Sot. SC;. Med. Vol. 27, No. I, pp. 1-3, 1988 Printed in Great Britain. All rights reserved

0277-9536188 $3.00 + 0.00 Copyright G 1988 Pergamon Press plc

INTRODUCTION

ANTHROPOLOGICAL STUDIES OF DIARRHEAL ILLNESS

JEANNINE COREIL’ and J. DENNIS MULL? ‘Department of Community and Family Health. The University of South Florida. College of Public Health, Tampa, FL 33612 and ‘Department of Family Medicine, The University of California-Irvine.

School of Medicine, Orange, CA 92668, U.S.A.

Childhood diarrhea accounts for four to five million deaths annually, and in many areas is the single most important cause of death in young children. More- over, diarrhea contributes to an even greater share of morbidity due to associated malnutrition and growth retardation [l-4]. Most infant and child deaths due to

diarrhea could be avoided through the use of oral rehydration therapy (ORT), a simple, inexpensive home treatment involving the replacement of fluid losses through oral intake of a solution containing either table salt and sugar or commercially packaged rehydration salts. Given the magnitude of the health problem and the high cost-effectiveness of the inter- vention, it is not surprising that large scale inter- national efforts have been directed at the promotion of ORT. By established criteria ORT represents the ideal ‘selective primary health care’ [5], yet the verti- cality of current programs has been the target of harsh criticism (6-81. The papers in this issue make a strong case for the importance of integrating ORT with local sociocultural context, and Kendall presents a thoughtful analysis of the selective versus compre- hensive primary health care issue.

International attention to the promotion of ORT for childhood diarrhea began with the establishment of the World Health Organization (WHO) Pro- gramme for Control of Diarrhoeal Diseases (CDD) in 1978, as part of the global commitment to primary health care (PHC). The objectives of the program are to reduce diarrhea1 mortality in infants and children worldwide by one-half, and to reduce morbidity and malnutrition associated with diarrhea] illness. The cornerstone of national programs has been home treatment of acute diarrhea with oral solutions of packaged rehydration salts (ORS) or household sugar and salt (SSS) to replace body fluids and prevent life-threatening dehydration, Less- emphasized components include the prevention of diarrhea and dietary management of illness episodes.

Since the early 1980s ORT has been the dominant focus of international health programs, involving numerous agencies and organizations. most notably UNICEF and the U.S. Agency for International Development (AID). More than 100 countries cur- rently have national CDD programs with support from various governmental, bilateral and private health sources [9]. Funding for ORT work has been generous, particularly in the area of research and evaluation, with an unusually heavy emphasis on anthropological perspectives and methods. Hence, the involvement of anthropologists with research on

1

diarrhea1 illness has been substantial, and has led to greater awareness, discussion and publication of an- thropological studies on this topic.

The idea for this special issue grew out of a 1985 symposium at the American Anthropological Associ- ation meetings entitled ‘Anthropology, Oral Re- hydration Therapy and Primary Health Care’. Authors of five of the papers in this volume were part of that symposium (Kendall, Nations, Mull, Coreil and Scrimshaw and Hurtado). The paper by Bentley was also presented at the AAA meetings that year in a different session. The rest of the papers were solicited from anthropologists who were involved in research on diarrhea management.

The relevance of anthropological perspectives and methods for the study of diarrhea] illness can be discussed in terms of PHC development, meth- odologic contribution and theoretical issues. Efforts to implement PHC programs have led to increased recognition of the importance of sociocultural con- text for achieving improvements in community health [IO]. The importance of social science research for PHC was the focus of a 1984 special issue of Social Science and Medicine [I I] entitled ‘Anthropology and Primary Health Care in Developing Countries’. The editors note in the introduction that while many of the lessons provided by the studies in the volume are certainly not new, “it is not necessarily the case that they have been learned” (p. 183). The same obser- vation can be made in reading the following set of papers dealing specifically with ORT and treatment of diarrhea. The familiar themes of cultural com- patibility, indigenous concepts and practices, local participation, and issues of power and control in health programs reappear, yet a few new elements can be noted.

The importance of ethnomedical knowledge for design of successful health interventions seems to have been more clearly acknowledged in the field of diarrhea control than has generally been the case for PHC. A good example of this is found in the Kendall, Foote and Martorell paper [ 121 which appeared in the PHC issue cited above, and which is referenced frequently in the diarrhea literature as demonstrating the value of anthropological research. Official WHO documents state the importance of determining the local definition and terminology for diarrhea in for- mulating educational materials [ 131. Although an- thropological studies have influenced this awareness, perhaps even more important has been the growth of social marketing strategies in the promotion of ORT

2 JEANNINE COREIL and J. DENNIS MULL

and other child survival practices. With its emphasis on qualitative studies of consumer perceptions as the foundation for intervention design, social marketing has indirectly buttressed traditional anthropological approaches.

Certain characteristics of recommended diarrhea management (i.e. ORT and dietary practices) set it apart from other PHC interventions and make cul- tural knowledge particularly relevant. These include (1) the fact that management is primarily based in the home and controlled by the child’s caretaker, as opposed to services located outside the household; (2) it is focused on a specific category of maladies for which local terminology and explanatory models manifest extreme diversity; and (3) existing tradi- tional therapies for digestive disorders generally and diarrhea in particular are everywhere well-developed and firmly rooted in ethnomedical systems. Thus diarrhea treatment lends itself to contextual analysis, and at the same time, the focus on a specific illness domain has facilitated the application of systematic ethnosemantic research techniques which grew out of cognitive anthropology.

Parallels can be drawn between current anthro- pological studies of diarrhea and the cross-cultural research on family planning acceptability of the 1970s [14]. In both cases the health practice involves a consumable ‘technologic’ product provided through a multinational network of commercial, govern- mental and community distribution systems, and requires careful study of local knowledge, attitudes and practices for design of effective intervention programs. Use of mass media in promotional cam- paigns has been most prominent in family planning and ORT programs. Finally, the involvement of anthropologists in formal roles within international health organizations on projects related to diarrhea1 diseases is comparable to the earlier participation in family planning activities.

Methodologically, anthropological diarrhea re- search has centered mainly on standard ethnographic designs involving ethnomedical description. commu- nity analysis, case studies and cultural interpretation of specific beliefs and practices. What is noteworthy about this body of research is the development of more systematic and rapid procedures for data col- lection, analysis and reporting [15, 161. This devel- opment has been partly in response to role demands of anthropologists recruited to direct planning phase research on large projects. Indeed. an institu- tionalized role for anthropologists in formative re- search seems to be emerging as international health planners increasingly recognize the necessity for base- line ethnographic studies in design of interventions. This recognition has grown beyond the usual ‘back- ground’ view of cultural context to a focused, prac- tical analysis of specific illness concepts, semantic attributes, terminology and care practices that can influence adoption of new health behaviors.

This methodoiogic role has become increasingly formalized in multiphase studies typically involving an initial ethnographic study. followed by a commu- nity or population survey, and both feeding into the design of an intervention program. The ethnographic COmPOmIt usually provides data on ethnomedical context and gathers specific information for devel-

oping the survey instrument. One objective of the ethnographic phase is to assess the cultural z%alidit.v of key questionnaire items before the survey is conduc- ted. The ethnographic data are also used to interpret quantitative survey results and community reactions to the intervention. This emergent formalized role for anthropology in diarrhea research may serve as a model for involvement in PHC generally.

In addition to this qualitative methodologic niche. anthropological studies of diarrhea management have incorporated survey approaches from behav- ioral epidemiology, partly in response to the growmg interface between the disciplines of medical anthro- pology and epidemiology [17]. Usually focused on single communities, these surveys investigate home management practices in relation to specific illness episodes, generating data amenable to multivariate statistical analysis [18, 191. Thus far, however. an- thropological involvement in the intervention phases of large scale projects has been limited.

A few theoretical points can be noted about the anthropological study of diarrhea1 illness. The first relates to the locus of illness management in the home and the control of therapy by family members. Historically this is the first time that a therapeutic (as opposed to preventive) health practice based primar- ily in the home has received such intensive worldwide promotion. That is, ORT and dietary management take place almost exclusively within the popular sector of health care [20], which entails a range of issues which anthropology is particularly suited to address. Despite the fact that the majority of all health care occurs within the popular domain. com- paratively little attention has been given to it by medical and social scientists. Traditional public health approaches have met a serious challenge in attempts to influence home-based therapy such as ORT. and the social sciences offer useful perspectives for responding to this challenge. At the same time. the involvement of anthropologists in studies of home treatment for diarrhea provides an opportunity to expand our understanding of popular sector health care.

In many ways the ethnomedical model which dom- inates the following studies is a restatement of basic tenets of applied anthropology, and certainly the authors do not claim to have discovered new lessons. However, while earlier work in cross-cultural public health tended to emphasize cultural barriers to be- havior change, recent studies, including those on diarrhea, seem to place greater emphasis on the positive uses of cultural knowledge to enhance pro- gram success. The earlier approach has been referred to as the ‘conflict’ model [21], while the latter view might be more aptly called the ‘insight’ model. with greater affinity to currently popular social marketing strategies.

The following ten papers address four general concerns touched upon in this introduction. The first three present conceptual issues related to anthro- pology and PHC: Weiss reviews and develops a conceptual framework for anthropological diarrhea research; Kendall challenges the current dichotomy between selective and integrated PHC using a Hon- duran case analysis; and Nations and Rebhun ana- lyze the control of ORT in Brazil as a means for

Anthropological studies of diarrhea] illness 3

reinforcing hierarchical power relations in health care. The papers by Nichter, Mull and Mull, and Simpson examine the influence of indigenous beliefs and practices on receptivity to ORT programs in Sri Lanka, Pakistan and Costa Rica respectively. A community survey of ORT knowledge and use in Haiti is reported by Coreil and Genece, and Bentley describes patterns of ORT use and dietary manage- ment of diarrhea in India. Finally, methodologic papers by Scrimshaw and Hurtado, and by Bentley, Pelto et al. present guidelines for maximizing eth- nographic data use in large scale projects.

Overall, the papers in this issue constitute a valu- able contribution to the social science literature on diarrhea control and PHC. Documenting as they do the important contribution that anthropological un- derstanding makes to behavioral innovations in the realm of public health, they implicitly and success- fully make the case for an expanded role for anthro- pologists in the international health field. Hopefully future work will go beyond restating the basic lessons herein and apply the knowledge toward achieving the goal of Health for All.

1.

2

3

4.

5.

6.

REFERENCES

Snyder J. D. and Merson M. H. The magnitude of the global problem of acute diarrhea] disease: a review of active surveillance data. Bull. Wld HIrh Org. 60, 605613, 1982. UNICEF. Report on the Srale of the World’s Children. UNICEF, New York, 1985. Black R. E., Brown K. H. and Becker S. Effects of diarrhoea associated with specific enteropathogens on the growth of children in rural Bangladesh. Pedr 73, 799-805, 1984. Martorell R. and Ho T. J. Malnutrition, morbidity and mortalitv. POP. Devl Rm. suvvl. 10. 49-68, 1984. Walsh J: A. and Warren K. &*Selective primary health care: an interim strategy for disease control in devel- oping countries. New Engl. J. Med. 301, 967-974, 1979. Gish 0. Selective primary health care: old wine in new bottles. Sot. Sci. Med. 16, 1049-1024, 1982. Berman P. A selective primary health care: is efficient sufficient? Sot. Sci. Med. 16, 10541059, 1982.

7

8.

9.

IO.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

Unger J. and Killingsworth J. R. Selective primary health care: a critical review of methods and results. Sot. Sci. Med. 22, 1001-1013, 1986. Rifkin S. B. and Walt G. Why health improves: defining the issues concerning ‘comprehensive primary health care’ and ‘selective primary health care’. Sot. Sci. Med. 23, 559-566, 1986. World Health Organization. Interim Programme ReDorf--1986. WHOICDDi87.26. WHO. Geneva. 1987. Foster G. M. Anthropological research perspectives on health problems in developing countries. Sot. Sci. Med. 18, 847-854, 1984. Bloom A. L. and Reid J. (Eds) Anthropology and primary health care in developing countries. Sot. Sci.

Med. 19, No. 3, 1984. Kendall C., Foote D. and Martorell R. Ethnomedicine and oral rehydration therapy: a case study of eth- nomedical investigation and program planning. Sot. Sci. Med. 19, 253-260, 1984. World Health Organization. Guidelines For The Train- ers of Community Health Workers on the Treatment and Prevention of Acute Diarrhoea. WHO/CDD/SER/IO. 1. WHO, Get&a, 1980. A Manual for the Trearment of Acure Diarrhoea. WHOICDDISERI80.2 REV. I. WHO, Geneva, 1984. Marshall J. F. Acceptability of fertility regulating meth- ods: designing technology to fit people. Prm. Med. 6, 6573, 1977. Bentley M. E. ef al. Rapid ethnographic assessment: applications in a diarrhea management program. Sot. Sci. Med. 27, 107-116, 1988. Scrimshaw S. C. M. and Hurtado E. Anthropological involvement in the central American diarrhea1 disease control project. Sot. Sci. Med. 27, 97-105, 1988. Janes C. R., Stall R. and Gifford S. M. (Eds) Anrhro- pology and Epidemiology. Reidel, Dordrecht, 1986. Bentley M. E. The household management of childhood diarrhea in rural North India. Sot. Sci. Med. 27.75-85, 1988. Coreil J. and Genece E. Adoption of oral rehydration therapy among Haitian mothers. Sot. Sci. Med. 27, 87-96, 1988. Kleinman A. Parients and Healers in the Context of Culture. University of California Press, Berkeley, Calif., 1980. Foster G. M. and Anderson B. G. Medical Anthro- pology. Wiley, New York, 1978.