Working Towards Changing Cultural Practices: A Personal History in Oral Health Advocacy in Southwestern Uganda

Ebino, loosely translated to mean false teeth, is termed more descriptively in scientific literature as “infant oral mutilation” or IOM

By Jean L Creasey DDS, FACD, FICD, FPFA

We all have our convictions about health and beliefs that for us stand unquestioned. The diversity of beliefs between individuals and groups of people is part of what makes life interesting and challenging at same the time. Chinese acupuncture has little in common with European aromatherapy and neither fully aligns with evidence-based western medicine. In fact, some therapies may even strike us as so counter to our own knowledge, we’d consider them barbarous. Through my dental outreach engagement in rural Uganda, I have come face to face with such practice dichotomies and have learned the importance of building relationships prior to suggesting change.

In much of Sub-Saharan Africa, traditional healers are historically common, generally revered and seen as sources of wisdom and justice. In less culturally sensitive times we, in the west, have referred to them as “witch doctors” but locally they are known, more respectfully, as “Abafumu”. Their medical remedies are based on the supernatural; magical beliefs and convictions that small demons are the sources of illnesses. Rural Africans have been much more likely to consult with a traditional healer than seek care from a trained physician due to cultural preferences, accessibility to treatment as well as cost.

I first became aware of a common, dentally related “traditional healer” practice in 2005. I had traveled from California to perform a dental health survey among the Batwa pygmy community in the Kanungu district of southwestern Uganda. This remote and mountainous district is also home to the famed and endangered mountain gorillas and designated as a World Heritage site for its breath-taking natural beauty and wildlife diversity. As I stood atop a high mountain top clearing, peering into the open mouths of locals who had gathered under the shade of a giant Ficus tree, I was certain I had the loveliest “clinic” location imaginable.  I had come to this area of Uganda to help collect salivary samples for the Max Plank Institute’s global study on the salivary microbiome and also to conduct a dental health assessment among this extraordinary population, long isolated from the modern world. Along with a generally lower incidence of caries, I noted a mysterious phenomena of missing lower canines in several young children and started asking my translator questions about it. Years later, I find myself asking more.

For almost twenty years now, I have regularly visited southwestern Uganda, where I have sought to improve oral health literacy and learn more about “Ebino”, a practice in which primary, mandibular, canine tooth buds are removed from infants by traditional healers.

For almost twenty years now, I have regularly visited southwestern Uganda, where I have sought to improve oral health literacy and learn more about “Ebino”, a practice in which primary, mandibular, canine tooth buds are removed from infants by traditional healers. Babies selected for this practice are most commonly febrile, but any apparent malady or pathology makes them targets. At times it is performed prophylactically to ward off future illnesses. Babies with intellectual or developmental disabilities (IDD) are no exception, as anxious parents seek remedies to health issues that are seen as remarkable.

Ebino, loosely translated to mean false teeth, is termed more descriptively in scientific literature as “infant oral mutilation” or IOM. It is performed by the Abafumu at the bequest of worried parents. While results of this practice are usually limited to loss of primary canines or collateral damage to permanent teeth, occasionally there are consequences far more serious, including sepsis, tetanus, HIV transmission or death. The procedure itself is performed utilizing a variety of instruments including wire, bicycle spokes, or razor blades. Because this “remedy” has no relationship to the underlying condition, critically needed medical care is often postponed and complicated when Ebino is performed. Further, because no anesthetic is utilized, young children are physically restrained during this painful procedure.

I never intended to make a remote Ugandan village a regular vacation destination, but have been drawn irresistibly by the warmth of the people and natural beauty of the area. Now, after 20 years of engagement, serving as a dental volunteer and consultant to Bwindi Community Hospital I feel it has been some of the most meaningful work of my life. 

Located on the edge of the Bwindi Impenetrable Forest, the hospital was founded in 2001 by my own Northern California Physician, Dr. Scott Kellermann and his wife, Carol, who initially went to do a medical needs survey and bring basic health care to an otherwise remote and unserved area.

They were drawn by the plight of the Batwa population, a marginalized minority group who had been evicted from living as hunter gatherers in the Bwindi Impenetrable Forest by the Ugandan government. The displaced Batwa, who comprise approximately 8% of the local population, lacked the skills to live as agrarians and were living as squatters along the edges of the forest perimeter. The medical needs survey showed had a devastating, under five mortality rate of 28%. Moved by the pleas of the Batwa community to stay, the Kellermanns proceeded to sell their California home and medical practice and relocate their lives to Uganda. Quickly they realized a lack of healthcare was not limited to the Batwa, but extended also their neighbors, the dominant Bakiga tribe ( 92%). The needs were overwhelming.

The Kellermann’s efforts began modestly, initially setting up mobile medical camps, often resourcefully hanging IV bags of anti-malarial drugs from tree branches. Water borne illnesses, malaria and malnutrition were the most common maladies then and the impact of instituting basic community health prevention and treatment schemes was huge. While some of the treatments were simple, living was not. Local food supply was scarce, there was no electricity and the unpaved roads frequently washed out in the rainy season. Thankfully, many generous funders came along side to support the work.

 Visitors today will find a modern, all-Ugandan staffed, 150 bed referral hospital, including an ICU, waiting mother’s hostel and an impressive health science campus housing schools of nursing, midwifery, plus planned medical and dental officer training programs. While the roads remain unpaved and deeply rutted, electricity and plumbing are mostly dependable. Year after year the hospital is recognized internationally for its excellence.

Each time I have visited, I engage in community dental health promotion and collaborate with BCH’s public health dental officer Onesmus, the only trained dental provider serving a population of 250,000. He is keen to address the ebino issue as I am.  In 2016, I visited two local schools to screen 3-6 year olds for the presence of ebino. My survey of 244 children revealed an ebino rate of 12%. Attitudes among the hospital staff and elementary teachers towards ebino ranged from vague familiarity, to ridicule of the practice to denial of its existence; all depending on where they grew up and their education levels. Individuals from rural areas expressed greater acceptance of the practice.

One evening I interviewed a local Abafumu, named Warren. Warren is an Abafumu of great renown and also doubles as a traditional musician at one of the nearby upscale lodges. My good friend Bwindi Hospital founder, Dr. Scott Kellermann had accompanied me to meet with Warren and act as translator.  I tentatively ascended the long, lantern-lit steps to the lodge. I was rewarded to find an oasis of hospitality: an open-air restaurant and bar serving cold beer and exotic drinks to guests who pay upward of $600 per night.  Surrounding the veranda was a lush lawn complete with a perfectly arranged central campfire, and camp chairs draped with folded blankets, neatly arranged around the circumference. I gazed across the valley to a mountain side covered in a lattice of mahogany and ficus trees, one seemingly stacked upon the other forming a mesmerizing weave of branch, trunk and leaf, just perfect for gorilla habitat.

Warren sat in front of the fire, flame and spark dancing in the soft light of early evening. He was dressed in simple costuming of a loose-fitting tunic covering his pants and shirt, a large brimmed straw hat and sandals. In one hand he held a traditional African instrument and in his other, a pipe of sorts. He quickly recognized Dr. Kellermann and greeted him warmly. His eyes crinkled and sparkled in a lovely way that revealed age, kindheartedness and wisdom, all at the same time.

Abafumu are reluctant to talk with outsiders about their practices as many are considered illegal under the law. Despite the fact that IOM is illegal, it continues. My opportunity to meet him was unusual and while I was anxious to get my questions answered, the interview needed to be handled with care. Relationships are especially paramount in African culture.

Dr. Scott and Warren spent time catching up; Warren recounted how, Scott, who founded the Hospital when there was no health clinic in the Bwindi area, once saved Warren’s wife from bleeding to death following the difficult home birth of a stillborn child.  Scott in turn, recalled how Warren’s mother-in-law, a powerful Abafumu named Batusa, had come to Scott’s aid when he sought to engage traditional healers in assuring the success of TB medication compliance and bed net distribution.

Indeed, mutual trust and relationships were important to both men and had proven indispensable to the success of the hospital. I waited patiently while Scott eventually got around to the topic of ebino.

I was not there to change Warren’s attitudes toward the practice, simply to learn more. He proudly shared that he had learned the art of his medicine from his father who had in turn learned from his father. There is a saying that, around the world anyone who engages in healthcare, no matter what the approach, surely must have a love of his fellow man and this was evident in Warren.

He became animated as he demonstrated the practice of removing the immature tooth buds from a fever-laden baby. According to the tradition of the Abafumu, when a feverish child is bothered by a “worm in the gum”, it must be removed. When the child dehydrates coincident to diarrhea or malaria, the primary canine tooth buds become prominent in appearance. This makes them easy targets for misplaced blame and removal. Many adults are familiar with the infection and pain frequently associated with third molar eruption. Hence, the theory that these primary teeth are the source of the problem seems plausible.

Warren described the process of using a thin wire and cutting under the tooth bud while demonstrating the action of how the tooth bud would pop out once it was separated from the alveolus. He spoke about the fact that many of the poorest of the poor in the outlying villages could not even afford to visit a health clinic and he felt that he was providing a needed service.  I surmised that convincing the abafumu that ebino was not an effective treatment would be unhelpful in reducing the practice. Seeking their collaboration in a respectful manner while at the same time improving the oral health literacy among rural populations looks the most promising approach.

A year later, I mentored 2 pre-dental students who spent 6 months conducting oral health literacy surveys throughout the sprawling Kanungu district, assessing attitudes among family decision makers towards the practice of ebino. They also organized a symposium of local Abafumu, with help from my friends Dr Scott and abafumu Warren, gleaning much insight into several traditional healer practices.

I look forward with hope to the coming years of continued collaboration with Bwindi Community Hospital, working to increase oral health literacy and community prevention efforts while respectfully engaging in collaborative efforts to discourage the practice of IOM.

This work will inform the Bwindi Community Hospital in their efforts to enhance working relationships with the Abafumu, respecting their community status while reducing their harmful practices. The hospital has a history of successfully collaborating with abafumu; re-training them as “village health promotors” on other public health campaigns that have resulted in improving TB medication compliance rates and increasing proper bed net use for malaria prevention. It is our hope that a similar collaborative effort will work with IOM reduction.  It was encouraging to see survey results reflecting that where ever overall health literacy levels were higher, the practice of IOM was less prevalent.

The gift of several years and many trips to Bwindi has allowed me a birds-eye view to the witness many successes at the Bwindi Community Hospital. I have seen the power of long relationships in building trust and mutual understanding. This has led to many good outcomes, the most recent being a new dental and vision care clinic that will also serve to train future vision and dental officers. This will help to address Uganda’s critical need for qualified providers. I look forward with hope to the coming years of continued collaboration with Bwindi Community Hospital, working to increase oral health literacy and community prevention efforts while respectfully engaging in collaborative efforts to discourage the practice of IOM.

If you are ever interested in volunteering as a visiting educator to the Bwindi dental officer training program, feel free to contact me: jlcreaseydds@gmail.com

About the Author

Jean L Creasey DDS, FACD, FICD, FPFA is an Asst. Professor, California Northstate University, College of Dental Medicine

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