Brown_Ch_41_(Dettwyler) - 41 alnutrition in Mali therine A...

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Unformatted text preview: 41 alnutrition in Mali therine A. Dettwyler - Medical anthropological research dealing with nutritional J tissues is. almost by definition, biocultural in its approach. [What foods people eat and how much they cat are deter- ' .mined not simply by hunger, a biological drive, but more bnportantly by politicalvecological factors that determine I. --the availability offood and cultural factors that shape the ' -.-acceptability and preparation of food. As we saw in selection ' .4 by Reynaldo Martorell, which questioned the “small but ‘ healthy" hypothesis, nutritional anthropologists must be concerned about measures of childhood growth and develop— nutritional intake. Researchers can assess the nutritional status of children by using standards. like the National Center for Health Statistics (NCHS) standards used in this selection. Undernutrition takes two forms. First is overall protein _ and calorie deficit, as described here in case studies from the 1 African country of Mali. Marasmus, a type of overall wast- ' ing, and kwashiorkor, an illness of protein deficiency often related to weaning, are particular types of malnutrition. ln the poor countries of the world, there is a well—documented 1., ' relation between undernutrition and infectious disease. 1 7; Poorly nourished children have a harder time recovering from bouts of infectious disease, while at the same time ill- ._ ness episodes slow growth rates. This situation is often _ tr found in relation to inappropriate infant formula feeding wherein babies may be given an extremely diluted solution of “milk” made with water that is full of pathogens. The in- teraction of disease and malnutrition means that under- weight children are more likely to die, as was sadly noted by the Brazilian shantytown mothers studied by Nancy _ I Scheper—Hughes in selection 40. i Malnutrition can also be the result of the lack of a spe- 1 rifle micronutrient such as iodine or vitamin A; a severe de- 1 ficiency of iodine, for example, can result in goiter and . I. mental retardation {Fernandez 1990; Greene 1977). Such ' L‘onsequences can be avoided by relatively simple programs --|-,'; -. rm. 1—— _ I Jr. _ . a. .l-n‘ o ——..-'-—-y--..—..—... __-.-.-Mls_ ' ment. Such measures reflect the biological consequences of e Biocultural Approach in Nutritional I .- nthropology: Case Studies of of adding iodine to salt. Whether such well-aimed "magic bullets" will do much to solve problems of world hunger, however, is another question. In this selection, Katherine Dettwyler provides individ- ual case studies ofchild malnutrition in Mali. These are like the cases she describes in her book of anthropological field- work, Dancing Skeletons (I 994). Mali is one of the poorest countries of the world, and as a consequence both child mal— nutritiOn and death rates are very high. This selection demonstrates that the relationship between socioeconomic status and malnutrition is not simple, for some of the cases here are the children of low-status mothers within a rela— tively prosperous extended family household. The vast ma- jority of malnutrition in Third World countries does not have a single identifiable cause. Local agricultural produc- tion and the marketing offiiod are central factors, but issues regarding the status of women or cultural rules about child feeding also must be considered. As you read this selection, consider these questions: I What are the particular situations of these Malian mothers and children that result in child malnutrition and early death? in any one of these cases, how might these tragic outcomes have been avoided? I Why is this study of malnutrition considered biocul— tural? Are there culturaifactors that might not get in- cluded in regular nutrition surveys? I What does the author mean when she says that in many instances children are severely malnourished because they “havefallen through the safety net of overlapping support systems that normally ensure a minimum level of nutrition and health for children in the commu- nity"? Why is she impressed that the traditional sys- tem is actually working? I Do you think it is relevant that two of the case studies are of twins? 389 390 Culture and Nutrition: Fat and Thin ocioecononiic status is often cited as the most im— portant factor influencing nutritional status in chil» dren, and, in general, national rates of malnutrition are negatively correlated with_per capita income. As Pryer and Crook (19885) have stated, “Appalling en— vironmental conditions and intense poverty are likely to be the two most important determinants of health and nutritional status of the slum and shanty town dwellers in many of the cities of the developing coun- tries." Although not disputing this conclusion, a num- ber of ethnographic studies have highlighted the role that cultural beliefs and practices regarding infant feeding and care also play in determining health and nutritional status in young children (Daniggelis 1987a, 1987b,- Guldan 1988; Hull and Simpson 1985; Marshall 1985; Zeitlin and Culdan 1988). The work of Zeitlin and her colleagues has fo- cused on the role of psychosocial and behavioral as- pects of child care and feeding in determining “positive deviance" in child health—those children who manage to thrive under conditions of environ- mental adversity (see Zeitlin, Ghasaemi, and Mansour 1990 for a review of the literature on positive de- viance). Others have focused on attributes of those children who fare particularly poorly under such con- ditions, including how they are perceived by their caretakers. For example, in a study of childhood deaths in northeastern Brazil, Scheper-Hughes found that mothers “gave up" on severely malnourished children and neglected them until they died (Scheper- Hughes 1987). Likewise, Mull and Mull report that among the Tarahumara of Mexico, children who are perceived as being "handicapped" may be allowed to starve to death, or are killed outright (Mull and Mull 1987). in Kenya, de Vries (1987) found that Masai in- fants who cry a lot are perceived as being fighters, with the personality and will necessary to survive the harsh conditions of life. These children are given more attention and nursed more often than quiet, placid ba- bies. The quieter babies thus suffer and die more often from malnutrition. The work of Bledsoe, Ewbank, and Isiugo—Abanihe (1988) and Bledsoe (1991) has focused on intrahouse- hold food distribution patterns and the effect of being a foster child on access to food and health care resources, growth, and health among the Mende of Sierra Leone. Bledsoe finds that, compared to “born” children of the household, young "fosters" have less access to food re- sources but are expected to perform more labor (Bledsoe 1991). Fosters also suffer more from malnutri- tion, but are ta ken to the hospital less often than "born" children (Bledsoe, Ewbank, and lsiugo-Abanihe 1988). These examples could all be described as in- stances of "socithntion," a term coined by Gokulanathan and Verghese to refer to growth fail- ure in children that is “due to factors other than poverty and the lack of availability of food materials" (19692118). Research in Mali (West Africa) suggests that sociocultural malnutrition contributes to the over- all malnutrition picture. A number of studies in Mali have compared expenditures for food and dietary in- takes of groups at different levels of socioeconomic status and from different parts of the country. All of these studies have concluded that relative income is not closely related to diet in Mali (Diakite 1968; C lairin et al. 1967; May 1968; Mondot-Bernard and Labonne 982). Members of all social classes consume the same éoods in the same quantities, and rising income is not orrelated with an increase in quantity or an improve- ment in the nutritional quality of the diet. In 1982 and 1983, and again in 1989, the author conducted research in a periurban community in Mali, focusing on the relationship between infant/ child feeding beliefs and practices and the growth and de- velopment of Children. The 1982—83 research was based on a mixed-longitudinal study of 136 children under four years of age. The 1989 research included a follow-up study of the children in the earlier sample. Previous publications based on this research have de- scribed the systems of beliefs concerning infant and child feeding practices (Dettwyler 1985, 1986), breast- feeding and weaning (Dettwyler 1985, 1987), the role of anorexia in malnutrition (Dettwyler 1989a), infant feeding styles (Dettwyler 1989b), and the relationship between relative poverty and nutritional status and growth in the entire sample (Dettwyler 1985, 1986). Treating the growth data in cross section, average growth for all children in the 1982—83 sample during the first three years of life corresponds closely to the fifth percentile of NCHS standards (Hamill et al. 979; . . .). A few children were growing at or above the NCHS fiftieth percentile, even though they came from relatively poor families (cf. “positive deviants,” Zeitlin, Ghassemi, and Mansour 1990), while others were well below the fifth percentile, including some from relatively well-off families. The children in the latter group can be described as having fallen through the safety net of overlapping support systems that normally ensure a minimal level of nutrition and health for children in the community. The data clearly indicate that relative poverty is not an accurate predictor of the observed variation in nutritional status and growth in this community, 3119 that differences in maternal attitudes, experience, anti er factors are responsible (Dettwyler 1986). in Mali; these factors include maternal age, marital problems, treated illness, allocation of household resource-f" maternal attitudes, maternal competence and experi‘ .mtgwcacH- . .._. - a._.._.._ -fl I ’ support networks, and the position of the mother _.. thin the social structure of a polygynous, patrilineal my. In this paper, case studies of three families from . research community illustrate how sociocultural Immunition in young children in Mali can be viewed a consequence of the interactions among many fac- ;. I value of a biocultural approach in which detailed ..-.-.. ographic data, gathered in conjunction with tradi- .:"nal anthropometric measurements, can illuminate ' DEMOGRAPHIC AND ETHNOGRAPHIC BACKGROUND 0F THE SAMPLE , The study community of Farimabougou (a psoudo— nym) is one of approximately ten periurban communi- ; fies located across the Niger River from the capital city of Bamako. During 1982 and 1983. a sample of 136 children were visited every four to eight weeks. The sample was constructed in a flexible, random manner, by walking the streets of the community, looking for families with young infants (not yet eating solid foods), explaining the project, and recruiting families willing to cooperate over an extended period of time. The study compounds were widely distributed and included all sectors of the community. A few infants, usually from neighboring compounds, were added to the study at the request of their mothers. Only three families dropped out of the study due to lack of inter— est. Several families were dropped because the index infant died during the measles epidemic that occurred during the month of the study. The final sample of 136 children came from 117 compounds and in- cluded 20 sibling pairs. Growth data were collected at each visit, and mul- tiple, semistructured interviews of mothers and other Caretakers, as well as participant-observation of child feeding activities, were used to collect data on infant feeding beliefs and practices and infant health. Growth data included anthropometric measures of weight, and of arm, head, and chest circumference, as well as number of teeth erupted and general stage of motor and language development. Exact ages were {determined from birth certificates, and the records of the local maternity clinic provided birth weights for some of the children.1 All interviews were conducted by the author in Bambara, the native language of most 0f the informants, with the assistance of a Malian in- terpreter. A follow-up study of the same children was Conducted in 1939. Approximately half of the children Malnutrition in Mall 391 were relocated, measured again when possible, and their mothers interviewed again. A brief description of the community will provide a wider context for the case studies that follow. Tradi- tionally, the Malian economy has been based on subsistence agriculture. Bamako and Farimabougou, hOWever, operate primarily on a cash economy. Most food is purchased in the daily market using cash ob- tained from the wage labor of fathers and, occasion- ally, mothers. Farimabougou is a poor community. In 1979, the World Bank defined the "urban poverty threshold" for Bamako as approximately $60.00 per month per household, and reported that the average income in Farimabougou is 40 percent lower than that of Bamako, with almost half of the households in Farimabougou below the urban poverty threshold (World Bank 1979). in terms of ethnic identity, the parents of children in the study identify themselves primarily as Bambara or Mandinka (67%); the rest are divided among Fulani, Senoufo, Songhrai, Bobo, and Dogon. According to information provided by the Institut du Sahel (T. T. Kane, pers. com. 1989), in 1989 Mali had a crude birth rate of 4771,000 and a crude death rate of 20/1,000, resulting in a natural growth rate of 2.7 percent. The infant mortality rate was 130/ 1,000, and the juvenile mortality rate was 159/ 1,000. Life ex- pectancy at birth was 47 years. The average number of births was 6.7 per woman. Data for these variables spe- cific to Farimabougou do not exist. During the 1982—83 study in Farimabougou, the average age for the introduction of solid foods was 7.9 months, with 14.4 months as the average age when children began eating the adult staples (millet and rice). The average age of weaning was 20.8 months, and women experienced an average duration of lacta« tional amenorrhea of 10.1 months. The average preg- nancy interval was 19.4 months, and the average interbirth interval was 26.5 months. Two of the caSe studies reported here involved twins. According to local maternity clinic records, the rate of twinning in Farirnabougou was 17.8/ 1,000 births in 1981 and 1982; this is almost identical to the rate reported by lmperato for the Bambara and Mandinka (17.9/ 1,000). According to lmperato: Twin births are extremely common among the Bambara and Malinke . . . Because twins are regarded among the Bambara and the Malinke as a blessing bestowed by the supreme being, their birth is received with great rejoic- ing. {lmperato 1977:119) in terms of child care in general, and infant feeding practices in particular, twins are not treated differently 392 Culture and Nutrition: Fat and Thin from single births. Twins often start life smaller than singleton births, and must share one mother’s milk. In two of the case studies below, being a twin undoubt- edly adds yet another risk factor for malnutrition. At the same time, other sets of twins in the sample sur- vived and flourished. in 1982453, the houses in Farimabougou were mostly of mud-brick construction with corrugated iron roofs and were located inside mud-walled com- pounds that were closely packed along narrow dirt streets. Compounds had neither rimning water nor electricity. Each compound had a pit latrine. House— hold garbage was thrown into a pit inside the com- pound, or out into the street. The Malian diet is baSed on millet and rice, accom- panied by various satires. Animal protein in the diet comes from beef, mutton, or fish, which are often pounded before being added to the sauce. According to several food consumption surveys, with the excep- tion of years of severe drought and of certain areas of far northern Mali, adult Malians have an adequate diet (Clarin et al. 1967; Diakite 1968; May 1968; Mondot—Bernard and Labonne 1982). The traditional social organization of the Bambara consists of extended families living in large com- pounds, polygynous marriages, patrilineal descent, and patrilocal residence (N’Diaye 1970). This type of compound social organization is seldom realized in Farimabougou. Usually only one adult male from a rural family migrates to the city, and he usually has only one wife clue to economic constraints. "Thus, most of the children in the larger sample came from parents in monogamous marriages and lived in compounds containing only nuclear family members. Except for a few Christian families, the people of Farimabougou are Moslem. For the most part, how— ever, women do not strictly follow Muslim teachings. They are not secluded, they seldom go to the mosque or pray at home, they rarely fast during Ramadan, and they are not familiar with Koranic guidelines concern- ing infant feeding. Islamic beliefs coexist with tradi- tional religious beliefs and practices. Sickness and death are usually attributed to Allah rather than to or- ganic causes, witchcraft, or sorcery. The maiority of women who participated in the study were born in rural villages and had lived in the urban environment for less than 20 years at the time of the initial study. They have had little or no formal edu— cation, speak Bambara but not French, and can neither read nor write. Health services for the residents of Farimabougou re provided primarily by traditional herbalists who “ell leaves in the market, and by a government-run I’MI (maternal/ child health center} located approxi- ately three kilometers away. Although the PMI visits re free, the numerous medicines that are usually pre- cribed are very expensive. Most children are born at e PMI, but mothers do not often take sick children to the PM for treatment, preferring to try traditional cures first. The nearest hospital is located in down— town Bamako, at least 20 minutes away by public transportation. In 1982—83. few children had been vac- cinated against any of the major childhood diseases, and oral rehydration solution as a treatment for diar- rhea was virtually unknown. Measles, malaria, upper respiratory infections, and diarrhea were the major ill- nesses of young children. According to Imperato, who has written in detail about traditional Bambara beliefs concerning measles: Measles is the most important diSease of childhood in Africa. It occurs throughout the continent, the inci- dence being highest in most areas every third year. Measles epidemics occur at the peak of the dry season in West Africa, from March through May, when stores of food and human nutritional levels are at their low- est. . , From 1958 through 1975, the annual number of measles cases reported in Mali has ranged from 10,000 to 40,000, with case mortalities of 15—20 percent. (Imperato 19771138) A serious outbreak of measles occurred during the ini- tial study in May of 1982. There were only a few cases of measles in 1983. Malaria affects children primarily during the rainy season Only—September). Only one child death was at— tributed to malaria during the initial study. Of the seven child deaths that occurred between the two stud- ies, four were reported to be due to malaria, and three to measles. In general, women welcome new pregnancies. Children areviewed as a source of wealth and prestige; the more children you have, the higher the family in— come will be, the more people there will be to support you when you are old, and the higher your status as a wife. Infertility is considered a tragedy. The Bambara believe that it is good luck to have a female child first. but both male and female children are valued. The growth data as well as interview data reveal no signifi- cant sex bias in terms of nutrition or health care. Thus, being a female is not a risk factor for malnu...
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