Infant mortality and infant care: Cultural and economic constraints on nurturing in Northeast Brazil

Sot..Sci. Med. Vol. 19.No. 5,pp. 535-546,1984 Printed in Great Britain.

0277~9536/84 S3.00+O.OO Copyright

All rights reserved

(1 1984 Pergamon Press Ltd

INFANT MORTALITY AND INFANT CARE: CULTURAL AND ECONOMIC CONSTRAINTS ON NURTURING IN NORTHEAST BRAZIL Department

NANCY SCHEPER-HUGHES of Anthropology, University of California, Berkeley, CA 94720, U.S.A.

Abstract-The Brazilian ‘Economic Miracle’ has had an adverse effect on infant and childhood mortality which has been steadily rising throughout Brazil since the late 1960s. An analysis of the reproductive histories of 72 marginally employed residents of a Northeast Brazilian rural shantytown explores the economic and cultural context that inhibits these mother’s abilities to rear healthy, living children and which forces them to devise ‘ethnoeugenic’ childrearing strategies that prejudice the life chances of those offspring judged ‘less fit’ for survival under the pernicious conditions of life on the A&o. it is suggested that the selective neglect of children is a direct consequence of the selective neglect of their mothers who have been excluded from participating in the national economy. The links between economic exploitation and maternal deprivation are further discussed with reference to the social causes of the ‘insufficient breastmilk syndrome’ and the commercial powdered milk dependency of these women.

I have seen death without weeping

The destiny of the Northeast is death Cattle they kill But to the people they do something worse Repentista singer Northeast Brazil is a region of vast proportions and of equally vast social, economic and developmental problems. It is an area twice the size of Texas with 36 million people, more than half of them still living in rural areas on fuzendas and sitios (farms and ranches) and on engenhos and usinas (sugar plantations and mills). ‘0 Nordeste’ has captured the imagination of poets, writers and film makers and, more recently, of social anthropologists. They are drawn to the remarkable contrasts: a land of cloying fields of sugar cane, of periodic droughts and floods and of many kinds of hungers: a land of authoritarian landlords and libertarian bandits; of penitential Christianity and of ecstatic messianic movements. Although the Northeast has been the focus of numerous development programs since the 1960s the area is still characterized by staggering, unmet human needs [ 1,2]. The most recent WHO data indicate that 58”;;, of the Nordestino population is illiterate and that the expectancy is 40 years [3]. The President of the Brazilian Pediatric Association announced in the summer of 1982 that approximately one million children under the age of 5 die each year in Brazil, largely as a result of parasitic infections interacting with chronic malnutrition and undernutrition. Ironically, the so-called Brazilian Economic Miracle of the past two decades, while markedly increasing the GNP of the country, has not had a correspondingly favorable effect on childhood mortality which has been steadily rising in the major urban centers of Brazil since the late 1960s [4-61. A recent Pan American Health Organization investigation of childhood mortality in a dozen rural and urban sites in eight Latin. American countries found the city of Recife in Pernambuco, Northeast Brazil. to have the highest infant mortality of all 535

urban centers sampled [7]. The PAHO data can be reduced in order to present a profile of the woman most likely to have suffered the loss of an infant or young child. She is illiterate, a rural migrant to an urban area and marginally employed. She is also likely to have lost a previous child and to have given birth to four or more other, living children. One frequent response of women worldwide to infant death is renewed pregnancy-an attempt, some epidemiologists conclude, to replace relatively quickly that which was lost [8-l 11. If so, the high rates of infant death represent, in addition to other problems, gross reproductive waste, draining the physical, economic and psychological resources of women who bear such vulnerable offspring. The bulk of existing literature on infant mortality has been conducted from the perspectives of population demography and policy-oriented maternal and child health. Both perspectives tend to interpret the extremely high rates of death and disease characteristic of young life in the developing world as the almost inevitable consequences of largely impersonal ecological, climactic or demographic conditions such as, for example, the droughts of Northeast Brazil, exposure to tropical infectious diseases or of overpopulation leading to chronic food shortages and malnutrition. What both these approaches frequently obscure is the role of economic relations in the social production of morbidity and mortality-in other words, the macroparasitism of class relations and exploitation. They have also largely neglected the micro-perspective, the extent to which psychocultural factors come into play as Third World women, mothers and workers, may be cast in the role of family strategists, necessarily allocating scarce resources so that some of their children may be more or less favored for survival. I am referring here to the recently developed hypothesis of ‘selective neglect’ [12], variously called ‘benign neglect’ [13], ‘masked deprivation’ or ‘passive infanticide’ [14-161, ail suggesting the possibility that highly stressed mothers

536

NANCY

SCHEPER-HUGHES

may themselves contribute, indirectly, to the high rates of infant death as a form of post-partum abortion or family planning. ‘Selective neglect’ implies the gradual elimination of one newborn or toddler from the circle of protective custody, and from the minimal nurturance and care necessary to survival under already extremely adverse conditions. According to the paradigm, the inequitable distribution of food, medical care, attention and love may be based on cultural preferences concerning sex, birth order or physical characteristics. The evidence, however, upon which the ‘selective neglect’ hypothesis is based has been largely circumstantial (as in the analysis of population demography statistics) or else ethnographically anecdotal. Worse, preliminary analyses are marred by an inexcusable ethnocentricism, such as references to Latin0 bairro mothers’ lack of ‘appropriate demonstration of grief at the death of an infant, and their fatalism and resignation to infant death as evidence of masked deprivation, when the socialization of affect is, of course, so highly variable across cultures. Furthermore, without careful attention to the larger socioeconomic and political context within which poor mothers reproduce and nurture, the selective neglect hypothesis could be readily interpreted as yet another variant of the tendency among social scientists to blame the victims of misfortune, as well as of the even more general tendency to blame the gamut of human problems on ‘bad mothers’ and ‘bad mothering’. What I am attempting to do in this current research project is to examine the cultural and economic context of nurturing in a single hillside shantytown, a favela of rural migrants called Alto do Cruzeiro (Crucifix Hill). I will look at early nurturing strategies in light of the larger framework of power and class relations that limit the options available to poor women. I am concerned not only with raising the question do these women selectively neglect some of their infants and hence place them at risk of death, but also the questions how and why they might do this. What does infant death and loss mean to them? How do they explain their choices and interpret their behaviors? And, finally, what external forces place them in situations where they must make such decisions, albeit less than fully consciously? Over the next several years I will undertake a rather broad social epidemiology of infant and childhood mortality in Northeast Brazil, using infant death as a kind of master metaphor of dynamic tensions in Nordestino social life: between rich and poor, strong and weak, male and female, old and young. Like Ivan Illich I am trying to build toward a history (and geography) of scarcity and human needs [17]. To this end infant mortality is illustrative of the pernicious effects of scarcity and deprivation on women’s lives and on their abilities to nurture, to give and to love. In the following pages I will briefly discuss some preliminary results from the first and exploratory stage of research conducted during the summer of 1982. The primary focus of the research was the collection of reproductive histories and in-depth interviews from 72 women of 0 Cruzeiro, the largest of three hillside shantytowns overlooking the interior market town of Ludeirus, located just two hours by

bus or car from Recife. the capital of Pernambuco. The interviews elicited demographic information. migration patterns, work history and record of marital and other significant relationships. This was followed by a discussion of each of the women’s pregnancies and their outcomes, including miscarriages. abortions, stillbirths. For each live birth the following information was recorded: location of and assistance with, the delivery; mother’s perceptions of the infant’s weight, health status, temperament; infant feeding practices; childhood illnesses. how treated and their outcomes. Following the reproductive history I asked each woman a series of open-ended and evaluative questions, including: Why do so many infants die here? What do infants need most in order to survive the first year of life? What could most improve the situation of mothers and infants here? Who has been your greatest source of comfort and support throughout your adult life? How many children are enough to raise? Do you prefer to raise sons or daughters and why? In addition to the collection of these reproductive histories, I also conducted interviews with, and observations of, health professionals, mothers and children in the primary clinical settings of Ladeiras: pharmacies, clinics and the hospital. I was able to work efficiently during this brief period because the fleld site, the shantytown of 0 Cruzeiro, was the very same location where I had previously lived and worked as a health/community development Peace Corps Volunteer in 1964-1967. In fact, several of the older women and their adult daughters included in my sample were the same (then) young mothers and toddlers with whom I had worked 20 years ago in the construction and operation of a cooperative day nursery for working mothers. THE CONTEXT

The political and agrarian problems of Northeast Brazil extend back to the earliest days of colonization when the patterns of latijiindia, monocultura and paternafismo were first established [18-231. I am referring to the creation of large plantations devoted to single cash crops at the expense of diversified and subsistence-based agriculture, and to the maintenance of essentially feudal, paternalistic and exploitative relations between landowners and workers. The market town of Ladeiras (a pseudonym) is located in the heart of the largest sugar cane producing area of the Northeast. The town’s population has more than doubled to 34,000 over the past three decades due to the exodus of rural workers from the interior of the state resulting from the industrialization of the sugar industry and the introduction of rural labor legislation in the 1950s. Forced to conform to minimum wage laws, many usina and engenho owners responded by radically reducing their work force. Cut loose from the paternalistic bonds to a particular landowner and his sugar mill, the rural laborer of the Northeast was proletarianized and became a ‘free agent’ and wage laborer who moved from plantation to plantation in search of seasonal employment. Ladeiras, centrally located in the Mona da mata and within commuting distance to several plantations and

Cultural and economic constraints

mills, became a home-base for many displaced sugar workers and their families. Initially they were squatters who were given tacit permission by the prefeito of the municipio to put up temporary straw huts on each of the three rocky hills overlooking the town. The Alto do Cruzeiro, with an estimated population of 5600 residents in the summer of 1982, is not only the largest and the poorest of the shantytowns, but is also the most politically activist, with a history of involvement in the Peasant League Movement of Francisco Juliao in the late 1950s. Over the past few decades many of the original migrants and squatters of 0 Cruzeiro have become permanent residents and the straw huts have been replaced by small homes of adobe and brick. Pirated electricity has been replaced by municipal streetlights and the dangerous kerosene lamps by light bulbs in most Alto homes. However, sanitation, sewage and water supply remain life-threatening to inhabitants of 0 Cruzeiro, especially to babies and young children who, virtually from birth, are afflicted with parasitic and other infectious diseases. Garbage is burned, buried or simply dumped in the tiny backyards where stray animals are free to forage and where small children are left to play. Although most homes have pit latrines, the poorest and most disorganized households dispose of their human wastes in the river that runs along the base of the hill. Of all their problems, however, Alto residents consider their precarious, unpredictable and often unpotable water supply to be their greatest health hazzard. At least twice a day women and children of the Alto line up with large tin cans to buy water from one of the three public faucets on the hill. During the dry season (particularly during periods of drought) the faucets are shut down for all but a few early morning and evening hours. Tension is high and tempers are short as the women are forced into competition for their share of water. But water, in addition to being a source of strife and dissension on the Alto, is also the issue that has united men and women in outbursts of angry political protest. Alto residents are convinced, despite the denials of municipal and state public officials, that during the dry season each year, reservoir water is mixed with highly polluted and contaminated river water. The belief is so pervasive that no wealthy resident of Ladeiras will drink anything other than bottled mineral water during the dry months. In addition, a visiting team of S.U.C.A.M. officers (a federal public health program) in Ladeiras during the summer of 1982 rather coercively distributed schistosomiasis medication in a door to door campaign, on the informed assumption that over 90% of the population would be infected with the disease through contact with the public water supply. With respect to health care, the families of the migrant and seasonal workers of the Alto are excluded from participation in the national health insurance programs of Brazil. The free medical care and services available to the poor at one municipal and one state health post and through the clinic of the local hospital are wholly inadequate and not infrequently iatrogenic [24]. The primary source of health care for residents of the Alto is obtained through one of several pharmacies in Ladeiras where the poor can

on nurturing in Brazil

537

negotiate with a trusted pharmacist over what might be the best and least expensive drug for their condition and where they can buy on credit. Although few traditional healers (curanderas, rezadeiras and parteiras) practice actively in urban shantytowns like 0 Cruzeiro [25], both self-treatment with herbal home remedies (‘remedios da gente’) and spiritual healing through Afro-Brazilian possession cults such as Xango and Umbanda are common. THE SAMPLE

The 72 mothers of 0 Cruzeiro who formed the research sample were not selected in a controlled fashion. Rather, they were the,first ones to volunteer following a meeting I held in the community’s school and social center. Many more women volunteered for the research than I could possibly have interviewed during the brief period of my stay. The only criterion for inclusion in the sample was that the woman had experienced at least one pregnancy. All understood that I was studying reproduction and early childhood. I did not stress to them my focus on infant and childhood mortality for fear of biasing their responses. The 72 mothers ranged in age from 19 to 71. The median age of 39 means that close to half had not yet completed their families. Two-thirds of the women in the sample were migrants to Ladeiras from rural areas and many has spent a considerable portion of their lives in seasonal migrations before coming to live on the Alto. Education and literacy were minimal: 31 of the women had never been to school and 47 of them could not sign their name. 65% of the women were married or in a stable, common-law relationship, 17% had a history of brief, short-term relationships and 18% were alone at the time of the interview (6 as widows who had not remarried, and seven as women who described themselves as recently ‘abandoned’). The predominant pattern of subsistence was based on the cooperation of all household members over 12 or 13 years of age. More than half of the women (57%) were employed at least seasonally and parttime in domestic service, agriculture, factory work or in the pottery or hammock cottage industries. Virtually all the women over 40 had spent at least some part of their working lives laboring ‘at the foot of the cane’ on a sugar plantation. Many of the younger women had spent the greater part of their working lives as domestics in the homes of the wealthy and middle class families of Ladeiras. Several of the older women rented a small plot of land (a roqado) outside of town where they planted a garden for household consumption. A few of the women raised goats which ran freely on the Alto, often resulting in squabbles among neighbors who considered the animals pests. Recently abandoned women with young children are sometimes forced into prostitution or street begging. Three women in my sample were in such dire straights at the time they were interviewed. There was considerably less diversity in the work available to men of the Alto : agricultural wage labor, construction and road repair, animal slaughtering and self-employment through odd jobs. Both unemployment and underemployment were high and

NANCY SCHEPER-HUGHES

538 Table

1. Reproductive histories summary

Total pregnancies Total living children Miscarriages/abortions Stillbirths

686 (9Siwomen) 329 (4.5 women) 85 ,6 101 (1.4iwomen)

Childhood deaths (birth-5 yr) Childhood deaths (6-12 vr)

25; (3.5/women) 5

N = 72; age 19-71; median age = 39.

many of the husbands and companions of women in my sample were at home or on the street during much of the day. Gambling and organizing or playing the popular numbers game, bichos, contributed to (or detracted from) the family income. Adolescents were expected to contribute to the family larder through part or full time employment, and this expectation contributed to the frequent elopments of teenagers. Some Alto mothers encouraged their 5 and 6 year old sons to scavenge in the marketplace and a few tended to look the other way when a child returned home with an obviously filched item. Daughters as young as 5 were used as babysitters while both parents were at work or away from the home and while older siblings were at school. The combined family income in 1982 was about Cr%5,000 a week or US%25.00, testifying to the poverty of employment. Virtually all family income was spent on the weekly marketing for food. All other necessities came out of the food budget. REPRODUCIWE SUMMARIES: CHILDHOOD MORTALITY PATTERNS

The women reported a total of 686 pregnancies, an average of 9.5 per woman. Of these pregnancies, 101 ended in spontaneous or induced abortion or stillbirth, an average of 1.4 per woman [26]. Of the remaining 585 live births reported, 251 offspring (43%) died between the ages of birth to 5 years (3.5 per woman), and another 5 children died between the ages of 6 and 12 years. There were, then, a total of 329 living children at the time of the study (4.5 per woman), but included among these were a number of infants and toddlers described as ‘sickly’ or ‘very weak’ by their mothers, and it might be assumed that at least some of these will not survive their fifth year. In addition, discounting the 28 women in the sample over the age of 45 and an additional 11 women who said they could bear no more children (due to either secondary or medically induced sterility) there were 33 still potentially fertile women in the sample. The figures cited in Table 1 are, therefore, incomplete and are only suggestive of the total fertility-mortality picture. Most studies of childhood mortality in developing countries have identified the period of highest risk

and vulnerability at about 1.5-2 years, the time when another sibling may have been born or is on the way. More important, it is the age when weaning from the breast to ‘table food’ is likely to have been completed and the toddler is confronted with dramatic changes and often deficiencies, in the diet and increased contact with contaminated water, foods and utensils. The fact that breastfeeding is an extremely attenuated pattern of infant care among the younger women of the Alto contributes, I believe, to the statistic that these children are at greatest risk during the first 6 months of life. 70% of the reported deaths occurred between birth and 6 months and 8296 of the deaths had occurred by the end of the first year. Not reflected in these statistics is that the Majority of Alto infants, those who survive as well as those who die, generally suffer their first ‘crisis’ of vomiting and diarrhea by the time they are a month old. The average infant of 0 Cruzeiro suffers four or more such crises, lasting from a few days to several weeks, during the first year of life. SEX AND BIRTH ORDER

The reproductive histories of these impoverished women do not immediately suggest a strong sex or birth order bias. The 72 mothers reported 251 deaths of offspring between the ages of 1 day and 5 years: 129 males and 122 females. They reported (and very probably underreported) an additional 16 stillbirths: 6 male, 3 female and 7 for which the sex was not reported. Given the well documented biological disadvantage of males during the first year of life [27-291, the higher rate of male to female deaths postpartum, especially in the first 2 months of life is to be expected. What might suggest a possible, but weak, sex bias is the trend of higher female to male deaths between 7 months and 5 years. Mothers were somewhat more inclined to attribute an ‘innate weakness’ @zqueza) to infant sons who did not survive, and were more likely to diagnose the folk illness ‘gusto’ (a rapid wasting away from diarrhea complicated by severe malnutrition) as a cause of death in their baby daughters, but these lines were not sharply drawn. Of the 329 children in the sample to have survived through puberty, 161 were girls and 168 were boys. Despite the existence of a fairly pervasive ideology of male dominance in Brazilian culture, the women of the Alto, representing the lowest social classes in Nordestino society (from ‘pobre’ to ‘pobrezinho’ to ‘pobredGo’, as one mother put it, meaning from poor to poorer to grinding poverty) did not seem to be deeply affected by any sense of female inferiority. To the contrary these women liked to present themselves

Table 2. Ages, sex at death (birth-5 yr) (N = 251) Postpartum (I-14 days) 15 days -7 weeks 2-6 months 7 months-l yr 13 months-2 yrs 2.5-5~~s Totals

Male

Female

21

12

33

18 57 13 I2 6 129

8 59 I7 15 II 122

26 116

.

Total

27 19 251

1

Cultural and economic constraints as sometimes fiercely independent individuals who. at least in their youth, had worked side by side with men in the fields and factories of Ladeiras. Although often

protesting that they were MOM’ tired, ‘finished up’ and totally spent, they admired in themselves and in other women the virtues of toughness, endurance, ingenuity, wit and a quality of physical, sexual and psychological vitality called unirru@o, the same essentially female quality that is celebrated each spring during Carnival. These women are not at all convinced that Brazil (or at least their corner of it) is a man’s world. Offered Irene: I think life is better for women. It’s easier for a woman to find work. A woman can do almost anything. She can work clearing the ground and cutting sugarcane as well as any man. And she can wash clothes, cook in the kitchens of the rich, anti she can take in washing and work in the factories. More women here can read and sign their names than men, so more of us are registered voters. The men here, poor beasts. what can they do? Imagine a man in desperation asking to take in laundry! A positive sense of the value of girl as well as boy children was conveyed in the consistent refusal of women to reply directly to questions regarding sexual preference of offspring. Both sexes were valued, but for different reasons-boys because they were easy to care for and could be sent out to ‘forage’ in the marketplace. Sons were also enjoyed and admired for their skill at street games and sports, an important aspect of community life on the Alto. Girls were wanted not only because they were useful at home, but because they grew up to be a mother’s best friend and support. Obviously, mothers would conclude, a woman would want to have at least one casal (a pair, one of each sex) and preferably two pairs, spaced closely together. Pregnent women rarely entertained questions regarding which sex they hoped to deliver and there was no sense of tragedy or misfortune accompanying the woman who gave birth to all girls. This, like many other aspects of life, was accepted as God’s will. With respect to birth order and childhood mortality, among the sub-set of children from completed families, the most protected cohorts were those occupying a middle rank, neither among the first nor among the last born. In a third of the families childhood deaths came in ‘runs’, in close sequence, occurring either at the beginning or at the end of the mother’s reproductive career. In the early years the immaturity and inexperience of the mother seemed to contribute to the deaths, while at the other end, a number of factors-physical, economic and psychological seemed to interact in such a way as to prejudice the survivability of later born children. Some of the women were quite explicit that their last born children had been a particular burden to them and that it was a ‘blessing’ that God decided to take them in their infancy. Nonetheless, there were no discernable patterns of favoritism based on primogeniture, and the last one to survive, the ca&u, was often particularly indulged by all members of the family. By far more important with respect to a mother’s tendency to invest in or distance herself from a particular infant was her perception of the child’s innate constitution and temperament: his or her

on nurturing in Brazil

539

qualities of ‘readiness’ for life. Mothers expressed a decided preference for children who evidenced early on the characteristics of fighters and survivors. Quick, sharp, active, verbal and developmentally precocious children were much preferred to quiet, docile, passive, inactive or slow children. Mothers spoke most warmly and fondly of those toddlers and young children who were a little ‘brabo’ (wild) and who were ‘sabido’ (wise, often in a crafty sense) and, above all, who were ‘jeitoso’ (skilful with objects, tasks, and in interpersonal relations). One mother of several children, three of whom died in early childhood, offered: I myself prefer a more active child, because when they are intelligent and lively they will never be parado (motionless or stumped) wherever they live. The worst temperament in a child is one who is morre de espitiru (listless), a child so calm that he sits there without any energy. When they grow up they’re good for nothing. The child who wants to run outdoors all day long, who wants to be out on the street playing soccer from the crack of dawn, that’s the same child who’s out hustling in the street later in the day. Now that’s a child with a good temperament! .The expressed disaffection by Alto mothers for their less animated and slower children is particularly unfortunate in an area where malnutrition, chronic hunger and parasitic infections interact with what appears to be maternal rejection to further contribute to these least favored traits. The extent to which these preferences are actually translated into maternal behaviors that may prejudice the survival of particular infants and young children will be discussed in the following sections. CAUSES OF CHILDHOOD MORTALITY: MOTHERS’ EXPLANATIONS

Although uneducated and, for the most part, illiterate, the fuvela mothers interviewed were all too keenly aware that the primary cause of infant and childhood mortality was gastroenteric and other infectious diseases resulting from living in, as they so graphically phrased it, a porcuria, pig sty. When asked, in general, why so many babies of 0 Cruzeiro die, the women were quick to reply: ‘they die because we are poor, because we are hungry’; ‘they die because the water we drink is filthy with germs’; ‘they die because we can’t keep them in shoes or away from this human garbage dump we live in’; ‘they die because we get worthless medical care’: ‘street medicine’, ‘medicine on the run’; ‘they die because we have no safe place to leave them when we go off to work’. When asked what it is that infants need most in order to survive the first year of life, the mothers invariably answered: ‘good food, proper nutrition, milk’. I soon became bored with its concreteness. The irony, however, was that not a single mother mentioned either a lack of food or insufficient milk as a primary cause of death for any of her own children, although these were certainly implied in those cases where the child was said to have ‘shriveled up’ or ‘withered away’ or ‘shrunk away’ to nothing. With respect to mothers’ interpretations of the causes of death for each of her own children, Table 3 offers a very condensed rendering of their

540

NANCY SCHEPER-HUGHES

Table 3. Causes of infant childhood deaths (mothers explanations) (birth-5 yr) (N = 251 deaths) (locus of responsibility: nature, fate) (a) Gastroenteric (various qualities of dysentry) (b) Other infectious, communicable diseases (c) ‘Teething’ (d) Fraqueza (born weak, dying, without ‘will to live’, disinterested in food (e) Other (skin, liver, blood diseases)

I. Naturalisric

71 41 13

37 13 Total 175 II. Supernaturahric (locus of responsibility: God, saints) (a) ‘De Repenre’ (taken suddenly by God, saints) 9 (b) Casrigo (child taken as a divine punishment for the sins of its mother or parents) 3 Total 12 III. Personalisric (locus of responsibility: humans (a) Malignant emotions (envy, shock, fear, desire) 14 (b) Resguardo Quebrodo (Postpartum or illness precautions, prohibitions, broken) 5 (b) Ma1 Troro (poor care due to uncontrollable events: poverty, sickness of mother, etc.) 6 (d) ‘Doenqa da Crinqa‘ (‘ugly diseases’ in which child is allowed to ‘whither away’ a minpuo) 36 Total 64

perceptions of the major pathogens affecting the lives of their offspring. Certainly, naturalistic explanations predominated in which biomedical conceptions of contagion through germs and microbes blended with humoral pathology and folk conceptions of the etiological significance of teething. The women were far less likely to attribute infant death to the will or actions of God, the saints or even to ‘fate’ than might have been expected. Human agency played a significant role in the women’s recognition of the adverse effects of poor care, pathogenic emotions (including fear, shock, envy and desire) and the breaking of dietary and behavioral precautions (resguardus) believed to be necessary during vulnerable and transitional periods of the lifecycle. Finally, the women themselves accepted at least partial responsibility for the deaths of those babies thought to be suffering from one of the many feared diseases subsumed under the term doenpzs da criaqa or doenp do menino (sicknesses of the child), a phenomenon I will discuss at length below. Underlying and uniting these etiological notions is a world view in which all of life is conceptualized as a luta, a power struggle between strong and weak. Death can be stronger than young life. Thus, mothers can speak of a child who ‘wanted’ to die, whose will and drive toward life was not sufficiently strong or well developed. Likewise, specific medicines and treatments are described as ‘stronger’ or ‘weaker’ than the diseases they are supposed to fight. Individual constitutions of both mothers and of children are described as weak, strong, resistant. A pregnant woman’s weakness, for example, can be transferred to her child in utero so that the infant is born frail and unfit for the long luta ahead. For a mother to say that her child suffered many crises during infancy but survived in any case is to give no credit to modem medical science .(which is seen as a very mixed bag of tricks); rather it is to testify proudly to some inner drive within the child. If a child succumbs to dentiqio (‘teething’) and dies, it is said that it was theforca de dentes (strength of the teeth) that overcame the little person. The folk

intestinal illness, ‘gusto,’ is an almost always fatal pediatric disease because the infant’s body offers no resistance and is quickly reduced to a hollow tube or a sieve. Whatever goes into the infant comes out directly in bouts of violent vomiting and diarrhea. The infant becomes ‘gasto’, spent, wasted, used up. her vital energy gone. The etiological system and body imagery used can be seen as a microcosm of the hierarchical social order in which strength, force, and power win out. It is a response to, and a reflection of, the miserable conditions of fuuelu existence. It is these survivor values that make fuvela women reluctant to care for and rear those infants and children perceived as innately or constitutionally weak. Multiple births. therefore, fare badly-few survive infancy on 0 Cruzeiro. An obsterical nurse reported that poor mothers will frequently examine their newborn twins and decide which is the stronger. The weaker and smaller one may be left behind for the hospital staff to dispose of as they see fit. There is no ‘coddling’ of children born with deformities. If, however, the blind, deaf or disabled child is ‘sabido’, he will turn his weakness into a strength by using it to extract money from the naive or soft-hearted. But mothers agreed that, in general, it is best if the frail and disabled die as babies. This allows them to return to heaven as little angels (angelinos), pure, unspoiled and protected from the harsher demands of material life. And so, a mother will reply to the question ‘how many children do you have?’ by saying; ‘two couples-a pair of disgraced ones here on earth, and a pair of little angels in heaven’. For weak creatures it is best. not so much that they had never been born at all, but that they live and die quickly, without putting up too long a struggle. Celia, for example, could speak of her four infants as having given her ‘no trouble’ in dying. They each ‘fluttered their eyes around wildly and then they were still’. If one can speak of a ‘preferred’ infant death it is the ‘sudden’ one, de repente, where God’s will is most apparent. ‘Nco teve jeito’, there was nothing that could be done. With the longer, slower deaths, however, there are more doubts and anxieties. Doenp da criunp is the most common of the slow deaths. DOENCA DA CRIANCA: ETHNOEUGENIC SELECTIVE

NEGLECT

Alto mothers spoke, covertly, of a cluster of symptoms that are greatly feared in children and which mothers do not actively seek to cure. These sicknesses are referred to by a euphemism, ‘sickness of the child’ in order to avoid repeating the anxiety-provoking specific names of the many folk sicknesses subsumed under the term [30]. Mothers volunteered that a child suffering from a ‘doenqa da criuqa’ was best left to die a gradual death, a mingua, meaning a child allowed to wither away without sufficient care. It is, quite simply, death by gradual neglect. Doenqa da crianqa may refer to any childhood sickness that while not necessarily life-threatening, is thought likely to leave a mother -.vith a permanently disabled. child: crippled, mad, epileptic or severely retarded. The symptoms that alert mothers include: fits and convulsions; lethargy; retarded verbal or

Cultural and economic constraints

motor development; an emaciated and ghost-like physical appearance (when the baby is said to look like an ‘old man’ or a ‘monkey’); social withdrawal and fear of normal interaction; sadness and ‘disanimation’. The folk etiology is multicausal. Teething-related diarrheas are often believed to be implicated. as are magical frights (susto, parrno) and mau olhado (evil eye). Almost any childhood illness can, under certain circumstances, be interpreted as a doeqa da crianqa and therefore, as beyond hope of normal recovery. At this stage of the research I do not know what exactly prompts a folk diagnosis of this kind, but I suspect that its flexibility allows mothers a great deal of latitude in deciding which of their children are not constitutionally favored for survival as normal children [31]. It appears that mothers act fairly autonomously in these decisions and do not discuss it at great length with their husbands. When such a child dies there is little public display of grief. A mother who does weep may be chastized by her neighbors who will remind her that the death was for the best. Thirty-nine children were said by their mothers to have died of a doenq da criaqa, but the same syndrome may be inferred in many other cases where untreated childhood illnesses were the cause of death. The following statements are illustrative: There are various qualities of doenca da criunp. Some die with rose colored marks all over their body; others die black colored. It is very ugly; with this disease it takes a long time for them to die. It takes a lot out of the mother. It makes you sad. This sickness we don’t treat. If you treat it the child will never be right. Some become crazy. Others are weak and sickly their entire life (Interview No. 35). There are two diseases we don’t like to talk about because they are the ugliest things in the world. So we just say doenq da criaqa and leave it at that. One of these comes from gotus de sereno (morning or evening mist). Anpther one is pastno, a terrible paralysis that the child gets from a bad shock. His skin turns black and he just sits there still and dumb in the hammock. really lifeless and stupid. We are afraid of these ugly things, these sicknesses of the child. It is best to let them die (Interview No. 11). They die with this sickness because they were meant to die. If they were meant to live it would happen that way as well. I think that if they were always weak, they wouldn’t be able to defend themselves in life. So it is really better to let the weak ones die (Interview No. 10). Doenqa da crianp is the same thing as molfubriu, a sickness that is ugly. ugly. People don’t want to take care of such a child. They don’t want to treat it. There’may be a cure that the doctors know of, but we would be afraid to give the medicine. because a child with this kind of sickness is never right again. He could grow up twisted and lame or crazy. Sometimes these children have fits in the middle of the street when they grow up. No poor person can take care of a child like that (Interview No. 17). Doenqcrdu criunp can come from many different things. It can come from a fright the child has. but also from dirty laundry and from strong germs that enter through the fingernails. It can come from diarrhea. Look, we don’t like talking about this: we are afraid of calling it up (Interview No. 34). If the symptoms occur very early in a child’s life, she may not be baptized or given a name until death is inevitable and a hurried. private baptism without ceremony is done. Although mothers act auton-

on nurturing

in

B-azil

541

omously within the household with respect to the selective treatment of their children, it is not uncommon for relatives or neighbors to intervene on behalf of a sick child and ask to adopt her. Nilza spoke fondly on her 8 year old $/ha de criapio (adopted daughter): She was a real sight when she came to me! An ugly little monkey and skinny like this. She was a nasty thing too. She didn’t want anyone to bother with her. I thought to myself, now here’s a child that not even a mother could love. They say she had one of those ‘ugly diseases’, but I thought, what do I care? I lost each of my own children, so I was willing to take a chance and I could see that she was not going to survive in that house. So I said, ‘Dona Maria, give me that little creature of yours and let me see if I can’t raise her. You won’t even miss her, and I have such pity on her. And look at her now! Did you ever see a prettier thing? It soon became mothers describe doeqa da crianp

apparent to me the more I heard the traits and characteristics of

that they were usually describing the symptoms caused by malnutrition and dehydration interacting with their own ‘selective inattention’. The more malnourished the baby, the more passive and less responsive the child was, and consequently, the more likely she would be left alone for long periods of time on the dirt or cement floor of the house or tied up in a hammock. Untreated diarrheas and dehydration contributed to the child’s withdrawal, the disinterest in food, the inability to balance a bloated belly on spindley legs and the failure to speak or imitate sounds. High fevers often produced the fit-like convulsions that mothers fear as the harbingers of future madness or epilepsy. Because dehydrated and marasmic children are so quiet and make so few demands, mothers are able to withdraw their attentions from them in order to attend to the needs of their more active and demanding children [32]. I saw many such children left alone in their hammocks, while their mothers were gone working in their roGados outside the town or washing clothes in the schistosome-infested river. The older sibling or neighbor woman who is requested to look in on the baby from time to time is often not within earshot when the baby’s feeble cries signal a final crisis and it dies alone and unattended--&a mingua’, as people say. NURSING FAILURE, CHILD SURVIVAL AND COVERT

“To

POLITICAL

PROTEST

Corn Sede”-I thirst Popular political graBiti in Ladeiras.

There are many conditions on the Alto do Cruzeiro that are hostile to child survival. Most serious are the ones that I have mentioned only in the passing: food shortages; contaminated water; crowded and substandard housing; unchecked infectious diseases: the absence of day care facilities for the children of working mothers; the lack of minimally adequate and free medical care. I have chosen instead to focus on aspects of maternal beliefs and behaviors that may also contribute to childhood mortality in order to address the indignities and inhumanities forced upon . . poor, migrant women who must at times make choices and

542

NANCY SCHEPER-HUGHES

decisions that no woman and mother should have to make. It should be clear from the foregoing that the selective neglect of children is a direct consequence of the selective neglect of their mothers who have been excluded from participating in the ‘Economic Miracle’ of Brazil. Nowhere, perhaps, are the links between economic exploitation and maternal deprivation more apparent than in the brief history of the precipitous decline of breastfeeding among these women and their own explanatory models to account for this. It is to this topic that I will now turn my attention. A fairly direct correlation has been established between infant survival and breastfeeding in the developing world. Yet it is also widely documented that each generation of new mothers in the Third World is less likely to nurse their offspring than the previous generation. This is especially true among rural migrants to urban centers where the kinds of work available to women are inimitable to successful breastfeeding, where there are strong pressures to abandon traditional ethnomedical beliefs and practices [33] and where powdered milk is one of the most readily available commercial foods, sold in large, economical sacks as well as in tins. A recent UNICEF report noted that in Brazil the percentage of babies breastfed for any length of time has fallen from 96% in 1940 to under 40% in 1974 [34]. This same report cites a Brazilian study which found that among a large sample of children of poor parents, bottle-fed babies were between three and four times more likely to be malnourished than breastfed babies. Alto do Cruzeiro mothers of the current generation use the breast as an early and not very dependable, supplement to the staple infant food, mingau, a thin, cooked gruel of fine maniac flour, sugar, water and powdered milk. Mingau may be offered to an infant as early as the second day of life and is invariably introduced by the second week. Alto mothers are responsive to infant cries, but do not necessarily equate crying with hunger. A crying infant will be picked up, spoken to, sniffed lovingly and then frequently handed over to another household member. If the infant still cannot be quieted, he will be offered mingau and then only after he has taken his fill will the breast be given, if it is to be given at all. Many young Alto mothers cannot afford sufficient quantities of commercial powdered milk to make mingau, in which case they either sharply decrease the amount of milk or eliminate it altogether from the recipe and make a thicker cereal called papa. Alto mothers recognize that not all infants can tolerate mingau or papa and when a first ‘crisis’ of diarrhea or vomiting occurs, they substitute rice or corn starch for the offending maniac. In very severe cases of diarrhea and vomiting (such as in ‘gasto’), the infant may be taken off mingau entirely and given only mild, herbal teas. But no mother in my sample reported using the breast as an alternative when mingau and papa offended an infant. Total weaning from the breast is completed as early as the second week of life and rarely any later than the third or fourth month. First and earlier born children are breastfed more often than later-born children, and more than onethird of all the children in the sample were never

breastfed at all. These ‘bottle babies’ were, with few exceptions, born within the past two decades and virtually all were born in a hospital. This contemporary pattern deviates markedly from the infant care and feeding practices of the older women in the sample (those over 50 years). the vast majority of whom had reared their children on engenhos and fazendas were breastfeeding and women’s work were less incompatible and where cow’s milk was plentiful and free to plantation and farm workers as part of the traditional terms of rural labor. The older women had commonly breastfed their babies for at least 1 and as many as 4 years. Mingaus and papas, made from whole cow’s milk were even

then an integral part of the baby’s diet, but they were introduced later and were used as a supplement to maternal milk after the nursing mother had already established an adequate milk supply. Breastfeeding was not enough to prevent a high childhood mortality even then. But the children of these older women, who labored in the cane fields and who lived far from medical services and public health clinics. were decimated by smallpox, malaria, measles and other infectious diseases (now under better control in much of Northeast Brazil). They did not die of dysentery, vomiting, marasmus and dehydrationthe ‘commerciogenic’ and man-made plagues of the current generation of infants. The older women and grandmothers in my sample were loud in their condemnation of current infant feeding practices, but their words seemed to fall on deaf ears. Said one: I breastfed all ten of my children, but I also gave them goat’s milk and farinha. The children do well on it. Today my grandchildren are dying of hunger because of that vile powdered milk, that canned milk, that milk in sacks. If the mother has no milk, then the baby should be given goat’s milk or cow’s milk. My daughters can’t afford the powdered milk, so our children are being raised on water. Soon their blood

will turn

to water

as well.

The radical erosion of breastfeeding exemplified in this small sample of women occurred during a very brief historical period. Twenty years ago when I first lived and worked on Alto do Cruzeiro, breastfeeding was still the norm and the only readily available powdered milk substitute was distributed freely under the ‘Food for Peace’ program. The women of the Alto readily accepted the powdered milk (which I myself distributed), but they told me that they used it only for their older children and in cooking. They told me that the American milk was not real milk, but came from plants and that it made their babies sick with diarrheas and vomiting, and that it sometimes made them go blind. I ‘educated’ the women about bottle sterilization and I stressed to them the positive attributes of the powdered milk as a ‘supplementary food’ for infants, as did the health post doctors, hospital workers and many political and ecclesiastical leaders of Ladeiras, each for our own ‘altruistic’ or self-serving ends. Much later I learned about night blindness caused by vitamin-A deficiency in babies exclusively bottle-fed on skimmed powdered milk. Similar Food for Peace powdered milk campaigns were waged during the 1960s throughout the interior of Northeast Brazil and contributed to the powdered

Cultural and economic constraints

milk dependency of these rural women. Nestle and other multinational food industries merely stepped in to fill the vacuum created when the Food for Peace program ended in Brazil during the 1970s. I doubt that the free milk I distributed ever did very much to foster international peace and understanding, but it certainly fostered big business for corporations like Nestle. The ultimate irony is that only two decades later Brazilian university student volunteers have been recruited to participate in a grassroots breastfeeding promotion campaign to reverse the damage cause by the earlier promotion and distribution of free powdered milk by young American volunteers. The campaign seems to have achieved some limited success among the educated, middle classes of S5o Paulo [35], but it has not reached the poor, rural and migrant populations at all. The question remains, however, why did the women of the Alto so readily give up their original resistance to powdered milk? How were they turned into consumers of a product that they do not need and which they cannot afford and that contributes significantly to the high infant mortality of the community? If we return, for a moment, to the reproductive histories we have a few clues. The younger mothers repeatedly stated that they had not so much actively weaned their infants as they had simply run out of milk. This explanation is compatible with the findings of a number of international surveys (including a WHO study of infant feeding patterns in nine countries) that indicate that world-wide the most common reason given by women for discontinuing breastfeeding is insufficient milk [36]. Among my sample of women breastmilk insufficiency was not observably correlated with the health or nutritional status of the mother. And so I challenged the younger and more vigorous women on their explanatory model: ‘Your own mothers were able to breastfeed-why not yourselves?’ One mother responded angrily, pointing to her breast: Look. They can suck and suck all they want and all they will get from me is blood. But why?, I persisted.

She replied:

Because we are weak, totally finished (acabudo), spent, wasted. no good. We have nothing to give our children, not even our own milk. Another

woman

said:

They are born already starving in the womb. They are born bruised and discolored, some with their tongues blackened and hanging out of their mouths. If we were to nurse them constantly we would all die of tuberculosis. Weak people can’t give much milk. Once again we have the metaphor of ‘u Aura’-the struggle between strong and weak, or what is even

more troubling, between weak and weaker over scarce resources. A second explanation offered by the younger women to account for early weaning was that the child itself had rejected the breast. And why not? For I was told by dozens of recently lactating mothers that their milk was ‘foul’ or ‘worthless’ and for many different reasons. The milk was said to be either ‘salty’ or ‘bitter’ or ‘watery’ or ‘sour’ or ‘infected’ or

on nurturing in Brazil

543

‘dirty’ or ‘diseased’. In all, their own breastmilk was rejected as unfit for the infant and as little more than a vehicle of contamination. Not only a mother’s diseases and her constitutional weaknesses, but also her sinful nature can be transmitted to the infant through breastmilk. If an infant dies suddenly, Alto mothers sometimes take comfort in the belief that an unbaptized baby, if it had never been breastfed, can go directly to heaven free of the stain of original sin which mother passes on to infant in the very carnal act of suckling. With breastmilk so negatively valued it is understandable why so many mothers seek the alternatives of mingau, papu and commercial powdered milk, despite the cost and the frequency with which so many of their infants sicken and even die on them. But what accounts for the disbelief in their own abilities to nuture young life? Do these women deceive themselves about the quantity and quality of their milk? Women living in more marginal areas of the world continue to successfully breastfeed their children, even during periods of famine when the mothers are, themselves, malnourished. I am quite convinced that the young women in my sample do suffer from breastmilk insufficiency. I am less convinced that they correctly perceive the negative attributes of their milk, although frequent breast infections in the population probably contribute to the perception of their milk as salty and diseased. The negative evaluations of their milk as sour, thin, foul-smelling and bitter, however, spring, I suggest, from a more psychological source. From what I could observe the younger mothers of 0 Cruzeiro, most of whom had given birth in the local hospital, became heir to some of the more iatrogenic notions of modern pediatric care, communicated to them by the hospital staff. Among these were the instructions to feed their infants according to a schedule of every three or every four hours, and to introduce supplemental feedings as soon as mother and child returned home from the hospital. Alto mothers were also taught to arrange a separate cot or infant hammock for the baby away from the mother and to encourage their infants to sleep through the night without feedings. While these transplanted American pediatric practices [37] have many obvious advantages for active working mothers in affluent industrialized societies, they are extremely maladaptive to the conditions obtaining in a Brazilian favela.

Scheduled infant feedings and the early introduction of supplemental foods not only increase the risk of contamination through dirty water and utensils, they interfere with the biology of breastfeeding. Frequent, uninterrupted and demand sucking during the crucial first weeks of life not only stimulates the hormones related to milk production, but also helps to establish the reciprocity between mother and infant that makes breastfeeding a mutually satisfying experience. In self-consciously ‘modernizing’ communities like Ladeiras where acculturation pressures are strong and where traditional ethnomedical practices (including demand feeding) are criticized by doctors, nurses and even schoolteachers, young mothers soon learn to conform to urban mores and to discredit the hesitant suggestions of their mothers and other older

NANCY SCHEPER-HUGHES

544

women. In this way the whole ‘culture of breastfeeding’ has been lost within a single generation. One result of the above process is the ‘insufficient milk’ syndrome, a social and biomedical artifact. When their milk supply begins to falter (because it was never properly established to begin with) the Alto mothers are quick to blame themselves: it must be because they are weak, diseased, empty. Similarly, when these young mothers refer to their own ‘milk of human kindness’ as scanty, curdled, bitter or sour, it has been transformed into a metaphore speaking to the scarcity and bitterness of their lives as women of the Alto. Through the medium of the body, the contradictions of the social order are reproduced in the disquieting image of the needy and dependent mother who ‘witholds’ her own milk from her children lest she be ‘devoured’ by them first. Nursing ‘failure’ reinforces these young women’s already deeply eroded sense of inner goodness, self-worth and self-sufficiency, that is most immediately symbolized in the autonomous act of nursing a newborn. What has been ‘taken’ from these women is their belief in their ability to give. As the mothers stated earlier: ‘We have nothing to give our children’ and ‘weak people can’t give much milk’. The cycle of economic dependency is now complete. Not only must these urban migrants purchase virtually everything adults and children use in the household, they must even buy commercial milk for their newborn. This represents, above all, the most pernicious form of ‘conspicuous consumption’ that international capitalism has ever been able to foist onto a vulnerable population. And its consequences are nothing short of deadly. Even so, we could interpret the anger that this topic engendered among my sample of women as the rumblings and expression of covert protest. If there is one raw and vital nerve among impoverished Nordestinoi, it is the horror of drought [38] . . and of thirst. Many of the original migrants to Alto do Cruzeiro came from the drought-plagued sertcio of Pernambuco in search not only of work, but of water. The irony was not entirely lost on my respondents that the waters of Ladeiras mixed with powdered milk are a source of disease and of death to the children of the Afto who are decimated by diarrheas and dehydration and who die ‘withered and ‘shriveled up like old men’ and who, as the mother stated earlier, are even born thirsty, ‘with their tongues blackened and hanging out of their mouths’. This same anger has sometimes been translated into action, most recently during the public ceremonies marking the centenary of Ladeiras during the spring of 1982. I was told by one mother that the ‘bloated’ (‘fofo’) speeches of the politicians were interrupted from time to time by chants of: ‘Ladeiras, one hundred years-and still no water’. CONCLUDING

OBSERVATIONS

Pensamos que a obra do sociologo sera sempre uma intervencrio e que sera enganar aos outros e iludir a si mesmo, si nao tomamos em consideracao esta verdade e a responsabilidade que elo comporta

Camillo Pellizi [39).

(We belive that a sociological work must always be in the nature of an intervention, and that we shall only deceive others as well as ourselves if we fail to take this truth and the responsibility it implies, into consideration.) It is my thesis that the macroparasitism of class exploitation and the microparasitism of amoeba, typhoid and schistosomiasis interact with the dispair of mothers who are at least partially resigned to rearing offspring with a high expectancy of their premature death [40]. Studies of the pathogenic effects of urbanization and modernization in the ‘developing’ world have tended to focus on the public sphere (the marketplace) to the neglect of the private or domestic sphere. Yet it is within the home where human relations and human needs are most immediately and profoundly affected by the reproduction of scarcity. It is both the internalization and projection of a psychology of want and deprivation that are expressed in Alto mothers’ ‘selective neglect’ of their frailer, weaker babies and in their perceptions of an ‘inner badness’ that has contaminated their breastmilk. It is also within the context of home and family life that these same women are beginning to struggle with an awareness of the connections between their ‘private troubles’ and larger social issues. It is fervently hoped that the message, ‘To corn sede’, scrawled across the walls of church and court house in Ladeiras, will ignite into further political action the anger of these victims of a drought that is as much political, and economic as it is geographic.

Acknowledgements-Field research for this study was supported by: the Duke-UNC Women’s Studies Research Center; a Southeast Consortium for International Development Fellowship in Technical Assistance; an R. J. Reynolds Industries Faculty Development Award. In Brazil I was aided by many generous colleagues and friends, including: Naomar de Almeida Filho; Roberto da Matta; Jairilson Silva Paim; Jacques Ferreira Lima Filho; Irene Lopes da Silva; Celma Lucia de Vasconcelos. My husband, D. Michael Hughes, whose own professional interests in child welfare directed me to many of the questions raised in the course of this study, participated actively in the fieldwork process. Jennifer, Sarah and Nathanael Hughes endured the rigors of the field with a patience, sensitivity and cooperation that greatly enriched the project. REFERENCES I.

2. 3. 4. 5.

6.

Robock S. Brazil’s Developing Northeast. Brookings Institute, Washington, DC, 1963. Aguiar N. (Ed.) The Structure of Brazilian Development. Transaction, New Brunswick, 1979. World Health Organization. World Health Statistics Annual. World Health Organization. Geneva, 1981. Paim S., Netto-Dias C. and De Araujo J. Influencia de fatores sociais e ambientais na mortalidade infantil. Boln Of sank pan-am. LXXXVIII, 327-340, 1980. Wood C. Infant mortality trends and capitalist development in Brazil: the case of Sao Paulo and Belo Horizonte. Latin Am. Persp. 4, No. 4, 56-65, 1977. Ramos J. Contribuiclo ao estudo da mortalidade infantil no municipio do Recife no period0 1965-1974.

M.A. thesis, Universidade Federal de Pemambuco, Departamento de Nutri&o do Centro de Ciencias da Saude, Recife, 1977. 7. Puffer R. and Serrano C. Patterns of Mortality in Childhood. PAHOjWHO Scientific Publication Number 262, Washington, DC, 1973.

Cultural and economic constraints 8. Ware H. The relationship between infant mortality and fertility: replacement and insurance effects. Proceedinns of the International Population Conference 1, pp. 205-225. Lierae I.U.S.S.P.. 1977. 9. World Health-Organization. Infant and Early Childhood Mortality in Relation to Fertility Patterns. WHO, Geneva, 1980. 10. Chowdhury A., Khan A. and Chen L. The effects of childhood mortality experiences on subsequent fertility. Popul. Stud. 30, 249-261, 1976. 11. Taylor C., Newman J. and Kelly N. The child survival hypothesis. Popul. Stud. 30, 263-271, 1976. 12. Scrimshaw S. Infant mortality and behavior in the regulation of family size. Popul. Dev. Rev. 4, 383-403,

26.

27. 28. 29.

1978.

13. Cassidy C. Benign neglect and toddler malnutrition. Social and Biological Predictors of Nutritional Physical Growth, and Neurological Development

14. 15.

16.

17. 18. 19. 20. 21.

22. 23.

24.

25

In

(Edited by Greene L. S. and Johnson F.), pp. 109-139. Academic Press, New York, 1980. Aguirre A. Columbia: the family in Candelaria. Stud. Fam. Plann. 1, No. 11, 1966. Rosenberg E. Ecological effects of sex-differential nutrition. Paper presented at the American Anthropological Association Meetings, New Orleans, 1973. Prough D. and Harlow R. ‘Masked Deprivation’ in infants and young children. In Deprivation ofMaternal Care (Edited by Ainsworth M.), pp. 205-225: Schocken, New York, 1966. Illich I. Gender, p. xi. Pantheon, New York, 1982. de Andrade M. The Land and People of Northeast Brazil. University of New Mexico Press, Albuquerque, 1980. de Castro J. Death in the Northeast. Vintage, New York, 1969. Forman S. The Brazilian Peasantry. Columbia University Press, New York, 1975. Goodman D. Rural structure, surplus population, and modes of production in a peripheral region: the Brazilian Northeast. Peas. Stud. 5, No. 1. October, 1977. Moraes C. Peasant leagues in Brazil. In Agrarian Problems and Peasant Movements in Latin America (Edited bv Stavenhaaen R.). Doubledav. Garden Citv, 1970. Palmeira My The aftermath of peasant mobilization: rural conflicts in the Brazilian Northeast since 1964. In The Structure of Brazilian Development (Edited by Aguiar N.), pp. 71-99. Transaction, New Brunswick, 1979. The free clinics were habitually understaffed and the dispensary shelves bare of the most commonly prescribed antibiotics and worm medications. Based on several days observations, the average consultation in the clinics lasted less than 2 minutes. These ‘consultations’ concerned negotiations between doctor and patient over prescription drugs, and were accompanied by no physical examination in the majority of cases. The microscope in the laboratory of the state health post was broken throughout the summer of 1982 and the lab technician, unable to work, simply extended her vacation period for several weeks, The available statistics from the local maternity hospital indicated that in 1981 there were’ a total of 867 births (60 of them C-section) indigent patients (‘nrio conamong non-paying, tribuintes’). Of these there were 37 stillbirths and an additional 16 infants who died postpartum in the hospital. For an excellent discussion of the folk ethnomedical system as it is practiced in the rural Nordestino community see Nations M. Illness of the Child: the Cultural Context

of Childhood

Diarrhea

in Northeast

30.

Status,

Brazil,

Chap. 4, “‘Traditional Beliefs and Practices Relating to Childhood Diarrhea”, pp. 60-90. Doctoral dis-

31.

32.

33.

34. 35.

on nurturing in Brazil

54s

sertation, Department of Anthropology, University of California, Berkeley, 1982. It is my guess that the women have underreported miscarriages, abortions and stillbirths. The forgetfulness of the older women respondents may have contributed to this, while among some of the younger women an initial reluctance to discuss induced (and illegal) abortions was apparent. Preston S. Mortality Patterns in National Populations. Academic Press, New York, 1976. Waldron I. Sex differences in human mortality: the role of genetic factors. Sot. Sci. Med. 17, 321-333, 1983. World Health Organization. World Health Statistics Annual, Vol. 1, Vzal Statistics and Causes of Death. WHO, Geneva, 1977, 1980, 1981. Nations M. op cit., p. 6, reports that the rural mothers of Pacatuba, Ceara use the term ‘doenqa da crianca’ to refer primarily to severe diarrhea and dehydration in their children. Certainly the cluster of symptoms that mothers of Alto do Cruzeiro identify with the syndrome (severe emaciation, passivity, lack of interest in food, fits and convulsions. paralysis, sunken eyes, etc.) overlap with the symptoms of severe diarrhea and dehydration. But, as will be explicated in the text of this article, not all diarrheas are classified by this term, only those that are thought to lead to permanent impairment in a constitutionally weak child or infant. It is, of course, entirely possible that there are regional variations with respect to the term’s usage. Gn the other hand, I suspect that without probing and some awareness on the part of the women interviewed that the anthropologist ‘understands’ its meanings, this information would not be readily volunteered. Once I became aware of the covert meanings of ‘doerqa da crianca’ I did enquire among a few trusted physicians in Ladeiras as to what they thought the commonly used term meant. I was told that ‘doeqa da crianca’ or ‘doeqa do menino’ was simply the way poor and uneducated mothers referred to ‘all’ common childhood ailments, which (based on my interviews) is quite clearly not the case. Nonetheless, these doctors were aware that mothers frequently disregarded treatment regimes for specific children, although they did not know on what basis they made these decisions. I am using the term ‘ethnoeugenic’ selective neglect advisedly. It has not escaped my attention that there are a number of parallels between these mothers’ explanations of their child rearing/child survival strategies and contemporary theory in socio-biology. As far as I am concerned both represent folk models of human action, and any correspondence between the two is purely coincidental. In a subsequent paper I analyze the psycho-cultural dynamics that allow poor women of the Alto to distance themselves from their offspring suIficiently to permit the kind of under-investment alluded to here. See ScheperHughes N. Basic strangeness: maternal detachment and infant survival in a Brazilian shantytown-a critique of bonding theory. In Studies in Comparative Human Development (Edited by Super C. and Harkness S.), Vol. 1. Academic Press, New York. In press. See Nations M. op cu., Chap. 5, for a full discussion of the impact of biomedicine on traditional ethnomedical beliefs and practices in the NordPstino community of Pacatuba. Grant J. The State of the World’s Children, 1982-1983, p. 4. UNICEF, Information Division, Geneva, Switzerland, 1983. Hardy E. et al. Breastfeeding promotion: effects of an educational program in Brazil. Stud. Fam. Plann. 13, 79-86.

1982.

36. Gussler J. and Briesemeister H. The insufficient milk syndrome: a biocultural explanation. Med. Anthrop. 4, 146174,

1980.

NANCY SCHEPER-HUGHES

546 37. An interview

with a pediatric physician in Ladeiras dealt with medical education and theories underlying pediatric practice. This physician suggested that there were currently ‘two schools of thought’ influencing Brazilian pediatricians, the American school (which was dominant) and the German or European school, which he believed had greater influence in the industrialized south of the nation. He suggested that the early introduction of supplementary foods and scheduled feedings represented the ‘American model’. I realize, of course,

that American pediatricians are divided on these issues today in the United States. 38. See de Castro J. op. cit. and Ramos C. Barren Lires (translation of Vidas Secas). University of Texas Press. Austin, 1965. 39. Cited in de Castro J. op. cit., p. 2. 40. I have borrowed the term ‘macroparasitism’ from McNeil] W. P/agues and Peoples. Anchor PressjDoubleday, Garden City, New York, 1976.