Mystification of a simple solution: oral rehydration therapy in northeast Brazil.

Problems in the control of access to and administration of oral rehydration therapy (ORT) in Northeast Brazil are described and discussed. Administration of ORT is controlled by the medical establishment, which is in general opposed to the use of home made and home administered ORT. Reasons for this resistance are discussed in terms of anthropological theories on ritual, mystification, and the social construction of reality; the medical establishment is described as using ORT as a symbol and guarantor of social status and power. Finally, an innovative program to circumvent the medical establishment by teaching ORT to traditional healers is described; the healers' integration of ORT into religious healing ceremonies is analyzed.

"I'm not dog, no!": cries of resistance against cholera control campaigns.

Popular reactions toward government efforts to control the recent cholera epidemic in Northeast Brazil are evaluated. Intensive ethnographic interviews and participant-observation in two urban slums (favelas), reveal a high level of resistance on the part of impoverished residents towards official cholera control interventions and mass media campaigns. "Non-compliance" with recommended regimens is described more as a revolt against accusatory attitudes and actions of the elite than as an outright rejection of care by the poor. "Hidden transcripts" about "The Dog's Disease," as cholera is popularly called, voices a history of social and economic inequity and domination in Northeast Brazil. Here, cholera is encumbered by the trappings of metaphor. Two lurid cultural stereotypes, pessoa imunda (filthy, dirty person) and vira lata (stray mutt dog) are used, it is believed, to equate the poor with cholera. The morally disgracing and disempowering imagery of cholera is used to blame and punish the poor and to collectively taint and separate their communities from wealthy neighborhoods. The authors argue that metaphoric trappings have tragic consequences: they deform the experience of having cholera and inhibit the sick and dying from seeking treatment early enough. Controlling cholera requires eliminating "blaming the victim" rhetoric while attacking the social roots of cholera: poverty, low earning power, female illiteracy, sexism, lack of basic sanitation and clean water supplies, medical hegemony, etc. For health interventions to be effective, it is necessary to take into account people's "hidden transcripts" when designing action programs.

'Nerves': folk idiom for anxiety and depression?

This study suggests that 'nerves' as presented in a primary care clinic is a lay idiom for emotional distress and documents a relationship between the folk ailment 'nerves' and anxiety and depression. One hundred and forty-nine patients at a Virginia clinic were studied, 47 with 'nerves', and 102 controls. Testing with the General Health Questionnaire (GHQ) and the Beck Depression Inventory (BDI) showed 'nerves' patients to be more anxious and depressed than controls. 'Nerves' patients had a mean GHQ score of 13.0 compared to 5.8 for controls (P less than 0.0001) and a BDI score of 7.6 compared to 2.5 for controls (P less than 0.0001). Testing with the Holmes-Rahe Social Readjustment Rating Scale showed 'nerves' patients to suffer more recent life stresses than controls: 'nerves' patients had a mean score of 187.1 compared to 119.3 for controls (P less than 0.05). 'Nerves' patients had somatic symptoms including gastrointestinal disturbances, headaches and shaking. 'Nerves' is most common among women and housewives, and is often attributed to misfortune and tragedy. The ethnomedical illness 'nerves' encompasses a rich array of cultural meanings reflecting the lifestyle and worldview of its sufferers. Despite its chronic debilitating nature, it is rarely recognized by physicians; it is, however, treated by alternative healers. Clinical implications are discussed and recommendations advanced, among them that physicians work with such healers in the recognition and treatment of 'nerves'.

Designing educational messages to improve weaning food hygiene practices of families living in poverty.

This paper describes a methodology to design feasible interventions to improve weaning food hygiene practices of families living in extreme poverty. Educational messages to promote specific behavioural changes were defined and tested by utilizing a combination of ethnographic, survey and observational methods, and integrating viewpoints and suggestions of mothers and caretakers into the decision-making process. This new approach culminated in a household trial in which five groups, each of 15 non-practising mothers, were invited to adopt defined behaviours (handwashing before and after defined events, boiling water for reconstituting powdered milk, feeding gruel by spoon rather than bottlefeeding, not storing gruels and milks, and all four together). All initiated the advocated behaviours and most (53-80%) sustained the new behaviours and practised them every time during a one-month period. Of the four advocated behaviours, spoon-feeding was the most difficult to adopt wholly. The methodology was developed in response to the high priority given to reducing weaning food contamination for diarrhoeal disease control, and the lack of any existing methodology for defining appropriate educational interventions in resource-poor regions. This approach, with its combination of qualitative and quantitative methods and community focus, is recommended for future studies to design hygiene and other health education interventions in developing countries.

Women's hidden transcripts about abortion in Brazil.

Two folk medical conditions, "delayed" (atrasada) and "suspended" (suspendida) menstruation, are described as perceived by poor Brazilian women in Northeast Brazil. Culturally prescribed methods to "regulate" these conditions and provoke menstrual bleeding are also described, including ingesting herbal remedies, patent drugs, and modern pharmaceuticals. The ingestion of such self-administered remedies is facilitated by the cognitive ambiguity, euphemisms, folklore, etc., which surround conception and gestation. The authors argue that the ethnomedical conditions of "delayed" and "suspended" menstruation and subsequent menstrual regulation are part of the "hidden reproductive transcript" of poor and powerless Brazilian women. Through popular culture, they voice their collective dissent to the official, public opinion about the illegality and immorality of induced abortion and the chronic lack of family planning services in Northeast Brazil. While many health professionals consider women's explanations of menstrual regulation as a "cover-up" for self-induced abortions, such popular justifications may represent either an unconscious or artful manipulation of hegemonic, anti-abortion ideology expressed in prudent, unobtrusive and veiled ways. The development of safer abortion alternatives should consider women's hidden reproductive transcripts.

Umbanda healers as effective AIDS educators: case-control study in Brazilian urban slums (favelas).

During a 12-month period (November 1994-October 1995), Afro-Brazilian Umbanda healers (Pais-de-Santo) taught 126 fellow healers from 51 Umbanda centres (terreiros) located in seven overcrowded slums (favelas) (population 104-343) in Brazil's northeast, the biomedical prevention of AIDS, including safe sex practices, avoidance of ritual blood behaviours and sterilization of cutting instruments. A face-to-face educational intervention by healers, marginalized in society yet respected by devotees, which blended traditional healing-its language, codes, symbols and images- and scientific medicine and addressed social injustices and discrimination was utilized in this project supported by the Brazilian Ministry of Health, National Program in STDs/AIDS. Significant increases (P < 0.001) in AIDS awareness, knowledge about risky HIV behaviour, information about correct condom use, and acceptance of lower-risk, alternative ritual blood practices and decreases (P < 0.001) in prejudicial attitudes related to HIV transmission were found among mobilized healers as compared to 100 untrained controls. Respected Afro-Brazilian Pais-de-Santo can be creative and effective partners in national HIV prevention programmes when they are equipped with biomedical information about AIDS.

Angels with wet wings won't fly: maternal sentiment in Brazil and the image of neglect.

Current theories of fatalism and neglect and current descriptions of childhood illness in impoverished Northeastern Brazil are evaluated. Findings of an ongoing multidisciplinary project indicate that neglect and fatalism theories are incomplete as applied to the Brazilian Northeast. Intensive interviews and observations with bereaved mothers and traditional healers show that mothers' failure to obtain medical care for severely ill children is due more to real-life bureaucratic and geographic barriers to access than to fatalistic or neglectful attitudes on the part of the poor, that mothers' flat affect in response to infant deaths is due more to folk Catholic beliefs than to lack of emotional attachment to infants, that fatalistic statements are often post hoc and do not indicate fatalistic behavior, and that decisions about whether to treat severely ill infants are made by mothers and families in consultation with traditional healers in accord with a folk system of classification of high risk infants. What have been described as "death accepting," "pathogenic," and "ethnoeugenic" attitudes are part of a folk ethical system developed to guide reactions to terminal childhood illness. We argue that human behavior, especially in the realm of health, cannot be understood without reference to both biomedical and psychosocial realities.

"Hidden" popular illnesses in primary care: residents' recognition and clinical implications.

This study documents that ethnomedical beliefs and practices play an important role in primary care in a southern community. Thirty-three of 73 patients from a rural Appalachian area coming to a university primary care internal medicine practice presented 54 ethnomedical complaints such as "high blood" (24.1%), "Weak 'n dizzy" (22.2%), "nerves" (16.7%), "sugar" (5.6%) and "fallin' out" (3.7%). Thirty-three patients had both biomedical and ethnomedical complaints, 40 patients had biomedical complaints without ethnomedical complaints and no patients presented with ethnomedical complaints alone. Over two-thirds of all patients consulted non-medical personnel for their complaints, mostly family and friends, and 70 percent self-treated prior to clinic consultation. Patients presenting with ethnomedical complaints when compared with those presenting with biomedical complaints sought advice of non-physicians significantly more often (p less than 0.02); no statistical difference, however, was found in their self-treatment practices. Ninety-two of 130 biomedical complaints were recorded by the patient's physician but none of the 54 ethnomedical complaints were formally recorded (p less than 0.001). The high incidence of ethnomedical complaints in this population and the failure of physicians to recognize these complaints demand that primary care medicine residents be taught improved history-taking skills and the essentials of ethnomedical illnesses if they are to provide culturally-sensitive patient care.

Brazilian popular healers as effective promoters of oral rehydration therapy (ORT) and related child survival strategies.

PIP: In Ceara State in northeastern Brazil in 1986 infant mortality reached 110-139 per 1000 live births, and 50% of those deaths were due to diarrhea and dehydration. Diarrheal deaths can be prevented by oral rehydration therapy (ORT), which replaces lost fluids and electrolytes with oral rehydration salts (ORS) and water. ORT was known in the 1830s, but only in the 1960s was the importance of sugar, which increases the body's ability to absorb fluid some 25 times, realized. In northeastern Brazil access to ORT has been severely limited by poverty, official incompetence, and bureaucratic restrictions. In 1984 a 2-year research project was initiated in the village of Pacatuba to test the theory that mobilizing and training popular healers in ORT would 1) increase awareness and use of ORS, 2) promote continued feeding during diarrhea, 3) increase breast feeding, and 4) reduce the use of costly and nonindicated drugs. 46 popular healers, including rezadeiras and oradores (prayers), Umbandistas (priests), espiritas (mediums), an herbalist, and a lay doctor, were recruited and trained. Most of these people practiced a mixture of folk medicine and religion and were highly respected in the community. For purposes of survey, Pacatuba was divided into 3 groups, each containing houses at 4 different income levels. The mothers in 204 Group 1 homes were interviewed concerning ORT and diarrhea-related knowledge before intervention, and 226 households in Group 2 were interviewed after intervention. The healers were taught the basic biomedical concept of rehydration and how to mix the ORS -- 7 bottle cap-fulls of sugar and 1 of salt in a liter of unsweetened traditional tea. The healers were also taught how to use the World Health Organization's (WHO) ORS packets (2% glucose, 90 mmol/1 of sodium chloride, 1.5 gm potassium chloride, and 2.9 gm sodium bicarbonate) for cases of moderate to severe dehydration. In addition, the healers were taught the 5 basic health messages: give ORS-tea for diarrhea and dehydration (or any similar folk illness, such as evil eye, fallen fontanelle), continue feeding, encourage breast feeding, eliminate drugs, and ask people to seek the healer quickly at the onset of diarrhea. The healers continued to perform all the popular rites and prayers traditionally associated with curing diarrhea. The healers distributed approximately 7400 liters of ORS-tea in 12 months at a unit cost of 48 cents (US). A post-intervention survey of diarrhea-related knowledge was then carried out among the 226 Group 2 households. Before the intervention 2.9% of the mothers knew about ORS; 71.2% did afterward. All of the healers demonstrated that they knew exactly how to mix the ORS-tea. Knowledge of the WHO packets also increased. The number of mothers who continued feeding their children during diarrhea increased to 92%. Following the introduction of the ORS-tea, purchases of the more costly WHO packets and other commercial medications and antibiotics fell off significantly. The people's belief in folk etiologies remained unchanged, showing that traditional healers can be successfully integrated into an effective health care program. The success rate of the ORT program in Pacatuba, carried out entirely by word of mouth, compares favorably with expensive mass media campaigns other places.^ieng

Prospective study of diarrheal illnesses in northeastern Brazil: patterns of disease, nutritional impact, etiologies, and risk factors.

Diarrhea is a leading cause of death in tropical countries. One of the highest childhood mortalities is in northeastern Brazil, where little is known about the morbidity, etiology, and risk factors of diarrhea. Prospective village surveillance over 30 months revealed diarrhea attack rates of more than seven episodes per child-year at six to 11 months of age among the children of the poorest families. Other risk factors included early weaning and the lack of toilets. Diarrhea led to weight loss and stunted growth. Enterotoxigenic Escherichia coli and rotaviruses were the most common pathogens, accounting for 21% and 19% of cases, respectively, followed by Shigella species (8.0%), Campylobacter jejuni (7.5%), Giardia species (6.7%), Strongyloides species (5.3%), and enteropathogenic E coli serotypes (4.6%). Most (84%) enterotoxigenic E coli were isolated during the rainy season of October to March (P less than 0.03), whereas 71% of rotaviral illnesses occurred during the drier months of June to October (P less than 0.03). In the present study, the early occurrence and nutritional impact of diarrhea and weaning, as well as the major etiologic agents of diarrhea and their different seasonal patterns have been defined for this region in which life-threatening diarrhea is endemic.