A Shared Path to Healing

In the year 2000 I was in California, working as chief of staff at a regional health center and keeping a busy family medicine practice, when I chanced on an appeal from Episcopal Medical Missions for a short-term assessment of the medical needs of the Batwa, a pigmy tribe in the southwest corner of Uganda. My wife Carol and I, then in our mid-fifties, decided to go. Four short weeks in Uganda transformed our lives. The Uganda government had evicted the Batwa from the rainforest in 1991 to creating Bwindi Impenetrable National Park, where tourists now trek to glimpse the endangered mountain gorilla. Bereft of their home, the Batwa were sick, their children were dying, and their culture was melting away. Yet we found them to be wise and resilient, and they welcomed us. We felt compelled to return to stay, which we did in 2001.

Our first years were difficult, but in time we learned to cooperate with the Bakiga, the dominant ethnic group in the villages surrounding the rainforest. With the help of their leaders and support from American donors, in 2003 we established Bwindi Community Hospital (BCH) in the town of Buhoma, to serve all the local people.

The author’s cabin. Photograph courtesy of the author.

The year 2010 finds us frustrated at our progress. There have been bright spots, but there are still so many deaths from malaria, needy patients coming too late to the hospital, people failing to complete drug-treatment regimens.

I have been reluctant for years to engage with a segment of the local healing community, the abafumu, practitioners of traditional medicine. They are highly respected by all – except me. Their approach to healing is so vastly different from my Western approach that I believe working with them is impossible.

Then Ken, fellow alum of Tulane School of Medicine, and his daughter Kristen arrive for a visit. They plan to study traditional methods used in our region to treat and prevent disease. After some weeks we meet to discuss what they have learned. Ken begins with an unwelcome question: “I have been talking with the abafumu. How do you relate to them?”

“Not so well,” I reply. I explain that the abafumu treat the Batwa with respect and their herbal remedies can have good effects. Yet others of their practices are unethical, even cruel. They use okuhanduura oburo (cutting) for various illnesses, cutting the patient’s skin and inserting medicinal herbs. The cuts quickly fester. Another practice, kwosya, involves applying hot, brand-like implements over a diseased area to draw out infection. Children arrive at our hospital with multiple second-degree burns. I can tell what an omufumu (singular of abafumu) believes ails a child by the location of the burns: if pneumonia is the target, there are burns over the chest; if prolonged diarrhea, the abdomen is branded.

But their most troubling practice is called ebino or kukura ameno, the removal of teeth in young children. When maternal antibodies wane, small children frequently develop mild illnesses. This often coincides with the eruption of the lower canines. The abafumu apparently associate the two, thinking the teeth cause the infections. So they yank them out.

Besides unnecessary tooth loss, nonsterile wire or bicycle spokes used for the extractions can cause infections or tetanus or can transmit HIV. Some children even die. So how, I ask Ken, “can I have a good relationship with abafumu who subject sick children to cuttings, burnings, and tooth extraction?”

Ken agrees about the dangers of the practices, but says, “Our research shows that at least 90 percent of your patients have visited an omufumu before coming to your hospital. You believe you cannot work with them; in reality, you can’t work without them.” He recalls Hippocrates: “Wherever the art of medicine is loved, there is also the love of humanity.”

Kristen adds, “Perhaps if you meet with the abafumu you can find common ground.”

Reluctantly, I ask an omufumu acquaintance to arrange a meeting. He accepts, but warns, “You may wish to meet with them, but they might not wish to meet with you.” We send out a message but get no reply. Nevertheless, on the appointed meeting day I hear drumming in the distance. About forty abafumu drift into our house, many wearing traditional dress. Their outfits intimidate me at first, but I recognize friends and begin to relax. We distribute warm sodas, freshly baked bread, and fruit as we gather in our living room.

We begin to talk. The abafumu rise in turn and introduce themselves and their particular area of expertise. I am amazed at their specializations: some treat malaria, others pneumonia or poisonings or lightning strikes. Those who treat marital discord proudly announce that their potency remedies are exceedingly efficacious. Very many are versed in casting and removing spells.

When it is my turn, I discuss my interest in tropical diseases and public health. I follow with a question: “Do you have any concerns about meeting with me?”

One elderly omufumu rises slowly to say, “We believe that you disrespect us and what we practice!”

I am disconcerted but try to respond sincerely: “I have trouble understanding your traditions. If you consider me judgmental, I am sorry. I will try to keep an open mind.”

Pointing a bony finger at me, he says, forcefully, “We all want to know what you think about our practices of burning, cutting, and extracting teeth.”

I am stymied; these are the three practices that most trouble me! Yet a negative answer will threaten our relationship and likely terminate the meeting.

In the prolonged silence, an ancient woman rises at the back of the room. A shawl covers her head and deep-set eyes glow from her shadowed face. Her hands grasp a cane. Her body is stooped from arthritis, but she seems to float effortlessly toward me. She exudes an aura of intense power.

The man next to me whispers, “That’s Batusa!”

My heart races at the name. I have heard about Batusa for years. She is the most respected and powerful of all the abafumu. Her spells reportedly bring either life or death. Indeed, I’ve admitted patients who claimed to be dying from her curses. Despite whatever remedies I applied, they all too frequently wasted away.

Batusa throws back her shawl, fixing her gaze on me. When I shrink back, I detect a subtle smile. She glides over to the fellow grilling me, places her hands on his shoulders and gently presses him down into his chair.

She turns to address the group. “We will not be talking about our differences. We will only talk about what we have in common!”

Letting this sink in, she continues, “What we have in common is improving the health of our people.”

Her smile widens as she approaches me, “This is a good man who is dedicating his time to the care of our community. We must work with him.”

From this moment, Batusa and I become bonded in friendship and cooperation.

Batusa. Photograph courtesy of the author.

After Batusa’s intervention, the group adjourns outside. Accompanied by drums, we sing and dance, which all the abafumu are expert at – and I am not. As we return to the meeting, I recall how the previous week had been especially bad for malaria. Two infants and a pregnant mother were initially treated by the abafumu; by the time they arrived at our hospital, it was too late and they died of malaria. I consider raising this concern.

Surprisingly, the abafumu beat me to it. “Will you teach us about omuswiija (malaria)?” they ask. “Our remedies are unsuccessful; too many children are dying – even our own children.”

We agree that we must meet again soon to tackle malaria.

A month later, the abafumu crowd into our living room again. I introduce Luke, a Tulane medical student with special interest in tropical diseases. Today omuswiija is our topic. My language skills are shaky, but the abafumu appreciate my attempts to speak Rukiga, their native tongue. I relate the recent circumstance of a child with malaria whom Luke had cared for at BCH. “Upon arrival Luke inserted an IV and gave medication for seizures. Blood was transfused and the child seemed to improve. However, the child suddenly had a seizure. The breathing became irregular.”

Speaking through an interpreter, Luke picks up the narrative and demonstrates how the child’s breathing slows and then ceases. He drops his arms in frustration: “The child dies.”

The abafumu nod; they understand death.

Luke continues, “The next day, as we attend the burial in the village, friends and relatives crowd around the tiny body. Their singing and sharing lift our spirits.”

An omufumu tells us, “We have an expression, Nitushemererwa hamwe kandi nitushasha hamwe – shared joy is double joy, shared grief is half grief.” Luke and I agree.

Only then does Luke discuss what is known about malaria as a disease. “We know malaria has afflicted people for at least 5,000 years. Today, malaria causes 1.2 million deaths per year worldwide, almost all in sub-Saharan Africa, and primarily in children under the age of five. Every thirty seconds a child dies from malaria.”

I confess that our efforts to distribute mosquito netting to prevent malaria have largely failed. The villagers seem to believe that a net is useless since omuswiija is due to Stan. The conversation becomes intense and reverential.

Batusa firmly states, “Stan causes omuswiija.”

Luke is perplexed. “What is Stan?”

Batusa continues, “Stan is a god of our ancestors. If adequate sacrifices are not made after a relative dies, Stan brings illness, especially omuswiija. Stan is powerful; he is not to be annoyed.”

“Why do you believe Stan causes omuswiija?” asks Luke.

“Because when young children have omuswiija, they shake with seizures. They are obviously demon-possessed. It is Stan. A net cannot prevent Stan from attacking children. Stan slips right through.”

Luke and I confer; he suggests that we show omuswiija to the abafumu.

The abafumu are confused by the idea that we might see omuswiija. But they accept our invitation to take a short walk to the hospital laboratory. The lab technicians encourage them to peer through the microscope lens. “Look where the eyepiece cursor is pointing. You’ll see circular red blood cells with small dots of malaria parasites inside them. These parasites damage the red blood cells, making the kids anemic.”

Next, we visit the children’s ward where mothers lie next to children being treated for malaria. Standing next to a comatose child, Luke explains, “This is how we treat malaria. There are two IVs. One brings blood to correct the anemia; the other infuses quinine to treat the malaria. If caught early enough, the treatment is almost always successful – although it is much better to prevent malaria than to treat it.”

The abafumu agree that omuswiija is best prevented.

A child receiving a transfusion. Photograph courtesy of the author.

Back at the hospital guesthouse, several medical students display drawings of the life cycle of anopheles mosquitos and how they transmit omuswiija via the parasitic plasmodia. They describe the life cycle of malaria in humans and mosquitoes. After considerable discussion, the abafumu agree that mosquitoes are the perpetrators and that bed nets might be useful in the prevention of omuswiija.

I eagerly announce, “We have obtained an inexpensive source for bed nets. We can provide them at no cost.”

I expect cheering, but the room is silent. Batusa speaks up: “Your plan has no chance for success! If the nets are to be valued, the people must contribute.”

Another adds, “Bed nets given at no cost are used as dresses or for catching small fish.”

The medical students object to any plan to make patients pay. One says, “In my country it is not proper to charge a poor person for something of little cost that can prevent their child from dying.”

Batusa insists: “Unless something is contributed, the nets are not prized or used correctly.”

Reluctantly, we agree with their plan. The abafumu agree on a price: 2,500 Uganda shillings (one dollar) per net – but a bow, arrow, or basket can also serve as payment.

When we announce our plan, several government officials and NGOs complain: “Americans have donors who can help poor African children. Why is there a charge?”

I explain, “This plan was developed by the abafumu; the fee demonstrates the value of the netting.”

The abafumu speak at public meetings and schools in the villages, explaining the necessity of using bed nets. They help us identify children under five and pregnant mothers, the most vulnerable groups, whom we especially want to reach. As we roll out the campaign, sales quickly increase to over 1,000 per month. After two years, we’ve distributed over 30,000 nets.

We celebrate this wonderful, small victory over malaria with a party for the abafumu. I announce, “Most children in our area are now sleeping under bed nets. Three years ago, Bwindi Community Hospital recorded one to two children dying of omuswiija every week. Over the last nine months, not one child has died from it. Omuswiija has been reduced by over 90 percent. Our children now survive because of the use of bed nets.”

“Bed nets and the support and cooperation of the abafumu,” adds Batusa.

Our agreement to meet monthly allows me and other hospital personnel to become well acquainted with the abafumu. As medical practitioners who know their patients, the abafumu often express concern about ailments they see. In one meeting we consider enkororo (“the cough,” or tuberculosis).

When I ask how they treat TB, a heated discussion ensues: some advocate cutting, others spells and incantations, others herbs. Finally, a venerable omufumu reluctantly states, “Our treatments for TB are unsuccessful. In fact, since we know the disease is easily spread, we tend to avoid patients with TB.”

I explain our situation. “We have drugs to treat TB, but they must be taken daily for eight months. If patients don’t take the medicines as prescribed, they can develop drug-resistant TB. I’m as disheartened and frustrated as you. Only half of our patients complete the TB regime.”

After a long pause, Batusa says, “Neither of us is treating this disease effectively. What if we combine our resources as we did with omuswiija?”

At our next monthly meeting, medical students Sean and Jessica join us to speak about TB. It is a common cause of death in the region and is increasing in Uganda. Sean and Jessica show the abafumu charts, diagrams, and visual aids demonstrating how coughing transmits TB.

Then they explain the eight-month treatment protocol: “Four drugs taken for two months, and then two drugs for an additional six months. Almost all cases of TB can be cured by adhering to this regimen.”

As we prepare to depart after sharing bread and tea at the guesthouse, Sean asks the abafumu a question that should have been on my mind but wasn’t: “Perhaps you have something to teach us about TB?”

Batusa replies, “Yes, there is much bazungu (white people) need to learn about TB. It is a disease of poverty. Unless you understand poverty, you will never successfully treat TB!”

Once again, I am humbled. Swathed in science and armed with medical cures, I have neglected to think of how my treatment proposals fit into day-to-day life in Africa. I admit, “I don’t understand a life of poverty or the constraints of being poor. Teach me.”

Eye-opening comments ensue: “Bazungu need to know how difficult life is in a remote village. Accessing health care requires a long and tiring walk…. Food is scarce and water supplies are distant…. Many go to bed without eating, worrying if their children will survive…. We live day to day and can’t think about tomorrow…. Those who have TB are poor and hungry. They need food.”

I interject, “We feed the TB patients for the first two-week phase of treatment, while they are in the hospital.”

“That is not enough,” one replies. “You need to provide food for the entire eight months of therapy.”

Batusa follows with the closer: “Dr. Scott, you misunderstand. Since TB is a disease of the poor, the whole family needs to be fed. And stop charging TB patients for any treatment.”

The bold proposal sets me back; I am speechless. My wife Carol recovers more quickly. “If the program is to be successful, we need to follow the advice of the abafumu,” she says. With time to do some mental math, I realize the cost of such a feeding program is far lower than that of treating even one patient who develops drug-resistant TB.

When I take the abafumu’s plan to BCH’s management team, they heartily endorse it and we scrape together the needed funds. There will be no more charges for any TB care. Sputum testing for TB and hospital visits will be free. All patients with tuberculosis will receive food during their treatment: five kilos of beans and five kilos of posho (cornmeal porridge) distributed when they return biweekly for their outpatient drug supply. As an incentive, an omufumu will receive a one-time allotment of five kilos of beans and five kilos of posho for each case of active tuberculosis they bring to the hospital.

The abafumu take responsibility for their patients’ completion of an unbroken eight-month tuberculosis therapy regime. The results are encouraging. There is a marked increase in the daily arrival of potential tuberculosis patients, many accompanied by abafumu. Many patients who were repetitively starting and stopping medications are now taking their medicines regularly.

The cooperative spirit fostered between the abafumu and the hospital in dealing with malaria and tuberculosis leads to a further important development. Together we form an organization called the Village Health Team. Team membership grows quickly to over five hundred. Each Village Health Team member oversees twenty to twenty-five households. They are on the lookout for cases of malnourished children, problem pregnancies, and diarrheal diseases. They also monitor general community health and assist with immunizations.

Village Health Team members visit TB patients in their homes every few weeks and encourage compliance with the medications. BCH’s records indicate that over 96 percent of our local TB patients are now taking their medications regularly, one of the highest compliance rates for TB therapy in East Africa.

As Batusa would remind us, these successes come only through cooperation with the abafumu. And what about those three traditional practices that she so deftly set aside in our first meeting: kwosya (burning), okuhanduura oboro (cutting), and ebino (forcibly extracting teeth)? The forum we established did not allow criticism from either side; rather, we simply shared information about our practices. After various other demonstrations of Western medical treatments like those for malaria or TB, the abafumu have come to value our approach, while sharing with us many of their herbal remedies, which we value. As these discussions have continued, over time we have noticed a drop in cuttings, burnings, and tooth extractions.

Looking back, it is easy to see how the Western medical opinions I brought to Uganda sometimes functioned as obstacles to collaboration with the very people I wished to serve. When we realize that we all have more to learn than to teach, when we gather to share our different perspectives, we can discover a common path to healing.