African Journal of Food Agriculture Nutrition and Development,
Vol. 7, No. 1, 2007
FILIAL FACTORS OF KWASHIORKOR SURVIVAL IN URBAN
GHANA: REDISCOVERING THE ROLES OF THE EXTENDED FAMILY
Richard L. Douglass1*,
Brenda F. McGadney-Douglass2, Phyllis Antwi3, Nana A. Apt4
*1Corresponding
Author. Senior Fulbright Scholar, School of Public Health, University of Ghana,
Legon 2001- 2002; Professor of Health Administration, Eastern Michigan
University, Ypsilanti, Michigan 48197, USA.
2Visiting Scholar, School of
Social Work, University of Ghana, Legon 2001-2002; Associate Professor of
Social Work, The University of Toledo, Toledo, Ohio 43606-3390, USA
3Professor, School of Public Health, University of Ghana-Legon, Accra, Ghana
4Dean of Academic Affairs, Ashesi
University, Accra, Ghana; Professor of Sociology, Director, Center for Social
Policy Studies, University of Ghana- Legon, Accra, Ghana
The
field research protocols, reported here were approved by IRB Committees at
Eastern Michigan University, Ypsilanti, Michigan (1999 and 2001), Wayne State
University, Detroit, Michigan (1999), and the University of Ghana (1999 and
2001).
Code Number: nd07004
ABSTRACT
This
paper discusses the findings of two field studies in urban Accra, Ghana that
investigated the social and familial factors that were associated with survival
of childhood kwashiorkor, a protein-caloric deficiency form of malnutrition
that is endemic in that nation. Data was collected from qualitative interviews
with family groups that included teenaged survivors of kwashiorkor, and the
adults who were involved in the young persons childhood rearing, including
those who were responsible for compliance with the Ghana Ministry of Health
malnutrition rehabilitation effort. Extensive interviews were documented in
audio and video tape and field notes by a team that included the fields of social
work, public health, nursing and sociology. All members of the participating
families who were involved in the data collection were offered compensation for
their time as well as full protection of privacy through the human subjects
informed consent protocol and oversight of the University of Ghana, Eastern Michigan
University and Wayne State University. The findings included reporting of a consistently
critical role of the grandmothers and other senior women in
the family units. The senior women either managed the economics and maintenance
of the extended household, or took principal responsibility for sustaining the
malnourished childrens participation in rehabilitation efforts. In some cases,
the mothers were deceased and two or more senior women in the family carried
out roles of parenting as well as familial economic support and coordination
of care for the afflicted child. The findings suggest that full compliance with
rehabilitation efforts for a single mother with multiple children and no extended
familial support system would be very difficult and more likely to result in
non-compliance and failure of the child to survive. Suggestions are offered for
family-oriented, community health education regarding the irony of this form
of
malnutrition being endemic in communities that do not lack appropriate food.
Implications for increased recognition and support for the elderly and senior
family members to enhance child survival are discussed within the context of
changing social and epidemiological profiles of urban centers in Ghana and elsewhere
among developing nations of sub-Saharan Africa.
Keywords: Kwashiorkor, Malnutrition, Rehabilitation
compliance, Grandmothers, Endemic malnutrition
What
befell the Child implanted in her womb?
Did we not refuse to attend the ceremony of his Birth?
And when he died so young of kwashiorkor, how many wept
for him?
Kofi Anyidoho (From
"Akansasnoma")
Professor of Literature, University of Ghana, Legon
French
FACTEURS FILIAUX DE LA SURVIE AU KWASHIORKOR
DANS
DES ZONES URBAINES DU GHANA: REDÉCOUVERTE DES RÔLES DE LA FAMILLE ÉLARGIE
Résumé
Ce document présente les résultats de deux études
de terrain effectuées dans des zones urbaines dAccra au Ghana. Ces études ont
porté sur les facteurs sociaux et familiaux qui ont été associés à la survie au
kwashiorkor de lenfance, une forme de malnutrition causée par la carence en
protéines et en calories, et cette malnutrition est endémique dans ce pays. Des
données ont été collectionnées à partir dinterviews qualitatives auprès de
groupes familiaux qui incluaient des adolescents survivants du kwashiorkor, et
des adultes qui ont été impliqués dans léducation de jeunes enfants, tels que
ceux qui étaient responsables de se conformer aux initiatives de réhabilitation
en matière de nutrition entreprises par le ministère ghanéen de la Santé. Des
interviews extensives ont été publiées sur cassettes audio et vidéo et au moyen
des notes de terrain par une équipe qui représentait des domaines tels que le
travail social, la santé publique, linfirmerie et la sociologie. Tous les
membres des familles participantes qui étaient impliquées dans la collecte des
données ont reçu une indemnisation pour leur temps ainsi que la protection des
renseignements fournis, à travers le protocole de consentement informé des
sujets humains et par la supervision de lUniversité du Ghana, lUniversité de
lEst de Michigan et lUniversité de lEtat de Wayne. Les résultats
comprenaient un rapport sur le rôle de plus en plus important des grand-mères
et dautres femmes âgées de la famille. Les femmes âgées soccupaient de la
gestion de léconomie et de lentretien du ménage élargi, ou alors elles
prenaient la principale responsabilité dappuyer la participation des enfants
mal nourris aux initiatives de réhabilitation. Dans certains cas, les mères
étaient décédées et deux ou plusieurs femmes âgées da la famille avaient pris
la relève dans les rôles des parents et de lappui familial au niveau
économique ainsi que la coordination des soins des enfants affligés. Les
résultats suggèrent que pour une mère seule qui a plusieurs enfants il serait
très difficile de se conformer entièrement aux initiatives de réhabilitation si
elle na pas dappui de la famille au sens large, et la conséquence serait sans
doute la non-conformité à ces initiatives et la non survie de lenfant. Des
suggestions sont offertes en vue dune éducation orientée vers la famille et la
santé de la communauté en ce qui concerne lironie de cette forme de
malnutrition qui est endémique dans des communautés qui nont pas
dalimentation appropriée. Des implications visant la revalorisation du rôle
des personnes âgées et des membres de famille âgés ainsi que lappui à ces
catégories de personnes pour quelles contribuent davantage à la survie des
enfants font lobjet de discussions dans le cadre du changement des profils
sociaux et épidémiologiques des centres urbains du Ghana et dailleurs dans des
pays en développement de lAfrique sub-saharienne.
Mots-clés: Kwashiorkor, malnutrition, se conformer
aux initiatives de réhabilitation, grand-mères, malnutrition endémique.
INTRODUCTION
Kwashiorkor
is the most prevalent form of protein energy malnutrition (PEM), and was
brought into the medical lexicon by Cicely Williams in 1933 [1]. In 1952, an
early WHO/FAO report described kwashiorkor as, "...the most serious and
widespread nutritional disorder known to medical and nutritional science" [2].
Students of human nutrition have studied clinical presentations of kwashiorkor
for over 50 years. Detailed clinical descriptions and medical guidance for
kwashiorkor were first published in 1954 [3]. Over the last seventy years
kwashiorkor's prominence has hardly diminished. Globally, in 1997 the WHO
estimated that about one third of all children are affected by Protein Energy
Malnutrition (PEM); over 20 % of these children live in Africa [4]. The
disorder complicates all infectious diseases, wrecks havoc on compromised
immune systems, and kills about 10 million children under 5 years of age
annually [4]. In Ghana, childhood malnutrition represents the sixth leading
cause of death among children under five, with over half of these deaths
attributed to kwashiorkor. Those who do not die often suffer from numerous
long-term complications, including physical stunting, depending on the age of
the child at onset of the disorder [5, 6].
Today,
aside from places where there is open warfare or major social cataclysmic
events, it is difficult to understand how this affliction of very young
children remains endemic in places like urban Ghana. It seems to be
inconsistent to find endemic malnutrition in places where food appears to be
widely available without a deeper understanding of the social factors that
cause PEM. If the general economic and social conditions of urban Accra or other
cities in Ghana are compared to many other places, kwashiorkor would not be
expected. In Accra, food is currently not in shortage, and protein-rich seafood
from the Bay of Guinea is in abundance in the markets. Kwashiorkor, however,
remains endemic, as it has for all of the last 70 years since Cicely Williams
called it "the problem that shouldn't be" [1, 8, 9]. She concluded
that kwashiorkor's etiology was more complicated than merely an absence of
sufficient and sufficiently nutritious food and poverty; kwashiorkor reflects
a
poverty of knowledge. In urban Ghana cases of childhood malnutrition, including
kwashiorkor, are found within neighborhoods, communities and markets with
abundantly available food.
The
research reported here reflects work that was initiated in January 1999 and
continued through June 2003. Initial qualitative data were collected in July
1999 as a pilot study that sought to determine the status of post-adolescent
young people who had suffered from kwashiorkor in urban Accra, Ghana [10, 11, 12]. Very little has been reported about the long-term consequences or effects of
kwashiorkor, while there is substantial literature dealing with the short-term,
clinical recovery of cases. Our purpose was expanded. From the pilot study, it
became clear that the physical/intellectual status of the cases of young adult
survivors was not as much of an issue, as was a need to understand how it was
that these youth survived while others did not. How were these cases detected,
diagnosed and successfully included in an extended treatment and rehabilitation
program? Our focus in the field shifted towards the behaviors, attitudes and
abilities of the adults in these children's lives that facilitated compliance
with the interventions of the Ghana Ministry of Health. While the pilot study
was an inquiry of the status of survivors, the work became an inquiry of the
compliance of whole family units with an intervention regimen [11,12].
It
has been our observation that Kwashiorkor's continuing presence in urban Accra
reflects social norms, customs, gender, and age discrimination, in addition
to poverty and/or a lack of knowledge about the nutritional needs of young
children [10]. Maternal illness or the presence of twins has also been
frequently associated with kwashiorkor [11, 12]. Substitutes for breast milk,
including concoctions such as egg white mixed with cocoa, have been documented
in cases that produced severe diarrhea, which became the precipitating medical
crisis that brought the child's kwashiorkor to the attention of the Ministry
of
Health. In fact, the majority of kwashiorkor cases come to medical attention
because of a physical crisis that is secondary to the ongoing malnutrition.
There
are many social and cultural factors that can be elements of normal activities
within homes and family life that have the effect of denying the most
vulnerable family members the protein and micronutrients that they require [11,
12, 13, and 14]. From a socio-clinical perspective, kwashiorkor can be
frustrating because, afflicted children are "good" behaviorally; they
are usually passive, quiet, and not agitated as would be expected of children
who are starving. A child's full, often-bloated, belly can be mistaken for the
child being anything but malnourished, and even fat, by a parent who does not
understand what is actually going on with the child. The classical red hair,
due to hair growth without sufficient nutrients, can be interpreted more as an
embarrassment to the family than as a medical problem. In fact, in urban Accra,
children with kwashiorkor are often not apparent because the red hair is often
masked with shoe polish or some other agent [10]. By the time the child is
recognized to be in poor health, it is often too late and permanent disability,
physical stunting, or death is the consequence.
Interventions
with kwashiorkor require recognition, acknowledgement of a medical problem,
acceptance of the need to act, and knowledge of what to do. In our fieldwork,
it was often observed that the mothers were not initially - responsible for
suspicion, recognition or acknowledgement of a pediatric medical problem; more
commonly it was a grandmother, or a great aunt, who recognized the child's
condition based on memories of widespread hunger in the past. The other most
likely source of initial recognition was by a community health nurse, who lives
and works in her community, as a constant presence of the Ministry of Health.
The community health nurses in urban Accra are often intimately familiar with
whole extended families, including all the deaths, sickness, births,
hospitalizations, accidents and other significant events within hundreds of
families. In our work, it was the community health nurses - given an absence
of
available medical records for all of the last 20 years - who made it possible
to find cases that had been detected and survived. Ongoing outcome evaluation
or available secondary data were unavailable for purposes of evaluating the
long-term kwashiorkor survivors [10, 11, 12].
Once
recognized to have kwashiorkor, either by family members or a nurse, the child
is typically hospitalized at the Korle-bu Teaching Hospital, returned to the
community, and then expected to participate in weekly rehabilitation and
nutrition support programs as an outpatient for up to three years. The
rehabilitation protocol includes monitoring the child's health, health and
nutrition education for the mother, provision and on-site preparation of food
supplements, and social support from mothers whose children have also had some
form of malnutrition [1, 11, and 12]. Sustained participation in the program,
however, is a challenge and non-compliance is a common problem. Children who do
not complete the program, because their parent could not comply with the weekly
regimen, as will be discussed below, are at high risk of failing health or
death. In our field interviews most of the participants were aware of children
who died subsequent to the parent dropping out of the rehabilitation program.
This awareness was a motivating factor for some to remain in compliance [10,
11, 12].
METHODOLOGY
Study Site
The
research reported here began with a pilot study in 1999 that was conducted
within the Jamestown district of Greater Accra. In this pilot effort, the
methods of case identification and selection, formulation of meaningful
hypotheses, and development of a data collection protocol were completed with
a small number of cases and their families (four youth, including a set of
twins
and three extended families). The initial research question was based on our
perception of a paucity of published long-term follow-up data on the quality
of life, health status, and social status of young adults who had suffered
from
kwashiorkor as children, but survived. Dettwyler made similar observations over
ten years ago [15]. Our initial concern was to determine what kind of
contributing member of the community, a kwashiorkor survivor would be; or,
would a "typical" survivor be dependent upon the family or community
and represent a cost, rather than an economic or social asset to the nation. It
was clear with even our small initial pilot study cases that were all strong
and contributing young people, that long-term consequences of stunting and
other disabilities, such as mental impairment, were not evident. Our initial
cases participated in school, had specific adult ambitions and expectations,
participated fully in familial responsibilities, and were normal in every
respect [10, 11, 12]. During the pilot study in 1999, however, we did find
suggestions of remarkable and extensive roles that grandmothers and great aunts
appeared to have played in the initial recognition and rehabilitation of the
survivors. We became aware of the extreme vulnerability of families who have
little or no cash savings, who have no property, and who live day-by-day in an
endless effort to provide meager food, shelter and basic needs. The 2001-2002
effort, therefore, was largely directed to determine not if the surviving cases
were functional young adults, but to find out how it was that they were able to
succeed in an extensive rehabilitation and intervention program while many
others did not. In other words, what was uniquely effective in these families
that sustained their compliance with the rehabilitation program?
Sample and Site Selection
Fieldwork
in 1999 began with case selection by the community health nurse staff of the
Princess Marie Louise Children's Hospital in Jamestown, a district of Greater
Accra. In the 2001 - 2002 effort, the research sites were extended beyond Jamestown to include the communities of Chorkor and Korle-Gono. These communities are
proximal to the Korle-bu Teaching Hospital complex and also to vast markets
where the families usually conducted most of their economic activities. All of
the families in the study were Ga, who most frequently are either fishermen or
market traders.
Medical
records of children's participation in the Ministry of Health nutritional
rehabilitation program, subsequent to an acute hospitalization are unlikely
sample frames for research in urban Ghana. Medical records, as with all paper
documents, are generally not available in the hospital or from polyclinics or
the families themselves. Such records have relatively short "shelf
lives" due to poor storage arrangements, climate and exposure to humidity.
The community health nurses usually represent the only option for case
recognition from previous years, because the nurses themselves, as previously
noted, often live in the neighborhoods in which they serve. Such arrangements
can last for many years, creating a living oral history, among these nurses, of
the lives of large numbers of people. This personal history was essential for
us because our research questions asked family members to remember events and
circumstances that might have taken place 16 - 20 years earlier. The community
health nurses became essential partners in the selection of cases, both in the
1999 pilot study and in the 2001 - 2002 field studies.
Data Collection
The
data collection protocol involved the participation of the research team
meeting with entire family groups at a location of convenience to the families.
The team involved the two senior authors of this paper, a social epidemiologist
and a social worker, a public health physician, a Ministry of Health community
health nurse, and one or more students who operated cameras and recorders.
Consulting team members included a nutritionist and a gerontological social
scientist (the third author of this paper).
A
total of 46 individuals, comprising 15 families, were included in family
interviews. These families included 15 index kwashiorkor survivor cases. Two
families had two index cases because the twin siblings had both been
kwashiorkor survivors. The families included 10 grandmothers, 11 mothers, 3
surrogate mothers, 2 fathers, 2 adult siblings and 3 aunts. Several
grandmothers, mothers and fathers who had been instrumental in the initial
survival of the kwashiorkor case were deceased at the time of these interviews
and their roles were discussed regarding their instrumental participation in
the initial diagnosis, participation in various aspects of the family's
functioning, and the index case's compliance with the Ministry's intervention
protocol. Among these 15 families, two mothers had abandoned their children.
Interviews
began with introductions about the purposes of the inquiry and completion of
all human subjects consent forms for both Eastern Michigan University and the
University of Ghana. Participants were given full documentation of the purposes
of the research and how to contact members of the research team. The
signatory process was video recorded for full documentation. The interviews
then proceeded to the following:
- An assessment of family relationships, including kinship and
informal, non-kinship dependencies;
- The roles of all senior family members with a focus on grandmothers
and similarly generation members of the immediate family;
- The specific roles of different family members regarding
participation and compliance with the nutritional rehabilitation program;
- Nutritional practices and beliefs of the family;
- Health practices and beliefs, including the use of traditional
healers in addition to, or instead of the Ministry of Health or private,
modern medical services;
- Religious beliefs and spirituality;
- An assessment of the kwashiorkor survivor's early childhood to
young adult health history and social functionality; and
- An assessment of the family's economic resources, work histories,
sources of income, and how the responsibilities of the household were
distributed.
The
interviews were directed first to the most senior member of the family.
Specific questions about current social functionality were directed to the
kwashiorkor survivors, themselves. These methods are consistent with similar
qualitative field efforts in comparable locations with vulnerable populations
in the developing world; including sub-Saharan Africa [16,17,18,19,20]. All
interviews were audio taped and video-recorded and all team members took field
notes. Ghanaian members of the team served as translators when required. Most
Ghanaians speak at least some English, however, detailed and emotional topics
are often more comfortably discussed in one of the vernacular languages that
are common in urban Accra. All participating family members, including
siblings, parents, grand parents and other immediate household members were
provided with a token of our appreciation for their willingness to participate
in these interviews ($20 US equivalence in Ghanaian Cedis, each). The
interviews often required over two hours to complete. Efforts were made to
ensure as much privacy as possible, despite the often-crowded conditions in
which participants lived or in the markets where some of the interviews took
place. Arrangements were made for possible follow-up interviews for clarification
or
for further discussion of points made during the interviews.
Data Analysis and Interpretation
The
descriptive and qualitative data were tabulated and organized with debriefing
sessions by the field team to ensure that information nuances and unique points
were recorded and credited accurately to specific family members. Deacon and
Piercy (2001), among others, have provided standardization of field and
clinical data from combinations of observer's structured notes and systematic
interpretation of findings; these processes were comparable to our process
immediately following each family interview. Key words and phrases, the
context of responses, repetition by different family members and a
quantification of specific phrases provided internal assessments of the
interviews. Grouped internal assessments then provided a means of generating
findings that were consistent among the interviews and discovery that was
either infrequent or distinctly different from others.
RESULTS
The
most general and consistent finding from these family interviews was the
collaborative and interdependent roles of the extended family members. Our
cases benefited from the active efforts of grandmothers, great aunts, and other
family members to ensure the child's rehabilitation participation and to remain
in compliance with the Ministry of Health rehabilitation programs. These
families were characterized by collective decision-making, rather than the
isolated decision-making of a single parent or caregiver. These families were
highly motivated, decision-making groups whose efforts ensured that the
afflicted child would survive; all participating family units were highly aware
of similarly malnourished children who had died.
In
most cases the collaborative decision-making did not include men. The fathers
of the index cases were only involved in two of the interviewed family
interviews; the issue of male involvement, especially the absence, or lack of
involvement, of most of the fathers or senior men in the lives of the index
cases was
consistent with discussions with most of these families. In all but two of the
families men, in general, and index case fathers, in particular, were absent
due to death, inability to participate because of work, or abandonment.
The
majority of mothers and surrogate mothers believed that the child became sick
due to lack of breast milk and/or because the child was given a substitute,
such as egg whites with cocoa. This finding is consistent with Appiah, who
commented on the knowledge about causes of kwashiorkor among women in the Volta
Region of Ghana [21]. Of Appiah's 95 interviewed women, of whom 46 had well
nourished children and the others had children with kwashiorkor, 67 believed
that the condition was caused by a lack of the right kind of food [13]. The
malnutrition cases in our study was often not the precipitating medical event
that brought the child to the attention of the Ministry of Health, or to a
hospital, as was first noted in our pilot study. Most frequently, diarrhea was
the precipitating clinical event. The mothers in our studies were less likely
to recognize kwashiorkor as a medical problem than the grandmothers or other
senior women in the household. This raises the important public health question
of the probability of a single parent with multiple children recognizing the
vulnerability of a sick child before the acuity of the condition would make
medical intervention and rehabilitation unlikely to succeed.
The
familial condition that was most closely associated with child survival, by way
of full compliance with the rehabilitation program's weekly participation, was
the presence of extended and senior family members. Grandmothers, more often
than the mothers, were the ones who recognized kwashiorkor as a medical
condition that could lead to a child's death. Grandmothers expressed their
memories and remembered specific situations of widespread hunger and starvation
in the past.
Once
the kwashiorkor case was enrolled in the Ministry of Health's rehabilitation
program, the family faced a daunting compliance challenge. These economically
vulnerable families were expected to participate for as long as three years in
weekly outpatient care and nutrition education programming, while also
struggling to earn sufficient incomes to provide food and shelter for the
extended family and other dependants. The grandmothers and other older women
would often either take responsibility for transporting and ensuring rehabilitation
program participation, to allow the mothers to work in the markets, or they
would take over the market duties to ensure that the family would have
sufficient income to provide food. These assumed responsibilities of the
grandmothers are consistent with Apt's study of Ghanaian elders, especially
grandmothers in a broader sociological context [22].
In
these Accra neighborhoods, there was little evidence of savings or surplus
economic resources; families living at this level of poverty, certainly including
the families in our interviews had little or no financial reserves. Because of
these circumstances, the burden of getting a child to a weekly rehabilitation
program, over an extended time frame, was significant because it profoundly
interrupted the essential economic activity of the family. In our opinion,
large and dedicated families, with knowledgeable and experienced grandmothers
or other senior women, were essential to the survival of these kwashiorkor
cases. Although we have no case evidence, it seems highly unlikely that a
single mother, with multiple children, without the support of extended and
dedicated family members, would be likely to meet the expectations of
rehabilitation participation, as well as to adequately meet the economic needs
of her family. Such is the harsh reality of a 24-hour market economy. We
believe, based on these interviews, that the participation and assistance of
the grandmothers and other older women in the family are likely to distinguish
between kwashiorkor rehabilitation cases in urban Accra that succeed, and those
that do not. We would speculate that single parents with multiple children, of
whom one had kwashiorkor, would find full compliance with the rehabilitation
program's expectations to be nearly impossible.
DISCUSSION
The
roles of grandmothers and senior women became apparent as these family-based
interviews were conducted. Initial observations were reinforced with the
addition of each new case. Throughout the process, however, we also noted the
nearly incomprehensible presence of malnutrition within communities and market
places where protein-rich foods were in abundance - and had been in abundance
in the recent past. Upon further discussions with colleagues and some of the
research participants, it became clear that poverty, per se, was clearly not
the principal cause of these cases of kwashiorkor, nor was the absence of
poverty the principal reason that the children survived. In some very
traditional homes, the oldest men have access to the meat, fish or fat first
and may conclude their meals before women or children can begin. Some women
expect to feed the men first and are as resistant to change as the men. Similar
customs, although significantly less common than in decades past, can continue
to put the youngest children at the bottom of the familial food chain [11, 12].
These and other contributing causes can be directly modified with culturally
sensitive and persistent public health education. Such education efforts must
be ongoing, because we noted that without personal experience or history, the
younger mothers were less likely - than the older women - to recognize
kwashiorkor as a medical disorder. Just as Williams first observed when
kwashiorkor was introduced into the medical lexicon, and from the very same
location, pediatric deaths from kwashiorkor are largely preventable, this is
not a problem of poverty; it is caused by a "poverty of knowledge" [1,
8, 9].
Clearly,
our work in urban Accra has limited generalizability without substantial
replication and verification in a variety of populations. We strongly encourage
such efforts. The consistency of our findings, however, regarding the senior
women in the families was noteworthy. The powerful roles of the senior women in
the survival of these kwashiorkor victims were a theme throughout each family's
interview. None of the younger women challenged or failed to support and
reinforce the conclusion that the child would have been in grave danger if the
senior women were not available, actively engaged in the life of the family and
child rearing, and that there were collective decisions regarding the child's
welfare.
In
addition to replication and investigation of the criticality of roles of
elderly women in child survival from malnutrition, it is also important to
consider investigations that directly compare the success of families without
extended familial members, such as single parents with a malnourished child,
against families with the collective participation of older women. This
comparative analysis would isolate the relative success or failure in
rehabilitation as a question of compliance with a long-term, rehabilitative and
medical intervention. The findings of such a comparative analysis would have
implications for the larger and more generalizable literature on compliance
with medical regimens.
When
conducting research "on the ground", in places like the crowded,
impoverished neighborhoods of urban Accra, Ghana, large public health questions
can quickly become condensed into issues of practicality and circumstance. In
Ghana, malnutrition represents the sixth leading cause of death of children less
than five years old [5, 6]. Dealing with this kind of endemic condition is a
source of
continuing frustration to public health leaders who must also deal with the
challenges of urbanization, population growth and migration into the urban
centers and inadequacy of sanitary or other essential elements of the
infrastructure. New public health challenges now constitute morbidity and
mortality threats that can eclipse traditional killers such as kwashiorkor [13,
14]. The efforts of community nurses as counselors, primary care specialists,
referral agents, advocates, and public health educators represent, in our
opinion, the best hope for thousands of vulnerable children in places like Accra.
We hope that the national ministries in such places recognize the cost-effectiveness
of the work of all these people. Similarly, appropriate
government ministries should recognize the vital roles of the older women in
the survival of children. The significant value of intergenerational
interdependence should be recognized as an essential element of economic
stability and improved public health. Three quarters of the women in Ghana are
in the labor force [5, 6]. Ghana is an extreme case, as it has as many women
in
the documented workforce as males and the proportions of women who are working
and are principal family breadwinners is rising faster than those for males.
Older women rarely retire in such environments and their continued familial
contributions are essential to the ability of younger women to contribute in
the labor force.
Collective
decision-making, such as we observed in the extended families of our index
cases is consistent with a larger perspective of parenting, and childrearing.
In many places that have experienced severe marginalization of indigenous
people, economic or political domination by small minorities or distant
nations, the survival of traditions as well as communities has been attributed
to the roles of senior women. We believe that collective decision-making for
important aspects of child rearing or a family's economic situation is a
hallmark of people who have faced oppression, economic or physical
exploitation, and other historical challenges and that this is true globally
[23, 26,27].
Contemporary
public health circumstances in many Sub-Saharan African nations suggest that
the value of collective decision making within familial structures will be an
essential HIV/AIDS, malaria, tuberculosis, roadway crash casualties, and
domestic or civil as well as international warfare all create increased
intergenerational dependence and cross-generational roles and responsibilities
that place substantial burdens on the oldest members of society. It would seem
to be most critical that governmental policies and resources acknowledge the
importance of the elderly members of society who often have the responsibility
to rear the next generations while also continuing to sustain other aspects of
families and communities [27].
CONCLUSIONS
We
know that previous efforts to provide adequate treatment and to seek the
eradication of malnutrition among children in emerging nations have primarily
focused on clinical interventions and community health education [28,29].
Providing nutritional education, economic circumstances that create adequate
supplies of appropriate food, and political stability, however, appear to be
necessary, but insufficient. Our cases were brought to treatment in a general
environment of political and economic stability. The collective familial
decision-making of these families was central to their sustained compliance in
rehabilitation, at the case level; we suggest that this element of the
successful outcomes of these cases is generalizable to the pursuit of
eradicating endemic kwashiorkor at the level of communities. Findings from
this study have demonstrated that informal active involvement of senior members
of the household, such as surrogate mothers and especially grandmothers, is
vital to the survival and physical and emotional well being of kwashiorkor
victims. The role and importance of senior women in the survival of these
children has been under-appreciated, but consistent with a broader
understanding of the significant, gender-specific roles, responsibilities, and
traditions of subSaharan, Africa's grandparents [24,30,31]. We would encourage
the public health authorities of nations with large, vulnerable populations of
children to find ways to support the senior members of the community,
especially the grandmothers and other older women, who are essential to these
nations' futures.
The
appropriate way to use such information and the means of engaging appropriate
members of Ministries of Health and organizations whose missions are focused
on child advocacy remain to be determined and must be sensitive to cultural
norms
and expectations. Such is the reality for all social or political responses to
human need. Male-female role expectations, intergenerational role dynamics in
a rapidly changing Africa, distribution of wealth, and the introduction of
nuclear families rather than multi-generation households all will influence any
public effort to attack endemic childhood malnutrition or under-nutrition.
These dynamic social considerations should become part of the debate over how
to generate programs and services that are effective to specific populations.
In
addition, our speculation of the relative probability of failure of a single
parent with multiple children of whom one has kwashiorkor, needs to be tested
in the field. We would not - based on these data alone - recommend discouraging
such cases from being enrolled into rehabilitation programs with limited
resources just because of the potential for non-compliance.
ACKNOWLEDGEMENTS
We
express our gratitude to Professor Edward Garrison of Dine College in New Mexico, USA, and Professor Bruce Owusu of the University of Ghana who were instrumental in the 1999 pilot study. The research team, included Beatrice Addo,
our principal community health nurse, and Mr. Frank Ampougah, who helped in too
many ways to list and three American undergraduate students, Mary Dankwa and
Elizabeth Brant of Eastern Michigan University, and Carlyn Scheinfeld of the
University of California (Santa Cruz), also participated in the research.
CONTRIBUTORS
Richard
Douglass and Brenda McGadney-Douglass developed this paper mutually. Professor
Phyllis Antwi played a key role in the research design and participated in
field interviews. Important conceptual development, verification of
sociological and related social science literatures from contemporary African
literatures were brought to our attention, and earnestly discussed between 2000
and 2003, in the context of our field work, with Professor Nana Apt, who is the
third listed author.
REFERENCES