MEDICINE and CULTURE Social indifference to child death
3-year-old Mercea was severely ill in February, 1989, and so since her birth at Ferreira Lima hospital in the sugar plantation town of Bom Jesus da Mata in northeast Brazil. Her mother, Biu, was a 43-year-old cane worker, a tough woman slight-of-build but with strong arms and long, thick brown hair (her one vanity) that she would pull back in a knot each morning. She rose in the dark to prepare a cup of black coffee before setting off on foot for a local plantation, where she was employed with her 9-year-old son as an unregistered field worker earning about$1-25/day. Mercea was left in the care of her 13-year-old sister, Xoxa, and sat in a dark comer endlessly scratching her infected bug bites and sores. Like many "nutritionally battered"l and had been
stunted toddlers her age, Mercea could not yet walk and she spoke only a few words, among which were incessant demands for fresh (undried and unsalted) meat. There had been no papa in the household since the night of Sdo_7odo (St John’s day) when Oscar, Biu’s second common-law husband, walked out with the couple’s gas stove, bed, and the healthiest two boys among Biu’s seven surviving children (of the 15 born to her), to live with a younger woman who, Oscar boasted, still had her teeth. "Infants are like birds", Biu once said, "here today, gone tomorrow. Alive or dead, it’s all the same to them. They don’t have that certain attachment to life of the older child". Mercea had, however, already survived over a dozen "crises" of fevers, violent diarrhoeas, and vomiting that had wasted her limbs and often brought her close to death. Next to Mercea’s hammock was a wooden table with half-used medicine bottles some of which, Biu said, had "worked for a while". They included antibiotics, antiseptic skin creams, cough medicines, analgesics, tranquillisers, and sleeping pills. None of these treatments had ever resolved the child’s main illness, which Biu described as a general "weakness" and "nervousness"-a nervoso infantile-that left Mercea unable to withstand the luta, the ordinary, everyday "struggle" that was life in the shantytown. Mercea never showed a real "taste" (gosto) or "knack" (jeito) for life. Mercea was reported to have violent episodes of "child attack", as women of the Alto refer to acute convulsions with head banging, eye rolling, and body rigidity. Biu, like many women of the Alto do Cruzeiro, regarded childhood convulsions as an early sign of incurable madness, epilepsy, or rabies. An antipsychotic medication that had been illegally purchased as a remedy lay next to Mercea. Infants and small babies of the Alto who have child attacks are allowed to die of what has been described as maternal "benign neglect’,/.3 and which I later called "ethnoeugenic selective neglect". Infant euthanasia is closer to the way shantytown women, most of whom are devout Catholics, view their own behavoiur. Mercea’s final crisis took place in the days before Brazilian carnaval when many shops and most public services were closed. Local hospital staff were on strike and would not be at work until Ash Wednesday. Both Biu and I planned to join the first night of carnaval but Mercea continued to have
Fig 1-Mercea in her coffin after "baptism".
choking cough. She could not get her breath, she was dehydrated, and vomited. Biu arranged for her 16-year-old daughter to look after Mercea. The next time Biu and I met was the morning after carnaval when we gathered at the home of Biu’s older sister to prepare Mercea’s body for burial. Biu was in shock; we barely had time to change out of our carnaval costumes. Mercea was laid out in her coffin in a white Holy
Communion dress and we covered Mercea’s barefeet and her body up to her chin with white flowers, as befitting an innocent angel-child. Mercea’s uncle and her designated godfather sprinkled the still body with holy water to baptise her and they prayed (fig 1). Mercea’s siblings and playmates carried her coffin to the municipal graveyard. Children bury children in many parts of Latin America. No church ceremony took place-300 childhood deaths per year in a town of 30 000 people have made child death seem ordinary. Only a small piece of paper from the civil registry office documents the death. The diagnosis was left blank on the form-the local Secretary of Health and other public officials have no interest in such matters. The grave-digger chided the children for leaving the coffin lid loose. "The ants will soon get to your sister", he told Mercea’s brother, Leonardo. When Xoxa returned home, from the plantation where she was briefly employed during carnaval, to learn that her little sister had died, she grieved deeply. Xoxa was especially upset that her sister was buried without stockings, and for several weeks she was bothered by "visions" of Mercea hovering over her cot pointing to her bare feet. "She can’t speak", said Xoxa, "because like all angel babies she is mute." On returning to the grave some time later we found that the area had been cleared and the space given to twin infants. Mercea’s remains had been tossed into the deep well called the "bone depository" at the west wall of the cemetery. Childhood environment "A child died today in thefavela. He was two months old. If he had lived, he would have gone hungry anyway." Carolina Maria de Jesus (Brazil).
Anthropologists study the child’s world by direct immersion (participant observation) in the mundane realities and minutiae of everyday life. The above vignette is an example of such field research among three generations of ADDRESS:
Department of Anthropology,
California, Berkeley, California 94720, USA. Correspondence to Prof N
and children in a single Brazilian shantytown.5 For many children, the everyday reality-what has been described as the "average, expectable environment of the child"6-is not one of "mutual adaptiveness" between an infant and the physical and social environs, but one of mutual antagonism in which premature sickness and death are all too predictable. I also want to emphasise the obvious, but often overlooked, relation between the welfare of mothers and children. The physical and nutritional neglect of children in poverty is often the result of economic "battering" and institutionalised social neglect of mothers who, like Biu, try but fail to protect their children. All parents share a common set of parenting goals.7 These include the physical survival and health of the child; the development of the child’s capacity for self-reliance and gradual autonomy; and the cultivation in the child of cultural attributes such as beauty, intelligence, and strength. The ecological and social context will determine which goal will most influence parental thinking and practice. Throughout human history, and currently in the developing world today, women (like Biu) have had to give birth to and nurture children under environmental conditions and social arrangements unfavourable to infant and child survival. Concern about child survival, when 30-40% mortality in the first year of life is not uncommon, leads to certain seemingly paradoxical practices and to various individual and collective defences. For instance, maternal attachment and bonding are much more gradual processes and develop only when the baby shows its readiness to live. Mothers may be slow to personalise the infant, to give it a name, or (in Catholic countries like Brazil) to baptise the child. Mothers are often unlikely to attribute consciousness and intentionality to an infant’s movements, The and vocalisations. of kicks, process anthropomorphisation becomes delayed until the mother is more certain that the infant will survive. Traditional practices of passive infanticide may be drawn on to select seemingly more healthy children for greater attention.s The association of high childhood mortality with high fertility9no allows newborn children to fill recently vacated family roles, such as first or last born son or daughter, with a minimum of grie £ 1’ Given the unpredictability of infant and child survival in the shantytowns of Brazil, the preferred form of family planning is tubal ligation after a woman has had a "safe" number of strong and healthy offspring. The ideal family size is four children (two of each sex), but women think it wise to have two or more "extra" children to safeguard against possible future death. women
Social indifference to child health "The opposite of love is not hate, it is indifference". Eli Weisel.
Parents and public officials throughout the world have often failed to see infant and child death as either a personal tragedy or an important social issue. Social12 and medical13,14 historians of childhood have described the modem invention of the idea of a child in the west, and the medical "discovery" of child mortality. Philippe Aries12 suggests that only in the mid to late nineteenth century in Europe were babies and small children understood as special kinds of human beings with individual needs and developmental requirements, rather than as small adults. If this attitude had not prevailed,
generations of babies might have been spared
"pap", a sweetened
tea mixed with stale breadcrumbs or arrowroot, the old world version of the migaus made of coarse manioc flour, contaminated water, and powdered
Fig 2-Small but healthy ?
milk that is fed to Brazilian infants today. Poor and working class western babies died in almost the same numbers as now found in Brazilian shantytowns. The medical profession was slow to identify child mortality as a serious medical and social issue. Birth registration only became compulsory in England in 1907 at the same time as the government launched its first national campaign against infant and child mortality." Childhood malnutrition was first identified as a paediatric disease in 1933, and the more specific diagnoses of marasmus, kwashiorkor, and protein-calorie malnutrition had to await descriptions by western-trained doctors who encountered these conditions in the tropics of west African colonies, although Engels15 had noted symptoms of malnourishment among families of the English working classes a century earlier. In the absence of a recognised diagnostic category for the infantile wasting disease characterised by oedema, apathy, partial loss of pigmentation, and "reddening" of the hair, colonial doctors adopted the local Ghanaian term, "kwasiorkor". 16 Thus, the social construction or "invention" of child malnutrition, and later of child survival, is fairly recent. Only gradually was the "naturalness" of child wasting, and much later of child "battering", 17 questioned.14 Even today, some researchers debate the long-term evolutionary "adaptiveness" of the small, nutritionally stunted, thirdworld child18 on the grounds that nutritionally dwarfed children consume less of the world’s scarce protein resources. William Stini and others18 have introduced the phrase "small but healthy" to describe nutritionally stunted children (fig 2). The role of western science in acceptance of