Concept of causes of disease and cure
Both in Africa and Asia, the causes of disease as under-stood by the majority of rural people fall into two groups; supernatural and physical.
The supernatural causes of diseases such as small-pox, chickenpox and measles, include the wrath of gods and goddesses. In India and neighbouring countries, such as Bangladesh and Pakistan, when a child has measles it is believed that a goddess has visited the home. The goddess has to be propitiated and no medical or other treatment is allowed, to avoid making her angry! As a result of this belief, the child with measles is kept inside the house and visitors are not allowed. The house is kept meticulously clean inside and out, and leaves of the neem tree (which have a bactericidal effect) are exhibited at the front door indicating that there is a child with measles in the house.
The child is also bathed with water that has been boiled with leaves of the neem tree. When the skin rash dries out the goddess is believed to have left the house. The child is then sent to the temple where thanksgiving and offerings are made. It is because of this practice that India became virtually the last country in South East Asia to introduce measles vaccine into its immunization programme in 1985.3
Cultural patterns and childhood diseases
The five aspects of cultural patterns that are of parti-cular and direct relevance to childhood disease are now considered.
Preparation for parenthood, mating, pregnancy and childbirth
Circumcision Female circumcision has been practised in a number of African countries but is now declining rapidly. Female circumcision has led to difficulties at delivery (because of extensively scarred external genitalia) and this may affect the newborn child.
A variety of operations, ranging from clitoridectomy to extensive mutilation of labia minora and majora of the female genitalia, have been reported. In many instances the operation is performed by non-skilled practitioners under unhygienic conditions. Serious complications such as surgical shock, bleeding, infection, tetanus and retention of urine, which may lead to death, are not uncommon.
In Sudan and Somalia, the so-called 'Pharaonic circumcision' has been practised on females. In this, the entire clitoris and labia minora and at least the anterior two-thirds of the medial part of the labia majora are removed. The two sides of the vulva are then stitched together by silk or catgut sutures (in the Sudan) or by thorns (in Somalia), thus obliterating the vaginal introitus except for a very small opening posteriorly to allow exit of urine and menstrual blood. Complete occlusion of the introitus is prevented by the insertion of a small piece of wood, usually a matchstick. 4
Early marriages and preferences for boys In India, tradi-tionally, boys and girls grow up to look upon marriage as a bond which should not be broken. This has had the effect of making Indian marriages very stable; a good positive cultural aspect which contributes to good child-care and child health development. However, in recent years there have been some suicidal maternal deaths and broken marriages because wives have been unable to settle high dowry demands from their husbands and/or from their husband's relatives. This is mainly an urban phenomenon due to a recent trend towards 'conspicuous consumerism'. This trend if left to increase will adversely affect children of suicidal mothers or broken marriages.
Early marriage has been practised within some communities in India. However, traditionally, girls who were married at a young age stayed with their parents and were allowed to join their husbands when they reached the age of puberty and slightly beyond. In recent years there has been a tendency to let married girls join their husbands before they are old enough to lead a married life. Girls below the age of 20 years who bear children tend to produce low-birth-weight babies, and indeed, 30 per cent of children born in India belong to this category. Early marriage is one cause of the high rate of low-birth-weight infants.
16 Cultural aspects of common childhood diseases
Early childhood and teenage marriages occur in several other Third World countries like Oman, Ethiopia and Sudan.4 Obvious disadvantages of child marriages include:
• high infant mortality rate;
• high incidence of low-birth-weight infants;
• early interruption of the education of girls;
• necessity of operative surgery during birth.
In Tanzania, circumcision among males and females is practised among some tribes just before marriage.
Until recently, male and female circumcision was compulsory by tribal traditions. Female circumcision is rapidly going out of fashion among educated communities in these tribes. Circumcision of males is done during childhood, particularly among the Muslim communities. Among a few tribes, however, circum-cision of males takes place when they are about to marry and is supposed to prepare young men to marry and have children. Some tribes in South Tanzania practise circumcision in the bush away from homes. Tetanus, sepsis and meningitis are the complications which await some of the circumcised young people. Those under-going circumcision also receive sex education. In North East Tanzania, specially nutritious feeds are given to circumcised males and females to make them look attractive to the opposite sex. Whereas circumcision has the possible beneficial effect of protecting males from cancer of the penis, circumcision of females (clitori-dectomy) leads to scarring of the vaginal orifice, with the later risk of obstructed labour.
Indian culture has a strong preference for boys.
Parental neglect of female children has led to higher morbidity and mortality among female infants and children than among the boys. Female infanticide, until recently, was practised among some Indian com-munities. At present, the male to female ratio in India is 1000: 935; cultural preference for boys directly contributes to this sex ratio.
Marriage among relatives Choice for mating is very important. Marriage among brothers, sisters, first and second cousins leads to a high transmission of genetic diseases. In some parts of India marriage among first cousins is practised, especially among the Muslims and Parsees. Among Muslims and South Indian Hindus, uncles and nieces marry. However, among North Indian Hindus, cousins are regarded as brothers and sisters and do not marry. Sickle-cell disease is common in Tanzania and in some tribal areas in India while {3-thalassemia is widespread in India. These two dis-eases are hereditary and if near relatives marry, the
chances of their offspring suffering from either disease will be very high.
In India and Tanzania, pregnant women are encouraged to eat less so that the child in the womb does not become too big and cause obstructed delivery. This practice may contribute to low birth weight and its associated higher mortality.
Childbirth - a dirty process Childbirth in India is regarded as a 'dirty process' in which 'dirty substances' like blood, faeces and urine are involved. Both the child and mother are 'dirty' after birth. In India, the delivery work is traditionally done by the lowest caste, the untrained birth attendant, with consequent high infant morbidity and mortality rate. In Nepal, up to 90 per cent of mothers in some areas deliver babies at home by themselves without assistance. It is also customary not to touch the mother and the baby until 40 days have elapsed after delivery. Such cultural trends have harmful effects on the newborn. In many places in India immunization cannot start earlier than three months because the baby and mother are regarded as dirty during this period and should not be touched.
This may lead to some children contracting whooping cough or tuberculosis before they receive DPT or BCG at three months.
Indigenous medical systems
In India and the neighbouring states of Sri Lanka, Bangladesh, Pakistan, Afghanistan and Nepal, tradi-tional, formal, indigenous medical systems exist beside the Western allopathic medical system. Ayurveda, U nani, Siddha, Homoeopathy and Naturopathy are medical systems that have existed in India for centuries.5 Most of these systems have training and research institutions allover the country. The Govern-ment of India manages these indigenous medical systems side by side with allopathic medicine. It is worth noting that these 'scientific' systems have a 'scientific' basis just like the Chinese acupuncture system. However, there are also other non-formal traditional systems of illness management which have a deep cultural basis but lack a scientific background.
While these practices may have some marginal bene-ficial psychological effect on the sick or may be harmless, some can be extremely harmful. Examples of such systems in India are bone-setters, herbalists, and a large group of people generally known as 'quacks'.
The indigenous traditional medical systems are well known to the people who have deep-rooted faith in them. The practitioners of these systems are found in
Traditional KAP in relation to culture and childhood diseases 17 rural as well as in urban areas (although practitioners of
allopathic medicine are mostly found in urban areas).
Most people use traditional systems of cure first, or side by side with Western medicine. The Indian govern-ment has been trying to integrate the Western and indi-genous medical systems by running two different direc-torates of these systems within the Health Ministry.
In Tanzania, the traditional healers do not have systematized, indigenous medical systems. Most of the traditional indigenous practitioners have learned their art from their parents or near-relatives. Some of their skills are useful in the field of mental health, psycho-logical problems, and chronic illnesses and some herbs have positive pharmacological effects. A recent study done by anthropologist Raimo Harjula in Tanzania6,
indicated that a local traditional medicine man managed diarrhoea in children according to the following format.
• Symptoms: toddler's diarrhoea with flatulence but without blood in stools
• Aetiology: dirty or unsuitable food
• Remedy: 'Mamiso' - a local name of a local plant (Bidens pilosah)
• Usage: the flowers of this plant are boiled and the solution is administered as the remedy - 15-20 flowers are needed for one dose taken twice a day The plant has been chemically analysed and its extracts have shown antibacterial activity against a variety of microorganisms, including five enteric pathogens. One merit of the remedy is that the child gets some sort of oral rehydrant which may be benefi-cial, although the rehydrant may not have the amount of salts required.
Each practitioner has his or her own methods. Some of their treatments have no scientific basis and are often harmless, but some can, at times, be harmful. There is a traditional healers association which is largely a trade union rather than a professional body. The Govern-ment of Tanzania has set up a research unie to study cures that might have a scientific basis and to attempt to integrate them into the national health system.
Food habits and taboos
Food habits have deep psychological roots and are associated with love, affection, warmth, self-image and social prestige. Diet is influenced by local conditions ( soil, climate) and religious customs and beliefs. Vege-tarianism is given a place of honour in Hindu society5.
Hindus (over 75 per cent of India's population) do not eat beef. Children of a pure vegetarian society do not
get access to animal protein, except milk. Animal protein is abundant in most parts of India and the cultural taboo in giving animal protein (beef) to children may contribute to iron and folate deficiency.
However, it is important to note that pure vegetaria-nism (no milk and milk products) may protect against metabolic diseases such as gout and hypercholestero-laemia. Muslims abhor pork for religious reasons. Eggs (which are excellent animal protein) are forbidden in some parts of India among pure vegetarians and among pregnant women. Women and children are forbidden to eat eggs in most African cultures, including Tanzania. Eating and drinking from common utensils is considered a sign of brotherhood among Indians and Tanzanians, but diseases such as oral and gastro-intestinal infections can be spread easily in this way.
Hindus, especially those from the South, do not eat from a common plate. They will not put their lips to a glass of water, but rather pour water into the mouth so that the glass remains clean for somebody else to use.
Men are served the best part of the food; children and women take whatever remains, usually quantitatively smaller amounts and qualitatively inferior with adverse nutritional consequences on the mother and child.
In India, high-protein foods like meat and milk are considered 'hot' foods and not given in diseases such as diarrhoea, fever and measles. Pregnant and nursing women are not given eggs, meat or even some legumes and vegetables because they are considered 'hot'. In winter, 'cold' things are eaten. Whereas milk is considered 'hot', buttermilk (which also has a high protein content) is considered 'cold' and can be given in diarrhoea.
Child-rearing practices
The cultural practices of rearing children may be classi-fied as good, harmless, uncertain and harmful. 2
Prolonged breast-feeding which is prevalent in Asia and Africa is good for infant nutrition and is an effective contraceptive in areas where family planning facilities are not available.8 The habit of abandoning breast-feeding following an episode of diarrhoea in the child (the mother's milk being pinpointed as the cause of the diarrhoea) results in more diarrhoea and increasing malnutrition (see Fig. 1.2.1.).
In India, application of oil or paste of turmeric on the anterior fontanelle is harmless. The practice of applying black soot mixed with oil to the eyelids, partly for beautification and partly warding off the effects of 'evil eye', has uncertain effects on the child which cannot yet be said to be a good or bad practice. Usually it is
18 Cultural aspects of common childhood diseases
Fig. 1.2.1 A dirty milk bottle teat used to feed an infant with artificial milk in India.
harmless medicated carbon oil, but if it contains lead could lead to poisoning (see Fig. 1.2.2).
However, certain practices in child-rearing have deleterious effects on the health of children. For example, the practice in India (and in Tanzania) of applying cow dung to the umbilicus of the newborn is a cause of annual deaths of up to a quarter of a million infants with neonatal tetanus. The practice oflate intro-duction of weaning food contributes to the prevalence of childhood malnutrition both in India and in Tanzania.
The practice ofleaving infants with younger children or of the mother taking the child to the fields, leads to the infants being fed less frequently with bad nutritional consequences. The well-known custom, in some parts of India and Tanzania, of not giving colostrum to newborns is responsible for the neonatal marasmus sometimes seen. In Tanzania, cases of neonatal marasmus have been reported as a result of the child being given only water after birth until the milk is 'clean' .
Patterns of household authority
The man is the head of the family and has absolute and final authority in the home among the major tribes in Tanzania, wives being completely subservient. This long-standing cultural pattern seems to have created an
atmosphere of relative marriage stability, ensuring stable child-care by both parents. However, among the educated and Western-oriented couples, families are run more democratically, with the wife sharing home management authority with the husband, although the husband still remains the functional head of the family.
Development of an 'anti-cultural' women's liberation movement among the educated class in Tanzania, has led to family arguments and disputes as to who should have the final say on home management. This trend seems to have led to rather unstable marriages, with adverse consequences for child-care and child health among the educated elite.
In India, the male is usually the head of the family.
However, in southern India, and elsewhere among more tribal communities, the head of the family is sometimes the female. This partly explains why, in the Kerala state of India, women are so highly literate with high status in the community. Kerala today enjoys a far lower infant mortality rate than the Government of India's goal set for the year 20001 The female family headship has contributed to this.9