tetracycline eye ointment, 50 chloramphenicol eye applicaps, 50 vitamin A capsules 200,000IU (we have recently stopped supplying vitamin A capsules as a national vitamin A programme has been launched in the country), eye health education materials, referral slips and reporting forms.
Most of the healers are illiterate. However, they get help from their children, grandchildren and even neighbours in filling the referral slips as well as reporting forms. The results of their efforts are encouraging. They have been referring cases of operable cataract, eye injuries, corneal ulcer and people with visual problems to the eye centres and eye hospitals.
Table 1 shows the results of monitoring the three month period, April – June 1995, in the Dhading and Nuwakot districts.
Table 1. Patients examined and referred, April-June 1995
|5. Refractive Error/Presbyopia||8||8||21||21|
|6. Other Causes of Red Eyes||11||9||19||11|
When the original training sessions were offered, traditional healers were suspicious as to why they had been called. By the end of the training, they understood the objectives and requested similar training in the future. We told them that refresher training could be organised once they started referring patients to the eye centres.
As promised, we organised the first refresher training course after six months and the the second after one year. The refresher training course not only reinforced the healers’ knowledge of eye care, but also strengthened the positive relationship between eye care centres and the community. The healers said that they previously saw very few eye patients. However, after they were trained, many more eye patients started coming to them to get traditional as well as medical treatment. They even demanded training certificates to show people that they are not only traditional healers but also part of the local eye care team.
The traditional healers we trained have completely changed their mode of treatment and no longer use ‘harmful’ traditional medicines in the eyes.
We look forward to providing more details about this programme, along with recommendations as to how these activities should be strengthened to reach rural traditional populations in need.
This programme is supported by the Seva Foundation, the Seva Service Society for Dhading and Nuwakot districts and by Foundation Eye Care Himalaya in the remote Jumla and Kalikot districts.
1 Brilliant G E, Pokhrel R P, Grasset N C, Brilliant E B. The Epidemiology of Blindness in Nepal. The Seva Foundation, 1988.
2 Miller C J. Faith Healers in the Himalayas. Center for Nepal and Asian Studies, Kathmandu, 1979.
3 Dahal R, Graham-Jones S, Lockett G. Traditional Healers and Primary Health Care in Nepal, 1986.