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This paper reports on an anthropological investigation in Jardim Primavera, a low-income suburban and semi-rural community in Rio de Janeiro, Brazil. The RAP (rapid assessment procedures) methodology was employed to assess the primary health care systems being used in an attempt to understand their functions and logic and to assess the impact of primary health care in the community. Survey questions and open-ended questions of structured interviews were used to develop an ethnographic overview of the community, focusing on health problems, health-seeking behaviour, and the various healing processes known to and used by the community. Three groups were targeted: primary health care providers, households, and the community. In a community such as Jardim Primavera, a rapid assessment could give the impression that a lack of resources and the transition from a rural to an urban setting are basic problems that could be alleviated by education, project planning, and funds. As is pointed out, however, the problems are greater and much more complex.
During four months in 1987 and two months in 1988, an anthropologic investigation was carried out in a low-income suburban and semi-rural community in Rio de Janeiro, Brazil, known as Jardim Primavera ("Spring Garden"). The objectives were twofold: (1) to assess the primary health care systems being used, both formal or institutional and informal or folk, in an attempt to understand their functions and logic; and (2) to assess the impact of primary health care, focusing on users' perception of the systems, that is, how users, mainly mothers and young children, perceive and react to them.
This study used anthropologic procedures such as participant observation, and formal and informal interviews as integral parts of a methodology known as rapid assessment procedures (RAP), an approach that was developed by experienced researchers in the health field who are also anthropologists [1]. It was and is important for anthropologists trained in classic methods of ethnographic research to see how these methods can be adapted to a shorter time frame, to a smaller sample, and to a more specific social and physical environment, and still be as reliable and valid as they have traditionally been thought to be. Using RAP as a guideline, the paper analyses the results of the investigation that were deemed the most crucial for an understanding of the social phenomena related to health and healing in Jardim Primavera.
Jardim Primavera lies within a network of small neighbourhoods in the metropolitan area of Rio de Janeiro. Until the 1920s, these neighbourhoods were part of small farms such as the one from which Jardim Primavera inherited its name. It is now a misleading name, since this hamlet no longer can be considered a garden; neither does it produce agricultural products, nor is it filled with flowers and vegetation.
Agricultural production there declined immediately after the Second World War. At the same time, the population increased at an astonishing pace due to the heavy influx of migrants from north-east Brazil (who still keep coming) who were escaping the poorer conditions of Brazilian rural life and a badly organized economic infrastructure.
In this community, the first fact that becomes visibly apparent is the overall lack of efficiency of the existing urban services, from transportation to everything that dwellers of a pare-urban development require to live at least half decently. The list of basic problems is extensive. Most streets are unpaved, paved roads show holes almost the size of a medium car, draining and sewage systems are either clogged or do not exist, public transportation (buses and trains) is deficient in terms of number and schedule (besides being expensive), and garbage collection is rare.
Partially due to these problems in the service infrastructure, the health care delivery system has also been notorious for its lack of efficiency and rationality. The only maternity centre in the area was closed due to increasing numbers of maternal deaths and rising infant mortality. There were two low-income clinics with good standards of service, but the poor transportation system impeded their use. Finally, local medical doctors charged fees that were relatively high for the majority of the local inhabitants.
The role of women in maintaining health and healing
Women, whether of low or middle income, act in such a way in the community that they are able to establish an informal network through their mutual solidarity and awareness of their duties as family health keepers. Such duties are defined from the perspective of their maternal roles and have been developed in the domestic as well as the supra-domestic spheres of their lives.
The importance of women's participation in the community as a whole is demonstrated through the high profile that they maintain in neighbourhood associations and the churches, especially in the pastoral action movements of the local Catholic church. Women also perform "invisible labour" in their families and in the community as informal health agents and care providers. It is through them that most knowledge of the use of herbs and simpatias (magical healing procedures) is fostered and maintained as an alternative to pharmaceutical and institutional healing methods. Housewives keep the medicinal herb gardens, sharing specimens and information on their preparation and use among neighbours. Their knowledge is orally and empirically transmitted from older to younger women, and their practices have been so strongly adhered to that modern doctors have been forced to accept some of these herbs and their cures.
Women are also the ones who make the final decision on whether to take a member of the family to a health centre, hospital, or local healer, or simply give a home remedy. Most are considered competent to take care of the sick and even to heal, but some are healing agents in their own right, with talents they inherited by birth and built upon with knowledge from their ancestors. These women mainly perform healing through prayer. Some are spiritualists or herbalists, but these two categories also include male healers. Only women become parteiras, or midwives.
Parteiras
Parteira is a category that falls between the institutional and the popular modes of healing, since some parteiras do receive formal training and are appointed by the municipal health office. Only females are permitted to become midwives because women in childbirth do not like to be attended by males' with the possible exception of their husbands. This attitude is carried over to male gynaecologists, to the point that some women-especially those from the lower classes or from very strong rural backgrounds-will not go to a gynaecologist even for prenatal care if only male physicians are available. Parteiras, however, are neighbour women whom they trust.
Mezinheiras
Mezinheiras are women with vast experience and knowledge in the use of medicinal plants and simpatias. They are supposed to heal through praying. The usual procedure is for them to shake a handful of leaves from any local bush around the patient's body while reciting Catholic prayers in which the healing power of God and Jesus is exalted and called forth. These women also prescribe herbal potions and use amulets during treatment. Most know some secret formulas to be used in the treatment of certain illnesses, and which should be given to the patient without his or her knowledge of the ingredients.
Although women are known to be herbalists, male herbalists tend to be sought after as being more knowledgeable and capable. Men tend to have more prestige as folk healers and charge for their services, whereas most women healers charge nothing or very little. This illustrates that prestige is still the domain of men in a society in which the subordination of women is considered the norm. Even prestigious female healers do not enjoy the same level of prestige as males, and female medical doctors are not as highly regarded as males. Although women choose not to see a male gynaecologist, this attitude is dictated by shame and not by the male physician's lack of prestige.
Common to all folk healers is that their activities tend to be preventive as well as curative, as their treatments involve the whole person, including the spiritual aspect, not just the specific body part that is ill. They are also responsible for the only mental health care that is practiced in Jardim Primavera. Thus, their treatments can be characterized as holistic. Medical doctors are usually consulted in critical illnesses or when the medicines and treatment prescribed by the folk healers do not have the desired effect. This situation is reversed when patients who fail to get well under a medical doctor's treatment look for a herbalist or simpatia as their last chance for healing.
The use of institutional health care systems
Two health centres are open six days of the week, from 8 a.m. to 5 p.m. They are adequately staffed to deal with primary health care needs and to recommend specialist care outside of Jardim Primavera for those who need it. The centres receive a steady flow of clients, who rate the medical attention as favourable, seeing the doctors as "good and caring folk".
One of the barriers to total acceptance of care, however, is the physicians' use of medical terminology. Most people confess to being confused or unclear about what the doctors tell them (except for one doctor, who uses medicinal herbs) or what the diagnosis was. Physicians frequently find it difficult to talk in other than official medical terms, and this difficulty may be intensified by their perception of a lack of formal education in their clients. Most clients said that they look for the doctor either to confirm a diagnosis they themselves made at home or to pinpoint an ailment that they did not know about. Obviously, a doctor cannot always meet these requests, unless the illness is a relatively simple one such as a cold, rheumatism, bronchitis, or asthma. (With respect to asthma and bronchitis, however, people generally disregard a doctor's prescription and rely on the simpatias already known in the community.)
Medicines prescribed by the doctor will be acquired if they are available at the health centre's pharmacy or if the doctor gives out samples. If they have to be bought at the drugstore, the doctor will have to convince the patient that death will be imminent if the drugs are not taken. One of the woman doctors demonstrated irritability towards this reluctance to buy medicines: "They will spend money on votive candles and spiritualist paraphernalia but not on medicines that will help save their lives." She added that many patients come back later in much worse condition because they did not get the medicine or, if they did, were unable to follow the instructions for its use.
An additional problem exists when people do get prescriptions filled. Frequently, if they become ill again with similar symptoms, they return to the druggist for more of the same medicine, thus avoiding another visit to the doctor. Because druggists do not keep prescriptions, there are no records of the original indication for a drug and they could be dispensing medication for incorrect usage.
Pharmacists, together with folk healers, are among the most frequently consulted health care providers in the community. They are viewed as counsellors on medicines, and are known to prescribe and sell birth-control pills, antibiotics, anti-depressants, and so on without doctors' prescriptions.
In view of all of these variables, how do researchers use RAP to obtain valuable sociological and anthropological data?
The procedures contained in the RAP guidelines are concerned "specifically with beliefs and perceptions regarding health, the prevention and treatment of illness, and the utilization of traditional and biomedical health resources" [1]. Following these guidelines, a series of interview routines was planned to gather information on income and number of residents in a household (independent variables) and on health needs, strategies for obtaining health services, concepts about health and illness, belief systems, and social networks. We relied on survey questions and open-ended questions in structured interviews. This was basically an ethnographic overview of the community, focusing on themes of health problems, health-seeking behaviour, and the various healing processes known to and used by the community.
Field tasks were targeted at three main groups: primary health care providers, households, and the community.
Primary health care providers
Observation and interviews were conducted at the two primary health care centres that serve lower-income families. Two medical doctors, one laboratory technician, three nurse's aides, five clients, and two administrators were interviewed. Waiting room conditions and medical consultations were observed. Similar procedures were applied regarding three folk healers, and we also interviewed three clients. Two pharmacists and three staff members of the three local drugstores were interviewed, and interactions in those settings were observed.
Households
Fifteen households were visited, and the women who handled family matters were interviewed regarding health and illness concepts, healing systems, and healers. These families all had children under five years of age. Ten of them were considered as low income, and five were lower-middle and middle class.
Community
Two officers of the Urban Planning Secretariat and three staff members of the Municipal Health Associations were interviewed. Two women leaders of the neighbourhood associations and their milk-distribution procedure were observed. Two priests of the Catholic church were informally interviewed.
Each investigator spent an average of four hours with each of the interviewed families, not including informal conversations with housewives outside the home environment. Women interviewed at home were also seen and talked with at the clinic, at bus stops, and in the street. Five days were spent at the Catholic-funded centre. Only three days were spent at the state health centre, because it did not open until the data collection was about to end. Health care staff were talked with outside the work environment. Three days were spent at the drugstores. Three days were spent at the Urban Planning offices, and two and a half days at the Municipal Health offices.
One woman healer was observed at work for five hours and interviewed for two hours, and her apprentice-daughter as well as another woman healer were interviewed for approximately three hours. The male healer was visited three times for nearly six hours each day. His apprentice-daughter was interviewed for two hours.
One Sunday morning was spent observing milk-distribution procedures. Women leaders who organize church committees and neighbourhood associations were most extensively interviewed. The home of one of them was the point of gathering for the research team as well as the place most local women went to get information about community events, to gossip, to share needed items from pots to medicinal plants, or to just plain unwind and rest before going back home. It was where most of us spent many hours of informal conversation and participant observation, as we shared meals, planned parties and community working teams, and explained about our work.
As a consequence of the users' perspectives and needs, much information on the use of medicinal botanical species was gathered, giving us an opportunity to go into an ethnobotanical inquiry. The male healer gave us a list of the most used remedies, with folk classifications, methods of preparation, dosages, and uses. Women in the households also told us about herbal remedies. One of the medical doctors at the Catholic-sponsored health centre aided in this part of the research, as he also prescribed herbal medicines to his patients. He was planning to start a medicinal garden somewhere near the church and health centre.
One of the social phenomena that stands out is the awareness on the part of clients of the cause-and-effect relationship between what is perceived as food and nutrition and what is perceived as health. Thus, the quest for health was equated to the quest for food. One woman summarized the perspective this way: "Our basic health problem here is lack of food."
Although the women had no apparent knowledge about the nutritional contents of food, it was clear to them that their children were not healthier because they lacked access to food (they don't eat much), so quantity was perceived as more important than quality. One woman commented, "Whatever I can get to feed my children is good for them." Mothers asserted that, to remain healthy, their children must be kept "with full stomachs". For example, mothers receiving milk coupons that were distributed through the Catholic Church traded a good portion of them for white bread instead of milk. They were giving their growing children less milk and more unenriched bread, made of white flour, salt, and water. The reasoning was that bread kills hunger whereas milk is watery and only leaves children crying for more.
Diet was not so much related to food as to behaviours, attitudes, and actions. For example, a pregnant woman's "diet" consists of not thinking bad thoughts that might harm the baby, and in keeping away from upsetting events so that she will not become "nervous" and affect the baby.
Food restrictions or taboos were related mostly to certain categories of illnesses and herbal medicines. They were based on the "hot-cold" theory that is so prevalent throughout Latin American rural and indigenous areas. This is a concept that ascribes illness to an imbalance of heat and cold in the body. Accordingly, health can be restored only through the restoration of the proper balance of these culturally perceived qualities: diseases that are perceived as "hot" are treated with remedies defined as "cold", and vice versa.
Some food restrictions were observed in children suffering from diarrhoea and dehydration symptoms, at which time mothers gave them plenty of hot herbal teas, made mainly from orange leaves and Melissa officinal is and kept them away from oily foods. Such changes in feeding patterns were said to have been influenced by intense radio and television campaigns advising people about the dangers of dehydration and diarrhoea, and teaching them how to prepare home oral rehydration solutions, what to feed children, and what to keep children from eating. Several types of diarrhoea are so common in the area, however, that for more than half of the interviewed families, they did not fall in the category of childhood illness; that is, if we asked what were the most common diseases in children in a household, more than half of the women did not mention diarrhoea. If we asked specifically about problems with bowel movements, the digestive system, and loss of fluids, we found that all of the children were plagued with diarrhoea several times a year, but were not considered sick.
"My children are perfectly healthy," was the assertion of mothers of children running around with chronic earaches, puffed-up bellies, running noses that never cleared up, and watery stools. Mothers mostly listed as illnesses problems related to the upper respiratory system such as asthma, bronchitis (which they swore medical doctors did not know how to treat effectively), and "nervousness" (nervoso). The last is a disease category that involves several symptoms: lack of appetite, disturbed sleep patterns, irritability, fatigue, apathy, crying bouts, and vomiting. It cannot be treated by a doctor, but requires the intervention of a folk healer.
It is clear that RAP users should "define their own research objectives, develop project-specific research questions, determining the necessary indicators, and prepare the data collection instruments accordingly" [1] In Jardim Primavera, we focused research on patterns of use of medical services and the health-seeking behaviours of families with young children, and not on one specific project.
We used the interview and observation guidelines outlined by the authors of RAP, making the changes deemed necessary for our context, thus excluding questions or procedures considered irrelevant and including others that emerged during the investigation process. Since RAP was originally written in English, we had to translate it into the type of Portuguese that is spoken in our community, in acceptable and understandable terms. That was possible not only because we are Brazilians but because we have become familiar, through time spent in similar communities, with the kind of language and concepts being used. Overall, however, the RAP book presented us with excellently planned outlines for the interviews, and a system for narrowing down obtained information into reasonable and interconnected blocks of problems and phenomena, which were suitable for data analysis.
After gathering information on households, community institutions, and health agents, the picture that emerged included visible as well as invisible factors, the latter being as important as, if not more than, the former. In an anthropologic investigation, it is fundamental not to confuse visible social relations with the invisible social structure and its logic. There fore, it was necessary to allow the hidden workings of the community to emerge through answers to questions on health and illness, and disease causation.
The need for educational programmes became evident, but even though people agreed on this need, the infrastructural problems they faced seemed even greater. They questioned the validity of such programmes for people who work a double shift in the fields, the factory, and at home. Even when leisure time is available, it would be difficult for most of them to reach the places where such educational sessions could be held.
In the case of Jardim Primavera, a rapid assessment could give the impression that lack of resources and the transition from a rural to an urban setting are the basic problems, and that they could be alleviated by energetic measures such as education, project planning, and a large injection of funds. The problems are much larger, however, and go much deeper. They involve the type of capitalism being developed in Brazil as well as the moral and ethical attitudes not only of the authorities, but also of the people who suffer because of them. Lack of access to health resources and failure to use the ones that are available are not simply resistance to modernization. They bespeak disenchantment with an "ideal" urban society and with the process of modernization itself. Such disenchantment looms larger and much more dramatically than we were able to assess. An analytic approach to the answers afforded by the RAP guidelines involves, most of all, an appraisal of the discourses, searching for the links between apparent struggles and constant failures to achieve a healthier and happier life.