Diarrhea Folklore in Nicaragua

Diarrhea Folklore In Nicaragua

Traditional "folklore" explanations and treatments are common in communities without modern medical care. Nicaragua is no exception.

According to a recent study, at least 12 types of diarrhea are recognized by Nicaraguan mothers. A basic classification in a paediatric text usually lists only three causes depending on whether the infection is due a virus, a bacteria, or a parasite.

Even without exposure to routine modern health care, most Nicaraguan mothers recognize that diarrhea is mostly about hygiene. The table below lists the causes recognized by the mothers.

Spanish	English
por la suciedad	because of dirtiness
falta de higiene	lack of hygiene
por las moscas	because of flies
las pachas sucias	dirty baby bottles
manos sucias	dirty hands

Some mothers have the mistaken belief that diarrhea is due to a problem with breastmilk. According to this erroneous belief, breast milk can be spoiled by eating cabbages or avocado during breast feeding, excessive maternal exposure to heat or sun, strong emotion or sadness, or breastfeeding while pregnant. Based on this folklore, Nicaraguan mothers sometimes stop breastfeeding, which makes the illness worse.

The table below lists the symptoms of diarrhea described by mothers.

Spanish	English
obra churre	bowel movements are loose
le pega llorazon en la barriga	belly cries
como si fuera agua	as if it were water
obra exigido	child has demanding defecations
obra seguido	child defecates continuously
ensucia mas de lo necesario	child dirties more than necessary
le pega maleza en el estomago	stomach becomes ill
obra ralo	child defecates liquid
obra demasiado	excessive defecations
se le afloja el estomago	stomach is loose

A small percentage of Nicaraguan mothers believe in causes that are not conventional. The table below lists some of these folklore causes.

Spanish	English
ojo	caused by the evil eye
pujo	caused by the presence of a drunk or sweating person or a woman in her first pregnancy
colerin	from eating pork from a pig that was enraged "con la colera del animal"

Folklore about parasitic infestation is common. The blood and pus in the stool is because the parasite knows how to bite the intestine. Children with parasites sleep with their eyes open, grind their teeth, drool, and eat but do not gain weight. The full moon stimulates parasites to move around in the intestine. Garlic is a good remedy and can be worn around the neck or rubbed on the belly.

Folklore treatments are common and the confidence of the mothers in these interventions is sometimes greater than their confidence in modern medical interventions. Folklore interventions include camomile, guava in leaves, bark and buds, hibiscus roots, granate, sago starch, achote, guasimo, and cinnamon.

Reference
Vázquez ML, Mosquera M, Kroeger A. People's concepts on diarrhea and dehydration in Nicaragua: the difficulty of the intercultural dialogue. Bras. Saude Mater. Infant. vol.2 no.3 Recife Sept./Dec. 2002. 

Diarrhea In Nicaragua

Diarrhea in Nicaragua

A recent informal survey of mothers in Gigante, Nicaragua identified gastrointestinal (GI) problems in the children as the most common health concern. As such, one of my visits this winter will focus on GI problems.

Many of the local GI problems are infection-related. In Canada we mostly suffer from viral and occasional bacterial gastroenteritis. Add worms and parasites to the list in Nicaragua. This blog will review viral gastroenteritis and subsequent blogs will review the other causes.

Rotavirus is the most common cause of diarrhea worldwide and diarrhea is the second most common cause of death in children in poor countries. There is no medication that controls Rotavirus. Once a child is infected with Rotavirus, the symptoms will last 5 to 7 days and the virus is shed in the stool for up to 10 days.

Scanning Electron Micrograph of Rotavirus Particles, courtesy of CDC. 

A vaccine was introduced in 2006, and in October 2006, Nicaragua was the first developing nation to implement universal infant immunization with the pentavalent Rotavirus vaccine.

Studies in developed countries show an impressive decrease in severe Rotovirus infection of up to 98% after immunization, but there are concerns that the vaccine might not be efficacious in a poor country. Malnutrition, storage issues for the vaccine, distribution of Rotavirus genotypes, simultaneous use of polio vaccine, and other factors can influence the effectiveness of a vaccine. Reassuringly, a study in Leon, Nicaragua, that compared data from 2003 to 2009, showed a statistical decline in diarrhea after the introduction of the vaccine.

Rotavirus infection usually strikes in the first year of life. As such, the vaccine program immunizes children at 2, 4, and 6 months of age. The local health ministry in Leon reported that vaccine coverage in 2007 was 98% for the first dose, 93% for the second dose, and 77% for all three doses. If this data is correct, the Nicaraguan campaign was as effective as similar programs in North America!

Notwithstanding the immunization program there will still be lots of diarrhea. Not all children will be vaccinated, the efficacy of the vaccine will likely be reduced, and there are other viral causes of diarrhea such as Norovirus, Astrovirus, Sapovirus and Adenovirus.

The peak Rotavirus season in Central America is during the dry season from January to March, so I can expect to see infants and toddlers with vomiting and watery diarrhea.

Death due to Rotavirus is usually due to dehydration. With the introduction of oral rehydration solution (ORS) in the sixties and the seventies, the mortality rate fell, and diarrhea is no longer the most common cause of infant mortality worldwide.

However, ORS is not always available or not properly administered. ORS is usually offered as a packet of salts that need to be mixed precisely in clean water. Precisely and clean water are concerns. If the salts are mixed in too little water or too much water the effectiveness is reduced, and when the ratio is way off, the solutions can create problems. Patient education is very important. Well water is contaminated in Nicaragua and tap water should be considered unsafe. Bottled water is the best source but this is expensive for many families. I will take ORS packets with me to Nicaragua and I will purchase supplies of bottled water in one liter containers. I have learned to mix the packets in bottled water at the clinic and to give the pre-mixed solutions to the family to avoid measurement error. 

Thank You Health Partners International of Canada

Health Partners International of Canada (HPIC)

HPIC provides medication packages to groups and individuals who provide health care in less fortunate areas of the world. The organization obtains the medications at discounted prices direct from pharmaceutical companies and then passes this discount along to the group or individual that provides the care. 

Medications are an expensive but essential component of health care, and the role HPIC plays allows modern treatment that might not otherwise be possible. Thank You HPIC.  

The pharmaceutical companies who provide the medications to HPIC play a key role in the Giving Process. Thank you to those pharmaceutical companies who participate in this worthy program. 

HPIC has helped me out on past trips to Nicaragua and to Haiti and I have requested their help for my trips this winter. Claudia Sighomnou, Director, Physician Programs with HPIC, is helping me with this project. Thank you Claudia Sighomnou!

HPIC depends on donations to continue their work and I recommend this organization as worthy of your support. http://www.hpicanada.ca/

Truckload of Gigante children brought to Clinic

The mothers in Gigante, Nicaragua, where I will help out this winter, recently identified GI issues as a top health care concern for their children. My request to HPIC therefore includes medications for worms, intestinal parasites, and bacterial gastroenteritis, and also for dehydration (oral rehydration solution packets), which is a common and serious problem associated with viral gastroenteritis. I will also take vitamins for nutrition, which is a key feature of any GI health problem. 

Planning for Nicaragua - Winter 2013/2014

Planning for Nicaragua - Winter 2013/14 

This winter I will help out in Gigante, a small fishing village on the Pacific Coast of Nicaragua. There are about 400 people in Gigante, which suggests there will be about 125 children. 

Several years ago, I met Bo Fox, the Executive Director for Project Woo in Nicaragua - www.projectwoo.org. Bo's Nicaragua home base is Gigante. When he heard that I was providing paediatric outpatient care in Limon, another small community about 30 or 40 minutes away by car, he arranged to bring several truckloads of Gigante children to the clinic. Bo brought the children in a pick-up truck. Most just needed check-ups and well child care but some were sick. 

I was impressed with Bo. He is one dedicated young man. In the last few years he has made a real difference for the people in Gigante. One of his first projects was to purchase a school bus to take the children to school. Before the bus, they needed to walk an hour and half each way to reach school. Not unexpectedly, school attendance has substantially increased. Wow! Simple solution for a big problem. 

Bo Fox, helping with a smile. 

When I learned earlier this year that Bo's next project is a health clinic in Gigante, I wanted to help out. Construction has started and the clinic is scheduled to be operational in January 2014. 

Build it and they will come, must be their motto. Illness and other health care challenges already live there in abundance. Soon the health clinic doors will open. The community hopes to attract doctors, nurses, and other international health care professionals to come and help out. I would like to be one of those people. 

So, I plan to visit in December to bring supplies and meds, establish local contacts, and to check out the new facility. In February I will return for two weeks and in March for another two weeks. With each visit I hope to have a new paediatric project to offer in addition to regular care. Bo is reaching out to the Mothers to determine their highest priorities for health care for their children. I don't want to presume. I would like to meet their paediatric health care needs as a community.