were trained by the Family Welfare Centres under the Population Welfare Program. In the Seventh Five Year Plan, 1988-93, the policy stated that theTB As would also be given fee task of motivating mothers for longer child birth-spacing and promotion of breastfeeding (Nur 1987:15; Planning Commission, 1988).
This particular dai’s mode of delivery is based on traditional methods. A detailed interview with her revealed that her gynaecological knowledge was not only limited but also overshadowed by supernatural rituals and beliefs which are found in various regions of the country. For example, during the initial few months of the pregnancy, cultural restrictions on the consumption of certain foods are imposed. Pregnant women are advised to avoid foods such as dates, dried fruit, tamarind, eggs and mangoes which are considered ‘hot’ and may abort the foetus. This food taboo is observed in the case of the first and most desired pregnancy. According to this belief, the kinds of food taken also affect the appearance of the child. Foods like spinach or egg-plant are usually avoided, as they would darken the complexion of the child, whereas milk and yoghurt make the baby fair. Eating plenty of food during pregnancy, however, is seen as the secret to having a big, healthy baby and women are recommended to have meat or chicken as much as possible. Having a lot of milk and butter is also perceived to ease the birth of the baby. It is a usual practice to give some concoction of butter and milk to the mother just before delivery. The rationale is that butter, being greasy, easily slips the baby out with less pain. If for some reason the child dies during the course of delivery, it is considered the ‘will of G od’.
Certain beliefs and associated behaviour are also observed by the pregnant woman; for example, she is usually advised to avoid women who are known to be infertile or who always give birth to dead children, because the saiya7 of such women will bring the same fate to the pregnant woman. This attitude is reflective of the hina ceremony held a day before a girl’s wedding when only married women (who have borne children) are asked to paint hina on the palms of the bride-to-be to make her marriage successful. Another belief is directly related to the appearance of a lunar or solar eclipse. During the time of the eclipse, a pregnant woman is required to stay indoors. Inside the home she occupies herself with household chores which do not involve using scissors or a knife or anything sharp and pointed, not even stitching with a needle. If she uses a sharp instrument, it is believed she will bear a deformed child, who will have a cut on his lip, ear, nose or some other part of the face.
The area has access to two Family Welfare Centres. One of them, with a permanent staff of about ten including at least two doctors, was at a walking distance of about ten minutes. Besides being a centre for maternal and child services, it was used for training field workers and served as a base for delivering services to the community in the surrounding areas. The two most prominent and aggressively pursued services were immunization and contraception campaigns. As confirmed by the inhabitants of the area and the workers of the Family Welfare Centres, the field workers, both male and female, visited the area to provide these services. U nder the Continuous M otivation System for prom oting contraceptive use, trained staff is assigned the task of motivating married couples to use contraception. This is done through surveying and listing households to register eligible couples who are thereafter regularly visited at home. The couples are specifically targeted for guidance in contraceptive use as well as supply (Iqbal, 1986).
In the case of immunization of the children, the routine was to go from house to house and enquire about the immunization status of the children, to list the households with eligible children along with providing the service where needed. Thereafter visits were made for the follow-up doses. In one of the galis, the routine was to make use of a local mosque
where the team was located temporarily. An announcement
would be made on theloudspeaker to let people know that the service was available for a specified period of the
day. Although many respondents reported having used the service, others preferred to go to the clinic or a nearby hospital. Many also complained that the visits were not frequent and that the workers were careless and rude. This also applied to the door-to-door service provided to m otivate m arried couples to use contraception for a sm aller family. Contraceptives such as condoms and others were recommended and appointments were made for those who chose a coil or other intra-uterine device. From detailed discussions with some respondents in the presence of their husbands, it was evident that these men were not in favour of the campaign and in some cases, the household members were strictly told not to let the workers inside the house.
Family Planning started as early as 1953 when some influential women privately initiated the Family Planning Association of Pakistan. A proper and independent organization was, however, established through the Third Five Year plan (1965-1970) to implement the Family Planning program. Dais along with doctors, paramedics and others were included in the program for motivational purposes (Planning Commission, 1965). In view of a very low rate of contraceptive use, the planners in the following Five Year Plan (1970-75) realized that the dais were incapable of performing the motivational task and they were replaced by trained teams of male and female motivators (Iqbal, 1986: 9-13; Planning Commission, 1970). Dais are, however, still included in delivering the service as part of the Continuous Motivation System and it seems that neither the dais nor the trained motivators are making much headway.
During the Sixth Five Year Plan, 1,156 hakims were involved in the health program for distribution of conventional contraceptives but according to national based estimates of contraceptive users, the impact was insignificant. In the Seventh Five Year Plan (1988- 93), emphasis was laid on providing better training and services in addition to increasing the number of hakims to 2,500 and that of homoeopaths to 1,500 (Planning Commission, 1988). Such initiatives remain ineffective as according to the estimates of the Pakistan Demographic and Health Survey (PDHS) 1990-1991, the current use of family planning methods by currently married women, at the time of the survey, was only about 12 per cent (Shah and Ali, 1992).
In or near the study area, there were a few traditional healers, such as the homoeopaths, hakims and ‘mystic healers’ (these also include maulvis and saints) whose method of healing is through offering prayer. Two of these were living in the study area while the other four, of whom two were hakims and the other two homoeopaths, lived in relatively large houses in the surrounding areas. In all cases, these health care providers practised at home and were said to be following the profession of their forefathers. The two operating in the survey area were living in small houses and the same premises were used for living as well as running the practice. One of them was a female whose healing method was essentially the use of various oil extracts for different kinds of illnesses. She was known for curing ailments associated with joints and bones: patients under treatment were required to visit her to have the affected part massaged regularly. After every treatment the massaged portion was wrapped in an ordinary piece of cloth to keep it warm lest cool air might nullify the effect of the medicine .and make it worse. The same method was applied for headaches, and throat and other ailments. The other practitioner was a spiritual healer, whose whole family of seven members lived in one room. The front of the room, a covered verandah, had a makeshift kitchen in one corner and the other side was occupied by a mazar8 where the patient seeking treatment sat and the healing was performed. The healer
used ashes while performing the treatment. He blew on the ash after having read a mantar9 and rubbed the ash on the forehead of the patient. Later some other things were murmured by the healer who again blew on the patient under treatment. In the end, a tahviz10 was tied on the forearm of the patient, to protect the person from all evils along with healing and providing protection from other illnesses. In one case a woman in the ninth month of pregnancy was taken to the mystic healer in a state of unconsciousness. The healer believed that the woman was possessed by an evil spirit. In the process of healing, candles were lit all around the woman and mantars were read continuously before her. When no change took place, an educated relative was notified who decided to take the woman to the hospital. Unfortunately it was too late: the woman was actually suffering from extreme high blood pressure and died of a brain haemorrhage. Another female was running a small clinic in one of the galis. W hen asked what was usually prescribed to a child patient in case of diarrhoea or fever, she mentioned some 'red syrup' (probably a mixture of vitamins, aspirin etc. normally prepared by clinics, especially for children) for fever and tablets for diarrhoea. In-depth discussion with her revealed that she had no medical knowledge, especially diagnosis and treatment of childhood illnesses.
Having the advantage of living in a larger house or having occupied the larger house with the intention of establishing a clinic, the hakims and the homoeopaths were running registered clinics by converting a portion of the house into a workplace: this part was not used for residential purposes. One such clinic had a proper waiting room for the patients, a room where the doctor attended the patients and another one where all the medicine were prepared and stored. Both the hakims and the homoeopaths essentially prepare the medicines themselves. Generally, the practitioner enquires about the patient’s complaint, without any proper physical checkup. Thereafter, the assistant is asked to prepare the doses which are a combination of a few medicine made of herbs. While the patient is under medication, certain foods, like tea, beef or anything considered to have a ‘hot’ effect on the body, are prohibited. It is also usually specified that the medicine should be taken, for example, one hour before or after the meal, or the first dose in the morning before breakfast. The process of healing is over a protracted period of time. The patient is given medicine for about a week or a fortnight and is required to report back. The next checkup determines the increase or decrease of the medication or a complete change of it. These traditional healers claim that they have a cure for almost all ailments except a heart attack or any such disease in its last stages requiring surgery, which is not part of the traditional healing. They say that the unique thing about traditional medicine is that it cures the root-cause of the disease and not only the symptoms as in the case of allopathic practice. They also believe that the traditional medicines are harmless and free of any side-effects, unlike the modern medicine, and even if a certain specified dose failed to cure the ailment or was taken in a greater quantity than prescribed, no part of the body would be adversely affected.
However, in spite of these healers, all households in the area reported going to the hospitals and clinics and showed great faith in the doctors practising modem medicine, especially in the event of child illness. Similar findings were reported by Rao and Richard (1984:353) in the rural areas of Tamil Nadu, India. They found it ‘surprising that the inexpensive local indigenous traditional practitioners are not the first choice for treating illness’. Modem medicine is thought to provide a quick remedy and it is associated with the modern world. The frequency and the type of the illness largely determines the use of both the modern
9 Chanted prayer or sacred word.
10 An amulet with scripts from the zodiac or the Koran. The script is usually folded and packed in a metallic tablet and either hung around the neck or tied to the arm.
and traditional methods of healing. For example, in case of respiratory and diarrhoeal illnesses, the most common amongst the children, mothers generally try simple traditional methods at home. If the illness persists they rush to a nearby hospital or a clinic and put the child on the medicine prescribed. With the notion that the child will be cured of the illness in about two days or so, they go to another doctor if the condition persists. In case of a stalemate or exacerbation of the child’s condition the mothers try traditional healers or other doctors. Some use both: they go to a modem doctor for a quick remedy but will also go to the traditional healers who profess that their treatment attacks the cause of the illness rather than the symptoms. There are also a few who depend on the traditional method of healing but would most definitely go to a doctor if the condition of the patient became serious. A few more orthodox and religious households also go to the mystic healer for keeping the evils away and for better overall health of the child, besides believing in modern medicine and using it in the event of any illness.
3.5. Summary
This chapter gave an overall description of the physical and social environment and provided brief impressions of the households and their members. The purpose was to show the environment in which health-related events take place, as well as contribute to a better understanding of the analyses presented in the following chapters.
The physical environment of the field site is typical of large cities in Pakistan, its main features being the galis, double or triple storeyed houses built on a small area with a maximum number of habitable rooms and with nalis running beside the houses. The residents have all the city amenities like electricity, piped water and toilets attached to a crude sewerage system. There is a variety of medical, educational and other facilities considered important for living and the general social development of the people. However, the area is representative of that part of the city which is less developed and is inhabited by the poor. This is apparent from the fact that in many cases, two or three families with a large number of members were living in one house. Around 60 per cent of them were living on a total household income of Rs. 900 to Rs. 3000 which is considered to be at the lower end of the income scale. Other permanent features of the area which showed that it was neither well developed nor properly maintained were the litter in the galis, the open drains, small shops operating from one room of a house and the dusty roads adjacent to the living area.
Most of the inhabitants were Muslims and Punjabis and followed the tradition of a joint family system. However, a few of the younger couples seemed to have broken away from the tradition and were living independently. Close to 50 per cent of the respondents had never attended school but all respondents had most of their children of school age in educational institutions. Almost all these children were studying in various government and private schools within the vicinity.
The inhabitants had access to two large government hospitals, two Family Welfare Centres and quite a number of private clinics and pharmacies close by. There were also a number of homoeopaths, hakims and spiritual healers. In spite of the modem medical facilities, the tradition of delivering babies at home continues to be the preferred practice by the majority. However, as a first choice all children were taken to either a hospital or a clinic in case of illness.