Microbial keratitis (MK), also known as corneal ulcer, is an infection of the cornea (the clear part of the front of the eye) that can lead to permanently reduced vision, blindness or even removal of the eye.

Around one million people a year will develop a fungal corneal infection, and it’s estimated that 6.2 million people are currently blind in one or both eyes globally due to corneal pathology with MK being the leading cause.

Nepal has the highest reported incidence of microbial keratitis globally, where infections are often seen in those who experience eye trauma from agricultural work. In low-resource countries however, access to modern healthcare can be limited due to income, transportation challenges and gaps in the local healthcare system. People instead often initially use home remedies and/or seek care from traditional healers, locally referred to as ‘Dhami’ in Nepal.

Reports from hospital-based studies suggest that up to 36% of patients have visited traditional healers to obtain treatment before attending a hospital for MK in Nepal.

New research from the International Centre for Eye Health surveyed 109 traditional healers in Siraha District, Nepal over a period of nine months.

All traditional healers contacted were ones who had previously provided treatment to patients with MK within their community. The median distance between the healer’s residence and a tertiary eye hospital was 24 km, and the majority (68%) had no formal education.

Of the group surveyed, some were further invited for in-depth individual interviews or focus group discussions.

The results found that:

• Traditional healers have limited knowledge about corneal ulcers and infections. They believe that infections can be caused by a curse or witchcraft, alongside trauma, insects, or symptoms related to conjunctivitis


• Only half of healers believe that using eye drops or medicines available from pharmacy shops or medical centres to treat eye diseases is good, while 27.5% of them were neutral. One healer remarked: “‘God may get angry if we use modern medicines and as a result eye condition may worsen”


• The majority of healers followed spiritual or mythical practices when treating patients with MK. The most common practice uses a herb that makes direct contact with the infected eye. This herb is then placed into muddy soil or under water to rot. The belief is, the sooner it rots the sooner the ulcer will fade. This practice can take over a month, significantly delaying patients from seeking further healthcare if the ulcer does not heal


• The majority of healers said that they don’t refer patients to health centres because they lack trust in the ability of the staff to manage eye conditions, particularly at community health posts

Despite these findings, the study discovered an appetite amongst traditional healers to be trained in modern eye health care, and to be advised in when and how to refer patients for further treatment. This desire could open a potential route to improve healthcare referral for MK patients in the community, with trusted traditional healers providing community care, before referring serious patients to the health system for further treatment.

Fostering such connections may help improve eye health services at district level and also improve the community health practice, ultimately minimizing the problems associated with delayed healthcare seeking behaviour.

The work provides further evidence for an ongoing cluster randomised controlled trial in this district, which is focusing on enhanced training of primary health centre staff to improve early detection and referral of MK. This study will also assess the impact of integrating healers and pharmacies in the referral system, to counter the burden of severe microbial keratitis in this region and reduce avoidable blindness.

Publication: Das Sanyam S, Yadav R, H. A. Mohamed Ahmed A et al. Role of traditional healers in the management of microbial keratitis in eastern Nepal. Wellcome Open Res 2024, 9:295 https://doi.org/10.12688/wellcomeopenres.21241.2