An editorial report exploring the role and effects of traditional medicine within communities of Sierra Leone by Madeleine von Haniel Torr
What we in the Western world call “traditional medicine” is an ancient practice, and draws on local knowledge, culture and religion to heal1. Though the developed world has largely seen a move away from home remedies and herbal poultices and towards evidence-based medicine, for many in the developing world, traditional methods remain the primary form of healthcare that they can access2. In Sierra Leone, these methods are referred to as “country medicine”. Country medicine can be found in all corners of Sierra Leone and comes in many forms. Its delivery ranges from family recipes handed down from parents to children and old wives’ tales, to a village healer who lives in a gated compound where they run a clinic and have a well-established reputation and patient base. In fact, there are those for whom this is their primary source of income and their way of supporting their family, similar to a doctor3.
During my Elective period, I spent four weeks at Magbenteh Community Hospital, a 100-bed facility in the Bombali District, which is in the North of Sierra Leone. Country medicine and its traditional methods of healing is something which is familiar to all members of staff across the four wards and outpatient department at this hospital. The majority of patients who present to the hospital are users of and believers in country medicine. During my placement there I learnt what effects it has on the day-to-day practice of modern medicine, and the problems that it causes for both patients and staff, who are the ones tasked with fighting its harmful effects on the health of the patients in their care.
Although Sierra Leone is a beautiful country with wonderfully welcoming people and abundant natural resources, the health statistics of the country are poor. Shockingly, the average life expectancy for males is fifty-two, and for females fifty-three4; the country is still feeling the crippling effects of the eleven year long civil war which started in 19915. As far as state-funded healthcare goes, the government provides free healthcare for under-fives, pregnant women and breastfeeding women6, but otherwise, much of the money to pay for medical care often comes out of a patient’s own pocket, depending on the funding the hospital receives from outside sources and the government. Paying a healer’s consultation fee is cheaper and seems easier than travelling to hospital and undergoing investigations.
This lack of resources extends further, as the need for healthcare cannot be met by the number of facilities available where modern medicine can be accessed7. The lack of health infrastructure is most acutely felt in rural areas, where the nearest hospital may be miles away, and the journey on the back of a motorbike taxi (one of the main forms of public transport) would seem daunting to anybody, let alone somebody who is ill. These factors, combined with the longstanding tradition of country medicine in Sierra Leone, mean that hospital is unfortunately often the last resort for the unwell.
As it does in other countries, much of traditional medicine in Sierra Leone centres around curses and the spiritual world: a person’s symptoms are often declared by a healer to be caused by a vengeful friend or co-worker who is jealous of their success. These superstitious beliefs are especially prevalent when it comes to mental health. As well as depression being sometimes downright dismissed as simple laziness, a psychotic patient may be seen as having been cursed by evil forces8.
Some country medicine practitioners truly believe they are able to heal the sick, but more malicious healers will use native belief in the supernatural to their advantage, in order to draw people in and make their methods seem more legitimate, such as making horoscope-like predictions about a person. Should their predictions be correct, this leads the patient to believe that the healer is all-knowing. “Fangae” is another dominant concept in the world of country medicine. The term means “witch gun”, a mysterious object that healers claim can be used to shoot someone with, thereby afflicting them with an illness9. In order to prove this, healers will perform simple magic tricks, seemingly withdrawing an object (the “bullet”) from underneath the patient’s skin. Through this form of pure deceit, patients’ trust in them is strengthened, and they will usually follow whatever advice or treatment they are given.
A healer’s practices may harm the patient indirectly in that they come in the form of an incantation or dismissal of the symptoms as something supernatural, which of course means that the proper intervention is not carried out. However, harm may also be done by the treatment being toxic in itself. Alkaloids, chemicals which can be found in many modern pharmaceuticals10, can be derived from plants such as Craterispermum laurinum, or nyelleh 11, a common herb taken to remedy malaria in Sierra Leone12. The director of medicine at Magbenteh himself reported that he used a common plant remedy for his own malaria prophylaxis but stressed that it is only beneficial when taken in the right doses. As with many medications, alkaloids have potentially lethal side effects13, and through uncontrolled methods of boiling up potent leaves and roots in a pot and making a patient drink the entire contents, country medicine practitioners are essentially delivering a toxic dose of medication to their patients.
Evidently, it is important to note that country medicine should not simply be dismissed as mumbo jumbo, as there is great power in nature’s resources. Many modern medicines have their roots in the natural world, for example the old practice of chewing on willow bark as a painkiller. Willow bark is now known to contain the precursor for aspirin, a well-known drug14. Country medicine sometimes only causes harm because of the manner in which it is delivered, when in fact the treatments can even be beneficial at the right doses. In the Western world, we have the luxury of being able to fund the progress of evidence-based medicine. If this were not the case, our health indicators might more closely resemble that of Sierra Leone’s.
Even during my short time at Magbenteh Community Hospital, the devastating effects of country medicine were evident on every ward. Belief in native medicine as a cure over seeking treatment at a hospital means that patients often only present to the medical team when they are already critically ill, or with multiple complications. A twenty-seven-year-old man was seen in the outpatient department with significant ascites. He admitted to having visited a country medicine healer in the past months who had given him an herbal drink, and, following an ultrasound, his liver was shown to be completely cirrhotic. Given that there is no organ transplant system available in Sierra Leone15, finding a new liver for somebody who needs it is impossible, shortening this man’s estimated life expectancy to just another few years. This sort of presentation is a common occurrence, with the head of the male ward at Magbenteh estimating that two to three deaths occur on the ward each week due to country medicine when the hospital is experiencing a busy time.
There is such a preference for country medicine amongst Sierra Leoneans that patients’ families will often threaten to remove a sick patient from hospital and bring them back to the healer, even if the medical team stress that it is this behaviour that has led their relative to become so critically ill. The lack of understanding of modern medicine and science means that many times patients and their families will require to see immediate results from medical treatment in order to be persuaded that the medical teams are effectively treating their condition. If they do not see their illness improving immediately, they will dismiss hospital treatment as ineffective, even if a healer has previously not been able to do any better, so strong is their scepticism.
This strong belief in faith healers also had destructive effects country wide, seen during the Ebola outbreak in Western Africa in that began in 2014. Ebola is a highly infectious and dangerous illness, and this outbreak was the worst one ever seen, with Sierra Leone being the worst country affected16. On talking to the staff at Magbenteh Hospital when doing the research for this project, they all believe that country medicine and faith healers played a large part in the spread of the disease across Sierra Leone from 2014 to 2015, an outbreak which eventually led to the deaths of 13,638 Sierra Leoneans17. In fact, the first large group of cases has been linked back to one particular faith healer. Her reputation amongst the population was such that patients from neighbouring Guinea, not knowing that they were infected with Ebola, travelled across the border to Sierra Leone to seek treatment from her18.
This treatment, and then subsequently her funeral when she herself died of Ebola, played a key part in the rapid spread of this deadly disease. It is known that isolation and infection control play a large part in the management and containment of Ebola19, as this disease is spread from person to person through direct contact with bodily fluids. Healers do not have the training to recognise haemorrhagic fever, or the knowledge to manage it effectively, and so the correct management simply did not occur, leading towards further spread. As mentioned before, traditional practices also occur within the home as part of daily life, and not just by appointed healers, making the scope for spread even larger.
Another important issue to consider, which perhaps has not made the news worldwide in the same shocking way that Ebola has, is the effects of traditional practices on pregnancy and infant and maternal mortality. The Maternal Mortality Ratio of Sierra Leone, which is the number of maternal deaths compared to live births, is the highest in the world20. Giving birth in the home with a tribal birth attendant present, rather than a qualified health professional, can directly cause maternal deaths due to the tribal birth attendant not being able to detect complications early21. When complications are noticed, a combination of ignorance, arrogance and superstition puts the mother and infant in further danger, as they may believe that they do not need modern medicine to overcome these complications. Members of staff at Magbenteh reported seeing a tribal birth attendant sit on the fundus of the woman in labour, as this was thought to be an effective way of dealing with the problem of obstructed labour, one of the leading causes of maternal death21. Another member of staff on the maternity ward reported that the birth attendant may even blame the woman for the complications during birth, claiming that she has brought them upon herself through practising witchcraft.
Although the situation of maternal mortality has improved since the end of the civil war20, the tradition of country medicine remains so deep rooted within Sierra Leone that many people still believe healers over science when it comes to labour, a phenomenon which, as already established, has potential to put their health at great risk. It is evident around the world that tradition and culture play a large part in the behaviour of a population, and this includes health-seeking behaviour, especially without the proper infrastructure in place to educate them about alternative options.
A way must be found to educate the population on health and modern medicine, in order to change public scepticism surrounding scientific methods. Lack of education is of course not equivalent to a lack of intelligence, and staff at Magbenteh have witnessed first-hand that many patients want to learn how to take control of their health and change their health-seeking habits. The country has seen a decrease in the number of home births20, a welcome change which the medical teams at Magbenteh but down to increased public awareness of the potential dangers of home births, something which the nurses themselves play a direct part in by giving lectures to the pregnant women waiting in line for the antenatal clinic.
Public health campaigns are something we in the United Kingdom are very familiar with, as our Department of Health and Public Health England put a great deal of resources into making sure that we are exposed to them everywhere we go, for example on public transport, the television and the internet. However, in countries such as Sierra Leone, where only 1.3% of the population were regular internet users in 201222, and public transport involves two people to each seat in a minibus, this is simply not a realistic way of doing things, so methods must be adapted accordingly.
Public outreach is perhaps one of the most powerful tools that can be used, especially in order to reach the more remote parts of the country. It is in the rural areas of the country where peripheral health units have the biggest part to play. Peripheral health units are primary healthcare facilities which run separately to hospitals and are located amongst communities to implement health programs23. With Sierra Leone having 788 peripheral health units compared to 131 hospitals23, any change that needs to be made within the healthcare sector should utilise these facilities in order to maximise efficiency of delivery. Due to the key part that clinical staff in these units play in early disease detection and prevention, training staff to simply tell patients about the harms of herbal remedies could have a significant effect.
However, lack of public education and awareness are unfortunately not the only barriers to alleviating the problems caused by country medicine. It is all very well making patients aware of the need to go to hospital rather than to a healer, but even when they do, poverty and lack of accessible medical services mean that the correct treatment is not available to them. A doctor at Magbenteh illustrated this issue by using the example of the ultrasound facilities at the hospital. The ultrasound machines at the hospital are only advanced enough to detect a small number of fetal abnormalities. If an abnormality is detected which cannot be investigated, the nearest facility which is capable of providing this service is in the capital city of Freetown, over 50 miles away from Magbenteh. The likelihood of the mother having the resources to make this journey and being able to afford the investigations and management when she gets there is very small, so she is usually powerless to change her situation anyway.
Of course, this does not mean that efforts to educate and train are pointless. What is for certain, is that healers, meaning those who practice country medicine for a living, must be incorporated into any efforts made to improve the situation. Many healers consider themselves dedicated to patient care and spiritual cleansing, and the Sierra Leone Indigenous Traditional Healers’ Union has already worked with government forces in the past to find and stop those healers whose malpractice leads to the unnecessary deaths of their patients24.
It is essential that healers are involved in any progress made, as they have a great deal of power within the community. Although those healers who are part of the Union are registered and certified, they are unlikely to have any medical training or practise according to medical guidelines. The solution in this case could be to empower healers rather than to stop them from trying to deliver care at all. People in Sierra Leone trust them, and as they are already placed within communities, they are in the best position to deliver effective healthcare. If healers could be trained to give evidence-based advice alongside their own remedies, and if they could learn how to triage effectively to decide which cases needed to be referred to the hospital and which could be treated within the community, Sierra Leoneans’ instincts to seek out these practitioners could be used to great benefit.
If patients are also being encouraged to use modern medicine, as long as traditional methods do not interact with these or cause harm to the patient, the two forms of healthcare may even be used together. Staff at Magbenteh witnessed this when the only way to prevent a family from discharging their relative from hospital was to allow them to bring a live chicken to the hospital and put it by the patient’s bed, whilst he received his medication prescribed by the doctors. Methods like this may seem unorthodox, but in situations such as these, it is a step in the right direction.
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