"I don't know why it works, but it works in many ways," Wang says. Standard treatments like Silvadene delay healing and require aggressive debridement — the removal of dead, damaged or infected tissues, which tend to dry onto the wound. The B&W regimen keeps the wound wet. "You begin to notice the living tissues separating from the dead tissues," Wang explains, "whereas when we use standard treatment, the tissues stick." The separation of tissues eliminates the need for vigorous scrubbing, thereby allowing new tissues to grow.

Still, the possibility of infection remains. The Plain community's healers report that infections occur rarely, if at all, when the B&W regimen is followed properly. Wang, who also trained as an immunologist, speculates that this might have something to do with the honey. Honey contains antimicrobials and has been used medicinally since Ancient Egypt. One of the earliest medical texts, known as the Edwin Smith Papyrus, details the use of honey on a wound.

The nurses also noticed B&W's effects. Lori Pelham, nurse manager for the Trauma Burn ICU, is impressed with how well B&W has worked on Plain community patients. She suspects that if the regimen were scientifically proven effective, it would be used by the general public. However, in the absence of such evidence, the burn unit staff must navigate the competing demands of evidence-based medicine and family-centered, culturally sensitive care.

Further complicating matters, "Word went out that I would consider the use of B&W," says Wang, chagrined that generalizations were being drawn from his work with a single individual. What's more: Plain community families began to arrive with the expectation that U-M surgeons would do no grafting.

Controversy and Conversation

Thomas Bardwell, a Mennonite who lives among Plain settlements in Michigan's Thumb, explains, "In the Amish community in the United States, if something happens today, within 24 hours or less, everybody will know." Many Amish families have access to a communal phone shack or they may use a neighbor's phone. Still others receive news from Bardwell himself. A former hospital administrator, he currently operates a crisis hotline for families seeking medical advice. He also serves as an intermediary between families and treating physicians.

"The Plain community needs a major hospital," says Bardwell, adding that families will pay a driver to transport them a thousand miles, bypassing other medical centers to receive care from someone they trust. "I've heard it said they only trust Dr. Wang. They may not agree with what he says, but they trust him. That's a big step in the Plain community." Bardwell praises the U-M nurses and describes Wang as "caring and compassionate." He would like to establish the U-M as a preferred center for Amish burn patients, though he knows this could be difficult given that not everyone at the U-M wants to negotiate with families.

Many support negotiations within the burn unit, but, Wang explains, others wonder, "Why are we bending over backwards?" This internal conflict creates a stress on the system. Criticism has also arrived from other facilities when patients have requested transfer to the U-M. The burn unit's preference is for a seriously burned child to be taken to the nearest American Burn Association-verified center. But families will then request transfer if told that B&W is prohibited. Wang has received phone calls from skeptical colleagues. One prominent burn surgeon even accused the U-M of enabling malpractice. (It's worth noting that for religious reasons, the Plain community doesn't sue.) "You have to understand," Wang says, "we surgeons all think we are the best. All of a sudden, you have these very reputable surgeons who are being told that they need to send [patients] to Dr. Wang at the University of Michigan."

Some even accused Wang of never doing surgery on his Amish patients.

"I don't avoid surgery," Wang says. "I just spend the time working with the family so that I get us all to the point [where surgery is an option]. Now, you can argue about whether I was endangering the child by spending an extra week or 10 days talking to the family and their community ... But my view is that I was very careful — it was extra work on our end to monitor. I don't think I ever put the patient in jeopardy."

In his earliest conversation with the pediatric intensivists, Wang began to suspect that optimal care may be different for the Amish than for the general population. In Plain communities, responsibility for a sick child belongs not just to the parents, but to the whole group. They arrive with multiple family members, healers and elders. They bring homemade sandwiches and other food in 5-gallon pails. "You have to take care of them in that context," Wang says.

For this reason, he initiated a series of meetings to determine how to convey optimal protocols — to stff at UMHS, to the Plain community and to outside medical centers.

As the meetings progressed, Plain community patients continued to arrive at U-M from across the Midwest, as well as from Pennsylvania and Canada. Pelham, the nurse manager in Trauma Burn, saw a need to educate staff about these patients and their culture. She invited Bardwell to the hospital to give a presentation about the history and beliefs of Plain people. It drew a large audience, including staff from outside the burn unit.

These educational efforts, along with the new protocol, have already benefited patients, including Kristopher Martin, a Mennonite boy from Missouri who was burned by an outdoor trash fire in 2012. A community healer assessed the severity of the boy's burns and recommended that the parents, Kevin and Stacey Martin, request treatment at U-M.

Kristopher was initially transported by ambulance to a community hospital, where he was relatively calm and comfortable, having been treated with the B&W and burdock leaves. Because U-M's helicopter was not available, Kristopher was flown to an ABA-verified burn center in Iowa City, where he stayed two days before being taken by ambulance to Ann Arbor.

Soon after arrival at U-M, Kristopher received skin grafting to his trunk and back, the areas most badly burned. Kevin and Stacey were then allowed to treat their son's hands and face with B&W. "You can barely see that he was even burned on his face and hands," Stacey says. Reflecting on her son's 6-week hospital stay, she adds, "We really appreciate that we were even able to get into U-M and do some of Kristopher's care ourselves. That was just a really wonderful feeling that they trusted us to do that."

The meetings have also begun to lay the groundwork for a clinical trial to assess the safety and efficacy of the B&W and the burdock leaf regimen. Wang serves as the principal investigator with Amy Skyles, a U-M adjunct clinical assistant professor of pharmacy and clinical pharmacist for UMHS Research Pharmacy, serving as one of two co-investigators. Though most in the Plain community want to avoid skin grafting altogether, Skyles, who believes the meetings have helped establish expectations for care, is more measured in her hopes: "Efficacy" could mean the regimen turns out to be a good debrider, minimizing use of painful standard methods and reducing the area that needs grafting.

But hurdles remain, including determining how to standardize the ointment and leaves in order to achieve FDA approval of the study. Herbal supplements are difficult to test: Their chemical makeup varies depending on when and where harvesting occurs. Ideally, Skyles would like to buy standardized sources before compounding the B&W ointment in the pharmacy. The burdock leaves are trickier. Wang and Skyles acknowledge that the leaves work as an occlusive dressing, but the Plain community believes the leaves also contain an active component that seeps into wounds and provides pain relief. They want the leaves simmered or scalded in order to preserve the active component. These heating methods, however, do not kill all bacteria, and so may pose a risk to the patient.

If FDA approval is secured, the university will conduct an open-label pilot study to establish safety under certain parameters, including thickness of burn and the percentage of body surface area burned. U-M will partner with two community hospitals in the Thumb to recruit and treat Plain community patients. If the results are promising, further studies will follow.

These efforts may seem like baby steps, but people on both sides are committed to the project. Keim, who first developed the B&W and the burdock treatment, appreciates UMHS' efforts to care for his community. Though he would like the burdock leaves to be approved, he is prepared to first see how the ointment alone fares in a clinical trial. For his part, Wang believes in the burn unit's efforts to foster a stronger relationship with Plain community patients, one in which mutual understanding, acceptance and trust will lead them to a common ground.

"They're a very separate community," he says. "And then, every once in a while, they need our help. And how we deliver that help, I think, tells everything about us as a society of caretakers."