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Dr Edward C. Green Senior Research Scientist in the School of Public Health, Center for Population and Development Studies, Harvard University Traditional Healers, Mothers and Childhood Diarrheal Disease in Swaziland: The Interface of Anthropology and Health Education
It is widely recognized that diarrheal diseases of infancy and childhood are a leading cause of death in less developed countries. It has also become increasingly recognized that the ultimate control of diarrheal disease depends on a comprehensive understanding of local beliefs and practices that relate positively or negatively to its transmission. Noting the importance of the mother in childhood diarrhea, the World Health Organization recently observed, "There is an urgent need to understand her present attitudes, perceptions, and practices regarding diarrhea as well as those of other community workers." Yet too often mere lip service is paid to cultural factors while actual research funds are allocated to engineering, epidemiology, biomedical research, economics, and other more conventional areas of disease control. In 1981, the United States Agency for International Development (USAID) contracted with the Academy for Educational Development to design and implement a health education program in Swaziland aimed at reducing the incidence of bilharzia and other diseases related to improper environmental sanitation or unsafe drinking water. As a resulting Rural Water-borne Disease Control (RWDC) Project developed, a shift in emphasis from bilharzia to childhood diarrhea and cholera followed a 1981 outbreak of cholera in southern Africa. The promotion of oral rehydration therapy (ORT) to prevent deaths from dehydration, particularly in cases of infant and child diarrhea, became a priority objective of the project. The Academy for Educational Development had recently accumulated considerable experience in promoting ORT in context-sensitive programs based on detailed understanding of folk nosologies, etiologies and treatment patterns, particularly in Honduras. The Mass Media and Health Practices (MMHP) Project in Honduras, begun in 1978, had achieved measurable success in promoting the adoption of ORT among rural mothers by 1982. In 1983 the present author, then anthropologist for the RWDC Project, was asked to prepare a report on what might be termed the anthropology of diarrhea in Swaziland. The report was to guide promotion of ORT in Swaziland as well as the development of health education strategies focused on childhood diarrhea. This report provides the substance of the present paper. Current policy of the Swaziland Ministry of Health accords the highest priority to combatting diarrheal diseases through a mix of strategies that gives primary emphasis to health education. ORT has been promoted in Swaziland for several years; its promotion is soon to be intensified through a special mass media campaign. The relevance of ORT in diarrheal disease is probably best expressed in the summary of a recent international conference on ORT: The experience reported at this conference unequivocably confirms that oral rehydration therapy can: reduce mortality, sometimes drastically, in communities, clinics, and hospitals; promote child growth and sound nutrition; lessen the morbidity burden; reduce hospitalization attendance, duration of stay and cost; and generate ancillary benefits such as minimizing the indiscriminate use of ineffective or harmful drugs.
The outline of this paper is as follows. After a brief description of research methods, a general description of Swazi health beliefs is presented followed by a detailed look at the three traditionally recognized forms of childhood diarrhea. Next is a discussion of factors that relate to a mother's decision as to where to take her sick child for treatment. In a concluding section, health education recommendations to the Swaziland Ministry of Health for culturally sensitive health education approaches are presented.
METHODS Aware of the pitfallls of attempting standard survey methods to elicit valid data on health beliefs and practices among a rural population, we decided to rely heavily on indigenous health practitioners as sources of information and to observe behavior first-hand whenever possible. A summary of research methods follows. First, a survey was conducted between August 1982 and January 1983, based on an open-ended questionnaire that focused on various aspects of traditional healing beliefs and practices. One hundred forty-four traditional healers of all major varieties representative of Swaziland's 4 geographic zones were interviewed. Second, systematic key informant interviewing was carried out focusing specifically on a wide range of traditional categories of illness, including those that relate to diarrheal symptoms. These interviews were conducted between May and June 1983 with 12 male and female traditional healers other than the 144 already surveyed. Third, similar interview procedures were followed focusing on beliefs an practices pertaining to diarrhea and closely related topics. Interviews were carried out during August 1983 among 14 geographically dispersed female traditional healers (not previously interviewed) and 2 traditional birth attendants. Interviewing for each of the above was carried out by th
Author and two Swazi assistants trained in qualitative research methods. Fourth, the author conducted participant-observation research and in-depth interviews with some 24 traditional healers from the original sample of 144 and a number of their patients between April 1981 and September 1983. This last approach, although by far the most time consuming, provided a necessary social and cultural context in which to interpret findings derived from the questionnaire, as well as a validity check to all self-reported information. The bulk of the information reported here derives from the second, third and fourth interview procedures. Information derived from the larger survey of healers is identified as such throughout the paper.
ETHNOMEDICAL BELIEFS IN THE CONTEXT OF CHILDHOOD DIARRHEA
Swazi health beliefs have been charactreized in a general way in an earlier paper. Suffice it to say here that for most Swazis, illness is believed to be caused by sorcery--i.e. the deliberate use of spells and medicines for harmful medicines--or less commonly by ancestral displeasure resulting in the withdrawal of spiritual protection. A relatively small number of illnesses such as colds, flu, and simple diarrhea are regarded as ordinary or naturally occurring. These are collectively known as umkhuhlane. Cutting across the categories of mystically related and naturally occurring are illnesses caused by dangers in the environment. These may be of several types. First, there may be vapors from powerful medicines that have been mixed carelessly or deliberately by a healer or by a lay person. Medicinal vapors are believed to linger for days or weeks around the spot where they were prepared or they can be blown for miles by the wind without losing their destructive potency. A common form of acute childhood diarrhea is attributed to this cause. Similarly, the traces of vapors of lightning (and to a lesser extent, thunder) are believed to linger for some time about areas where they "struck." Lightning and thunder strikes are generally believed to be deliberate acts of aggression by supernatural means. Pregnant mothers and babies are said to be particularly susceptable to thenoxious effects of such vapors. Another form of acute childhood diarrhea is attributed to these vapors. Furthermore, the environment can become polluted with evil spirits or "spirit-familiars" that have been removed from a victim by a traditional healer. Removed spirits are believed to attempt entry of any other person that happens to be in the vicinity. Overlapping the broad category of sorcery-induced illnesses are those thought to be caused by magical poisons that are hidden by one's enemies in places that a victim is likely to walk past or come in dirct contact with. The best known illness of this sort is umklwebho, which is often associated with arthritis-like symptoms, but many other symptoms and syndromes are thought to be similarly caused. "Lines" of poison are believed to be left on pathways, to the peril of intended or accidental victims who pass that way. Poisons may be placed along thresholds of latrines or even on toilet seats in order to pinpoint victims and their kin with more accuracy. Fears of this sort have been found to constrain some Swazis from building latrines. Related to the medicinal vapors mentioned above are various undesirable elements or agents (emagciwane) that are thought to be in the air and are especially associated with crowds of people, changes of seasons, and certain other situations or conditions. One explanation recorded by interviewers for the 1981 outbreak of cholera in Swaziland, as well as for other contagious diseases that especially affect children, was that an unscrupulous traditional healer deliberately "blows" noxious agents into the air in order to sicken children and thereby build up his healing practice. It is significant that in most of the foregoing examples, diseases or agents of disease are thought to travel through the air. Indeed, tifo temoya (airborne diseases) is a general term in the Swazi language denoting contagious diseases that are contracted through inhalation. In our survey of 144 traditional healers, we asked for examples of tifo temoya. Multiple responses were permitted and recorded. Thirty-eight cited evil spirits; 37 cited colds, flu or asthma; 27 cited tuberculosis (sifuba); 25 cited migraine or severe headaches (sipoliyani); 16 cited stomachache; 16 cited a type of hysteria (lihabiya) attributed to sorcery; 14 cited a type of acute psychosis (ufufunyane); 13 cited bad dreams; 11 cited diarrhea and 4 cited cholera. As will be seen in the following section, "airborne diseases" (tifo temoya) account for a much higher proportion of childhood diarrheal diseases than is suggested in answers to the preceding question. Comments accompanying the above answers from five of the respondents help illuminate the concept of airborne diseases: Tifo temoya can move by air from one area to another... You may hear old people say that there is a hot air coming from the east that will cause fever. Then after a while you will feel the fever.... Some tifo temoya are when the seasons change and you get the flue.... They are infectious diseases caused by witchcraft and the air can spread them to other people.... These diseases mostly affect children. There is no equivalent concept of waterborne diseases. Although this can easily be expressed in siSwati (tifo temanti), water is not generally believed to be a carrier of disease or germs (emagciwane) unless it is stagnant and visibly contains "dirt" such an animal or human waste. For the most part, flowing water is thought to be safe to drink, since dirt of any sort is thought to quickly sttle on the banks of rivers or streams. As we found in an earlier survey, visual criteria are primarily referred to when Swazis judge the potability of water. When 144 healers were asked, "What diseases, if any, are caused by water?" 43% saided bilharzia or likhubalo (an illness said to result from domestic sorcery with symptoms similar to those of urinary bilharzia); 26% said they did not know of any diseases caused by water; 20% said cholera; 7% said stomachache; and 4% said diarrhea. When the same sample of healers was asked, "What diseases, if any, are caused by human feces?" 55% replied that they did not believe any diseases were so caused; 17% said cholera; 17% said diarrhea, and 11% said stomachache. Eleven respondents made comments like, "That's the concern of doctors and nurses" and gave no specific answers. Answers to the above questions that refer to bilharzia, cholera and probably to diarrhea as well, reflect the effects of intensified health education efforts on the part of the Swaziland Government since 1981. The ability to provide answers that satisfy government interviewers does not necessarily mean the traditional healer actually believes what he or she is saying. When an interviewer begins to probe, it becomes apparent that most healers do not believe that water or human feces are significant agents of disease transmission. For most Swazis--healers or otherwise--there are two types of explanations for disease causation: the traditional and the modern or scientific. From participant-observation research it is clear that most Swazis believe the traditional explanation, yet many or most refer to modern explanations in survey interview situations. The significance of the survey responses just presented is that considerable doubt was expressed that either waste or feces carry any diseases whatever, and that no traditional disease categories were referred to (with the possible exceptions of diarrhea and likhubalo, although the latter may be used synonymously with bilharzia). Since all survey-type questions posed to healers were open-ended, the spontaneous or additional comments of respondents often provided insights into genuine attitudes and beliefs. For example, a number of healers said that while they have heard from the radio or from doctors that cholera is caused or carried by human feces, they have yet to see the proof of this proposition and therefore they do not believe it. In the words of one healer, "They say diseases like cholera are caused by feces that aren't disposed properly, but I don't believe that because our ancestors never had toilets and yet they were never affected by cholera." While on the subject of disease transmission, it can be noted that the vector role of flies in certain types of diseases is fairly well recognized. In a sample survey of rural Swazi homesteads, about 20% of respondents who gave an answer attributed infant diarrhea to flies carrying dirt to babies' food. Interestingly, this understanding seems to be traditional. A number of traditional healers mentioned flies when asked to comment on the possible role of feces in disease and one commented, "We Swazis have always known that flies bring disease and that our enemies send flies to make us ill." DIARRHEA IN THE TRADITIONAL CONTEXT Diarrhea--or loose, wet feces--is known as umsheko in siSwati. The term can refer either to symptoms whenever and with whomever they occur, or to a category of illness found typically in infants and children. Two other major categories of childhood diarrhea are traditionally recognized, kuhabula and umphezulu. These will be examined in some detail because they involve some of the outstanding symptoms associated with acute, infectious diarrhea that accounts for much of the high infant and child mortality in Swaziland.
Umsheko Umsheko as a childhood illness syndrome is recognized as the frequent passing of wet, loose stools. The stools are not greenish in appearance (which to Swazis indicates a more serious diarrheal illness), but they may appear crystalline or "porridge-like." Other symptoms described by traditional healers include aching or grumbling stomach, loss of appetite, and vomiting. To treat umsheko, a number of different herbal decoctions known by the generic term timbita tekusonga ("herbs that harden the stool") are administered orally. If the diarrhea responds to such decoctions within three days, the illness is considered naturally-caused (umkhuhlane). Causes recognized as natural include "bad food," insufficient food, "heat" in a child; "evil wind" or a change of seasons (both said to cause colds anf flu); drinking cow's milk, powdered milk or spoiled milk; eating unripe fruits, beans, soft drinks, sweets, white pumpkins or liver; a change in a child's diet including type of milk; the physical relocation of a child; eating any sour or raw food; or contamination of food by flies. Other causes cited by healers that may reflect the view espoused by government health education include drinking unboiled water, bottle as opposed to breast feeding and leaving food uncovered. Similar views were expressed by non-healers in our earlier sample survey of 455 rural homesteads. When asked, "What causes the diarrhea which kills babies?", 29% of those responding said bad food or diet; 19% said flies; 15% said dirty baby dishes; 6% said dirty water; 5% said evil spirits; 3% said bad environment; 3% said heat; and 19% gave miscellaneous answers. It is significant that 275 respondents, or 61% of the total, preferred to give no answer to the question. This is possibly because the diarrhea that kills is not considered to be the naturally-caused umsheko, but one of the two unnatural or mystical forms of diarrhea described below. As mentioned before, Swazi respondents tend to withhold views that they know are regarded as supernatural, superstitious, or even primitive by government interviewers. Umsheko is sometimes attributed to flu or bile. Bile is thought to be caused by a child eating the wrong foods for its digestive system. It is said to accumulate in the stomach and it must be purged through enema (kucatseka) or induced vomiting (kuhlanta). The former method is commonly used to treat and prevent a number of traditional Swazi illnesses; induced vomiting seems to never be used with babies or younger children. One variety of umsheko, or natural diarrhea, is thought to accompany teething in a baby (but no other developmental stage). The teething is said to cause heat in a child, and the heat in turn causes diarrhea. Accompanying this form of diarrhea, children are said to have flue or fever (imbho) symptoms. They also cry in a certain way and seem to fear separation from their mothers. Stools are described as yellowish, partly solid and not malordorous as with the types of diarrhea regarded as more serious. Children lose energy, but regain this once the diarrhea stops. Healers claimed that children's health is not really affected by teething diarrhea; in fact "stronger" children may not even present the symptoms. Traditional medicines are sometimes rubbed on a child's emerging teeth "to make them grow faster" and thereby decrease the opportunity for diarrhea. Some healers claimed that teething diarrhea can be prevented by tying the seeds from a certain tree around the waist of a child of teething age. Stool-hardening herbal decoctions are generally used to treat this form of diarrhea. Healers were asked if they thought diarrhea tended to occur more often during certain times of the year. Answers were varied but of those who specified a season, summer was cited most often since heat is believed to cause diarrhea. Some referred to summer as the rainy season. Others said diarrhea tends to occur at the change of seasons, as with flu. A third group believed that there is more diarrhea now than in the past and since it seems to occur all the time, it cannot be seasonal. In response to another question, most healers claimed there is no way to prevent diarrhea in children or that the cure and the prevention are by the same means, i.e. stool-hardening herbs. Some healers said that routine herbal enemas (kucatseka) keeps a baby's stomach clean and there prevent umsheko. Some healers also noted that a few mothers are responding to health education efforts and are beginning to make sure food is covered, to build latrines and to boil water--especially for mixing baby food--in order to prevent infant diarrhea. This is confirmed by earlier survey findings among the general population. FEEDING DURING THE DIARRHEA EPISODES Although there has been a trend away from breastfeeding over several generations, and although the contributing role of bottlefeeding in infant diarrhea is not well understood by most Swazi mothers, traditional healers were unanimous in emphasizing to interviewers the importance of breastfeeding during episodes of diarrhea. Specifically, they agreed that a breastfed child must remain on the breast during diarrhea, and a bottle- or cup-fed child should be returned to breastfeeding if possible. While this coincides with health education messages of recent years, female traditional healers and birth attendants emphasized that the importance of breastfeeding in cases of infant diarrhea has long been established in Swaziland. Some healers mentioned the importance of giving infants only boiled water during diarrhea episodes. Most healers felt that babies with diarrhea should additionally be fed with solid foods if that is part of their normal diet. Many healers commented that a baby's strength must be kept up during diarrhea and that witholding food would result in a child losing strength. Some said they watch a child carefully to see how to reacts to each food introduced, and any food that seems to exacerbate the diarrhea is discontinued. There was general agreement that mother's mlk was best during infant diarrhea, followed by soft or liquid foods, and finally by solid foods. Some foods, specifically sorghum and mealie (maize) porridge are thought to harden stools during infant diarrhea. Sometimes sorghum is mixed with herbs for timbita tekusonga, the stool-hardening medicines used to treat umsheko. If umsheko does not respond to the usual treatment methods, it is suspected that it might be one of two more serious childhood illnesses, kuhabula or umphezula. Kuhabula. Kuhabula is regarded as a more serious form of infant diarrhea, one that is not natural. A sunken fontanelle on the infant's head is perhaps the outstanding symptom. Others are loss of strength, vomiting, incessant crying "day andnight," eyes becoming white and upturned, ribs appearing to come together, and crying with a "low voice." Some healers mentioned that infants may close their eyes, or keep them openw itha fixed stare, and/or have eyes that appear sunken in their heads. There may also be a twisting of the infant's neck, headache or other general pain. Although regarded as a diarrheal disease, diarrhea is not considered the outstanding symptom of kuhabula. It is significant that what medical science recognizes as symptoms of dehydration is not regarded by Swazi healers as relating in any way to wter or water-loss. For example, sunken fontanelles is seen as a symptom equivalent to diarrhea, not as something that results from diarrhea or loss of body fluids. When asked if she believed that sunken fontanelles could result from fluid loss, one healer replied, "Doctors believe that. We traditional healers are concerned with the real cause of diarrhea--the spells." According to Swazi belief, babies are not born with kuhabula, but they can be infected soon after birth by inhaling the smoke or invisible vapors of tinyamatane. Tinyamatane is a general term referring to mixed herbal medicines and sometimes dried animal skins that are burned in preparation for therapeutic fumigations (kubhunyisela) or traditional vaccinations (kugata). Tinyamatane (singular: inyamatane) are used to protect clan members against illness. Babies become ill with kuhabula when they inhale tinyamatane other than those of their own clan. Their exposure may be accidental or deliberate. In the former case, a healer may mix his medicines at home and either fail to purify the mixing area subsequently, fail to warn parents of children in the vicinity, or fail or provide medicinal antidotes for local children. In any case, children are said to inhale medicinal fumes which cause kuhabula. Kuhabula can also be accidental if a healer or ordinary person who has recently mixed herbal medicines then visits a homestead where children are present. Exposure to medicinal vapors is said to be deliberate when a healer or other preparer of medicines is hostile to a family and wishes to harm the children. Although kuhabula is primarily a children's illness, old people, especially if they are "weak," can be susceptible to tinyamatane vapors and become ill with kuhabula. As mentioned above, there are clan-specific tinyamatane with which children are fortified against a variety of dangers. Typically within the first few weeks of a child's life a healer or elder of the clan burns the tinyamatane by placing it on hot coals. As smoke rises from the coals the child, perhaps accompanied by family members, is covered by blankets so that he must inhale the smoke. Virtually all Swazi children have undergone protection of this sort. It is believed that those who are unprotected will become victims of kuhabula as well as other serious childhood afflictions. Thus there are two ways to protect a baby from kuhabula: prophylactic fumigation with clan medicines or administration of antidotes in advance of exposure to the vapors of foreign or non-clan tinyamatane. When a child exhibits the symptoms of kuhabula, he is generally taken at once to a traditional healer. A diviner-healer (sangoma, thokoza) might confirm the diagnosis through "bone-throwing" or some other means of divination. Divination may also be used to determine which specific tinyamatane fumes a child has been exposed to. Once this is determined, the same medicinal mixture is made, placed over hot coals, and the sick child is fumigated in the manner described above. Several healers remarked that parents and siblings of the sick child should be fumigated at the same time in order to protect them from kuhabula. In the final stage of the healing procedure, ashes from the burnt medicines are transferred by the fingertips of the child'smother or other family member to the tongue of the child (a process called kucapha). The same ashes are then rubbed on top of the child's head. In addition to fumigation, which is the common therapy for kuhabula, some healers give babies enemas in order to purify or "drain bad air out of" the stomach. Some also prepare herbal decoctions for a baby to drink. Some healers emphasized that if the same tinyamatane that caused the illness cannot be found, the child will die. Such pronouncements to mothers of weak, dehydrated children surely have the effect of raising their anxiety levels and making them highly suggestible to the advice of the diagnosing healers. It would certainly tend to make recourse to modern medical therapy seem fruitless and risky. Umphezulu. The third commonly recognized childhood diarrheal illness, umphezulu or inyoni (16), is characterized by the following symptoms: greenish diarrhea that may later become yellowish; greenish blood vessels visible in the child's stomach or forehead; constant crying that sounds "birdlike" or like the bleating of a baby goat; loss of appetite; an expanded stomach ("swollen with air"); an expanded-appearing navel; a grumbling or noisy stomach; and "cracks" along the fontanelles which later become depressions. Unlike the other two forms of diarrhea, a baby is believed to be born with umphezulu since it is contracted in utero and results from the behavior of the mother while pregnant. Specifically, umphezulu is caused by: (1) a pregnant woman passing through an area where lightning has recently struck, or crossing over a place where enemies have deliberately spread harmfulmedicines; (2) a pregnant woman failing to keep her head covered at all times. Prenatal exposure of the baby to lightning vapors seems to be the commonest cause of umphezulu. Since lightning (or thunder) vapors are invisible and are believed to linger for a considerable time, it is difficult for a pregnant mother to feel that she has never exposed her baby to the vapors. Some healers claim the ability to determine whether or not babies have been born with umphezulu by the second month of life. Healers tend to agree that the illness can be prevented and cured by the same means. The therapeutic procedure begins with taking the baby to a place where lightning has recently struck (enyonini). A hole is then dug and a fire built in it. The baby is positioned over the hole and given an enema. Some healers identified the enema medicine as a mixture called lubane; some mentioned mixing milk with whatever they use for the enema. The baby's feces resulting from the enema are left in the hole, which is then refilled. In addition to the foregoing, some healers perform traditional vaccination (kugata) around the baby's naval. A razor blade, usually unsterilized, is used to make shallow cuts and ashes (insiti) of medicines burned over hot coals are rubbed into the resulting cuts. Herbal decoctions for drinking may also be used to treat umphezulu. Hospital or clinic treatment for umphezulu is regarded by healers as dangerous as well as ineffective. It seems that as with the process of fumigation to prevent kuhabula, most Swazi babies undergo the enema procedure just described in order to prevent umphezulu. To summarize: there are three traditionally recognized types of infant diarrhea. Although their symptoms overlap somewhat, they are viewed as separate syndromes with different causes, cures, and potentials for prevention. Umsheko is regarded as natural, of brief duration, non-dehydrating, and caused by diet, teething, or mild fevers. Diarrhea initially regarded as umsheko can later be diagnosed as kuhabula or umphezulu if it persists and if symptoms such as sunken fontanelles appear. Enema is used as a treatment method for the more serious form of diarrhea, thereby contributing to dehydration. Some fumigation is used to treat kuhabula. Herbal teas may be used for any illness associated with diarrhea; those used for simple umsheko are said to have stool-hardening properties. Choice of therapies for childhood diarrhea has been described briefly in context but will now be discussed in more detail. Recourse to Therapy Decisions regarding therapy for childhood diarrhea are usually made by the mother. Younger mothers are advised by their generally more conservative mothers-in-law. Fathers and other male homestead members, unless they are healers themselves, are usually content to leave such decision-making to women. As discussed in an earlier report (17), Swazi healers and patients tend to classify illnesses as African or traditional on the one hand, or modern, European, or "doctors" on the other. African illnesses include all those supernatural agents, which as we have seen accounts for most of the more important illnesses that Swazis recognize. Modern diseases constitute a less well-defined category, but they may include recently introduced illnesses, "naturally-caused" illnesses or illnesses of any presumed cause that respond well to modern methods of treatment. When a sample of 144 traditional healers was asked to designate diseases best treated by modern medicine, they mentioned (in order): cholera, tuberculosis, heart disease, venereal disease, bilharzia, high blood pressure, stomachache and dental problems. Only three healers mentioned diarrhea. In a separate question, some healers were asked to designate the leading types of problems for which their help was sought by patients. The predominant problems were umklwebho, a type of "bewitchment," and the general category of children's diseases. Both were cited 34 times. Among children's diseases, the diarrheal syndromes of umphezulu and kuhabula were often cited, as was the preparation and administration of herbal decoctions and enemas for the prevention of common childhood diseases. Problems that do not respond within a reasonable time to domestic treatment, as well as problems known by their symptoms to involve supernatural agents, are referred to traditional healers. From the local consumer's point of view, the traditional health sector consists basically of herbalists, diviners, or Christian ("Zionist") faith healers (19). Differences in health beliefs between the three healer types are not significant in the context of this paper. Healing practices of Christian faith healers differ from those of herbalists and diviners mainly in that various types of holy water (siwasho) are used instead of herbal and animal-derived medicines. However, the focus of this paper is on herbalists and diviners, since limitations of time led to the exclusion of faith healers from in-depth interviews on childhood diarrhea. There is also focus on Swazi mothers, the majority of whom share the same health beliefs as traditional healers, although mothers' beliefs tend to be less well-formulated and elaborate than those of healers. It is noteworthy that at least half of the traditional healers in Swaziland are women, and nearly all of these are mothers. The beliefs of both healers and mothers tend to be influenced to varying degrees by scientific medical concepts. The choice of one type of healer over another may depend on physical accessibility, kinship and friendship ties. Christian affiliation or orientation, the type of health problem and the perceived need for divination or inspired diagnosis. Problems that cannot be handled adequately by the first traditional healer may be taken to one or more other traditional healers, and at some point help from clinic or hospital might be sought. Other health problems that do not respond to domestic medicines, especially those of the relatively restricted category "modern" diseases, may be referred directly to a modern health practitioner. For reasons that are not yet clear, women are far likelier than men to visit clinics, particularly pregnant women or those with children. This may be because children are highly valued in Swazi society; women have almost exclusive responsibility for children; infant and child mortality rates are high (and the dangers facing children are recognized especially by mothers); and there is emphasis on maternal and child health in both preventive and curative medical services provided by government. Peri-urban residents and Swazis with more education probably make better use of modern sector health facilities, but most such people visit traditional healers as well. It should be noted that most traditional healers make patient referrals to clinics and hospitals and that many see a natural division of labor between healers and doctors. The division of labor is not only between African and modern disease, but between what Swazis see as treating the symptoms or the ultimate cause of illness. Especially in the case of illnesses whose symptoms respond readily to modern drugs, traditional healers believe that patients should first go to a doctor and then return to the healer for treatment of the ultimate cause of the illness, which is usually bewitchment. Treatment of infant diarrhea follows the behavioral model just described. When a baby has diarrhea, some mothers use domestic herbal medicines right away. Others wait for a day or two before beginning treatment. From the descriptions of traditional healers it seems that most mothers first use timbita tekusonga to harden the stool. Others may give their baby herbal decoctions that actually promote diarrhea, followed by herbal enemas intended to clean out the baby's stomach. Several healers commented that mothers should not administer medicines by themselves; rather they should send children directly to a traditional healer at the first sign of diarrhea. Some observed that herbal medicines are very dangerous to babies. One said "Diarrhea doesn't respond to traditional medicines these days," and expressed the view that babies should be taken directly to a clinic for treatment. However, most healers recommended that babies be brought to them by at least the second or third day of diarrhea and they implied that a clinic should be a last resort when and if traditional medicines fail. Some claimed that visiting a healer before going to a clinic will empower the clinic medicine to work. Others claimed outright that clinic medicines could kill children or adults who have an African disease. Such statements reflect healers' belief that they can and should treat the mystical cause of an illness even if doctors may be better able to treat the symptoms. A few mothers are beginning to orally rehydrate their babies by means of a homemade sugar and salt solution they have been taught to use by extension workers and nurses. Print media and radio programs have reinforced this message. Four out of 15 healers questioned on the subject said that some mothers in their areas are suing sugar/salt solutions when herbal medicines fail to stop diarrhea in their babies. Their comments suggest a lack of a clear understanding of the function of the sugar/salt solution. The same four healers reported that they used sugar/salt solutions themselves when their traditional medicines failed and before they referred a child to a hospital or clinic. These crude estimates are offered in the absence of survey data on oral rehydration. Regarding the next recourse after the failure of home treatment of diarrhea, healers emphasized that the choice is up to the mother. However, it seems obvious that healer beliefs and attitudes heavily influence the thinking and therefore the decision-making of mothers. This seems especially true in light of our preliminary census finding that there is some sort of traditional (or Christian-"Zionist") healer in roughly every 12 rural homesteads (20). Mothers do in fact generally turn to a nearby traditional healer for advice on their child's diarrhea before going to a clinic. This is because most Swazi mothers share a common belief system with healers, as well as proximity and convenience. Such consultations may also be expected by elders of the homestead, in particular the mother-in-law who tends to wield considerable authority over her daughter-in-law. Consultations with traditional healers presumably lead not only to (further) traditional therapy, but to at least some acceptance of the healer's explanations in terms of mystical vapors, enemy-induced lightning strikes, and the like. Healers' treatment of the three recognized forms of infant diarrhea has already been described. If diarrhea persists in spite of (or because of) these treatment methods, the sick child may be taken to one or more different healers before clinic help is sought. In the words of one traditional birth attendant, "I take my child to the hospital only after all my traditional healers are defeated." Some mothers--a minority it seems--take their children directly to a clinic at the first signs of diarrhea, or at least after home treatment fails. A minority of traditional healers encourage this and claim they prefer to refer cases of infant diarrhea to a clinic rather than treat such cases themselves. One healer, probably with the recent outbreak of cholera in mind, commented, "There are so many diarrheas these days that a mother should either use her own medicines or send her child to a clinic right away." However, if clinic treatment seems ineffective a mother may take her child back to a traditional healer for further treatment. Advised one healer, "If the doctor's medicine doesn't work quickly, the mother should take the child back to a traditional healer because the diarrhea may be accompanied by evil spirits (tilwane) or something else that only we understand." Thus a child may be subjected to therapies and medicines from several traditional and modern practitioners in quick succession, or even simultaneously. Most traditional healers took a dim view of this and said that mothers should stick to one practitioner long enough for the medicine to take effect. Several said they advised mothers to wait several days to see if clinic medicine will work before they bring or return their children to traditional healers. Even timbita tekusonga, they noted, takes 2 or 3 days to stop diarrhea. According to interviews and limited observations, neither mothers nor healers make much use of patent medicines. One peri-urban traditional birth attendant mentioned using milk of magnesia in cases of her own children's diarrhea, but most interviewees said that Swazis are not familiar with store-bought medicines intended for diarrhea in either children or adults. Some added that such medicines are inaccessible to most Swazis, expensive, unpredictable and non-traditional. Before concluding this section, it may be necessary to correct an impression that could develop from the foregoing, namely that traditional healers may be unscrupulous opportunists that exploit the fears and superstitions that plague Swazi mothers in times of stress. It should be stressed that traditional medical beliefs shared by Swazi patients and healers alike are part of a time-honored, coherent, logically consistent, self-reinforcing system that satisfies many of the physical, mental and spiritual needs of the Swazi people. Most healers are sincere and acting in good faith when they divine the causes of infant diarrhea and prescribe their medicines. Indeed, interviews showed that healers treat their own children no differently from other children in cases of diarrhea. This should be kept in mind when planning educational and other interventions. Health Education Implications Health education strategy must begin with an acknowledgement that (1) traditional medical beliefs and practices are unusually tenacious in Swaziland. One measure of this is the high number of healers supported by a relatively small population; (2) there is one traditional healer (not including traditional birth attendants) per 110 population compared to about one physician per 10,000 population; (3) traditional healers are opinion leaders in matters pertaining to health. It follows that (4) traditional healers should be part of the focus of health education efforts and health education should build upon rather than directly confront traditional beliefs and practices whenever possible. Some specific suggestions are offered in this section. It is a common practice in many societies to withhold food and fluids (including breast-milk) from a baby suffering from diarrhea, thereby exacerbating not only dehydration but malnutrition--which itself contributes to death from childhood diarrhea. Fortunately Swazis believe that fluids, especially breast-milk, are necessary in order to maintain a child's strength. This belief and the resulting practice should be reinforced; nutrition and dehydration education could be presented in the context of keeping up a baby's strength. In this same connection, "home remedies" such as sorghum or maize porridge may serve to prevent dehydration in children. The World Health Organization now recommends that mothers be encouraged to prepare and give home remedies by mouth, particularly if they contain sodium and glucose concentrations that are between 50-100 mmol/1 and there is even a small amount of potassium (21). Porridges used by Swazi mothers should be analyzed for their nutrient context and, if they are found suitable, they should be promoted to "keep up the child's strength" during diarrhea. Swazi healers recognize the symptoms of dehydration, but do not associate these with loss of body fluids. It should be possible to teach the consequences of fluid loss without ridiculing or confronting beliefs about kuhabula and umphezulu. In such a context the dangers of administering enemas could be better understood, as well as the need to use some form of oral rehydration. Health education should emphasize that ORT serves to restore body fluids lost through diarrhea but should not be expected to stop diarrhea. More difficult to accommodate are beliefs that clinic medicines can kill a child with an African disease, or that initial recourse to traditional treatment is necessary in order to empower clinic medicines. If the process of dehydration can be adequately explained, it may be useful to point out that the rehydration process (which sometimes must be intravenous) does not involve actual medicines, but rather the replacement of things needed by the body ("sugar and salt"). It should be emphasized that if spells need to be counteracted, this should be done after rehydration of the child. Swazis further believe that germ-like particles (emagciwane) pass through the wind or air. Recent advances in electron microscopy indicate that many cases of gastroenteritis in infants and young children are viral (rotaviral) in origin (22). Some of these viruses may be "carried in wind" as Swazis believe. It is well established, however, that water and human feces are primary conveyors of any sort of diarrhea-causing pathogens, including rotavirus. Parallels could be drawn between tifo temoya (airborne diseases) and tifo temanti (waterborne diseases); if unseen agents can be carried by air, they can be carried by water or personal contact as well. It is possible that Swazi conceptions of the different properties of water and air and of the process of transmission might make the acceptance of such a parallel difficult further research is warranted to clarify this point. If further conceptual barriers are discovered, educational strategies should still be based on emphasizing the common ground between traditional Swazi and scientific concepts and on relating new ideas to familiar ones. Widespread beliefs relating to prevention of the diarrheas of childhood--but not the specific practices--could be built upon when teaching preventive measures. Swazis are correct in believing that simple forms of diarrhea probably cannot be prevented, while the more serious, life-threatening forms can be. Clearly, the acceptance of water as a conveyor of germs would greatly facilitate acceptance and adoption of preventive practices. To return to oral rehydration, there should be no great obstacles in the way of either mother or healers of either sex adopting the practice, other than that it is not traditional and that it is based on an alien concept of rehydration. In favor of adoption is the similarity between oral rehydration solutions and traditional anti-diarrheal herbal teas. An unknown but presumably small proportion of mothers and healers have already begun to mix and use a homemade solution of sugar and salt that has been promoted by the Ministry of Health. Working in favor of adoption are the high value of children in Swazi society and the fear and uncertainty regarding cholera since its recent outbreak. Since June 1983 the Health Education Unit has promoted the use of ORT in face-to-face seminars with traditional healers. This was begun on a pilot basis with the expectation of an evaluation of results after a period of some months. Even before an evaluation, fears were expressed by some government officials that healers would simply add ORT to their other diarrheal medicines, and that if a child then died after the administration of traditional medicines, ORT and the Swazi government would be blamed for the deaths. In light of what we know about traditional thinking, this seems very unlikely. It can easily be demonstrated--and this is always done at seminars for healers--that ORT is completely harmless if the salts are prepared and administered properly. Furthermore, the reality is that in the foreseeable future, most mothers will bring their children to healers before bringing them to a clinic, if for no other reason than the accessibility of healers. To expect healers to refer all cases of childhood diarrhea to clinics prior to treatment is to expect them not to act in their own economic self-interest, to suspend their sincere beliefs about the mystical causes of childhood diarrhea, and to ignore what healers may regard as serious cases requiring emergency treatment. The Swaziland government should therefore continue to distribute ORT packets to traditional healers, on a pilot basis, with the hope that oral rehydration therapy will become at least part of a healer's therapy for dehydrated children. At the same time health education directed toward healers can attempt to demonstrate the dangers of a number of traditional treatments for diarrhea, notably enemas. Over time it can be hoped that enemas will be used less often while use of oral rehydration will increase. The belief that there are more diarrheal diseases and more hazards in childbearing now than in the past can be built upon to convince both mothers and healers that clinic services must be relied upon. At the same time, the realities of current clinic outreach require that a certain amount of medical self-reliance be promoted. Promotion of oral rehydration in the home should reinforce a self-reliance that already exists. A "breast is best" campaign has already been underway for a number of years in Swaziland, and certainly increased breastfeeding would result in morbidity and mortality rate decreases in the childhood diarrheas. Here, tradition is working in favor of the health educator, although urbanization, the employment of women and other forces of modernization tend to work against breastfeeding. The suspicion among Swazi women and healers that powdered or cow's milk causes diarrhea can be reinforced during education about the benefits of breast milk and the wisdom of the Swazi ancestors in recognizing this. The above are offered as examples of a realistic approach to health education in Swaziland. Certainly there is much opportunity for imagination and creativity in this endeavor, the important thing is that the strength and tenacity of traditional beliefs and practices always be kept foremost in mind. Two groups should be primary "targets" for health education: traditional healers and mothers. The former are the primary opinion leaders in all matters of health, including diarrheal diseases. Health education efforts cannot have much impact if they are actively or passively opposed by traditional healers. Mistrust and misunderstanding do exist between healers and modern health personnel, but the seminars begun by the Health Education Unit provide one means by which understanding, trust, and even cooperation can develop. The seminars should be expanded in order to reach more healers, but they should first be evaluated so as to ensure maximum effectiveness and therefore, impact. It may be feasible to use radio as a medium through which to communicate with traditional healers, but this bears further investigation. In any case preliminary evaluations of recently developed radio programs concerned with diarrheal disease and intended for the general public have been promising. These programs have acknowledged the existence of traditional beliefs and behavior to an extent previously unknown (or better, untried) in Swaziland, and health education is presented in the context of familiar, realistic and interesting dramatic vignettes. Other approaches to radio education such as candid discussions with traditional healers or the testimonies of healers who have come to recognize the benefits of oral rehydration, could be fruitful. Regarding the recommended focus on mothers, a recent international conference on oral rehydration concluded the following: The mother is a partner in oral rehydration delivery. In childcare, the mother possesses many advantages, not the least of which are her motivation, her ever-presence, and her capacity to undertake immediate and timely action. The mother is the first-line responder to all children's illnesses, including diarrhea (23).
These comments apply very much in Swaziland where the mother has nearly sole responsibility for the well-being of her children.
Preliminary evaluations of the health radio programs already referred to indicate that whatever the intended audience, women were the primary listeners and men felt that the programs relate to "women's affairs." Acknowledging this, the program might have even more impact if they were tailored more specifically to women's interests. REFERENCES See for example Elmendorf M. and Isely R. Public and private roles of women in water supply and sanitation programs. Hum. Org. 42, 195, 1983. WHO. The Management of Diarrhoea and Use of Oral Rehydration Therapy: A Joint WHO/UNICEF Statement, p. 21. HO, Geneva. See also, Third Programme Report 1981-81, Programme for Control of Diarrheal Diseases. WHO, Geneva, 1982. See for example Kendall C., Foot D. and Martorell R. Anthropology, communications, and health: the mass media and health practices program in Honduras. Hum. Org. 42, 353-360, 1983, Smith W. et al. Delivering oral rehydration therapy to the village. Paper presented to the International Health Conference, National Council for International Health, Washington, D.C., 1983. Kendall C. Anthropology, communication, evaluation, and health: the case of Honduras' National Diarrhea Control Program. Paper presented at Society for Applied Anthropology Annual Meeting, Lexington, KY, 1982. Swaziland Government, National Health Policy, Ministry of Health, Mbabane, 1983. Chen L. Summary of conference proceedings. Paper presented at the International Conference on Oral Rehydration Therapy, Washington, DC, 1983. Green E. and Makhubu L. Traditional healers in Swaziland: toward improved cooperation between the traditional and modern health sectors. Soc. Sci. Med. 18, 1071-1079, 1984. Umkhuhlane is not as wide a category as the outsider might presume. Pimples and blackheads, for example, are classed as conditions "sent" by enemies. For a description of "ecological" disease beliefs among the culturally related Zulu, see Nqubane H. Body and Mind in Zulu Medicine, pp. 24-29. Academic Press. Green E. A Knowledge, Attitudes and Practices Survey of Water and Sanitation in Swaziland, p. 37. Swaziland Ministry of Health, 1982. Ibid, p. 49. Explanations of this sort for cholera and smallpox are found elsewhere in Africa. See, for example, Imperato P.J. and Traore D. Traditional beliefs about smallpox and its treatment in the Republic of Mali. In African Therapeutic Systems (Edited by Ademuwajun Z.A., Ayode J., Harrison I. and Warren D.), p. 15, Crossroads Press, Waltham, MA, 1979. Green E., op. cit., p. 16.
Ibid., p. 51. Ibid., p. 51. Ibid., pp. 68-73. Inyoni, or "bird," is synonym for umphezulu because Swazis and other southern Bantu traditionally hold that lightning travels in the form of a bird and lightning vapors cause umphezulu. Green E. and Makhubu L. op. cit., pp. 10-11. "Pluralistic" is used here to describe a situation where two or more paradigmatically distinct medical systems (e.g. "African" and "scientific") exist for the consumer. cf. Press I. Problems in the definition and classification of medical systems. Soc. Sci. Med. 14B, 45-57, 1980. See Green E. and Makhubu L. op. cit., pp. 6-8 for a description of healer types. Green E. and Makhubu L. op. cit., p. 9. World Health Organization. The Management of Diarrhoea and use of Oral Rehydration Therapy: A Joint WHO/UNICEF Statement, pp. 11, 18-19. WHO, Geneva, 1983. Scientific Working Group on Viral Diarrhoeas. Recent advances in knowledge of retavirus diarrhoea: Report of the Scientific Working Group on Viral Diarrhoeas. Geneva, 1982. Chen L. op. cit. While some of these medicinal herbs may be harmful, little is actually known about their effects. As Cosminsky recently noted, "A blanket condemnation of the utilization of all herbs is not warranted in the present state of our knowledge." Cosminsky S. Traditional midwifery and contraception. In Traditional Medicine and Health Care (Edited by Bannerman R. et al.), p. 152. WHO, Geneva, 1983.
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