Culture, Health and Disease

Social and cultural influences on health programmes in developing countries

Margaret Read

• Publisher: Routledge
• Year: 2013
• Print ISBN:
  9780415264303
• eBook ISBN:
  9781136428166
• Topic: Medicine
• Subtopic: Health Care Delivery

Tavistock Press was established as a co-operative venture between the Tavistock Institute and Routledge & Kegan Paul (RKP) in the 1950s to produce a series of major contributions across the social sciences.
This volume is part of a 2001 reissue of a selection of those important works which have since gone out of print, or are difficult to locate. Published by Routledge, 112 volumes in total are being brought together under the name The International Behavioural and Social Sciences Library: Classics from the Tavistock Press.
Reproduced here in facsimile, this volume was originally published in 1966 and is available individually. The collection is also available in a number of themed mini-sets of between 5 and 13 volumes, or as a complete collection.

PART I

Traditional systems of care in sickness

CHAPTER 1

Survival studies and health hazards

TECHNIQUES FOR SURVIVAL IN A HARSH ENVIRONMENT

Around the beginning of this century, some of the early anthropologists studied the aborigines in Central Australia, and discovered a relationship between their social organization, their food quest, and their religious ritual. These small aboriginal bands wrested a living from an unpropitious environment through hunting and through collecting grubs and roots. They built up what they regarded as a measure of security through rituals which linked each band to an area and to the possible food to be found there, and ensured continuity and preservation through a system of seasonal ceremonies and taboos. The food quest was of such vital importance to the aboriginal population that all their life was organized around it; and measures of severe social discipline were enforced in the small communities to ensure that no one individual exploited the scarce resources so as to deprive his fellows of the necessary food for keeping alive.

Archaeological evidence has shown that the Eskimo in his Arctic habitat has survived for more than 2,000 years with a material culture and manner of living which were common to many small groups. The similarity of their language and non-material culture suggests that these groups may have been in touch with each other from time to time, and able to move from one locality to another, as the quest for food demanded.

Before western nations pushed into the Arctic and made certain demands upon the local people and their environment, the Eskimo found his food, clothing, shelter, light, fuel, and medicines in that environment. In a paper on survival problems of American Arctic populations Dr Margaret Lantis lists the techniques which were used by the Eskimo to assure a food supply. Besides moving in a seasonal pattern within a defined area, the Eskimo had

‘a remarkable range of techniques for storing food: for example, dried, frozen, kept frozen or unfrozen in containers made of whole sealskin, animal stomach or other pouch, in stone, wood or pottery vessel … or in a pit in the ground. Food was placed on racks, in wooden storehouses, in ice caves, or in the house itself. Besides mammals, the birds and their eggs, fish and their eggs, greens, roots and berries, shell fish, octopus (in the Aleutians), and crustaceans were eaten if their presence was known; and there were customary methods of storing most of them … Recognizing food was one of the adaptive skills of a frontier people’ (Lantis, 1957, p. 125).

Studies of health conditions among the Somali in the arid region of north-east Africa bring out the rigours of a nomadic life for people dependent on their herds and the need to find pasture and water for them. The perpetual search for water governs their migrations, regulated by those watering places where there is a permanent supply, and now by the additional cisterns or tanks that are being built, to which water is carried in trucks. Food for humans is always short, though there is a strong belief that milk, the chief element in their diet, is the only food that can sustain life by itself. Among the women there is a high fertility rate, but there is also a high rate of infant mortality. In a report on a study of heart disease among Somali tribesmen (WHO, 1963a), doctors in the capital of Somalia tried to establish a relationship between the diet, consisting almost entirely of camel’s milk, and the extreme rarity of atherosclerotic conditions. They concluded that, in spite of the simplicity and monotony of the diet, physical development is good and shows a remarkable power of resistance to hard and demanding living conditions. They also considered that the people live in accordance with century-old custom, and are emotionally balanced and free from nervous tension because their way of living is closely adapted to the surrounding conditions, into which they were born and in which they will remain all their lives.

There are certain conclusions to be drawn from this brief look at survival in harsh and isolated environments. First, the people learned to adjust their forms of livelihood to the limitations of their surroundings, in which their basic needs for food, shelter, and care for their health had to be met; second, the people were organized in relatively small groups, and so preserved their mobility in search of food and water; third, they accepted the rigours of their life and believed in the value of establishing harmony with their environment through rituals and ceremonies.

SOME TYPICAL ENVIRONMENTAL HAZARDS

Most tropical areas illustrate the hazards to people’s health arising from the contamination or shortage of water; from the scarcity or imbalance of food supplies; and from infections and infestations arising from the environment.

Water shortage

In the French-speaking Soudan the outstanding need is for an international project to ensure

‘improved rural water supplies in the campaign against contact diseases, particularly yaws, endemic syphilis and leprosy. It may seem a mere flight of fancy to envisage a copious (not necessarily purified) water supply in every village of the Soudan. But no other public health project can compare with this in value. The water exists, in rivers, swamps and underground: all that is needed is the money and the engineers to carry it to human settlements’ (Waddy, 1962, p. 108).

Food shortage

In rural areas poorer families always have a difficult choice in deciding how to spend their small amount of cash. In a South India nutrition survey (Someswara Rao et al., 1959) 79 per cent of the rural families had incomes of Rs 50 and under per month. Eighty-two per cent of these families had cases of marasmus or protein-calorie deficiency conditions in their children. Their habitual diet of cooked cereals, eaten once or at most twice daily, with vegetables added sometimes only twice a week, could have been augmented by milk from their own cow or buffalo. But 90 per cent of the milk produced in these households was sold for cash needed for essential purchases.

Environmental diseases

A constant challenge to human health in the tropics comes from the diseases that arise from the biological environment of human settlements. One of the papers at the IUHE conference mentioned in the Preface described the malaria-eradication service in Ethiopia (Zelleke, 1962). Here, the basic reason for the underdevelopment of fertile areas was the existence of malaria, since 60 per cent of the land surface, most of it fertile valleys and plains, was actually or potentially malarious. Three pilot projects with their extensions had resulted in some 500,000 people, as well as new settlers in improved land areas, now living well protected from malaria. In Viet Nam a malaria-eradication team found that the women and children went to live on the rice fields to protect the crops until the harvest was over. An examination of the children showed that those living in the villages where the houses had been sprayed had a spleen rate of 4.7 and a parasite rate of 6; whereas the children living on the fields had comparable rates of 80 and 55. Here, obviously, the malaria-eradication programme would have to include spraying the temporary huts on the rice fields in order to adapt the programme to the necessary migration of the people from the village sites to protect their food supply. The same kind of situation was found to exist in Ceylon, Burma, and Thailand.

In parts of Africa, human sleeping sickness is still an environmental menace, and its control demands perpetual vigilance:

‘Human sleeping sickness … is a disease of very slow onset. Often there is an interval of two years between infection and the onset of symptoms: during all this period the unwitting sufferer carries trypanosomes in his blood and is infectious to vector tsetse flies. Africans are great travellers, without respect for the frontiers elaborated by nineteenth, and now twentieth, century politics, and sleeping sickness is spread by human carriers. The vector tsetses require a humid microclimate. In the dry zones they exist only in very close proximity to water; since everyone uses the same river crossings and waterholes, man-fly contact is perfect, and an infected traveller can start a chain of epidemics along his route. Even if the treatment, and where to get it, are well known, only a small proportion of sleeping sickness victims find their way to a hospital or treatment centre, and this is therefore a disease that can wipe out entire populations’ (Waddy, 1962).

Another environmental disease with an intermediate host – a snail – associated with water is schistosomiasis or bilharziasis. It is recognized as second in importance to malaria as a parasitic disease, and hence is a major public health problem wherever it occurs. It has a high incidence in younger age groups, since children become infected from two years on, and it affects both their physical and mental development. It diminishes the productive power and physical strength of adults and saps resistance to other infections. As an increasing environmental health hazard it is closely connected with opening up more cultivatable land through irrigation, as in Egypt, where the disease has existed in the Nile Valley for centuries:

‘With the existing pattern of rural life in Egypt, contact with snail-infested water is not only highly probable but more often than not inevitable. Very early in life, children accompany their mothers to canals for domestic activities. They are fond of playing in shallow water. At school age, rural children take to swimming in canals as a main summer entertainment practice. Later on, rural life practices bring the people to canals for irrigation, fishing, bathing animals, washing, filling jars, washing crops, and for many other domestic and occupational purposes.’¹

The fly, Simulium damnosum, the cause of onchocerciasis or ‘river blindness’, is another environmental enemy to man:

‘The effects of onchocerciasis in a hyperendemic area include high rates of blindness affecting chiefly the adult males in their prime, who should be forming the labour force; also pruritis of such severity as to lead to suicide…. There is no doubt that hyperendemic onchocerciasis and its diabolic little vector cause retreat from the river valleys with which it is associated….

‘Consider the fate of a placid, fertile river valley in the African savannah, after a primitive agricultural community settles in it. Primitive farming, with its technique of grass-burning, inevitably leads to soil erosion. As soil erosion starts, the run-off of rainwater into the river becomes more precipitate, rocks start to appear, and Simulium damnosum starts to breed on a large scale. The combination of soil erosion and the Simulium nuisance causes a human retreat from the river, and so the process of creating soil erosion and new Simulium breeding grounds is carried further and further up the watershed until the whole valley is depopulated and eroded’ (Waddy, 1962, pp. 103–4).

TRADITIONAL RESPONSES TO ILL HEALTH

Hazards to health exist everywhere. Some are man made, as the ‘smog’ in urban centres. Others arise from biological and physical environments hitherto unconquered. They range from extremes of heat or cold or lack of water to local infestations and infections which modern science is slowly discovering how to control. In most tropical areas health hazards loom large in the lives of the inhabitants and take a heavy toll in death and disability. The populations of these areas have developed some degree of self-reliance, and have endeavoured to use their empirical knowledge acquired by trial and error to cope with the heavy rates of sickness and death.

To deal with this burden of recurrent sickness, they have built up systems of folk medicine and traditional care for the sick. Health personnel working in these areas sooner or later discover the existence of folk medicine, and observing certain ineffective manifestations of its practice they are inclined to be scornful of its remedies. As a rule it appears to them as a series of odd ‘customs’, and they are at a loss to relate one ‘custom’ to another, or to understand the reasoning that motivates certain actions and underlies firmly held beliefs. These beliefs and practices often endure in spite of the availability of modern medical care, which is accepted in many areas where rural people have learned to welcome its successful curative services.

Social scientists have studied ways of analysing these traditional systems, so that they can be understood not as a collection of customs with no coherent meaning, but as complexes of social relationships and cultural patterns of behaviour and thought. There appear to be three basic elements in these systems of traditional aid in sickness:

1. The social structure and social organization of the people, from which arise the nature and degree of the mutual dependence of individuals in sickness and in health, in childhood and in age, and their respect for and dependence on those who are recognized as possessing certain traditional skills as healers.

2. The methods of treatment in sickness and the measures taken to prevent and ward off accidents and illness.

3. The concepts of the natural and the supernatural world, which give people some basis for their beliefs about the onset of sickness, the likelihood of cure, and the preservation of health.

¹ Personal communication.

CHAPTER 2

Role of the kin group in illness

As medical care and modern public health programmes reach out in effective and permanent units to the remoter rural areas, the problems of the health personnel who work in these rural units emerge, and appear to be far more complicated than those encountered in urban centres. There, advice and treatment are given in clinics and hospitals to which patients have come voluntarily and where they are, at least physically, under the control of the professional health personnel. The health worker in a rural area becomes aware, perhaps for the first time, of the existence of another ‘medical care’ system based on ideas about the causes and treatment of disease evolved over long years of experience by the people in terms of their environment, their pattern of living, and their beliefs about human, environmental, and supernatural relationships.

Let us suppose that the health worker is able to visit the villages and people’s homes and extend his knowledge at present limited to seeing patients in the setting of the health centre or mobile clinic. Careful observation and some discreet questioning will show that, in a village, when a person is taken ill, he turns to people related to him who live in the same household or in nearby households. These may consult other relations in the village, and in the wider group of kin who live in neighbouring settlements. What is the role of this narrower or wider kin group in relation to the sick person?

The first thing the kinsfolk do is to take notice of the illness, take care of and comfort the sick person, and make him feel that he has support in his suffering. Other members of his kin group may be called in to observe the symptoms, and if these do not yield to the home remedies that are advised, they decide to call a ‘specialist’ from among the traditional practitioners. Members of the kin group are present at the consultation with the ‘specialist’, carry out whatever tre...

Table of contents

• Cover Page
• Half Title page
• series
• Title Page
• Copyright Page
• Original Title Page
• Original Copyright Page
• Contents
• Preface
• Acknowledgements
• Introduction
• Part I Traditional systems of care in sickness
• Part II Social groups, culture patterns, and health
• Part III The forward look and the backward glance
• References
• Index