|Oral Rehydration Therapy and the Control of Diarrheal Diseases (Peace Corps, 1985, 566 p.)|
|Module Five: Working with the community|
|Session 13 - The impact of culture on diarrhea|
DR. MARILYN NATIONS
Assistant Professor of Internal Medicine/Anthropology
University of Virgina Medical School
Division of Geographic Medicine
In northeastern Brazil, infant mortality from diarrhea and dehydration is an among the highest in Latin America. It is estimated that 159 out of 1,000 children born in urban northeast Brazil die before their first birthday,1 with diarrhea as the primary or contributing cause of death in 54% of the cases.2 And, because unrecorded early deaths are common. particularly in rural areas of Brazil, actual childhood fatalities most certainly climb even higher. Regardless of which statistics are cited, it is fair to say that in this arid region gastrointestinal illnesses take an enormous toll on infant lives, resulting in immeasurable losses for poor Brazilian families.
Faced with the serious and direct threat diarrhea and dehydration pose for infant survival, it is not surprising that natures throughout the world have evolved their own locally adapted healing systems to help them combat this major child health problem. I will first discuss the elaborate traditional medicine system in northeastern Brazil as it relates specifically to enteric diseases. Next, I will show how these longstanding indigenous health approaches are rapidly changing, sometimes for the worse, with the recent widespread introduction of biomedicine in northeastern Brazil. Finally, I will discuss the implications of traditional healing for the delivery of primary medical services, particularly oral rehydration therapy and related diarrheal diseases control interventions.
This exercise is important if we are to increase the understanding between the people who struggle with diarrheal illness and death on the one hand, and health professionals who aim to treat and prevent it on the other. Confronted with data that document the existence of radically different view points pertaining to childhood illness, we can appreciate restore fully the important role human culture plays in shaping the diarrheal episode. That other health ideas and healing ways exist and are embraced by countless poor families living in rural and serve urban areas in developing countries will hopefully aid health profession to move beyond their own explanatory models of disease,3 including enteric infections. This awareness hopefully will stimulate a reassessment of the limitations and strengths of the biomedical approach to diarrheal diseases and lead to the development of culture-sensitive approaches to control which skillfully articulate the biomedical and popular spheres of care.
The research was carried out from July 1979 to June 1980 with a three-month follow-up in 1981 in Pacatuba, a rural town with a population of about 7,000 in the Brazilian northeast, about thirty-two kilometers from Fortaleza, the state capital. Field observations were occasionally extended beyond Pacatuba; I accompanied village mothers and their sick children to the Marieta Calas Rehydration Center and to a number of hospitals located in the capital when necessary. When I utilized quantitative methods, such as formal questionnaires, medicinal plant collection and botanical identification, and recording of diarrheal illness episodes in children, I relied most heavily upon qualitative anthropological techniques including participant-observation and informal, open-ended interviews with key informants, particularly traditional healers. To the extent possible, I participated actively in the lives of village families in order to understand what diarrhea meant to them. I saw, in a sense, childhood diarrhea and death through the eyes of a village mother by participating fully in the women's sphere of village life. I learned by involving myself and my family directly in the lives of Brazilian peasants plagued by this ubiquitous threat.
The role of traditional medicine in diarrheal diseases
Diarrhea is an illness of poverty in Pacatuba; it flourishes among the poorest village families with low incomes, faulty nutrition, poor living conditions, and inadequate clean water supplies. Their infants, ages seven to twelve months; are at highest risk for both the most total days and episodes of diarrhea, which climbs on average to a staggering fifty days, or over nine episodes, per person per year.4 To cure their ailing children, poor village parents in northeast Brazil for hundreds of years have relied solely on their own folk medical wisdom. Ancestors borrowed many of these healing ways from Dutch and Portugese colonizers and the West African slaves they captured and brought with them. Other medical beliefs and practices evolved as direct responses to specific illnesses and environmental conditions in Pacatuba. Through trial and error experimentation, people developed their own explanations about the causes of illness, diagnostic techniques, therapeutic practices, a pharmacopeia, preventive strategies, and carefully selected healers to assist them with major health problems, such as diarrhea and dehydration. Enhanced childhood survival, perhaps, reinforced the continued use, generation after generation, of a large number of these popular medical practices.
Traditionally at least three types of indigenous healers treated children with enteric infections: the rezdaira or rezador (prayers); the raizeiro (herbalist); and the Mae de Santo (voodoo healer). These "doctors of the poor", however, differ significantly in their training, powers, and healing ways. Rezadeiras (-dors), the most common type of lay healer in Pacatuba, are deeply religious women and men who are endowed with the power to heal from God, a special healing force that they inherit either directly from the deity or from an elderly folk healer shortly before his/her death. Because most rezadeiras are illiterate, they must learn healing skills not from books, but from their mothers. fathers, or elderly neighbors; they imitate a practicing healer with whom they associate, watching, reciting prayers, and learning, to prepare home remedies under the expert eye of their mentor. Unlike rezadeiras, who rely primarily on god-given healing powers, the raizeiros de-emphasize the supernatural role in illness. As herbalists, they cure with chemical substances extracted from medicinal plants and, more recently, with modern pharmaceuticals. The Mae de Santo head of the religious sect, Umbanda - a voodoo-like religious synchronization of ancient African, Brazilian, and Catholic belief - is distinguished from the other traditional healers in several important ways. As a spirit medium, she has direct contact while in trance with supernatural beings from whom she receives the power to heal. This voodoo healer, unlike the prayers or herbalists, also has the power to cause harm in the form of sickness and even death. Because of her tremendous supernatural power, flirtation with the underworld, and demands for food and money offering, she is feared, respected, kept at a social distance, and often unacceptable to more pious clients.
These healers' skills are in particular demand by village parents, since according to popular thought diarrhea and dehydration are symptoms of a number of folk-defined illnesses including evil eve (guebranto mau olhado) fright disease (susto) spirit intrusion (sombra, encosto) intestinal heat (quintura do intestino) and fallen fontanelle (caida da moliera). An envious glance at a beautiful child by neighbors. friends. or strangers; a sudden, unexpected fright from, say, a passing train or barking dog; intrusion of a dead person's spirit into a child's body; heat that accumulates inside the intestine and upsets the hot-cold humoral equilibrium can all result in diarrhea just as a fall or blow on the head is believed to cause the child's fontanelle to sink into its skull. a signal of grave illness and almost certain death.
Healers and parents arrive as a definitive diagnosis by recalling recent social events believed to trigger diarrhea and noting the child's symptoms and the consistency, color and smell of his stool.
The course of treatment, although quite foreign to most Western medical professionals, follows logically from this popular diagnosis: the appropriate healer is sought among available alternatives, standard confirmatory techniques are used; and, finally, rituals and treatment are directed at ameliorating the folk-assigned cause of illness. The evil eve. for instance, is drawn out of the child's body by passing three leaves over the victim's body whit' praying. The evil enters the large, fragile leaves. which will quickly; and the rezadeira, careful not to spill their evil contents, flings them out an open window. The evil disease forces, including diarrhea, are thought to disappear with the leaves, leaving the child's body "clean" and disease-free. In the case of fright disease, the header must lift and realign the dislocated internal body parts that have fallen out of place with a sudden start in order to stop the diarrhea. This the healer does by reciting a verse and then lifting the infant's buttocks and hitting them lightly three times. When a child has been possessed by a spirit, the healer must talk to and negotiate with the spirit an acceptable payment of food, candles, or money in order to appease it and coax it out of the child's body. For intestinal heat. the healer (often the herbalist or parent) must re- establish the child's humoral balance by counteracting :he excessive heat with "cold" remedies, foods, or baths, and in extreme cases the "heat" must be flushed out of the body by frequent purges - therapies based on the Greek Principle of Opposition described by Hippocrates.5 Lastly, to effect a cure for a sunken fontanelle, the healer attempts to raise it to its original position by holding the child upside down by its ankles and tapping the stoles of its feet or by pulling the infant's hair upward and pushing on the hard palate.
To prevent childhood illness, specific prayers, amulets, and behavioral strategies were advised for each folk illness But the best protection against infant diarrhea was the traditional pattern of prolonged breastfeeding. Mothers almost always initiated the vital flow of milk without complication shortly after birth. After establishing a milk supply, they continued nursing - the only source of the infant's nutrition - for about the first six to twelve months of life. Even after this, village mothers supplied a significant but diminishing amount of breastmilk for several more years. That breastfeeding played a critical role for infant health in Pacatuba's past is evident from the number of folk medical practice evolved, such as the forty-day resting-in period (resquardo) high caloric and protein-rich postpartum diets, and wide use of plant galactagogues to stimulate milk flow, to insure that mothers not only initiated but continued lactating.
Prolonged breastfeeding did not, of course, sweet all infant diarrhea; the sources of infection were everywhere. Parents in Pacatuba, like members of other peasant communities, were able to draw upon an extensive herbal pharmacopoeia in time of illness. Local healers identified some twenty-one plant remedies they routinely used to treat childhood diarrhea, of which fifteen were identified by Brazilian botanists. A computerized search revealed that of these fifteen, eleven have been recognized by medical researchers as specific to some aspect of gastroenteritis. Specifically, these plants possess amebacidal, anticholinergic, antihelminthic, antibacterial, or antiviral qualities and perhaps, in the case of coconut water act as an oral rehydration.
The impact of modern medicine on traditional practices.
The traditional health beliefs and practices described above, however, are not static; they are being rapidly modified as modernization sweeps through Brazil and biomedicine makes in-roads into the northeast. Western-style hospitals, rehydration centers, medical schools, and special clinics increasingly provide health care in major cities and, to a more limited extent, in rural communities, such as Pacatuba. Clearly, rural families stand to profit from modern medical miracles: antibiotics that cure tuberculosis, meningitis, and pneumonia, and vaccinations that prevent polio, diphtheria, and measles. However, modern medicine's effect on the rural poor is paradoxical. While sophisticated technology exists; it is often ill-adapted to rural conditions inaccessible, and unable to effectively treat diarrhea, Pacatuba's commonest childhood ailment. Moreover, beneficial traditional medical strategies are often not recognized until they have been completely undermined.
For example, despite increasing numbers of modern health professionals in the northeast, they remain concentrated in distant cities, are expensive and often are removed socially from the culture of their poor rural patients. Instead, we learned from analysis of forty illness episodes that diarrhea in poor homes continues to be resolved for the most part, using local resources. Mothers were the first to diagnose and treat their children with a wide variety of herbal remedies shortly after symptoms appeared only a mean of 0.6 days into the episode; the mother then administered over-the-counter pharmaceuticals, on hand or borrowed. After 1.2 days, families consulted traditional healers. Shortly after beginning of the local ceremony. 2.7 days after onset, parents consulted pharmacy attendants to purchase additional drugs. But not until over eight days elapsed, when dehydration was obvious, did a small number of families consult local physicians; rehydration centers and hospitals, if resorted to at all, were not sought until 9.6 and 12.5 days, respectively, when the chances of severe dehydration are marked.6 That traditional healers continue to play a significant role in the early management of diarrhea! illnesses, even in the face of modern medicine, became apparent in our subsequent study of sixty-two infants admitted to an intravenous rehydration center in Fortaleza7: 57 (91.9%) infants had already been treated by indigenous healers for a number of folk illnesses prior to admission. Moreover using standard microbiological culture and bioassay methods, we determined that these common folk illnesses treated by healers were associated with enteric pathogens such as enterotoxigenic E. coli (ST and LT) (24.5%), rotavirus (10.5%), Campylobacter fetus subsp. jejuni (3.5%), and Entamoeba histolytica (1.8%).
Besides the introduction of new healers, modern disease etiologies such as "enterite" and "microbes" are occasionally referred to by village mothers, yet the poorest parents continue to define diarrhea in folk-disease terms and believe that the underlying cause, often supernatural, must be tended by indigenous healers. By no means, however, does this belief keep them from simultaneously seeking help from doctors for the same or different problems. Similarly, the traditional practice of prolonged breastfeeding is being dramatically replaced by bottle-feeding; we have reported sharp declines in both the total numbers of Pacatuba's women initiating breastfeeding and the length of time they lactate, trends most apparent among wealthier village women, but also occurring among the poorest women since 1964. This modification of traditional preventive wisdom has had a significant detrimental impact on children's health, since we have also shown that a bottle-fed infant in Pacatuba suffers twelve times more days of diarrhea than an exclusively breastfed infant. Finally, parents are increasingly looking away from their sweetened herbal teas for therapy towards an almost limitless number of modern "anti-diarrheal" drugs. These include antibiotics like chloramphenicol and tetracycline, cathartics, antimotility agents, and pectin-containing antidiarrheals, the majority of which have been judged by the World Health Organization to be ineffective, unindicated, or, indeed, harmful.
Implications for diarrheal diseases control programs
These insights from Pacatuba impressed on our minds two important facts. First, whether health professionals recognize it or not, villagers do not exist in a health care vacuum. Quite the contrary: they have their own health care system, based on tradition, with deeply ingrained and culturally shared illnesses. beliefs, and practices relating to enteric diseases. Secondly, village parents nowadays no longer solely depend on folk-healing ways, but are eclectic in their help-seeking, behavior and readily integrate biomedicine when needed. As a consequence of these discoveries, we became convinced that what was needed was an innovative approach to diarrhea! diseases control, a health delivery strategy that would build on the strengths of the existing indigenous system while at the same time incorporating effective modern therapy.
Fortunately, there now exists a simple, safe, inexpensive, and effective medical therapy to treat diarrhea, regardless of its specific etiology: oral rehydration therapy. By simply drinking a solution of water sugar, and salts to replace the water and salt lost by the body during diarrhea, countless lives can be saved from diarrhea and dehydration. Although the solution advocated by WHO is judged most effective in rehydrating children, even simple table salt and sugar or cereal-based solutions made from rice water— readily available in rural village homes—are effective rehydrants. Despite the overwhelming acclaims for ORT in reducing infant mortality, getting the solution and methods to poor families most in need remains a major problem.
Our answer to the problem of accessibility has been to design an alternative oral rehydration program that mobilizes traditional healers, integrates ORT into the traditional healing ceremonies, and builds referral networks that link healers to community-based hospital care for children judged to be at high risk. By spoon-feeding ORT as a supplement to medicinal teas and in the context of healing rituals, healers working together with and instructing village mothers can treat most diarrhea without ever resorting to outside help. When properly approached, we have found healers interested in ORT or any modern method that works, as long; as it can be easily incorporated without destroying their own medical tradition. Government officials have also given their tentative support, pending evaluation, to this lay-healing initiative on the grounds that the quality of health care would not be compromised when incorporated into the national health care delivery system.
While collaboration with traditional healers for the delivery of ORT and other primary health care services presents several problems, such as their practice of potentially harmful folk treatments (also present in modern diarrheal management), low literacy, and resistance from medical professionals, to name a few, we believe these can be overcome with creative approaches. The advantages of recognizing traditional healers as ideal providers of village-based ORT far outweigh these problems. from our viewpoint: they are already there, provide good coverage of poor children, are sought early in the course of illness; are trusted by village mothers; speak the same illness language; recognize clinical symptoms associated with diarrhea and dehydration even though they may call them by different names; and prepare accurate ORT, a skill we attribute to their life-long experience in preparing traditional remedies. In addition, indigenous practitioners follow up children during the three- to nine-day healing ritual and, perhaps most important, strongly advocate preventive breastfeeding.
In conclusion, if we take seriously the challenge of providing basic health care to all people within the next twenty years, it is time we look beyond hospital-based strategies to creative new delivery schemes. Traditional healers have been recognized by numerous social scientists to be critical providers of health care for many so-called hard-to-reach populations. And a number of international agencies, such as WHO. have also recently recognized their important contributions to world health: USAID and The World Rural Medical Association issued policy statements in favor of delivery strategies that incorporate traditional healers in 1979 and 1980, respectively. An alternative traditional healer-centered program, at least in the case of diarrhea! diseases control, offers great potential for the delivery of care that not only reaches poor families, but is also medically sound and culturally appropriate.
1. Dra. Maria Auxiliadora de Sousa, Professor of Social Medicine, Federal University of CeEara, Fortaleza, Brazil, personal communication, June 9, 1983
2. Puffer, P. R., Serrano, C. V. Patterns of mortality in children. Washington, D.C.: PAHO No. 262, 1973.
3. Kleinman, A, Eisenberg, L., Good, B. "Culture, illness and care: clinical lessons from anthropologic and cross-cultural research." Ann.lnt.Med. 8 (1978):251 -8.
4. Shields, D. S.; Kirchhoff, L. O.; Sauer, K. T. Nations, M. K.; Araujo, J. G.; de Sousa, M. A.; Guerrant, R. L. Prospective studies of diarrheal illnesses in Northeast Brazil: patterns of disease, etiologies and risk factors. Presented at ICAAC Meetings, Miami Beach, Florida, October 1982.
5. Chadwick, J., Mann, W.N., eds. The Medical Works of Hippocrates: A New Translation from the Original Greek Made Especially for English Readers by the Collaboration of John Chadwick M.A.. and W. N. Mann, M.D. Oxford: Blackwell Scientific Publications, 1950.
6. Nations, M. K. Illness of the child: the cultural context of childhood diarrhea in Northeast Brazil. Berkeley, California: Department of Anthropology, 1982 (dissertation).
(From: ICORT Proceedings. pp. 48-51)