A clash of beliefs: why our Western approach to pain didn’t work in a rural Zulu community

Graduating as a health professional can be both exciting and daunting. When we first qualified as physiotherapists, we couldn’t wait to get started. We were sent to a beautiful, rural, remote area of South Africa where we started clinical work under minimal supervision. But it was not long before we found ourselves out of our depth and wondering how to adapt. Our city-based training had prepared us well for administering effective, evidence-based therapy within a modern urban setting, but as soon as we hit the rural setting, that framework started to show its cracks. Most of our patients were traditional Zulu women who bore heavy physical loads and immense social stress. Their understanding of pain differed vastly from anything we had ever encountered – let alone been trained to address – and they spoke a different language (both literally and metaphorically). We found it difficult to apply what we had been taught: we could see that our principles of physiotherapy needed to be adapted quite dramatically, but we didn’t know where to start.

Rural Zulu women don’t have chairs – or short hamstrings. They don’t carry loads in their arms – they carry babies on their backs and almost everything else on their heads. They keep their legs together at all times, which makes traditional squat-to-lift advice redundant. Every day, they walk long distances to fetch water, carrying 25-litre containers on their heads. They tend their subsistence gardens standing on their feet, bent forwards with amazingly long hamstrings and straight spines to bring their hands to the ground, and stay in that position for hours while they plant seedlings and harvest food. We found the ergonomic principles which we had been taught to be completely irrelevant in this context: these women have to bend, lift and carry to survive – and the way they adapted to do that may, in fact, be more sensible than the approaches recommended by westernised occupational safety guidelines.

Traditional Zulu beliefs about pain commonly involved the idea that the whole person was ill, or that they had been bewitched. Pain was often widespread and did not have a clear structural focus. Trying to “explain pain” to patients with these beliefs, when we shared neither their language nor their culture, seemed like an insurmountable challenge. Manual therapy approaches lost their relevance: specific impairments were difficult to detect, most patients could only be seen monthly and the facilities in which we saw them had limited privacy for bodily exposure. Specific exercises and ergonomic advice seemed inappropriate in light of the enormous physical demands of the women’s lifestyles.

In this Paper we highlight our extraordinary experiences as young graduate physiotherapists in this setting. We explore aspects of the lifestyle and culture of the women we were privileged to work with. We reflect on the inadequacy of our ‘western world’ perspective for dealing with pain in this community, where our patients’ pain beliefs and life experiences were so different from our own. We highlight the enormous challenges to providing effective care to impoverished and culturally distinct, rural populations. These concerns are not unique to South Africa. Most countries in our increasingly globalised world have a diversity of cultural groups within them. We consider how physiotherapy programmes may be able to equip graduates to better adapt to different cultural and economically disadvantaged groups for the management of musculoskeletal pain.

Tory Madden

Tory MaddenTory arrived from South Africa to start her PhD at BiM.  She is a physiotherapist who worked clinically before turning her focus toward research.  She is interested in pretty much anything related to pain and neuroscience, thanks to some particularly inspirational teaching by Romy Parker during her undergraduate training at the University of Cape Town.
Tory’s research looks at classical conditioning and pain.  She is also an associate editor for BiM.  She tries to spend much of her spare time exercising to compensate for the vast quantity of chocolate that lives in her bottom desk drawer.  Luckily, she loves trail running as much as she does food.


Victoria J Madden, Peter O’Sullivan, Julia Fisher, Busisiwe Malambule (2013). ‘Our training left us unprepared’ – two physiotherapists’ reflections after working with women with low back pain in a rural Zulu community in South Africa. Journal of Community and Health Sciences, 8 (2) PDF


  1. Apologies… amendment to reference
    Dalton, E. Dynamic Body is (2011)

  2. Thanks Tory for sharing your very interesting insights and experiences in the field. So fascinating how belief systems are such powerful affect of pain experience-
    What came to my mind is some research that has been carried out on African women from different countries, looking at the efficiency of carrying loads on the head (http://www.ncbi.nlm.nih.gov/pubmed/20186424)
    and interestingly new research looking at the role of the thoracolumbar fascia in a newly proposed model of gait (Gracovetsky, S. (1988). The Spinal Engine. Vienna, Austria, and New York, NY: Springer-Verlag, http://www.swingwalker.net/zambia.pdf
    Zorn, A., & Hodeck, K. (2000) Walk with elastic fascia. In Dalton, E. (Ed) Dynamic Body, p96-123)

    It would be interesting to see whether there is any correlation between perceived/experienced LBP and efficiency of gait/carrying loads and also cross referencing this with any cultural variance in pain experience between African women of different populations.

    It would be a massive study or series of studies! It could be interesting to examine if specific cultural practices that deal with functional loaded activities have a variety of ways in which they deal with pain and what might be the neurobiological or physiological correlates that might go some way to explain these observations.
    Thanks for stimulating these thoughts and good luck with your ongoing research.

  3. Tory, thanks for your articulate response, observations and insight. I was trying to understand whether the overt pain behaviours were culturally biased or whether they were also a product of threat via decreased connection – when a connection was made – did the pain behaviours decrease? – I wondered whether there were the same behaviours in the presence of Maryke? More research, yes, but appreciate the dialogue and your observations.

  4. Tory Madden says

    Stu, thanks for your positive feedback! As you suggest, it is likely that our poor language skills may have partially driven the increased pain behaviours since, in general, gestures had to be used more than they might have! We didn’t have access to fluent translation sufficiently often to say whether or not patients showed less pain behaviour when they didn’t need other gestures to replace language-based communication. Having said that, our facility with Zulu did improve while we were there, but we certainly didn’t notice a change in overt pain behaviours.
    I did initially find the dramatic pain behaviour distressing. To be frank, the whole setting was quite confronting at first, and it took me a while to get used to that. As we said in the paper, we had had some training in understanding pain, but not enough to help us to make sense of what we saw in Umkhanyakude.
    We tried many strategies for management! Listening was important. We often gave very basic advice on modifying daily activities, and worked with patients to find ways to keep them doing their work, but pacing themselves through it. We often gave some (culturally) modified exercises and problem-solved with patients to work out when and how they could do them with privacy. I am not able to say, with any certainty, how effective our approach was, which I realise will be disappointing – it is to us.
    Again, the resounding call is, ‘More research!’

  5. Tory, really useful presentation. In terms of lack of understanding re language, did you feel that there was an increased emphasis on display behaviours of pain due to your lack of understanding of the language? Based on your western understanding, did you find yourself increasingly distressed in the presence of such strong pain behaviours despite your training in understanding pain? I am curious. In terms of approach, I realize that there was little adoption of your methods to deal with their pain. By the end of your work, did you try to seek out one simple strategy that might be adopted or did you switch to a more empathetic approach and just strive for greater understanding or as Jan had more succinctly stated, what did you end up doing? I would be very interested in Maryke’s viewpoints from Manguzi Hospital. Thanks.

  6. As someone who is religious and suffers chronic pain, I wonder how appealing to their spirituality as a means to deal with pain. Prayer, mediation or an equivalent method appropriate to their beliefs as a way for them to create a heathy narrative that will lessen the negative effects. If they believe they are primarily spiritual beings, then a focus on the body will never connect. But empowering them to have a spiritual authority over their pain may be helpful 🙂

    Though that’s my laypersons opinion.

    Great article!

  7. I think dependence (even heavy dependence) is fine so long as it’s not ongoing dependence. I’m thinking of emergency medicine as a good example, but really all healthcare involves a high degree of dependence. Preferably the healthcare system has client independence as one of its end goals.

    The approach I suggested would have to be effective of course and that would mean not just dry needling and rubs, but the proper relational work and fear reduction work. But once you’ve helped a large number of clients, then trust is built. Once built, then the ideas surrounding the treatment can be modified. The idea of ‘bewitching’ has a very external locus of control, but this could be modified once fear has been removed from the equation. “Bewitching” could become “negative feelings”.


  8. Tory Madden says

    Thanks, everyone, for your comments! It’s great to have some discussion about these issues.

    EG, I’m interested that you say that you would try to work within the belief system and use treatments like dry needling and a ‘special healing’ rub. Would you not be concerned about creating dependence on your ‘magical’ treatments, and thus disempowering your patient?

    Jan, your question is the one that occupies many therapists (and probably not enough researchers) across the world! I wish I had an answer. We really struggled to identify a treatment approach that yielded helpful results for more than a few patients. Maryke Bezuidenhout, a physio at Manguzi Hospital, has a great deal of experience in this context and would be better positioned to reflect on what approaches show promise of efficacy. Unfortunately there seems to have been very little research that is relevant to non-Westernised and strongly traditional African settings, and more is needed. I realise that that this doesn’t answer your question, but the truth is that we don’t yet have any really good answers. If you (or anyone else) knows of other research that we may have missed, I’d be very grateful to know about it!

  9. This sentence was really interesting: “Patients rarely localised the pain to a particular area during these movements or distinguished a specific movement as more unpleasant than others”.

    – Being unable to localize pain is a sign of strong aversion to pain.
    – If there’s no belief in a structural cause of pain, then why would certain movements be problematic?! Our reality is what we believe.

    I’ll answer the hypothetical question I posed above and see what others think.

    I would temporarily adopt the ‘witchcraft’ belief system and work within it. I think changing this sort of belief is almost impossible within a short time frame. Such changes occur over decades typically.

    I’d create a treatment which is similar in appearance to the traditional healer’s. That would allow me to promote it as “the same as the traditional healers but a bit more advanced, and cheaper”. This way beliefs are not threatened nor resistance evoked.

    – instead of porcupine needles, I’d do dry needling (not that it does anything, but that’s beside the point).
    – Because of the likelihood of strong pain aversion in many of the women, I would use a metaphor of “facing one’s demons” or something along those lines.
    – instead of an ash or cow dung, I might use some sort of rub “with special healing herbs”.

    Ever grateful to Milton Erickson and Carl Rogers, both of whom would have had no difficulty at all in this situation.


    PS. The picture so the women in the field reminded me of Van Gogh’s earlier work. He did quite a few paintings similar to this. Note the pose. http://www.vangoghgallery.com/catalog/Painting/404/Peasant-Woman-Digging.html

  10. Jan Carstoniu says

    I agree that this is very interesting but after reading the article I’m more interested in finding out what you actually ended up doing and what resulted.

    I certainly believe that a patient’s beliefs and culture must be dealt with appropriately in any clinical situation but how to do this and deliver effective pain care is the question that jumped out at me.

  11. Great, describing the cultural differences in (illness) perceptions about pain and about your own western perceptions how to deal with it! An important topic in every society and for every PT! Good work

  12. Hi Tory
    As a fellow South African, I totally agree- we need to stop trying to instill our ‘Western’ ideologies and be more mindful of patient’s experience, context and cultural belief system is imperative.

  13. Very interesting I had the same experience in Rural Eastern cape in Fact 🙂

  14. Hi Tory,

    Interesting findings, particularly the beliefs about bewitching.

    If you were given one week only to go into such a village and offer the women help for their back pain, how would you go about it? How would you ensure effectiveness?

    Would you impose your modern western beliefs or work within the confines or their existing belief structure?

    Regards, EG