Inr. J. Nun. Stud.. Vol. 27, No. 4, PP. 343-353. Printed in Great Britain.
1990.
0
00X-7489/W $3.00+0.00 1990 Pergamon Press plc
Nepal: integrating traditional and modern health services in the remote area of Bashkharka ANJU
SHARMA
and JANE
ROSS
Faculty of Nursing, University of Alberta.
Abstract-Within a framework of Primary Health Care (PHC) and Health Promotion (HP), the focus of this paper is on integrating traditional and modern health care in the remote area of Bashkharka, Nepal. The relevance to integrated health care of factors such as geography, ethnicity, religion, national infrastructure and international development agencies are discussed. Issues concerning the relationship between the theory and practice of PHC and HP are raised.
Introduction
Primary Health Care (PHC), which was officially launched by the World Health Organization (WHO) in 1978, has become an attractive model for international health. With comprehensive aims and flexible structure, it heralded pervasive, low-cost health care relevant to the needs of local communities and people in any country. Health Promotion (HP), adopted by WHO in 1984, correlated well with PHC and provided additional scope for sustaining health and primary health care. Primary Health Care called for the recognition and incorporation of indigenous medical systems while Health Promotion emphasized the need for increasing knowledge and disseminating information based on the public’s experience of health and how it may be achieved (Kickbusch, 1984). The rhetoric of these complementary approaches has been extensive. Implementation of the models, however, appears difficult for a range of complex reasons. Recognizing the fundamental role of nursing in Primary Health Care and Health Promotion, this paper discusses some of the reasons that make their implementation so difficult in Nepal. It indicates that diverse methods and theories (such as economics, development, anthropology and gender) are helpful for modern nursing practice which, in cooperation with other disciplines, attempts to achieve ‘Health for All’. An early draft of this paper Health, University of Alberta,
was presented to the interdisciplinary 4 April 1989. 343
class: A Survey of Issues in International
344
A. SHARMA
AND
J. ROSS
Nepal is a country where PHC has been officially adopted and where the rationale of HP influences attempts to integrate traditional and modern health care. Although the focus of this paper is on integrating traditional health practices and modern health care in the remote area of Bashkharka, an overview of the country and health services is necessary. Geography
Nepal is a relatively small developing country in the heart of Asia, lying against the Himalayas between India on the south and China to the north. It has an area of 147,181 sq. km (Regmi, 1988). On the basis of altitude, the country has three natural geographical regions (Fig. 1) which impose deterrents to health and health care delivery. (i) Himalayan region: contains the world famous peaks of Mount Everest (8,848 m). This is a cold region where many parts are permanently snow covered. (ii) Terai region: the most arable land in Nepal, however it occupies only 17% of the total flat land area. (iii) Mid-mountain region: occupying 68% of total land area and containing the capital city of Kathmandu and its surrounding arable lands, it raises major challenges for PHC and HP. Despite available land and food, nutritional status is inadequate and protein intake is particularly low. A study of malnutrition in Kenya by Olenja (1984) illustrates the importance which culturally based nutritional research has for health promotion. Olenja’s study shows that the presence of nutritional food and the provision of health information is likely to be ineffective unless people can afford to eat the food that is produced and can understand health education in terms of their own world view. Based on her research, Olenja asserts that the poor are quite amenable to change if they can afford it and can understand the benefits available. Bashkharka, is located in this region, 85 miles from the capital. In Bashkharka and its surroundings, there are no motorable roads or airlink services so it is especially hard to provide health care to the people living there. The value of community centred primary health care in such a place cannot be over-emphasized.
?ashkharka ?
Fig. 1.
INTEGRATING
TRADITIONAL
AND MODERN
HEALTH
SERVICES
345
Administration and development planning The country is divided into five major developmental regions and 75 districts encompassed within 14 zones. This divisional structure is important for health and health care delivery as follows: the development regions are responsible for planning and implementing programmes for the control of disabling diseases (e.g. malaria, leprosy, infectious diseases) which are present in all the regions, and for integrating the health sector with other sectors (e.g. food production, agriculture, animal husbandry, environmental sanitation) in the interests of improving conditions. This is an expensive undertaking in which international agencies are welcome to assist with disease control/prevention and health promotion, especially in the rural areas. Economic resources Although Nepal is landlocked it has a strong resource base derived principally from forests and agriculture. Forests, which cover about one-third of the total land area, yield products such as timber, bamboo, indigenous paper, herbs and drugs. Agriculture, accounting for 93% of the population’s livelihood, includes the main crops of rice, maize, millet, wheat, potato, sugar cane and oil seeds (especially mustard). The implications of population distribution in achieving health-for-all, a main tenet of PHC, beg consideration and research. Mountain agriculture “requires tremendous labor inputs for much lower levels of productivity than realized in plains regions” (Levine, 1988: p. 232). Consequently, in upper regions, where food is most scarce, the relationship between energy output and food intake appears to be an inverse one. Tea, produced as a limited cash crop, is generally exported to developed countries in exchange for hard currency. Money generated from cash crops, however, may not contribute favourably to the economic growth of the country due to limited production and differential access to outside markets. Recently, cottage industries, tourism and carpet making have been emerging as a source of income for people in remote as well as urban areas. Although the export of carpets to developed countries is a remunerative industry, there are social (Fricke, 1989) and health hazards associated with this type of work (Burra,‘1990). Women for example, are primarily hired for this low-paying work from which chest infections and chronic coughs can result in response to prolonged inhalation of wool fibres. Theoretical analysis of economics and PHC can, at this point, become deep and far-reaching. Dependency theory (Godelier, 1977) and Development/Underdevelopment theory (Frank, 1980) pertain. Briefly, they hold that international market forces increase the dependency of local communities and economies on market centres external to a country. The impact of international market forces on primary health care in a subsistence setting such as Nepal can be drastic, especially when the downward pressure intensifies on women to marginalize them further. Population: religion, culture and beliefs The population of Nepal includes high-altitude inhabitants (Mongloid-Stock/Sherpas, Tamang, Kirantis), mid-mountainous people (Tamang, Magars, Tharus, Danuars, Chepang) and the low land dwellers (Indian immigrants) in a rich and sometimes complicated mix of customs which can have great impact on health and health care practices. In order to provide appropriate health care in remote areas such as Bashkharka a good knowledge of the clients’ ethnic group, their beliefs about health and disease, their language and religion is essential. The main religions of Nepal are Hinduism (90%) Buddhism (9Vo), Muslim and Christian (1 To).
346
A. SHARMA
AND
J. ROSS
Language The official language of the country is Nepali but different languages are spoken from region to region and also within the same region. Few people in Bashkharka speak Nepali because they are not exposed to its use. Without a common language, and relying on translators, it is difficult for health personnel to help people understand health, disease prevention and health promotion. Without a common language, it is likewise difficult for the people to express their health needs to health personnel and for health workers to determine whether or not the people understand what is taught. Political system The political system plays a major part in the development of national health, education, transport and communication systems. Until 1951, Nepal had an autocratic government which did not facilitate development of the country as a whole. During this period the people were isolated inside the country by political decree, without access to foreign aid or contacts with people from other countries. After 1951 a democratic system of government emerged which changed the overall situation by opening the country to substantial foreign assistance. People were then allowed to obtain higher education within and outside the country. Concern about the health of all the people began to evolve along with plans for improved systems of transport and communication, all of which are necessary for effective health care (Wood, 1967). Transport and communication Although transport and communication have been expanding steadily since 1951, geographical conditions and the cost of improving these systems have been deterrents to rapid progress. In Bashkharka the land is extremely rugged, making health care inaccessible to most people. People often walk two to four days to get to a health post, and goods (including drugs) must be transported from one place to another on backs of the people. It is not uncommon for sick persons to be brought for treatment on the backs of others. In this situation, the equal access to health care (within 10 km) advocated by PHC, is far from a reality. Education Ninety-two per cent of the people live in rural areas and do not have equal access to education facilities enjoyed by those who live in the urban area. (Regmi, 1988). With a literate population of only 33%, Nepal is facing the major problem of lack of awareness about health and healthy living. While the links between literacy and health seem apparent the scientific relationship is not well demonstrated. Nonetheless, to assist development, people must become literate. Although education has been a priority for politicians and health care administrators of Bashkharka-who know that education contributes to improved health-progress is slow. Without education, ‘health’ may have little or no meaning. For example, Sharma found people commonly do not believe that flies transfer disease, so, to them, it does not matter if flies sit on their food. They say, “Flies are so little, how can they be bad? Let them sit”. Compounding rural/urban inequities in education are those related to gender and education. People in remote areas still believe that girls should not be educated because they are meant to do the household work, look after cattle and work in the fields. It is this customary belief which holds the percentage of rural girls attending school as low as
INTEGRATING
TRADITIONAL
AND MODERN
HEALTH
SERVICES
341
1%. Primary Health Care and Health Promotion for rural women, then, should be designed in ways congruent with custom. This may well mean moving health education classes to the farm settings where the women work and linking health concepts to their own values. In urban areas equal educational opportunities theoretically exist for boys and girls. Health Care System in Nepal
A range of therapeutic treatments used in Nepal are also practised in Bashkharka: (i) traditional medicine, (ii) ritual healing (Dhami and Jhankari), (iii) Ayurvedic medicine and (iv) Western medicine. Sharma found that people often mix therapies combining Western medicine with traditional medicine or ritual healing (Dhami-Jhankari) in a hierarchy of alternatives (Nyamwaya, 1982) or resorts (Kleinman, 1980; Schwartz, 1969). Dhami-Jhankari
Both rural and urban people seek Dhami-Jhankari ritual consultation for psychological or psychiatric problems believed to result from the ill effect of an ‘evil eye’ or ‘bad star’. These clients are not treated with medical therapy but are advised in the worship of different gods. People may consult Dhami-Jhankari many times, paying a minimum amount (e.g. rupees 10 equaling about 20 pence sterling) for each visit. If symptoms persist after some months of consultation, a person may see a psychiatrist. However, there is social stigma associated with psychiatric problems so a psychiatrist is avoided if possible. Dhami-Jhankari is valued because it is a discreet consultative and treatment process. Ayurvedic
medicine
For minor conditions such as coughs and colds, to major diseases such as heart disease and diabetes, people of all socio-economic classes commonly select Ayurvedic (homeopathic) medicine, a situation which is similar to health seeking in India (Baer and Bruinsma, 1988). While Ayurvedic treatment appears simple it requires its own expertise. A common treatment involves mixing herbal powder such as cumin or cloves with water to alleviate abdominal cramps. The work of Ayurvedic practitioners is based on the fundamental premise of ‘Triddosa Siddantha’, the principle of three natures or humors (Coburn 1987). According to Triddosa Siddantha, health, disease and body types are controlled by the balance of: (i) wind-the nerve humor, (ii) bile/blood-circulatory humor and (iii) water-the mucous or digestive system humor. The objective of Ayurvedic practitioners is to identify, establish and maintain this individually identified balance for each patient. There are many reasons why people opt for Ayurvedic treatment. First of all, the client does not have to pay for seeing the Ayurvedic practitioner and treatment is available to those who seek it; its availability is sustained because it is not imported. Moreover, patients do not have to undergo extensive tests prior to treatment and they find the treatment effective for specific problems (e.g. jaundice, abdominal and chest complaints). In a study comparing Ayurvedic and biomedical treatments for infective hepatitis, Coburn (1987) found that patients receiving Ayurvedic treatment were cured sooner than those receiving modern medicine. Modern
health care
All hospitals and health posts in Nepal are run by the government and there is, as yet, no insurance system. The family has to bear all sickness and hospital expenses except for
348
A. SHARMA
AND
J. ROSS
doctors’ hospital visits and nursing care. Medical care of poor people may be provided if financial assessment, made at the time of admission, indicates their inability to pay. Medical and nursing personnel make this assessment by enquiring about the livestock (cattle, goats, chickens, ducks) and land held by clients and their families. Health care is not generally accessible to remote people even though a system of health posts, based on population density and the natural geographical divisions, has been set up with provisions for referral. The mid-mountainous region including Bashkharka has 10,000 people per health post, the Terai region has 15,000 people per health post, and the Himalayan region 5,000. The referral system does not work well because of clients’ low economic status and their consequent inability to pay for services, and the fact that government doctors often have private practices, a situation which means that a system of informal access to medical doctors exists outside the public health system. In PHC, nurses are beginning to integrate useful traditional practices into the modern health care system by training Health Assistants (HA) and Community Medical Auxiliaries (CMA) for preventive measures, and Auxiliary Nurse Midwives (ANM) for maternal/child health work. According to government PHC policy, there should be one HA or CMA, one ANM, and a ‘peon’ (to keep the clinic clean) at each health post. Implementing primary health care policy with the staff available, however, has been difficult on a number of accounts. In reality the peon often tends to act as a health worker and may unofficially take charge of the health post (Justice, 1983). The peon has more contact with community members than other health personnel and is seen as one who, because of association and local experience, knows about illness and health matters. Justice (1983) found the peon giving injections, doing dressings and carrying out other tasks in remote areas as well as in the government hospital at Kathmandu. Although Justice may have mistaken ‘compounders’ (those who do injections and change dressings) for peons in some cases, the informal health worker obviously has value to local people. ANMs, who are trained to render maternal/child services in the remote areas, often are not accepted socially and culturally because they are strangers to their assigned work places and because of cultural mores holding that young women should not live by themselves.* Problems are likewise noted in the supervisory system: Public Health Nurses (PHN) stationed at the district level should support and supervise ANMs at least once a month in each health post. Justice (1984) found, however, that PHNs tended to supervise the health posts only once in a two year term. Even in health posts which were, theoretically, accessible by roads, supervision was not carried out because, in reality, there was no transport. PHNs were, also, frightened that they would be robbed while carrying out their duties. There were other reasons for the apparent failure of the system: the allowance of the female PHN was less than that of the male health inspector, inservice education was lacking and there was inadequate support provided to the PHN by the central administration at Kathmandu. Stone (1986) notes that Primary Health Care has other problems: (i) it fails to appreciate villagers’ values and their perceived health needs, (ii) PHC has tended to view Nepali culture as a barrier to health education, and (iii) PHC has mistakenly assumed that rural people indiscrimately follow traditional practices. While PHC is organized primarily to provide health education, Stone found that villagers value modern curative services and feel little need for new health knowledge. *A similar situation involving discrimination Schuster (1981) in her Zambian study.
re. nurses’ age and origins
outside
the community
is reported
by
INTEGRATING
TRADITIONAL
AND MODERN HEALTH
SERVICES
349
Traditional medicine: practices and beliefs It is imperative to remember that traditional medicine remains the only source of health care for many people in the developing countries (Bannerman, 1982). There are numerous traditional health practices, including rituals, which should be documented. Inappropriate practices should be discouraged while useful practices are encouraged and integrated into modern health care. Given the high infant mortality rates, it is not surprising that rituals to protect child health have emerged. Examples, therefore, are drawn from child care to illustrate the relevance which knowledge of traditional customs has for Primary Health Care and Health Promotion. Among the many child rearing practices, oil massage ranks prominently. Although commonly practised, the physiological effect of oil massage on Nepali infants has only been reported descriptively* (Reissland and Burghart, 1987). Nepali mothers, however, say that oil massage helps children to sleep well, eat well and gain weight.? Empirical observation in Nepal indicates that crying babies are not a concern; this may be because they are very much cuddled and caressed or because crying is viewed as normal and therefore not irritating to care givers.S In their descriptive account of oil massage among the Maithili of North India and West Nepal, Reissland and Burghart (1987) report that babies are massaged and placed in the sun for two or three hours every day until they are five or six months old in order to soothe and strengthen the muscles and bones. The uterus, say the Maithili, is a small place where the living conditions become increasingly damp and cramped for the fetus as the months pass by. Massage, therefore, preferably with mustard oil, is needed to relieve the effect of these conditions and make the child invulnerable to danger. Nepalis believe that the oil used in massage is absorbed by the skin, adding to the fatty tissue in the body. In an area where food security is often problematic and infant mortality is high, local people value this practice in the assuagement of threats to infant life. Until now research has not examined the functional aspects of this assumption. Head and face shaping is a second important child rearing practice. To achieve the desired shape, infants are put to sleep on pillows filled with mustard seeds which conform to the head and shape it. To achieve high noses and wide foreheads, marks of beauty in Nepali men and women, children’s faces are massaged for shape. When considered in terms of their application to health, oil and shaping-massage appear effective for mother/infant emotional attachment and conducive to motor development. There are some practices of doubtful therapeutic value such as feeding children ginger, celery seed or garlic (separately or in combination) to produce body heat and relieve coughs and colds. An inappropriate practice is the withdrawal of most vegetables from breastfeeding mothers because they are thought to cause infant diarrhoea and colds. Reissland and Burghart (1987) report that children are held upside down and swung in the air to reduce childhood fears, a custom which likely does not reduce fear and may in fact be injurious to babies. In many ethnic groups, solids and salt are ceremonially introduced (at *In the West back rubs are commonly given to adults to stimulate circulation in tissues under pressure and in muscles at rest, and for their sedative effect (Temple, 1967). Longworth (1982) found that slow-stroke back massage produced physiological responses in females (e.g. heart rate, skin response and skin temperature). tin a Philippine study (Porter, 1972) massage was associated with better weight gain in children. Mothers in the American study of Booth ef al. (1985) reported that massage quietened their babies. SElliott’s paper (1990) stimulated interest among third world participants (Ethnography of Childhood Workshop, 1987) who wondered why infants’ colic and crying are problematic in western societies.
350
A. SHARMA
AND
J. ROSS
five months for boys and six months for girls) to the infant’s life and diet during the rice ceremony (Levine, 1988). If rice takes the place of other foods, the child may not sustain optimum growth and development. A practice which seems innocuous but may be detrimental to infant health is that of touching a febrile baby with a mixture of uncooked rice and turmeric powder before sprinkling the mixture liberally around the house (in the evening) to curtail the startle reflex and alleviate fever (both thought due to the evil eye). When this custom prevents family members from understanding and implementing effective medically supported measures for fever reduction it may contribute to a deteriorating condition of the baby. Sharma observed in a children’s hospital that illiterate parents did not understand intravenous infusion and oral rehydration therapy in the treatment of diarrhoea: “Whenever we started I.V. therapy they would just remove it. When they see that watery diarrhoea they think that giving more fluid to the child will cause more diarrhoea.” By understanding the principles of the traditional system, steps can be taken to establish health care that reaches everyone, including the children who are the most vulnerable. International assistance: the contribution of two nongovernment organizations (NGOs) Foreign assistance has become an important factor in the development of Nepal and some projects are particularly effective in linking foreign resources with local needs. With respect to primary health care, the projects of the Swiss Association for Technical Assistance (SATA) and Save The Children Fund (SCF), U.K., are noted for their appropriateness. In consideration of the geographical difficulties and socio-cultural factors limiting effective health outreach, the SATA funded a model school for training nurses in Jiri, close to Bashkharka. The purpose of the school is to train young women who will work in an area similar to the one in which they were born and raised. This training is appropriate and beneficial for Nepali nurses and community members alike as familiarity with the local situation assists both groups to be more receptive to the other. Especially in remote areas, people have great faith in traditional healers. Usually local, these traditional healers are the first therapy contact made by the family after which, if necessary, they are guided in seeking another therapy such as Dhami-Jhankari, Ayurvedic or modern medicine. Since traditional healers play such a vital role in the community, Save The Children Fund (SCF), U.K. has launched a PHC programme in Bashkharka which builds on existing resources by training traditional healers and integrating them into the modern health care system. The SCF programme emphasizes maternal-child health and supports the governmentrun health posts through the provision of supplies such as vitamins, antibiotics, injections, lotions, etc. When the project began clinic attendance was thwarted by local healers who felt threatened by the new venture, and frightened people into believing that use of modern medicine would result in death (Sharma, personal discussions, 1986-1987). To break the barrier between traditional healers and modern health care, negotiations were undertaken to incorporate the traditional healers into the PHC project. These healers were trained in essential skills such as the preparation of rehydration solution, simple dressings, making nutritious flour, and scabies treatment. They were also taught the importance of infant immunization and provided with slips for referring clients to the health post. In these ways the training conferred useful knowledge and increased status to traditional healers in the programme. As Werner (1977) suggests, health programmes should work with local healers to foster good community response.
INTEGRATING
TRADITIONAL
AND
MODERN
HEALTH
SERVICES
351
While visiting homes, Sharma observed that the trained healers were quite effective in their work and often more readily approved by families than were medical health workers. This is due, perhaps, to the fact that rural people are more confident in therapists who share social and religious history. As medical workers are strangers, there is always a gap between them and community members. By training existing healers SCF contributed to lessening the gap between traditional medicine and Western medicine, supporting mutal dependency.* Currently SCF is supporting a project developed by the Nepal Pediatric Society and Nepal Health Learning Materials Staff to edit guidelines for the management of common illnesses of children in Nepal (WHO/UNDP, 1989). Training of traditional birth attendants (TBAs) Although the focus of the nursing project established in Bashkharka was maternal and child health, there was a lack of attention to the health of mothers. As part of PHC the Department of Health, Nursing Division began to address the lack of female staff in Bashkharka by training traditional birth attendants. When nursing students were posted to Bashkharka in 1986 for twelve weeks community health,? one of their assignments was to integrate traditional birth attendants into the modern health care system in a manner similar to the project started by Save The Children Fund. For a training period of one week, selected birth attendants were taught to differentiate normal and abnormal fetal heart sounds, handwashing techniques (to which they were not accustomed), safe delivery (not pulling or pushing the baby), sterilization of knife and thread (to cut and tie the umbilical cord), and methods of delivering the placenta. Since most of the women could not read or write, the teaching was based on practical demonstration, group discussion, and pictures which could easily be understood.$ Integrative practices have not yet been evaluated comprehensively, but it can be inferred from teacher/student evaluations of the project that the integration of traditional birth attendants into modern health care is a step in the right direction. Pre- and post-training checklists indicate that the attendants’ knowledge and performance improved after training. Sharma observed that more children came to clinics after implementation of the PHC programmes, indicating that healers and TBAs were cooperating with health personnel in respect of treatment. They also participate in the process of health education by acting as village cryers, encouraging people to attend clinic for their health problems. Other effects were noted after the integrated programmes began: many families knew how to make rehydration solution at home, families who had suffered chronically from scabies appeared less infected, and the Bashkharka community reported that they had to sacrifice fewer animals to reward the healers. Conclusion
Although talk about “Health for all by the year 2000” is common, and the benefits of culturally based health promotion are espoused, primary health care is not available and *Similar projects have been tried elsewhere with varying results, for example in the Philippines (Caragay, 1982), Swaziland (Green and Makhubu, 1986), and South Africa (Edwards, 1986). Wee Post-Basic Community Health Curriculum (1986). Tribhuvan University Institute of Medicine, Nursing Campus, Maharaygung, Kathmandu. SSimilar approaches are used to train traditional birth attendants in Sierra Leone (Ross, 1988), Nigeria (Brink, 1982) and elsewhere.
352
A. SHARMA AND J. ROSS
accessible to all people, nor has the “peoples’ knowledge” been widely and well-incorporated into health programmes. Reflecting on examples cited in this paper it is apparent that factors such as rugged terrain, limited education, inadequate finance, transport and communication, in combination with some cultural and religious beliefs, can be hindrances to providing effective health care for everyone in Nepal. Traditional medicine (with emphasis on custom, social organization and faith) and scientific medicine (based on reason and scientific research) can both benefit from each other (Ransome-Kuti, 1986). In Bashkharka, programmes have begun to integrate the strengths of both in order to reduce problems such as communicable diseases and high infant-maternal mortality/morbidity rates. Programmes are beginning in remote communities throughout Nepal. It is imperative that the praxis of primary health care be shared from region to region (WHOAJNDP 1989) to improve the general health status of the people. It is also imperative that new approaches to health care in developing areas of the world knit together the strength of custom with the skills and theory of modern medicine and do not marginalize the people, yet again. While PHC and HP appear to hold great promise, their substance and implementation should be evaluated by local communities, national governments and international development agencies alike with lessons from Dependency Theory at hand, insisting that the way forward seeks direction from the meaning of the past.
References Baer, C. and Bruinsma, N. (1989). A study of the coexistence of Ayurvedic and Allopathic medicine in Kerala state India. Cunudian Public Health Association, International Health Exchange Program, Ottawa. Bannerman, R. H. (1982). Traditional medicine in modern health care. World Hith Forum 3, 8-13. Booth, C. L., Johnson-Crowley, N. and Bernard, K. E. (1985). Infant massage and exercise: Worth the effort. Maternal and Child Health. 10, 184-188. Brink, P. J. (1982). Traditional birth attendants among the Annang of Nigeria: Current practices and proposed programmes. Sot. Sci. Med. 16, 1883-1892. Burra, N. (1990). Child labour in India: An overview. In Through the Looking Glass: Children and Health Promotion, J. Ross and V. Bergum (Eds). Canadian Public Health Association, Ottawa. Caragay, R. N. (1982). Training indigenous health workers: A Philippines experience. World Hlth Forum 3, 159-163. Coburn, B. (1987). Dr Mana keeping traditional Ayurvedic alive. Yeti Flight Tales 8-10. Edwards, S. D. (1986). Traditional and modern medicine in South Africa: A research study. Sot. Sci. Med. 22, 1273-1276. Elliott, R. (1990). Rocking, ranting and raging: The problem of the excessively crying infant. In Through the Looking Glass: Children and Health Promotion, J. Ross and V. Bergum (Eds). Canadian Public Health Association, Ottawa. Frank, A. G. (1980). Crisis: in the World Economy. Heineman, London. Fricke, T. E. (1988/89). Studying family traditions in Nepal. Institutefor Social Research Newsletter 16(2), 3. Godelier, M. (1977). Perspectives on Marxist Anthropology. Cambridge University Press, Cambridge. Green, E. C. and Makhubu, L. (1986). Traditional healers in Swaziland: Toward improved cooperation between the traditional and modern health sectors. Sot. Sci. Med. 18, 1071-1079. Heffernan, A. and Mott, S. (1984). Baby massage-a teaching model. Aust. Nurses J. 13, 36-37. Hide, D. W. and Guyer, B. M. (1982). Prevalence of infant colic. Arch. Disease Childhood 57, 559-560. Justice, J. (1983). The invisible health worker: The role of the peon in Nepal’s health service. Sot. Sci. Med. 17, 967-970. Justice, J. (1984). Can socio-cultural information improve health planning? A case study of Nepal’s assistant nurse-midwife. Sot. Sci. Med. 19, 193-198. Kickbusch, I. (1984). Health Promotion: A World Health Organization discussion document on the concept and principles. Canadian Public Health Association. Heulth Digest. 8(6), 101-102. Kleinman, A. (1980). Putients and Healers in the Context of Culture. University of California Press, Berkeley. Levine, N. (1988). Women’s work and infant feeding; a case from rural Nepal. Ethnology, XXVII, 231-248. Longworth, J. C. D. (1982). Psychophysiological effects of slow stroke back massage in normotensive females. Adv. Nurs. Sci. 4. 44-61.
INTEGRATING
TRADITIONAL
AND MODERN HEALTH
SERVICES
353
D. (1982). The Management of Illness in an East African Society: A Study of Choice and Constraint in Health Care Among the Pokot. Unpublished Ph.D. thesis. University of Cambridge. Olenja, J. M. (1984). Social Factors in the Incidence of Malnutrition: A Case Study of Samia in Busia District, West Kenya. Unpublished Ph.D. thesis. University of Cambridge. Porter, L. S. (1972). The impact of physical-physiological activity on infant’s growth and development. Nurs. Res. 21, 210-219. Ransome-Kuti, 0. (1986). Child health in Nigeria: past, present and future. Arch. Disease Childhood 61, 198-204. Regmi, B. R. (1988). National Planning Commission Secretariat. Central Bureau of Statistics, Kathmandu. Reissland, N. and Burghart, R. (1987). The role of massage in South Asia: child health and development. Sot. Sci. Med. 25, 231-239. Ross, J. (1988). Upgrading traditional midwifery in Sierra Leone: An overview with special reference to Koinadugu District. Midwifery 4, 58-69. Ross, J. S. (1990). Perinatal Care: The Kuranko context of choice. Women’s Hith Care Int. Schuster, 1. (1981). Perspectives in development: The problem of nurses and nursing in Zambia. J. Develop. Stud, 17, 77-97. Schwartz, L. R. (1969). The hierarchy of resorts in curative practices: The Admiralty Islands. J. Hlth Sot. Behav. 10, 201-209. Stone, L. (1986). Primary health care for whom? Village perspectives from Nepal. Sot. Sci. Med. 22,293-302. Temple, K. D. (1967). The back rub. Am. J. Nurs. 67, 2102-2103. Werner, D. (1977). Where There is no Doctor. Hesperian Foundation, Palo Alto, California. WHO/UNDP (1989). Health learning materials. Nepal. Network News 12 (October), 19, 26-27, Geneva. Wood, H. R. (1967). The Development of Education in Nepal. Department of Health Education and Welfare, US. Wamwaya,
(Received 10 April 1990; accepted for publication 17 July 1990)
1990.
0
00X-7489/W $3.00+0.00 1990 Pergamon Press plc
Nepal: integrating traditional and modern health services in the remote area of Bashkharka ANJU
SHARMA
and JANE
ROSS
Faculty of Nursing, University of Alberta.
Abstract-Within a framework of Primary Health Care (PHC) and Health Promotion (HP), the focus of this paper is on integrating traditional and modern health care in the remote area of Bashkharka, Nepal. The relevance to integrated health care of factors such as geography, ethnicity, religion, national infrastructure and international development agencies are discussed. Issues concerning the relationship between the theory and practice of PHC and HP are raised.
Introduction
Primary Health Care (PHC), which was officially launched by the World Health Organization (WHO) in 1978, has become an attractive model for international health. With comprehensive aims and flexible structure, it heralded pervasive, low-cost health care relevant to the needs of local communities and people in any country. Health Promotion (HP), adopted by WHO in 1984, correlated well with PHC and provided additional scope for sustaining health and primary health care. Primary Health Care called for the recognition and incorporation of indigenous medical systems while Health Promotion emphasized the need for increasing knowledge and disseminating information based on the public’s experience of health and how it may be achieved (Kickbusch, 1984). The rhetoric of these complementary approaches has been extensive. Implementation of the models, however, appears difficult for a range of complex reasons. Recognizing the fundamental role of nursing in Primary Health Care and Health Promotion, this paper discusses some of the reasons that make their implementation so difficult in Nepal. It indicates that diverse methods and theories (such as economics, development, anthropology and gender) are helpful for modern nursing practice which, in cooperation with other disciplines, attempts to achieve ‘Health for All’. An early draft of this paper Health, University of Alberta,
was presented to the interdisciplinary 4 April 1989. 343
class: A Survey of Issues in International
344
A. SHARMA
AND
J. ROSS
Nepal is a country where PHC has been officially adopted and where the rationale of HP influences attempts to integrate traditional and modern health care. Although the focus of this paper is on integrating traditional health practices and modern health care in the remote area of Bashkharka, an overview of the country and health services is necessary. Geography
Nepal is a relatively small developing country in the heart of Asia, lying against the Himalayas between India on the south and China to the north. It has an area of 147,181 sq. km (Regmi, 1988). On the basis of altitude, the country has three natural geographical regions (Fig. 1) which impose deterrents to health and health care delivery. (i) Himalayan region: contains the world famous peaks of Mount Everest (8,848 m). This is a cold region where many parts are permanently snow covered. (ii) Terai region: the most arable land in Nepal, however it occupies only 17% of the total flat land area. (iii) Mid-mountain region: occupying 68% of total land area and containing the capital city of Kathmandu and its surrounding arable lands, it raises major challenges for PHC and HP. Despite available land and food, nutritional status is inadequate and protein intake is particularly low. A study of malnutrition in Kenya by Olenja (1984) illustrates the importance which culturally based nutritional research has for health promotion. Olenja’s study shows that the presence of nutritional food and the provision of health information is likely to be ineffective unless people can afford to eat the food that is produced and can understand health education in terms of their own world view. Based on her research, Olenja asserts that the poor are quite amenable to change if they can afford it and can understand the benefits available. Bashkharka, is located in this region, 85 miles from the capital. In Bashkharka and its surroundings, there are no motorable roads or airlink services so it is especially hard to provide health care to the people living there. The value of community centred primary health care in such a place cannot be over-emphasized.
?ashkharka ?
Fig. 1.
INTEGRATING
TRADITIONAL
AND MODERN
HEALTH
SERVICES
345
Administration and development planning The country is divided into five major developmental regions and 75 districts encompassed within 14 zones. This divisional structure is important for health and health care delivery as follows: the development regions are responsible for planning and implementing programmes for the control of disabling diseases (e.g. malaria, leprosy, infectious diseases) which are present in all the regions, and for integrating the health sector with other sectors (e.g. food production, agriculture, animal husbandry, environmental sanitation) in the interests of improving conditions. This is an expensive undertaking in which international agencies are welcome to assist with disease control/prevention and health promotion, especially in the rural areas. Economic resources Although Nepal is landlocked it has a strong resource base derived principally from forests and agriculture. Forests, which cover about one-third of the total land area, yield products such as timber, bamboo, indigenous paper, herbs and drugs. Agriculture, accounting for 93% of the population’s livelihood, includes the main crops of rice, maize, millet, wheat, potato, sugar cane and oil seeds (especially mustard). The implications of population distribution in achieving health-for-all, a main tenet of PHC, beg consideration and research. Mountain agriculture “requires tremendous labor inputs for much lower levels of productivity than realized in plains regions” (Levine, 1988: p. 232). Consequently, in upper regions, where food is most scarce, the relationship between energy output and food intake appears to be an inverse one. Tea, produced as a limited cash crop, is generally exported to developed countries in exchange for hard currency. Money generated from cash crops, however, may not contribute favourably to the economic growth of the country due to limited production and differential access to outside markets. Recently, cottage industries, tourism and carpet making have been emerging as a source of income for people in remote as well as urban areas. Although the export of carpets to developed countries is a remunerative industry, there are social (Fricke, 1989) and health hazards associated with this type of work (Burra,‘1990). Women for example, are primarily hired for this low-paying work from which chest infections and chronic coughs can result in response to prolonged inhalation of wool fibres. Theoretical analysis of economics and PHC can, at this point, become deep and far-reaching. Dependency theory (Godelier, 1977) and Development/Underdevelopment theory (Frank, 1980) pertain. Briefly, they hold that international market forces increase the dependency of local communities and economies on market centres external to a country. The impact of international market forces on primary health care in a subsistence setting such as Nepal can be drastic, especially when the downward pressure intensifies on women to marginalize them further. Population: religion, culture and beliefs The population of Nepal includes high-altitude inhabitants (Mongloid-Stock/Sherpas, Tamang, Kirantis), mid-mountainous people (Tamang, Magars, Tharus, Danuars, Chepang) and the low land dwellers (Indian immigrants) in a rich and sometimes complicated mix of customs which can have great impact on health and health care practices. In order to provide appropriate health care in remote areas such as Bashkharka a good knowledge of the clients’ ethnic group, their beliefs about health and disease, their language and religion is essential. The main religions of Nepal are Hinduism (90%) Buddhism (9Vo), Muslim and Christian (1 To).
346
A. SHARMA
AND
J. ROSS
Language The official language of the country is Nepali but different languages are spoken from region to region and also within the same region. Few people in Bashkharka speak Nepali because they are not exposed to its use. Without a common language, and relying on translators, it is difficult for health personnel to help people understand health, disease prevention and health promotion. Without a common language, it is likewise difficult for the people to express their health needs to health personnel and for health workers to determine whether or not the people understand what is taught. Political system The political system plays a major part in the development of national health, education, transport and communication systems. Until 1951, Nepal had an autocratic government which did not facilitate development of the country as a whole. During this period the people were isolated inside the country by political decree, without access to foreign aid or contacts with people from other countries. After 1951 a democratic system of government emerged which changed the overall situation by opening the country to substantial foreign assistance. People were then allowed to obtain higher education within and outside the country. Concern about the health of all the people began to evolve along with plans for improved systems of transport and communication, all of which are necessary for effective health care (Wood, 1967). Transport and communication Although transport and communication have been expanding steadily since 1951, geographical conditions and the cost of improving these systems have been deterrents to rapid progress. In Bashkharka the land is extremely rugged, making health care inaccessible to most people. People often walk two to four days to get to a health post, and goods (including drugs) must be transported from one place to another on backs of the people. It is not uncommon for sick persons to be brought for treatment on the backs of others. In this situation, the equal access to health care (within 10 km) advocated by PHC, is far from a reality. Education Ninety-two per cent of the people live in rural areas and do not have equal access to education facilities enjoyed by those who live in the urban area. (Regmi, 1988). With a literate population of only 33%, Nepal is facing the major problem of lack of awareness about health and healthy living. While the links between literacy and health seem apparent the scientific relationship is not well demonstrated. Nonetheless, to assist development, people must become literate. Although education has been a priority for politicians and health care administrators of Bashkharka-who know that education contributes to improved health-progress is slow. Without education, ‘health’ may have little or no meaning. For example, Sharma found people commonly do not believe that flies transfer disease, so, to them, it does not matter if flies sit on their food. They say, “Flies are so little, how can they be bad? Let them sit”. Compounding rural/urban inequities in education are those related to gender and education. People in remote areas still believe that girls should not be educated because they are meant to do the household work, look after cattle and work in the fields. It is this customary belief which holds the percentage of rural girls attending school as low as
INTEGRATING
TRADITIONAL
AND MODERN
HEALTH
SERVICES
341
1%. Primary Health Care and Health Promotion for rural women, then, should be designed in ways congruent with custom. This may well mean moving health education classes to the farm settings where the women work and linking health concepts to their own values. In urban areas equal educational opportunities theoretically exist for boys and girls. Health Care System in Nepal
A range of therapeutic treatments used in Nepal are also practised in Bashkharka: (i) traditional medicine, (ii) ritual healing (Dhami and Jhankari), (iii) Ayurvedic medicine and (iv) Western medicine. Sharma found that people often mix therapies combining Western medicine with traditional medicine or ritual healing (Dhami-Jhankari) in a hierarchy of alternatives (Nyamwaya, 1982) or resorts (Kleinman, 1980; Schwartz, 1969). Dhami-Jhankari
Both rural and urban people seek Dhami-Jhankari ritual consultation for psychological or psychiatric problems believed to result from the ill effect of an ‘evil eye’ or ‘bad star’. These clients are not treated with medical therapy but are advised in the worship of different gods. People may consult Dhami-Jhankari many times, paying a minimum amount (e.g. rupees 10 equaling about 20 pence sterling) for each visit. If symptoms persist after some months of consultation, a person may see a psychiatrist. However, there is social stigma associated with psychiatric problems so a psychiatrist is avoided if possible. Dhami-Jhankari is valued because it is a discreet consultative and treatment process. Ayurvedic
medicine
For minor conditions such as coughs and colds, to major diseases such as heart disease and diabetes, people of all socio-economic classes commonly select Ayurvedic (homeopathic) medicine, a situation which is similar to health seeking in India (Baer and Bruinsma, 1988). While Ayurvedic treatment appears simple it requires its own expertise. A common treatment involves mixing herbal powder such as cumin or cloves with water to alleviate abdominal cramps. The work of Ayurvedic practitioners is based on the fundamental premise of ‘Triddosa Siddantha’, the principle of three natures or humors (Coburn 1987). According to Triddosa Siddantha, health, disease and body types are controlled by the balance of: (i) wind-the nerve humor, (ii) bile/blood-circulatory humor and (iii) water-the mucous or digestive system humor. The objective of Ayurvedic practitioners is to identify, establish and maintain this individually identified balance for each patient. There are many reasons why people opt for Ayurvedic treatment. First of all, the client does not have to pay for seeing the Ayurvedic practitioner and treatment is available to those who seek it; its availability is sustained because it is not imported. Moreover, patients do not have to undergo extensive tests prior to treatment and they find the treatment effective for specific problems (e.g. jaundice, abdominal and chest complaints). In a study comparing Ayurvedic and biomedical treatments for infective hepatitis, Coburn (1987) found that patients receiving Ayurvedic treatment were cured sooner than those receiving modern medicine. Modern
health care
All hospitals and health posts in Nepal are run by the government and there is, as yet, no insurance system. The family has to bear all sickness and hospital expenses except for
348
A. SHARMA
AND
J. ROSS
doctors’ hospital visits and nursing care. Medical care of poor people may be provided if financial assessment, made at the time of admission, indicates their inability to pay. Medical and nursing personnel make this assessment by enquiring about the livestock (cattle, goats, chickens, ducks) and land held by clients and their families. Health care is not generally accessible to remote people even though a system of health posts, based on population density and the natural geographical divisions, has been set up with provisions for referral. The mid-mountainous region including Bashkharka has 10,000 people per health post, the Terai region has 15,000 people per health post, and the Himalayan region 5,000. The referral system does not work well because of clients’ low economic status and their consequent inability to pay for services, and the fact that government doctors often have private practices, a situation which means that a system of informal access to medical doctors exists outside the public health system. In PHC, nurses are beginning to integrate useful traditional practices into the modern health care system by training Health Assistants (HA) and Community Medical Auxiliaries (CMA) for preventive measures, and Auxiliary Nurse Midwives (ANM) for maternal/child health work. According to government PHC policy, there should be one HA or CMA, one ANM, and a ‘peon’ (to keep the clinic clean) at each health post. Implementing primary health care policy with the staff available, however, has been difficult on a number of accounts. In reality the peon often tends to act as a health worker and may unofficially take charge of the health post (Justice, 1983). The peon has more contact with community members than other health personnel and is seen as one who, because of association and local experience, knows about illness and health matters. Justice (1983) found the peon giving injections, doing dressings and carrying out other tasks in remote areas as well as in the government hospital at Kathmandu. Although Justice may have mistaken ‘compounders’ (those who do injections and change dressings) for peons in some cases, the informal health worker obviously has value to local people. ANMs, who are trained to render maternal/child services in the remote areas, often are not accepted socially and culturally because they are strangers to their assigned work places and because of cultural mores holding that young women should not live by themselves.* Problems are likewise noted in the supervisory system: Public Health Nurses (PHN) stationed at the district level should support and supervise ANMs at least once a month in each health post. Justice (1984) found, however, that PHNs tended to supervise the health posts only once in a two year term. Even in health posts which were, theoretically, accessible by roads, supervision was not carried out because, in reality, there was no transport. PHNs were, also, frightened that they would be robbed while carrying out their duties. There were other reasons for the apparent failure of the system: the allowance of the female PHN was less than that of the male health inspector, inservice education was lacking and there was inadequate support provided to the PHN by the central administration at Kathmandu. Stone (1986) notes that Primary Health Care has other problems: (i) it fails to appreciate villagers’ values and their perceived health needs, (ii) PHC has tended to view Nepali culture as a barrier to health education, and (iii) PHC has mistakenly assumed that rural people indiscrimately follow traditional practices. While PHC is organized primarily to provide health education, Stone found that villagers value modern curative services and feel little need for new health knowledge. *A similar situation involving discrimination Schuster (1981) in her Zambian study.
re. nurses’ age and origins
outside
the community
is reported
by
INTEGRATING
TRADITIONAL
AND MODERN HEALTH
SERVICES
349
Traditional medicine: practices and beliefs It is imperative to remember that traditional medicine remains the only source of health care for many people in the developing countries (Bannerman, 1982). There are numerous traditional health practices, including rituals, which should be documented. Inappropriate practices should be discouraged while useful practices are encouraged and integrated into modern health care. Given the high infant mortality rates, it is not surprising that rituals to protect child health have emerged. Examples, therefore, are drawn from child care to illustrate the relevance which knowledge of traditional customs has for Primary Health Care and Health Promotion. Among the many child rearing practices, oil massage ranks prominently. Although commonly practised, the physiological effect of oil massage on Nepali infants has only been reported descriptively* (Reissland and Burghart, 1987). Nepali mothers, however, say that oil massage helps children to sleep well, eat well and gain weight.? Empirical observation in Nepal indicates that crying babies are not a concern; this may be because they are very much cuddled and caressed or because crying is viewed as normal and therefore not irritating to care givers.S In their descriptive account of oil massage among the Maithili of North India and West Nepal, Reissland and Burghart (1987) report that babies are massaged and placed in the sun for two or three hours every day until they are five or six months old in order to soothe and strengthen the muscles and bones. The uterus, say the Maithili, is a small place where the living conditions become increasingly damp and cramped for the fetus as the months pass by. Massage, therefore, preferably with mustard oil, is needed to relieve the effect of these conditions and make the child invulnerable to danger. Nepalis believe that the oil used in massage is absorbed by the skin, adding to the fatty tissue in the body. In an area where food security is often problematic and infant mortality is high, local people value this practice in the assuagement of threats to infant life. Until now research has not examined the functional aspects of this assumption. Head and face shaping is a second important child rearing practice. To achieve the desired shape, infants are put to sleep on pillows filled with mustard seeds which conform to the head and shape it. To achieve high noses and wide foreheads, marks of beauty in Nepali men and women, children’s faces are massaged for shape. When considered in terms of their application to health, oil and shaping-massage appear effective for mother/infant emotional attachment and conducive to motor development. There are some practices of doubtful therapeutic value such as feeding children ginger, celery seed or garlic (separately or in combination) to produce body heat and relieve coughs and colds. An inappropriate practice is the withdrawal of most vegetables from breastfeeding mothers because they are thought to cause infant diarrhoea and colds. Reissland and Burghart (1987) report that children are held upside down and swung in the air to reduce childhood fears, a custom which likely does not reduce fear and may in fact be injurious to babies. In many ethnic groups, solids and salt are ceremonially introduced (at *In the West back rubs are commonly given to adults to stimulate circulation in tissues under pressure and in muscles at rest, and for their sedative effect (Temple, 1967). Longworth (1982) found that slow-stroke back massage produced physiological responses in females (e.g. heart rate, skin response and skin temperature). tin a Philippine study (Porter, 1972) massage was associated with better weight gain in children. Mothers in the American study of Booth ef al. (1985) reported that massage quietened their babies. SElliott’s paper (1990) stimulated interest among third world participants (Ethnography of Childhood Workshop, 1987) who wondered why infants’ colic and crying are problematic in western societies.
350
A. SHARMA
AND
J. ROSS
five months for boys and six months for girls) to the infant’s life and diet during the rice ceremony (Levine, 1988). If rice takes the place of other foods, the child may not sustain optimum growth and development. A practice which seems innocuous but may be detrimental to infant health is that of touching a febrile baby with a mixture of uncooked rice and turmeric powder before sprinkling the mixture liberally around the house (in the evening) to curtail the startle reflex and alleviate fever (both thought due to the evil eye). When this custom prevents family members from understanding and implementing effective medically supported measures for fever reduction it may contribute to a deteriorating condition of the baby. Sharma observed in a children’s hospital that illiterate parents did not understand intravenous infusion and oral rehydration therapy in the treatment of diarrhoea: “Whenever we started I.V. therapy they would just remove it. When they see that watery diarrhoea they think that giving more fluid to the child will cause more diarrhoea.” By understanding the principles of the traditional system, steps can be taken to establish health care that reaches everyone, including the children who are the most vulnerable. International assistance: the contribution of two nongovernment organizations (NGOs) Foreign assistance has become an important factor in the development of Nepal and some projects are particularly effective in linking foreign resources with local needs. With respect to primary health care, the projects of the Swiss Association for Technical Assistance (SATA) and Save The Children Fund (SCF), U.K., are noted for their appropriateness. In consideration of the geographical difficulties and socio-cultural factors limiting effective health outreach, the SATA funded a model school for training nurses in Jiri, close to Bashkharka. The purpose of the school is to train young women who will work in an area similar to the one in which they were born and raised. This training is appropriate and beneficial for Nepali nurses and community members alike as familiarity with the local situation assists both groups to be more receptive to the other. Especially in remote areas, people have great faith in traditional healers. Usually local, these traditional healers are the first therapy contact made by the family after which, if necessary, they are guided in seeking another therapy such as Dhami-Jhankari, Ayurvedic or modern medicine. Since traditional healers play such a vital role in the community, Save The Children Fund (SCF), U.K. has launched a PHC programme in Bashkharka which builds on existing resources by training traditional healers and integrating them into the modern health care system. The SCF programme emphasizes maternal-child health and supports the governmentrun health posts through the provision of supplies such as vitamins, antibiotics, injections, lotions, etc. When the project began clinic attendance was thwarted by local healers who felt threatened by the new venture, and frightened people into believing that use of modern medicine would result in death (Sharma, personal discussions, 1986-1987). To break the barrier between traditional healers and modern health care, negotiations were undertaken to incorporate the traditional healers into the PHC project. These healers were trained in essential skills such as the preparation of rehydration solution, simple dressings, making nutritious flour, and scabies treatment. They were also taught the importance of infant immunization and provided with slips for referring clients to the health post. In these ways the training conferred useful knowledge and increased status to traditional healers in the programme. As Werner (1977) suggests, health programmes should work with local healers to foster good community response.
INTEGRATING
TRADITIONAL
AND
MODERN
HEALTH
SERVICES
351
While visiting homes, Sharma observed that the trained healers were quite effective in their work and often more readily approved by families than were medical health workers. This is due, perhaps, to the fact that rural people are more confident in therapists who share social and religious history. As medical workers are strangers, there is always a gap between them and community members. By training existing healers SCF contributed to lessening the gap between traditional medicine and Western medicine, supporting mutal dependency.* Currently SCF is supporting a project developed by the Nepal Pediatric Society and Nepal Health Learning Materials Staff to edit guidelines for the management of common illnesses of children in Nepal (WHO/UNDP, 1989). Training of traditional birth attendants (TBAs) Although the focus of the nursing project established in Bashkharka was maternal and child health, there was a lack of attention to the health of mothers. As part of PHC the Department of Health, Nursing Division began to address the lack of female staff in Bashkharka by training traditional birth attendants. When nursing students were posted to Bashkharka in 1986 for twelve weeks community health,? one of their assignments was to integrate traditional birth attendants into the modern health care system in a manner similar to the project started by Save The Children Fund. For a training period of one week, selected birth attendants were taught to differentiate normal and abnormal fetal heart sounds, handwashing techniques (to which they were not accustomed), safe delivery (not pulling or pushing the baby), sterilization of knife and thread (to cut and tie the umbilical cord), and methods of delivering the placenta. Since most of the women could not read or write, the teaching was based on practical demonstration, group discussion, and pictures which could easily be understood.$ Integrative practices have not yet been evaluated comprehensively, but it can be inferred from teacher/student evaluations of the project that the integration of traditional birth attendants into modern health care is a step in the right direction. Pre- and post-training checklists indicate that the attendants’ knowledge and performance improved after training. Sharma observed that more children came to clinics after implementation of the PHC programmes, indicating that healers and TBAs were cooperating with health personnel in respect of treatment. They also participate in the process of health education by acting as village cryers, encouraging people to attend clinic for their health problems. Other effects were noted after the integrated programmes began: many families knew how to make rehydration solution at home, families who had suffered chronically from scabies appeared less infected, and the Bashkharka community reported that they had to sacrifice fewer animals to reward the healers. Conclusion
Although talk about “Health for all by the year 2000” is common, and the benefits of culturally based health promotion are espoused, primary health care is not available and *Similar projects have been tried elsewhere with varying results, for example in the Philippines (Caragay, 1982), Swaziland (Green and Makhubu, 1986), and South Africa (Edwards, 1986). Wee Post-Basic Community Health Curriculum (1986). Tribhuvan University Institute of Medicine, Nursing Campus, Maharaygung, Kathmandu. SSimilar approaches are used to train traditional birth attendants in Sierra Leone (Ross, 1988), Nigeria (Brink, 1982) and elsewhere.
352
A. SHARMA AND J. ROSS
accessible to all people, nor has the “peoples’ knowledge” been widely and well-incorporated into health programmes. Reflecting on examples cited in this paper it is apparent that factors such as rugged terrain, limited education, inadequate finance, transport and communication, in combination with some cultural and religious beliefs, can be hindrances to providing effective health care for everyone in Nepal. Traditional medicine (with emphasis on custom, social organization and faith) and scientific medicine (based on reason and scientific research) can both benefit from each other (Ransome-Kuti, 1986). In Bashkharka, programmes have begun to integrate the strengths of both in order to reduce problems such as communicable diseases and high infant-maternal mortality/morbidity rates. Programmes are beginning in remote communities throughout Nepal. It is imperative that the praxis of primary health care be shared from region to region (WHOAJNDP 1989) to improve the general health status of the people. It is also imperative that new approaches to health care in developing areas of the world knit together the strength of custom with the skills and theory of modern medicine and do not marginalize the people, yet again. While PHC and HP appear to hold great promise, their substance and implementation should be evaluated by local communities, national governments and international development agencies alike with lessons from Dependency Theory at hand, insisting that the way forward seeks direction from the meaning of the past.
References Baer, C. and Bruinsma, N. (1989). A study of the coexistence of Ayurvedic and Allopathic medicine in Kerala state India. Cunudian Public Health Association, International Health Exchange Program, Ottawa. Bannerman, R. H. (1982). Traditional medicine in modern health care. World Hith Forum 3, 8-13. Booth, C. L., Johnson-Crowley, N. and Bernard, K. E. (1985). Infant massage and exercise: Worth the effort. Maternal and Child Health. 10, 184-188. Brink, P. J. (1982). Traditional birth attendants among the Annang of Nigeria: Current practices and proposed programmes. Sot. Sci. Med. 16, 1883-1892. Burra, N. (1990). Child labour in India: An overview. In Through the Looking Glass: Children and Health Promotion, J. Ross and V. Bergum (Eds). Canadian Public Health Association, Ottawa. Caragay, R. N. (1982). Training indigenous health workers: A Philippines experience. World Hlth Forum 3, 159-163. Coburn, B. (1987). Dr Mana keeping traditional Ayurvedic alive. Yeti Flight Tales 8-10. Edwards, S. D. (1986). Traditional and modern medicine in South Africa: A research study. Sot. Sci. Med. 22, 1273-1276. Elliott, R. (1990). Rocking, ranting and raging: The problem of the excessively crying infant. In Through the Looking Glass: Children and Health Promotion, J. Ross and V. Bergum (Eds). Canadian Public Health Association, Ottawa. Frank, A. G. (1980). Crisis: in the World Economy. Heineman, London. Fricke, T. E. (1988/89). Studying family traditions in Nepal. Institutefor Social Research Newsletter 16(2), 3. Godelier, M. (1977). Perspectives on Marxist Anthropology. Cambridge University Press, Cambridge. Green, E. C. and Makhubu, L. (1986). Traditional healers in Swaziland: Toward improved cooperation between the traditional and modern health sectors. Sot. Sci. Med. 18, 1071-1079. Heffernan, A. and Mott, S. (1984). Baby massage-a teaching model. Aust. Nurses J. 13, 36-37. Hide, D. W. and Guyer, B. M. (1982). Prevalence of infant colic. Arch. Disease Childhood 57, 559-560. Justice, J. (1983). The invisible health worker: The role of the peon in Nepal’s health service. Sot. Sci. Med. 17, 967-970. Justice, J. (1984). Can socio-cultural information improve health planning? A case study of Nepal’s assistant nurse-midwife. Sot. Sci. Med. 19, 193-198. Kickbusch, I. (1984). Health Promotion: A World Health Organization discussion document on the concept and principles. Canadian Public Health Association. Heulth Digest. 8(6), 101-102. Kleinman, A. (1980). Putients and Healers in the Context of Culture. University of California Press, Berkeley. Levine, N. (1988). Women’s work and infant feeding; a case from rural Nepal. Ethnology, XXVII, 231-248. Longworth, J. C. D. (1982). Psychophysiological effects of slow stroke back massage in normotensive females. Adv. Nurs. Sci. 4. 44-61.
INTEGRATING
TRADITIONAL
AND MODERN HEALTH
SERVICES
353
D. (1982). The Management of Illness in an East African Society: A Study of Choice and Constraint in Health Care Among the Pokot. Unpublished Ph.D. thesis. University of Cambridge. Olenja, J. M. (1984). Social Factors in the Incidence of Malnutrition: A Case Study of Samia in Busia District, West Kenya. Unpublished Ph.D. thesis. University of Cambridge. Porter, L. S. (1972). The impact of physical-physiological activity on infant’s growth and development. Nurs. Res. 21, 210-219. Ransome-Kuti, 0. (1986). Child health in Nigeria: past, present and future. Arch. Disease Childhood 61, 198-204. Regmi, B. R. (1988). National Planning Commission Secretariat. Central Bureau of Statistics, Kathmandu. Reissland, N. and Burghart, R. (1987). The role of massage in South Asia: child health and development. Sot. Sci. Med. 25, 231-239. Ross, J. (1988). Upgrading traditional midwifery in Sierra Leone: An overview with special reference to Koinadugu District. Midwifery 4, 58-69. Ross, J. S. (1990). Perinatal Care: The Kuranko context of choice. Women’s Hith Care Int. Schuster, 1. (1981). Perspectives in development: The problem of nurses and nursing in Zambia. J. Develop. Stud, 17, 77-97. Schwartz, L. R. (1969). The hierarchy of resorts in curative practices: The Admiralty Islands. J. Hlth Sot. Behav. 10, 201-209. Stone, L. (1986). Primary health care for whom? Village perspectives from Nepal. Sot. Sci. Med. 22,293-302. Temple, K. D. (1967). The back rub. Am. J. Nurs. 67, 2102-2103. Werner, D. (1977). Where There is no Doctor. Hesperian Foundation, Palo Alto, California. WHO/UNDP (1989). Health learning materials. Nepal. Network News 12 (October), 19, 26-27, Geneva. Wood, H. R. (1967). The Development of Education in Nepal. Department of Health Education and Welfare, US. Wamwaya,
(Received 10 April 1990; accepted for publication 17 July 1990)
