Who are we to say?

20 World Health • 49th Yeor, No. 2, Morch-Aprill996 Who are we to say? Ellen M. Einterz A doctor confronted every day with the clash of different beliefs and socioeconomic pressures tries to take a balanced view to promote better understanding between professional health workers and their patients. C ommunities in rural Africa are commonly served by medical personnel who were born, raised and trained in distant parts of their multicultural country. These doctors and nurses, even if they are from the same country, may speak none of the local languages and may be familiar with few of the cultural characteristics which defme the population for whose health care they have become responsible. Judgements too hastily made- the people are ignorant, indifferent, closed to new ideas, unwilling to cooperate - may leave the medical worker deeply discouraged. In the village where I work in northern Cameroon, popular belief holds that a breast-feeding infant who imbibes the milk of a mother newly pregnant with her next child will fall gravely ill. The milk, they say, is contaminated by the fetus and infects the suckling child, causing diarrhoea, anorexia and weight loss. At the first suspicion of a new preg- nancy, therefore, a lactating mother stops breast-feeding, regardless of the age of the weanling, who, as a consequence eats less nutritiously, loses weight, suffers recurrent episodes of diarrhoea, develops kwashiorkor and subsequently dies. Knowing her child had sucked at her breast before she realized she was pregnant again, the mother under- Medica/science alone does not provide all the answers; doctors need to understand the culture and beliefs of the people they treat. stands that his early demise was to be expected. Does she understand wrong? We medical doctors have our own explanation. We believe that some combination of the child's basic nutritional requirements was not provided, and that this deficiency set off a cascade of other problems which resulted in death. But to the mother her explanation is equally plausible. The villagers say that a tetanus baby, with his puckered face, clenched fists and flexed limbs, resembles a monkey, and that he became that way because, unknow- ingly, his father killed a monkey or his mother ate monkey meat during pregnancy. Are they wrong? Demonstration of the tetanus bacillus in a cut umbilical cord does not explain how or why the germ got there in the first place, or why it should "cause" this sickness. In this context it can be difficult to convince pregnant women of the need for immunization against tetanus. Fears and dangers As in many societies relatively unex- posed to modem Western thought, epileptics are believed to be inhab- ited by the devil. According to this view, they are not evil people, but the devil , having wormed its way inside them, causes them to flail about from time to time. A grand mal seizure can be a frightening thing for anyone anywhere to witness, and neurolo- gists will admit that altered elec- World Health • 49th Yeor, No. 2, Morch-Aprill996 troencephalogram patterns are a result, not a cause, of the problem. Infertility is still disastrous for women in many parts of the world, including most African societies. A woman who fails to conceive is less likely than others to be able to settle into a successful marriage. Women who deliver children who all subse- quently die do not suffer a similar fate. Infertility, not childlessness, provokes the stigma. Conveniently, people accept that some women can conceive and remain pregnant with- out delivering for many years. Such women continue to menstruate regu- larly and do not alter their abdominal girth as they and their husbands wait patiently for the baby to grow and get ready to come out. The women explain that they can feel the child moving inside them and sense sin- cerely that aU is well, only slow. One night a young man who did not know I only practised "Western" medicine appeared at my door in a state of pain and agitation. He had just been bitten by a snake, which he had killed and wrapped in an old black plastic bag tied with grass. He unwrapped it for me and I recognized the deadly Echis carinatus. I told him that hospitalization and injec- tions of antivenin would be required. He told me that he was to be married one week from that night; the snakebite therefore could not have been an accident. Someone or some spirit had cursed him and only some- one who knew how to lift the curse could save him; aU the antivenin in the world would be of no avail. He left in search of a marabout (holy man), and did not come back. He died on what was to have been his wedding day, the curse evidently unlifted. Occasionally a snakebite victim dies in spite of what would ordinarily be considered adequate treatment. Other patients with other illnesses also occasionally die inex- plicably, in defiance of medical logic. Is it then surprising that peo- ple believe there are spirits to ap- pease, curses to counter, sacrifices to offer? In some societies it is thought that there is a sort of beetle, a fat brown bug with a slow clunky walk, that bites some breast-feeding women and causes mastitis, they say. Generally the women don't know they've been bitten until the pain starts in the breast. The same bug in the same way causes orchitis (in- flammation of the testicles) in men. And in children, it causes the swollen feet of kwashiorkor. I don't hold to the bug theory, but I have no better explanation for why some breast- feeding women get mastitis while others don't, or why only some men get orchitis or why only some mal- nourished children become so swollen. Must differing explanations impede health care? Parents who do not want their baby to suffer the disastrous consequences of drinking the milk of a pregnant mother are more likely to delay conceiving until the child in arms is weaned. A health worker would advise no differently. Though it may be difficult for some to imagine disgruntled spirits send- ing snakes to do their bidding, it is not so difficult to understand well- ness as a state of being in harmony with one's self, one's community and one 's environment. Monkeys may not transmit tetanus by being eaten, but they are involved in the transmis- sion of yellow fever and other lethal 21 viruses, so that avoidance of unnec- essary interaction with them is prob- ably not a bad idea. To outsiders, the tangle of truths, half-truths, superstitions and un- knowns that make up any culture can be like a jungle. Effective health workers learn to tread gently, open- ing new paths through the jungle without trampling flowers or top- pling trees. Few of those, after all, are real obstacles, and experienced trekkers understand that as new saplings take root and new flowers bloom, there will be time enough to prune old branches. The essential task is to proceed with open eyes, unblinded by bias, and to be prepared to take the long way around, should some cultural barrier demand a detour. • Or Ellen M. Einterz is District Medical Officer at the District Hospital and Public Health Service for the District of Kolofata. Her address is Hopital de District de Kolofata, B.P. 111 , Mora, Extreme-Nord, Cameroan. A maternity centre in Ben in. In many parts of the world, women can only achieve social status through getting pregnant.