BMJ  2004;328:1573 (26 June), doi:10.1136/bmj.328.7455.1573

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PERSONAL VIEW

Wasting time with people

"Waste time with people," advised the African bishop with a smile. "You Europeans are always concerned about projects and budgets. The African does not worry about them—just waste time with people." He gave me this advice in 1996 shortly before I came out to work in Uganda. Since then his words have kept coming back to me, and I reflect on their truth and wisdom and how difficult it has been for me, as someone with European values and attitudes, to apply them.

I supervise eight rural health centres in the west of Uganda, scattered among the foothills of the Rwenzori mountains. I love driving out on winding dirt tracks, past steep fields planted with cassava and coffee, and dodging the ubiquitous goats, to an isolated health centre run by two or three nurses and community health workers, a centre with few drugs but many patients. The dedication and perseverance of the staff are a real inspiration to me.

Health centres in Uganda, even those built and run entirely by Ugandans, are based on a European model. As in the United Kingdom health centres in Uganda require certain ways of operating, such as staffing structures, duty rosters, plans, budgets, and so on, having their roots in certain cultural values and norms, such as how we use time, money, and power. The underlying assumption is that the Western way is the better one, and this implies that Western values are also superior.

Africans are being lured away from their own traditional medicine to Western systems

Uganda has its own cultural values and norms, and despite my years here I can only claim a superficial understanding of them. As I sit in my office, people wander around the compound with no sense of urgency, greeting everyone they meet—not with a nod and a grunt but with a long exchange about their health and welfare and family. People are important and worth "wasting" time with.

Traditional medicine still forms an essential part of rural health care for most people here. Some of it is dangerous and destructive: the removal of milk teeth with a bicycle spoke as a cure for diarrhoea, or the extraction of rudimentary breast tissue for pneumonia. But much of it is good, useful, and has something to teach doctors trained in the Western model. This community, composed mainly of peasant farmers, has a wealth of knowledge about the use of plants and understanding of their medicinal uses that seems not to be confined to the traditional healers, as I had expected. People are familiar with the use of lemon and eucalyptus for coughs and colds, aloe vera for burns and peptic ulcers, and papaya for cleaning dirty wounds, treating worm infestations, and as a soap substitute, among numerous other uses. Like complementary medicine in Europe, traditional medicine in Uganda is holistic, linking together body, mind, spirit, and community and giving value to a whole range of factors that not even a good general practitioner in the United Kingdom would consider.

Underlying all this are the cultural values and norms of the local people, which, combined with knowledge passed from one generation to another, give a strong sense of ownership. Sadly, their knowledge and practices are in danger of being lost, overwhelmed by the tide of "modernisation."

The fact that manufactured quinine will work in a London hospital does not mean that it will be as effective in rural Uganda. It will not work if patients do not see the need for the drug or cannot reach the health centre or if, when they arrive, the staff are away, the drugs out of stock, out of date, or counterfeit, or if the wrong dose is given or the patients do not complete the course. Despite years of health education of the community and training of health workers these are still everyday problems. At the same time I see people bypassing the plants in their garden and their grandparents' knowledge to spend a month's income on foreign, processed aloe vera in a plastic bottle with a smart label, believing it to be a "modern" medicine.

In the West we are looking at the potential benefits of complementary medicine in the face of the weaknesses and failings of traditional Western medicine, but Africans are being lured away from their own traditional medicine to Western systems and practices with their promise of high tech solutions, which they can neither use nor afford. Rather than seeking to replace the practices of generations that are intrinsic to the culture and give people their sense of self worth, scientific methods could be used to validate or improve African traditional medicine in a two way exchange of knowledge and understanding.

When I passed on the bishop's advice to waste time with people to a group of North Americans and Europeans working in Africa they roared with laughter. Why did they laugh? If they had identified an obvious cultural difference, then such differences need to be reflected in our own health systems.

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Kasese, Uganda simon.Sharon{at}gmx.net

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