Where There Is No Doctor - A Village Health Care Handbook (Hesperian Foundation, 1993, 516 p.)

Where There Is No Doctor - A Village Health Care Handbook (Hesperian Foundation, 1993, 516 p.) WORDS TO THE VILLAGE HEALTH WORKER (Brown Pages) (introduction...) Health Needs and Human Needs Many Things Relate to Health Care Take a Good Look at Your Community Using Local Resources to Meet Needs Deciding What to Do and Where to Begin Trying a New Idea Working Toward a Balance Between People and Land Working Toward a Balance Between Prevention and Treatment Sensible and Limited Use of Medicines Finding Out What Progress Has Been Made (Evaluation) Teaching and Learning Together - The Health Worker as an Educator Tools for Teaching Making the Best Use of This Book

Where There Is No Doctor - A Village Health Care Handbook (Hesperian Foundation, 1993, 516 p.)

WORDS TO THE VILLAGE HEALTH WORKER (Brown Pages)

Who is the village health worker?

A village health worker is a person who helps lead family and neighbors toward better health. Often he or she has been selected by the other villagers as someone who is especially able and kind.

Some village health workers receive training and help from an organized program, perhaps the Ministry of Health. Others have no official position, but are simply members of the community whom people respect as healers or leaders in matters of health. Often they learn by watching, helping, and studying on their own.

In the larger sense, a village health worker is anyone who takes part in making his or her village a healthier place to live.

This means almost everyone can and should be a health worker:

· Mothers and fathers can show their children how to keep clean;

· Farm people can work together to help their land produce more food;

· Teachers can teach schoolchildren how to prevent and treat many common sicknesses and injuries;

· Schoolchildren can share what they learn with their parents;

· Shopkeepers can find out about the correct use of medicines they sell and give sensible advice and warning to buyers;

· Midwives can counsel parents about the importance of eating well during pregnancy, breast feeding, and family planning.

This book was written for the health worker in the larger sense. It is for anyone who wants to know and do more for his own, his family's or his people's well-being.

If you are a community health worker, an auxiliary nurse, or even a doctor, remember: this book is not just for you. It is for all the people. Share it!

Use this book to help explain what you know to others. Perhaps you can get small groups together to read a chapter at a time and discuss it.

THE VILLAGE HEALTH WORKER LIVES AND WORKS AT THE LEVEL OF HIS PEOPLE. HIS FIRST JOB IS TO SHARE HIS KNOWLEDGE.

Health Needs and Human Needs

Dear Village Health Worker,

This book is mostly about people's health needs. But to help your village be a healthy place to live, you must also be in touch with their human needs. Your understanding and concern for people are just as important as your knowledge of medicine and sanitation.

Here are some suggestions that may help you serve your people's human needs as well as health needs:

1. BE KIND. A friendly word, a smile, a hand on the shoulder, or some other sign of caring often means more than anything else you can do. Treat others as your equals. Even when you are hurried or worried, try to remember the feelings and needs of others. Often it helps to ask yourself, “What would I do if this were a member of my own family?”

Treat the sick as people. Be especially kind to those who are very sick or dying. And be kind to their families. Let them see that you care.

HAVE COMPASSION.

Kindness often helps more than medicine. Never be afraid to show you care.

2. SHARE YOUR KNOWLEDGE. As a health worker, your first job is to teach. This means helping people learn more about how to keep from getting sick. It also means helping people learn how to recognize and manage their illnesses - including the sensible use of home remedies and common medicines.

LOOK FOR WAYS TO SHARE YOUR KNOWLEDGE.

There is nothing you have learned that, if carefully explained, should be of danger to anyone. Some doctors talk about self-care as if it were dangerous, perhaps because they like people to depend on their costly services. But in truth, most common health problems could be handled earlier and better by people in their own homes.

3. RESPECT YOUR PEOPLE'S TRADITIONS AND IDEAS.

Because you learn something about modern medicine does not mean you should no longer appreciate the customs and ways of healing of your people. Too often the human touch in the art of healing is lost when medical science moves in. This is too bad, because...

In this way, you will be adding to your people's culture, not taking away.

Of course, if you see that some of the home cures or customs are harmful (for example, putting excrement on the freshly cut cord of a newborn baby), you will want to do something to change this. But do so carefully, with respect for those who believe in such things. Never just tell people they are wrong. Try to help them understand WHY they should do something differently.

People are slow to change their attitudes and traditions, and with good reason. They are true to what they feel is right. And this we must respect.

Modern medicine does not have all the answers either. It has helped solve some problems, yet has led to other, sometimes even bigger ones. People quickly come to depend too much on modern medicine and its experts, to overuse medicines, and to forget how to care for themselves and each other.

So go slow - and always keep a deep respect for your people, their traditions, and their human dignity. Help them build on the knowledge and skills they already have.

WORK WITH TRADITIONAL HEALERS AND MIDWIVES - NOT AGAINST THEM.

Learn from them and encourage them to learn from you.

4. KNOW YOUR OWN LIMITS.

KNOW YOUR LIMITS

No matter how great or small your knowledge and skills, you can do a good job as long as you know and work within your limits. This means: Do what you know how to do. Do not try things you have not learned about or have not had enough experience doing, if they might harm or endanger someone.

But use your judgment.

Often, what you decide to do or not do will depend on how far you have to go to get more expert help.

KNOW YOUR LIMITS.

For example, a mother has just given birth and is bleeding more than you think is normal. If you are only half an hour away from a medical center, it may be wise to take her there right away. But if the mother is bleeding very heavily and you are a long way from the health center, you may decide to massage her womb or inject an oxytocic even if you were not taught this.

Do not take unnecessary chances. But when the danger is clearly greater if you do nothing, do not be afraid to try something you feel reasonably sure will help.

Know your limits - but also use your head. Always do your best to protect the sick person rather than yourself.

5. KEEP LEARNING. Use every chance you have to learn more. Study whatever books or information you can lay your hands on that will help you be a better worker, teacher, or person.

Always be ready to ask questions of doctors, sanitation officers, agriculture experts, or anyone else you can learn from.

Never pass up the chance to take refresher courses or get additional training.

Your first job is to teach, and unless you keep learning more, soon you will not have anything new to teach others.

KEEP LEARNING - Do not let anyone tell you there are things you should not learn or know.

6. PRACTICE WHAT YOU TEACH.

People are more likely to pay attention to what you do than what you say. As a health worker, you want to take special care in your personal life and habits, so as to set a good example for your neighbors.

Before you ask people to make latrines, be sure your own family has one.

Also, if you help organize a work group - for example, to dig a common garbage hole - be sure you work and sweat as hard as everyone else.

PRACTICE WHAT YOU TEACH (or who will listen to you?)

7. WORK FOR THE JOY OF IT.

If you want other people to take part in improving their village and caring for their health, you must enjoy such activity yourself. If not, who will want to follow your example?

Try to make community work projects fun. For example, fencing off the public water hole to keep animals away from where people take water can be hard work. But if the whole village helps do it as a 'work festival' - perhaps with refreshments and music - the job will be done quickly and can be fun. Children will work hard and enjoy it, if they can turn work into play.

You may or may not be paid for your work. But never refuse to care, or care less, for someone who is poor or cannot pay.

This way you will win your people's love and respect. These are worth far more than money.

WORK FIRST FOR THE PEOPLE-NOT THE MONEY. (People are worth more.)

8. LOOK AHEAD - AND HELP OTHERS TO LOOK AHEAD.

A responsible health worker does not wait for people to get sick. She tries to stop sickness before it starts. She encourages people to take action now to protect their health and well-being in the future.

Many sicknesses can be prevented. Your job, then, is to help your people understand the causes of their health problems and do something about them.

Most health problems have many causes, one leading to another. To correct the problem in a lasting way, you must look for and deal with the underlying causes. You must get to the root of the problem.

For example, in many villages diarrhea is the most common cause of death in small children. The spread of diarrhea is caused in part by lack of cleanliness (poor sanitation and hygiene). You can do something to correct this by digging latrines and teaching basic guidelines of cleanliness.

But the children who suffer and die most often from diarrhea are those who are poorly nourished. Their bodies do not have strength to fight the infections. So to prevent death from diarrhea we must also prevent poor nutrition.

And why do so many children suffer from poor nutrition?

· Is it because mothers do not realize what foods are most important (for example, breast milk)?

· Is it because the family does not have enough money or land to produce the food it needs?

· Is it because a few rich persons control most of the land and the wealth?

· Is it because the poor do not make the best use of land they have?

· Is it because parents have more children than they or their land can provide for, and keep having more?

· Is it because fathers lose hope and spend the little money they have on drink?

· Is it because people do not look or plan ahead? Because they do not realize that by working together and sharing they can change the conditions under which they live and die?

HELP OTHERS TO LOOK AHEAD.

You may find that many, if not all, of these things lie behind infant deaths in your area. You will, no doubt, find other causes as well. As a health worker it is your job to help people understand and do something about as many of these causes as you can.

But remember: to prevent frequent deaths from diarrhea will take far more than latrines, pure water, and 'special drink' (oral rehydration). You may find that child spacing, better land use, and fairer distribution of wealth, land, and power are more important in the long run.

The causes that lie behind much sickness and human suffering are short-sightedness and greed. If your interest is your people's well-being, you must help them learn to share, to work together, and to look ahead.

Many Things Relate to Health Care

We have looked at some of the causes that underlie diarrhea and poor nutrition. Likewise, you will find that such things as food production, land distribution, education, and the way people treat or mistreat each other lie behind many different health problems.

The chain of causes leading to death from diarrhea.

If you are interested in the long-term welfare of your whole community, you must help your people look for answers to these larger questions.

Health is more than not being sick. It is well-being: in body, mind, and community. People live best in healthy surroundings, in a place where they can trust each other, work together to meet daily needs, share in times of difficulty and plenty, and help each other learn and grow and live, each as fully as he or she can.

Do your best to solve day-to-day problems. But remember that your greatest job is to help your community become a more healthy and more human place to live.

You as a health worker have a big responsibility.

Where should you begin?

Take a Good Look at Your Community

Because you have grown up in your community and know your people well, you are already familiar with many of their health problems. You have an inside view. But in order to see the whole picture, you will need to look carefully at your community from many points of view.

As a village health worker, your concern is for the well-being of all the people - not just those you know well or who come to you. Go to your people. Visit their homes, fields, gathering places, and schools. Understand their joys and concerns. Examine with them their habits, the things in their daily lives that bring about good health, and those that may lead to sickness or injury.

Before you and your community attempt any project or activity, carefully think about what it will require and how likely it is to work. To do this, you must consider all the following:

1. Felt needs - what people feel are their biggest problems.

2. Real needs - steps people can take to correct these problems in a lasting way.

3. Willingness - or readiness of people to plan and take the needed steps.

4. Resources - the persons, skills, materials, and/or money needed to carry out the activities decided upon.

As a simple example of how each of these things can be important, let us suppose that a man who smokes a lot comes to you complaining of a cough that has steadily been getting worse.

1. His felt need is to get rid of his cough.

2. His real need (to correct the problem) is to give up smoking.

3. To get rid of his cough will require his willingness to give up smoking. For this he must understand how much it really matters.

4. One resource that may help him give up smoking is information about the harm it can do him and his family. Another is the support and encouragement of his family, his friends, and you.

Finding Out the Needs

As a health worker, you will first want to find out your people's most important health problems and their biggest concerns. To gather the information necessary to decide what the greatest needs and concerns really are, it may help to make up a list of questions.

On the next 2 pages are samples of the kinds of things you may want to ask. But think of questions that are important in your area. Ask questions that not only help you get information, but that get others asking important questions themselves.

Do not make your list of questions too long or complicated - especially a list you take from house to house. Remember, people are not numbers and do not like to be looked at as numbers. As you gather information, be sure your first interest is always in what individuals want and feel. It may be better not even to carry a list of questions. But in considering the needs of your community, you should keep certain basic questions in mind.

Figure

What things in your people's daily lives (living conditions, ways of doing things, beliefs, etc.) do they feel help them to be healthy?

What do people feel to be their major problems, concerns, and needs - not only those related to health, but in general?

What are different houses made of? Walls? Floors? Are the houses kept clean? Is cooking done on the floor or where? How does smoke get out? On what do people sleep?

Are flies, fleas, bedbugs, rats, or other pests a problem? In what way? What do people do to control them? What else could be done?

Is food protected? How could it be better protected?

What animals (dogs, chickens, pigs, etc.), if any, are allowed in the house? What problems do they cause?

What are the common diseases of animals? How do they affect people's health? What is being done about these diseases?

Where do families get their water? Is it safe to drink? What precautions are taken?

How many families have latrines? How many use them properly?

Is the village clean? Where do people put garbage? Why?

How many people live in the community? How many are under 15 years old?

How many can read and write? What good is schooling? Does it teach children what they need to know? How else do children learn?

How many babies were born this year? How many people died? Of what? At what ages? Could their deaths have been prevented? How?

Is the population (number of people) getting larger or smaller? Does this cause any problems?

How often were different persons sick in the past year? How many days was each sick? What sickness or injuries did each have? Why?

How many people have chronic (long-term) illnesses? What are they?

How many children do most parents have? How many children died? Of what? At what ages? What were some of the underlying causes?

How many parents are interested in not having any more children or in not having them so often? For what reasons? (See Family Planning)

NUTRITION

Figure

How many mothers breast feed their babies? For how long? Are these babies healthier than those who are not breast fed? Why?

What are the main foods people eat? Where do they come from?

Do people make good use of all foods available?

How many children are underweight or show signs of poor nutrition?

How much do parents and schoolchildren know about nutritional needs?

How many people smoke a lot? How many drink alcoholic or soft drinks very often? What effect does this have on their own and their families' health?

LAND AND FOOD

Figure

Does the land provide enough food for each family? How long will it continue to produce enough food if families keep growing?

How is farm land distributed? How many people own their land?

What efforts are being made to help the land produce more?

How are crops and food stored? Is there much damage or loss? Why?

HEALING, HEALTH

Figure

What role do local midwives and healers play in health care?

What traditional ways of healing and medicines are used? Which are of greatest value? Are any harmful or dangerous?

What health services are nearby? How good are they? What do they cost? How much are they used?

How many children have been vaccinated? Against what sicknesses?

What other preventive measures are being taken? What others might be taken? How important are they?

SELF-HELP

Figure

What are the most important things that affect your people's health and well-being - now and in the future?

How many of their common health problems can people care for themselves? How much must they rely on outside help and medication?

Are people interested in finding ways of making self-care safer, more effective, and more complete? Why? How can they learn more? What stands in the way?

What are the rights of rich people? Of poor people? Of men? Of women? Of children? How is each of these groups treated? Why? Is this fair? What needs to be changed? By whom? How?

Do people work together to meet common needs? Do they share or help each other when needs are great?

What can be done to make your village a better, healthier place to live? Where might you and your people begin?

Using Local Resources to Meet Needs

How you deal with a problem will depend upon what resources are available.

Some activities require outside resources (materials, money, or people from somewhere else). For example, a vaccination program is possible only if vaccines are brought in - often from another country.

Other activities can be carried out completely with local resources. A family or a group of neighbors can fence off a water hole or build simple latrines using materials close at hand.

Some outside resources, such as vaccines and a few important medicines, can make a big difference in people's health. You should do your best to get them. But as a general rule, it is in the best interest of your people to

The more you and your people can do for yourselves, and the less you have to depend on outside assistance and supplies, the healthier and stronger your community will become.

Not only can you count on local resources to be on hand when you need them, but often they do the best job at the lowest cost. For example, if you can encourage mothers to breast feed rather than bottle feed their babies, this will build self-reliance through a top quality local resource - breast milk! It will also prevent needless sickness and death of many babies.

Encourage people to make the most of local resources.

BREAST MILK - A TOP QUALITY LOCAL RESOURCE - BETTER THAN ANYTHING MONEY CAN BUY!

In your health work always remember:

Deciding What to Do and Where to Begin

After taking a careful look at needs and resources, you and your people must decide which things are more important and which to do first. You can do many different things to help people be healthy. Some are important immediately. Others will help determine the future well-being of individuals or the whole community.

In a lot of villages, poor nutrition plays a part in other health problems. People cannot be healthy unless there is enough to eat. Whatever other problems you decide to work with, if people are hungry or children are poorly nourished, better nutrition must be your first concern.

There are many different ways to approach the problem of poor nutrition, for many different things join to cause it. You and your community must consider the possible actions you might take and decide which are most likely to work.

Here are a few examples of ways some people have helped meet their needs for better nutrition. Some actions bring quick results. Others work over a longer time. You and your people must decide what is most likely to work in your area.

POSSIBLE WAYS TO WORK TOWARD BETTER NUTRITION

FAMILY GARDENS

CONTOUR DITCHES to prevent soil from washing away

ROTATION OF CROPS

Every other planting season plant a crop that returns strength to the soil - like beans, peas, lentils, alfalfa, peanuts or some other plant with seed in pods (legumes).

This year maize

Next year beans

MORE WAYS TO WORK TOWARD BETTER NUTRITION

IRRIGATION OF LAND

FISH BREEDING

BEEKEEPING

NATURAL FERTILIZERS - Compost pile

BETTER FOOD STORAGE

SMALLER FAMILIES - THROUGH FAMILY PLANNING

Trying a New Idea

Not all the suggestions on the last pages are likely to work in your area. Perhaps some will work if changed for your particular situation and resources at hand. Often you can only know whether something will work or not by trying it. That is, by experiment.

START SMALL

When you try out a new idea, always start small. If you start small and the experiment fails, or something has to be done differently, you will not lose much. If it works, people will see that it works and can begin to apply it in a bigger way.

Do not be discouraged if an experiment does not work. Perhaps you can try again with certain changes. You can learn as much from your failures as your successes. But start small.

Here is an example of experimenting with a new idea.

You learn that a certain kind of bean, such as soya, is an excellent body-building food. But will it grow in your area? And if it grows, will people eat it?

Start by planting a small patch - or 2 or 3 small patches in different conditions of soil or water. If the beans do well, try preparing them in different ways, and see if people will eat them. If so, try planting more beans in the conditions where you found they grew best. But try out still other conditions in more small patches to see if you can get an even better crop.

There may be several conditions you want to try changing. For example, type of soil, addition of fertilizer, amount of water, or different varieties of seed. To best understand what helps and what does not, be sure to change only one condition at a time and keep all the rest the same.

For example, to find out if animal fertilizer (manure) helps the beans grow, and how much to use, plant several small bean patches side by side, under the same conditions of water and sunlight, and using the same seed. But before you plant, mix each patch with a different amount of manure, something like this:

1 shovel manure

2 shovels manure

3 shovels manure

4 shovels manure

5 shovels manure

This experiment shows that a certain amount of manure helps, but that too much can harm the plants. This is only an example. Your experiments may give different results. Try for yourself!

Working Toward a Balance Between People and Land

Health depends on many things, but above all it depends on whether people have enough to eat.

Most food comes from the land. Land that is used well can produce more food. A health worker needs to know ways to help the land better feed the people - now and in the future. But even the best used piece of land can only feed a certain number of people. And today, many of the people who farm do not have enough land to meet their needs or to stay healthy.

In many parts of the world, the situation is getting worse, not better. Parents often have many children, so year by year there are more mouths to feed on the limited land that the poor are permitted to use.

Many health programs try to work toward a balance between people and land through 'family planning', or helping people have only the number of children they want. Smaller families, they reason, will mean more land and food to go around. But family planning by itself has little effect. As long as people are very poor, they often want many children. Children help with work without having to be paid, and as they get bigger may even bring home a little money. When the parents grow old, some of their children - or grandchildren - will perhaps be able to help care for them.

For a poor country to have many children may be an economic disaster. But for a poor family to have many children is often an economic necessity - especially when many die young. In the world today, for most people, having many children is the surest form of social security they can hope for.

Some groups and programs take a different approach. They recognize that hunger exists not because there is too little land to feed everyone, but because most of the land is in the hands of a few selfish persons. The balance they seek is a fairer distribution of land and wealth. They work to help people gain greater control over their health, land, and lives.

It has been shown that, where land and wealth are shared more fairly and people gain greater economic security, they usually choose to have smaller families. Family planning helps when it is truly the people's choice. A balance between people and land can more likely be gained through helping people work toward fairer distribution and social justice than through family planning alone.

It has been said that the social meaning of love is justice. The health worker who loves her people should help them work toward a balance based on a more just distribution of land and wealth.

Figure

Working Toward a Balance Between Prevention and Treatment

Figure

A balance between treatment and prevention often comes down to a balance between immediate needs and long-term needs.

As a health worker you must go to your people, work with them on their terms, and help them find answers to the needs they feel most. People's first concern is often to find relief for the sick and suffering. Therefore, one of your first concerns must be to help with healing.

But also look ahead. While caring for people's immediate felt needs, also help them look to the future. Help them realize that much sickness and suffering can be prevented and that they themselves can take preventive actions.

But be careful! Sometimes health planners and workers go too far. In their eagerness to prevent future ills, they may show too little concern for the sickness and suffering that already exist. By failing to respond to people's present needs, they may fail to gain their cooperation. And so they fail in much of their preventive work as well.

Treatment and prevention go hand in hand. Early treatment often prevents mild illness from becoming serious. If you help people to recognize many of their common health problems and to treat them early, in their own homes, much needless suffering can be prevented.

If you want their cooperation, start where your people are. Work toward a balance between prevention and treatment that is acceptable to them. Such a balance will be largely determined by people's present attitudes toward sickness, healing, and health. As you help them look farther ahead, as their attitudes change, and as more diseases are controlled, you may find that the balance shifts naturally in favor of prevention.

You cannot tell the mother whose child is ill that prevention is more important than cure. Not if you want her to listen. But you can tell her, while you help her care for her child, that prevention is equally important.

Use treatment as a doorway to prevention. One of the best times to talk to people about prevention is when they come for treatment. For example, if a mother brings a child with worms, carefully explain to her how to treat him. But also take time to explain to both the mother and child how the worms are spread and the different things they can do to prevent this from happening (see Chapter 12). Visit their home from time to time, not to find fault, but to help the family toward more effective self-care.

Sensible and Limited Use of Medicines

One of the most difficult and important parts of preventive care is to educate your people in the sensible and limited use of medicines. A few modern medicines are very important and can save lives. But for most sicknesses no medicine is needed. The body itself can usually fight off sickness with rest, good food, drinking lots of liquid, and perhaps some simple home remedies.

People may come to you asking for medicine when they do not need any. You may be tempted to give them some medicine just to please. But if you do, when they get well, they will think that you and the medicine cured them. Really their bodies cured themselves.

Instead of teaching people to depend on medicines they do not need, take time to explain why they should not be used. Also tell people what they can do themselves to get well.

This way you are helping people to rely on local resources (themselves), rather than on an outside resource (medicine). Also, you are protecting their health, for there is no medicine that does not have some risk in its use.

Three common health problems for which people too often request medicines they do not need are (1) the common cold, (2) minor cough, and (3) diarrhea.

The common cold is best treated by resting, drinking lots of liquids, and at the most taking aspirin. Penicillin, tetracycline, and other antibiotics do not help at all.

For minor coughs, or even more severe coughs with thick mucus or phlegm, drinking a lot of water will loosen mucus and ease the cough faster and better than cough syrup. Breathing warm water vapor brings even greater relief. Do not make people dependent on cough syrup or other medicines they do not need.

For most diarrhea of children, medicines do not make them get well. Many commonly used medicines (neomycin, streptomycin, kaolin-pectin, Lomotil, chloramphenicol) may even be harmful. What is most important is that the child get lots of liquids and enough food. The key to the child's recovery is the mother, not the medicine. If you can help mothers understand this and learn what to do, many children's lives can be saved.

Medicines are often used too much, both by doctors and by ordinary people. This is unfortunate for many reasons:

· It is wasteful. Most money spent on medicine would be better spent on food.

· It makes people depend on something they do not need (and often cannot afford).

· Every medicine has some risk in its use. There is always a chance that an unneeded medicine may actually do the person harm.

· What is more, when some medicines are used too often for minor problems, they lose their power to fight dangerous sicknesses.

An example of a medicine losing its power is chloramphenicol. The extreme overuse of this important but risky antibiotic for minor infections has meant that in some parts of the world chloramphenicol no longer works against typhoid fever, a very dangerous infection. Frequent overuse of chloramphenicol has allowed typhoid to become resistant to it.

For all the above reasons the use of medicines should be limited.

But how? Neither rigid rules and restrictions nor permitting only highly trained persons to decide about the use of medicines has prevented overuse. Only when the people themselves are better informed will the limited and careful use of medicines be common.

This is especially true in areas where modern medicines are already in great use.

WHEN MEDICINES ARE NOT NEEDED, TAKE TIME TO EXPLAIN WHY.

For more information about the use and misuse of medicines, see Chapter 6. For the use and misuse of injections, see Chapter 9. For sensible use of home remedies, see Chapter 1.

Finding Out What Progress Has Been Made (Evaluation)

From time to time in your health work, it helps to take a careful look at what and how much you and your people have succeeded in doing. What changes, if any, have been made to improve health and well-being in your community?

You may want to record each month or year the health activities that can be measured. For example:

· How many families have put in latrines?

· How many farmers take part in activities to improve their land and crops?

· How many mothers and children take part in an Under-Fives Program (regular check-ups and learning)?

This kind of question will help you measure action taken. But to find out the result or impact of these activities on health, you will need to answer other questions such as:

· How many children had diarrhea or signs of worms in the past month or year - as compared to before there were latrines?

· How much was harvested this season (corn, beans, or other crops) - as compared to before improved methods were used?

· How many children show normal weight and weight-gain on their Child Health Charts - as compared to when the Under-Fives Program was started?

· Do fewer children die now than before?

To be able to judge the success of any activity you need to collect certain information both before and after. For example, if you want to teach mothers how important it is to breast feed their babies, first take a count of how many mothers are doing so. Then begin the teaching program and each year take another count. This way you can get a good idea as to how much effect your teaching has had.

You may want to set goals. For example, you and the health committee may hope that 80% of the families have latrines by the end of one year. Every month you take a count. If, by the end of six months, only one-third of the families have latrines, you know you will have to work harder to meet the goal you set for yourselves.

To evaluate the results of your health activities it helps to count and measure certain things before, during, and after.

But remember: The most important part of your health work cannot be measured. It has to do with the way you and other people relate to each other; with people learning and working together; with the growth of kindness, responsibility, sharing, and hope. It depends on the growing strength and unity of the people to stand up for their basic rights. You cannot measure these things. But weigh them well when you consider what changes have been made.

Teaching and Learning Together - The Health Worker as an Educator

As you come to realize how many things affect health, you may think the health worker has an impossibly large job. And true, you will never get much done if you try to deliver health care by yourself.

Your community's well-being depends on the involvement not of one person, but of nearly everyone. For this to happen, responsibility and knowledge must be shared.

This is why your first job as a health worker is to teach - to teach children, parents, farmers, schoolteachers, other health workers - everyone you can.

The art of teaching is the most important skill a person can learn. To teach is to help others grow, and to grow with them. A good teacher is not someone who puts ideas into other people's heads; he or she is someone who helps others build on their own ideas, to make new discoveries for themselves.

Teaching and learning should not be limited to the schoolhouse or health post. They should take place in the home and in the fields and on the road. As a health worker one of your best chances to teach will probably be when you treat the sick. But you should look for every opportunity to exchange ideas, to share, to show, and to help your people think and work together.

On the next few pages are some ideas that may help you do this. They are only suggestions. You will have many other ideas yourself.

TWO APPROACHES TO HEALTH CARE

Tools for Teaching

Flannel-graphs are good for talking with groups because you can keep making new pictures. Cover a square board or piece of cardboard with a flannel cloth. You can place different cutout drawings or photos on it. Strips of sandpaper or flannel glued to the backs of cutouts help them stick to the flannelboard.

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Posters and displays. “A picture is worth a thousand words.” Simple drawings, with or without a few words of information, can be hung in the health post or anywhere that people will look at them. You can copy some of the pictures from this book.

If you have trouble getting sizes and shapes right, draw light, even squares in pencil over the picture you want to copy.

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Now draw the same number of squares lightly, but larger, on the poster paper or cardboard. Then copy the drawing, square for square.

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If possible, ask village artists to draw or paint posters. Or have children make posters on different subjects.

Models and demonstrations help get ideas across. For example, if you want to talk with mothers and midwives about care in cutting the cord of a newborn child, you can make a doll for the baby. Pin a cloth cord to its belly. Experienced midwives can demonstrate to others.

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Color slides and filmstrips are available on different health subjects for many parts of the world. Some come in sets that tell a story. Simple viewers and battery-operated projectors are also available.

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A list of addresses where you can send for teaching materials to use for health education in your village can be found in chapter Addresses for teaching materials.

Other Ways to Get Ideas Across

Story telling. When you have a hard time explaining something, a story, especially a true one, will help make your point.

For example, if I tell you that sometimes a village worker can make a better diagnosis than a doctor, you may not believe me. But if I tell you about a village health worker called Irene, who runs a small nutrition center in Central America, you may understand.

One day a small sickly child arrived at the nutrition center. He had been sent by the doctor at a nearby health center because he was badly malnourished. The child also had a cough, and the doctor had prescribed a cough medicine. Irene was worried about the child. She knew he came from a very poor family and that an older brother had died a few weeks before. She went to visit the family and learned that the older brother had been very sick for a long time and had coughed blood. Irene went to the health center and told the doctor she was afraid the child had tuberculosis. Tests were made, and it turned out that Irene was right.... So you see, the health worker spotted the real problem before the doctor - because she knew her people and visited their homes.

Stories also make learning more interesting. It helps if health workers are good story tellers.

Play acting. Stories that make important points can reach people with even more force if they are acted out. Perhaps you, the schoolteacher, or someone on the health committee can plan short plays or 'skits' with the schoolchildren.

For example, to make the point that food should be protected from flies to prevent the spread of disease, several small children could dress up as flies and buzz around food. The flies dirty the food that has not been covered. Then children eat this food and get sick. But the flies cannot get at food in a box with a wire screen front. So the children who eat this food stay well.

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Working and Learning Together for the Common Good

There are many ways to interest and involve people in working together to meet their common needs. Here are a few ideas:

1. A village health committee. A group of able, interested persons can be chosen by the village to help plan and lead activities relating to the well-being of the community - for example, digging garbage pits or latrines. The health worker can and should share much of his responsibility with other persons.

2. Group discussions. Mothers, fathers, schoolchildren, young people, folk healers, or other groups can discuss needs and problems that affect health. Their chief purpose can be to help people share ideas and build on what they already know.

3. Work festivals. Community projects such as putting in a water system or cleaning up the village go quickly and can be fun if everybody helps. Games, races, refreshments, and simple prizes help turn work into play. Use imagination.

4. Cooperatives. People can help keep prices down by sharing tools, storage, and perhaps land. Group cooperation can have a big influence on people's well-being.

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5. Classroom visits. Work with the village schoolteacher to encourage health-related activities, through demonstrations and play acting. Also invite small groups of students to come to the health center. Children not only learn quickly, but they can help out in many ways. If you give children a chance, they gladly become a valuable resource.

6. Mother and child health meetings. It is especially important that pregnant women and mothers of small children (under five years old) be well informed about their own and their babies' health needs. Regular visits to the health post are opportunities for both check-ups and learning. Have mothers keep their children's health records and bring them each month to have their children's growth recorded (see the Child Health Chart). Mothers who understand the chart often take pride in making sure their children are eating and growing well. They can learn to understand these charts even if they cannot read. Perhaps you can help train interested mothers to organize and lead these activities.

7. Home visits. Make friendly visits to people's homes, especially homes of families who have special problems, who do not come often to the health post, or who do not take part in group activities. But respect people's privacy. If your visit cannot be friendly, do not make it - unless children or defenseless persons are in danger.

Ways to Share and Exchange Ideas in a Group

As a health worker you will find that the success you have in improving your people's health will depend far more on your skills as a teacher than on your medical or technical knowledge. For only when the whole community is involved and works together can big problems be overcome.

People do not learn much from what they are told. They learn from what they think, feel, discuss, see, and do together.

So the good teacher does not sit behind a desk and talk at people. He talks and works with them. He helps his people to think clearly about their needs and to find suitable ways to meet them. He looks for every opportunity to share ideas in an open and friendly way.

Perhaps the most important thing you can do as a health worker is to awaken your people to their own possibilities... to help them gain confidence in themselves. Sometimes villagers do not change things they do not like because they do not try. Too often they may think of themselves as ignorant and powerless. But they are not. Most villagers, including those who cannot read or write, have remarkable knowledge and skills. They already make great changes in their surroundings with the tools they use, the land they farm, and the things they build. They can do many important things that people with a lot of schooling cannot.

If you can help people realize how much they already know and have done to change their surroundings, they may also realize that they can learn and do even more. By working together it is within their power to bring about even bigger changes for their health and well-being.

Then how do you tell people these things?

Often you cannot! But you can help them find out some of these things for themselves - by bringing them together for discussions. Say little yourself, but start the discussion by asking certain questions. Simple pictures like the drawing on the next page of a farm family in Central America may help. You will want to draw your own picture, with buildings, people, animals, and crops that look as much as possible like those in your area.

USE PICTURES TO GET PEOPLE TALKING AND THINKING TOGETHER

Show a group of people a picture similar to this and ask them to discuss it. Ask questions that get people talking about what they know and can do. Here are some sample questions:

· Who are the people in the picture and how do they live?

· What was this land like before the people came?

· In what ways have they changed their surroundings?

· How do these changes affect their health and well-being?

· What other changes could these people make? What else could they learn to do? What is stopping them? How could they learn more?

· How did they learn to farm? Who taught them?

· If a doctor or a lawyer moved onto this land with no more money or tools than these people, could he farm it as well? Why or why not?

· In what ways are these people like ourselves?

This kind of group discussion helps build people's confidence in themselves and in their ability to change things. It can also make them feel more involved in their community.

At first you may find that people are slow to speak out and say what they think. But after a while they will usually begin to talk more freely and ask important questions themselves. Encourage everyone to say what he or she feels and to speak up without fear. Ask those who talk most to give a chance to those who are slower to speak up.

You can think of many other drawings and questions to start discussions that can help people look more clearly at problems, their causes, and possible solutions.

***

What questions can you ask to get people thinking about the different things that lead to the condition of the child in the following picture?

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Try to think of questions that lead to others and get people asking for themselves. How many of the causes underlying death from diarrhea will your people think of when they discuss a picture like this?

Making the Best Use of This Book

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Anyone who knows how to read can use this book in her own home. Even those who do not read can learn from the pictures. But to make the fullest and best use of the book, people often need some instruction. This can be done in several ways.

A health worker or anyone who gives out the book should make sure that people understand how to use the list of Contents, the Index, the Green Pages and the Vocabulary. Take special care to give examples of how to look things up. Urge each person to carefully read the sections of the book that will help her understand what may be helpful to do, what could be harmful or dangerous, and when it is important to get help (see especially Chapters 1, 2, 6, and 8, and also the SIGNS OF DANGEROUS ILLNESS). Point out how important it is to prevent sickness before it starts. Encourage people to pay special attention to Chapters 11 and 12, which deal with eating right (nutrition) and keeping clean (hygiene and sanitation).

Also show and mark the pages that tell about the most common problems in your area. For example, you can mark the pages on diarrhea and be sure mothers with small children understand about 'special drink' (oral rehydration). Many problems and needs can be explained briefly. But the more time you spend with people discussing how to use the book or reading and using it together, the more everyone will get out of it.

You as a health worker might encourage people to get together in small groups to read through the book, discussing one chapter at a time. Look at the biggest problems in your area - what to do about health problems that already exist and how to prevent similar problems in the future. Try to get people looking ahead.

Perhaps interested persons can get together for a short class using this book (or others) as a text. Members of the group could discuss how to recognize, treat, and prevent different problems. They could take turns teaching and explaining things to each other.

To help learning be fun in these classes you can act out situations. For example, someone can act as if he has a particular sickness and can explain what he feels. Others then ask questions and examine him (Chapter 3). Use the book to try to find out what his problem is and what can be done about it. The group should remember to involve the 'sick' person in learning more about his own sickness - and should end up by discussing with him ways of preventing the sickness in the future. All this can be acted out in class.

Exciting and effective ways to teach about health care are in the book Helping Health Workers Learn, also available from the Hesperian Foundation.

As a health worker, one of the best ways you can help people use this book correctly is this: When persons come to you for treatment, have them look up their own or their child's problem in the book and find out how to treat it. This takes more time, but helps much more than doing it for them. Only when someone makes a mistake or misses something important do you need to step in and help him learn how to do it better. In this way, even sickness gives a chance to help people learn.

Dear village health worker - whoever and wherever you are, whether you have a title or official position, or are simply someone, like myself, with an interest in the well-being of others - make good use of this book. It is for you and for everyone.

But remember, the most important part of health care you will not find in this book or any other. The key to good health lies within you and your people, in the care, the concern, and appreciation you have for each other. If you want to see your community be healthy, build on these.

Yours truly,

David Werner

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NOTICE

This book is to help people meet most of their common health needs for and by themselves. But it does not have all the answers. In case of serious illness or if you are uncertain about how to handle a health problem, get advice from a health worker or doctor whenever possible.

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Where There Is No Doctor - A Village Health Care Handbook (Hesperian Foundation, 1993, 516 p.) Chapter 1 - HOME CURES AND POPULAR BELIEFS (introduction...) Home Cures That Help Beliefs That Can Make People Well Beliefs That Can Make People Sick Witchcraft - Black Magic - and the Evil Eye Questions and Answers on Some Folk Beliefs and Home Remedies Sunken Fontanel or Soft Spot Ways to Tell Whether a Home Remedy Works or Not Medicinal Plants Homemade Casts-for Keeping Broken Bones in Place Enemas, Laxatives, and Purges: When to Use Them and When Not To

Where There Is No Doctor - A Village Health Care Handbook (Hesperian Foundation, 1993, 516 p.)

Chapter 1 - HOME CURES AND POPULAR BELIEFS

Everywhere on earth people use home remedies. In some places, the older or traditional ways of healing have been passed down from parents to children for hundreds of years.

Many home remedies have, great value. Others have less. And some may be risky or harmful. Home remedies, like modern medicines, must be used with caution.

Home Cures That Help

For many sicknesses, time-tested home remedies work as well as modern medicines - or even better. They are often cheaper. And in some cases they are safer.

For example, many of the herbal teas people use for home treatment of coughs and colds do more good and cause fewer problems than cough syrups and strong medicines some doctors prescribe.

Also, the 'rice water', teas, or sweetened drinks that many mothers give to babies with diarrhea are often safer and do more good than any modern medicine. What matters most is that a baby with diarrhea gets plenty of liquids.

FOR COUGHS, COLDS, AND COMMON DIARRHEA, HERBAL TEAS ARE OFTEN BETTER, CHEAPER AND SAFER THAN MODERN MEDICINES.

The Limitations of Home Remedies

Some diseases are helped by home remedies. Others can be treated better with modern medicine. This is true for most serious infections. Sicknesses like pneumonia, tetanus, typhoid, tuberculosis, appendicitis, diseases caused by sexual contact, and fever after childbirth should be treated with modern medicines as soon as possible. For these diseases, do not lose time trying to treat them first with home remedies only.

It is sometimes hard to be sure which home remedies work well and which do not. More careful studies are needed. For this reason:

Old Ways and New

Some modern ways of meeting health needs work better than old ones. But at times the older, traditional ways are best. For example, traditional ways of caring for children or old people are often kinder and work better than some newer, less personal ways.

Not many years ago everyone thought that mother's milk was the best food for a young baby. They were right! Then the big companies that make canned and artificial milk began to tell mothers that bottle feeding was better. This is not true, but many mothers believed them and started to bottle feed their babies. As a result, thousands of babies have suffered and died needlessly from infection or hunger. For the reasons breast is best.

For more ideas for building on local traditions, see Helping Health Workers Learn, Chapter 7.

Beliefs That Can Make People Well

Some home remedies have a direct effect on the body. Others seem to work only because people believe in them. The healing power of belief can be very strong.

For example, I once saw a man who suffered from a very bad headache. To cure him, a woman gave him a small piece of yam, or sweet potato. She told him it was a strong painkiller. He believed her - and the pain went away quickly.

It was his faith in her treatment, and not the yam itself, that made him feel better.

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Many home remedies work in this I way. They help largely because people have faith in them. For this reason, they are especially useful to cure illnesses that are partly in people's minds, or those caused in part by a person's beliefs, worry, or fears.

Included in this group of sicknesses are: bewitchment or hexing, unreasonable or hysterical fear, uncertain 'aches and pains' (especially in persons going through stressful times, such as teenage girls or older women), and anxiety or nervous worry. Also included are some cases of asthma, hiccups, indigestion, stomach ulcers, migraine headaches, and even warts.

For all of these problems, the manner or 'touch' of the healer can be very important. What it often comes down to is showing you care, helping the sick person believe he will get well, or simply helping him relax.

Sometimes a person's belief in a remedy can help with problems that have completely physical causes.

For example, Mexican villagers have the following home cures for poisonous snakebite:

1. to use 'guaco' leaves

2. to bite the snake

3. to apply tobacco

4. to apply the skin of a poisonous lizard

5. to smear the snake's bile on the bite

In other lands people have their own snakebite remedies - often many different ones. As far as we know, none of these home remedies has any direct effect against snake poison. The person who says that a home remedy kept a snake's poison from harming him at all was probably bitten by a non-poisonous snake!

Yet any of these home remedies may do some good if a person believes in it. If it makes him less afraid, his pulse will slow down, he will move and tremble less, and as a result, the poison will spread through his body more slowly. So there is less danger!

But the benefit of these home remedies for snakebite is limited. In spite of their common use, may people still become very ill or die. As far as we know:

For snakebite it is usually better to use modern treatment. Be prepared: obtain 'antivenoms' or 'serums' for poisonous bites before you need them. Do not wait until it is too late.

Beliefs That Can Make People Sick

The power of belief can help heal people. But it can also harm them. If a person believes strongly enough that something will hurt him, his own fear can make him sick. For example:

Once I was called to see a woman who had just had a miscarriage and was still bleeding a little. There was an orange tree near her house. So I suggested she drink a glass of orange juice. (Oranges have vitamin C which helps strengthen blood vessels.) She drank it - even though she was afraid it would harm her.

Her fear was so great that soon she became very ill. I examined her, but could find nothing physically wrong. I tried to comfort her, telling her she was not in danger. But she said she was going to die. At last I gave her an injection of distilled (completely pure) water. Distilled water has no medical effect. But since she had great faith in injections, she quickly got better.

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Actually, the juice did not harm her. What harmed her was her belief that it would make her sick. And what made her well was her faith in injections!

In this same way, many persons go on believing false ideas about witchcraft, injections, diet, and many other things. Much needless suffering is the result.

Perhaps, in a way, I had helped this woman. But the more I thought about it, the more I realized I had also wronged her; I had led her to believe things that were not true.

I wanted to set this right. So a few days later, when she was completely well, I went to her home and apologized for what I had done. I tried to help her understand that not the orange juice, but her fear had made her so sick. And that not the injection of water, but her freedom from fear had helped her get well.

By understanding the truth about the orange, the injection, and the tricks of her own mind, perhaps this woman and her family will become freer from fear and better able to care for their health in the future. For health is closely related to understanding and freedom from fear.

Witchcraft - Black Magic - and the Evil Eye

If a person believes strongly enough that someone has the power to harm him, he may actually become ill. Anyone who believes he is bewitched or has been given the evil eye is really the victim of his own fears (see Susto).

A 'witch' has no power over other people, except for her ability to make them believe that she has. For this reason:

Some people think that they are 'bewitched' when they have strange or frightening illnesses (such as tumors of the genitals or cirrhosis of the liver). Such sicknesses have nothing to do with witchcraft or black magic. Their causes are natural.

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Do not waste your money at 'magic centers' that claim to cure witchcraft. And do not seek revenge against a witch, because it will not solve anything. If you are seriously ill, go for medical help.

Questions and Answers on Some Folk Beliefs and Home Remedies

These examples are from the mountains of Mexico, the area that I know best. Perhaps some of the beliefs of your people are similar. Think about ways to learn which beliefs in your area lead to better health and which do not.

Sunken Fontanel or Soft Spot

The fontanel is the soft spot on the top of a newborn baby's head. It is where the bones of his skull have not formed completely. Normally it takes a year to a year and a half for the soft spot to close completely.

Mothers in different lands realize that when the soft spot sinks inward their babies are in danger. They have many beliefs to explain this. In Latin America mothers think the baby's brains have slipped downward. They try to correct this by sucking on the soft spot, by pushing up on the roof of the mouth, or by holding the baby upside down and slapping his feet. This does not help because... A sunken soft spot is really caused by dehydration.

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This means the child is losing more liquid than he is drinking. He is too dry - usually because he has diarrhea, or diarrhea with vomiting.

Treatment:

1. Give the child plenty of liquid: breast milk, Rehydration Drink made with water, sugar/and salt only or boiled water...

2. If necessary, treat the causes of the diarrhea and vomiting. For most diarrheas, medicine is not needed, and may do more harm than good.

TO CURE A SUNKEN SOFT SPOT...

Note: If the soft spot is swollen or bulges upward, this may be a sign of meningitis. Begin treatment at once, and get medical help.

Ways to Tell Whether a Home Remedy Works or Not

Because a lot of people use a home cure does not necessarily mean it works well or is safe. It is often hard to know which remedies are helpful and which may be harmful. Careful study is needed to be sure. Here are four rules to help tell which remedies are least likely to work, or are dangerous. (Examples are from Mexican villages.)

1. THE MORE REMEDIES THERE ARE FOR ANY ONE ILLNESS, THE LESS LIKELY IT IS THAT ANY OF THEM WORKS.

For example: In rural Mexico there are many home remedies for goiter, none of which does any real good. Here are some of them:

1. to tie a crab on the goiter

2. to rub the goiter with the hand of a dead child

3. to smear the brains of a vulture on the goiter

4. to smear human feces on the goiter

Not one of these many remedies works. If it did, the others would not be needed. When a sickness has just one popular cure, it is more likely to be - a good one. For prevention and treatment of goiter use iodized salt.

2. FOUL OR DISGUSTING REMEDIES ARE NOT LIKELY TO HELP - AND ARE OFTEN HARMFUL.

For example:

1. the idea that leprosy can be cured by a drink made of rotting snakes

2. the idea that syphilis can be cured by eating a vulture

These two remedies do not help at all. The first one can cause dangerous infections. Belief in remedies like these sometimes causes delay in getting proper medical care.

3. REMEDIES THAT USE ANIMAL OR HUMAN WASTE DO NO GOOD AND CAN CAUSE DANGEROUS INFECTIONS. NEVER USE THEM.

Examples:

1. Putting human feces around the eye does not cure blurred vision and can cause infections.

2. Smearing cow dung on the head to fight ringworm can cause tetanus and other dangerous infections.

Also, the droppings of rabbits or other animals do not help heal burns. To use them is very dangerous. Cow dung, held in the hand, cannot help control fits. Teas made from human, pig, or any other animal feces do not cure anything. They can make people sicker. Never put feces on the navel of a newborn baby. This can cause tetanus.

4. THE MORE A REMEDY RESEMBLES THE SICKNESS IT IS SAID TO CURE, THE MORE LIKELY ITS BENEFITS COME ONLY FROM THE POWER OF BELIEF.

The association between each of the following illnesses and its remedy is clear in these examples from Mexico:

1. for a nosebleed, using yesca (a bright red mushroom)

2. for deafness, putting powdered rattlesnake's rattle in the ear

3. for dog bite, drink tea made from the dog's tail

4. for scorpion sting, tying a scorpion against the stung finger

5. to prevent diarrhea when a child is teething, putting a necklace of snake's fangs around the baby's neck

6. to 'bring out' the rash of measles, making tea from kapok bark

These remedies, and many other similar ones, have no curative value in themselves. They may be of some benefit if people believe in them. But for serious problems, be sure their use does not delay more effective treatment.

Medicinal Plants

Many plants have curative powers. Some of the best modern medicines are made from wild herbs.

Nevertheless, not all 'curative herbs' people use have medical value... and those that have are sometimes used the wrong way. Try to learn about the herbs in your area and find out which ones are worthwhile.

Here are a few examples of plants that can be useful if used correctly:

ANGEL'S TRUMPET (Datura arborea)

The leaves of this and certain other members of the nightshade family contain a drug that helps to calm intestinal cramps, stomach-aches, and even gallbladder pain.

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Grind up 1 or 2 leaves of Angel's Trumpet and soak them for a day in 7 tablespoons (100 ml.) of water.

Dosage: Between 10 and 15 drops every 4 hours (adults only).

CORN SILK (the tassels or 'silk' from an ear of maize)

A tea made from corn silk makes a person pass more urine. This can help reduce swelling of the feet - especially in pregnant women.

Boil a large handful of corn silk in water and drink 1 or 2 glasses. It is not dangerous.

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GARLIC

A drink made from garlic can often get rid of pinworms.

Chop finely, or crush, 4 cloves of garlic and mix with 1 glass of liquid (water, juice, or milk).

Dosage: Drink 1 glass daily for 3 weeks.

To treat vaginal infections with garlic.

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CARDON CACTUS (Pachycerius pectin-aboriginum)

Cactus juice can be used to clean wounds when there is no boiled water and no way to get any. Cardon cactus also helps stop a wound from bleeding, because the juice makes the cut blood vessels squeeze shut.

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Cut a piece of the cactus with a clean knife and press it firmly against the wound.

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When the bleeding is under control, tie a piece of the cactus to the wound with a strip of cloth.

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After 2 or 3 hours, take off the cactus and clean the wound with boiled water and soap. There are more instructions on how to care for wounds and control bleeding on pages 82 to 87.

ALOE VERA (Sabila)

Aloe vera can be used to treat minor burns and wounds. The thick, slimy juice inside the plant calms pain and itching, aids healing, and helps prevent infection. Cut off a piece of the plant, peel back the outer layer, and apply the fleshy leaf or juice directly to the burn or wound.

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Aloe can also help treat stomach ulcers and gastritis. Chop the spongy leaves into small pieces, soak them in water overnight, and then drink one glass of the slimy, bitter liquid every 2 hours.

PAPAYA

Ripe papayas are rich in vitamins and also aid digestion, Eating them is especially helpful for weak or old people who complain of upset stomach when they eat meat, chicken, or eggs. Papaya makes these foods easier to digest.

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Papaya can also help get rid of intestinal worms, although modern medicines often work better. Collect 3 or 4 teaspoons (15-20 ml.) of the 'milk' that comes out when the green fruit or trunk of the tree is cut. Mix this with an equal amount of sugar or honey and stir it into a cup of hot water. If possible, drink along with a laxative.

Or, dry and crush to a powder the papaya seeds. Take 3 teaspoons mixed with 1 glass water or some honey 3 times a day for 7 days.

Papayas can also be used for treating pressure sores. The fruit contains chemicals that help soften and make dead flesh easier to remove. First clean and wash out a pressure sore that has dead flesh in it. Then soak a sterile cloth or gauze with 'milk' from the trunk or green fruit of a papaya plant and pack this into the sore. Repeat cleaning and repacking 3 times a day.

Homemade Casts-for Keeping Broken Bones in Place

In Mexico several different plants such as tepeguaje (a tree of the bean family) and solda con solda (a huge, tree-climbing arum lily) are used to make casts. However, any plant wilt do if a syrup can be made from it that will dry hard and firm and will not irritate the skin. In India, traditional bone-setters make casts using a mixture of egg whites and herbs instead of a syrup made from plant juices. But the method is similar. Try out different plants in your area.

For a cast using tepeguaje: Put 1 kilogram of the bark into 5 liters of water and boil it until only 2 liters is left. Strain and boil it until a thick syrup is formed. Dip strips of flannel or clean sheet in the syrup and carefully use as follows.

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Make sure the bones are in a good position.

Do not put the cast directly against the skin.

Wrap the arm or leg in a soft cloth.

Then follow with a layer of cotton or wild kapok.

Finally, put on the wet cloth strips so that, they form a cast that is firm but not too tight.

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Most doctors recommend that the cast cover the joint above and the joint below the break, to keep the broken bones from moving.

This would mean that, for a broken wrist, the cast should cover almost the whole arm, like this:

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Leave the finger tips uncovered so that you can see if they keep a good color.

However, traditional bone-setters in China and Latin America use a short cast on a simple break of the arm saying that a little movement of the bone-ends speeds healing. Recent scientific studies have proven this to be true.

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A temporary leg or arm splint can be made of cardboard, folded paper, or the thick curved stem of dried banana leaf, or palm leaf.

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CAUTION: Even if the cast is not very tight when you put it on, the broken limb may swell up later. If the person complains that the cast is too tight, or if his fingers or toes become cold, white, or blue, take the cast off and put on a new, looser one.

Never put on a cast over a cut or a wound.

Enemas, Laxatives, and Purges: When to Use Them and When Not To

Many people give enemas and take laxatives far too often. The 'urge to purge' is world wide.

Enemas and purges are very popular home cures. And they are often very harmful. Many people believe fever and diarrhea can be 'washed out' by giving an enema (running water into the gut through the anus) or by using a purge, or strong laxative. Unfortunately, such efforts to clean or purge the sick body often cause more injury to the already damaged gut.

Figure

CASES IN WHICH IT IS DANGEROUS TO USE ENEMAS OR LAXATIVES

Never use an enema or laxative if a person has a severe stomach-ache or any other sign of appendicitis or 'acute abdomen', even if he passes days without a bowel movement.

Never give an enema or laxative to a person with a bullet wound or other injury to the gut.

Never give a strong laxative to a weak or sick person. It will weaken him more.

Never give an enema or purge to a baby less than 2 years old.

Never give a laxative or purge to a child with high fever, vomiting, diarrhea or signs of dehydration. It can increase dehydration and kill the child.

Do not make a habit of using laxatives often (see Constipation)

THE CORRECT USES OF ENEMAS

1. Simple enemas can help relieve constipation (dry, hard, difficult stools). Use warm water only, or water with a little soap in it.

2. When a person with severe vomiting is dehydrated, you can try replacing water by giving an enema of Rehydration Drink made with water, sugar, and salt only, very slowly.

PURGES AND LAXATIVES THAT ARE OFTEN USED

CORRECT USES OF LAXATIVES AND PURGES

Laxatives are like purges but weaker. All the products listed above are laxatives when taken in small doses and purges when taken in large doses. Laxatives soften and hurry the bowel movement; purges cause diarrhea.

Purges: The only time a person should use a strong dose of a purge is when he has taken a poison and must clean it out quickly. At any other time a purge is harmful.

Laxatives: One can use milk of magnesia or other magnesium salts in small doses, as laxatives, in some cases of constipation. People with hemorrhoids (piles) who have constipation can take mineral oil but this only makes their stools slippery, pot soft. The dose for mineral oil is 3 to 6 teaspoons at bedtime (never with a meal because the oil will rob the body of important vitamins in the food). This is not the best way.

Suppositories, or bullet-shaped pills that can be pushed up the rectum, can also be used to relieve constipation or piles.

A BETTER WAY

Foods with fiber. The healthiest and most gentle way to have softer, more frequent stools is to drink a lot of water and to eat more foods with lots of natural fiber, or 'roughage' like cassava, yam, or bran (wheat husks) and other whole grain cereals. Eating plenty of fruits and vegetables also helps.

People who traditionally eat lots of food with natural fiber suffer much less from piles, constipation, and cancer of the gut than do people who eat a lot of refined 'modern' foods. For better bowel habits, avoid refined foods and eat foods prepared from unpolished or unrefined grains.

Where There Is No Doctor - A Village Health Care Handbook (Hesperian Foundation, 1993, 516 p.) Chapter 2 - SICKNESSES THAT ARE OFTEN CONFUSED What Causes Sickness? Different Kinds of Sicknesses and Their Causes Non-Infectious Diseases Infectious Diseases Sicknesses That Are Hard to Tell Apart Examples of Local Names for Sicknesses Misunderstandings Due to Confusion of Names Confusion between Different Illnesses That Cause Fever

Where There Is No Doctor - A Village Health Care Handbook (Hesperian Foundation, 1993, 516 p.)

Chapter 2 - SICKNESSES THAT ARE OFTEN CONFUSED

What Causes Sickness?

Persons from different countries or backgrounds have different ways to explain what causes sickness.

A baby gets diarrhea. But why?

People in small villages may say it is because the parents did something wrong, or perhaps because they made a god or spirit angry.

A doctor may say it is because the child has an infection.

A public health officer may say it is because the villagers do not have a good water system or use latrines.

A social reformer may say the unhealthy conditions that lead to frequent childhood diarrhea are caused by an unfair distribution of land and wealth.

A teacher may place the blame on lack of education.

Figure

People see the cause of sickness in terms of their own experience and point of view. Who then is right about the cause? Possibly everyone is right, or partly right. This is because...

Each of the causes suggested above may be a part of the reason why a baby gets diarrhea.

To prevent and treat sickness successfully, it helps to have as full an understanding as possible about the common sicknesses in your area and the combination of things that causes them.

In this book, different sicknesses are discussed mostly according to the systems and terms of modern or scientific medicine.

To make good use of this book, and safe use of the medicines it recommends, you will need some understanding of sicknesses and their causes according to medical science. Reading this chapter may help.

“Why my child?”

Different Kinds of Sicknesses and Their Causes

When considering how to prevent or treat different sicknesses, it helps to think of them in two groups: infectious and non-infectious.

Infectious diseases are those that spread from one person to another, Healthy persons must be protected from people with these sicknesses.

Non-infectious diseases do not spread from person to person. They have other causes. Therefore, it is important to know which sicknesses are infectious and which are not.

Non-Infectious Diseases

Non-infectious diseases have many different causes. But they are never caused by germs, bacteria, or other living organisms that attack the body. They never spread from one person to another. It is important to realize that antibiotics, or medicines that fight germs, do not help cure non-infectious diseases.

EXAMPLES OF NON-INFECTIOUS DISEASES

Infectious Diseases

Infectious diseases are caused by bacteria and other organisms (living things) that harm the body. They are spread in many ways. Here are some of the most important kinds of organisms that cause infections and examples of sicknesses they cause:

EXAMPLES OF INFECTIOUS DISEASES

Bacteria, like many of the organisms that cause infections, are so small you cannot see them without a microscope - an instrument that makes tiny things look bigger. Viruses are even smaller than bacteria.

Figure

Antibiotics (penicillin, tetracycline, etc.) are medicines that help cure certain illnesses caused by bacteria. Antibiotics have no effect on illnesses caused by most viruses, such as colds, flu, mumps, chickenpox, etc. Do not treat virus infections with antibiotics. They will not help and may be harmful (see Antibiotics).

Sicknesses That Are Hard to Tell Apart

Sometimes diseases that have different causes and require different treatment result in problems that look very much alike. For example:

1. A child who slowly becomes thin and wasted, while his belly gets more and more swollen, could have any (or several) of the following problems:

· malnutrition
· a lot of roundworms, (usually together with malnutrition)
· advanced tuberculosis
· a long-term severe urinary infection
· any of several problems of the liver or spleen
· leukemia (cancer of the blood)

Figure

2. An older person with a big, open, slowly growing sore on the ankle could have:

· bad circulation that results from varicose veins or other causes
· diabetes
· infection of the bone (osteomyelitis)
· leprosy
· tuberculosis of the skin
· advanced syphilis

Figure

The medical treatment for each of these diseases is different, so to treat them correctly it is important to tell them apart.

Many illnesses at first seem very similar. But if you ask the right questions and know what to look for, you can often learn information and see certain signs that will help tell you what illness a person has.

This book describes the typical history and signs for many illnesses. But be careful! Diseases do not always show the signs described for them - or the signs may be confusing. For difficult cases, the help of a skilled health worker or doctor is often needed. Sometimes special tests or analyses are necessary.

SICKNESSES THAT ARE OFTEN CONFUSED OR GIVEN THE SAME NAME

Many of the common names people use for their sicknesses were first used long before anyone knew about germs or bacteria or the medicines that fight them. Different diseases that caused more or less similar problems - such as 'high fever' or 'pain in the side' - were often given a single name. In many parts of the world, these common names are still used. City-trained doctors often neither know nor use these names. For this reason, people sometimes think they apply to 'sicknesses doctors do not treat'. So they treat these home sicknesses with herbs or home remedies.

Actually, most of these home sicknesses or 'folk diseases' are the same ones known to medical science. Only the names are different.

For many sicknesses, home remedies work well. But for some sicknesses, treatment with modern medicine works much better and may be life-saving. This is especially true for dangerous infections like pneumonia, typhoid, tuberculosis, or infections after giving birth.

To know which sicknesses definitely require modern medicines and to decide what medicine to use, it is important that you try to find out what the disease is in the terms used by trained health workers and in this book.

If you are unsure what the sickness is - expecially if it seems serious - try to get medical help.

The rest of this chapter gives examples of common or traditional names people use for various sicknesses. Often a single name is given to diseases that are different according to medical science.

Examples cannot be given for each country or area where this book may be used. Therefore, I have kept those from the Spanish edition, with names used by villagers in western Mexico. They will not be the same names you use. However, people in many parts of the world see and speak of their illnesses in a similar way. So the examples may help you think about how people name diseases in your area.

Can you think of a name your people use for the following 'folk diseases'? If you can, write it in after the Spanish name, where it says.

Name in Your Area: ______________________

Examples of Local Names for Sicknesses

Spanish Name: EMPACHO (STOPPED-UP GUT) Name in Your Area: ______________________

In medical terms empacho (impaction) means that the gut is stopped up or obstructed. But in Mexican villages any illness causing stomach-ache or diarrhea may be called empacho. It is said that a ball of hair or something else blocks a part of the gut. People put the blame on witches or evil spirits, and treat with magic cures and cupping (see picture). Sometimes folk healers pretend to take a ball of hair and thorns out of the gut by sucking on the belly.

Figure

Different illnesses that cause stomach pain or discomfort and are sometimes called empacho are:

· diarrhea or dysentery with cramps
· worms
· swollen stomach due to malnutrition
· indigestion or stomach ulcer
· and rarely, true gut obstruction or appendicitis

Most of these problems are not helped much by magic cures or cupping. To treat empacho, try to identify and treat the sickness that causes it.

Spanish Name: DOLOR DE IJAR (SIDE PAINS) Name in Your Area: ______________________

This name is used for any pain women get in one side of their belly. Often the pain goes around to the mid or lower back. Possible causes of this kind of pain include:

· an infection of the urinary system (the kidneys, the bladder, or the tubes that join them)
· cramps or gas pains (see diarrhea)
· menstrual pains
· appendicitis
· an infection, cyst, or tumor in the womb or ovaries or an out-of-place pregnancy

Figure

Spanish Name: LA CONGESTION (CONGESTION) Name in Your Area: ____________________

Any sudden upset or illness that causes great distress is called la congesti�n by Mexican villagers. People speak of congesti�n of:

the head,

the chest,

the stomach,

or the whole body.

It is said that la congesti�n strikes persons who break 'the diet', by eating foods that are forbidden or taboo after childbirth, while taking a medicine, or when they have a cold or cough. Although these foods usually cause no harm and are sometimes just what their bodies need, many people will not touch them because they are so afraid of getting la congesti�n.

Different illnesses that are sometimes called la congesti�n are:

· Food poisoning, from eating spoiled food: causes sudden vomiting followed by diarrhea, cramps, and weakness.

· A severe allergic reaction, in allergic persons after they eat certain foods (shellfish, chocolate, etc.), take certain medicines, or are injected with penicillin. May cause vomiting, diarrhea, cold sweat, breathing trouble, itchy rash, and severe distress.

· Any sudden upset of the stomach or gut: see diarrhea, vomiting, and acute abdomen.

· Sudden or severe difficulty breathing: caused by asthma, pneumonia, or something stuck in the throat.

· Illnesses that cause fits or paralysis: see fits, tetanus, meningitis, polio, and stroke.

· Heart attacks: mostly in older persons.

Spanish Name: LATIDO (PULSING) Name in Your Area: ____________________

Latido is a name used in Latin America for a pulsing or 'jumping' in the pit of the stomach. It is really the pulse of the aorta or big blood vessel coming from the heart. This pulse can be seen and felt on a person who is very thin and hungry. Latido is often a sign of malnutrition - or hunger! Eating enough good food is the only real treatment.

Spanish Name: SUSTO (HYSTERIA, FRIGHT) Name in Your Area: ____________________

According to Mexican villagers, susto is caused by a sudden fright a person has had, or by witchcraft, black magic, or evil spirits. A person with susto is very nervous and afraid. He may shake, behave strangely, not be able to sleep, lose weight, or even die.

Possible medical explanations for susto:

1. In many people, susto is a state of fear or hysteria, perhaps caused by the 'power of belief. For example, a woman who is afraid someone will hex her becomes nervous and does not eat or sleep well. She begins to grow weak and lose weight. She takes this as a sign she has been hexed, so she becomes still more nervous and frightened. Her susto gets worse and worse.

2. In babies or small children, susto is usually very different. Bad dreams may cause a child to cry out in his sleep or wake up frightened. High fevers from any illness can cause very strange speech and behavior (delirium). A child that often looks and acts worried may be malnourished. Sometimes early signs of tetanus or meningitis are also called susto.

Treatment:

When the susto is caused by a specific illness, treat the illness. Help the person understand its cause. Ask for medical advice, if needed.

When the susto is caused by fright, try to comfort the person and help him understand that his fear itself is the cause of his problem. Magic cures and home remedies sometimes help.

If the frightened person is breathing very hard and fast, his body may be getting too much air - which may be part of the problem:

EXTREME FRIGHT OR HYSTERIA WITH FAST HEAVY BREATHING (HYPERVENTILATION)

Signs:

· person very frightened
· breathing fast and deep
· fast, pounding heartbeat
· numbness or tingling of face, hands, or feet
· muscle cramps

Figure

Figure

Figure

Treatment:

· Keep the person as quiet as possible.

· Have her put her face in a paper bag and breathe slowly. She should continue breathing the same air for 2 or 3 minutes. This will usually calm her down.

· Explain to her that the problem is not dangerous, and she will soon be all right.

Misunderstandings Due to Confusion of Names

This page shows 2 examples of misunderstandings that can result when certain names like 'cancer' and 'leprosy' mean one thing to medical workers and something else to villagers. In talking with health workers - and in using this book:

Spanish Name: CANCER (CANCER) Name in Your Area: ____________________

Mexican villagers use the word cancer for any severe infection of the skin, especially badly infected wounds or gangrene.

In modern medical language, cancer is not an infection, but an abnormal growth or lump in any part of the body. Common types of cancer that you should watch out for are:

cancer of the skin

breast cancer

cancer of the womb or ovaries

Any hard, painless, slowly growing lump in any part of your body may be cancer. Cancer is often dangerous and may need surgery.

At the first suspicion of cancer seek medical help.

Spanish Name: LEPRA (LEPROSY) Name in Your Area: ____________________

Mexican villagers call any open spreading sore lepra. This leads to confusion, because medical workers use this term only for true leprosy (Hansen's disease). Sores commonly called lepra are:

· impetigo and other skin infections
· sores that come from insect bites or scabies
· chronic sores or skin ulcers such as those caused by poor circulation
· skin cancer
· less commonly, leprosy or tuberculosis of the skin

This child has impetigo, not leprosy.

Confusion between Different Illnesses That Cause Fever

Spanish Name: LA FIEBRE (THE FEVER) Name in Your Area: ___________________

Correctly speaking, a fever is a body temperature higher than normal. But in Latin American, a number of serious illnesses that cause high temperatures are all called la fiebre - or 'the fever'.

To prevent or treat these diseases successfully, it is important to know how to tell one from another.

Figure

Here are some of the important acute illnesses in which fever is an outstanding sign. The drawings show the fever pattern (rise and fall of temperature) that is typical for each disease.

Malaria:

Begins with weakness, chills and fever. Fever may come and go for a few days, with shivering (chills) as the temperature rises, and sweating as it falls. Then, fever may come for a few hours every second or third day. On other days, the person may feel more or less well.

MALARIA - TYPICAL FEVER PATTERN

Typhoid:

Begins like a cold. Temperature goes up a little more each day. Pulse relatively slow. Sometimes diarrhea and dehydration. Trembling or delirium (mind wanders). Person very ill.

TYPHOID - TYPICAL FEVER PATTERN

Typhus:

Similar to typhoid. Rash similar to that of measles, with tiny bruises.

Hepatitis:

Person loses appetite. Does not wish to eat or smoke. Wants to vomit (nausea). Eyes and skin turn yellow; urine orange or brown; stools whitish. Sometimes liver becomes large, tender. Mild fever. Person very weak.

HEPATITIS-TYPICAL FEVER PATTERN

Pneumonia:

Fast, shallow breathing. Temperature rises quickly. Cough with green, yellow, or bloody mucus. May be pain in chest. Person very ill.

PNEUMONIA - TYPICAL FEVER PATTERN

Rheumatic fever:

Most common in children and teenagers. Pain in joints. High fever. Often comes after a sore throat. May be pain in the chest with shortness of breath. Or uncontrolled movements of arms and legs.

RHEUMATIC FEVER - TYPICAL FEVER PATTERN

Brucellosis (undulant fever, Malta fever):

Begins slowly with tiredness, headache, and pains in the bones. Fever and sweating most common at night. Fever disappears for a few days only to come back again. This may go on for months or years.

BRUCELLOSIS - TYPICAL FEVER PATTERN

Childbirth fever:

Begins a day or more after giving birth. Starts with a slight fever, which often rises later. Foul-smelling vaginal discharge. Pain and sometimes bleeding.

CHILDBIRTH FEVER - TYPICAL FEVER PATTERN

All of these illnesses can be dangerous. In addition to those shown here, there are many other diseases (especially in tropical countries) that may cause similar signs and fevers. These illnesses are not always easy to tell apart. Most are serious or dangerous. When possible - seek medical help.

Where There Is No Doctor - A Village Health Care Handbook (Hesperian Foundation, 1993, 516 p.) Chapter 3 - HOW TO EXAMINE A SICK PERSON (introduction...) Questions General Condition of Health Temperature How to Use a Thermometer Breathing (Respiration) Pulse (Heartbeat) Eyes Ears, Throat, and Nose Skin The Belly (Abdomen) Muscles and Nerves

Where There Is No Doctor - A Village Health Care Handbook (Hesperian Foundation, 1993, 516 p.)

Chapter 3 - HOW TO EXAMINE A SICK PERSON

To find out the needs of a sick person, first you must ask important questions and then examine him carefully. You should look for signs and symptoms that help you tell how ill the person is and what kind of sickness he may have.

Always examine the person where there is good light, preferably in the sunlight - never in a dark room.

There are certain basic things to ask and to look for in anyone who is sick. These include things the sick person feels or reports (symptoms), as well as things you notice on examining him (signs). These signs can be especially important in babies and persons unable to talk. In this book the word 'signs' is used for both symptoms and signs.

When you examine a sick person, write down your findings and keep them for the health worker in case he is needed.

Questions

Start by asking the person about her sickness. Be sure to ask the following:

What bothers you most right now?

What makes you feel better or worse?

How and when did your sickness begin?

Have you had this same trouble before, or has anyone else in your family or neighborhood had it?

Figure

Continue with other questions in order to learn the details of the illness.

For example, if the sick person has a pain, ask her:

Where does it hurt? (Ask her to point to the exact place with one finger.)

Does it hurt all the time, or off and on?

What is the pain like? (sharp? dull? burning?)

Can you sleep with the pain?

If the sick person is a baby who still does not talk, look for signs of pain. Notice his movements and how he cries. (For example, a child with an earache sometimes rubs the side of his head or pulls at his ear.)

General Condition of Health

Before touching the sick person, look at him carefully. Observe how ill or weak he looks, the way he moves, how he breathes, and how clear his mind seems. Look for signs of dehydration and of shock.

Notice whether the person looks well nourished or poorly nourished. Has he been losing weight? When a person has lost weight slowly over a long period of time, he may have a chronic illness (one that lasts a long time).

Also note the color of the skin and eyes. These sometimes change when a person is sick. (Dark skin can hide color changes. So look at parts of the body where the skin is pale, such as palms of the hands or soles of the feet, the fingernails, or the insides of the lips and eyelids.)

· Paleness, especially of the lips and inside the eyelids, is a sign of anemia. Skin may also go lighter as a result of tuberculosis or kwashiorkor.

· Darkening of the skin may be a sign of starvation.

· Bluish skin, especially blueness or darkness of the lips and fingernails, may mean serious problems with breathing or with the heart. Blue-gray color in an unconscious child may be a sign of cerebral malaria.

· A gray-white coloring, with cool moist skin, often means a person is in shock.

· Yellow color (jaundice) of the skin and eyes may result from disease in the liver (hepatitis, cirrhosis, or amebic abscess) or gallbladder. It may also occur in newborn babies, and in children born with sickle cell disease.

Look also at the skin when a light is shining across it from one side. This can show the earliest sign of measles rash on the face of a feverish child.

Temperature

It is often wise to take a sick person's temperature, even if he does not seem to have a fever. If the person is very sick, take the temperature at least 4 times each day and write it down.

Figure

If there is no thermometer, you can get an idea of the temperature by putting the back of one hand on the sick person's forehead and the other on your own or that of another healthy person. If the sick person has a fever, you should feel the difference.

Figure

It is important to find out when and how the fever comes, how long it lasts, and how it goes away. This may help you identify the disease. Not every fever is malaria, though in some countries it is often treated as such. Remember other possible causes. For example:

· Common cold, and other virus infections. The fever is usually mild.

· Typhoid causes a fever that goes on rising for 5 days. Malaria medicine does not help.

· Tuberculosis sometimes causes a mild fever in the afternoon. At night the person often sweats, and the fever goes down.

How to Use a Thermometer

Every family should have a thermometer. Take the temperature of a sick person 4 times a day and always write it down.

How to read the thermometer (using one marked in degrees centigrade - °C):

Figure

How to take the temperature:

1. Clean the thermometer well with soap and water or alcohol. Shake it hard, with a snap of the wrist, until it reads less than 36 degrees.

Figure

2. Put the thermometer...

under the tongue (keeping the or mouth shut)

or

in the armpit if there is danger of biting the thermometer

or

carefully, in the anus of a small child (wet or grease it first)

3. Leave it there for 3 or 4 minutes.

4. Read it. (An armpit temperature will read a little lower than a mouth reading; in the anus it will read a little higher.)

5. Wash the thermometer well with soap and water.

Note: In newborn babies a temperature that is unusually high or unusually low (below 36°) may mean a serious infection.

· To learn about other fever patterns.
· To learn what to do for a fever.

Breathing (Respiration)

Pay special attention to the way the sick person breathes - the depth (deep or shallow), rate (how often breaths are taken), and difficulty. Notice if both sides of the chest move equally when she breathes.

If you have a watch or simple timer, count the number of breaths per minute (when the person is quiet). Between 12 and 20 breaths per minute is normal for adults and older children. Up to 30 breaths a minute is normal for children, and 40 for babies. People with a high fever or serious respiratory illnesses (like pneumonia) breathe more quickly than normal. More than 40 shallow breaths a minute in an adult, or 60 in a small child, usually means pneumonia.

Listen carefully to the sound of the breaths. For example:

· A whistle or wheeze and difficulty breathing out can mean asthma.

· A gurgling or snoring noise and difficult breathing in an unconscious person may mean the tongue, mucus (slime or pus), or something else is stuck in the throat and does not let enough air get through.

Look for 'sucking in' of the skin between ribs and at the angle of the neck (behind the collar bone) when the person breathes in. This means air has trouble getting through. Consider the possibility of something stuck in the throat, pneumonia, asthma, or bronchitis (mild sucking in).

If the person has a cough, ask if it keeps her from sleeping. Find out if she coughs up mucus, how much, its color, and if there is blood in it.

Pulse (Heartbeat)

To take the person's pulse, put your fingers on the wrist as shown. (Do not use your thumb to feel for the pulse.)

If you cannot find the pulse in the wrist, feel for it in the neck beside the voicebox,

or put your ear directly on the chest and listen for the heartbeat (or use a stethoscope if you have one).

Pay attention to the strength, the rate, and the regularity of the pulse. If you have a watch or timer, count the pulses per minute.

NORMAL PULSE FOR PEOPLE AT REST

The pulse gets much faster with exercise and when a person is nervous, frightened, or has a fever. As a general rule, the pulse increases 20 beats per minute for each degree (°C) rise in fever.

When a person is very ill, take the pulse often and write it down along with the temperature and rate of breathing.

It is important to notice changes in the pulse rate. For example:

· A weak, rapid pulse can mean a state of shock.
· A very rapid, very slow, or irregular pulse could mean heart trouble.
· A relatively slow pulse in a person with a high fever may be a sign of typhoid.

Eyes

Look at the color of the white part of the eyes. Is it normal, red, or yellow? Also note any changes in the sick person's vision.

Have the person slowly move her eyes up and down and from side to side. Jerking or uneven movement may be a sign of brain damage.

Pay attention to the size of the pupils (the black 'window' in the center of the eye). If they are very large, it can mean a state of shock. If they are very large, or very small, it can mean poison or the effect of certain drugs.

Look at both eyes and note any difference between the two, especially in the size of the pupils:

Figure

A big difference in the size of the pupils is almost always a medical emergency.

· If the eye with the larger pupil hurts so badly it causes vomiting, the person probably has GLAUCOMA.

· If the eye with the smaller pupil hurts a great deal, the person may have IRITIS, a very serious problem.

· Difference in the size of the pupils of an unconscious person or a person who has had a recent head injury may mean brain damage. It may also mean STROKE.

Always compare the pupils of a person who is unconscious or has had a head injury.

Ears, Throat, and Nose

Ears: Always check for signs of pain and infection in the ears - especially in a child with fever or a cold. A baby who cries a lot or pulls at his ear often has an ear infection.

Pull the ear gently. If this increases pain, the infection is probably in the tube of the ear (ear canal). Also look for redness or pus inside the ear. A small flashlight or penlight will help. But never put a stick, wire, or other hard object inside the ear.

Figure

Find out if the person hears well, or if one side is more deaf than the other. Rub your thumb and fingers together near the person's ear to see if he can hear it. For deafness and ringing of the ears see chapter 22.

Throat and Mouth: With a torch (flashlight) or sunlight examine the mouth and throat. To do this hold down tongue with a spoon handle or have the person say 'ahhhhh...' Notice if the throat is red and if the tonsils (2 lumps at the back of the throat) are swollen or have spots with pus. Also examine the mouth for sores, inflamed gums, sore tongue, rotten or abscessed teeth and other problems. (Read Chapter 17.)

Nose: Is the nose runny or plugged? (Notice if and how a baby breathes through his nose.) Shine a light inside and look for mucus, pus, blood; also look for redness, swelling, or bad smell. Check for signs of sinus trouble or hayfever.

Skin

It is important to examine the sick person's whole body, no matter how mild the sickness may seem. Babies and children should be undressed completely. Look carefully for anything that is not normal, including:

· sores, wounds, or splinters
· rashes or welts
· spots, patches, or any unusual markings
· inflammation (sign of infection with redness, heat, pain and swelling)
· swelling or puffiness
· swollen lymph nodes (little lumps in the neck, the armpits, or the groin)
· abnormal lumps or masses
· unusual thinning or loss of hair, or loss of its color or shine
· loss of eyebrows (leprosy?)

Always examine little children between the buttocks, in the genital area, between the fingers and toes, behind the ears, and in the hair (for lice, scabies, ringworm, rashes, and sores).

Figure

The Belly (Abdomen)

If a person has pain in the belly, try to find out exactly where it hurts.

Learn whether the pain is steady or whether it suddenly comes and goes, like cramps or colic.

When you examine the belly, first look at it for any unusual swelling or lumps.

The location of the pain often gives a clue to the cause (see the following page).

First, ask the person to point with one finger where it hurts.

Then, beginning on the opposite side from the spot where he has pointed, press gently on different parts of the belly to see where it hurts most.

See if the belly is soft or hard and whether the person can relax his stomach muscles, A very hard belly could mean an acute abdomen - perhaps appendicitis or peritonitis.

If you suspect peritonitis or appendicitis, do the test for rebound pain.

Feel for any abnormal lumps and hardened areas in the belly.

If the person has a constant pain in the stomach, with nausea, and has not been able to move her bowels, put an ear (or stethoscope) on the belly, like this:

Listen for gurgles in the intestines. If you hear nothing after about 2 minutes, this is a danger sign. (See Emergency Problems of the Gut, p. 93.)

These pictures show the areas of the belly that usually hurt when a person has the following problems:

Ulcer

Appendicitis

Gallbladder

Liver

Urinary system

Inflammation or tumor of the ovaries, or out-of-place pregnancy, etc.

Muscles and Nerves

If a person complains of numbness, weakness, or loss of control in part of his body, or you want to test it: notice the way he walks and moves. Have him stand, sit, or lie completely straight, and carefully compare both sides of his body.

Face: Have him smile, frown, open his eyes wide, and squeeze them shut. Notice any drooping or weakness on one side.

Figure

If the problem began more or less suddenly, think of a head injury, stroke, or Bell's palsy.

If it came slowly, it may be a brain tumor. Get medical advice.

Also check for normal eye movement, size of pupils, and how well he can see.

Arms and legs: Look for loss of muscle. Notice - or measure - difference in thickness of arms or legs.

Have him squeeze your fingers to compare strength in his hands

and push and pull with his feet against your hand.

Any string or ribbon will do to check if the distance around the arms or legs is different.

Watch how he moves and walks. If muscle loss or weakness affects the whole body, suspect malnutrition or a chronic.(long-term) illness like tuberculosis.

If muscle loss and weakness is uneven or worse on one side, in children, think first of polio; in adults, think of a back problem, a back or head injury, or stroke.

For more information on muscle testing and physical examination of disabled persons, see Disabled Village Children, Chapter 4.

Check for stiff ness or tightness of different muscles:

· If the jaw is stiff or will not open, suspect tetanus or a severe infection of the throat or of a tooth. If the problem began after he yawned or was hit in the jaw, he may have a dislocated jaw.

Figure

· If the neck or back is stiff and bent backwards, in a very sick child, suspect meningitis. If the head will not bend forward or cannot be put between the knees, meningitis is likely.

Figure

· If a child always has some stiff muscles and makes strange or jerky movements, he may be spastic.

· If strange or jerky movements come suddenly, with loss of consciousness, he may have fits. If fits happen often, think of epilepsy. If they happen when he is ill, the cause may be high fever or dehydration or tetanus or meningitis.

Figure

To check for loss of feeling in the hands, feet, or other parts of the body:

Have the person cover his eyes. Lightly touch or prick the skin in different places. Ask him to say 'yes' when he feels it.

· Loss of feeling in or near spots or patches on the body is probably leprosy.
· Loss of feeling in both hands or feet may be due to diabetes or leprosy.
· Loss of feeling on one side only could come from a back problem or injury.

Figure

Where There Is No Doctor - A Village Health Care Handbook (Hesperian Foundation, 1993, 516 p.) Chapter 4 - HOW TO TAKE CARE OF A SICK PERSON (introduction...) The Comfort of the Sick Person Special Care for a Person Who Is Very Ill Liquids Food Cleanliness and Changing Position in Bed Watching for Changes Signs of Dangerous Illness When and How to Look for Medical Help What to Tell the Health Worker Patient Report

Where There Is No Doctor - A Village Health Care Handbook (Hesperian Foundation, 1993, 516 p.)

Chapter 4 - HOW TO TAKE CARE OF A SICK PERSON

Sickness weakens the body. To gain strength and get well quickly, special care is needed.

Medicines are often not necessary. But good care is always important. The following are the basis of good care:

The Comfort of the Sick Person

1. The Comfort of the Sick Person

A person who is sick should rest in a quiet, comfortable place with plenty of fresh air and light. He should keep from getting too hot or cold. If the air is cold or the person is chilled, cover him with a sheet or blanket. But if the weather is hot or the person has a fever, do not cover him at all.

Figure

2. Liquids

In nearly every sickness, especially when there is fever or diarrhea, the sick person should drink plenty of liquids: water, tea, juices, broths, etc.

Figure

3. Personal Cleanliness

It is important to keep the sick person clean. He should be bathed every day. If he is too sick to get out of bed, wash him with a sponge or cloth and lukewarm water. His clothes, sheets, and covers must also be kept clean. Take care to keep crumbs and bits of food out of the bed.

A SICK PERSON SHOULD BE BATHED EACH DAY

4. Good Food

If the sick person feels like eating, let him. Most sicknesses do not require special diets.

A sick person should drink plenty of liquids and eat a lot of nourishing food (see Chapter 11).

If the person is very weak, give him as much nourishing food as he can eat, many times a day. If necessary, mash the foods, or make them into soups or juices.

Figure

Energy foods are especially important - for example, porridges of rice, wheat, oatmeal, potato, or cassava. Adding a little sugar and vegetable oil will increase the energy. Also encourage the sick person to drink plenty of sweetened drinks, especially if he will not eat much.

A few problems do require special diets:

stomach ulcers and heartburn
appendicitis, gut obstruction, acute abdomen (in these cases take no food at all)
diabetes
heart problems
gallbladder problems

Special Care for a Person Who Is Very Ill

Figure

Liquids

1. Liquids

It is extremely important that a very sick person drink enough liquid. If he only can drink a little at a time, give him small amounts often. If he can barely swallow, give him sips every 5 or 10 minutes.

Measure the amount of liquids the person drinks each day. An adult needs to drink 2 liters or more every day and should urinate at least a cup (60 cc.) of urine 3 or 4 times daily. If the person is not drinking or urinating enough, or if he begins to show signs of dehydration, encourage him to drink more. He should drink nutritious liquids, usually with a little salt added. If he will not drink these, give him a Rehydration Drink. If he cannot drink enough of this, and develops signs of dehydration, a health worker may be able to give him intravenous solution. But the need for this can usually be avoided if the person is urged to take small sips often.

Food

2. Food

If the person is too sick to eat solid foods, give her soups, milk, juices, broths, and other nutritious liquids (see Chapter 11). A porridge of cornmeal, oatmeal, or rice is also good, but should be given together with body-building foods. Soups can be made with egg, beans, or well-chopped meat, fish, or chicken. If the person can eat only a little at a time, she should eat several small meals each day.

Cleanliness and Changing Position in Bed

3. Cleanliness

Personal cleanliness is very important for a seriously ill person. She should be bathed every day with warm water.

Change the bed clothes daily and each time they become dirty. Soiled or bloodstained clothes, bedding, and towels of a person with an infectious disease should be handled with care. To kill any viruses or germs, wash these in hot soapy water, or add some chlorine bleach.

4. Changing Position in Bed

A person who is very weak and cannot turn over alone should be helped to change position in bed many times each day. This helps prevent bed sores.

A child who is sick for a long time should be held often on her mother's lap.

Frequent changing of the person's position also helps to prevent pneumonia, a constant danger for anyone who is very weak or ill and must stay in bed for a long time. If the person has a fever, begins to cough, and breathes with fast, shallow breaths, she probably has pneumonia.

Watching for Changes

5. Watching for Changes

You should watch for any change in the sick person's condition that may tell you whether he is getting better or worse. Keep a record of his 'vital signs'. Write down the following facts 4 times a day:

temperature (how many degrees)

pulse (beats per minute)

breathing (breaths per minute)

Also write down the amount of liquids the person drinks and how many times a day he urinates and has a bowel movement. Save this information for the health worker or doctor.

It is very important to look for signs that warn you that the person's sickness is serious or dangerous. A list of Signs of Dangerous Illness is on the next page. If the person shows any of these signs, seek medical help immediately.

Signs of Dangerous Illness

Figure

A person who has one or more of the following signs is probably too sick to be treated at home without skilled medical help. His life may be in danger. Seek medical help as soon as possible.

1. Loss of large amounts of blood from anywhere in the body

2. Coughing up blood

3. Marked blueness of lips and nails (if it is new)

4. Great difficulty in breathing; does not improve with rest

5. The person cannot be wakened (coma)

6. The person is so weak he faints when he stands up

7. A day or more without being able to urinate

8. A day or more without being able to drink any liquids

9. Heavy vomiting or severe diarrhea that lasts for more than one day or more than a few hours in babies

10. Black stools like tar, or vomit with blood or feces

11. Strong, continuous stomach pains with vomiting in a person who does not have diarrhea or cannot have a bowel movement

12. Any strong continuous pain that lasts for more than 3 days

13. Stiff neck with arched back, with or without a stiff jaw

14. More than one fit (convulsions) in someone with fever or serious illness

15. High fever (above 39° C) that cannot be brought down or that lasts more than 4 or 5 days

16. Weight loss over an extended time

17. Blood in the urine

18. Sores that keep growing and do not go away with treatment

19. A lump in any part of the body that keeps getting bigger

20. Problems with pregnancy and childbirth: any bleeding during pregnancy swollen face and trouble seeing in the last months long delay once the waters have broken and labor has begun severe bleeding

When and How to Look for Medical Help

Seek medical help at the first sign of a dangerous illness. Do not wait until the person is so sick that it becomes difficult or impossible to take him to a health center or hospital.

If a sick or injured person's condition could be made worse by the difficulties in moving him to a health center, try to bring a health worker to the person. But in an emergency when very special attention or an operation may be needed (for example, appendicitis), do not wait for the health worker. Take the person to the health center or the hospital at once.

When you need to carry a person on a stretcher, make sure he is as comfortable as possible and cannot fall out. If he has any broken bones, splint them before moving him. If the sun is very strong, rig a sheet over the stretcher to give shade yet allow fresh air to pass underneath

Figure

What to Tell the Health Worker

For a health worker or doctor to recommend treatment or prescribe medicine wisely, she should see the sick person. If the sick person cannot be moved, have the health worker come to him. If this is not possible, send a responsible person who knows the details of the illness. Never send a small child or a fool.

Before sending for medical help, examine the sick person carefully and completely. Then write down the details of his disease and general condition (see Chapter 3).

On the next page is a form on which you can make a PATIENT REPORT. Several copies of this form are at the end of this book. Tear out one of these forms and carefully complete the report, giving all the details you can.

Patient Report

TO USE WHEN SENDING FOR MEDICAL HELP

Name of the sick person: ________________________ Age: _________
Male _____ Female _____ Where is he (she)? _____________________
What is the main sickness or problem right now? ___________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
When did it begin? ___________________________________________
How did it begin? ____________________________________________
Has the person had the same problem before? ____ When? ___________
Is there fever? ____ How high? ____ When and for how long? ________
Pain? ________Where? ____________________What kind? _________

What is wrong or different from normal in any of the following?

Skin: _________________________ Ears: _______________________
Eyes: ________________________Mouth and throat: _____________
Genitals: __________________________________________________
Urine: Much or little? __________Color? ______ Trouble urinating? __
Describe: ________________ Times in 24 hours: ___Times at night: ___
Stools: Color? _____________ Blood or mucus? _______ Diarrhea?____
Number of times a day: ____ Cramps? ____ Dehydration? _____ Mild or
severe? ______________Worms? ____ What kind? _________________
Breathing: Breaths per minute: _____ Deep, shallow, or normal? ______
Difficulty breathing (describe): _____________ Cough (describe): _____
_______________ Wheezing? _____ Mucus? _____ With blood? ______
Does the person have any of the SIGNS OF DANGEROUS ILLNESS?
__________ Which? (give details) _______________________________
Other signs: ________________________________________________
Is the person taking medicine? ______ What? ______________________
Has the person ever used medicine that has caused a rash, hives (or bumps)
with itching, or other allergic reactions? ______ What? _______________
The state of the sick person is: Not very serious: ______ Serious: _______
Very serious: ______________

On the back of this form write any other information you think may be important.

Where There Is No Doctor - A Village Health Care Handbook (Hesperian Foundation, 1993, 516 p.) Chapter 5 - HEALING WITHOUT MEDICINES (introduction...) Healing with Water Times When the Right Use of Water May Do More Good than Medicines

Where There Is No Doctor - A Village Health Care Handbook (Hesperian Foundation, 1993, 516 p.)

Chapter 5 - HEALING WITHOUT MEDICINES

For most sicknesses no medicines are needed. Our bodies have their own defenses, or ways to resist and fight disease. In most cases, these natural defenses are far more important to our health than are medicines.

To help the body fight off or overcome a sickness, often all that is needed is to:

keep clean

get plenty of rest

eat well and drink a lot of liquid

Even in a case of more serious illness, when a medicine may be needed, it is the body that must overcome the disease; the medicine only helps. Cleanliness, rest, nutritious food, and lots of water are still very important.

Much of the art of health care does not - and should not - depend on use of medications. Even if you live in an area where there are no modern medicines, there is a great deal you can do to prevent and treat most common sicknesses - if you learn how.

If people simply learned how to use water correctly, this alone might do more to prevent and cure illnesses than all the medicines they now use... and misuse.

Healing with Water

Most of us could live without medicines. But no one can live without water. In fact, over half (57%) of the human body is water. If everyone living in farms and villages made the best use of water, the amount of sickness and death - especially of children - could be reduced.

For example, correct use of water is basic both in the prevention and treatment of diarrhea. In many areas diarrhea is the most common cause of sickness and death in small children. Contaminated (unclean) water is often part of the cause.

An important part of the prevention of diarrhea and many other illnesses is to make sure that drinking water is safe. Protect wells and springs from dirt and animals by putting fences or walls around them. Use cement or rock to provide good drainage around the well or spring, so that rain or spilled water runs away from it.

Where water may be contaminated, an important part of the prevention of diarrhea is to boil or filter the water used for drinking or for preparing foods. This is especially important for babies. Babies' bottles and eating utensils should also be boiled. If regular boiling of bottles is not possible, it is safer to use a cup and spoon. Washing hands with soap and water after a bowel movement (shifting) and before eating or handling foods is also important.

PREVENTION

A common cause of death in children with diarrhea is severe dehydration, or loss of too much water from the body. By giving a child with diarrhea plenty of water (best with sugar or cereal and salt), dehydration can often be prevented or corrected (see Rehydration Drink).

TREATMENT

Giving lots of liquids to a child with diarrhea is more important than any medicine. In fact, if enough liquid is given, no medicine is usually needed in the treatment of diarrhea.

On the next 2 pages are a number of other situations in which it is often more important to use water correctly than to use medicines.

Times When the Right Use of Water May Do More Good than Medicines

PREVENTION

TREATMENT

In each of the above cases (except pneumonia) when water is used correctly, often medicines are not needed. In this book you will find many suggestions for ways of healing without need for medicine. Use medicines only when absolutely necessary.

Where There Is No Doctor - A Village Health Care Handbook (Hesperian Foundation, 1993, 516 p.) Chapter 6 - RIGHT AND WRONG USES OF MODERN MEDICINES (introduction...) Guidelines for the Use of Medicine The Most Dangerous Misuse of Medicine When Should Medicine Not Be Taken?

Where There Is No Doctor - A Village Health Care Handbook (Hesperian Foundation, 1993, 516 p.)

Chapter 6 - RIGHT AND WRONG USES OF MODERN MEDICINES

Some medicines sold in pharmacies or village stores can be very useful. But many are of no value. Of the 60,000 medicines sold in most countries, the World Health Organization says that only about 200 are necessary.

Also, people sometimes use the best medicines in the wrong way, so that they do more harm than good. To be helpful, medicine must be used correctly.

Many people, including most doctors and health workers, prescribe far more medicines than are needed - and by so doing cause much needless sickness and death.

Some medicines are much more dangerous than others. Unfortunately, people sometimes use very dangerous medicines for mild sicknesses. (I have seen a baby die because his mother gave him a dangerous medicine, chloramphenicol, for a cold.) Never use a dangerous medicine for a mild illness.

REMEMBER: MEDICINES CAN KILL

Guidelines for the Use of Medicine

Guidelines for the use of medicine:

1. Use medicines only when necessary.
2. Know the correct use and precautions for any medicine you use (see the GREEN PAGES).
3. Be sure to use the right dose.
4. If the medicine does not help, or causes problems, stop using it.
5. When in doubt, seek the advice of a health worker.

Note: Some health workers and many doctors give medicines when none is needed, often because they think patients expect medicine and will not be satisfied until they get some. Tell your doctor or health worker you only want medicine if it is definitely needed. This will save you money and be safer for your health.

The Most Dangerous Misuse of Medicine

Here is a list of the most common and dangerous errors people make in using modern medicines. The improper use of the following medicines causes many deaths each year. BE CAREFUL!

1. Chloramphenicol (Chloromycetin)

2. Oxytocin (Pitocin), Pituitrin, and Ergonovine (Ergotrate)

3. Injections of any medicine

4. Penicillin

Penicillin works only against certain types of infections. Use of penicillin for sprains, bruises, or any pain or fever is a great mistake. As a general rule, injuries that do not break the skin, even if they make large bruises, have no danger of infection; they do not need to be treated with penicillin or any other antibiotic. Neither penicillin nor other antibiotics helps colds.

Penicillin is dangerous for some people. Before using it, know its risks and the precautions you must take.

5. Kanamycin and Gentamicin (Garamycin)

Too much use of these antibiotics for babies has caused permanent hearing loss (deafness) in millions of babies. Give to babies only for life-threatening infections. For many infections of the newborn, ampicillin works as well and is much less dangerous.

6. Anti-diarrhea medicines with hydroxyquinolines (Clioquinol, di-iodohydroxyquinoline, halquinol, broxyquinoline: Diodoquin, Enteroquinol, Amicline, Quogyl, and many other brand names)

In the past clioquinols were widely used to treat diarrhea. These dangerous medicines are now prohibited in many countries - but in others are still sold. They can cause permanent paralysis, blindness, and even death. For treatment of diarrhea, see Chapter 13.

7. Cortisone and cortico-steroids (Prednisolone, dexamethasone, and others)

These are powerful anti-inflammatory drugs that are occasionally needed for severe attacks of asthma, arthritis, or severe allergic reactions. But in many countries, steroids are prescribed for minor aches and pains because they often give quick results. This is a big mistake. Steroids cause serious or dangerous side effects - especially if used in high doses or for more than a few days. They lower a person's defenses against infection. They can make tuberculosis much worse, cause bleeding of stomach ulcers, and make bones so weak that they break easily.

8. Anabolic steroids (Nandrolone decanoate, Durabolin, Deca-Durabolin, Orabolin; stanozolol, Cetabon; oxymetholone, Anapolon; ethylestrenol, Organaboral. There are many other brand names.)

Anabolic steroids are made from male hormones and are mistakenly used in tonics to help children gain weight and grow. At first the child may grow faster, but he will stop growing sooner and end up shorter than he would have if he had not taken the medicine. Anabolic steroids cause very dangerous side effects. Girls grow hair on their faces like boys, which does not go away, even when the child stops taking the medicine. Do not give growth tonics to children. Instead, to help your child grow, use the money to buy food.

9. Arthritis medicines (Butazones: oxyphenbutazone, Amidozone; and phenylbutazone, Butazolidin)

These medicines for joint pain (arthritis) can cause a dangerous, sometimes deadly, blood disease (agranulocytosis). They can also damage the stomach, liver, and kidneys. Do not use these dangerous medicines. For arthritis, aspirin or ibuprofen is much safer and cheaper. For pain and fever only, acetaminophen can be used.

10. Vitamin B₁₂, liver extract, and iron injections

11. Other vitamins

As a general rule, DO NOT INJECT VITAMINS. Injections are more dangerous, more expensive, and usually no more effective than pills.

Unfortunately, many people waste their money on syrups, tonics, and 'elixirs' that contain vitamins. Many lack the most important vitamins. But even when they contain them, it is wiser to buy more and better food. Body-building and protective foods like beans, eggs, meat, fruit, vegetables, and whole grains are rich in vitamins and other nutrients. Giving a thin, weak person good food more often will usually help him far more than giving him vitamin and mineral supplements.

THE BEST WAY TO GET VITAMINS:

For more information about vitamins, when they are necessary, and the foods that have them, read Chapter 11.

12. Combination medicines

Sometimes, 2 or more medicines are combined in the same pill or tonic. Usually they are less effective, and more expensive, when prepared this way. Sometimes they do more harm than good. If someone wants to prescribe combination medicines, ask him or her to prescribe only the medicine that is really necessary. Do not waste your money on these medicines.

Some common combination medicines that should be avoided are:

· cough medicines which contain medicines both to suppress a cough and also to get rid of mucus. (Cough medicines are almost always useless and a waste of money, whether or not they combine medicines.)

· antibiotics combined with anti-diarrhea medicine

· antacids to treat stomach ulcers together with medicine to prevent stomach cramps

· 2 or more pain medicines (aspirin with acetaminophen - sometimes also with caffeine)

13. Calcium

Note: In Mexico and other countries where people eat a lot of corn tortillas or other foods prepared with lime, it is foolish to use calcium injections or tonics (as is often done to 'give strength' or 'help children grow'). The body gets all the calcium it needs from the lime.

14. 'Feeding' through the veins (Intravenous or 'I.V.' solutions)

In some areas, persons who are anemic or very weak spend their last penny to have a liter of I.V. solution put into their veins. They believe that this will make-them stronger or their blood richer. But they are wrong! Intravenous solution is nothing more than pure water with some salt or sugar in it. It gives less energy than a large candy bar and makes the blood thinner, not richer. It does not help anemia or make the weak person stronger.

Also when a person who is not well trained puts the I.V. solution into a vein, there is danger of an infection entering the blood. This can kill the sick person.

Intravenous solution should be used only when a person can take nothing by mouth, or when she is badly dehydrated.

If the sick person can swallow, give her a liter of water with sugar (or cereal) and salt (see Rehydration Drink). It will do as much for her as injecting a liter of I.V. solution. For people who are able to eat, nutritious foods do more to strengthen them than any type of I.V. fluid.

If a sick person is able to swallow and keep down liquids...

Figure

When Should Medicine Not Be Taken?

Many people have beliefs about things they should not do or eat when taking medicines. For this reason they may stop taking a medicine they need. In truth, no medicine causes harm just because it is taken with certain foods - whether pork, chili pepper, guava, oranges, or any other food. But foods with lots of grease or spices can make problems of the stomach or gut worse - whether or not any medicine is being taken. Certain medicines will cause bad reactions if a person drinks alcohol (see metronidazole).

There are situations when, without a doubt, it is best not to use certain medicines:

1. Pregnant women or women who are breast feeding should avoid all medicines that are not absolutely necessary. (However, they can take limited amounts of vitamins or iron pills without danger.)

Figure

2. With newborn children, be very careful when using medicines. Whenever possible look for medical help before giving them any type of medicine. Be sure not to give too much.

3. A person who has ever had any sort of allergic reaction - hives, itching, etc. - after taking penicillin, ampicillin, a sulfonamide, or other medicines, should never use that medicine again for the rest of his life because it would be dangerous (see Dangerous reactions from injections of certain medicines).

Figure

4. Persons who have stomach ulcers or heartburn should avoid medicines that contain aspirin. Most painkillers, and all steroids make ulcers and acid indigestion worse. One painkiller that does not irritate the stomach is acetaminophen (paracetamol).

Figure

5. There are specific medicines that are harmful or dangerous to take when you have certain illnesses. For example, persons with hepatitis should not be treated with antibiotics or other strong medicines, because their liver is damaged, and the medicines are more likely to poison the body.

6. Persons who are dehydrated or have disease of the kidneys should be especially careful with medicines they take. Do not give more than one dose of a medicine that could poison the body unless (or until) the person is urinating normally. For example, if a child has high fever and is dehydrated, do not give him more than one dose of acetaminophen or aspirin until he begins to urinate. Never give sulfa to a person who is dehydrated.

Where There Is No Doctor - A Village Health Care Handbook (Hesperian Foundation, 1993, 516 p.) Chapter 7 - ANTIBIOTICS: WHAT THEY ARE AND HOW TO USE THEM (introduction...) Guidelines for the Use of Antibiotics What to Do if an Antibiotic Does Not Seem to Help Importance of Limited Use of Antibiotics

Where There Is No Doctor - A Village Health Care Handbook (Hesperian Foundation, 1993, 516 p.)

Chapter 7 - ANTIBIOTICS: WHAT THEY ARE AND HOW TO USE THEM

When used correctly, antibiotics are extremely useful and important medicines. They fight certain infections and diseases caused by bacteria. Well-known antibiotics are penicillin, tetracycline, streptomycin, chloramphenicol, and the sulfa drugs, or sulfonamides.

The different antibiotics work in different ways against specific infections. All antibiotics have dangers in their use, but some are far more dangerous than others. Take great care in choosing and using antibiotics.

There are many kinds of antibiotics, and each kind is sold under several 'brand names'. This can be confusing. However, the most important antibiotics fall into a few major groups:

* Note: Ampicillin is a type of penicillin that kills more kinds of bacteria than do ordinary penicillins.

If you have a brand-name antibiotic and do not know to which group it belongs, read the fine print on the bottle or box. For example, if you have some Paraxin 'S' but do not know what is in it, read the fine print. It says 'chloramphenicol'.

Never use an antibiotic unless you know to what group it belongs, what diseases it fights, and the precautions you must take to use it safely.

Information on the uses, dosage, risks, and precautions for the antibiotics recommended in this book can be found in the GREEN PAGES. Look for the name of the medicine in the alphabetical list at the beginning of those pages.

Guidelines for the Use of Antibiotics

GUIDELINES FOR THE USE OF ALL ANTIBIOTICS

1. If you do not know exactly how to use the antibiotic and what infections it can be used for, do not use it.

2. Use only an antibiotic that is recommended for the infection you wish to treat. (Look for the illness in this book.)

3. Know the risks in using the antibiotic and take all the recommended precautions (see the GREEN PAGES).

4. Use the antibiotic only in the recommended dose - no more, no less. The dose depends on the illness and the age or weight of the sick person.

5. Never use injections of antibiotics if taking them by mouth is likely to work as well. Inject only when absolutely necessary.

6. Keep using the antibiotics until the illness is completely cured, or for at least 2 days after the fever and other signs of infection have gone. (Some illnesses, like tuberculosis and leprosy, need to be treated for many months or years after the person feels better. Follow the instructions for each illness.)

7. If the antibiotic causes a skin rash, itching, difficult breathing, or any serious reactions, the person must stop using it and never use it again.

8. Only use antibiotics when the need is great. When antibiotics are used too much they begin not to work as well.

GUIDELINES FOR THE USE OF CERTAIN ANTIBIOTICS

1. Before you inject penicillin or ampicillin, always have ready ampules of Adrenalin (epinephrine) to control an allergic reaction if one occurs.

2. For persons who are allergic to penicillin, use another antibiotic such as erythromycin or a sulfa.

3. Do not use tetracycline, ampicillin, or another broad-spectrum antibiotic for an illness that can probably be controlled with penicillin or another narrow-spectrum antibiotic. Broad-spectrum antibiotics attack many more kinds of bacteria than narrow-spectrum antibiotics.

4. As a rule, use chloramphenicol only for certain severe or life-threatening illnesses like typhoid. It is a dangerous drug. Never use it for mild illness. And never give it to newborn children (except perhaps for whooping cough).

5. Never inject tetracycline or chloramphenicol. They are safer, less painful, and do as much or more good when taken by mouth.

6. Do not give tetracycline to pregnant women or to children under 8 years old. It can damage new teeth and bones.

7. As a general rule, use streptomycin, and products that contain it, only for tuberculosis - and always together with other anti-tuberculosis medicines. Streptomycin in combination with penicillin can be used for deep wounds to the gut, appendicitis, and other specific infections when ampicillin is not available (or is too costly), but should never be used for colds, flu, and common respiratory infections.

8. All medicines in the streptomycin group (including kanamycin and gentamicin) are quite toxic (poisonous). Too often they are prescribed for mild infections where they may do more harm than good. Use only for certain very serious infections for which these medicines are recommended.

9. Eating yogurt or curdled milk helps to replace necessary bacteria killed by antibiotics like ampicillin and to return the body's natural balance to normal (see next page).

What to Do if an Antibiotic Does Not Seem to Help

For most common infections antibiotics begin to bring improvement in a day or two. If the antibiotic you are using does not seem to help, it is possible that:

1. The illness is not what you think. You may be using the wrong medicine. Try to find out more exactly what the illness is - and use the right medicine.

2. The dose of the antibiotic is not correct. Check it.

3. The bacteria have become resistant to this antibiotic (they no longer are harmed by it). Try another one of the antibiotics recommended for that illness.

4. You may not know enough to cure the illness. Get medical help, especially if the condition is serious or getting worse.

These three children had a cold...

Antibiotics do no good for the common cold.

Use antibiotics only for infections they are known to help.

Importance of Limited Use of Antibiotics

The use of all medicines should be limited. But this is especially true of antibiotics, for the following reasons:

1. Poisoning and reactions. Antibiotics not only kill bacteria, they can also harm the body, either by poisoning it or by causing allergic reactions. Many people die each year because they take antibiotics they do not need.

2. Upsetting the natural balance. Not all bacteria in the body are harmful. Some are necessary for the body to function normally. Antibiotics often kill the good bacteria along with the harmful ones. Babies who are given antibiotics sometimes develop fungus or yeast infections of the mouth (thrush) or skin (moniliasis). This is because the antibiotics kill the bacteria that help keep fungus under control.

For similar reasons, persons who take ampicillin and other broad-spectrum antibiotics for several days may develop diarrhea. Antibiotics may kill some kinds of bacteria necessary for digestion, upsetting the natural balance of bacteria in the gut.

3. Resistance to treatment. In the long run, the most important reason the use of antibiotics should be limited, is that WHEN ANTIBIOTICS ARE USED TOO MUCH, THEY BECOME LESS EFFECTIVE.

When attacked many times by the same antibiotic, bacteria become stronger and are no longer killed by it. They become resistant to the antibiotic. For this reason, certain dangerous diseases like typhoid are becoming more difficult to treat than they were a few years ago.

In some places typhoid has become resistant to chloramphenicol, normally the best medicine for treating it. Chloramphenicol has been used far too much for minor infections, infections for which other antibiotics would be safer and work as well, or for which no antibiotic at all is needed.

Throughout the world important diseases are becoming resistant to antibiotics - largely because antibiotics are used too much for minor infections. If antibiotics are to continue to save lives, their use must be much more limited than it is at present. This will depend on their wise use by doctors, health workers, and the people themselves.

For most minor infections antibiotics are not needed and should not be used. Minor skin infections can usually be successfully treated with mild soap and water, or hot soaks, and perhaps painting them with gentian violet. Minor respiratory infections are best treated by drinking lots of liquids, eating good food, and getting plenty of rest. For most diarrheas, antibiotics are not necessary and may even be harmful. What is most important is to drink lots of liquids, and provide enough food as soon as the child will eat.

For more information on learning to use antibiotics sensibly, see Helping Health Workers Learn, Chapter 19.

Where There Is No Doctor - A Village Health Care Handbook (Hesperian Foundation, 1993, 516 p.) Chapter 8 - HOW TO MEASURE AND GIVE MEDICINE (introduction...) Medicine in Liquid Form How to Give Medicines to Small Children How to Take Medicines Dosage Instructions for Persons Who Cannot Read

Where There Is No Doctor - A Village Health Care Handbook (Hesperian Foundation, 1993, 516 p.)

Chapter 8 - HOW TO MEASURE AND GIVE MEDICINE

SYMBOLS:

HOW FRACTIONS ARE SOMETIMES WRITTEN:

MEASURING

Medicine is usually weighed in grams (gm.) and milligrams (mg.).

1000 mg. = 1 gm. (one thousand milligrams make one gram)
1 mg. =.001 gm. (one milligram is one one-thousandth part of a gram)

Examples:

Note: In some countries some medicines are still weighed in grains; gr. = grain and 1 gr. = 65 mg. This means a 5 gr. aspirin tablet weighs about 300 mg.

Many times it is important to know how many grams or milligrams are in a medicine.

For example, if you want to give a small piece of adult aspirin to a child, instead of baby aspirin, but you do not know how big a piece to give...

.3 gm. = 300 mg. and .075 gm. = 75 mg. So, you can see that one adult aspirin weighs 4 times as much as one baby aspirin.

So if you cut an adult aspirin into 4 pieces, you can give the child 1 piece in place of a baby aspirin. Both are equal, and the piece of adult aspirin costs less.

CAUTION: Many medicines, especially the antibiotics, come in different weights and sizes. For example, tetracycline may come in 3 sizes of capsules:

Figure

Be careful to only give medicine in the recommended amounts. It is very important to check how many grams or milligrams the medicine contains.

For example: if the prescription says: Take tetracycline, 1 capsule of 250 mg. 4 times a day, and you have only 50 mg. capsules, you have to take five 50 mg. capsules 4 times a day (20 capsules a day).

Figure

MEASURING PENICILLIN

Penicillin is often measured in units.

Many forms of penicillin (pills and injections) come in doses of 400,000 U.

400,000 U. = 250 mg.

Medicine in Liquid Form

Syrups, suspensions, tonics, and other liquid medicines are measured in milliliters:

Often liquid medicines are prescribed in tablespoons or teaspoons:

Figure

When instructions for a medicine say: Take 1 tsp., this means take 5 ml.

Many of the 'teaspoons' people use hold as much as 8 ml. or as little as 3 ml. When using a teaspoon to give medicine, it is important that it measure 5 ml. - No more. No less.

How to Make Sure that the Teaspoon Used for Medicine Measures 5 ml.

How to Give Medicines to Small Children

Many medicines that come as pills or capsules also come in syrups or suspensions (special liquid form) for children. If you compare the amount of medicine you get, the syrups are usually more expensive than pills or capsules. You can save money by making your own syrup in the following way:

When making syrups for children from pills or capsules, be very careful not to give too much medicine.

CAUTION: To prevent choking, do not give medicines to a child while she is lying on her back, or if her head is pressed back. Always make sure she is sitting up or that her head is lifted forward. Never give medicines by mouth to a child while she is having a fit, or while she is asleep or unconscious.

HOW MUCH MEDICINE SHOULD YOU GIVE TO CHILDREN WHEN YOU ONLY HAVE THE INSTRUCTIONS FOR ADULTS?

Generally, the smaller the child, the less medicine he needs. Giving more than needed can be dangerous. If you have information about the doses for children, follow it carefully. If you do not know the dose, figure it out by using the weight or age of the child. Children should generally be given the following portions of the adult dose:

Adults: 1 dose

Children 8 to 13 years: 1/2 dose

Children 4 to 7 years: 1/4 dose

Children 1 to 3 years: 1/8 dose

Give a child under 1 year old the dose for a child of 1 year, but ask medical advice when possible.

How to Take Medicines

It is important to take medicines more or less at the time recommended. Some medicines should be taken only once a day, but others must be taken more often. If you do not have a clock, it does not matter. If the directions say '1 pill every 8 hours', take 3 a day: one in the morning, one in the afternoon, and one at night. If they say '1 pill every 6 hours', take 4 each day: one in the morning, one at midday, one in the afternoon, and one at night. If the directions are '1 every 4 hours', take 6 a day, allowing more or less the same time between pills.

Figure

Whenever you give a medicine to someone else, it is a good idea to write the instructions and also to have the person repeat to you how and when to take the medicine. Make very sure he understands.

Dosage Instructions for Persons Who Cannot Read

To remind people who cannot read when to take their medicine, you can give them a note like this (1)

In the blanks at the bottom draw the amount of medicine they should take and carefully explain what it means. (2)

Figure

For example:

This means 1 tablet 4 times a day, 1 at sunrise (3), 1 at noon, 1 at sunset, and 1 in the middle of the night.

Figure

This means 1/2 tablet 4 times a day.

This means 1 capsule 3 times a day.

This means 1/4 tablet twice a day.

This means 2 teaspoons twice a day.

WHEN YOU GIVE MEDICINES TO ANYONE...

Always write all the following information on the note with the medicine - even if the person cannot read:

· the person's name (1)
· the name of the medicine (2)
· what it is for (3)
· the dosage (4)

This information can be put on the same note as the drawing for dosage.

A page of these dosage blanks is included at the end of the book. Cut them out and use them as needed. When you run out, you can make more yourself.

When you give medicine to someone, it is a good idea to keep a record of this same information. If possible, keep a complete Patient Report.

TAKING MEDICINES ON A FULL OR EMPTY STOMACH

Some medicines work best when you take them when the stomach is empty - that is, one hour before meals.

Other medicines are less likely to cause upset stomach or heartburn (chest pain) when taken along with a meal or right afterwards.

Antacids do the most good if you take them when the stomach is empty, 1 or 2 hours after meals and at bedtime.

Note: It is best to take medicines while you are standing or sitting up. Also, try to drink a glass of water each time you take a medicine. If you are taking a sulfa medicine, it is important to drink lots of water, at least 8 glasses a day, to prevent harm to the kidneys.

Where There Is No Doctor - A Village Health Care Handbook (Hesperian Foundation, 1993, 516 p.) Chapter 9 - INSTRUCTIONS AND PRECAUTIONS FOR INJECTIONS When to Inject and When Not To Emergencies When It Is Important to Give Injections Medicines Not to Inject Risks and Precautions Dangerous Reactions From Injecting Certain Medicines How to Avoid Serious Reactions to a Penicillin Injection How to Prepare a Syringe for Injection How to Inject How Injections Can Disable Children How to Clean (Sterilize) Equipment

Where There Is No Doctor - A Village Health Care Handbook (Hesperian Foundation, 1993, 516 p.)

Chapter 9 - INSTRUCTIONS AND PRECAUTIONS FOR INJECTIONS

When to Inject and When Not To

Figure

Injections are not needed often. Most sicknesses that require medical treatment can be treated as well or better with medicines taken by mouth. As a general rule:

Injections should be used only when absolutely necessary. Except in emergencies, they should be given only by health workers or persons trained in their use.

The only times medicines should be injected are:

1. When the recommended medicine does not come in a form that can be taken by mouth.
2. When the person vomits often, cannot swallow, or is unconscious.
3. In certain unusual emergencies and special cases (see the next page).

WHAT TO DO WHEN THE DOCTOR PRESCRIBES INJECTIONS

Doctors and other health workers sometimes prescribe injections when they are not needed. After all, they can charge more money for injections. They forget the problems and dangers of giving injections in rural areas.

1. If a health worker or healer wants to give you an injection, be sure the medicine is appropriate and that she takes all the necessary precautions.

2. If a doctor prescribes injections, explain that you live where no one is well trained to give injections and ask if it would be possible to prescribe a medicine to take by mouth.

3. If a doctor wants to prescribe injections of vitamins, liver extract, or vitamin B₁₂ but has not had your blood tested, tell him you would prefer to see another doctor.

Emergencies When It Is Important to Give Injections

In case of the following sicknesses, get medical help as fast as you can. If there will be any delay in getting help or in taking the sick person to a health center, inject the appropriate medicine as soon as possible. For details of the doses, consult the pages listed below. Before injecting, know the possible side effects and take the needed precautions (see the Green Pages).

Medicines Not to Inject

In general, it is better never to inject the following:

1. Vitamins. Rarely are injected vitamins any better than vitamins taken by mouth. Injections are more expensive and more dangerous. Use vitamin pills or syrups rather than injections. Better still, eat foods rich in vitamins.

2. Liver extract, vitamin B₁₂, and iron injections (such as Imferon). Injecting these can cause abscesses or dangerous reactions (shock). Ferrous sulfate pills will do more good for almost all cases of anemia.

3. Calcium. Injected into a vein calcium is extremely dangerous, if not given very slowly. An injection in the buttock may cause a large abscess. Untrained people should never inject calcium.

4. Penicillin. Nearly all infections that require penicillin can be effectively treated with penicillin taken by mouth. Penicillin is more dangerous when injected. Use injectable penicillin only for dangerous infections.

5. Penicillin with streptomycin. As a general rule, avoid this combined medicine. Never use it for colds or the flu because it does not work. It can cause serious problems - sometimes deafness or death. Also, overuse makes it more difficult to cure tuberculosis or other serious illness.

6. Chloramphenicol or tetracycline. These medicines do as much or more good when taken by mouth. Use capsules or syrups rather than injections.

7. Intravenous (I.V.) solutions. These should be used only for severe dehydration and given only by someone who is well trained. When not given correctly they can cause dangerous infections or death.

8. Intravenous medicines. There is so much danger in injecting any medicine in the vein that only well-trained health workers should do it. However, never inject into a muscle (the buttock) medicine that says 'for intravenous use only'. Also, never inject in the vein medicine that says 'for intramuscular use only'.

Risks and Precautions

The risks of injecting any medicines are (1) infection caused by germs entering with the needle and (2) allergic or poisonous reactions caused by the medicine.

1. To lower the chance of infection when injecting, take great care that everything is completely clean. It is very important to boil the needle and syringe before injecting. After boiling, do not touch the needle with your fingers or with anything else.

Never use the same needle and syringe to inject more than one person without boiling it again first. Carefully follow all of the instructions for injecting (see following pages).

Be sure to wash your hands well before preparing or giving injections.

An abscess like this one comes from injecting with a needle that has not been well boiled and is not sterile (completely clean and germ-free).

2. It is very important to know what reactions a medicine can produce and to take the recommended precautions before injecting.

If any of the following signs of allergic or poisonous reaction appear, never give the same or similar medicine again:

· hives (patchy swellings on skin) or a rash with itching
· swelling anywhere
· difficulty breathing
· signs of shock
· dizzy spells with nausea (wanting to vomit)
· problems with vision
· ringing in the ears or deafness
· severe back pain
· difficulty urinating

Hives, or a rash with itching, can appear a few hours or up to several days after getting an injection. If the same medicine is given to the person again, it may cause a very severe reaction or even death.

This child was injected with a needle that was not sterile (boiled and completely free of germs).

The dirty needle caused an infection that produced a large, painful abscess (pocket of pus) and gave the child a fever. Finally, the abscess burst as shown in the picture below.

This child was injected for a cold. It would have been far better to give him no medicine at all. Rather than doing good, the injection caused the child suffering and harm.

Figure

Figure

To avoid problems like these:

Inject only when absolutely necessary.

· Boil the syringe and needle just before giving the injection and be very careful to keep them completely clean.

· Use only the medicine recommended for the disease and be sure it is still in good condition and not spoiled.

· Inject in the correct place. Do not inject infants and small children in the buttock. Instead, inject them in the upper, outer part of the thigh. (Notice that this child was injected too low on the buttock, where it is possible to damage the nerve.)

Dangerous Reactions From Injecting Certain Medicines

The following groups of medicines sometimes produce a dangerous reaction called ALLERGIC SHOCK a short time after injection:

The risk of a serious reaction is greater in a person who has previously been injected with one of these medicines or with another medicine of the same group. This risk is especially great if the medicine caused an allergic reaction (hives, rash, itching, swelling, or trouble breathing) a few hours or days after the injection was given.

To prevent a serious reaction from an injection:

1. Use injections only when absolutely necessary.

2. Before injecting one of the medicines listed above, always have ready 2 ampules of epinephrine (Adrenalin) and an ampule of an antihistamine like promethazine (Phenergan) or diphenhydramine (Benadryl).

3. Before injecting, always ask if at any other time a similar injection caused itching or other reactions. If the person says yes, do not use this medicine or any other medicine of the same group, either injected or taken by mouth.

4. In very serious cases, like tetanus or snakebite, if there is a good chance that the antitoxin might produce an allergic reaction (if the person suffers from allergies or asthma or has had horse serum before), inject promethazine or diphenhydramine 15 minutes before giving the antitoxin: adults, 25 to 50 mg.; children, 10 to 25 mg, depending on their size.

5. After injecting any medicine, always stay with the person for 30 minutes to watch for any of the following signs of ALLERGIC SHOCK:

· cool, moist, pale, gray skin (cold sweat)
· weak, rapid pulse or heartbeat
· difficulty breathing
· loss of consciousness

6. If these signs appear, immediately inject epinephrine (Adrenalin): adults, 1/2 ml.; children, 1/4 ml. Treat the person for SHOCK. Follow by giving an antihistamine in double the normal dose.

How to Avoid Serious Reactions to a Penicillin Injection

How to Prepare a Syringe for Injection

Before preparing a syringe, wash hands with soap and water.

1. Take the syringe apart and boil it and the needle for 20 minutes.

2. Pour out the boiled water without touching the syringe or the needle.

3. Put the needle and the syringe together, touching only the base of the needle and the button of the plunger.

4. Clean the ampule of distilled water well, then break off the top.

5. Fill the syringe. (Be careful that the needle does not touch the outside of the ampule.)

6. Rub the rubber of the bottle with clean cloth wet with alcohol or boiled water.

7. Inject the distilled water into the bottle with the powdered medicine.

8. Shake until the medicine dissolves.

9. Fill the syringe again.

10. Remove all air from the syringe.

Be very careful not to touch the needle with anything - not even the cotton with alcohol. If by chance the needle touches your finger or something else, boil it again.

WHERE TO GIVE AN INJECTION

Before injecting, wash hands with soap and water.

It is preferable to inject in the muscle of the buttocks, always in the upper outer quarter.

Figure

WARNING: Do not inject into an area of skin that is infected or has a rash.

Do not inject infants and small children in the buttock. Inject them in the upper outer part of the thigh.

Figure

How to Inject

1. Clean the skin with soap and water (or alcohol - but to prevent severe pain, be sure the alcohol is dry before injecting).

2 Put the needle straight in, all the way (If it is done with one quick movement, it hurts less)

3. Before injecting, pull back on the plunger. (If blood enters the syringe, take the needle out and put it in somewhere else).

4. If no blood enters, inject the medicine slowly.

5. Remove the needle and clean the skin again.

6. After injecting, rinse the syringe and needle at once. Squirt water through the needle and then take the syringe apart and wash it. Boil before using again.

How Injections Can Disable Children

When used correctly, certain injected medicines are important to health.

Vaccinations, including those that are injected, help to protect a child's health and prevent disability. However, to reduce the chance of paralysis from polio, it is best not to give vaccinations (immunizations) or any other injections when a child has a fever or signs of a cold. This could be a mild polio infection without paralysis. If so, the irritation caused by an injection could cause permanent paralysis from the polio. Some experts say that each year thousands of children are paralyzed by polio because of injections. Most of these injections are not needed.

1 out of every 3 cases of polio is caused by injections.

For more information on how injections disable children, see Disabled Village Children, Chapter 3.

For ideas on teaching people about the danger of unnecessary injections, see Helping Health Workers Learn, Chapters 18, 19, and 27.

How to Clean (Sterilize) Equipment

Many infectious diseases, such as AIDS, hepatitis, and tetanus, can be passed from a sick person to a healthy person through the use of syringes, needles, and other instruments that are not sterile (this includes the instruments used for piercing ears, acupuncture, tattoos, or circumcision). Many skin infections and abscesses also start because of this. Any time the skin is cut or pierced, it should only be done with equipment that has been sterilized.

Here are some ways to sterilize equipment:

· Boil for 20 minutes. (If you do not have a clock, add 1 or 2 grains of rice to the water. When the rice is cooked, the equipment will be sterile.)

· Or steam for 15 minutes in a special pot called a pressure cooker (or autoclave).

· Or soak for 20 minutes in a solution of 1 part chlorine bleach to 7 parts water, or in a solution of 70% ethanol alcohol. If possible, prepare these solutions fresh each day, because they lose their strength. (Be sure to sterilize the inside of a syringe by pulling some solution inside and then squirting it out.)

When you are helping someone who has an infectious disease, wash your hands often with soap and water.