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Mothers, injections and poliomyelitis
Sm. Sci. Med. Vol. 35, No. 6, pp. 795-798, 1992 Printed in Great Britain. All rights reserved
MOTHERS,
Copyright
INJECTIONS
0
0277-9536/92 $5.00 + 0.00 1992 Pergamon Press Ltd
AND POLIOMYELITIS
H. V. WYATT Department
of Clinical
Medicine,
University
of Leeds,
32 Hyde Terrace,
Leeds LS2 9LN,
U.K.
Abstract-Injections are very popular in developing countries and it will be very difficult to wean adults from wanting injections for themselves. However, injections may transmit disease agents, cause abscesses and provoke paralytic poliomyelitis. Mothers have often recognized the causal link between injection of their child and subsequent paralysis of that limb, but unnecessary injections still cripple many children each year. Our priority should be to urge mothers to resist unnecessary injections for their sick children. Doctors who might resist prohibition of injections for adults, might accept the small loss of income from not injecting sick babies and children.
Key words-abscess,
child health,
injections,
mothers,
poliomyelitis
primary health care (PHC) hospitals can be due to injection abscesses (personal observations). In Gabon, about 1 person in 450 is at risk each year of a gluteal abscess [5]. The substances injected and dirty techniques can cause inflammation which may increase the risk of paralytic poliomyelitis in nonimmune children as much as 25fold [6,7]. Medical anthropologists have made most of the few studies on the practice of injections [8,9] but the studies have focussed on social rather than medical aspects. Few studies except those on poliomyelitis, have shown the extent of the harm done by injections. There has been no study of injections given to children under 1 yr who form the most vulnerable group with the highest incidence of illness. There is only one study of the mothers whose children receive injections (see below).
INTRODUCTION
In Madagascar as early as 1924, mothers attributed their children’s paralysis to earlier injections in the affected limb. In Samoa in 1928 the local people attributed paralysis of 138 out of 1766 children to earlier injections although Western doctors disagreed. In the Congo in the 1940’s, although Western doctors were sceptical, mothers called the condition ‘injection paralysis’. In 1950, all these paralyses were seen as poliomyelitis provoked by injections [I]. Mothers had recognized a possible danger in injections. In India where about three-quarters of all paralytic polio cases closely follow an injection, mothers are aware that the paralysed limb is almost always the one injected (see below). Yet children still receive unnecessary injections. The mother’s observation must be backed by education. Injections are very popular in developing countries, but the reasons may be complex:
EDUCATION In the face of these well-known risks, how is it that doctors and health workers still use unsterile syringes and needles, in many cases for unnecessary treatments? Why do patients apparently insist on injections rather than oral medication? We must educate three groups, those who should sterilize equipment, those who give injections and those who either demand or accept injections. This last group includes mothers who allow injections for their children.
1. Injections may epitomize Western Medicine: a single injection cured the very disfiguring lesions of yaws, a cure which was everywhere described as ‘miraculous’ [ 11. 2. Injections often reinforce traditional beliefs about healing and disease. 3. Payment for giving injections may form a large part of the income of doctors and healers. Injections, however, are not without risk. Unless needles and syringes are sterile, hepatitis B virus (HBV), human immunodeficiency virus (HIV), malarial parasites and other disease agents including the spirochetes which cause syphilis may be transmitted [2]. In Ahmedabad, India, in 1984 the use of unsterile blood collection apparatus and syringes, and the use of infected blood caused viral hepatitis which killed nearly 1000 people and affected perhaps another 4000 [3,4]. Improper use also results in a high risk of injection abscesses-as many as 2% of admissions to
Health
workers
We have to educate and alert health workers to the dangers of unsterile injections and to the need for the repair and use of sterilizers and autoclaves. Apathy and inertia will lie in the way, but any increase in sterility will be a gain. Doctors and health workers are taught the necessity of sterile syringes and needles. However, although autoclaves and sterilizers are common, they are often unused (personal observations). In Ahmedabad in 1984,40% of sterilization 195
196
H. V. WYATT
drums were defective and of 14,000 doctors, 5000 had no sterilizing equipment; there were also 4000 unqualified doctors [3]. In one hospital I visited, there were many syringes and needles, an electric sterilizer and mains electricity yet on an open wooden rack were 4 needles with fitted syringes which were used all day: the doctor knew of the risks of hepatitis, but conformed to slack habits. In Burkina Faso, Africa, the use of injections at rural dispensaries was observed for one month [lo]. For each 1000 injections the dispensaries used respectively, 14, 21 and 250 syringes and 70, 120 and 700 needles. In many places, there may not be money to buy enough syringes or equipment or to repair or replace the old and broken. Doctors know that there is a discrepancy between theory and practice. The givers of injections A consultation with a doctor or other healer costs little, perhaps Rupees (Rs) 5 in India. The doctor will give a prescription which is taken to a drug store, although in some places drugs may be bought from stalls. The drug store may be owned by the doctor who may have shares in a local factory producing the drugs he prescribes. The drug may be taken back to the surgery where the doctor charges for the injection. Giving injections may be the most profitable part of the doctor’s work. I was told of doctors in India who give 200 injections in a morning at Rs 10 or more a time, earning nearly $200. The doctor has every reason to believe in the magic of injections. The majority of poor people in India earn about Rs 7 to 10 a day. Education of doctors and other injection givers will be very difficult [l 11.Even to persuade them to use sterile syringes and needles will be difficult: I studied a local doctor who had a sterilizer, syringes and needles, yet he reused the syringe and the sterilizer was not hot enough. Fees for unnecessary drugs and injections contribute to the doctor’s income. In the West, long after research evidence of their harmful effects, there is a sad history of tonsillectomies and unnecessary X-rays: it is all too easy to convince oneself that a profitable operation benefits the patient. In Nigeria, however, one doctor was able to stop all unnecessary injections in his rural practice, but the policy was not popular at first [12]. Many or perhaps most injections are given by traditional healers, anyone with a syringe and health workers acting privately [8]. Few have any concept of sterility of infection. How will we educate these injectors in East Africa? Pseudo ‘Red Cross’ nurses turn up in the villages. In smart uniforms, without any training, they sell. . single injections of penicillin against impotence injections of vitamin K if you have a cut or wound. Veterinary nurses inject people with tetracyclin meant for cows. Rich cattle owners inject themselves and their families--everybody with the same needle-and if the ampoule is not quite enough they dilute it with water [13].
Those who receive Injections, whether the withdrawal or giving of fluids, are symbolic and blend traditional and Western concepts of medicine. The receivers believe they are getting value for money and seem to distrust pills and syrups. Perhaps the intimacy of the injection is equivalent to the laying-on of hands. In some cultures, the efficacy of the treatment is proportional to the pain: blunt needles may be judged very efficacious. A patient explained to me that after injections, he had developed an abscess: the doctor told him that the injections had localized the poisons from the rest of his body and that the hospital could now draw out these poisons from the abscess to complete his (the doctor’s) cure. In others, injections are seen as hot and are thought to act immediately. The reasons people prefer injections may be many, varied and complex. It may take a very great effort to discover why people prefer injections and to change attitudes [9]. THE MESSAGE
Medical messages constantly reinforce the potency of injections as a force for good. Artists all too often show a syringe as an easy visual short hand for health on stamps, posters, advertisements and logos. The great campaigns for immunization against childhood diseases like the Expanded Programme on Immunization (EPI), use the syringe to inject the triple diphtheria-tetanus-pertussis (DPT) vaccine and also the inactivated poliovaccine (IPV). In Pakistan, government publicity uses the Urdu term ‘hifazati teekay (preventative injections)’ for vaccination which includes oral poliovaccine (OPV) (personal communication, F. Rehman). Mothers are the chief target of powerful images: propaganda and international agencies present syringes in a good light without warning of possible harm. Even though it must be used for immunization, health workers at all levels must reject the syringe as a universal symbol for health. CHILDREN AND INJECTIONS
A survey in Burkina Faso showed that children &4yr were given fewer injections per consultation than older children and adults, nevertheless these young children received 78, 517, 660 and 750 injections per 1000 consultations respectively in four dispensaries [lo]. The IO-fold difference in rate of injections suggests that education is possible. Of India, little is known. In a study in 1984 of 2400 patients in several towns, Trisha Greenhalgh found that a third of all patients visiting a private doctor were given one or more injections [14]. Forty-two percent were given antimicrobials, 36% vitamins or haematinics and 18 % analgesics. An earlier survey of traditional healers in Mysore State showed that half the patients received injections [15]. Another survey
Mothers and polio of traditional healers showed that the giving of injections varied although 87% of the healers possessed syringes and needles [16]. Unfortunately, the only survey of medicines given to children, groups all children O-5 yr and does not mention injections [17]. There was an average of 5 to nearly 8 drugs per episode according to the type of practitioner. The average prescription cost was Rs 32 for neonates and Rs 30 for others. The authors, commenting on the drugs prescribed, said their use ‘may be grossly harmful’, ‘therapeutic sin’, ‘gross abuse’, ‘little or no benefit’, ‘dangerous’ and ‘useless’. Poliomyelitis
and unnecessary
injections
An analysis of the case-histories of 262 children with acute paralytic poliomyelitis in Pondicherry, south east India, showed that about 70% had received one or more injections just before paralysis [18]. These injections which included antihistamines, prostigmine, gentamycin, terramycin, penicillins, other antibiotics and vitamin B complexes, were given for fever and diarrhoea. There was little clinical justification either for the drugs or the giving by injection. Some children received 6 injections in a single day; others were given injections for several days after limbs were paralysed after a first injection. In children without injections, the chance of paralysis in left and right legs was equal. Injections changed the pattern of paralysis in the uninjected as well as in the injected limb. The number of legs paralysed and the severity of paralysis were increased by injections. Death in the acute illness was more likely following injections and recovery from muscle paralysis seemed less likely. This is very strong evidence that nearly three quarters of the children suffered unnecessary of more severe paralysis because of unnecessary injections. Very few of the cases of poliomyelitis were caused by necessary injections of DPT vaccines, although, contrary to good practice, several children with fever had been given DPT. Probably 200,000 children suffer paralytic polio every year in India and perhaps half have permanent disabilities. Although more OPV is being used, it may be a long time before all babies are immunized with effective vaccine. As the median age of paralysis is now about 12 months, all babies should receive three doses of OPV before 4 months. With 800,000 villages in India, this will be very hard to achieve. However, if three quarters of the cases are caused by unnecessary injections, fewer injections would reduce the cases of paralysis-and perhaps less money would be spent on unnecessary and dangerous drugs. Poliovaccines have reduced the incidence of polio to very low levels in many countries, but civil disorder, famine, floods and war can interrupt primary health care and leave children at risk of polio, particularly if injections are given. Poliomyelitis is a known and well documented risk following injection of young children: as many
191
as 150,000 Indian children a year may suffer paralytic polio as the result of unnecessary injections. Immediate action is needed. MOTHERS
AND INJECTIONS
In Meghalaya, a hilly north east state of India between Bangladesh and Burma, injections are not popular and there is considerable opposition to immunizations e.g. DPT. There is a popular belief that women should not be touched by iron and this now includes needles. There is little polio paralysis (personal observations and examination of hospital and other records) but there has been no study of the low polio prevalence in the absence of adequate immunization. In contrast, in Tamil Nadu, a state on the east coast of India, injections are very popular-and polio is very common. At each of three sessions, I asked about 50 women primary health workers about their knowledge of polio and attitudes to injections. Although they are poor, illiterate and chosen from among the most disadvantaged women, they attain hope and confidence: unlike most other women, even those with education, they are articulate and unafraid of strangers. About 1 in 10 of the women had had an injection in the past month-for backache, stomach and chest pains, etc. About one third had had jaundice (possibly caused by an injected hepatitis virus). All the women preferred injections to pills or syrups, “you immediately feel better after an injection but it takes a day or more for a pill to make you better.” None would go to a doctor who did not give injections. All had seen injection abscesses and several had abscesses-a child with a large scar from an injection abscess was immediately shown me. All the women knew about sterility and said that they would buy disposable syringes. They knew about AIDS but all thought that a person infected would be ill with AIDS within 2 months. Each woman cares for about 500 families and all had between 1 and 5 polio cases among these families, including twins, four in one family and a mother and her child. When asked what caused polio, they replied that it was caused by a virus but said that the mothers believed it was caused by a great sin of the parents or it was the child’s destiny or sin in a previous life. All knew of cases or stories of polio following injection of a limb e.g. a nephew with polio after an injection, two children with paralysis in an arm following injection in that arm (paralysis in an arm is rare in India, author). None thought that the paralysis was caused by the injection, “the child was going to be paralysed in the leg and the doctor injected a drug, but the drug was not powerful enough to prevent the paralysis.” Some of the older women in the group remembered the 1950s when there were no injections and they remembered no polio. Although all were prepared to accept abscesses as a consequence of injections, they
798
H.V. WYATT
said that if there was a reaction after an immunization, or a case of polio, the mothers in their block would refuse all further immunizations for their children: it would take a great deal of persuasion before immunizations could be resumed. These health workers were later convinced that unnecessary injections could cause paralysis in children already incubating a polio virus infection and said that they would try to persuade other mothers to resist injections for sick babies. We do not know how many mothers would really prefer their babies not to be given injections; some mothers may ask for injections only to conform. An American epidemiologist was told by doctors in Togo, Africa, that mothers preferred their children with malaria to be treated by injections [19]. When the mothers themselves were asked, 56% preferred oral treatment and only 10% preferred injections. Of the ones who preferred it, 71% said there was no risk of paralysis with oral treatment. It may be very difficult to persuade adult men and women to decline injections for themselves. Doctors and other healers would certainly be very apprehensive at any campaign to limit all injections but a start with limiting injections to babies is possible and, because injectors would lose little income, might not raise too much opposition. Some mothers already believe that injections are too hot or dangerous for babies and have recognized the effects injections have on their children. Mothers, already the target for the EPI and advice about health care, are the one group which might respond to education about injections for their children. Our research and education should be concentrated on mothers: they have the strength and the power to effect change. It will not be easy to differentiate: to condemn the giving of medicines by injection as dangerous, but at the same time to support the DPT vaccine as beneficial. We must emphasize that injected vaccines are safe for children in good health. However, any injections at all may harm children already sick: sick children need oral rehydration or syrups, not needles (see above). Can we mobilize the mothers to resist injections and insist on syrups for their children? Rotary International has adopted the PolioPlus campaign to eliminate polio and has donated vaccine. In addition, there are clubs throughout India with Polio Volunteers and Rotary wives. We must galvanize groups of women activists through their national and international links. We must eliminate the syringe and needle from logos, placards, billboards and television as the all too easily accepted symbol of health. Mothers and grandmothers could become an army against harmful injections.
Adults may continue to prefer injections for themselves but the mothers among them may respond to pleas for their children. Our motto should be: Breast feed, immunize. No injections except vaccines. Syrups, never injections for sick children Acknowledgements-I
am grateful to Save the Children Fund and the Leeds Philosophical and Literary Society for grants towards expenses, and to Dr S. Mahadevan, Marc and Jessie Bonnet and the Working Women’s Forum of Madras for stimulating discussions and hospitality.
REFERENCES
1. Wyatt H. V. Provocation poliomyelitis: neglected clinical observations from 1914 to 1950. Bull. Hist. Med. 55, 543-557,
1981.
2. Waytt H. V. Injections and AIDS. Trop. Doctor 16, 97-98,
1986.
3. Menon R. The fatal strain. India Today 31 May, pp. 68869, 1984. 4. Singh R. Trading in blood. India Today 31 May, pp. 48-52, 1985. 5. Soeters R. and Aus C. Hazards of injectable therapy. Trop. Doctor 19, 124-125, 1989. 6. Wyatt H. V. Provocation of poliomyelitis by multiple injections. Trans. R. Sot. @op. Med. Hyg. 79, 355-358, 1985. 7. Wyatt H. V. Poliomyelitis in developing countries: lower limb paralysis and injections. Trans. R. Sot. trop. Med. Hyg. 83, 545-549,
1989.
8. Wyatt H. V. The popularity of injections in the Third World: origins and consequences for poliomyelitis. Sot. Sci. Med. 9, 911-915, 1984. 9. Reeler A. V. Injections: a fatal attraction? Sot. Sci. Med. 31, 1119-1125, 1990. 10. Vincent-Ballereau F.. Lafaix C. and Haroche G. Incidence of intramuscular injections in rural dispensaries in developing countries. Trans. R. Sot. trop. Med. Hyg. 83, 106, 1989. 11. Wyatt H. V. Injections cripple: injections kill. J. Indian Med. Assoc. 84, 193-194,
1986.
12. Nwokolo N. and Parry E. H. 0. Injections and health. Trop. Doctor 19, 97-98, 1989. 13. DeWind C. M. Health for all by the year 2000: why we might not get there. Br. Med. J. 299, 867, 1989. 14. Greenhalgh T. Drug prescription and self-medication in India: an exploratory survey. Sot. Sci. Med. 25, 307-318, 1987. 15. Alexander C. A. and Shivaswamy M. K. Traditional healers in Mysore. Sot. Sci. Med. 5, 595-601, 1971. 16. Bhatia J. C., Vir D., Timmappaya A. and Chuttani C. S. Traditional healers and modern medicine. Sot. Sci. Med. 9, 15-21, 1975. 17. Prakash O., Mathur G. P., Singh Y. D. and Kushwaha K. P. Prescription audit of under six children living in periurban areas. Indian Pediut. 26, 900-903, 1989. 18. Wyatt H. V. et al. Trans R. Sot. trop. Med. Hyg. In press. 19. Deming M. Foreign trip report. IHPO, Centers for Disease Control, U.S. Public Health Service, Atlanta GA 30333, p. 17, 1984.
MOTHERS,
Copyright
INJECTIONS
0
0277-9536/92 $5.00 + 0.00 1992 Pergamon Press Ltd
AND POLIOMYELITIS
H. V. WYATT Department
of Clinical
Medicine,
University
of Leeds,
32 Hyde Terrace,
Leeds LS2 9LN,
U.K.
Abstract-Injections are very popular in developing countries and it will be very difficult to wean adults from wanting injections for themselves. However, injections may transmit disease agents, cause abscesses and provoke paralytic poliomyelitis. Mothers have often recognized the causal link between injection of their child and subsequent paralysis of that limb, but unnecessary injections still cripple many children each year. Our priority should be to urge mothers to resist unnecessary injections for their sick children. Doctors who might resist prohibition of injections for adults, might accept the small loss of income from not injecting sick babies and children.
Key words-abscess,
child health,
injections,
mothers,
poliomyelitis
primary health care (PHC) hospitals can be due to injection abscesses (personal observations). In Gabon, about 1 person in 450 is at risk each year of a gluteal abscess [5]. The substances injected and dirty techniques can cause inflammation which may increase the risk of paralytic poliomyelitis in nonimmune children as much as 25fold [6,7]. Medical anthropologists have made most of the few studies on the practice of injections [8,9] but the studies have focussed on social rather than medical aspects. Few studies except those on poliomyelitis, have shown the extent of the harm done by injections. There has been no study of injections given to children under 1 yr who form the most vulnerable group with the highest incidence of illness. There is only one study of the mothers whose children receive injections (see below).
INTRODUCTION
In Madagascar as early as 1924, mothers attributed their children’s paralysis to earlier injections in the affected limb. In Samoa in 1928 the local people attributed paralysis of 138 out of 1766 children to earlier injections although Western doctors disagreed. In the Congo in the 1940’s, although Western doctors were sceptical, mothers called the condition ‘injection paralysis’. In 1950, all these paralyses were seen as poliomyelitis provoked by injections [I]. Mothers had recognized a possible danger in injections. In India where about three-quarters of all paralytic polio cases closely follow an injection, mothers are aware that the paralysed limb is almost always the one injected (see below). Yet children still receive unnecessary injections. The mother’s observation must be backed by education. Injections are very popular in developing countries, but the reasons may be complex:
EDUCATION In the face of these well-known risks, how is it that doctors and health workers still use unsterile syringes and needles, in many cases for unnecessary treatments? Why do patients apparently insist on injections rather than oral medication? We must educate three groups, those who should sterilize equipment, those who give injections and those who either demand or accept injections. This last group includes mothers who allow injections for their children.
1. Injections may epitomize Western Medicine: a single injection cured the very disfiguring lesions of yaws, a cure which was everywhere described as ‘miraculous’ [ 11. 2. Injections often reinforce traditional beliefs about healing and disease. 3. Payment for giving injections may form a large part of the income of doctors and healers. Injections, however, are not without risk. Unless needles and syringes are sterile, hepatitis B virus (HBV), human immunodeficiency virus (HIV), malarial parasites and other disease agents including the spirochetes which cause syphilis may be transmitted [2]. In Ahmedabad, India, in 1984 the use of unsterile blood collection apparatus and syringes, and the use of infected blood caused viral hepatitis which killed nearly 1000 people and affected perhaps another 4000 [3,4]. Improper use also results in a high risk of injection abscesses-as many as 2% of admissions to
Health
workers
We have to educate and alert health workers to the dangers of unsterile injections and to the need for the repair and use of sterilizers and autoclaves. Apathy and inertia will lie in the way, but any increase in sterility will be a gain. Doctors and health workers are taught the necessity of sterile syringes and needles. However, although autoclaves and sterilizers are common, they are often unused (personal observations). In Ahmedabad in 1984,40% of sterilization 195
196
H. V. WYATT
drums were defective and of 14,000 doctors, 5000 had no sterilizing equipment; there were also 4000 unqualified doctors [3]. In one hospital I visited, there were many syringes and needles, an electric sterilizer and mains electricity yet on an open wooden rack were 4 needles with fitted syringes which were used all day: the doctor knew of the risks of hepatitis, but conformed to slack habits. In Burkina Faso, Africa, the use of injections at rural dispensaries was observed for one month [lo]. For each 1000 injections the dispensaries used respectively, 14, 21 and 250 syringes and 70, 120 and 700 needles. In many places, there may not be money to buy enough syringes or equipment or to repair or replace the old and broken. Doctors know that there is a discrepancy between theory and practice. The givers of injections A consultation with a doctor or other healer costs little, perhaps Rupees (Rs) 5 in India. The doctor will give a prescription which is taken to a drug store, although in some places drugs may be bought from stalls. The drug store may be owned by the doctor who may have shares in a local factory producing the drugs he prescribes. The drug may be taken back to the surgery where the doctor charges for the injection. Giving injections may be the most profitable part of the doctor’s work. I was told of doctors in India who give 200 injections in a morning at Rs 10 or more a time, earning nearly $200. The doctor has every reason to believe in the magic of injections. The majority of poor people in India earn about Rs 7 to 10 a day. Education of doctors and other injection givers will be very difficult [l 11.Even to persuade them to use sterile syringes and needles will be difficult: I studied a local doctor who had a sterilizer, syringes and needles, yet he reused the syringe and the sterilizer was not hot enough. Fees for unnecessary drugs and injections contribute to the doctor’s income. In the West, long after research evidence of their harmful effects, there is a sad history of tonsillectomies and unnecessary X-rays: it is all too easy to convince oneself that a profitable operation benefits the patient. In Nigeria, however, one doctor was able to stop all unnecessary injections in his rural practice, but the policy was not popular at first [12]. Many or perhaps most injections are given by traditional healers, anyone with a syringe and health workers acting privately [8]. Few have any concept of sterility of infection. How will we educate these injectors in East Africa? Pseudo ‘Red Cross’ nurses turn up in the villages. In smart uniforms, without any training, they sell. . single injections of penicillin against impotence injections of vitamin K if you have a cut or wound. Veterinary nurses inject people with tetracyclin meant for cows. Rich cattle owners inject themselves and their families--everybody with the same needle-and if the ampoule is not quite enough they dilute it with water [13].
Those who receive Injections, whether the withdrawal or giving of fluids, are symbolic and blend traditional and Western concepts of medicine. The receivers believe they are getting value for money and seem to distrust pills and syrups. Perhaps the intimacy of the injection is equivalent to the laying-on of hands. In some cultures, the efficacy of the treatment is proportional to the pain: blunt needles may be judged very efficacious. A patient explained to me that after injections, he had developed an abscess: the doctor told him that the injections had localized the poisons from the rest of his body and that the hospital could now draw out these poisons from the abscess to complete his (the doctor’s) cure. In others, injections are seen as hot and are thought to act immediately. The reasons people prefer injections may be many, varied and complex. It may take a very great effort to discover why people prefer injections and to change attitudes [9]. THE MESSAGE
Medical messages constantly reinforce the potency of injections as a force for good. Artists all too often show a syringe as an easy visual short hand for health on stamps, posters, advertisements and logos. The great campaigns for immunization against childhood diseases like the Expanded Programme on Immunization (EPI), use the syringe to inject the triple diphtheria-tetanus-pertussis (DPT) vaccine and also the inactivated poliovaccine (IPV). In Pakistan, government publicity uses the Urdu term ‘hifazati teekay (preventative injections)’ for vaccination which includes oral poliovaccine (OPV) (personal communication, F. Rehman). Mothers are the chief target of powerful images: propaganda and international agencies present syringes in a good light without warning of possible harm. Even though it must be used for immunization, health workers at all levels must reject the syringe as a universal symbol for health. CHILDREN AND INJECTIONS
A survey in Burkina Faso showed that children &4yr were given fewer injections per consultation than older children and adults, nevertheless these young children received 78, 517, 660 and 750 injections per 1000 consultations respectively in four dispensaries [lo]. The IO-fold difference in rate of injections suggests that education is possible. Of India, little is known. In a study in 1984 of 2400 patients in several towns, Trisha Greenhalgh found that a third of all patients visiting a private doctor were given one or more injections [14]. Forty-two percent were given antimicrobials, 36% vitamins or haematinics and 18 % analgesics. An earlier survey of traditional healers in Mysore State showed that half the patients received injections [15]. Another survey
Mothers and polio of traditional healers showed that the giving of injections varied although 87% of the healers possessed syringes and needles [16]. Unfortunately, the only survey of medicines given to children, groups all children O-5 yr and does not mention injections [17]. There was an average of 5 to nearly 8 drugs per episode according to the type of practitioner. The average prescription cost was Rs 32 for neonates and Rs 30 for others. The authors, commenting on the drugs prescribed, said their use ‘may be grossly harmful’, ‘therapeutic sin’, ‘gross abuse’, ‘little or no benefit’, ‘dangerous’ and ‘useless’. Poliomyelitis
and unnecessary
injections
An analysis of the case-histories of 262 children with acute paralytic poliomyelitis in Pondicherry, south east India, showed that about 70% had received one or more injections just before paralysis [18]. These injections which included antihistamines, prostigmine, gentamycin, terramycin, penicillins, other antibiotics and vitamin B complexes, were given for fever and diarrhoea. There was little clinical justification either for the drugs or the giving by injection. Some children received 6 injections in a single day; others were given injections for several days after limbs were paralysed after a first injection. In children without injections, the chance of paralysis in left and right legs was equal. Injections changed the pattern of paralysis in the uninjected as well as in the injected limb. The number of legs paralysed and the severity of paralysis were increased by injections. Death in the acute illness was more likely following injections and recovery from muscle paralysis seemed less likely. This is very strong evidence that nearly three quarters of the children suffered unnecessary of more severe paralysis because of unnecessary injections. Very few of the cases of poliomyelitis were caused by necessary injections of DPT vaccines, although, contrary to good practice, several children with fever had been given DPT. Probably 200,000 children suffer paralytic polio every year in India and perhaps half have permanent disabilities. Although more OPV is being used, it may be a long time before all babies are immunized with effective vaccine. As the median age of paralysis is now about 12 months, all babies should receive three doses of OPV before 4 months. With 800,000 villages in India, this will be very hard to achieve. However, if three quarters of the cases are caused by unnecessary injections, fewer injections would reduce the cases of paralysis-and perhaps less money would be spent on unnecessary and dangerous drugs. Poliovaccines have reduced the incidence of polio to very low levels in many countries, but civil disorder, famine, floods and war can interrupt primary health care and leave children at risk of polio, particularly if injections are given. Poliomyelitis is a known and well documented risk following injection of young children: as many
191
as 150,000 Indian children a year may suffer paralytic polio as the result of unnecessary injections. Immediate action is needed. MOTHERS
AND INJECTIONS
In Meghalaya, a hilly north east state of India between Bangladesh and Burma, injections are not popular and there is considerable opposition to immunizations e.g. DPT. There is a popular belief that women should not be touched by iron and this now includes needles. There is little polio paralysis (personal observations and examination of hospital and other records) but there has been no study of the low polio prevalence in the absence of adequate immunization. In contrast, in Tamil Nadu, a state on the east coast of India, injections are very popular-and polio is very common. At each of three sessions, I asked about 50 women primary health workers about their knowledge of polio and attitudes to injections. Although they are poor, illiterate and chosen from among the most disadvantaged women, they attain hope and confidence: unlike most other women, even those with education, they are articulate and unafraid of strangers. About 1 in 10 of the women had had an injection in the past month-for backache, stomach and chest pains, etc. About one third had had jaundice (possibly caused by an injected hepatitis virus). All the women preferred injections to pills or syrups, “you immediately feel better after an injection but it takes a day or more for a pill to make you better.” None would go to a doctor who did not give injections. All had seen injection abscesses and several had abscesses-a child with a large scar from an injection abscess was immediately shown me. All the women knew about sterility and said that they would buy disposable syringes. They knew about AIDS but all thought that a person infected would be ill with AIDS within 2 months. Each woman cares for about 500 families and all had between 1 and 5 polio cases among these families, including twins, four in one family and a mother and her child. When asked what caused polio, they replied that it was caused by a virus but said that the mothers believed it was caused by a great sin of the parents or it was the child’s destiny or sin in a previous life. All knew of cases or stories of polio following injection of a limb e.g. a nephew with polio after an injection, two children with paralysis in an arm following injection in that arm (paralysis in an arm is rare in India, author). None thought that the paralysis was caused by the injection, “the child was going to be paralysed in the leg and the doctor injected a drug, but the drug was not powerful enough to prevent the paralysis.” Some of the older women in the group remembered the 1950s when there were no injections and they remembered no polio. Although all were prepared to accept abscesses as a consequence of injections, they
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said that if there was a reaction after an immunization, or a case of polio, the mothers in their block would refuse all further immunizations for their children: it would take a great deal of persuasion before immunizations could be resumed. These health workers were later convinced that unnecessary injections could cause paralysis in children already incubating a polio virus infection and said that they would try to persuade other mothers to resist injections for sick babies. We do not know how many mothers would really prefer their babies not to be given injections; some mothers may ask for injections only to conform. An American epidemiologist was told by doctors in Togo, Africa, that mothers preferred their children with malaria to be treated by injections [19]. When the mothers themselves were asked, 56% preferred oral treatment and only 10% preferred injections. Of the ones who preferred it, 71% said there was no risk of paralysis with oral treatment. It may be very difficult to persuade adult men and women to decline injections for themselves. Doctors and other healers would certainly be very apprehensive at any campaign to limit all injections but a start with limiting injections to babies is possible and, because injectors would lose little income, might not raise too much opposition. Some mothers already believe that injections are too hot or dangerous for babies and have recognized the effects injections have on their children. Mothers, already the target for the EPI and advice about health care, are the one group which might respond to education about injections for their children. Our research and education should be concentrated on mothers: they have the strength and the power to effect change. It will not be easy to differentiate: to condemn the giving of medicines by injection as dangerous, but at the same time to support the DPT vaccine as beneficial. We must emphasize that injected vaccines are safe for children in good health. However, any injections at all may harm children already sick: sick children need oral rehydration or syrups, not needles (see above). Can we mobilize the mothers to resist injections and insist on syrups for their children? Rotary International has adopted the PolioPlus campaign to eliminate polio and has donated vaccine. In addition, there are clubs throughout India with Polio Volunteers and Rotary wives. We must galvanize groups of women activists through their national and international links. We must eliminate the syringe and needle from logos, placards, billboards and television as the all too easily accepted symbol of health. Mothers and grandmothers could become an army against harmful injections.
Adults may continue to prefer injections for themselves but the mothers among them may respond to pleas for their children. Our motto should be: Breast feed, immunize. No injections except vaccines. Syrups, never injections for sick children Acknowledgements-I
am grateful to Save the Children Fund and the Leeds Philosophical and Literary Society for grants towards expenses, and to Dr S. Mahadevan, Marc and Jessie Bonnet and the Working Women’s Forum of Madras for stimulating discussions and hospitality.
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