ORT: The Need for Education and Participation
Considering that Mozambique had one of the worst health situations in Africa at the time of liberation, there is no question that an enormous amount has been accomplished, and that a great potential exists for accomplishing even more. The level and quality of services I observed in the health centers was outstanding. Of note were the competence and high quality of work of the técnicos and agentes de saúde, as compared to corresponding health workers in other countries of Africa and elsewhere where I have visited.
As part of the Ministry of Health's objective to improve health care, specific focus has been placed on diarrhea control for children under the age of five. While it is recognized that reducing the incidence of diarrhea is a long-term process that depends on improving the economy and living conditions for he majority of the population, given the constraints and present economic crisis, diarrhea control efforts have focused on reducing mortality through oral rehydration therapy (ORT). The national program follows World Health Organization (WHO) and UNICEF guidelines, which emphasize the production and distribution of oral rehydration solution (ORS) packets based on the WHO formula.
Unfortunately, the results of a national program of oral rehydration have been disappointing. Reasons for low ORT effectiveness include: South Africa sponsored terrorism that hampers factory productivity; inadequate educational component: insufficient consideration of people's beliefs, traditions and home remedies; and inadequate health infrastructure, especially in remote parts of the country.
In the areas studied, most mothers know about oral rehydration. One-third to one-half of the mothers have used it either in packets or home mix. Low effectiveness seems related to incorrect or incomplete use. Although people are given step-by-step instructions, often they are not helped to adequately understand the underlying principles. Emphasis is put on what to do, rather than on understanding why. According to the Maputo study, mothers are taught fairly well about how to prepare ORS, but are no taught fairly well about how to prepare ORS, but are not taught enough about how and why it works, how much and how long to give it, the need to continue breast-feeding and other related information. Nor are they usually taught how to recognize signs of dehydration and other danger signs, what to do if they occur, or when to return to the health center. Also, health workers tend not to ask the mother enough about the details of the child's condition, when it began what treatment has already been given, and what the mother believes about the causes and treatment of diarrhea. Inadequate Consideration by Health Workers of People's Traditions and Beliefs
There are many beliefs about the causes of diarrhea and many traditional forms of treatment. Some people's beliefs lead to problems with the management of diarrhea and unless health workers take these beliefs into account and try to deal with people's doubts and fears, management of diarrhea will often be unsuccessful. Other traditions are helpful to the management of diarrhea and need to be encouraged.
Thanks to the excellent policy of the Ministry of Health to restrict the availability of baby bottles and artificial milks, breast-feeding is still almost universal. On the average, mothers breast-feed their babies for a year or longer, with the result that relatively few babies are malnourished or die from diarrhea in the first year of life. It is in the second year, when customarily the children are weaned abruptly and often fed inadequately, that the rates of malnutrition and death from diarrhea rise sharply.
A problem arises from the traditional belief that sexual activity poisons breast milk. During the time when polygamy was the practice it was taboo for a man to sleep with a wife who was breast-feeding. Recently, as monogamy becomes the norm, violation of the taboo has become acceptable. Yet, when a baby gets diarrhea, the mother often believes her poisoned milk to be the cause of her child's illness. She suddenly weans her child at the very time when the child most needs the continuation of breast-feeding to survive an episode of diarrhea. Health workers not only do not usually discuss these beliefs with the mothers, but often do not mention how important it is to continue breast-feeding when the child has diarrhea.
In some parts of the country mothers withhold food and drink when a child has diarrhea, because they observe that diarrhea seems to increase as soon as the child eats or drinks. Too often health workers give instructions only about the steps for preparing ORS, without explaining how it works. Mothers do not realize that putting in enough liquid, not stopping the diarrhea, will save the child's life.
On the positive side, traditional forms of oral rehydration are widely used, at least in some parts of Mozambique, with "rice water" probably the most common form. In areas where most homes have rice, more lives probably could be saved if health workers would encourage giving rice water in sufficient quantity, instead of just ORS packets, which are so often not available, or where a long (often dangerous) walk is required to get them. If a solution from powdered rice is promoted this could be even more effective.
Unfortunately, health workers too often discourage the use of rice water, rather than teaching people to prepare and use it better. One local "confidant" in Inhambane told a researcher that many mothers give their children rice water for diarrhea, but deny doing so to health workers because they fear being scolded. In typical WHO fashion, the "home mix" has often been introduced as a second-class substitute.
It has become clear that Mozambique cannot, in the foreseeable future, produce enough ORS packets to meet more than a small fraction of the country's needs. Nor does the country at present have the health infrastructure for adequate distribution of packets. Even if it could produce enough packets, there are strong arguments for using home mixes as the primary approach to ORT. Home mixes permit greater self-reliance and do not foster dependency on products. Dependency even on health centers is risky, as they are in constant jeopardy of terrorist attacks.
In view of the economic crisis in Mozambique, it also seems wise to invest in providing education, which will become self-propagating after a critical number of persons is reached, rather than in a provision of products, the cost of which will forever increase with the demand.
Often not enough attention is paid to the experience, traditions and ideas of the people of Mozambique. If diarrhea control were approached more as a participatory process, I feel that a great deal could be learned from the people. In my brief visit, I saw evidence that in some areas of the country people have traditional methods of diarrhea control that are reducing mortality from diarrhea more effectively than the WHO strategies.
We learned the details about a range of different cereal-based home cures from a group of about 40 mothers who are members of the women's organization in a barrio on the outskirts of Inhambane. The enthusiasm of the women was great once they realized that we really respected their traditions and wanted to learn from them. They had a flood of questions, mostly relating to unusual or traditional illnesses that they didn't dare ask about at the health centers. For example, one mother asked why three of her children always begin vomiting every time the moon was full. For some of their questions, we "moderns" had no ready answers. But at least we admitted our ignorance respectfully, without slighting the mother or scoffing at her "unscientific" ideas. At the end of the session, we thanked the mothers for making a contribution to our understanding for improve diarrhea control in Mozambique. The women cheered and clapped. Night had fallen and it was long beyond normal working hours when we left, but nobody seemed to mind.
This meeting with the women's organization in a poor Inhambane barrio shows the potential for greater involvement of community people in what might be called "participatory research". Studies can be conducted with the people and not just of them. When people become the subjects rather than the objects of research they are far more likely to respond honestly, openly and with sufficient depth to contribute important information on critical questions that investigators might not think to ask.
Using the School System and Mass Organizations for Participatory Research
Although mothers are usually the persons taught about ORT, often those who spend most time caring for young children are their older brothers and sisters. Yet little has been done to teach children about ORT or to coordinate with the Ministry of Education to include ORT and other aspects of primary health care in primary education.
A good way to start participatory research might be through the school system, perhaps in cooperation with the women's organizations or other organizaçao de masa. If teachers and schoolchildren could become involved in collecting and analyzing information relevant to diarrhea control in their communities, this could be not only a valuable contribution to a national plan for diarrhea control, but also contribute to the process of making schooling more relevant to the urgent needs of people in their communities.
Possibly the main promotion of ORT education should shift from the health system to the school system, especially in areas under attack. Far more villages have schools than have health posts, and the bandidos usually do not attack the schools (but do attack health posts). With cooperation of the Ministry of Education, schoolteachers and schoolchildren can become the front line workers in diarrhea control.
Teachers and schoolchildren in several countries have become involved in helping both to study and to meet health needs in their community by applying ideas provided in the international "CHILD-to-child"(1) program. By going home after school and asking questions of their mothers, children can conduct a community survey overnight. The next day at school, with the help of their teachers, they can record and analyze their data. For example, in one such overnight survey in Mexico, schoolchildren in one village found that over half of their mothers were bottle-feeding rather than breast-feeding their babies. Their research showed that the incidence of diarrhea in their baby brothers and sisters was five times as great in those who are bottle-fed as in those who are breast-fed.
Fortunately, bottle-feeding is not so much of a problem in Mozambique. However, schoolchildren might be able to make revealing studies on such questions as incidence of diarrhea, length of episode, response of mothers and children to different methods of oral rehydration or treatments of diarrhea, both "modern" and traditional. They might also report on such important questions as how many ORS packets their mothers received at health posts and how well families understand the information provided. Where schoolchildren alone are unable to gather all the important information, schoolteachers could collaborate with members of the women's or mass organizations.
In general the importance of improvement in schooling cannot be overemphasized, not only for the health of the people, but for the health of the nation. The present school system, still based largely on the Portuguese model, does little to foster a confidence-building, critical, problem-solving approach.
I was struck by the contrast between the mothers in the women's organization and the group of schoolchildren whom we met in a barrio of Inhambane. The women, who were mostly unschooled and illiterate, were able to talk openly and confidently with us, and to analyze problems that affected their lives. They cooperated earnestly with us in looking for answers to important problems. By contrast, the schoolchildren we met with were completely intimidated. Rather than trying to help us find useful answers to the questions we asked them, they were concerned only a give "safe" answers that would keep them out of trouble. When one child timidly answered a question, all the rest of the children dutifully repeated the same answer (yes, they had a baby brother who had diarrhea once the year before). These children doubtlessly spend a lot of time caring for their baby brothers and sisters. But we did not succeed in getting any honest or useful information from them. The school director apologized afterward, explaining, "This is the first time the children have been asked questions to which they have not been given the answer in advance."
Given this situation, conducting participatory research and home surveys with children who already have been substantially damaged by colonial-type schooling will not be easy. But it could provide an early wedge in transforming the school system so that it truly belongs to and serves Mozambique.
Although discussion about educational process may on the surface seem irrelevant to diarrhea control, I believe it is relevant, not only to diarrhea control but to all aspects of health education, and to the process of involving the people of Mozambique in helping to meet the country's needs. Schooling still desperately needs to be adapted to the Mozambican realities and to its goal of social equality and power of the people." A young black Mozambican who teaches agents sanitarios told me he was using Helping Health Workers Learn in his classes(2). He said that Mozambique desperately needed to free itself from the authoritarian, top-down memorization-based approach to school, and develop a more equitable, participatory approach to learning. A participatory approach to diarrhea control involving the school system could help advance the process of continuing national liberation.
(1) CHILD-to-child is a program in which older children learn to take care of the health needs of their younger siblings.
(2) Helping Health Workers Learn is a book of methods, aids and ideas for village-level instructors.
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