Page Two P H Y S I O T H E R A P Y October, 1953. Physiotherapy in Relation to the Treatment of Non-European Patients Paper read by M ISS LOIS DYER, M .C.S.P. at the First International Congress of Physical Therapy in London, September 1953. TH E problem o f giving M edical Services to th e non- E uropeans in South Africa, in view o f the fact th at they constitute approxim ately 80 per cent, o f the popula­ tion and are a constant source o f difficulty and infection, is o f param ount im portance and could be discussed en d ­ lessly. All the difficulties and fundam ental differences - find their counterpart, though perhaps to a lesser degree in the application o f Physiotherapy to this group o f people. T he non-E uropeans in South Africa comprise, the B antu o r native, th e C oloureds, who are those o f any mixed blood, the Indians, M alay and Chinese— in fact, anyone whose skin is not white. T he B antu form the largest group and it is a b o u t them th a t I am going to talk. O ne’s approach to the B antu race is o f necessity different from th a t used for the E uropean. I t is a largely prim itive race which does not understand E uropean methods o f medical treatm ent, and even am ong the urbanised group, with which I have had m ost experience, a t least 60 per cent, o f th e non-E uropeans have treatm ent by their own people before attending H ospital. They are used to th e methods o f their w itchdoctors who spend four fifths o f th e tim e after a spot diagnosis, discussing w hat they consider is the pathology o f the condition, and then prescribe their various herbs as remedies for this, th a t and the o ther sym ptom . T he belief is still firmly held th a t illness is caused by evil spirits o f their dead relatives and acquaintances, and this tends tow ards a certain fatalistic acceptance o f illness. I m ust quote an example to give you some idea o f the superstition an d m istrust against which medicine has to battle. A n A frican Staff N urse who was trained at one o f the non-E uropean H ospitals in Johannesburg, and who was a good nurse, decided to get m arried a couple o f years after the,com pletion o f her training. This she did, and shortly afterw ards she had a baby. T he baby became ill, an d this Staff N urse first took her child to the witch­ doctor, and only when its condition deteriorated did she bring it to the hospital. I f th a t is the attitude o f what was a reasonably intelligent native w om an with a medical training, it is easy to im agine w hat the actions o f the lay A frican public are. Tim e and again one has first to undo the dam age done physically and psychologically by the w itchdoctor, before progressing to the routine scientific treatm ent o f the patient. T he language difficulty is o f course a m ajor one, an,d even with the use o f intelligent interpreters, it is not easy to establish th e relationship with the patient which one does when speaking the same tongue. T he A frican has no idea o f prophylactic medicine an d indeed usually does not come to the hospital unless his condition is very painful, o r is sufficiently incapacitating to prevent his working. A p art from the psychological factor which has to be com batted no m atter w hat form o f medicine the patient is to receive, there are very real difficulties encountered physically and economically, and I w ould like to try and give you a picture o f some o f them as met w ith in the P hysiotherapy D epartm ent. Firstly, th e native does no t understand the need for physiotherapy, and would usually far rath er be given a bottle o f medicine to help his broken leg and w ould be better pleased w ith it, no m atter how vile the taste. We all know how difficult it is to explain to som e E uropeans why they are being m ade to use their muscles, and why they m ust be given breathing exercises when they com plain bitterly th a t it is an operation on their knee th a t they are going to have! W ith th e Africans, it is w orth trying to explain simply w hat one is doing, but even though they smile an d co-operate quite well while one is with them , it is obvious th a t they think this is another o f th e white m an ’s idiosyncrasies to be accepted, n o t questioned a n d certainly not understood. The high incidences o f tuberculosis, venereal disease and m alnutrition manifested in m any forms, tends to lower th e resistance o f the A fricans to general infection, although it is am azing considering their living conditions and com plete lack o f hygiene and knowledge o f food values, th a t it is( n o t even lower. T heir constant exposure to disease and conditions o f sepsis m ust stim ulate the form ation o f vast num bers o f antibodies and create a certain immunity. Again, it is astonishing to see a p atient who has perhaps been immobilised for six m onths w ith a fractured femur, th e callus form ation often being slow because o f th e low calcium production, come o u t o f traction and within two o r three weeks have full knee flexion. This is probably due to the fact th a t the prim itive native still tends to use his joints naturally and has not had to undergo the abuses o f jo in t function which o u r m odern civilisation demands. M ost cases sent for treatm ent are due to traum a, since the A frican is exposed to many industrial hazards ap art from the com m on causes o f accidents am ong Europeans. T here are m any cases o f assault, chiefly stab w ounds and injuries caused by hitting each o ther with sticks and pieces o f iron. This seems to be a favourite pastim e particularly at the week-ends when many o f them do not work, and drunkenness is com m on. Then one has the usual medical conditions to treat, plus an enorm ous num ber o f septics. B urns are very com m on, prim arily due to the prim itive m ethods o f cooking and heating which they employ. I have rarely seen a case o f fibrositis, and very few rheum atoids. T he B antu, however, appears to be more prone to osteoarthritis than the E uropean, although it is interesting to note with this particular disease th a t the jo in ts m o st com m only affected are quite different in the ̂ tw o races. Definite anatom ical differences in th e knee jo in ts o f th e Bantu and E uropean seem to account for the fact th a t medial meniscus injuries are extremely rare in the B antu. I t is only in the last few years, since so many have adopted the E uropean dietary habits, together with th e strain o f city life, th a t one has seen cases o f appendicitis, gastric ulcers and a certain evidence o f psychological and functional illnesses. Lead swinging was practically unknow n until the last W ar, when the habit seemed to have been picked u p in th e A rm y. However, one still sees very little o f it, chiefly because when an African is ill, he has no means o f earning, since very few are entitled to unem ploym ent benefits. H e either has to get better quickly and return to full earning capacity, o r he and his wife and children starve. This makes life much easier for the physiotherapist since the patients have a definite will to get better and co-operate well. ' They are usually prepared to tolerate m ore pain than the E uropean, and it seems th at the pain threshold is much higher. They are renowned for their stoicism and unending patience. T reatm ent in classes is very popular, as is w ork involving apparatus, and com petition is keen, rather as it is with R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) October, 1953. P H Y S I O T H E R A P Y Page Three children. In fact o n e’s approach is ofteh sim ilar to that used with E uropean children. T heir basic knowledge of native crafts m akes them particularly am enable to work in the O ccupational T herapy departm ent an d the men, women and children produce some most beautiful articles. One m ajor technical difference in the treatm ent o f the natives is caused by their pigm entation. W hen treating open areas th e dosage is o f course as for a European, b ut when treating the skin itself, I have found th a t one has to m ultiply the norm al dose by ab o u t four times, and look very hard to see th e reaction. Different tribes have different am ounts o f pigm entation an d one has to grade the dosage accordingly. Largely because o f the bed shortage, patients are only kept in H ospital if they are really ill, and so they are dis­ charged as soon as possible. This again is a trib u te to their amazing stam ina, for one could not possibly do this with E uropeans. This does raise a problem, however, in th a t attendance as an outpatient is always difficult, because o f tran sp o rt fares, an d many cases are lost to us because o f this im portant factor. A s far as possible, those needing concentrated treatm ent are kept in, but it is no t always practicable, nor very often does the patient desire it. In many H ospitals, th e authorities even go as far as adm itting babies as lodgers when their m others are ill, to try and relieve the social problem o f w hat to do with the child. M ost A fricans prefer to get hom e as soon as possible. This creates difficulty as far as long term cases a re con­ cerned, such as paraplegics. As soon as they are capable o f struggling about, they are anxious to go back to their kraals, and one never seems able to continue long enough to obtain a 'really first class result. A nother problem is th a t o f trying to m ake the African realise the im portance o f w earing appliances which may have been issued to him . They often cause discomfort, and so he removes them . Plasters are m ade tw o o r three times stronger th an those for Europeans, to w ithstand th e w ear and te a r they m ust endure in the native’s way o f life, but many is the tim e I have seen a plaster cut and altered because th e patient has found it uncom fortable or inconvenient. T he same problem seems to arise over hom e exercises, whose value they seem unable to appreciate. Once the p atient is, discharged from hospital, it is very h ard to m ake him realise the im portance o f being able to follow him up a n d this is a great draw back as far as records are concerned. I f he feels well, th e A frican sees no point in attending th e hospital. A nother aspect which unfortunately has to be faced far too often is th at a patient arrives at th e D epartm ent frightened and slightly on th e defensive because o f the treatm ent he has received in o th er departm ents. N on- E uropean H ospitals are always overcrowded and under­ staffed it seems, and one has to have a great deal o f patience to cope with th e enorm ous num ber o f cases. It is easy to become irritated by their lack o f understanding and ap p aren t stupidity in m any instances, and it must be con­ fessed it is n o t always pleasant to w ork w ith the African whose od o u r is different from th a t o f th e E uropean, and whose habits an d clothing are not the cleanest. O n top of his initial fear and m istrust o f the hospital m ethods, the A frican finds him self bullied an d shouted a t far to o fre­ quently, when a little tolerance an d understanding w ould gain his confidence an d completely alter his attitude. I find treating non-E uropeans a m ost stim ulating and satisfying experience, and provided they are treated with comm on decency and consideration, they are ju st as grateful for th eir treatm ent, an d often m ore so, th an the average E uropean. N early all o f them are am enable, polite and eager to help if they can. I look forw ard to the day, which is n o t far off, when we shall be able to train non-E uropean physiotherapists to treat their own people, so th a t with m any o f the present barriers thus lifted, we shall see really w orth while work an d another progressive step will have been taken tow ards producing a responsible African race. The most vitalising x of all m easures T h at was th e description given 18 years ago by a distinguished lecturer to general ultra-violet light therapy; it still holds good today. Except in certain selected conditions where the use o f ultra-violet is definitely contra-indicated, it can be said th a t there is no invalid o r convalescent whose con­ dition cannot be am eliorated by th e judicious use o f ultra­ violet rays. T he im pact o f this high-energy radiation upon the skin sets into m otion a train o f photochem ical and physiological processes to which the whole body responds, thus giving fresh im petus to the processes o f healing. In spite o f the spectacular results obtained in o th er fields o f therapy in recent years, no o th er single m ethod has produced such beneficial effects in th e hum an system, and w ith such com plete lack o f adverse sequela;. Supply and service through: The British G eneral E le ctric Co. Ltd. v » t A A* H A N O V I A L T D . M agnet House, Loveday & Anderson Streets, SPECIALIST S IN A C T IN O TH E R A PY JO H A N N E SB U R G . EQUIPMENT. Branches: C ape Town, P o rt Elizabeth, Salisbury, and Bulawayo. jBSjMS S L O U G H • E N G L A N D R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )