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Contents

Brown Pages

WORDS TO THE VILLAGE HEALTH WORKER

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

Balance Between People and Land

Balance Between Prevention and Treatment

Sensible and Limited Use of Medicines

Finding Out What Progress Has Been Made

Teaching and Learning Together

Tools for Teaching

Making the Best Use of This Book


Chapter 1

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

Sunken Fontanel or Soft Spot

Ways to Tell Whether a Home Remedy Works or Not

Medicinal Plants

Homemade Casts, for Broken Bones

Enemas, Laxatives, and Purges


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

Example of Local Names for Sicknesses

Misunderstanding Due to Confusion of Names

Confusion between Different Illnesses That Cause Fever


Chapter 3

HOW TO EXAMINE A SICK PERSON

Questions

General Condition of Health

Temperature

Thermometer: How to Use

Breathing (Respiration)

Pulse (Heartbeat)

Eyes

Ears

Skin

Belly (Abdomen)

Muscles and Nerves


Chapter 4

HOW TO TAKE CARE OF A SICK PERSON

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


Chapter 5

HEALING WITHOUT MEDICINES

Healing with Water

When Water Is Better than Medicines


Chapter 6

RIGHT AND WRONG USE OF MODERN MEDICINES

Guidelines for the Use of Medicine

When Should Medicine Not Be Taken?

Misuse of Medicines: The Most Dangerous


Chapter 7

ANTIBIOTICS: WHAT THEY ARE AND HOW TO USE THEM

Guidelines for the Use of Antibiotics

What to Do if an Antibiotic Does Not Seem to Help

Importance of Limited Use of Antibiotics


Chapter 8

HOW TO MEASURE AND GIVE MEDICINE

Medicine in Liquid Form

Dosage Instructions for Persons Who How to Give Medicines to Small Children

Cannot Read

How to Take Medicines


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

Avoiding Serious Reactions to Penicillin

How to Prepare a Syringe for Injection

How to Inject

How Injections Can Disable Children

How to Sterilize Equipment


Chapter 10

FIRST AID

Basic Cleanliness and Protection

Fever

Shock

Loss of Consciousness

When Something Gets Stuck in the Throat

Drowning

When Breathing Stops: Mouth-to-Mouth Breathing

Emergencies Caused by Heat

How to Control Bleeding from a Wound

How to Stop Nosebleeds

Cuts, Scrapes, and Small Wounds

Large Cuts: How to Close Them

Bandages

Infected Wounds

Bullet, Knife, and Other Serious Wounds

Emergency Problems of the Gut (Acute Abdomen)

Appendicitis, Peritonitis

Burns

Broken Bones (Fractures)

How to Move a Badly Injured Person

Dislocations (Bones Out of Place at a Joint)

Strains and Sprains

Poisoning

Snakebite

Other Poisonous Bites and Stings


Chapter 11

NUTRITION: WHAT TO EAT TO BE HEALTHY

Sicknesses Caused by Not Eating Well

Why It Is Important to Eat Right

Preventing Malnutrition

Main Foods and Helper Foods

Eating Right to Stay Healthy

How to Recognize Malnutrition

Eating Better When You Do Not Have Much Money or Land

Where to Get Vitamins: In Pills or in Foods?

Things to Avoid in Our Diet

Diet for Small Children

Harmful Ideas about Diet

Special Diets for Specific Health Problems

Anemia

Rickets

High Blood Pressure

People Who Are Too Heavy

Constipation

Diabetes

Acid Indigestion, Heartburn, and Stomach Ulcers

Goiter (A Swelling or Lump on the Throat)


Chapter 12

PREVENTION: HOW TO AVOID MANY SICKNESSES

Cleanliness, and Problems from Lack of Cleanliness

Basic Guidelines of Cleanliness

Sanitation and Latrines

Worms and Other Intestinal Parasites

Roundworm (Ascaris)

Pinworm (Threadworm, Enterobius)

Whipworm (Trichuris)

Hookworm

Tapeworm

Trichinosis

Amebas

Giardia

Blood Flukes (Schistosomiasis, Bilharzia)

Vaccinations (lmmunizations), Simple, Sure Protection

Other Ways to Prevent Sickness and Injury

Habits That Affect Health


chapter 13

SOME VERY COMMON SICKNESSES

Dehydration

Diarrhea and Dysentery

The Care of a Person with Acute Diarrhea

Vomiting

Headaches and Migraines

Colds and the Flu

Stuffy and Runny Noses

Sinus Trouble (Sinusitis)

Hay Fever (Allergic Rhinitis)

Allergic Reactions

Asthma

Cough

Bronchitis

Pneumonia

Hepatitis

Arthritis (Painful, Inflamed Joints)

Back Pain

Varicose Veins

Piles (Hemorrhoids)

Swelling of the Feet and Other Parts of the Body

Hernia (Rupture)

Seizures (Fits, Convulsions)


chapter 14

SERIOUS ILLNESSES THAT NEED SPECIAL MEDICAL ATTENTION

Tuberculosis (TB, Consumption)

Rabies

Tetanus (Lockjaw)

Meningitis

Malaria

Dengue (Breakbone Fever, Dandy Fever)

Brucellosis (Undulant Fever, Malta Fever)

Typhoid Fever

Typhus

Leprosy (Hansen’s Disease)


chapter 15

SKIN PROBLEMS

General Rules for Treating Skin Problems

Instructions for Using Hot Compresses

Identifying Skin Problems

Scabies

Lice

Bedbugs

Ticks and Chiggers

Small Sores with Pus

Impetigo

Boils and Abscesses

Itching Rash, Welts, or Hives

Things That Cause Itching or Burning of the Skin

Shingles (Herpes Zoster)

Ringworm, Tinea (Fungus Infections)

White Spots on the Face and Body

Mask of Pregnancy

Pellagra and Other Skin Problems Due to Malnutrition

Warts (Verrucae)

Corns

Pimples and Blackheads (Acne)

Cancer of the Skin

Tuberculosis of the Skin or Lymph Nodes

Erysipelas and Cellulitis

Gangrene (Gas Gangrene)

Ulcers of the Skin Caused by Poor Circulation

Bed Sores

Skin Problems of Babies

Eczema (Red Patches with Little Blisters)

Psoriasis


chapter 16

THE EYES

Danger Signs

Injuries to the Eye

How to Remove a Speck of Dirt from the Eye

Chemical Burns of the Eye

Red, Painful Eyes, Different Causes

‘Pink Eye’ (Conjunctivitis)

Trachoma

Infected Eyes in Newborn Babies (Neonatal Conjunctivitis)

Iritis (Inflammation of the Iris)

Glaucoma

Infection of the Tear Sac (Dacryocystitis)

Trouble Seeing Clearly

Cross-Eyes and Wandering Eyes

Sty (Hordeolum)

Pterygium

Scrape, Ulcer, or Scar on the Cornea

Bleeding in the White of the Eye

Bleeding Behind the Cornea (Hyphema)

Pus Behind the Cornea (Hypopyon)

Cataract

Night Blindness and Xerophthalmia

Spots or ‘Floaters’ Before the Eyes

Double Vision

River Blindness (Onchocerciasis)


chapter 17

THE TEETH, GUMS, AND MOUTH

Care of Teeth and Gums

If You Do Not Have a Toothbrush

Toothaches and Abscesses

Pyorrhea, a Disease of the Gums

Sores or Cracks at the Corners of the Mouth

White Patches or Spots in the Mouth

Cold Sores and Fever Blisters


chapter 18

THE URINARY SYSTEM AND THE GENITALS

Urinary Tract Infections

Kidney or Bladder Stones

Enlarged Prostate Gland

Diseases Spread by Sexual Contact (Sexually Transmitted Infections, STDs)

Gonorrhea (Clap, VD, the Drip) and Chlamydia

Syphilis

Bubos: Bursting Lymph Nodes in the Groin

Use of a Catheter to Drain Urine

Problems of Women

Vaginal Discharge

How a Woman Can Avoid Many Infections

Pain or Discomfort in a Woman’s Belly

Infertility: Men and Women Who Cannot Have Children


chapter 19

INFORMATION FOR MOTHERS AND MIDWIVES

The Menstrual Period (Monthly Bleeding in Women)

The Menopause (When Women Stop Having Periods)

Pregnancy

How to Stay Healthy during Pregnancy

Minor Problems during Pregnancy

Danger Signs in Pregnancy

Check-ups during Pregnancy (Prenatal Care)

Record of Prenatal Care

Things to Have Ready before the Birth

Preparing for Birth

Signs That Show Labor Is Near

The Stages of Labor

Care of the Baby at Birth

Care of the Cut Cord (Navel)

The Delivery of the Placenta (Afterbirth)

Hemorrhaging (Heavy Bleeding)

Medicines to Control Bleeding After Birth or Miscarriage: Oxytocin, Misoprostol, Ergometrine

Difficult Births

Tearing of the Birth Opening

Care of the Newborn Baby

Illnesses of the Newborn

The Mothers Health after Childbirth

Childbirth Fever (Infection after Giving Birth)

Care of the Breasts

Lumps or Growths in the Lower Part of the Belly

Miscarriage (Spontaneous Abortion)

High Risk Mothers and Babies


chapter 20

FAMILY PLANNING, HAVING THE NUMBER OF CHILDREN YOU WANT

Family Planning

How Women Become Pregnant

Family Planning Methods

Other Methods of Family Planning

Natural Methods of Family Planning

These Methods Do Not Prevent Pregnancy

Methods for Those Who Never Want to Have More Children


chapter 21

HEALTH AND SICKNESSES OF CHILDREN

Condoms

Birth Control Pills (Oral Contraceptives)

What to Do to Protect Children’s Health

Children’s Growth, and the ‘Road to Health’

Child Health Chart

Review of Children’s Health Problems Discussed in Other Chapters

Health Problems of Children Not Discussed in Other Chapters

Earache and Ear Infections

Sore Throat and Inflamed Tonsils

Rheumatic Fever

Infectious Diseases of Childhood

Chickenpox

Measles (Rubeola)

German Measles (Rubella)

Mumps

Whooping Cough

Diphtheria

Infantile Paralysis (Polio)

How to Make Simple Crutches

Problems Children Are Born With

Dislocated Hip

Umbilical Hernia (Belly Button that Sticks Out)

Swollen Testicle (Hydrocele or Hernia)

Mentally Slow, Deaf, or Deformed Children

Spastic Child (Cerebral Palsy)

Slow Development in the First Months of Life

Sickle Cell Disease

Helping Children Learn


chapter 22

HEALTH AND SICKNESSES OF OLDER PEOPLE

Summary of Health Problems Discussed in Other Chapters

Other Important Illnesses of Old Age

Heart Trouble

Words to Younger Persons Who Want to Stay Healthy When Older

Stroke (Apoplexy, Cerebro-Vascular Accident, CVA)

Deafness

Loss of Sleep (Insomnia)

Diseases Found More Often in People over Forty

Cirrhosis of the Liver

Gallbladder Problems

Accepting Death


chapter 23

THE MEDICINE KIT

How to Care for Your Medicine Kit

Buying Supplies for the Medicine Kit

Home Medicine Kit

Village Medicine Kit

Words to the Village Storekeeper (or Pharmacist)


THE GREEN PAGES

THE USES, DOSAGE, AND PRECAUTIONS FOR MEDICINES

List of Medicines in the Green Pages

Index of Medicines in the Green Pages

Information on Medicines


ADDITIONAL INFORMATION

HIV and AIDS

Sores on the Genitals

Circumcision and Excision

Special Care for Small, Early, and Underweight Babies

Ear Wax

Leishmaniasis

Guinea Worm

Emergencies Caused by Cold

Blood Pressure: How to Measure

Poisoning from Pesticides

Complications from Abortion

Drug Abuse and Addiction

VOCABULARY, Explaining Difficult Words

ADDRESSES FOR TEACHING MATERIALS

INDEX (Yellow Pages)

Introduction

This handbook has been written primarily for those who live far from medical centers, in places Where There Is No Doctor.

But even where there are doctors, people can and should take the lead in their own health care. So this book is for everyone who cares.

It has been written in the belief that:

  1. Health care is not only everyone’s right, but everyone’s responsibility.

  2. Informed self-care should be the main goal of any health program or activity.

  3. Ordinary people provided with clear, simple information can prevent and treat most common health problems in their own homes, earlier, cheaper, and often better than can doctors.

  4. Medical knowledge should not be the guarded secret of a select few, but should be freely shared by everyone.

  5. People with little formal education can be trusted as much as those with a lot. And they are just as smart.

  6. Basic health care should not be delivered, but encouraged.

Clearly, a part of informed self-care is knowing one’s own limits. Therefore guidelines are included not only for what to do, but for when to seek help.

The book points out those cases when it is important to see or get advice from a health worker or doctor. But because doctors or health workers are not always nearby, the book also suggests what to do in the meantime, even for very serious problems.

This book has been written in fairly basic English, so that persons without much formal education (or whose first language is not English) can understand it.

The language used is simple but, I hope, not childish. A few more difficult words have been used where they are appropriate or fit well. Usually they are used in ways that their meanings can be easily guessed. This way, those who read this book have a chance to increase their language skills as well as their medical skills.

Important words the reader may not understand are explained in a word list or vocabulary at the end of the book. The first time a word listed in the vocabulary is mentioned in a chapter it is usually written in italics.

Where There Is No Doctor was first written in Spanish for farm people in the mountains of Mexico where, years ago, the author helped form a health care network now run by the villagers themselves.

Where There Is No Doctor has been translated into more than 80 languages and is used by village health workers in over 100 countries.

The first English edition was the result of many requests to adapt it for use in Africa and Asia. I received help and suggestions from persons with experience in many parts of the world.

But the English edition seems to have lost much of the flavor and usefulness of the original Spanish edition, which was written for a specific area, and for people who have for years been my neighbors and friends.

In rewriting the book to serve people in many parts of the world, it has in some ways become too general.

To be fully useful, this book should be adapted by persons familiar with the health needs, customs, special ways of healing, and local language of specific areas.

Persons or programs who wish to use this book, or portions of it, in preparing their own manuals and activities for villagers or health workers are encouraged to do so.

We often grant permission at no charge, provided the parts reproduced are distributed free or at cost, not for profit.

Please see the explanation online at hesperian.org/about/open-copyright, or contact us at permissions@hesperian.org to answer any questions. Our goal is to help you design a program that works for you, not to make money.

For local or regional health programs that do not have the resources for revising this book or preparing their own manuals, it is strongly suggested that if the present edition is used, leaflets or inserts be supplied with the book to provide additional information as needed.

In the Green Pages (the Uses, Dosage, and Precautions for Medicines) blank spaces have been left to write in common brand names and prices of medicines.

Once again, local programs or organizations distributing the book would do well to make up a list of generic or low-cost brand names and prices, to be included with each copy of the book.

This book was written for anyone who wants to do something about his or her own and other people’s health.

However, it has been widely used as a training and work manual for community health workers.

For this reason, an introductory section has been added for the health worker, making clear that the health worker’s first job is to share her knowledge and help educate people.

Today in over-developed as well as under-developed countries, existing health care systems are in a state of crisis.

Often, human needs are not being well met. There is too little fairness. Too much is in the hands of too few.

Let us hope that through a more generous sharing of knowledge, and through learning to use what is best in both traditional and modern ways of healing, people everywhere will develop a kinder, more sensible approach to caring, for their own health, and for each other.

Note about this New Edition

In this revised edition of Where There Is No Doctor, we have added new information and updated old information, based on the latest scientific knowledge. Health care specialists from many parts of the world have generously given advice and suggestions.

When it would fit without having to change page numbers, we have added new information to the main part of the book. (This way, the numbering stays the same, so that page references in our other books, such as Helping Health Workers Learn, will still be correct.)

The Additional Information section at the end of the book has information about health problems of growing or special concern: HIV and AIDS, sores on the genitals, leishmaniasis, complications from abortion, guinea worm, and others.

Here also are topics such as measuring blood pressure, misuse of pesticides, drug addiction, and a method of caring for early and underweight babies.

New ideas and information can be found throughout the book, medical knowledge is always changing! For example:

Nutrition advice has changed. Experts used to tell mothers to give children more foods rich in proteins. But it is now known that what most poorly nourished children need is more energy-rich foods. Many low-cost energy foods, especially grains, provide enough protein if the child eats enough of them. Finding ways to give enough energy foods is now emphasized, instead of the ‘four food groups’.

• Advice for treatment of stomach ulcer is different nowadays. For years doctors recommended drinking lots of milk. But according to recent studies, it is better to drink lots of water, not milk.

• Knowledge about special drinks for diarrhea (oral rehydration therapy) has also changed. Not long ago experts thought that drinks made with sugar were best. But we now know that drinks made with cereals do more to prevent water loss, slow down diarrhea, and combat malnutrition than do sugar-based drinks or “ORS” packets.

• A section has been added on sterilizing equipment. This is important to prevent the spread of certain diseases, such as HIV.

• We have also added sections on dengue, sickle cell disease, and contraceptive implants. We revised information about treatment of snakebite.

• Read details on building the fly-killing VIP latrine.

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. 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…

Sickness usually results from a combination of causes

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.

18

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 (see page 55), do not help cure non-infectious diseases.

Remember: Antibiotics are of no use for non-infectious diseases.

examples of NON-INFECTIOUS DISEASES

Problems caused by:

something that wears out or goes wrong within the body

  • rheumatism
  • heart attack epileptic seizures stroke
  • migraine headaches cataract
  • cancer

something from outside that harms or troubles the body

  • allergies
  • asthma
  • poisons
  • snakebite
  • cough from smoking
  • stomach ulcer
  • alcoholism

lack of something the body needs

  • malnutrition
  • anemia
  • pellagra
  • night blindness and xerophthalmia
  • goiter and hypothyroidism
  • cirrhosis of the liver (part of the cause)

Problems people are born with

  • harelip
  • crossed or wall-eyes (squint)
  • other deformities
  • epilepsy (some kinds)
  • mental slowness
  • birthmark

Problems that begin in the mind (mental illnesses)

  • fear that something is harmful when it is not (paranoia)
  • nervous worry (anxiety)
  • belief in hexes (witchcraft)
  • uncontrolled fear (hysteria)

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:

19

examples of INFECTIOUS DISEASES


Organism that causes the sickness:


bacteria (microbes or germs)


tuberculosis

How it is spread or enters the body: through the air (coughing)

Principal medicine: different antibiotics for different bacterial infections


tetanus

How it is spread or enters the body: dirty wounds

Principal medicine: different antibiotics for different bacterial infections


some diarrhea

How it is spread or enters the body: dirty fingers, water, flies

Principal medicine: different antibiotics for different bacterial infections


pneumonia (some kinds)

How it is spread or enters the body: through the air (coughing)

Principal medicine: different antibiotics for different bacterial infections


gonorrhea, chlamydia, and syphillis

How it is spread or enters the body: sexual contact

Principal medicine: different antibiotics for different bacterial infections


earache

How it is spread or enters the body: with a cold

Principal medicine: different antibiotics for different bacterial infections


infected wounds

How it is spread or enters the body: contact with dirty things

Principal medicine: different antibiotics for different bacterial infections


sores with pus

How it is spread or enters the body: direct contact (by touch)

Principal medicine: different antibiotics for different bacterial infections


virus (germs smaller than bacteria)


colds, flu, measles, mumps, chickenpox, infantile paralysis, virus diarrhea

How it is spread or enters the body: from someone who is sick, through the air, by coughing. flies, etc.

Principal medicine: acetaminophen and other painkillers


rabies

How it is spread or enters the body: animal bites

Principal medicine: vaccinations prevent some virus infections


warts

How it is spread or enters the body: touch

Principal medicine: vaccinations prevent some virus infections


HIV

How it is spread or enters the body: body fluids of someone infected get inside another person ́s body

Principal medicine: Antiretroviral medicines fight HIV.


Fungus


ringworm fungus athlete’s foot, jock itch, yeast infection

How it is spread or enters the body: by touch or from clothing

Principal medicine: nystatin, miconazole, gentian violet, ointments with undecylenic, benzoic, or salicylic acid


internal parasites (harmful animals living in the body)


In the gut: worms, amebas (dysentery)

How it is spread or enters the body: feces-to-mouth lack of cleanliness

Principal medicine: different specific medicines


internal parasites (harmful animals living in the body)


In the blood: malaria

How it is spread or enters the body: mosquito bite

Principal medicine: a combination of malaria medicines


External parasites (harmful animals living on the body)


lice, fleas bedbugs scabies

How it is spread or enters the body: by contact with infected persons or their clothes

Principal medicine: permethrin, keeping very clean


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.

Antibiotics (penicillin, tetracycline, etc.) are medicines that help cure certain illnesses caused by bacteria.

Antibiotics have no effect on illnesses caused by 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).

20

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 (see page 112)

    • a lot of roundworms, (see page 140), (usually together with malnutrition)

    • advanced tuberculosis (see page 179)

    • a long-term severe urinary infection (see page 234)

    • any of several problems of the liver or spleen

    • leukemia (cancer of the blood)

    • HIV (see page 339)

  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 (see page 213)

    • diabetes(see page 127)

    • infection of the bone (osteomyelitis)

    • leprosy (see page 191)

    • tuberculosis of the skin (see page 212)

    • advanced syphilis (see page 237)

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.

Work within your limits! In using this book, remember it is easy to make mistakes. Never pretend you know something you do not. If you are not fairly sure what an illness is and how to treat it, or if the illness is very serious, get medical help.

21

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 cannot find the sickness you are looking for in this book, look for it under a different name or in the chapter that covers the same sort of problem. Use the list of CONTENTS and the Index

If you are unsure what the sickness is, especially 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.

examples of local names for sicknesses


STOPPED-UP GUT

Means that the gut is stopped up or obstructed (see page 94). 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.

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

• diarrhea or dysentery with cramps (see page 153)

• worms (see page 140)

• swollen stomach due to malnutrition (see page 112)

• indigestion or stomach ulcer (see page 128)

• and rarely, true gut obstruction or appendicitis (see page 94)

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.


SIDE PAINS

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, (see page 234)

• cramps or gas pains (see diarrhea 153)

• menstrual pains (see page 245)

• appendicitis (see page 94)

• an infection, cyst, or tumor in the womb or ovaries (see page 243) or an ectopic pregnancy (see page 280)


22

CONGESTION

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

the head, the chest, the stomach, or the whole body. It is said that la congestión strikes persons who break ‘the diet’ (see page 123), 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 congestión.

Different illnesses that are sometimes called la congestión are:

• Food poisoning, from eating spoiled food: causes sudden vomiting followed by diarrhea, cramps, and weakness (see page 135).

• 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 (see page 166).

• Any sudden upset of the stomach or gut: see diarrhea (see page 153), vomiting (see page 161), and acute abdomen (see page 93).

• Sudden or severe difficulty breathing: caused by asthma (page 167), pneumonia (page 171), or something stuck in the throat (page 79).

• Illnesses that cause seizures (fits) or paralysis: see seizures (page 178), tetanus (page 182), meningitis (page 185), polio (page 314), and stroke (page 327).

• Heart attacks: mostly in older persons (page 325).


23

CONGESTION

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

the head, the chest, the stomach, or the whole body. It is said that la congestión strikes persons who break ‘the diet’ (see page 123), 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 congestión. Different illnesses that are sometimes called la congestión are:

• Food poisoning, from eating spoiled food: causes sudden vomiting followed by diarrhea, cramps, and weakness (see page 135).

• 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 (see page 166).

• Any sudden upset of the stomach or gut: see diarrhea (page 153), vomiting (page 161), and acute abdomen (page 93).

• Sudden or severe difficulty breathing: caused by asthma (page 167), pneumonia (page 171), or something stuck in the throat (page 79).

• Illnesses that cause seizures (fits) or paralysis: see seizures (page 178), tetanus (page 182), meningitis (page 185), polio (page 314), and stroke (page 327).

• Heart attacks: mostly in older persons (page 325).


PULSING

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 (page 112), or hunger! Eating enough good food is the only real treatment (see page 110 and page 111).


24

HYSTERIA, FRIGHT

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

Possible medical explanations for hysteria:

  1. In many people, hysteria is a state of fear, perhaps caused by the ‘power of belief’ (see page 4). 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, hysteria 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 (page 112). Sometimes early signs of tetanus (page 182) or meningitis (page 185) are also called susto.

Treatment:

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

When the hysteria 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

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.

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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:

Avoid misunderstanding, go by the signs and history of a person’s sickness, not the name people give it!


Spanish Name: CÁNCER (CANCER)

Mexican villagers use the word cáncer for any severe infection of the skin, especially badly infected wounds (page 88) or gangrene (page 213).

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:

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)

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, page 191). Sores commonly called lepra are:

• impetigo and other skin infections (page 202)

• sores that come from insect bites or scabies (page 199)

• chronic sores or skin ulcers such as those caused by poor circulation (page 213)

• skin cancer (page 211)

• less commonly, leprosy (page 191) or tuberculosis of the skin (page 212)

26

confusion between different illnesses that cause fever

Spanish Name: LA FIEBRE (THE FEVER)

Correctly speaking, a fever is a body temperature higher than normal. But in Latin America, 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.

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: (see page 186)

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.

Typhoid: (see page 188)

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.

Typhus: (see page 190)

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

Hepatitis: (see page 172)

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.

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Pneumonia: (see page 171)

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

Rheumatic fever: (see page 310)

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.

Brucellosis (undulant fever, Malta fever): (see page 188)

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.

Childbirth fever: (see page 276)

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.

All of these illnesses can be dangerous. In addition to those shown here, there are many other diseases that may cause similar signs and fever. For example, fevers that last for more than 1 month, or night sweats, may be caused by HIV infection (see page 399). When possible, seek medical help.

3

sick person: how to examine

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 (see page 44).

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?

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.)

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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 (see page 151) and of shock (page 77).

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 (page 124). Skin may also go lighter as a result of tuberculosis (page 179), or kwashiorkor (page 113).

• Darkening of the skin may be a sign of starvation (see page 112).

• Bluish skin, especially blueness or darkness of the lips and fingernails, may mean serious problems with breathing (page 79, 167, and 313) or with the heart (page 325). Blue-gray color in an unconscious child may be a sign of cerebral malaria (page 186).

• A gray-white coloring, with cool moist skin, often means a person is in shock (page 77).

• Yellow color (jaundice) of the skin and eyes may result from disease in the liver (hepatitis, page 172, cirrhosis, page 328, or amebic abscess, page 145) or gallbladder (page 329). It may also occur in newborn babies (page 274), and in children born with sickle cell disease (page 321). 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 (page 311).

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.

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.

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 (page 163). 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.

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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):

  • Turn the thermometer until you can see the silver line.

  • The point where the silver line stops marks the temperature.

  • Normal: 37

  • Fever: 37 > 39

  • High Fever: 39 > 42

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.

  2. Put the thermometer:

    • under the tongue (keeping the or mouth shut)

    • in the armpit if there is danger of biting or the thermometer

    • 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° C) may mean a serious infection (see page 275).

♦ To learn about other fever patterns, see page 26 to page 27.

♦ To learn what to do for a fever, see page 75.

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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 younger children, and 40 for babies.

People with a high fever or serious respiratory illness breathe more quickly than normal. For example, more than 30 shallow breaths a minute in an adult usually means pneumonia, as does 60 breaths a minute for a newborn baby.

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

• A whistle or wheeze and difficulty breathing out can mean asthma (see page 167).

• 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 (page 79), pneumonia (page 171), asthma (page 167), or bronchitis (mild sucking in, see page 170).

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.

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.

PULSE (HEARTBEAT)

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

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

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

normal pulse for people at rest

adults - from 60 to 80 per minute

children - 80 to 100

babies - 100 to 140

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 (see page 77).

  • A very rapid, very slow, or irregular pulse could mean heart trouble (see page 325).

  • A relatively slow pulse in a person with a high fever may be a sign of typhoid (see page 188).

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EYES

Look at the color of the white part of the eyes. Is it normal, red (page 219), 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 and color of the pupils (the black ‘window’ in the center of the eye). If they are very large, it can mean a state of shock (see page 77). If they are very large, or very small, it can mean poison or the effect of certain drugs. If there is a white glow, it can mean cataracts (see page 225) or cancer.

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

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 (see page 222).

  • If the eye with the smaller pupil hurts a great deal, the person may have IRITIS, a very serious problem (see page 221).

  • 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 (see page 327).

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

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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 may have an ear infection (page 309).

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.

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 page 327.

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 (see page 309). 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 hay fever (page 165).

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, see page 88)

  • abnormal lumps or masses

  • unusual thinning or loss of hair, or loss of its color or shine (page 112)

  • loss of eyebrows (leprosy? page 191)

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).

For identification of different skin problems, see pages 196–198.

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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 (see page 94).

If you suspect peritonitis or appendicitis, do the test for rebound pain described on page 95.

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, page 93.)

A silent belly is like a silent dog. Beware!

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

Ulcer (see page 128) pain in the ‘pit of the stomach

Appendicitis (see page 94) First it hurts here later it hurts here

Gallbladder (see page 329) the pain often reaches to the back

Liver (see page 172, page 144, and page 328) pain here, at times it spreads to the chest

Urinary system (see page 234) mid or low back pain, often goes around the waist to the lower part of the belly

Ectopic pregnancy (see page 280) pain on one side or both, sometimes with pain in the shoulder or neck

Note: For different causes of back pain, see page 173

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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.

If the problem began more or less suddenly, think of a head injury (page 91), stroke (page 327), or Bell’s palsy (page 327).

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

Also check for normal eye movement, size of pupils (page 217), and how well he can see.

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

Watch how he moves and walks. If muscle loss or weakness affects the whole body, suspect malnutrition (page 112) or a chronic (long-term) illness like tuberculosis.

Have him squeeze your fingers to compare strength in his hands and push and pull with his feet against your hand.

Also have him hold his arms straight out and turn his hands up and down.

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

Have him lie down and lift one leg and then the other.

Note any weakness or trembling.

If muscle loss and weakness is uneven or worse on one side, in children, think first of polio (page 314); 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.

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Check for stiffness or tightness of different muscles

  • If the jaw is stiff or will not open, suspect tetanus (page 182) or a severe infection of the throat (page 309) or of a tooth (page 231). If the problem began after he yawned or was hit in the jaw, he may have a dislocated jaw.

  • 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 (page 185). meningitis

  • If a child always has some stiff muscles and makes strange or jerky movements, he may be spastic (page 320).

  • If strange or jerky movements come suddenly, with loss of consciousness, he may have seizures (page 178). If seizures happen often, think of epilepsy.

If they happen when he is ill, the cause may be high fever (page 76) or dehydration (page 151) or tetanus (page 182) or meningitis (page 185).

To test a person’s reflexes when you suspect tetanus, see page 183.

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 (page 191). • Loss of feeling in both hands or feet may be due to diabetes (page 127) or leprosy.

  • Loss of feeling on one side only could come from a back problem (page 174) or injury.

4

sick person: how to take care

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

The care a sick person receives is frequently the most important part of his treatment.

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

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 (see page 75).

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.

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.

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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.

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. These are explained on the following pages:

  • anemia 124
  • stomach ulcers and heartburn 128
  • appendicitis, gut obstruction, acute abdomen (in these cases take no food at all) 93
  • diabetes 127
  • heart problems 325
  • gallbladder problems 329
  • high blood pressure 125

SPECIAL CARE FOR A PERSON WHO IS VERY ILL

1. Liquids

It is extremely important that a very sick person drink enough liquid. 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 (240 ml.) 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 (page 151), 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 (see page 152). 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.

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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.

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 (see page 214). 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 (see page 171).

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 pulse breathing (how many degrees) (beats per minute) (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.

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SIGNS OF DANGEROUS ILLNESS

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.

Until help comes, follow the instructions on the pages indicated:

  1. Loss of large amounts of blood from anywhere in the body 82, 264, 281

  2. Coughing up blood 179

  3. Marked blueness of lips and nails (if it is new) 30

  4. Great difficulty in breathing; does not improve with rest 167, 325

  5. The person cannot be wakened (coma) 78

  6. The person is so weak he faints when he stands up 325

  7. Twelve hours or more without being able to urinate 234

  8. A day or more without being able to drink any liquids 151

  9. Heavy vomiting or severe diarrhea that lasts for more than one day or more than a few hours in babies. 151

  10. Black stools like tar, or vomit with blood or feces 128

  11. Strong, continuous stomach pains with vomiting in a person who does not have diarrhea or cannot have a bowel movement 93

  12. Any strong continuous pain that lasts for more than 3 days 29 > 38

  13. Stiff neck with arched back, with or without a stiff jaw 182 , 185

  14. More than one seizure (fit) in someone with fever or serious illness 76, 185

  15. High fever (above 39° C) that cannot be brought down or that lasts more than 4 or 5 days 75

  16. Weight loss over an extended time 20, 400

  17. Blood in the urine 146, 234

  18. Sores that keep growing and do not go away with treatment 191, 196, 211, 212

  19. A lump in any part of the body that keeps getting bigger 196, 280

  20. Very high blood pressure (220/120 or greater) 327

  21. Problems with pregnancy and childbirth:

  • any bleeding during pregnancy 249, 281

  • high blood pressure (140/90 or greater) 249

  • long delay once the waters have broken and labor has begun 267

  • severe bleeding 264

43

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 (see page 99). If the sun is very strong, rig a sheet over the stretcher to give shade yet allow fresh air to pass underneath

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.

When you send someone for medical help, always send a completed information form with him.

44

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 listed on page page 42 ?

  • 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

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.

People will get well from most sicknesses , including the common cold and ‘flu’, by themselves, without need for 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.

Many sicknesses can be prevented or treated without medicine.

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.

46

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.

Prevention

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 water spoon. Washing hands with soap and water after a bowel movement (shitting) and before eating or handling foods is also important.

Treatment

A common cause of death in children with diarrhea is severe dehydration, or loss of too much water from the body (see page 151).

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, p. 152).

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.

47

TIMES WHEN THE RIGHT USE OF WATER MAY DO MORE GOOD THAN MEDICINES

prevention

to help prevent / use water

  1. diarrhea, worms, gut infections / boil or filter drinking water, wash hands, etc. 135

  2. skin infections / bathe often 153

  3. wounds becoming infected; tetanus / wash wounds well with soap and clean water 84, 89

48

treatment

In the following list:

to treat: / use water in this way:

  1. diarrhea, dehydration / drink plenty of liquids 152

  2. illnesses with fever / drink plenty of liquids 75, 76

  3. high fever / remove clothing and soak body with water 76

  4. minor urinary infections (common in women) / drink plenty of water 235

  5. cough, asthma, bronchitis, pneumonia / drink a lot of water and breathe hot water vapors (to loosen mucus) 166

  6. sores, impetigo, ringworm of skin or scalp, cradle cap, pimples / scrub with soap and clean water 201, 202, 205, 211, 215,

  7. infected wounds, abscesses, boils / hot soaks or compresses 88, 202,

  8. stiff, sore muscles and joints / hot compresses 102, 173, 174

  9. strains and sprains / the first day: soak joint in cold water; then use hot soaks 102

  10. itching, burning, or weeping irritations of the skin / cold compresses 193, 194

  11. minor burns / hold in cold water at once 96

  12. sore throat or tonsillitis / gargle with warm salt water 96

  13. acid, lye, dirt, or irritating substance in eye / flood eye with cool water at once, and continue for 30 minutes 219

  14. stuffed up nose / sniff salt water 164

  15. constipation, hard stools / drink lots of water (also, enemas are safer than laxatives, but do not overuse) 15, 126

  16. cold sores or fever blisters / hold ice on blister for several minutes at first sign 232

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.

6

modern medicines: right and wrong uses

Medicines must be used correctly!

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.

There is some danger in the use of any medicine.

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 parents 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

  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.

Only use a medicine when you are sure it is needed and when you are sure how to use it.

50

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)

The popular use of this medicine (page 356) for simple diarrhea and other mild sicknesses is extremely unfortunate, because it is so risky. Use chloramphenicol only for very severe illnesses, like typhoid (see page 188). Never give it to babies younger than 1 month old.

2. Oxytocin (Pitocin), Ergonovine (Ergotrate), and Misoprostol (Cytotec)

Unfortunately, some woman use these medicines (page 390) to speed up childbirth or ‘give strength’ to the mother in labor. This practice is very dangerous. It can kill the mother or the child. Use these medicines only to control bleeding after the child is born (see page 266).

3. Injections of any medicine

The common belief that injections are usually better than medicine taken by mouth is not true. Many times medicines taken by mouth work as well as or better than injections. Also, most medicine is more dangerous injected than when taken by mouth. Injections given to a child who has a mild polio infection (with only signs of a cold) can lead to paralysis (see page 74). Use of injections should be very limited (read Chapter 9 carefully).

4. Penicillin

Penicillin works only against certain types of infections. (page 350) 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 (see page 163).

Penicillin is dangerous for some people. Before using it, know its risks and the precautions you must take, see page 70 and page 350.

5. Gentamicin (Garamycin)

Too much use of this antibiotic (page 358) 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.

51

6. Anti-diarrhea medicines with hydroxyquinolines

Anti-diarrhea medicines with hydroxyquinolines (Clioquinol, di-iodohydroxyquinoline, halquinol, broxyquinoline: Diodoquin, Enteroquinol, Amicline, Quogyl, and many other brand names) (page 369)

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 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 (page 378) or ibuprofen (page 379) is much safer and cheaper. For pain and fever only, acetaminophen (page 379) can be used.

10. Vitamin B12, liver extract, and iron injections

Vitamin B12 and liver extract do not help anemia or ‘weakness’ except in rare cases. (page 392) Also, they have certain risks when injected.

They should only be used when a specialist has prescribed them after testing the blood. Also, avoid injectable iron, such as Imferon. To combat anemia, iron pills are safer and work as well (see page 124).

52

11. Other vitamins

As a general rule, DO NOT INJECT VITAMINS. Injections are more dangerous, more expensive, and usually no more effective than pills. (page 391)

Unfortunately, many people waste their money on syrups, tonics, and ‘elixirs’ that contain vitamins. Many lack the most important vitamins (see page 118).

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 (see page 111).

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, especially page 111 and page 118.

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 unnecessary medicines. Some medicines for HIV come in combination pills (see page 397). This makes them easier to take. 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)

53

13. Calcium

Injecting calcium into a vein can be extremely dangerous. It can quickly kill someone if not injected very slowly. Injecting calcium into the buttocks sometimes causes very serious abscesses or infections.

Never inject calcium without first seeking medical advice!

Note: In Mexico and other countries where people eat a lot of corn tortillas or other foods prepared with lime (“cal”, not the fruit), 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 (see page 151).

If the sick person can swallow, give her a liter of water with sugar (or cereal) and salt (see Rehydration Drink, page 152). 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 . . .

54

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 (see page 128).

Certain medicines will cause bad reactions if a person drinks alcohol (see metronidazole, page 368).

There are situations when, without a doubt, it is best no to use certain medicines:

Pregnant women

  1. Pregnant women or women who are breastfeeding should avoid all medicines that are not absolutely necessary. (However, they can take limited amounts of vitamins or iron pills without danger. Also, pregnant or breastfeeding women with HIV should take medicines to prevent spreading HIV to the baby, see page 398.)

Newborn children

  1. 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.

A person who’s allergic

  1. 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, page 70).

Persons who have stomach ulcers or heartburn

  1. Persons who have stomach ulcers or heartburn should avoid medicines that contain aspirin. Most painkillers, and all steroids (see page 51) make ulcers and acid indigestion worse. One painkiller that does not irritate the stomach is acetaminophen (paracetamol, see page 379).

Persons who have specific illness

  1. There are some medicines that are harmful or dangerous to take when you have a specific illness.

For example, persons with hepatitis should not be treated with certain antibiotics or other strong medicines, because their liver is damaged, and the medicines are more likely to poison the body (see page 172).

Persons who are dehydrated or have disease of the kidneys

  1. Persons who are dehydrated or have disease of the kidneys should be especially careful with medicines they take. Do not give more than one does 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 (see page 76), 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.

7

antibiotics: how to use

When used correctly…

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, erythromycin, cotrimoxazole, and ciprofloxacin.

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:

PENICILLINS

generic name: penicillin, ampicillin, amoxicillin

examples of brands: Pen-V-K


MACROLIDES

generic name: erythromycin

examples of brands: Erythrocin


TETRACYCLINES

generic name: tetracycline, doxycycline

examples of brands: Terramycin


CHLORAMPHENICOL

examples of brands: Chloromycetin


SULFAS SULFONAMIDES

generic name: cotrimoxazole, sulfisoxazole

examples of brands: Bactrim, Gantrisin


AMINOGLYCOSIDES

generic name: gentamicin

examples of brands: Garamycin


CEPHALOSPORINS

generic name: ceftriaxone, cephalexin

examples of brands: Keflex


QUINOLONES

generic name: ciprofloxacin

examples of brands: Cipro

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’.

Look up chloramphenicol in the GREEN PAGES (page 356). You will find it must be used only for a few very serious illnesses, like typhoid, and is especially dangerous when given to the newborn.

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 medicine in the alphabetical list at the beginning of those pages.

56

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 does, 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. Antibiotics must be given for their full course. Stopping before you have finished all the days of treatment, even if you feel better, can make the infection return in a form that is even harder to cure. (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 (see page 70).

  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 (page 70).

  2. For persons who are allergic to penicillin, use another antibiotic such as erythromycin or cotrimoxazole (see page 354 and page 357).

  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 (see page 58). Broad spectrum antibiotics attack many more kinds of bacteria than narrow spectrum antibiotics.

  4. Use chloramphenicol only for certain severe or life-threatening illnesses, such as typhoid, when no other effective medicine is available. It is a dangerous drug. Never use it for mild illness (see page 313).

  5. Do not give tetracycline to pregnant women or to children under 8 years old. It can damage new teeth and bones (see page 355).

  6. Use streptomycin only for tuberculosis, and always together with other anti-tuberculosis medicines (see page 361).

  7. All medicines in the aminoglycoside 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.

  8. 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).

57

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.

Antibiotics do no good for the common cold. Use antibiotics only for infections they are known to help.

58

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, page 232) or skin (moniliasis, page 242). 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 (page 370). 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 (page 155), and provide enough food as soon as the child will eat.

Do not use antibiotics for infections the body can fight successfully by itself. Save them for when they are most needed.

For more information on learning to use antibiotics sensibly, see [_Helping Health Workers Learn_](#addresses-for-teaching-materials), Chapter 19.

8

measure and give medicine: how to

SYMBOLS

’=’ means “is equal to” or “is the same as”

’+’ means “and” or “plus”

FRACTIONS

How fractions are sometimes written:

1 tablet = one whole tablet = 1/2 tablet = half of a tablet

1 1/2 tablet = one and one-half tablets

1/4 tablet = one quarter, or one-fourth of a tablet

1/8 tablet = one-eighth of a tablet (dividing it into 8 equal pieces and taking 1 piece)

MEASURING

Medicine is usually weighed in grams (g), milligrams (mg), or micrograms (mcg).

1000 mg = 1 g (one thousand milligrams make one gram)

1 mg = 0.001 g (one milligram is one one-thousandth part of a gram)

1000 mcg = 1 mg (one thousand micrograms make one milligram)

Examples

  • One adult aspirin tablet contains 300 milligrams of aspirin. (.3 g, 0.3 g, 0.300 g, 300 mg. All these are different ways of saying 300 milligrams.)

  • One baby aspirin contains 75 milligrams of aspirin. ( .075 g, 0.075 g, 75.0 mg, 75 mg. All these are different ways of saying 75 milligrams. )

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.

60

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…

read the small print on the labels of each. It says: aspirin: acetylsalicylic acid 0.3 g. (acetylsalicylic acid = aspirin)

4 (75mg) baby aspirins add = to 1 (300mg) regular aspirin

0.3 g = 300 mg and 0.075 g = 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:

  • 250mg
  • 100mg
  • 50mg

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).

50 mg + 50 mg + 50 mg + 50 mg + 50 mg = 250 mg

measuring penicillin

Penicillin is often measured in units.

U = unit 1,600,000 U = 1 g or 1,000 mg

Many forms of penicillin (pills and injections) come in doses of 400,000 U. 400,000 U = 250 mg

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MEDICINE IN LIQUID FORM

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

ml = milliliter 1 liter = 1000 ml

Often liquid medicines are prescribed in tablespoons or teaspoons:

  • 1 teaspoon (tsp) = 5 ml
  • 1 tablespoon (Tbs) = 15 ml
  • 3 teaspoons = 1 tablespoon

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

  1. Buy a 5 ml measuring spoon.

  2. Buy a medicine that comes with a plastic spoon. This measures 5 ml when it is full and may also have a line that shows when it is half full (2.5 ml). Save this spoon and use it to measure other medicines.

  3. Fill any small spoon that you have at home with 5 ml of water, using a syringe or something else to measure, and make a mark on the spoon at the level of the liquid.

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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:

  • Grind up the pill very well or open the capsule
  • Mix the powder with boiled water (that has cooled) and sugar or honey.
  • You must add lots of sugar or honey when the medicine is very bitter (tetracycline or chloroquine).

When making syrups for children from pills or capsules, be very careful not to give too much medicine. Also, do not give honey to babies under 1 year of age. Though it is rare, some babies can have a dangerous reaction.

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(66 lbs): 1/2 dose

Children 4 to 7 years(33 lbs): 1/4 dose

Children 1 to 3 years(17.6 lbs): 1/8 dose

Child under 1 year old (11 lbs - 5KG): the dose for a child of 1 year, but ask medical advice when possible.

1 kilogram (kg) = 2.2 pounds (lbs)

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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.

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.

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

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

For example:

This means 1 tablet 4 times a day, 1 at sunrise, 1 at noon, 1 at sunset, and 1 in the middle of the night. This means 1/2 tablet 4 times a day. This means 1/4 tablet twice a day. This means 1 capsule 3 times a day. This means 2 teaspoons twice a day.

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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 • the name of the medicine • what it is for • the 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 (see p. 44).

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

Take these medicines 1 hour before or 2 hours after meals:

• penicillin • ampicillin • doxycycline • tetracycline

It is better not to drink milk 1 hour before or after taking doxycycline or tetracycline.

Take these medicines together with or soon after meals (or with a lot of water):

• aspirin and medicine that contains aspirin • ibuprofen • iron (ferrous sulfate) • vitamins • erythromycin

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.

9

injections: instructions and precautions

WHEN TO INJECT AND WHEN NOT TO

Injections are not needed often. Most sicknesses that require medical treatment can be treated as well or better with medicines taken by mouth. Each year, millions of people, especially children, become ill, disabled, or die as a result of unnecessary injections. Combating misuse and overuse of medicines is as important to good health as vaccination, clean water, or the correct use of latrines. As a general rule:

It is more dangerous to inject medicine than to take it by mouth.

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.

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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).

Sicknesses: Severe pneumonia, Gangrene

Inject these medicines: benzylpenicillin

Sicknesses: Infections after childbirth

Inject these medicines: ampicillin and gentamicin taken with metronidazole by mouth.

Sicknesses: Tetanus

Inject these medicines: penicillin and antitetanus immunoglobulin with metronidazole by mouth.

Sicknesses: Appendicitis or Peritonitis

Inject these medicines: ampicillin OR ciprofloxacin, OR ceftriaxone, with metronidazole by mouth.

Sicknesses: Poisonous snakebite, Scorpion sting (in children,

Inject these medicines: antitoxins and antivenon

Sicknesses: Meningitis when you do not suspect tuberculosis

Inject these medicines: ampicillin and ceftriaxone OR gentamicin

Sicknesses: Meningitis when you suspect tuberculosis

Inject these medicines: ampicillin together with streptomycin and, if possible, other TB medicines.

Sicknesses: Vomiting when it cannot be controlled

Inject these medicines: antihistamines, for example, promethazine

Sicknesses: Severe allergic reaction and allergic shock

Inject these medicines: epinephrine Adrenalin (page 70) and, if possible, diphenhydramine (Benadryl)

The following chronic illnesses may require injections, but they are rarely emergencies. It is best to consult a health worker for treatment.

Sicknesses: Tuberculosis

Inject these medicines: streptomycin together with other TB medicines taken by mouth

Sicknesses: Syphilis

Inject these medicines: benzathine penicillin) and benzathine penicillin

Sicknesses: Gonorrhea

Inject these medicines: ceftriaxone OR spectinomycin with other medicines taken by mouth

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WHEN NOT TO INJECT

NEVER give injections if you can get medical help quickly.

NEVER give an injection for a sickness that is not serious.

NEVER give injections for a cold or the flu.

NEVER inject a medicine that is not recommended for the illness you want to treat.

NEVER give an injection unless your needle has been boiled or sterilized.

NEVER inject a medicine unless you know and take all the recommended precautions.

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 (see page 111).

  2. Liver extract, vitamin B12, and iron injections (such as Imferon). Injecting these can cause abscesses or dangerous reactions (shock, page 70). Ferrous sulfate pills will do more good for almost all cases of anemia (page 392).

  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. Chloramphenicol or tetracycline. These medicines do as much or more good when taken by mouth. Use capsules or syrups rather than injections (page 355 and page 356).

  6. 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 (page 53).

  7. 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’.

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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.

  1. 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 (see page 70)

• dizzy spells with nausea (wanting to vomit)

• problems with vision

• ringing in the ears or deafness

• severe back pain

• difficulty urinating

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).

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 (see page 70).

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.

CAUTION: If possible, always give medicine by mouth instead of by injection especially to children.

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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.)

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DANGEROUS REACTIONS FROM INJECTING CERTAIN MEDICINES

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

• penicillins (including ampicillin) {scorpion antivenom

• antitoxins that are made from horse serum snake antivenom

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.

Rarely, ALLERGIC SHOCK may result from the sting of a wasp or bee or from medicine taken by mouth.

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, page 385) and an ampule of an antihistamine like promethazine (Phenergan, page 385) or diphenhydramine (Benadryl, page 386).

  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 scorpion 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 (see page 386).

  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

  1. If these signs appear, immediately inject epinephrine (Adrenalin): adults, 1/2 ml; children, 1/3 to 1/4 ml, depending on their size. Treat the person for SHOCK (see page 77). Follow by giving an antihistamine in double the normal dose.

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How to Avoid Serious Reactions to a Penicillin Injection

  1. For mild to moderate infections: give penicillin pills instead of injections

  2. Before injecting ask the person:

“Have you ever had a rash, itching, swelling, or trouble breathing after getting an injection of penicillin?”

If the answer is yes, do not use penicillin, ampicillin, or amoxicillin. Use another antibiotic like erythromycin (page 354) or a sulfonamide (page 356).

  1. Before injecting penicillin: always have ampules of EPINEPHRINE (Adrenalin) ready.

  2. After injecting: stay with the person for at least 30 minutes.

  3. If the person becomes very pale, his heart beats very fast, he has dif culty breathing, or he starts to faint, immediately inject into a muscle (or just under the skin) half an ampule of EPINEPHRINE (Adrenalin, a quarter of an ampule in small children) and repeat in 10 minutes if necessary.

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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.

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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.

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.

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.

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HOW INJECTIONS CAN DISABLE CHILDREN

When used correctly, certain injected medicines, such as vaccinations, are important to protect a child’s health and prevent disability. But if injections are given with needles or syringes that are not sterilized, the injections may cause a serious infection.

Unclean needles and syringes can spread germs that cause HIV or other serious diseases, such as hepatitis, from one person to another. Dirty needles and syringes can also cause infections that lead to paralysis or death. Never inject more than 1 person with the same needle or syringe without disinfecting it first.

Some injected medicines can cause dangerous allergic reactions, poisoning, deafness, or other harmful effects. For example, pregnant women are often given hormone injections to speed up childbirth and ‘give strength’, but these injections are dangerous for the mother and can cause brain damage or death of the baby.

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 HIV (see page 399), hepatitis (see page 172), and tetanus (see page 182), can spread 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 be done only with equipment that has been sterilized.

Here are some ways to sterilize equipment:

  • Boil for 30 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 use pressure steaming for 30 minutes in a pressure cooker (or an 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.

10

first aid

BASIC CLEANLINESS AND PROTECTION

When a person is hurt, the most important thing is to help. But you also must protect yourself from HIV and other blood-borne diseases. When someone is bleeding:

  1. If possible, show the injured person how to stop the bleeding themselves, by applying direct pressure on the wound.

  2. If they cannot do this, keep the blood off yourself by wearing gloves or a clean plastic bag on your hands, and placing a clean, thick cloth directly over the wound before applying pressure.

Avoid objects soiled with blood. Be careful not to prick yourself with needles or other sharp objects around the person you are helping. Cover cuts or other wounds with dry, clean bandages to protect them.

Be especially careful when you have to provide first aid where there are many people wounded from an accident or fighting.

If you do get blood or other body fluids on you, wash your hands with soap and water as soon as possible. If other parts of your body were touched by body fluids (especially your eyes), wash them thoroughly with lots of water.

FEVER

When a person’s body temperature is too hot, he has a fever. Fever is not a sickness, but a sign of many different sicknesses. A high fever (over 39°C or over 102°F) can be a sign of a dangerous problem, especially in a small child. When a person has a fever:

  1. Uncover him completely. Small children should be undressed completely and left naked until the fever goes down.

Never wrap the child in clothing or blankets. To wrap up a child with fever is dangerous

Fresh air or a breeze will not harm a person with fever. On the contrary, a fresh breeze helps lower the fever.

  1. Also take aspirin to lower fever (see page 378). For children, it is safer to give acetaminophen (paracetamol, page 380). Be careful not to give too much.

  2. Anyone who has a fever should drink lots of water, juices, or other liquids. For small children, especially babies, drinking water should be boiled first (and then cooled). Make sure the child passes urine regularly. If she does not pass much urine, or the urine is dark, give a lot more water.

  3. When possible, find and treat the cause of the fever.

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Very High Fevers

A very high fever can be a sign of a dangerous illness. Bring the fever down as soon as you can and treat the cause of the fever, if possible. High fever can cause seizures (convulsions) and is most dangerous for small children.

When a fever goes very high, over 40°, it must be lowered at once:

  1. Put the person in a cool place.

  2. Remove all clothing.

  3. Fan him.

  4. Pour water over him, or put cloths soaked in cool water on his chest and forehead. Fan the cloths and change them often to keep them cool. Continue to do this until the fever goes down (below 38°).

  5. Give him plenty of cool (not cold) water to drink.

  6. Give a medicine to bring down fever. Aspirin or acetaminophen works well, but for children under 12 years old it is safer to use acetaminophen.

Dosage for acetaminophen (using 300 mg. adult tablets):

  • Persons over 12 years: 2 tablets every 4 hours

  • Children 6 to 12 years: 1 tablet every 4 hours

  • Children 3 to 6 years: 1/2 tablet every 4 hours

  • Children under 3 years: 1/4 tablet every 4 hours

If a person with fever cannot swallow the tablets, grind them up, mix the powder with some water, and put it up the anus as an enema or with a syringe without the needle.

If a high fever does not go down soon, if the person is unconscious, or if seizures (fits, convulsions) begin, continue cooling with water and seek medical help at once.

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SHOCK

Shock is a life threatening condition that can result from a large burn, losing a lot of blood, severe illnesses, dehydration, or severe allergic reaction.

Heavy bleeding inside the body, although not seen, can also cause shock.

Signs of shock:

  • weak, rapid pulse (more than 100 per minute for an adult, more than 140 per minute for a child over 2 years old, and more than 190 per minute for a baby)

  • ‘cold sweat’; pale, cold, damp skin

  • blood pressure drops dangerously low

  • mental confusion, weakness, or loss of consciousness.

What to do to prevent or treat shock:

At the first sign of shock, or if there is risk of shock:

  • Loosen any belts or tight clothing the person may be wearing.

  • Have the person lie down with his feet a little higher than his head, like this: However, if he has a severe head injury, put him in a ‘half sitting’ position (page 91).

  • Stop any bleeding. Use gloves or a plastic bag to keep the blood off your hands.

  • If the person feels cold, cover him with a blanket.

  • If he is conscious and able to drink, give him sips of water or other drinks. If he looks dehydrated, give a lot of liquid, and Rehydration Drink (page 152). If he does not respond quickly, give intravenous fluids if you know how.

  • Treat his wounds, if he has any.

  • If he is in pain, give him aspirin or another pain medicine, but not one with a sedative such as codeine.

  • Keep calm, reassure the person, and seek medical help.

If the person is unconscious:

  • Lay him on his side with his head low.

  • If he has vomited, clear his mouth immediately. Be sure his head is low, tilted back, and to one side (see above) so he does not breathe vomit into his lungs. If he has a neck or spine injury, do not tilt his head or move his back.

  • Do no give him anything by mouth until he becomes conscious.

  • If you or someone nearby knows how, give intravenous solution (normal saline) at a fast drip.

  • Seek medical help fast.

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LOSS OF CONSCIOUSNESS

Common causes of loss of consciousness are:

• drunkenness

• a hit on the head (getting knocked out)

• shock (page 77)

• seizures (page 178)

• poisoning (page 103)

• fainting (from fright, weakness, low blood sugar, etc.)

• heat stroke (page 81)

• stroke (page 327)

• heart attack (page 325)

If a person is unconscious and you do not know why, immediately check each of the following:

  1. Is he breathing well?

If not, tilt his head way back and pull the jaw and tongue forward. If something is stuck in his throat, pull it out. If he is not breathing, use mouth-to-mouth breathing at once (see page 80).

  1. Is he losing a lot of blood?

If so, control the bleeding (see page 82).

  1. Is he in shock (moist, pale skin; weak, rapid pulse)?

If so, lay him with his head lower than his feet and loosen his clothing (see page 77).

  1. Could it be heat stroke (no sweat, high fever, hot, red skin)?

If so, shade him from the sun, keep his head higher than his feet, and soak him with cold water (ice water if possible) and fan him (see page 81).

How to position an unconscious person:

  • very pale skin: (shock, fainting, etc.): flat, pillow under feet.

  • red or normal skin: (heat stroke, stroke, heart problems, head injury): with head higher (put 2 bricks under the head feet of the bed.)

If there is any chance that the unconscious person is badly injured:

It is best not to move him until he becomes conscious. If you have to move him, do so with great care, because if his neck or back is broken, any change of position may cause greater injury (see page 100).

Look for wounds or broken bones, but move the person as little as possible. Do not bend his back or neck.

Never give anything by mouth to a person who is unconscious.

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WHEN SOMETHING GETS STUCK IN THE THROAT

When food or something else sticks in a person’s throat and he cannot breathe, quickly do this:

♦ Bend him over at the waist.

♦ Use the palm of your hand to give 5 firm blows on the middle of the back.

If this does not work:

♦ Stand behind him and wrap your arms around his waist.

♦ Put your fist against his belly above the navel and below the ribs.

♦ Press into his belly with a sudden strong upward jerk. This forces the air from his lungs and should free his throat. Repeat several times if necessary. (For fat persons, pregnant women, persons in wheelchairs, or small children, place hands on the chest, not the belly.)

If the person is a lot bigger than you, or is already unconscious, lay him on his back, tilt his head to one side, and sit over him like this, with the heel of your lower hand on his belly between his navel and ribs. Make a quick, strong upward push.

Repeat several times if necessary. If he still cannot breathe, try mouth-to- mouth breathing (see next page).

DROWNING

A person who has stopped breathing has only 4 minutes to live! Act fast!

Start mouth-to-mouth breathing at once (see next page), if possible, even before the drowning person is out of the water, as soon as it is shallow enough to stand.

ALWAYS START MOUTH-TO-MOUTH BREATHING AT ONCE.

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WHAT TO DO WHEN BREATHING STOPS

mouth-to-mouth breathing

Common causes for breathing to stop are:

• something stuck in the throat

• the tongue or thick mucus blocking the throat of an unconscious person

• drowning, choking on smoke, or poisoning

• a strong blow to the head or chest

• a heart attack

A person can die within 4 minutes if he does not breathe.

Do all of the following as quickly as you can:

Step 1:

Quickly use a finger to remove anything stuck in the mouth or throat.

Step 2:

Quickly but gently lay the person face up. Gently tilt his head back, and pull his jaw forward.

Step 3:

Pinch his nostrils closed with your fingers, open his mouth wide, cover his mouth with yours, and blow strongly into his lungs so that his chest rises. Pause to let the air come back out and blow again. Repeat about once every 5 seconds. With babies and small children, cover the nose and mouth with your mouth and breathe very gently about once every 3 seconds.

Continue mouth-to-mouth breathing until the person can breathe by himself, or until there is no doubt he is dead. Sometimes you must keep trying for an hour or more.

Note: Unless there is an open sore or bleeding in the mouth, it is not possible to give or get hepatitis or HIV from mouth-to-mouth breathing.

If a person stops breathing, begin mouth-to-mouth breathing IMMEDIATELY.

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EMERGENCIES CAUSED BY HEAT

Heat Cramps

In hot weather people who work hard and sweat a lot sometimes get painful cramps in their legs, arms, or stomach. These occur because the body lacks salt.

Treatment:

Put a teaspoon of salt in a liter of boiled water and drink it. Repeat once every hour until the cramps are gone. Have the person sit or lie down in a cool place and gently massage the painful areas.

Heat Exhaustion

Signs:

A person who works and sweats a lot in hot weather may become very pale, weak, and nauseous, and perhaps feel faint. The skin is cool and moist. The pulse is rapid and weak. The temperature of the body may rise but is usually normal (see page 31).

Treatment:

Have the person lie down in a cool place, raise his feet, and rub his legs. Give salt water to drink: 1/2 teaspoon of salt in a liter of water. (Give nothing by mouth while the person is unconscious.)

Heat Stroke

Heat stroke is not common, but is very dangerous. It occurs especially in older people, very fat people, and alcoholics during hot weather.

Signs:

The skin is red, very hot, and dry. Not even the armpits are moist. The person has a very high fever, sometimes more than 42°C, and a rapid heartbeat. Often he is unconscious.

Treatment:

The body temperature must be lowered immediately. Put the person in the shade. Soak him with cold water (ice water if possible) and fan him. Continue until the fever drops. Seek medical help.

DIFFERENCES BETWEEN HEAT-EXHAUSTION AND HEAT-STROKE

HEAT-EXHAUSTION:

• sweaty, pale, cool skin • large pupils • weakness

HEAT-STROKE:

• dry, red, hot skin • high fever • the person is very ill or unconscious

For emergencies caused by cold, see page 408 and page 409.

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HOW TO CONTROL BLEEDING FROM A WOUND

  1. Raise the injured part.

  2. With a clean thick cloth (or your hand if there is no cloth) press directly on the wound. Keep pressing until the bleeding stops. This may take 20 minutes or sometimes an hour or more. This type of direct pressure will stop the bleeding of nearly all wounds, sometimes even when a part of the body has been cut off.

Occasionally direct pressure will not control bleeding, especially when the wound is very large or an arm or leg has been cut off.

If this happens:

♦ Keep pressing on the wound.

♦ Keep the wounded part as high as possible.

♦ You can maintain pressure by binding the wound tightly with a bandage or a piece of clean clothing.

♦ Squeeze at pressure points on the artery that brings blood to that part of the body. Pressure points are where, using the flat part of your fingers, you can push the artery against a bone to shut off or slow down the flow of blood.

♦ Keep pressing for 20 minutes before looking to see if the bleeding has stopped. Keep pressing with your other hand on the wound itself. Applying pressure is hard work, do not give up!

PRECAUTIONS:

• Using a tourniquet to stop the bleeding usually results in total loss of the arm or leg. Only use a tourniquet if you have no other option. Never use a string or wire. It can cut right through the skin.

Never use dirt, kerosene, lime, or coffee to stop bleeding.

• When bleeding or injury is severe, raise the feet and lower the head to prevent shock (see page 77).

• Keep blood from getting into any cuts or sores on your skin (see page 75).

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HOW TO STOP NOSEBLEEDS

  1. Sit quietly and upright.

  2. Blow the nose gently to remove mucus and blood.

  3. Have the person pinch the nose firmly for 10 minutes or until the bleeding has stopped.

If this does not control the bleeding . . .

Pack the nostril with a wad of cotton, leaving part of it outside the nose. If possible, first wet the cotton with Vaseline or lidocaine with epinephrine (page 379).

Then pinch the nose firmly again. Do not let go for 10 minutes or more. Do not tip the head back.

Leave the cotton in place for a few hours after the bleeding stops; then take it out very carefully.

In older persons especially, bleeding may come from the back part of the nose and cannot be stopped by pinching it.

In this case, have the person hold a cork, corn cob, or other similar object between his teeth and, leaning forward, sit quietly and try not to swallow until the bleeding stops. (The cork helps keep him from swallowing, and that gives the blood a chance to clot.)

Prevention:

If a person’s nose bleeds often, smear a little Vaseline inside the nostrils twice a day. Or sniff water with a little salt in it (see page 164).

Eating oranges, tomatoes, and other fruits may help to strengthen the veins so that the nose bleeds less.

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CUTS, SCRAPES, SMALL WOUNDS: How to treat.

First, wash your hands very well with soap and water.

If the wound is bleeding or oozing, wear gloves or plastic bags on your hands. Wash the skin around the wound with soap and cool, boiled water.

Now wash the wound well with cool, boiled water (and soap, if the wound has a lot of dirt in it. Soap helps clean but can damage the flesh).

When cleaning the wound, be careful to clean out all the dirt. Lift up and clean under any flaps of skin. You can use clean tweezers, or a clean cloth or gauze, to remove bits of dirt, but always boil them first to be sure they are sterile.

If possible, squirt out the wound with cool boiled water in a syringe or suction bulb.

Any bit of dirt that is left in a wound can cause an infection.

After the wound has been cleaned, apply a thin layer of antibiotic cream like Neosporin if you have it. Then place a piece of clean gauze or cloth over the top.

It should be light enough so that the air can get to the wound and help it to heal. Change the gauze or cloth every day and look for signs of infection (see page 88).

If you have a dirty wound or a puncture wound, and have never had a tetanus immunization (see page 388), get one within 2 days.

Cleanliness is of first importance in preventing infection and helping wounds to heal.

NEVER put animal or human feces or mud on a wound. These can cause dangerous infections, such as tetanus.

NEVER put alcohol, tincture of iodine, or Merthiolate directly into a wound; doing so will damage the flesh and make healing slower.

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LARGE CUTS: how to close them

A recent cut that is very clean will heal faster if you bring the edges together so the cut stays closed.

Close a deep cut only if all of the following are true:

• the cut is less than 12 hours old,

• the cut is very clean, and

• it is impossible to get a health worker to close it the same day.

Before closing the cut, wash it very well with cool, boiled water (and soap, if the wound is dirty). If possible, squirt it out with a syringe and water. Be absolutely sure that no dirt or soap is left hidden in the cut.

There are two methods to close a cut:

  • ‘BUTTERFLY’ BANDAGES OF ADHESIVE TAPE

  • STITCHES OR SUTURES WITH THREAD

To find out if a cut needs stitches see if the edges of the skin come together by themselves. If they do, usually no stitches are needed.

To stitch a wound:

♦ Boil a sewing needle and a thin thread (nylon or silk is best) for 20 minutes.

♦ Wash the wound with cool, boiled water, as has been described.

♦ Wash your hands very well with boiled water and soap.

♦ Sew the wound like this: Make the first stitch in the middle of the cut, and tie it closed. If the skin is tough, hold the needle with a pair of pliers (or needle holder) that has been boiled. Make enough other stitches to close the whole cut.

Leave the stitches in place for 5 to 14 days (on the face 5 days; the body 10 days; the hand or foot 14 days). Then remove the stitches: cut the thread on one side of the knot and pull the knot until the thread comes out.

WARNING: Only close wounds that are very clean and less than 12 hours old. Old, dirty, or infected wounds must be left open. Bites from people, dogs, pigs, or other animals should also be left open. Closing these can cause dangerous infections.

If the wound that has been closed shows any signs of infection, remove the stitches immediately and leave the wound open (see page 88).

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BANDAGES

Bandages are used to help keep wounds clean. For this reason, bandages or pieces of cloth used to cover wounds must always be clean themselves. Cloth used for bandages should be washed and then dried with an iron or in the sun, in a clean, dust free place.

Make sure the wound has first been cleaned, as shown on page 84. If possible, cover the wound with a sterile gauze pad before bandaging. These pads are often sold in sealed envelopes in pharmacies.

Or prepare your own sterile gauze or cloth. Wrap it in thick paper, seal it with tape, and bake it for 20 minutes in an oven. Putting a pan of water in the oven under the cloth will keep it from charring.

If a bandage gets wet or dirt gets under it, take the bandage off, wash the cut again, and put on a clean bandage. Change the bandage every day.

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EXAMPLES OF BANDAGES

It is better to have no bandage at all than one that is dirty or wet.

CAUTION: Be careful that a bandage that goes around a limb is not so tight it cuts off the flow of blood.

Many small scrapes and cuts do not need bandages. They heal best if washed with soap and water and left open to the air. The most important thing is to keep them clean.

Note: For children it is often better to bandage the whole hand or foot instead of one finger or toe. The bandage will not come off as easily.

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INFECTED WOUNDS

HOW TO RECOGNIZE AND TREAT THEM

A wound is infected if:

• it becomes red, swollen, hot, and painful,

• it has pus,

• or if it begins to smell bad.

The infection is spreading to other parts of the body if:

• it causes fever,

• there is a red line above the wound,

• or if the lymph nodes become swollen and tender. Lymph nodes, often called ‘glands’, are little traps for germs that form small lumps under the skin when they get infected.

Swollen lymph nodes behind the ear are a sign of an infection on the head or scalp, often caused by sores or lice. Or German measles may be the cause.

Swollen nodes below the ear and on the neck indicate infections of the ear, face, or head (or tuberculosis).

Swollen nodes below the jaw indicate infections of the teeth or throat.

Swollen nodes in the armpit indicate an infection of the arm, head, or breast (or sometimes breast cancer).

Swollen nodes in the groin indicate an infection of the leg, foot, genitals, or anus.

Treatment of infected wounds:

♦ Put hot compresses over the wound for 20 minutes 4 times a day. Or hold an infected hand or foot in a bucket of hot water.

♦ Keep the infected part at rest and elevated (raised above the level of the heart).

♦ If the infection is severe, use an antibiotic like dicloxacillin (page 350), or clindamycin (page 358), or an injectable penicillin (See page 351 to page 353), and also give metronidazole (page 368).

WARNING: If the wound has a bad smell, if brown or gray liquid oozes out, or if the skin around it turns black and forms air bubbles or blisters, this may be gangrene. Seek medical help fast. Meanwhile, follow the instructions for gangrene on page 213.

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WOUNDS THAT ARE LIKELY TO BECOME DANGEROUSLY INFECTED

These wounds are most likely to become dangerously infected:

• puncture wounds and other deep wounds that do not bleed much

• wounds made where animals are kept: in corrals, pig pens, etc.

• large wounds with severe mashing or bruising

• bites, especially from pigs, dogs, or people

• bullet wounds

Special care for this type of ‘high risk’ wound:

  1. Wash the wound well with boiled water and soap. Remove all pieces of dirt, blood clots, and dead or badly damaged flesh. Squirt out the dirt using a syringe or suction bulb.

  2. If the wound is very deep or if it is from a knife or bullet, give an antibiotic such as cloxacillin (page 350) or clindamycin (page 358).

  3. If the wound is a bite, give an antibiotic such as penicillin (page 351), doxycycline (page 355), or cotrimoxazole (page 357). Also give metronidazole (page 368).

  4. Never close this type of wound with stitches or ‘butterfly’ bandages. Leave the wound open. If it is very large, a skilled health worker or a doctor may be able to close it later.

The danger of tetanus is very great in people who have not been vaccinated against this deadly disease.

To lower the risk, a person who has not been vaccinated against tetanus should get a tetanus vaccination (page 147) and, if possible, an injection of tetanus immune globulin (page 388). If the wound is from an animal bite and there is a chance of rabies (see page 181), get injections of rabies vaccine and rabies immunoglobulin right away.

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BULLET, KNIFE, AND OTHER SERIOUS WOUNDS

Danger of infection: Any deep bullet or knife wound runs a high risk of dangerous infection. For this reason an antibiotic, such as cloxacillin (page 350) or clindamycin (page 358) should be used at once.

Persons who have not been vaccinated against tetanus should, if possible, be given an injection of antitetanus immunoglobulin (page 388), and also be vaccinated against tetanus.

If possible, seek medical help.

Bullet Wounds in the Arms or Legs:

♦ If the wound is bleeding a lot, control the bleeding as shown on page 82.

♦ If the bleeding is not serious, let the wound bleed for a short while. This will help clean it out.

♦ Wash the wound with cool, boiled water. In the case of a gunshot wound, wash the surface (outside) only. It is usually better not to poke anything into the hole. After cleaning, apply a clean bandage.

♦ Give antibiotics.

CAUTION:

If there is any possibility that the bullet has hit a bone, the bone may be broken.

Using or putting weight on the wounded limb (standing, for example) might cause a more serious break, like this:

If a break is suspected, it is best to splint the limb and not to use it for several weeks.

When the wound is serious, raise the wounded part a little higher than the heart and keep the injured person completely still.

YES: This way the wound will heal faster and is less likely to become infected.

YES: Make a sling like this to support an arm with a gunshot wound or other serious injury.

NO: Walking on an injured leg or sitting with the leg hanging down will slow healing and encourage infection.

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Deep Chest Wounds

Chest wounds can be very dangerous. Seek medical help at once.

♦ If the wound has reached the lungs and air is being sucked through the hole when the person breathes, cover the wound at once so that no more air enters. Spread Vaseline or vegetable fat on a gauze pad or clean bandage and wrap it tightly over the hole like this: (CAUTION: If this tight bandage makes breathing more difficult, try loosening or removing it.)

♦ Put the injured person in the position in which he feels most comfortable.

♦ If there are signs of shock, give proper treatment (see page 77).

♦ Give antibiotics and painkillers.

Bullet Wounds in the Head

♦ Place the injured person in a ‘half sitting’ position.

♦ Cover the wound with a clean bandage.

♦ Give antibiotics (penicillin).

♦ Seek medical help.

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Deep Wounds in the Abdomen

Any wound that goes into the belly or gut is dangerous. Seek medical help immediately. But in the meantime:

Cover the wound with a clean bandage.

If the guts are partly outside the wound, cover them with a clean cloth soaked in lightly salted, cool, boiled water. Do not try to push the guts back in. Make sure the cloth stays wet.

If the wounded person is in shock, raise his feet higher than his head.

Give absolutely nothing by mouth: no food, no drink, not even water, unless it will take more than 2 days to get to a health center. Then give water only, in small sips.

If the wounded person is awake and thirsty, let him suck on a piece of cloth soaked in water.

Inject antibiotics (see the following page for instructions).

Never give an enema, even if the belly swells up or the injured person does not move his bowels for days. If the gut is torn, an enema or purge can kill him.

DO NOT WAIT FOR A HEALTH WORKER.

IMMEDIATELY TAKE THE INJURED PERSON TO THE CLOSEST HEALTH CENTER OR HOSPITAL. He will need an operation.

EMERGENCY PROBLEMS OF THE GUT

Acute abdomen is a name given to a number of sudden, severe conditions of the gut for which prompt surgery is often needed to prevent death.

Appendicitis, peritonitis, and gut obstruction are examples (see following pages).

In women, pelvic inflammatory disease (often with vaginal discharge, see page 243), or an ectopic pregnancy (page 280) can also cause an acute abdomen.

The exact cause of acute abdomen may be uncertain until a surgeon cuts open the belly and looks inside.

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Medicine for a wound that goes into the gut (Also for appendicitis or peritonitis)

Until you can get medical help, do the following:

Inject ampicillin (page 352), 1 g (four 250 mg ampules) every 6 hours. Also give metronidazole (page 369), 500 mg every 6 hours.

If there is no ampicillin:

Give ciprofloxacin (page 356), 500 mg every 12 hours. Also give metronidazole. OR inject ceftriaxone (page 358), 2 g every 24 hours. Also give metronidazole.

If you do not have these antibiotics in injectable form, give ampicillin or ciprofloxacin by mouth, together with metronidazole and very little water.

If a person has continuous severe gut pain with vomiting, but does not have diarrhea, suspect an acute abdomen.

ACUTE ABDOMEN

Take to a hospital, surgery may be needed:

• continuous severe pain that keeps getting worse

• constipation and vomiting

• belly swollen, hard, person protects it

• severely ill

LESS SERIOUS ILLNESS

Probably can be treated in the home or health center:

• pain that comes and goes (cramps)

• moderate or severe diarrhea

• sometimes signs of an infection, perhaps a cold or sore throat

• he has had pains like this before

• only moderately ill

If a person shows signs of acute abdomen, get him to a hospital as fast as you can.

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OBSTRUCTED GUT

An acute abdomen may be caused by something that blocks or ‘obstructs’ a part of the gut, so that food and stools cannot pass.

More common causes are:

• a ball or knot of roundworms (Ascaris, page 140)

• a loop of gut that is pinched in a hernia (page 177)

• a part of the gut that slips inside the part below it (intussusception)

Almost any kind of acute abdomen may show some signs of obstruction. Because it hurts the damaged gut to move, it stops moving.

Signs of an obstructed gut:

  • Get this person to a hospital as fast as possible. His life is in danger and surgery may be needed.

  • Sudden vomiting with great force! The vomit may shoot out a meter or more. It may have green bile in it or smell and look like feces.

  • Steady, severe pain in the belly.

This child’s belly is swollen, hard, and very tender. It hurts more when you touch it. He tries to protect his belly and keeps his legs doubled up. His belly is often ‘silent’. (When you put your ear to it, you hear no sound of normal gurgles.)

He is usually constipated (little or no bowel movements). If there is diarrhea, it is only a little bit. Sometimes all that comes out is some bloody mucus.

Appendicitis, Peritonitis

These dangerous conditions often require surgery. Seek medical help fast.

Appendicitis is an infection of the appendix, a finger shaped sac attached to the large intestine in the lower right hand part of the belly. An infected appendix sometimes bursts open, causing peritonitis.

Peritonitis is an acute, serious infection of the lining of the cavity or bag that holds the gut. It results when the appendix or another part of the gut bursts or is torn.

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Signs of appendicitis:

• The main sign is a steady pain in the belly that gets worse and worse.

• The pain often begins around the navel (‘bellybutton’) but it soon moves to the lower right side.

• There may be loss of appetite, vomiting, constipation, or a mild fever.

Tests for Appendicitis or Peritonitis

IF IT SEEMS THAT A PERSON HAS APPENDICITIS OR PERITONITIS:

♦ Seek medical help immediately. If possible, take the person where he can have surgery.

♦ Do not give anything by mouth and do not give an enema. Only if the person begins to show signs of dehydration, give sips of water or Rehydration Drink (page 152) made with sugar and salt, but nothing more.

♦ The person should rest very quietly in a half-sitting position.

Note: When peritonitis is advanced, the belly becomes hard like a board, and the person feels great pain when his belly is touched even lightly. His life is in danger. Take him to a medical center immediately and on the way give him the medicines indicated at the top of page 93.

Have the person cough and see if this causes sharp pain in the belly.

Or, slowly but forcefully, press on the abdomen a little above the left groin until it hurts a little.

Then quickly remove the hand.

If a very sharp pain (rebound pain) occurs when the hand is removed, appendicitis or peritonitis is likely.

If no rebound pain occurs above the left groin, try the same test above the right groin.

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BURNS

Prevention:

Most burns can be prevented. Take special care with children: Do not let small babies go near a fire.

Keep lamps and matches out of reach.

Turn handles of pans on the stove so children cannot reach them.

Keep chemicals in closed containers and keep them away from children.

Minor Burns that Do Not Form Blisters (1st degree)

To help ease the pain and lessen the damage caused by a minor burn, put the burned part in cool water at once. No other treatment is needed. Take aspirin or acetaminophen for pain. Avoid giving aspirin to children.

Burns that Cause Blisters, Chemical Burns, and Electric Burns (2nd degree).

Do not break blisters. Do not put ice on the burn. If the blisters are broken, wash gently with soap and boiled water that has been cooled. Rinse with water for 30 minutes. Then put a piece of sterile gauze on the burn loosely so it does not put pressure on the wound. Never smear on grease or butter.

Covering the burn with honey or the inside meat of an aloe plant helps prevent and control infection and speed healing. Gently wash off the old honey or aloe and put on new at least twice a day.

It is very important to keep the burn as clean as possible. Protect it from dirt, dust, and flies.

If signs of infection appear, pus, bad smell, fever, or swollen lymph nodes, apply compresses of warm salt water (1 teaspoon salt to 1 liter water) 3 times a day. Boil both the water and cloth before use. With great care, remove the dead skin and flesh.

You can spread on a little antibiotic ointment such as Neosporin (page 370). In severe cases, consider taking an antibiotic such as dicloxacillin (page 350), clindamycin (page 358), or ciprofloxacin (page 358).

Deep Burns (3rd degree)

These are burns that destroy the skin and expose raw or charred flesh, or do not show until a few hours after a chemical gets on the skin.

They are always serious, as are any burns that cover large areas of the body. Take the person to a health center at once.

In the meantime wrap the burned part with a very clean cloth or towel moistened with clean water.

If it is impossible to get medical help, treat the burn as described above.

If you do not have Vaseline, leave the burn in the open air, covering it only with a loose cotton cloth or sheet to protect it from dust and flies.

Keep the cloth very clean and change it each time it gets dirty with liquid or blood from the burn. Give an antibiotic.

Never put grease, fat, hides, coffee, herbs, or feces on a burn.

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Special Precautions for Very Serious Burns

Any person who has been badly burned can easily go into shock (see page 77) because of combined pain, fear, and the loss of body fluids from the oozing burn.

Comfort and reassure the burned person. Give him aspirin or acetaminophen for the pain and codeine if you can get it. Bathing open wounds in slightly salty water also helps calm pain. Put 1 teaspoon of salt for each liter of cool, boiled water.

Give the burned person plenty of liquid. If the burned area is large (more than twice the size of his hand), make up the following drink:

  • To a liter of water add:

  • half a teaspoon of salt

  • and half a teaspoon of bicarbonate of soda.

  • Also put in 2 or 3 tablespoons of sugar or honey and some orange or lemon juice if possible.

  • The burned person should drink this as often as possible, especially until he urinates frequently. He should drink 4 liters a day for a large burn, and up to 12 liters a day for a very large burn.

  • It is important for persons who are badly burned to eat foods rich in protein (See page 110 and page 111). No type of food needs to be avoided.

Burns around the Joints

When someone is badly burned between the fingers, in the armpit, or at other joints, gauze pads with Vaseline on them should be put between the burned surfaces to prevent them from growing together as they heal.

Also, fingers, arms, and legs should be straightened completely several times a day while healing.

This is painful but helps prevent stiff scars that limit movement. While the burned hand is healing, the fingers should be kept in a slightly bent position.

Sterile gauze pads with Vaseline

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BROKEN BONES (fractures)

When a bone is broken, the most important thing to do is keep the bone in a fixed position. This prevents further damage and lets it mend.

Before trying to move or carry a person with a broken bone, keep the bones from moving with splints, strips of bark, or a sleeve of cardboard. Later a plaster cast can be put on the limb at a health center, or perhaps you can make a ‘cast’ according to local tradition (see page 14).

Setting broken bones: If the bones seem more or less in the right position, it is better not to move them, this could do more harm than good.

If the bones are far out of position and the break is recent, you can try to ‘set’ or straighten them before putting on cast. The sooner the bones are set, the easier it will be. Before setting, if possible give diazepam to relax the muscles and calm pain (see page 389). Or give codeine (page 383).

HOW TO SET A BROKEN WRIST

Pull the hand with a slow, steady force for 5 to 10 minutes, increasing the force, to separate the bones. With one person still pulling the hand, have another gently line up and straighten the bones.

WARNING: It is possible to do a lot of damage while trying to set a bone. Ideally, it should be done with the help of someone with experience. Do not jerk or force.

how long does it take for broken bones to heal?

The worse the break or the older the person, the longer healing takes.

Children’s bones mend rapidly. Those of old people sometimes never join. A broken arm should be kept in a cast for about a month, and no force put on it for another month. A broken leg should remain in a cast for about 2 months.

A broken upper leg or hip often needs special attention. It is best to splint the whole body like this:

and to take the injured person to a health center at once.

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BROKEN NECKS AND BACKS

If there is any chance a person’s back or neck has been broken, be very careful when moving him. Try not to change his position. If possible, bring a health worker before moving him. If you must move him, do so without bending his back or neck. For instructions on how to move the injured person, see the next page.

BROKEN RIBS

These are very painful, but almost always heal on their own. It is better not to splint or bind the chest. The best treatment is to take aspirin or acetaminophen (avoid giving aspirin to children), and rest.

To keep the lungs healthy, take 4 to 5 deep breaths in a row, every 2 hours. Do this daily until you can breathe normally. At first, this will be very painful. It may take months before the pain is gone completely.

A broken rib does not often puncture a lung. But if a rib breaks through the skin, or if the person coughs blood or develops breathing difficulties (other than pain), use antibiotics and seek medical help.

BROKEN BONES THAT BREAK THROUGH THE SKIN (open fractures)

Since the danger of infection is very great in these cases, it is always better to get help from a health worker or doctor in caring for the injury.

Wear gloves or plastic bags on your hands and clean the wound and the exposed bone very gently but thoroughly with cool, boiled water.

Cover with a clean cloth.

Never put the bone back into the wound until the wound and the bone are absolutely clean.

Splint the limb to prevent more injury.

If the bone has broken the skin, use an antibiotic immediately to help prevent infection: dicloxacillin (page 350), clindamycin (page 358), or ceftriaxone (page 358).

BROKEN THIGH OR HIP BONE

CAUTION: Never rub or massage a broken limb or a limb that may possibly be broken.

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HOW TO MOVE A BADLY INJURED PERSON

With great care, lift the injured person without bending him anywhere. Take special care that the head and neck do not bend.

Have another person put the stretcher in place.

With the help of everyone, place the injured person carefully on the stretcher.

Tightly folded clothing

If the neck is injured or broken, put tightly folded clothing or sandbags on each side of the head to keep it from moving.

When carrying, try to keep the feet up, even on hills.

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DISLOCATIONS (bones that have come out of place at a joint)

Three important points of treatment:

♦ Try to put the bone back into place. The sooner the better!

♦ Keep it bandaged firmly in place so it does not slip out again (about a month).

♦ Avoid forceful use of the limb long enough for the joint to heal completely (2 or 3 months).

how to set a dislocated shoulder

Have the injured person lie face down on a table or other firm surface with his arm hanging over the side. Pull down on the arm toward the floor, using a strong, steady force, for 15 to 20 minutes. Then gently let go. The shoulder should ‘pop’ back into place.

Or attach something to the arm that weighs 5 to 10 kg (start with 5 kg, but do not go higher than 10 kg) and leave it there for 15 to 20 minutes.

After the shoulder is in place, bandage the arm firmly against the body. Keep it bandaged for a week to a month.

To prevent the shoulder from becoming completely stiff, un-bandage the arm for a few minutes 3 times a day and, with the arm hanging at the side, move it gently in narrow circles.

Do not lift any weight with the arm for a month so the shoulder does not pop out of place again.

If you cannot put the dislocated limb back in place, look for medical help at once. The longer you wait, the harder it will be to correct.

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STRAINS AND SPRAINS (bruising or tearing in a twisted joint)

Many times it is impossible to know whether a hand or foot is bruised, sprained, or broken. It helps to have an X-ray taken.

But usually, breaks and sprains are treated more or less the same. Keep the joint motionless. Wrap it with something that gives firm support. Use crutches to give a sprained foot as much rest as possible. Serious sprains need at least 3 or 4 weeks to heal. Broken bones take longer.

To relieve pain and swelling, keep the sprained part raised high. During the first day or two, put ice wrapped in cloth or plastic, or cold, wet cloths over the swollen joint for 20 to 30 minutes once every hour.

This helps reduce swelling and pain. After 24 to 48 hours (when the swelling is no longer getting worse), soak the sprain in hot water several times a day.

For the first day soak the sprained After 1 or 2 days use hot soaks. joint in cold water.

You can keep the twisted joint in the correct position for healing by using a homemade cast (see page 14) or an elastic bandage.

Wrapping the foot and ankle with an elastic bandage will also prevent or reduce swelling. Start from the toes and wrap upward, as shown here. Be careful not to make the bandage too tight, and remove it briefly every hour or two. Also take aspirin or acetaminophen.

If the pain and swelling do not start to go down after 48 hours, seek medical help.

CAUTION: Never rub or massage a sprain or broken bone. It does no good and can do more harm.

If the foot seems very loose or ‘floppy’ or if the person has trouble moving his toes, look for medical help. Surgery may be needed.

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POISONING

Many children die from swallowing things that are poisonous. To protect your children, take the following precautions:

Keep all poisons out of reach of children.

Never keep kerosene, gasoline, or other poisons in cola or soft drink bottles, because children may try to drink them.

SOME COMMON POISONS TO WATCH OUT FOR:

• rat poison

• DDT, lindane, sheep dip, and other insecticides or plant poisons

• medicine (any kind when much is swallowed; take special care with iron pills)

• tincture of iodine

• bleach

• cigarettes

• rubbing or wood alcohol

Treatment:

• poisonous leaves, seeds, berries, or mushrooms

• castor beans

• matches

• kerosene, paint thinner, gasoline, petrol, lighter fluid

• lye or caustic soda

• salt, if too much is given to babies and small children

• spoiled food (see page 135)

If you suspect poisoning, do the following immediately:

♦ If the child is unconscious, lay him on his side. If he stops breathing, give him mouth-to-mouth breathing (page 80).

♦ If the child is awake and alert, give him plenty of water or milk to drink to dilute the poison (about 1 glass of water every 15 minutes).

♦ If you have activated charcoal (page 388), give it right away, mixed into a glass of water.

♦ If the child is awake and alert and you are sure vomiting is safe, you can make him vomit. Put your finger in his throat or make him drink very salty water.

CAUTION: Do not make a person vomit if he has swallowed kerosene, gasoline (petrol), bleach, paint thinner, some pesticides, strong acids or corrosive substances (lye), or if he is unconscious.

Cover the person if he feels cold, but avoid too much heat. If poisoning is severe, look for medical help.

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SNAKEBITE

Note: Try to get information on the kinds of snakes in your area and put it on this page.

RATTLESNAKE

North America. Mexico, and Central America.

When someone has been bitten by a snake, try to find out if the snake was poisonous or harmless. Their bite marks are usually different:

POISONOUS SNAKE

The bite of most poisonous snakes leaves marks of the 2 fangs (and sometimes, little marks made by the other teeth).

PROBABLY A NON-POISONOUS SNAKE

If the bite of a snake leaves only 2 rows of teeth marks, but no fang marks, it is less likely that the snake is poisonous. But it still could be.

People often believe that certain harmless snakes are poisonous. Try to find out which of the snakes in your area are truly poisonous and which are not.

Contrary to popular opinion, boa constrictors and pythons are not poisonous.

Please do not kill non-poisonous snakes, because they do no harm. On the contrary, they kill mice and other pests that do lots of damage. Some even kill poisonous snakes.

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Treatment for poisonous snakebite:

  1. Stay quiet; do not move the bitten part. The more it is moved, the faster the poison will spread through the body. If the bite is on the foot, the person should not walk at all. Send for medical help.

  2. Remove jewelry because swelling can spread rapidly.

  3. Wrap the bitten area with a wide elastic bandage or clean cloth to slow the spread of poison. Keeping the arm or leg very still, wrap it tightly, but not so tight it stops the pulse at the wrist or on top of the foot. If you cannot feel the pulse, loosen the bandage a little.

  4. Wind the bandage over the hand or foot, and up the whole arm or leg. Make sure you can still feel the pulse.

  5. Then, put on a splint to prevent the limb from moving (see page 14).

  6. Carry the person, on a stretcher if possible, to the nearest health center.

If you can, also take the snake, because different snakes may require different antivenoms (antitoxins, see page 387).

If an antivenom is needed, leave the bandage on until the injection is ready, and take all precautions for ALLERGIC SHOCK (see page 70).

Also give tetanus antitoxin (page 388). If there is no need for antivenom, remove the bandage.

Poisonous snakebite is dangerous. Send for medical help, but always do the things explained above at once.

Most folk remedies for snakebite do little if any good (see page 3).

Some treatments can cause infection or make the effects of the venom worse.

Do not:

• cut the skin or the flesh around the bite

• tie anything tight around the bite or the person’s body • put ice on or around the bite

• shock the person with electricity

• try to suck the blood or the venom out of the bite

Have anti-venoms for snakes in your area ready and know how to use them, before someone is bitten!

Never drink alcohol after a snakebite. It makes things worse!

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BITE OF THE BEADED LIZARD (gila monster)

The bite of the beaded lizard is treated just like a poisonous snakebite, except that there are no good antivenoms for it.

The bite can be very dangerous. Wash the bite area well. Avoid movement and keep the bite below the level of the heart.

SCORPION STING

Some scorpions are far more poisonous than others. To adults, scorpion stings are rarely dangerous. Take aspirin or acetaminophen and if possible put ice on the sting to help calm the pain.

For the numbness and pain that sometimes last weeks or months, hot compresses may be helpful (see page 193).

To children under 5 years old, scorpion stings can be dangerous, especially if the sting is on the head or body. In some countries scorpion antitoxin is available (page 387).

To do much good it must be injected within 2 hours after the child has been stung. Give acetaminophen for the pain. If the child stops breathing, use mouth to mouth breathing (see page 80). Also give tetanus antitoxin (see page 388).

If the child who was stung is very young or has been stung on the main part of the body, or if you know the scorpion was of a deadly type, seek medical help fast.

SPIDER BITES: BLACK WIDOW AND OTHERS

The majority of spider bites, including that of the tarantula, are painful but not dangerous. The bite of a few kinds of spiders, such as the ‘black widow’ and related species, can make an adult quite ill.

They can be dangerous for a small child. A black widow bite often causes painful muscle cramps all over the body, and extreme pain in the stomach muscles which become rigid. (Sometimes this is confused with appendicitis!)

Give acetaminophen or aspirin and look fo medical help. Most cures sold in stores are a waste of money and do not help. Diazepam (page 390) may help reduce muscular spasms.

If signs of shock develop, treat for allergic shock (page 70).

Injections of cortisone may be needed in children. Also give tetanus antitoxin (see page 388).

A good antivenom exists but is hard to get.

11

nutrition: eat to be healthy

SICKNESSES CAUSED BY NOT EATING WELL

Good food is needed for a person to grow well, work hard, and stay healthy. Many common sicknesses come from not eating enough.

A person who is weak or sick because he does not eat enough, or does not eat the foods his body needs, is said to be poorly nourished, or malnourished. He suffers from malnutrition. Poor nutrition can result in the following health problems:

in children

  • failure of a child to grow or gain weight normally (see p. 297)
  • slowness in walking, talking, or thinking
  • big bellies, thin arms and legs
  • common illnesses and infections that last longer, are more severe, and more often cause death
  • lack of energy, child is sad and does not play
  • swelling of feet, face, and hands, often with sores or marks on the skin
  • thinning, straightening, or loss of hair, or loss of its color and shine
  • poor vision at night, dryness of eyes, blindness

in anyone

  • weakness and tiredness
  • loss of appetite
  • anemia
  • sores in the corners of the mouth
  • painful or sore tongue
  • ‘burning’ or numbness of the feet

Although the following problems may have other causes, they are sometimes caused and are often made worse by not eating well:

  • diarrhea
  • frequent infections
  • ringing or buzzing in the ears
  • headache
  • bleeding or redness of the gums
  • skin bruises easily
  • nosebleeds
  • stomach discomfort
  • dryness and cracking of the skin
  • heavy pulsing of the heart or of the ‘pit’ of the stomach (palpitations)
  • anxiety (nervous worry) and various nerve or mental problems • cirrhosis (liver disease)

Poor nutrition during pregnancy causes weakness and anemia in the mother and increases the risk of her dying during or after childbirth. It is also a cause of miscarriage, or of the baby being born dead, too small, or with a disability.

Eating right helps the body resist sickness

Not eating well may be the direct cause of the health problems just listed. But most important, poor nutrition weakens the body’s ability to resist all kinds of diseases, especially infections:

  • Poorly nourished children are much more likely to get severe diarrhea, and to die from it, than are children who are well nourished.

  • Measles is especially dangerous where many children are malnourished.

  • Tuberculosis is more common, and gets worse more rapidly, in those who are malnourished.

  • Cirrhosis of the liver, which comes in part from drinking too much alcohol, is more common and worse in persons who are poorly nourished.

  • Even minor problems like the common cold are usually worse, last longer, or lead to pneumonia more often in persons who are poorly nourished.

Eating right helps the sick get well

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Not only does good food help prevent disease, it helps the sick body fight disease and become well again. So when a person is sick, eating enough nutritious food is especially important.

Unfortunately, some mothers stop feeding a child or stop giving certain nutritious foods when he is sick or has diarrhea, so the child becomes weaker, cannot fight off the illness, and may die. Sick children need food! If a sick child will not eat, encourage him to do so.

Feed him as much as he will eat and drink. And be patient. A sick child often does not want to eat much. So feed him something many times during the day. Also, try to make sure that he drinks a lot of liquid so that he pees (passes urine) several times a day. If the child will not take solid foods, mash them and give them as a mush or gruel.

Often the signs of poor nutrition first appear when a person has some other sickness. For example, a child who has had diarrhea for several days may develop swollen hands and feet, a swollen face, dark spots, or peeling sores on his legs. These are signs of severe malnutrition. The child needs more good food! And more often. Feed him many times during the day.

During and after any sickness, it is very important to eat well.

EATING WELL AND KEEPING CLEAN ARE THE BEST GUARANTEES OF GOOD HEALTH.

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WHY IT IS IMPORTANT TO EAT RIGHT

People who do not eat right develop malnutrition. This can happen from not eating enough food of any kind (general malnutrition or ‘undernutrition’), from not eating the right kinds of foods (specific types of malnutrition), or from eating too much of certain foods (getting too fat, see p. 126).

Anyone can develop general malnutrition, but it is especially dangerous for:

  • children, because they need lots of food to grow well and stay healthy;

  • women of child bearing age, especially if they are pregnant or breastfeeding, because they need extra food to stay healthy, to have healthy babies, and to do their daily work;

  • elderly persons, because often they lose their teeth and their taste for food, so they cannot eat much at one time, even though they still need to eat well to stay healthy;

  • people with HIV, because they need more food to fight their infection.

A malnourished child does not grow well. She generally is thinner and shorter than other children. Also, she is more likely to be irritable, to cry a lot, to move and play less than other children, and to get sick more often. If the child also gets diarrhea or other infections, she will lose weight. A good way to check if a child is poorly nourished is to measure the distance around her upper arm.

Checking Children for Malnutrition: The Sign of the Upper Arm

After 1 year of age, any child whose middle upper arm measures less than 11 1⁄2 cm. around is malnourished , no matter how ‘fat’ his feet, hands, and face may look. If the arm measures between 11 1⁄2 and 12 1⁄2 cm., he is at risk of becoming malnourished.

Another good way to tell if a child is well nourished or poorly nourished is to weigh him regularly: once a month in the first year, then once every 3 months. A healthy, well nourished child gains weight regularly. The weighing of children and the use of the Child Health Chart are discussed fully in Chapter 21.

PREVENTING MALNUTRITION

To stay healthy, our bodies need plenty of good food. The food we eat has to fill many needs. First, it should provide enough energy to keep us active and strong. Also, it must help build, repair, and protect the different parts of our bodies. To do all this we need to eat a combination of foods every day.

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MAIN FOODS AND HELPER FOODS

In much of the world, most people eat one main low-cost food with almost every meal. Depending on the region, this may be rice, maize, millet, wheat, cassava, potato, breadfruit, or banana. This main food usually provides most of the body’s daily food needs.

However, the main food alone is not enough to keep a person healthy. Certain helper foods are needed. This is especially true for growing children, women who are pregnant or breastfeeding, and older people.

Even if a child regularly gets enough of the main food to fill her, she may become thin and weak. This is because the main food often has so much water and fiber in it, that the child’s belly fills up before she gets enough energy to help her grow.

We can do 2 things to help meet such children’s energy needs:

  • Feed children more often, at least 5 times a day when a child is very young, too thin, or not growing well. Also give her snacks between meals.

CHILDREN, LIKE CHICKENS, SHOULD ALWAYS BE PECKING.

  • Also add high energy ‘helper foods’ such as oils and sugar or honey to the main food. It is best to add vegetable oil or foods containing oils, nuts, groundnuts (peanuts), or seeds, especially pumpkin or sesame seeds.

If the child’s belly fills up before her energy needs are met, the child will become thin and weak.

to meet her energy needs, a child would need to eat this much boiled rice.

but child needs only this much rice when some vegetable oil is mixed in.

High energy foods added to the main food help to supply extra energy. Also, 2 other kinds of helper foods should be added to the main food:

When possible, add body–building foods (proteins) such as beans, milk, eggs, groundnuts, fish, and meat.

Also try to add protective foods such as orange or yellow fruits and vegetables, and also dark green leafy vegetables. Protective foods supply important vitamins and minerals.

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EATING RIGHT TO STAY HEALTHY

The ‘main food’ your family eats usually provides most, but not all, of the body’s energy and other nutritional needs. By adding helper foods to the main food you can make low cost nutritious meals. You do not have to eat all the foods listed here to be healthy.

Eat the main foods you are accustomed to, and add whatever ‘helper foods’ are available in your area. Try to include ‘helper foods’ from each group, as often as possible.

REMEMBER: Feeding children enough and feeding them often (3 to 5 times a day) is usually more important than the types of food you feed them.

GO FOODS (energy helpers)

Examples:

  • Fats (vegetable oils, butter, ghee, lard)
  • Foods rich in fats (coconut, olives, fatty meat)
  • Nuts (groundnuts, almonds, walnuts, cashews)
  • Oil seeds (pumpkin, melon, sesame, sunflower)
  • Sugars (sugar, honey, molasses, sugar cane, jaggery)

  • Note: Nuts and oil seeds are also valuable as body-building helpers.

MAIN FOODS

Examples:

  • Cereals and grains (wheat, maize, rice, millet, sorghum)
  • Starchy roots** (cassava, potatoes, taro)
  • Starchy fruits (banana, plantain, breadfruit)

Note: Main foods are cheap sources of energy. The cereals also provide some protein, iron, and vitamins, at low cost.

GROW FOODS

proteins or body-building helpers

Examples: - Legumes (beans, peas, and lentils) - Nuts (groundnuts, walnuts, cashews, and almonds) - Oil seeds (sesame and sunflower) - Animal products (milk, eggs, cheese, yogurt, fish, chicken, meat, small animals such as mice, and insects)

GLOW FOODS

vitamins and minerals or protective helpers

Examples: - Vegetables (dark green leafy plants, tomatoes, carrots, pumpkin, sweet potato, and peppers) - Fruits (mangoes, oranges, papayas)

Note to nutrition workers: This plan for meeting food needs resembles teaching about ‘food groups’, but places more importance on giving enough of the traditional ‘main food’ and above all, giving frequent feedings with plenty of energy-rich helpers. This approach is more adaptable to the resources and limitations of poor families.

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HOW TO RECOGNIZE MALNUTRITION

Among poor people, malnutrition is often most severe in children, who need lots of nutritious food to grow well and stay healthy. There are different forms of malnutrition:

mild malnutrition

This is the most common form, but it is not always obvious. The child simply does not grow or gain weight as fast as a well- nourished child. Although he may appear rather small and thin, he usually does not look sick. However, because he is poorly nourished, he may lack strength (resistance) to fight infections. So he becomes more seriously ill and takes longer to get well than a well nourished child.

Children with this form of malnutrition suffer more from diarrhea and colds. Their colds usually last longer and are more likely to turn into pneumonia. Measles, tuberculosis, and many other infectious diseases are far more dangerous for these malnourished children. More of them die.

It is important that children like these get special care and enough food before they become seriously ill. This is why regular weighing or measuring around the middle upper arm of young children is so important. It helps us to recognize mild malnutrition early and correct it.

Follow the guidelines for preventing malnutrition.

severe malnutrition

This occurs most often in babies who stopped breastfeeding early or suddenly, and who are not given sufficient high energy foods often enough. Severe malnutrition often starts when a child has diarrhea or another infection. We can usually recognize children who are severely malnourished without taking any measurements. The 2 main examples are:

dry malnutrition, or marasmus

This child does not get enough of any kind of food. He is said to have dry malnutrition or marasmus. In other words, he is starved. His body is small, very thin and wasted. He is little more than skin and bones.

This child needs more food, especially energy foods.

THIS CHILD IS JUST SKIN AND BONES.

This child’s condition is called wet malnutrition because his feet, hands, and face are swollen. This can happen when a child does not eat enough ‘body building’ helper foods, or proteins. More often it happens when he does not get enough energy foods, and his body burns up whatever proteins he eats for energy.

Eating beans, lentils, or other foods that have been stored in a damp place and are a little moldy may also be part of the cause.

This child needs more food more often, a lot of foods rich in energy, and some foods rich in protein (see p. 111).

Also, try to avoid foods that are old, and may be spoiled or moldy.

other forms of malnutrition

First the child becomes swollen. The other signs come later.

THIS CHILD IS SKIN, BONES, AND WATER.

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wet malnutrition (kwashiorkor)

Other forms of malnutrition may result when certain vitamins and minerals are missing from the foods people eat. Many of these specific types of malnutrition are discussed more fully later in this chapter and in other parts of this book:

• Night blindness in children who do not get enough vitamin A (see p. 226).

• Rickets from lack of vitamin D (see p. 125).

• Various skin problems, sores on the lips and mouth, or bleeding gums from not eating enough fruits, vegetables, and other foods containing certain vitamins (see page 208 and 232).

• Anemia in people who do not get enough iron (see p. 124).

• Goiter from lack of iodine (see p. 130).

For more information about health problems related to nutrition, see Helping Health Workers Learn, Chapter 25, and Disabled Village Children, Chapters 13 and 30.

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Examples

This mother and child are from a poor family and are both poorly nourished. The father works hard, but he does not earn enough to feed the family well.

The patches on the mother’s arms are a sign of pellagra, a type of malnutrition. She ate mostly maize and not enough nutritious foods such as beans, eggs, fruit, meat, and dark green vegetables.

The mother did not breastfeed her baby. She fed him only maize porridge. Although this filled his belly, it did not provide enough nutrition for him to grow strong.

As a result, this 2 year old child is severely malnourished. He is very small and thin with a swollen belly, his hair is thin, and his physical and mental development will be slower than normal. To prevent this, mothers and their children need to eat better.

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ways of eating better when you do not have much money or land

There are many reasons for hunger and poor nutrition. One main reason is poverty.

In many parts of the world a few people own most of the wealth and the land.

They may grow crops like coffee or tobacco, which they sell to make money, but which have no food value.

Or the poor may farm small plots of borrowed land, while the owners take a big share of the harvest. The problem of hunger and poor nutrition will never be completely solved until people learn to share with each other fairly.

But there are many things people can do to eat better at low cost, and by eating well gain strength to stand up for their rights. On pages w13 and w14 of “Words to the Village Health Worker” are several suggestions for increasing food production.

These include improved use of land through rotating crops, contour ditches, and irrigation; also ideas for breeding fish, beekeeping, grain storage, and family gardens. If the whole village or a group of families works together on some of these things, a lot can be done to improve nutrition.

When considering the question of food and land, it is important to remember that a given amount of land can feed only a certain number of persons. For this reason, some people argue that ‘the small family lives better’. However, for many poor families, to have many children is an economic necessity.

By the time they are 10 or 12 years old, children of poor families often produce more than they cost. Having a lot of children increases the chance that parents will receive the help and care they need in old age.

In short, lack of social and economic security creates the need for parents to have many children. Therefore, the answer to gaining a balance between people and land does not lie in telling poor people to have small families.

It lies in redistributing the land more fairly, paying fair wages, and taking other steps to overcome poverty. Only then can people afford small families and hope to achieve a lasting balance between people and land. (For a discussion of health, food, and social problems, see Helping Health Workers Learn.)

When money is limited, it is important to use it wisely. This means cooperation and looking ahead. Too often the father of a poor family will spend the little bit of money he has on alcohol and tobacco rather than on buying nutritious food, a hen to lay eggs, or something to improve the family’s health. Men who drink together would do well to get together sometime when they are sober, to discuss these problems and look for a healthy solution.

Also, some parents buy sweets or soft drinks (fizzy drinks) for their children when they could spend the same money buying eggs, milk, nuts or other nutritious foods. This way their children could become more healthy for the same amount of money. Discuss this with the families and look for solutions.

IF YOU HAVE A LITTLE MONEY AND WANT TO HELP YOUR CHILD GROW STRONG:

Do not buy him a soft drink or sweets, buy him 2 eggs or a handful of nuts.

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Better Foods at Low Cost

Many of the world’s people eat a lot of bulky, starchy foods, without adding enough helper foods to provide the extra energy, body building, and protection they need. This is partly because many helper foods are expensive, especially those that come from animals, like milk and meat.

People can be strong and healthy when most of their proteins and other helper foods come from plants.

Most people cannot afford much food from animals. Animals require more land for the amount of food they provide. A poor family can usually be better nourished if they grow or buy plant foods like beans, peas, lentils, and groundnuts together with a main food such as maize or rice, rather than buy costly animal foods like meat and fish.

However, where family finances and local customs permit, it is wise to eat, when possible, some food that comes from animals. This is because even plants high in protein (body-building helpers) often do not have all of the different proteins the body needs.

Try to eat a variety of plant foods. Different plants supply the body with different proteins, vitamins, and minerals. For example, beans and maize together meet the body’s needs much better than either beans or maize alone. And if other vegetables and fruits are added, this is even better.

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Here are some suggestions for getting more vitamins, minerals, and proteins at low cost.

  1. Breast milk. This is the cheapest, healthiest, and most complete food for a baby. The mother can eat plenty of plant foods and turn them into the perfect baby food, breast milk. Breastfeeding is not only best for the baby, it saves money and prevents diseases!

  2. Eggs and chicken. In many places eggs are one of the cheapest and best forms of animal protein. They can be cooked and mixed with foods given to babies who cannot get breast milk. Or they can be given along with breast milk as the baby grows older.

Eggshells that are boiled, finely ground, and mixed with food can provide needed calcium for pregnant women who develop sore, loose teeth or muscle cramps.

Chicken is a good, often fairly cheap form of animal protein, especially if the family raises its own chickens.

  1. Liver, heart, kidney, and blood. These are especially high in protein, vitamins, and iron (for anemia) and are often cheaper than other meat. Also fish is often cheaper than other meat, and is just as nutritious.

  2. Beans, peas, lentils, and other legumes are a good cheap source of protein. If allowed to sprout before cooking and eating, they are higher in vitamins. Baby food can be made from beans by cooking them well, and then straining them through a sieve, or by peeling off their skins, and mashing them.

Beans, peas, and other legumes are not only a low-cost form of protein. Growing these crops makes the soil richer so that other crops will grow better afterwards. For this reason, crop rotation and mixed crops are a good idea (see p. w13).

  1. Dark green leafy vegetables have some iron, a lot of vitamin A, and some protein. The leaves of sweet potatoes, beans and peas, pumpkins and squash, and baobab are especially nutritious. They can be dried, powdered, and mixed with babies’ gruel.

Note: Light green vegetables like cabbage and lettuce have less nutritional value. It is better to grow ones with dark colored leaves.

  1. Cassava (manioc) leaves contain 7 times as much protein and more vitamins than the root. If eaten together with the root, they add food value, at no additional cost. The young leaves are best.

  2. Lime soaked maize (corn). When soaked in lime (cal) before cooking, as is the custom in much of Latin America, maize is richer in calcium. Soaking in lime also allows more of the vitamins (niacin) and protein to be used by the body.

  3. Rice, wheat, and other grains are more nutritious if their outer skins are not removed during milling. Moderately milled rice and whole wheat contain more proteins, vitamins, and minerals than the white, over milled product.

Note: The protein in wheat, rice, maize, and other grains can be better used by the body when they are eaten with beans or lentils.

  1. Cook vegetables, rice, and other foods in little water. And do not overcook. This way fewer vitamins and proteins are lost. Be sure to drink the leftover water, or use it for soups or in other foods.

  2. Many wild fruits and berries are rich in vitamin C as well as natural sugars. They provide extra vitamins and energy. (Be careful not to eat berries or fruit that are poisonous.)

  3. Cooking in iron pots or putting a piece of old iron or horseshoe in the pan when cooking beans and other foods adds iron to food and helps prevent anemia. More iron will be available if you also add tomatoes.

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For another source of iron, put some iron nails in a little lemon juice for a few hours. Then make lemonade with the juice and drink it.

  1. In some countries, low-cost baby food preparations are available, made from different combinations of soybean, cotton seed, skim milk, or dried fish. Some taste better than others, but most are well balanced foods. When mixed with gruel, cooked cereal, or other baby food, they add to its nutrition content at low cost.

WHERE TO GET VITAMINS: pills, injections, syrups, or foods?

Anyone who eats a good mixture of foods, including vegetables and fruits, gets all the vitamins he needs. It is always better to eat well than to buy vitamin pills, injections, syrups, or tonics.

Sometimes nutritious foods are scarce. If a person is already poorly nourished, or has a serious illness like HIV, he should eat as well as he can and perhaps take vitamins besides.

Vitamins taken by mouth work as well as injections, cost less, and are not as dangerous. Do not inject vitamins! It is better to swallow them, preferably in the form of nutritious foods.

If you want vitamins, buy eggs or other nutritious foods instead of pills or injections.

If you buy vitamin preparations, be sure they have all these vitamins and minerals:

♦ Niacin (niacinamide)

♦ Vitamin B1 (thiamine)

♦ Vitamin B2 (riboflavin)

In addition, certain people need extra:

♦ Folic Acid (folicin), for pregnant women

♦ Iron (ferrous sulfate, etc.), especially for pregnant women.

(For people with anemia, multi-vitamin pills do not have enough iron to help much. Iron pills are more helpful.)

♦ Vitamin B6 (pyridoxine), for small children and persons taking medicine for tuberculosis

♦ Calcium, for children and breastfeeding mothers who do not get enough calcium in foods such as milk, cheese, or foods prepared with lime

♦ Vitamin A

♦ Vitamin C (ascorbic acid)

♦ Vitamin D

♦ Iodine (in areas where goiter is common) for small children

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THINGS TO AVOID IN OUR DIET

A lot of people believe that there are many kinds of foods that will hurt them, or that they should not eat when they are sick. They may think of some kinds of foods as ‘hot’ and others as ‘cold’, and not permit hot foods for ‘hot’ sicknesses or cold foods for ‘cold’ sicknesses.

Or they may believe that many different foods are bad for a mother with a newborn child. Some of these beliefs are reasonable but others do more harm than good. Often the foods people think they should avoid when they are sick are the very foods they need to get well.

A sick person has even greater need for plenty of nutritious food than a healthy person. We should worry less about foods that might harm a sick person and think more about foods that help make him healthy, for example: high energy foods together with fruit, vegetables, legumes, nuts, milk, meat, eggs, and fish.

As a general rule:

The same foods that are good for us when we are healthy are good for us when we are sick.

Also, the things that harm us when we are healthy do us even more harm when we are sick.

Avoid these things:

  • alcoholic drinks

  • tobacco

  • greasy food

  • a lot of sugar and sweets

  • too much coffee

• Alcohol causes or makes worse diseases of the liver, stomach, heart, and nerves. It also causes social problems.

• Smoking can cause chronic (long-term) coughing or lung cancer and other problems (see p. 149). Smoking is especially bad for people with lung diseases like tuberculosis, asthma, and bronchitis.

• Too much greasy food or coffee can make stomach ulcers and other problems of the digestive tract worse.

• Too much sugar and sweets spoil the appetite and rot the teeth. However, some sugar with other foods may help give needed energy to a sick person or poorly nourished child.

A few diseases require not eating certain other foods. For example, people with high blood pressure, certain heart problems, or swollen feet should use little or no salt. Too much salt is not good for anyone. Stomach ulcers and diabetes also require special diets (see pages 127).

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THE BEST DIET FOR SMALL CHILDREN

0 > 6 The first 6 months of life

For the first 6 months give the baby breast milk and nothing else. It is better than any baby food or milks you can buy. Breast milk helps protect the baby against diarrhea and many infections. It is best not to give extra water or teas, even in hot weather.

Some mothers stop breastfeeding early because they think that their milk is not good enough for their baby, or that their breasts are not making enough milk. However, a mother’s milk is always very nutritious for her baby, even if the mother herself is thin and weak.

If a woman has HIV, sometimes she can pass HIV to a baby in her breast milk. But if she does not have access to clean water, her baby is more likely to die from diarrhea, dehydration, and malnutrition than AIDS. Now medicines can prevent the spread of HIV to babies through breast milk (see p. 398).

But only you can evaluate the conditions in your home and community and decide what to do.

Nearly all mothers can produce all the breast milk their babies need:

♦ The best way for a mother to keep making enough breast milk is to breastfeed the baby often, eat well, and drink lots of liquids.

♦ Do not give the baby other foods before he is 6 months old, and always breastfeed before giving the other foods.

♦ If a mother’s breasts produce little or no milk, she should continue to eat well, drink lots of liquids and let the baby suck her breasts often.

After each breastfeeding, give the baby, by cup (not bottle), some other type of milk, like boiled cow’s or goat’s milk, canned milk, or powdered milk. (Do not use condensed milk.) Add a little sugar or vegetable oil to any of these milks.

Note: Whatever type of milk is used, some cooled, boiled water should be added.

0 > 6 Two examples of correct formulas

NO.1

  • 2 parts boiled, cooled cow’s milk

  • 1 part boiled, cooled water

  • 1 large spoonful sugar or oil for each large glass

NO.2

  • 2 parts canned evaporated milk

  • 3 parts boiled, cooled water

  • 1 large spoonful sugar or oil for each large glass

If non–fat milk is used, add another spoonful of oil.

♦ If possible, boil the milk and water. It is safer to feed the baby with a cup (or cup and spoon) than to use a baby bottle. Baby bottles and nipples are hard to keep clean and can cause infections and diarrhea (see p. 154). If a bottle is used, boil it and the nipple each time before the baby is fed.

♦ If you cannot buy milk for the child, make a porridge from rice, cornmeal, or other cereal. Always add to this some skinned beans, eggs, meat, chicken, or other protein. Mash these well and give them as a liquid. If possible add sugar and oil.

WARNING: Cornmeal or rice water alone is not enough for a baby. The child will not grow well. He will get sick easily and may die. The baby needs a main food with added helper foods.

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6 > 12 From 6 months to 1 year of age

  1. Keep giving breast milk, if possible until the baby is 2 or 3 years old.

  2. When the baby is 6 months old, start giving her other foods in addition to breast milk. Always give the breast first, and then the other foods. It is good to start with a gruel or porridge made from the main food (p. 111) such as maize meal or rice cooked in water or milk. Then start adding a little cooking oil for extra energy. After a few days, start adding other helper foods (see p. 110). But start with just a little of the new food, and add only 1 at time or the baby may have trouble digesting them. These new foods need to be well cooked and mashed. At first they can be mixed with a little breast milk to make them easier for the baby to swallow.

  3. Prepare inexpensive, nutritious feedings for the baby by adding helper foods to the main food (see p. 110). Most important is to add foods that give extra energy (such as oil) and, whenever possible, extra iron (such as dark green leafy vegetables).

Remember, a young child’s stomach is small and cannot hold much food at one time. So feed her often, and add high-energy helpers to the main food:

A spoonful of cooking oil added to a child’s food means he has to eat only 3/4 as much of the local main food in order to meet his energy needs. The added oil helps make sure he gets enough energy (calories) by the time his belly is full.

CAUTION: The time when a child is most likely to become malnourished is from 6 months to 2 years old. This is because breast milk by itself does not provide enough energy for a baby after 6 months of age. Other foods are needed, but often the foods given do not contain enough energy either. If the mother also stops breastfeeding, the child is even more likely to become malnourished.

For a child of this age to be healthy we should:

♦ Keep feeding her breast milk as much as before.

♦ Feed her other nutritious foods also, always starting with just a little.

♦ Feed her at least 5 times a day and also give her snacks between meals.

♦ Make sure the food is clean and freshly prepared.

♦ Filter, boil, or purify the water she drinks.

♦ Keep the child and her surroundings clean.

♦ When she gets sick, feed her extra well and more often, and give her plenty of liquids to drink. For mothers infected with HIV: After 6 months, your baby will be bigger and stronger, and will have less danger of dying from diarrhea. If you have been breastfeeding her, now you should switch to other milks and feed the baby other foods. This way the baby will have less risk of getting HIV.

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12 > One year and older

After a child is 1 year old, he can eat the same foods as adults, but should continue to breastfeed (or drink milk whenever possible).

Every day, try to give the child plenty of the main food that people eat, together with ‘helper’ foods that give added high energy, proteins, vitamins, iron, and minerals (as shown on p. 111) so that he will grow up strong and healthy.

To make sure that the child gets enough to eat, serve him in his own dish, and let him take as long as he needs to eat his meal.

Children and candy: Do not accustom small children to eating a lot of candy and sweets or drinking soft drinks (colas). When they have too many sweets, they no longer want enough of the other foods they need. Also, sweets are bad for their teeth.

However, when food supply is limited or when the main foods have a lot of water or fiber in them, adding a little sugar and vegetable oil to the main food provides extra energy and allows children to make fuller use of the protein in the food they get.

12 > Best diet for small children

THE FIRST SIX MONTHS:

  • breast milk

  • and nothing else

FORM 6 MONTHS TO 2 YEARS:

  • breast milk

  • cow, goat

  • or other well-cooked, nutritious foods

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HARMFUL IDEAS ABOUT DIET

  1. The diet of mothers after giving birth:

In many areas there is a dangerous popular belief that a woman who has just had a baby should not eat certain foods. This folk diet, which forbids some of the most nutritious foods and may only let the new mother eat things like cornmeal, noodles, or rice soup, makes her weak and anemic. It may even cause her death, by lowering her resistance to hemorrhage (bleeding) and infection.

After giving birth a mother needs to eat the most nutritious foods she can get.

In order to fight infections or bleeding and to produce enough milk for her child, a new mother should eat the main food together with plenty of body building foods like beans, eggs, chicken, and if possible, milk products, meat, and fish. She also needs protective foods like fruits and vegetables, and high energy helpers (oils and fatty foods). None of these foods will harm her; they will protect her and make her stronger.

  1. It is not true that oranges, guavas, or other fruits are bad for a person who has a cold, the flu, or cough. In fact, fruits like oranges and tomatoes have a lot of vitamin C, which may help fight colds and other infections.

  2. It is not true that certain foods like pork, spices, or guavas cannot be eaten while taking medicine. However, when a person has a disease of the stomach or other parts of the digestive system, eating a lot of fat or greasy foods may make this worse whether or not one is taking medicines.

Here is a healthy mother who ate many kinds of nutritious foods after giving birth

Here lies a mother who was not given nutritious foods after giving birth

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SPECIAL DIETS FOR SPECIFIC HEALTH PROBLEMS

Anemia

A person with anemia has thin blood. This happens when blood is lost or destroyed faster than the body can replace it. Blood loss from large wounds, bleeding ulcers, or dysentery can cause anemia. So can malaria, which destroys red blood cells. Not eating enough foods rich in iron can cause anemia or make it worse.

Women can become anemic from blood loss during monthly bleeding (menstrual periods) or childbirth if they do not eat the foods their bodies need. Pregnant women are at risk of becoming severely anemic, because they need to make extra blood for their growing babies.

In children anemia can come from not eating foods rich in iron. It can also come from not starting to give some foods in addition to breast milk, after the baby is 6 months old. Common causes of severe anemia in children are hookworm infection (see p. 142), chronic diarrhea, and dysentery.

The signs of anemia are:

• pale or transparent skin

• pale insides of eyelids

• white fingernails

• pale gums

• weakness and fatigue

Treatment and prevention of anemia:

• If the anemia is very severe, face and feet may be swollen, the heartbeat rapid, and the person may have shortness of breath.

• Children and women who like to eat dirt are usually anemic.

Eat foods rich in iron. Meat, fish, and chicken are high in iron. Liver is especially high. Dark green leafy vegetables, beans, peas, and lentils also have some iron. It also helps to cook in iron pots (see p. 117). To help the body absorb more iron, eat raw vegetables and fruit with meals, and avoid drinking coffee and tea with food.

♦ If the anemia is moderate or severe, the person should take iron (ferrous sulfate pills, p. 392). This is especially important for pregnant women who are anemic. For nearly all cases of anemia, ferrous sulfate tablets are much better than liver extract or vitamin B12. As a general rule, iron should be given by mouth, not injected, because iron injections can be dangerous and are no better than pills.

♦ If the anemia is caused by dysentery (diarrhea with blood), hookworm, malaria, or another disease, this should also be treated.

♦ If the anemia is severe or does not get better, seek medical help. This is especially important for a pregnant woman.

Many women are anemic. Anemic women run a greater risk of miscarriage and of dangerous bleeding in childbirth. It is very important that women eat as much of the foods high in iron as possible, especially during pregnancy. Allowing 2 to 3 years between pregnancies lets the woman regain strength and make new blood (see Chapter 20).

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Rickets

Children whose skin is almost never exposed to the sunlight may become bowlegged and develop other bone deformities (rickets). This problem can be combatted by giving the child fortified milk and vitamin D (found in fish liver oil). However, the easiest and cheapest form of prevention is to be sure direct sunlight reaches the child’s skin for at least 10 minutes a day or for longer periods more often. (Be careful not to let his skin burn.) Never give large doses of vitamin D over long periods, as it can poison the child.

Signs of rickets:

  • bony necklace

  • curved bones

  • big joints bowed legs

SUNLIGHT IS THE BEST PREVENTION AND TREATMENT OF RICKETS.

High Blood Pressure (Hypertension)

High blood pressure can cause many problems, such as heart disease, kidney disease, and stroke. Fat people are especially likely to have high blood pressure.

Signs of dangerously high blood pressure:

• frequent headaches

• pounding of the heart and shortness of breath with mild exercise

• weakness and dizziness

• occasional pain in the left shoulder and chest

All these problems may also be caused by other diseases. Therefore, if a person suspects he has high blood pressure, he should see a health worker and have his blood pressure measured.

A BLOOD PRESSURE CUFF for measuring blood pressure is a bracelet that you slip up an arm.

WARNING: High blood pressure at first causes no signs, and it should be lowered before danger signs develop. People who are overweight or suspect they might have high blood pressure should have their blood pressure checked regularly. For instructions on measuring blood pressure, See page 410 and page 411.

What to do to prevent or care for high blood pressure:

♦ If overweight, lose weight (see next page).

♦ Avoid fatty foods, especially pig fat, and foods with a lot of sugar or starch. Always use vegetable oil instead of pig fat.

♦ Prepare and eat food with little or no salt.

♦ Do not smoke. Do not drink much alcohol.

♦ When the blood pressure is very high, the health worker may give medicines to lower it. Many people can lower their blood pressure by losing weight if they are fat (next page), and by learning to relax.

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People Who Are Too Heavy

To be very fat is not healthy. Very heavy people are more likely to get high blood pressure, stroke, gallstones, some kinds of diabetes, arthritis in legs and feet, and other problems. Sometimes being too heavy brings on illness, and sometimes illness may cause you to become too heavy.

As our diets change and traditional foods are replaced by processed foods, especially “junk foods” high in calories but low in nutrition, people tend to gain weight in ways that are not healthy.

Losing weight may help with the illnesses mentioned above. Losing weight is also important if you are having difficulty doing your daily activities. You can lose weight by:

♦ eating less greasy, fatty, or oily foods.

♦ eating less sugar or sweet foods.

♦ getting more exercise.

♦ stop eating processed foods and eat fresh fruits and vegetables instead.

Constipation

A person who has hard stools and has not had a bowel movement for 3 or more days is said to be constipated. Constipation is often caused by a poor diet (especially not eating enough fruits, green vegetables, or foods with natural fiber like whole grain bread) or by lack of exercise.

Drinking more water and eating more fruits, vegetables, and foods with natural fiber like whole grain bread, cassava, wheat bran, rye, carrots, turnips, raisins, nuts, pumpkin or sunflower seeds, is better than using laxatives.

It also helps to add a little vegetable oil to food each day. Older people especially may need to walk or exercise more in order to have regular bowel movements.

A person who has not had a bowel movement for 4 or more days, if he does not have a sharp pain in his stomach, can take a mild salt laxative like milk of magnesia. But do not take laxatives often.

Do not give laxatives to babies or young children. If a baby is severely constipated, gently put a little cooking oil in her rectum. Or, if necessary, gently break up and remove the hard stool (feces) with a greased finger.

Never use strong laxatives or purgatives, especially if there is stomach pain.

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Diabetes

Persons with diabetes have too much sugar in their blood. This problem can start when a person is young (Type 1 diabetes) or older (Type 2 diabetes). Type 1 diabetes is usually more serious, and young people need a medicine called insulin to control it. But most people with diabetes have Type 2, starting after age 40.

Early signs of diabetes:

• always thirsty

• urinates (pees) often and a lot • always tired

• always hungry

• weight loss

Later, more serious signs:

• itchy skin

• periods of blurry eyesight

• some loss of feeling in hands or feet

• frequent vaginal infections

• sores on the feet that do not heal

• loss of consciousness (in extreme cases)

All these signs may be caused by other person diseases. In order to find out whether a has diabetes, test her urine to see if there is sugar in it. One way to test the urine is to taste it. If it tastes sweet to you, have 2 other persons taste it. Have them also taste the urine of 3 other people. If everyone agrees that the same person’s urine is sweeter, she is probably diabetic.

Another way of testing urine is to use special paper strips (for example, Uristix). If these change color when dipped in the urine, it has sugar in it.

If the person is a child or young adult, he should be seen by an experienced health worker or doctor.

When a person gets diabetes after he is 40 years old, it can often be best controlled without medicines, by eating correctly and getting plenty of exercise. The diabetic person’s diet is very important and must be followed carefully for life.

The diabetic diet: Fat people with diabetes should lose weight until their weight is normal. Diabetics must not eat any sugar or sweets, or foods that taste sweet. It is important for them to eat lots of fresh vegetables and high fiber foods, such as whole grain breads. But diabetics should also eat some other starchy foods, like beans, rice, and potatoes, and also foods high in protein.

Diabetes in adults can sometimes be helped by drinking the sap of the prickly pear cactus (nopal, Opuntia). To prepare, cut the cactus into small pieces and crush them to squeeze out the liquid. Drink 1 1⁄2 cups of the liquid 3 times each day before meals.

To prevent infection and injury to the skin, clean the teeth after eating, keep the skin clean, and always wear shoes to prevent foot injuries. For poor circulation in the feet (dark color, numbness), rest often with the feet up. Follow the same recommendations as for varicose veins (p. 175).

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Acid Indigestion, Heartburn, and Stomach Ulcers

Acid indigestion and ‘heartburn’ often come from eating too much heavy or greasy food or from drinking too much alcohol or coffee. These make the stomach produce extra acid, which causes discomfort or a ‘burning’ feeling in the stomach or mid chest.

Some people mistake the chest pain, called ‘heartburn’, for a heart problem rather than indigestion. If the pain gets worse when lying down, it is probably heartburn.

Frequent or lasting acid indigestion is a warning sign of an ulcer. An ulcer is a chronic sore in the digestive system, usually caused by bacteria.

Too much acid in the stomach prevents it from healing. It may cause a chronic, dull (sometimes sharp) pain in the pit of the stomach. As with acid indigestion, often the pain lessens when the person eats food or drinks a lot of water.

The pain usually gets worse an hour or more after eating, if the person misses a meal, or after he drinks alcohol or eats fatty or spicy foods. Pain is often worse at night. Without a special examination (endoscopy) it is often hard to know whether a person with frequent stomach pain has an ulcer or not.

If the ulcer is severe, it can cause vomiting, sometimes with fresh blood, or with digested blood that looks like coffee grounds. Stools with blood from an ulcer are usually black, like tar.

WARNING: Some ulcers are painless or ‘silent’, and the first sign is blood in vomit, or black, sticky stools. This is a medical emergency. The person can quickly bleed to death. GET MEDICAL HELP FAST.

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Prevention and Treatment:

Whether stomach or chest pain is caused by heartburn, acid indigestion, or an ulcer, a few basic recommendations will probably help calm the pain and prevent it from coming back.

♦ Do not eat too much. Eat small meals and eat frequent snacks between meals.

♦ Notice what foods or drinks make the pain worse and avoid them. These usually include alcoholic drinks, coffee, spices, pepper, carbonated drinks (soda, pop, colas), and fatty or greasy foods.

♦ If the heartburn is worse at night when lying flat, try sleeping with the upper body somewhat raised.

♦ Drink a lot of water. Try to drink 2 big glasses of water both before and after each meal. Also drink a lot of water frequently between meals. If the pain comes often, keep drinking water like this, even in those times when you have no pain.

♦ Avoid tobacco. Smoking or chewing tobacco increases stomach acid and makes the problem worse.

♦ Take antacids. The best, safest antacids contain magnesium and aluminum hydroxide. (See page 380for information, dose, and warnings about different antacids.)

♦ If the above treatments do not work, you may have an ulcer. Use 2 medicines to treat the bacteria that causes the ulcer: either amoxicillin (p. 352) or tetracycline (p. 355); and metronidazole (p. 368). Also take omeprazole (Prilosec, p. 381) or ranitidine (Zantac, see p. 381) to reduce the production of acid in the stomach. These medicines help to calm the pain and heal the sore.

♦ Aloe vera is a plant found in many countries that heal ulcers. Chop the spongy leaves into small pieces, soak them in water overnight, and then drink one glass of the slimy, bitter water every 2 hours.

An ulcer is an open sore in the stomach or gut.

CAUTION:

  1. Some antacids, such as sodium bicarbonate (baking soda) and Alka-Seltzer may quickly calm acid indigestion, but soon cause more acid. They should be used only for occasional indigestion, never for ulcers. This is also true for antacids with calcium.

  2. Some medicines, such as aspirin and ibuprofen, make ulcers worse. Persons with signs of heartburn or acid indigestion should avoid them, use acetaminophen instead of aspirin. Cortico-steroids also make ulcers worse (see p. 51).

It is important to treat an ulcer early. Otherwise it may lead to dangerous bleeding or peritonitis.

Ulcers sometimes get better if the person is careful with what he eats and drinks.

Anger, tension, and nervousness increase acid in the stomach. Learning to relax and keep calm will help. Treatment with antibiotics is necessary to prevent the ulcer from returning.

Avoid having minor stomach problems get worse by not eating too much, by not drinking much alcohol or coffee, and by not smoking or using tobacco.

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Goiter (a Swelling or Lump on the Throat)

A goiter is a swelling or big lump on the throat that results from abnormal growth of a gland called the thyroid.

Most goiters are caused by a lack of iodine in the diet. Also, a lack of iodine in a pregnant woman’s diet sometimes causes babies to die or to be born mentally slow and/or deaf (hypothyroidism, p. 318). This can happen even though the mother does not have a goiter.

Goiter and hypothyroidism are most common in mountain areas where there is little natural iodine in the soil, water, or food. In these areas, eating a lot of certain foods like cassava makes it more likely for a person to get a goiter.

How to prevent or cure a goiter and prevent hypothyroidism: Everyone living in areas where people get goiters should use iodized salt. Use of iodized salt prevents the common kind of goiter and will help many goiters go away. (Old, hard goiters can only be removed by surgery, but this is usually not necessary.)

If it is not possible to get iodized salt, it may be possible to get iodine oil to take by mouth or injection. Or, mix 1 drop of povidone iodine in 1 liter of water and drink a glass of the mixture every week.

Most home cures for goiter do not do any good. However, eating crab and other seafood can do some good because they contain iodine. Mixing a little seaweed with food also adds iodine. But the easiest way is to use iodized salt.

HOW TO KEEP FROM GETTING A GOITER

NEVER use regular salt.

ALWAYS use iodized salt.

IODIZED SALT costs only a little more than other salt and is much better.

Also, if you live in an area where goiters are common, or you are beginning to develop a goiter, try to avoid eating much cassava or cabbage.

Note: If a person with a goiter trembles a lot, is very nervous, and has eyes that bulge out, this may be a different kind of goiter (toxic goiter). Seek medical advice.

12

Prevention: How to Avoid Many Sicknesses

An ounce of prevention is worth a pound of cure! If we all took more care to eat well, to keep ourselves, our homes, and our villages clean, and to be sure that our children are vaccinated, we could stop most sicknesses before they start. In Chapter 11 we discussed eating well. In this chapter we talk about cleanliness and vaccination

CLEANLINESS, and problems that come from lack of cleanliness

Cleanliness is of great importance in the prevention of many kinds of infections, infections of the gut, the skin, the eyes, the lungs, and the whole body. Personal cleanliness (or hygiene) and public cleanliness (or sanitation) are both important.

Many common infections of the gut are spread from one person to another because of poor hygiene and poor sanitation. Germs and worms (or their eggs) are passed by the thousands in the stools or feces (shit) of infected persons. These are carried from the feces of one person to the mouth of another by dirty fingers or contaminated food or water. Diseases that are spread or transmitted from feces-to- mouth in this way, include:

  • diarrhea and dysentery (caused by amebas and bacteria)
  • intestinal worms (several types)
  • hepatitis, typhoid fever, and cholera
  • certain other diseases, like polio, are sometimes spread this same way

The way these infections are transmitted can be very direct.

For example: A child who has worms and who forgot to wash his hands after his last bowel movement, offers his friend a cracker. His fingers, still dirty with his own stool, are covered with hundreds of tiny worm eggs (so small they cannot be seen). Some of these worm eggs stick to the cracker. When his friend eats the cracker, he swallows the worm eggs, too.

Soon the friend will also have worms. His mother may say this is because he ate sweets. But no, it is because he ate shit!

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Many times pigs, dogs, chickens, and other animals spread intestinal disease and worm eggs. For example:

  • A man with diarrhea or worms has a bowel movement behind his house

  • A pig eats his stool, dirtying its nose and feet.

  • Then the pig goes into the house.

  • In the house a child is playing on the floor. In this way, a bit of the man’s stool gets on the child, too.

  • Later the child starts to cry, and the mother takes him in her arms.

  • Then the mother prepares food, forgetting to wash her hands after handling the child.

  • The family eats the food.

  • And soon, the whole family has diarrhea or worms.

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Many kinds of infections, as well as worm eggs, are passed from one person to another in the way just shown.

If the family had taken any of the following precautions, the spread of the sickness could have been prevented:

  • if the man had used a latrine or out-house,

  • if the family had not let the pigs come into the house,

  • if they had not let the child play where the pig had been,

  • if the mother had washed her hands after touching the child and before preparing food.

If there are many cases of diarrhea, worms, and other intestinal parasites in your village, people are not being careful enough about cleanliness.

If many children die from diarrhea, it is likely that poor nutrition is also part of the problem. To prevent death from diarrhea, both cleanliness and good nutrition are important (see page 154 and Chapter 11).

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BASIC GUIDELINES OF CLEANLINESS

Personal Cleanliness (Hygiene)

  1. Always wash your hands with soap when you get up in the morning, after having a bowel movement, and before cooking or eating.

  2. Bathe often every day when the weather is hot. Bathe after working hard or sweating. Frequent bathing helps prevent skin infections, dandruff, pimples, itching, and rashes. Sick persons, including babies, should be bathed daily.

  3. In areas where hookworm is common, do not go barefoot or allow children to do so. Hookworm infection causes severe anemia. These worms enter the body through the soles of the feet (see page 142).

  4. Brush your teeth every day and after each time you eat sweets. If you do not have a toothbrush and toothpaste, rub your teeth with salt and baking soda (see page 230). For more information about the care of teeth, see Chapter 17.

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Cleanliness in the Home

  1. Do not let pigs or other animals come into the house or places where children play.

  2. Do not let dogs lick children or climb up on beds. Dogs, too, can spread disease.

  3. If children or animals have a bowel movement near the house, clean it up at once. Teach children to use a latrine or at least to go farther from the house.

  4. Hang or spread sheets and blankets in the sun often. If there are bedbugs, pour boiling water on the cots and wash the sheets and blankets all on the same day (see page 200).

  5. De-louse the whole family often (see page 200). Lice and fleas carry many diseases. Dogs and other animals that carry fleas should not come into the house.

  6. Do not spit on the floor. Spit can spread disease. When you cough or sneeze, cover your mouth with your hand or a cloth or handkerchief.

  7. Clean house often. Sweep and wash the floors, walls, and beneath furniture. Fill in cracks and holes in the floor or walls where roaches, bedbugs, and scorpions can hide.

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Cleanliness in Eating and Drinking

  1. Ideally, all water that does not come from a pure water system should be boiled, filtered, or purified before drinking.

This is especially important for small children, people with HIV, and times when there is a lot of diarrhea or cases of typhoid, hepatitis, or cholera. However, to prevent disease, having enough water is more important than having pure water.

Also, asking poor families to use a lot of time or money for fire wood to boil drinking water may do more harm than good, especially if it means less food for the children or more destruction of forests. For more information on clean water, see A Community Guide to Environmental Health, Chapter 5.

A good, low-cost way to purify water is to put it in a clean, clear bottle or a clear plastic bag and leave it in direct sunlight for at least 6 hours. If it is cloudy, leave the water exposed to sun for at least 2 days. This method will kill most germs in the water.

  1. Do not let flies and other insects land or crawl on food. These insects carry germs and spread disease. Do not leave food scraps or dirty dishes lying around, as these attract flies and breed germs. Protect food by keeping it covered or in boxes or cabinets with wire screens.

  2. Before eating fruit that has fallen to the ground, wash it well. Do not let children pick up and eat food that has been dropped, wash it first.

  3. Only eat meat and fish that is well cooked. Be careful that roasted meat, especially pork and fish, do not have raw parts inside. Raw pork carries dangerous diseases.

  4. Chickens carry germs that can cause diarrhea. Wash your hands after preparing chicken before you touch other foods.

  5. Do not eat food that is old or smells bad. It may be poisonous. Do not eat canned food if the can is swollen or squirts when opened. Be especially careful with canned fish. Also, be careful with chicken that has passed several hours since it was cooked. Before eating left-over cooked foods, heat them again, very hot. If possible, give only foods that have been freshly prepared, especially to children, elderly people, and very sick people.

  6. People with tuberculosis, flu, colds, or other diseases that spread easily should eat separately from others. Plates and utensils used by sick people should be cleaned very well before being used by others.

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How to Protect Your Children’s Health

  1. A sick child like this one should sleep apart from children who are well. Sick children or children with sores, itchy skin, or lice should always sleep separately from those who are well. Children with infectious diseases like whooping cough, measles, or the common cold should sleep in separate rooms, if possible, and should not be allowed near babies or small children.

  2. Protect children from tuberculosis. People with long-term coughing or other signs of tuberculosis should cover their mouths whenever they cough. They should never sleep in the same room with children. They should see a health worker and be treated as soon as possible. Children living with a person who has tuberculosis should be vaccinated against TB (B.C.G. Vaccine).

  3. Bathe children, change their clothes, and cut their fingernails often. Germs and worm eggs often hide beneath long fingernails.

  4. Treat children who have infectious diseases as soon as possible, so that the diseases are not spread to others.

  5. Follow all the guidelines of cleanliness mentioned in this chapter. Teach children to follow these guidelines and explain why they are important. Encourage children to help with projects that make the home or village a healthier place to live.

  6. Be sure children get enough good food. Good nutrition helps protect the body against many infections. A well-nourished child will usually resist or fight off infections that can kill a poorly nourished child (read Chapter 11).

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Public Cleanliness (Sanitation)

  1. Keep wells and public water holes clean. Do not let animals go near where people get drinking water. If necessary, put a fence around the place to keep animals out.

Do not defecate (shit) or throw garbage near the water hole. Take special care to keep rivers and streams clean upstream from any place where drinking water is taken.

  1. Burn all garbage that can be burned. Garbage that cannot be burned should be buried in a special pit or place far away from houses and the places where people get drinking water.

  2. Build latrines (out-houses, toilets) so pigs and other animals cannot reach the human waste. A deep hole with a little house over it works well. The deeper the hole, the less problem there is with flies and smell.

Here is a drawing of a simple out-house that is easy to build.

It helps to throw a little lime, dirt, or ashes in the hole after each use to reduce the smell and keep flies away.

Out-houses should be built at least 20 meters from homes or the source of water. If you do not have an out-house, go far away from where people bathe or get drinking water. Teach your children to do the same.

Ideas for better latrines are found on the next pages. Also latrines can be built to produce good fertilizer for gardens. See A Community Guide to Environmental Health, Chapter 7.

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BETTER LATRINES

The latrine or out-house shown on the previous page is very simple and costs almost nothing to make. But it is open at the top and lets in flies.

Closed latrines are better because the flies stay out and the smell stays in. A closed latrine has a platform or slab with a hole in it and a lid over the hole. The slab can be made of wood or cement. Cement is better because the slab fits more tightly and will not rot.

One way to make a cement slab:

  1. Dig a shallow pit, about 1 meter square and 7 cm. deep. Be sure the bottom of the pit is level and smooth.

  2. Make or cut a wire mesh or grid 1 meter square. The wires can be 1⁄4 to 1⁄2 cm. thick and about 10 cm. apart. Cut a hole about 25 cm. across in the middle of the grid.

  3. Put the grid in the pit. Bend the ends of the wires, or put a small stone at each corner, so that the grid stands about 3 cm. off the ground.

  4. Put an old bucket in the hole in the grid.

  5. Mix cement with sand, gravel, and water and pour it until it is about 5 cm. thick. (With each shovel of cement mix 2 shovels of sand and 3 shovels of gravel.)

  6. Remove the bucket when the cement is beginning to get hard (about 3 hours). Then cover the cement with damp cloths, sand, hay, or a sheet of plastic and keep it wet. Remove the slab after 3 days.

If you prefer to sit when you use the latrine, make a cement seat like this: Make a mold, or you can use 2 buckets of different sizes, one inside the other.

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Closed latrine

To make the closed latrine, the slab should be placed over a round hole in the ground. Dig the hole a little less than 1 meter across and between 1 and 2 meters deep. To be safe, the latrine should be at least 20 meters from all houses, wells, springs, rivers or streams. If it is anywhere near where people go for water, be sure to put the latrine downstream.

  • more than 20 m.

  • Keep your latrine clean.

  • Wash the slab often.

  • Be sure the hole in the slab has a cover and that the cover is kept in place.

  • A simple cover can be made of wood.

Fly-trapping VIP latrine

  • y screen

  • vent pipe

  • Keep door closed.

  • 3 m.

To make the Ventilated Improved Pit (VIP) latrine, make a larger slab (2 meters square) with 2 holes in it. Over one hole put a ventilation pipe, covered with fly screen (wire screen lasts longer). Over the other hole build an out house, which must be kept dark inside. Leave this hole uncovered.

This latrine helps get rid of odors and flies: smells escape through the pipe, and flies get trapped there and die!

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WORMS AND OTHER INTESTINAL PARASITES

There are many types of worms and other tiny animals (parasites) that live in people’s intestines and cause diseases. Those which are larger are sometimes seen in the stools (feces, shit):

  1. ROUNDWORM (Ascaris)

  2. PINWORM (threadworm)

  3. WHIPWORM (Trichuris)

  4. HOOKWORM

  5. TAPEWORM

The only worms commonly seen in the stools are roundworms, pinworms, and tapeworms. Hookworms and whipworms may be present in the gut in large numbers without ever being seen in the stools.

Note on worm medicines:

Many ‘worm medicines’ contain piperazine. These work only for roundworms and pinworms and should not be given to babies and small children. Mebendazole (Vermox) is safer and attacks many more kinds of worms.

Albendazole and pyrantel also work for many kinds of worms, but they may be expensive. Thiabendazole attacks many kinds of worms, but causes dangerous side effects and should usually not be used.

See pages 373 to 375 for more information on all these medicines.

Roundworm (Ascaris)

20 to 30 cm. long. Color: pink or white

How they are spread:

Feces-to-mouth. Through lack of cleanliness, the roundworm eggs pass from one person’s stools to another person’s mouth.

Effect on health:

Once the eggs are swallowed, young worms hatch and enter the bloodstream;

this may cause general itching. The young worms then travel to the lungs, sometimes causing a dry cough or at worst, pneumonia with coughing of blood. The young worms are coughed up, swallowed, and reach the intestines, where they grow to full size.

Many roundworms in the intestines may cause discomfort, indigestion, and weakness. Children with many roundworms often have very large, swollen bellies.

Rarely, roundworms may cause asthma, or a dangerous obstruction or blockage in the gut (see page 94). Especially when the child has a fever, the worms sometimes come out in the stools or crawl out through the mouth or nose. Occasionally they crawl into the airway and cause gagging.

Prevention

Use latrines, wash hands before eating or handling food, protect food from flies, and follow the guidelines of cleanliness described in the first part of this chapter.

Treatment:

Mebendazole will usually get rid of roundworms. For dosage see page 373. Piperazine also works (see page 374). Some home remedies work fairly well. For a home remedy using papaya See page 13.

WARNING: Do not use thiabendazole for roundworms. It often makes the worms move up to the nose or mouth and can cause gagging.

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Pinworm, Threadworm, Seatworm (Enterobious)

1 cm. long. Color: white. Very thin and threadlike.

How they are transmitted:

These worms lay thousands of eggs just outside the anus (ass hole). This causes itching, especially at night. When a child scratches, the eggs stick under his nails, and are carried to food and other objects. In this way they reach his own mouth or the mouths of others, causing new infections of pinworms.

Effect on health:

These worms are not dangerous. Itching may disturb the child’s sleep.

Treatment and Prevention:

♦ A child who has pinworms should wear tight diapers or pants while sleeping to keep him from scratching his anus.

♦ Wash the child’s hands and buttocks (anal area) when he wakes up and after he has a bowel movement. Always wash his hands before he eats.

♦ Cut his fingernails very short.

♦ Change his clothes and bathe him often wash the buttocks and nails especially well.

♦ Put Vaseline in and around his anus at bedtime to help stop itching.

♦ Give mebendazole worm medicine. For dosage, see page 373. Piperazine also works. When one child is treated for these worms, it is wise to treat the whole family at the same time. For a home remedy using garlic, see page 12.

♦ Cleanliness is the best prevention for threadworms. Even if medicine gets rid of the worms, they will be picked up again if care is not taken with personal hygiene. Pinworms only live for about 6 weeks. By carefully following the guidelines of cleanliness, most of the worms will be gone within a few weeks, even without medicine.

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Whipworm (Trichuris, Trichocephalus)

3 to 5 cm. long. Color: pink or gray.

This worm, like the roundworm, is passed from the feces of one person to the mouth of another person. Usually this worm does little harm, but it may cause diarrhea. In children it occasionally causes part of the intestines to come out of the anus (prolapse of the rectum).

Prevention:

The same as for roundworm.

Treatment:

If the worms cause a problem, give mebendazole. For dosage, see page 374. For prolapse of the rectum, turn the child upside down and pour cool water on the intestine. This should make it pull back in.

Hookworm

1 cm. long. Color: red.

Hookworms cannot usually be seen in the feces.

A stool analysis is needed to prove that they are there.

How hookworms are spread:

  1. The baby hookworms enter a person’s bare feet. This can cause red marks on the feet and itching.

  2. In a few days they reach the lungs through the blood stream. They may cause a dry cough (rarely with blood).

  3. The person coughs up the young worms and swallows them.

  4. A few days later the person may have diarrhea or a stomach-ache.

  5. The hookworms attach themselves to the walls of the gut. Many worms can cause weakness and severe anemia.

  6. The hookworm eggs leave the body in the person’s stools. The eggs hatch on moist soil.

Hookworm infection can be one of the most damaging diseases of childhood. Any child who is anemic, very pale, or eats dirt may have hookworms. If possible, his stools should be analyzed.

Treatment:

Use mebendazole, albendazole, or pyrantel. For dosage and precautions, See page 373 to page 375. Treat anemia by eating foods rich in iron and if necessary by taking iron pills (page 124).

Prevent hookworm: Build and use latrines. Do not let children go barefoot.

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Tapeworm

In the intestines tapeworms grow several meters long. But the small, flat, white pieces (segments) found in the feces are usually about 1 cm. long. Occasionally a segment may crawl out by itself and be found in the underclothing.

People get tapeworms from eating pork (pig meat), beef (cow meat) or other meat or fish that is not well cooked.

Prevention:

Be careful that all meat is well cooked, especially pork. Make sure no parts in the center of roasted meat or cooked fish are still raw.

When a person eats poorly cooked meat, the cysts become tapeworms in his intestines.

The cysts may cause headaches, seizures, or death.

Adult tape worm in man belly segments in man feces

Eggs that enter the person’s mouth from his feces, through lack of cleanliness, can form cysts in his brain.

The pig eats the eggs in the man’s stools.

The worm eggs, the pig has eaten, form cysts in the meat.

Effect on health: Tapeworms in the intestines sometimes cause mild stomach aches, but few other problems.

The greatest danger exists when the cysts (small sacs containing baby worms) get into a person’s brain. This happens when the eggs pass from his stools to his mouth. For this reason, anyone with tapeworms must follow the guidelines of cleanliness carefullyand get treatment as soon as possible.

Treatment:

Take niclosamide (Yomesan, page 375), or praziquantel (page 375). Follow instructions carefully.

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Trichinosis

These worms are never seen in the stools. They burrow through the person’s intestines and get into her muscles. People get these worms, like tapeworms, from eating infected pork or other meat that is not well cooked.

Effect on health: Depending on the amount of infected meat eaten, the person may feel no effects, or she may become very sick or die. From a few hours to 5 days after eating the infected pork, the person may develop diarrhea and feel sick to her stomach.

In serious cases the person may have:

• fever with chills

• muscle pain

• swelling around the eyes and sometimes swelling of the feet Severe cases may last 3 or 4 weeks.

• small bruises (black or blue spots) on the skin

• bleeding in the whites of the eyes

Treatment: Seek medical help at once. Albendazole or mebendazole may help. For dosages, See page 373 and page 374. (Cortico-steroids may help, but should be given by a health worker or doctor.)

Important: If several people who ate meat from the same pig get sick afterward, suspect trichinosis. This can be dangerous; seek medical attention.

Prevention of trichinosis:

♦ Only eat pork and other meat that has been well cooked.

♦ Do not feed scraps of meat or leftovers from butchering to pigs unless the meat has first been cooked.

Amebas

These are not worms, but tiny animals or parasites that can be seen only with a microscope (an instrument that makes things look much bigger).

How they are transmitted:

The stools of infected people contain millions of these tiny parasites. Because of poor sanitation, they get into the source of drinking water or into food, and other people become infected.

Signs of infection with amebas:

Many healthy people have amebas without becoming sick. However, amebas are a common cause of severe diarrhea or dysentery (diarrhea with blood) especially in persons already weakened by other sickness or poor nutrition. Less commonly, amebas cause painful, dangerous abscesses in the liver.

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Typical amebic dysentery consists of:

• diarrhea that comes and goes sometimes alternating with constipation

• cramps in the belly and a need to have frequent bowel movements, even when little or nothing or just mucus comes out

• many loose (but usually not watery) stools with lots of mucus, sometimes stained with blood

• in severe cases, much blood; the person may be very weak and ill

• if there is fever, it means there may also be a bacterial infection

Diarrhea with blood may be caused by either amebas or bacteria. However, bacterial dysentery (Shigella) begins more suddenly, the stools are more watery, and there is almost always fever (page 158). As a general rule:

Diarrhea + blood + fever = bacterial infection (Shigella)

Diarrhea + blood + no fever = amebas

Occasionally bloody diarrhea has other causes. To be sure of the cause, a stool analysis may be necessary.

Sometimes amebas get into the liver and form an abscess or pocket of pus. This causes tenderness or pain in the right upper belly.

Pain may extend into the right chest and is worse when the person walks. (Compare this with gallbladder pain, page 329; hepatitis, page 172; and cirrhosis, page 328.)

If the person with these signs begins to cough up a brown liquid, an amebic abscess is draining into his lung.

Treatment:

♦ If possible get medical help and a stool analysis.

♦ Amebic dysentery can be treated with metronidazole, if possible followed by diloxanide furoate. For dosage, length of treatment, and precautions, see page 368.

♦ For amebic abscess, treat as for amebic dysentery. Be sure to take both metronidazole and diloxanide furoate (page 368).

Prevention:

Make and use latrines, protect the source of drinking water, and follow the guidelines of cleanliness. Eating well and avoiding fatigue and drunkenness are also important in preventing amebic dysentery.

Giardia

The giardia, like the ameba, is a microscopic parasite that lives in the gut and is a common cause of diarrhea, especially in children. The diarrhea may be chronic or intermittent (may come and go).

A person who has yellow, bad-smelling diarrhea that is frothy (full of bubbles) but without blood or mucus, probably has giardia.

The belly is swollen with gas and uncomfortable, there are mild intestinal cramps, and the person farts and burps a lot. The burps have a bad taste, like sulfur. There is usually no fever.

Giardia infections sometimes clear up by themselves. Good nutrition helps. Severe cases are best treated with metronidazole (see page 368). Quinacrine (Atabrine, page 369) is cheaper and often works well, but causes worse side effects.

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BLOOD FLUKES (SCHISTOSOMIASIS, BILHARZIA)

This infection is caused by a kind of worm that gets into the bloodstream. Different types of blood flukes are found in different parts of the world.

One kind, common in Africa and the Middle East, causes blood in the urine. Other types, which cause bloody diarrhea, occur in Africa, South America, and Asia.

In areas where these diseases are known to occur, any person who has blood in his urine or stools should have a sample of it tested for fluke eggs.

Signs:

• The most common sign is blood in the urine (especially when passing the last drops)or, for other kinds of flukes, bloody diarrhea.

• Pain may occur in the lower belly and between the legs; it is usually worst at the end of urinating. Low fever, weakness, and itching may occur. In women, there may be sores that look like a sexually transmitted infection.

• After months or years, the kidneys, liver or spleen may be damaged or enlarged, which can cause pain and eventually even death.

• Sometimes there are no early signs. In areas where schistosomiasis is very common, persons with only mild signs or belly pain should be tested.

Treatment:

See a health worker. Praziquantel works for all types of blood flukes. Oxamniquine works for some kinds of blood flukes (see page 376).

Prevention:

Blood flukes are not spread directly from person to person. Part of their life they must live inside a certain kind of small water snail.

Blood flukes spread like this:

  1. Infected person urinates or defecates in water.

  2. Urine or feces has worm eggs in it.

  3. Worm eggs hatch and go into snails.

  4. Young worms leave snail and go into another person.

  5. In this way, someone who washes or swims in water where an infected person has urinated or defecated also becomes infected.

To prevent schistosomiasis, cooperate with programs to kill snails and treat infected persons. But most important: Everyone should learn to use latrines and NEVER URINATE OR DEFECATE IN OR NEAR WATER.

For information on guinea worm, which is also spread in water, see page 406 and page 407.

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VACCINATIONS (IMMUNIZATIONS)SIMPLE, SURE PROTECTION

Vaccines protect against many dangerous diseases. Each country has a schedule of vaccinations, usually given for free. It is better to take your children to the nearest health center to be vaccinated while they are healthy than to take them for treatment when they are sick or dying. The most important vaccines are:

  1. DPT, for diphtheria, whooping cough (pertussis), and tetanus. A child needs 4 or 5 injections usually given at 2 months, 4 months, 6 months, and 18 months old. Sometimes one more injection is given between 4 and 6 years old.

  2. POLIO (infantile paralysis). The child needs drops in the mouth or an injection 4 or 5 times. In some countries the first vaccination is given at birth and the other 3 doses are given at the same time as the DPT injections. In other countries, the first 3 doses are given at the same time as the DPT injections, the fourth dose is given between 12 and 18 months of age, and a fifth dose is given when the child is 4 years old. In a family where someone has HIV, do not use drops, use injections only.

  3. BCG, for tuberculosis. A single injection is given under the skin of the left arm. Children can be vaccinated at birth or anytime afterwards. If any member of the household has tuberculosis, it is important to vaccinate babies in the first few weeks or months after birth. The vaccine makes a sore and leaves a scar.

  4. MEASLES. A child needs 1 injection given no younger than 9 months of age, and often a second injection at 15 months or older. In many countries a ‘3 in 1’ vaccine called MMR is given for measles, mumps, and rubella (German measles). One injection is given between 12 and 15 months old, and a second is given between 4 and 6 years of age. Do not give measles vaccinations to a child with HIV.

  5. HepB (Hepatitis B). This vaccine is given in a series of 3 injections, at the same time as DPT injections. In some countries the first HepB is given at birth, the second at 2 months old, and the third at 6 months old. Make sure there are at least 4 weeks between the first and second injection, and 8 weeks between the second and third.

  6. Hib (for Haemophilus influenza type b, which is a germ that causes meningitis and pneumonia in young children). Generally this vaccine is given in a series of 3 injections together with the first 3 DPT injections.

  7. Td or TT (Tetanus toxoid), for tetanus (lockjaw) for adults and children over 12 years old. Throughout the world, tetanus vaccination is recommended with 1 injection every 10 years. In some countries a Td injection is given between 9 and 11 years of age (5 years after the last DPT vaccination), and then every 10 years. Pregnant women should be vaccinated during each pregnancy so that their babies will be protected against tetanus of the newborn (see page 182 and page 250).

  8. Rotavirus. Give the oral vaccine 2 or 3 times (depending on the manufacturer) at 2 months, 4 months, and (if needed) 6 months old. It prevents this diarrhea disease, a leading cause of death for young children.

Vaccines for measles, polio, and tuberculosis must be kept frozen or very cold (under 8° C). The vaccines for Hepatitis B, tetanus, and the DPT must be kept very cold (under 8° C) but never frozen.

Vaccine that has been prepared but not used should be thrown away. DPT is still good and useable if it remains cloudy 1 hour after preparing it.

If it becomes clear or has white flecks in it, it is spoiled and will not work. For ways to keep vaccines cold, see Helping Health Workers Learn, Chapter 16.

Vaccinate your children on time. Be sure they get the complete series of each vaccine they need

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OTHER WAYS TO PREVENT SICKNESS AND INJURY

In this chapter we have talked about ways to prevent intestinal and other infections through hygiene, sanitation, and vaccination. All through this book you will find suggestions for the prevention of sickness and injury from building healthy bodies by eating nutritious foods to the wise use of home remedies and modern medicines.

The Introduction and Words to the Village Health Worker give ideas for getting people working together to change the conditions that cause poor health.

In the remaining chapters, as specific health problems are discussed, you will find many suggestions for their prevention. By following these suggestions you can help make your home and village healthier places to live.

Keep in mind that one of the best ways to prevent serious illness and death is early and sensible treatment.

Before ending this chapter, we would like to mention a few aspects of prevention that are touched on in other parts of the book, but deserve special attention.

Habits that Affect Health

Some of the habits that people have not only damage their own health but in one way or another harm those around them. Many of these habits can be broken or avoided but the first step is to understand why breaking these habits is so important.

DRINKING

If alcohol has brought much joy, it has also brought much suffering especially to the families of those who drink. A little alcohol now and then may do no harm. But too often a little leads to a lot. In much of the world, heavy or excessive drinking is one of the underlying causes of major health problems even for those who do not drink.

Not only can drunkenness harm the health of those who drink (through diseases such as cirrhosis of the liver, page 328, and hepatitis, page 172), but it also hurts the family and community in many ways. Through the loss of judgment when drunk and of self respect when sober it leads to much unhappiness, waste, and violence, often affecting those who are loved most.

How many fathers have spent their last money on drink when their children were hungry? How many sicknesses result because a man spends the little bit of extra money he earns on drink rather than on improving his family’s living conditions? How many persons, hating themselves because they have hurt those they love, take another drink to forget?

Once a person realizes that alcohol is harming the health and happiness of those around him, what can he do? First, he must admit that his drinking is a problem. He must be honest with himself and with others. Some individuals are able to simply decide to stop drinking. More often people need help and support from family, friends, and others who understand how hard it may be to give up this habit.

People who have been heavy drinkers and have stopped are often the best persons to help others do the same. In many areas Alcoholics Anonymous (AA) groups exist where recovering alcoholics help one another to stop drinking (see page 429).

Drinking is not so much a problem of individuals as of a whole community. A community that recognizes this can do much to encourage those who are willing to make changes. If you are concerned about the misuse of alcohol in your community, help organize a meeting to discuss these problems and decide what actions to take.

For more about harm from alcohol, and community action, see Helping Health Workers Learn, Chapters 5 and 27.

Many problems can be resolved when people work together and give each other help an

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SMOKING

There are many reasons why smoking is dangerous to your own and your family’s health.

  1. Smoking increases the risk of cancer of the lungs, mouth, throat, and lips. (The more you smoke, the greater the chance of dying of cancer.)

  2. Smoking causes serious diseases of the lungs, including chronic bronchitis and emphysema (and is deadly for persons who already have these conditions or have asthma).

  3. Smoking can cause stomach ulcers or make them worse.

  4. Smoking increases your chance of suffering or dying from heart disease or stroke.

  5. Children whose parents smoke have more cases of pneumonia and other respiratory illness than children whose parents do not smoke.

  6. Babies of mothers who smoked during pregnancy are smaller and develop more slowly than babies whose mothers did not smoke.

  7. Parents, teachers, health workers, and others who smoke set an unhealthy example for children and young people, increasing the likelihood that they too will begin smoking.

  8. Also, smoking costs money. It looks like little is spent, but it adds up to a lot.

In poorer countries, many of the poorest persons spend more on tobacco than the country spends per person on its health program. If money spent on tobacco were spent for food instead, children and whole families could be healthier.

Anyone interested in the health of others should not smoke, and should encourage others not to smoke.

SMOKING DAMAGES

  • lungs
  • stomach
  • heart and circulation
  • pregnant women (their babies)
  • children of those who smoke
  • the family food budget.

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CARBONATED DRINKS (soft drinks, sodas, Coke)

In some areas these drinks have become very popular. Often a poor mother will buy carbonated drinks for a child who is poorly nourished, when the same money could be better used to buy 2 eggs or other nutritious food.

Carbonated drinks have no nutritional value apart from sugar. And for the amount of sugar they contain, they are very expensive.

Children who are given a lot of carbonated drinks and other sweet things often begin to get cavities and rotten teeth at an early age. Carbonated drinks are especially bad for persons with acid indigestion or stomach ulcer.

Natural drinks you make from fruits are healthier and often much cheaper than carbonated drinks.

IF YOU WANT HEALTHY CHILDREN AND HAVE A LITTLE MONEY TO BUY THEM SOMETHING…

YES: buy them a couple of eggs or other nutritious food, not carbonated drinks!

NO: Do not get your children used to drinking carbonated drinks.

13

some very common sicknesses

DEHYDRATION

Most children who die from diarrhea die because they do not have enough water left in their bodies. This lack of water is called dehydration.

Dehydration results when the body loses more liquid than it takes in. This can happen with severe diarrhea, especially when there is vomiting too. It can also happen in very serious illness, when a person is too sick to take much food or liquid.

People of any age can become dehydrated, but dehydration develops more quickly and is most dangerous in small children.

Any child with watery diarrhea is in danger of dehydration

It is important that everyone, especially mothers, know the signs of dehydration and how to prevent and treat it.

Signs of dehydration:

  • thirst is often a first, early sign of dehydration
  • little or no urine; the urine is dark yellow
  • sudden weight loss
  • dry mouth
  • sunken, tearless eyes
  • sagging in of the ‘soft spot’ in infants
  • loss of elasticity or stretchiness of the skin

Very severe dehydration may cause rapid, weak pulse (see Shock, page 77), fast, deep breathing, fever, or seizures (fits, convulsions, page 178).

When a person has watery diarrhea, or diarrhea and vomiting, do not wait for signs of dehydration. Act quickly , read on.

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To prevent or treat dehydration

When a person has watery diarrhea, act quickly:

  • Give lots of liquids to drink: Rehydration Drink is best. Or give a thin cereal porridge or gruel, teas, soups, or even plain water.

  • Keep giving food. As soon as the sick child (or adult) will accept food, give frequent feedings of foods he likes and accepts.

  • To babies, keep giving breast milk often, and before other drinks.

A special Rehydration Drink helps to prevent or treat dehydration, especially in cases of severe watery diarrhea:

2 WAYS TO MAKE ‘HOME MIX’ REHYDRATION DRINK

WITH SUGAR AND SALT

(Raw sugar or molasses can be used instead of sugar)

  • In 1 liter of clean WATER put half of a level teaspoon of SALT and 8 level teaspoons of SUGAR.

  • CAUTION: Before adding the sugar, taste the drink and be sure it is less salty than tears.

  • To either Drink add half a cup of fruit juice, coconut water, or mashed ripe banana, if available. This provides potassium which may help the child accept more food and drink.

WITH POWDERED CEREAL AND SALT

(Powdered rice is best. Or use nely ground maize, wheat our, sorghum, or cooked and mashed potatoes.)

  • In 1 liter of WATER put half a teaspoon of SALT And 8 heaping teaspoons (or 2 handfuls) of powdered CEREAL.

  • Boil for 5 to 7 minutes to form a liquid gruel or watery porridge. Cool the Drink quickly and start giving it to the child.

  • CAUTION: Taste the Drink each time before you give it to be sure it is not spoiled. Cereal drinks can spoil in a few hours in hot weather.

IMPORTANT

Adapt the Drink to your area. If liter containers or teaspoons are not in most homes, adjust quantities to local forms of measurement. Where people traditionally give cereal gruels to young children, add enough water to make it liquid, and use that. Look for an easy and simple way.

Give the dehydrated person sips of this Drink every 5 minutes, day and night, until he begins to urinate normally. A large person needs 3 or more liters a day.

A small child usually needs at least 1 liter a day, or 1 glass for each watery stool. Keep giving the Drink often in small sips, even if the person vomits. Not all of the Drink will be vomited.

WARNING: If dehydration gets worse or other danger signs appear, go for medical help (see page 159). It may be necessary to give liquid in a vein (intravenous solution).

Note: In some countries packets of Oral Rehydration Salts (ORS) are available for mixing with water. These contain a simple mix of sugar, salt, citrate, zinc, and potassium (see page 381).

However, homemade drinks, especially cereal drinks, when correctly prepared are often cheaper, safer, and more effective than ORS packets.

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DIARRHEA AND DYSENTERY

When a person has loose or watery stools, he has diarrhea. If mucus and blood can be seen in the stools, he has dysentery.

Diarrhea can be mild or serious. It can be acute (sudden and severe) or chronic (lasting many days).

Diarrhea is more common and more dangerous in young children, especially those who are poorly nourished.

Diarrhea has many causes. Usually no medicines are needed, and the child gets well in a few days if you give him lots of Rehydration Drink and food. (If he does not eat much, give him a little food many times a day.)

Occasionally, special treatment is needed. However, most diarrhea can be treated successfully in the home, even if you are not sure of the exact cause or causes.

THE MAIN CAUSES OF DIARRHEA

  • poor nutrition (page 154) weakens the child and makes diarrhea from other causes more frequent and worse

  • shortage of water and unclean conditions (no latrines) spread the germs that cause diarrhea

  • virus infection or ‘intestinal flu’

  • an infection of the gut caused by bacteria (page 131), amebas (page 144), or giardia (page 145)

  • worm infections (page 140 to 144) (most worm infections do not cause diarrhea)

  • infections outside the gut (ear infections, page 309; tonsillitis, page 309; measles, page 311; urinary infections, page 234)

  • malaria (falciparum type, in parts of Africa, Asia, the Paci c, Latin America and the Caribbean, page 186)

  • food poisoning (spoiled food, page 135)

  • HIV (long-lasting diarrhea may be an early sign of AIDS, page 399)

  • inability to digest milk (mainly in severely malnourished children and certain adults)

  • difficulties babies have digesting foods that are new to them (page 154)

  • allergies to certain foods (seafood, cray sh, etc., page 166); occasionally babies are allergic to cow’s milk or other milks

  • side effects produced by certain medicines, such as ampicillin or tetracycline (page 58)

  • laxatives, purges, irritating or poisonous plants, certain poisons

  • eating too much unripe fruit or heavy, greasy foods

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Preventing diarrhea:

Although diarrhea has many different causes, the most common are infection and poor nutrition. With good hygiene and good food, most diarrhea could be prevented. And if treated correctly by giving lots of drink and food, fewer children who get diarrhea would die.

Diarrhea is also very dangerous for people with HIV, especially children. Using cotrimoxazole can prevent diarrhea in persons with HIV (see page 357).

Children who are poorly nourished get diarrhea and die from it far more often than those who are well nourished. Yet diarrhea itself can be part of the cause of malnutrition.

Malnutrition causes diarrhea. Diarrhea causes malnutrition

And if malnutrition already exists, diarrhea rapidly makes it worse.

This results in a vicious circle, in which each makes the other worse. For this reason, good nutrition is important in both the prevention and treatment of diarrhea.

Prevent diarrhea by preventing malnutrition. Prevent malnutrition by preventing diarrhea

To learn about the kinds of foods that help the body resist or fight off different illnesses, including diarrhea, read Chapter 11.

The prevention of diarrhea depends both on good nutrition and cleanliness. Many suggestions for personal and public cleanliness are given in Chapter 12. These include the use of latrines, the importance of clean water, and the protection of foods from dirt and flies.

Here are some other important suggestions for preventing diarrhea in babies:

  • Breastfeed rather than bottle feed babies. Give only breast milk for the first 6 months. Breast milk helps babies resist the infections that cause diarrhea. If it is not possible to breastfeed a baby, feed her with a cup and spoon. Do not use a baby bottle because it is harder to keep clean and more likely to cause an infection.

  • When you begin to give the baby new or solid food, start by giving her just a little, mashing it well, and mixing it with a little breast milk. The baby has to learn how to digest new foods. If she starts with too much at one time, she may get diarrhea. Do not stop giving breast milk suddenly. Start with other foods while the baby is still breastfeeding.

  • Keep the baby clean, and in a clean place. Try to keep her from putting dirty things in her mouth.

  • Do not give babies unnecessary medicines.

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Treatment of diarrhea:

For most cases of diarrhea no medicine is needed. If the diarrhea is severe, the biggest danger is dehydration. If the diarrhea lasts a long time, the biggest danger is malnutrition. So the most important part of treatment has to do with giving enough liquids and enough food.

No matter what the cause of diarrhea, always take care with the following:

1 - PREVENT OR CONTROL DEHYDRATION.

A person with diarrhea must drink a lot of liquids. If diarrhea is severe or there are signs of dehydration, give him Rehydration Drink (page 152). Even if he does not want to drink, gently insist that he do so. Have him take several swallows every few minutes.

2 - MEET NUTRITIONAL NEEDS.

A person with diarrhea needs food as soon as he will eat. This is especially important in small children or persons who are already poorly nourished. Also, when a person has diarrhea, food passes through the gut very quickly and is not all used. So give the person food many times a day, especially if he only takes a little at a time.

♦ A baby with diarrhea should go on breastfeeding.

♦ An underweight child should get plenty of energy foods and some body-building foods (proteins) all the time he has diarrhea, and extra when he gets well. If he stops eating because he feels too sick or is vomiting, he should eat again as soon as he can.
Giving Rehydration Drink will help the child be able to eat. Although giving food may cause more frequent stools at first, it can save his life.

♦ If a child who is underweight has diarrhea that lasts for many days or keeps coming back, give him more food more often, at least 5 or 6 meals each day. Often no other treatment is needed.

♦ If possible, give zinc supplements to a baby or child with diarrhea (see page 381).

FOODS FOR A PERSON WITH DIARRHEA

When the person is vomiting or feels too sick to eat, he should drink:

  • watery mush or broth of rice, maize powder, or potato

  • rice water (with some mashed rice) chicken, meat, egg, or bean broth

  • REHYDRATION DRINK

  • Breast milk yogurt or fermented milk drinks

As soon as the person is able to eat, in addition to giving the drinks listed at the left, he should eat a balanced selection of the following foods or similar ones:

energy foods

  • ripe or cooked bananas

  • crackers

  • rice, oatmeal, or other well-cooked grain

  • fresh maize (well cooked and mashed)

  • potatoes

  • applesauce (cooked) papaya

  • (It helps to add a little sugar or vegetable oil to foods.)

body-building foods

  • chicken (boiled or roasted)

  • eggs (boiled)

  • meat (well cooked, without much fat or grease)

  • beans, lentils, or peas (well cooked and mashed)

  • fish (well cooked)

  • milk (sometimes this causes problems, see the next page)

DO NOT EAT OR DRINK

  • fatty or greasy foods

  • most raw fruits

  • any kind of laxative or purge

  • highly seasoned food

  • alcoholic drinks

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Diarrhea and milk:

Breast milk is the best food for babies. It helps prevent and combat diarrhea. Keep giving breast milk when the baby has diarrhea.

Cow’s milk, powdered milk, or canned milk can be good sources of energy and protein. Keep on giving them to a child with diarrhea. In a very few children these milks may cause more diarrhea. If this happens, try giving less milk and mixing it with other foods.

But remember: a poorly nourished child with diarrhea must have enough energy foods and protein. If less milk is given, well cooked and mashed foods such as chicken, egg yolk, meat, fish, or beans should be added.

Beans are easier to digest if their skins have been taken off and they are boiled and mashed.

As the child gets better, he will usually be able to drink more milk without getting diarrhea.

Medicines for diarrhea:

For most cases of diarrhea no medicines are needed. But in certain cases, using the right medicine can be important. However, many of the medicines commonly used for diarrhea do little or no good. Some are actually harmful:

GENERALLY IT IS BETTER NOT TO USE THE FOLLOWING MEDICINES IN THE TREATMENT OF DIARRHEA:

‘Anti diarrhea’ medicines with bismuth subsalicylate (such as Pepto-Bismol or Kaopectate, page 383) make diarrhea thicker and less frequent. But they do not correct dehydration or control infection. Some anti diarrhea medicines, like loperamide (Imodium) or diphenoxylate (Lomotil) may even cause harm or make infections last longer.

‘ANTI DIARRHEA MEDICINES’ ACT LIKE PLUGS. THEY KEEP IN THE INFECTED MATERIAL THAT NEEDS TO COME OUT.

‘Anti-diarrhea’ mixtures containing neomycin or streptomycin should not be used. They irritate the gut and often do more harm than good.

Antibiotics like ampicillin and tetracycline are useful only in some cases of diarrhea (see page 158).

But they themselves sometimes cause diarrhea, especially in small children. If, after taking these antibiotics for more than 2 or 3 days, diarrhea gets worse rather than better, stop taking them the antibiotics may be the cause.

Chloramphenicol (page 356) should never be used for diarrhea

Laxatives and purges should never be given to persons with diarrhea. They will make it worse and increase the danger of dehydration.

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Special treatment in different cases of diarrhea:

While most cases of diarrhea are best treated by giving plenty of liquids and food, and no medicine, sometimes special treatment is needed.

In considering treatment, keep in mind that some cases of diarrhea, especially in small children, are caused by infections outside the gut. Always check for infections of the ears, the throat, and the urinary system. If found, these infections should be treated. Also look for signs of measles.

If the child has mild diarrhea together with signs of a cold, the diarrhea is probably caused by a virus, or ‘intestinal flu’, and no special treatment is called for. Give lots of liquids and all the food the child will accept.

In certain difficult cases of diarrhea, analysis of the stools or other tests may be needed to know how to treat it correctly. But usually you can learn enough from asking specific questions, seeing the stools, and looking for certain signs Here are some guidelines for treatment according to signs.

  1. Sudden, mild diarrhea. No fever. (Upset stomach? ‘Intestinal flu’?)

♦ Drink lots of liquids. Usually no special treatment is needed. It is usually best not to use ‘anti-diarrhea’ medicines such as bismuth subsalicylate (Kaopectate, page 383) or diphenoxylate (Lomotil).

They are never necessary and do not help either to correct dehydration or get rid of infection so why waste money buying them? Never give them to persons who are very ill, or to small children.

  1. Diarrhea with vomiting. (Many causes)

♦ If a person with diarrhea is also vomiting, the danger of dehydration is greater, especially in small children. It is very important to give the Rehydration Drink (page 152), tea, soup, or whatever liquids he will take.

Keep giving the Drink, even if the person vomits it out again. Some will stay inside. Give sips every 5 to 10 minutes.

♦ If you cannot control the vomiting or if the dehydration gets worse, seek medical help fast.

  1. Diarrhea with mucus and blood. Often chronic. No fever. There may be diarrhea some days and constipation other days. (Possibly amebic dysentery. For more details, See page 144 to page 145.)

♦ Use metronidazole (page 368). Take the medicine according to the recommended dose. If the diarrhea continues after treatment, seek medical advice.

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  1. Severe diarrhea with blood, with fever. (Bacterial dysentery caused by Shigella)

♦ Give ceftriaxone or ciprofloxacin (see page 358). Pregnant women and children under 18 years old should not use ciprofloxacin. (For children under 8 weeks old, seek medical help.)

Shigella is often resistant to ampicillin (page 352), co-trimoxazole (page 357), and azithromycin, but they are still being used.

If the first medicine you try does not bring improvement within 2 days, try another or seek medical help.

Women in the first 3 months of pregnancy should not use co-trimoxazole (see page 357). Azithromycin is safe during pregnancy and for children. For adults, give 1 g (1000 mg) by mouth once a day for 3 days. For children’s doses, see a health worker.

♦ Also give zinc, 20 mg once a day, for 14 days. 5. Severe diarrhea with fever, usually no blood.

♦ Fever may be partly caused by dehydration. Give lots of Rehydration Drink (page 152). If the person is very ill and does not improve within 6 hours after beginning Rehydration Drink, seek medical help.

♦ Check for signs of typhoid fever. If present, treat for typhoid (see page 188).

♦ In areas where falciparum malaria is common, also treat persons with diarrhea and fever for malaria (see page 186), especially if they have an enlarged spleen.

  1. Yellow, bad smelling diarrhea with bubbles or froth, without blood or mucus. Often a lot of gas in the belly, and burps that taste bad, like sulfur.

♦ This may be caused by parasites called giardia (see page 145) or perhaps by malnutrition. In either case, plenty of liquid, nutritious food, and rest are often the best treatment.

Severe giardia infections can be treated with metronidazole (page 368). Quinacrine (Atabrine) is cheaper, but has worse side effects (page 369).

  1. Chronic diarrhea (diarrhea that lasts a long time or keeps coming back).

♦ This can be in part caused by malnutrition, or by a chronic infection such as that caused by amebas or giardia. See that the child eats more nutritious food more times a day (page 110). If the diarrhea still continues, seek medical help.

  1. Diarrhea like rice water. (Cholera)

♦ ‘Rice water’ stools in very large quantities may be a sign of cholera. In countries where this dangerous disease occurs, cholera often comes in epidemics (striking many people at once) and is usually worse in older children and adults.

Severe dehydration can develop quickly, especially if there is vomiting also. It is important to treat the dehydration continuously with rehydration drink and other liquids (see page 152).

Cholera should be reported to the health authorities. Seek medical help.

A ‘cholera bed’ like this can be made for persons with very severe diarrhea. Watch how much liquid the person is losing and be sure he drinks larger amounts of Rehydration Drink. Give him the Drink almost continuously, and have him drink as much as he can.

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Care of Babies with Diarrhea

Diarrhea is especially dangerous in babies and small children. Often no medicine is needed, but special care must be taken because a baby can die very quickly of dehydration.

♦ Continue breastfeeding and also give sips of Rehydration Drink.

♦ If vomiting is a problem, give breast milk often, but only a little at a time. Also give Rehydration Drink in small sips every 5 to 10 minutes (see Vomiting, page 161).

♦ If there is no breast milk, try giving frequent small feedings of some other milk or milk substitute (like milk made from soybeans) mixed to half normal strength with boiled water. If milk seems to make the diarrhea worse, give some other protein (mashed chicken, eggs, lean meat, or skinned mashed beans, mixed with sugar or well-cooked rice or another carbohydrate, and boiled water).

♦ If possible, give zinc supplements (see page 381).

GIVE HIM BREAST MILK

♦ If the child is younger than 1 month, try to find a health worker before giving any medicine. If there is no health worker and the child is very sick, give him an ‘infant syrup’ that contains ampicillin: half a teaspoon 4 times daily (see page 352). It is better not to use other antibiotics.

When to Seek Medical Help in Cases of Diarrhea

Diarrhea and dysentery can be very dangerous especially in small children.

In the following situations you should get medical help:

• if diarrhea lasts more than 4 days and is not getting better or more than 1 day in a small child with severe diarrhea

• if the person shows signs of dehydration and is getting worse

• if the child vomits everything he drinks, or drinks nothing, or if frequent vomiting continues for more than 3 hours after beginning Rehydration Drink

• if the child begins to have seizures, or if the feet and face swell

• if the person was very sick, weak, or malnourished before the diarrhea began (especially a little child or a very old person)

• if there is much blood in the stools. This can be dangerous even if there is only very little diarrhea (see gut obstruction, page 94).

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THE CARE OF A PERSON WITH ACUTE DIARRHEA

1. Are there signs of dehydration (little or no urine, sunken eyes, dry mouth, etc.)?

YES: Control the dehydration: Drink lots of liquids and REHYDRATION DRINK. (see page 152)

NO: Prevent dehydration: Drink lots of liquids.

PREVENT OR CORRECT MALNUTRITION:

Give food as soon as the person will eat. Bland, well-mashed foods are best a lot of energy foods with some body-building foods. Continue breastfeeding.

2. Is there fever that lasts more than 6 hours after starting to treat the dehydration?

YES:
Give ampicillin (page 352) or cotrimoxazole (see page 358).

No better within 3 days: then consider:

Are there signs of typhoid fever? (temperature rises every day, slow pulse, very ill, etc., see page 188)

YES: Continue to give cotrimoxazole, ampicillin, or chloramphenicol for 2 weeks. (see page 356). If then No better SEEK MEDICAL HELP.

NO: SEEK MEDICAL HELP

NO: then consider:

Diarrhea with blood or mucus?

YES: Give metronidazole for amebas. (see page 369)

NO: then consider:

Diarrhea yellow and very frothy?

YES: Give metronidazole or quinacrine for giardia. (see page 369). If then No better SEEK MEDICAL HELP.

NO: Give no medicine. Continue giving Rehydration Drink and food. If then No better SEEK MEDICAL HELP.

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VOMITING

Many people, especially children, have an occasional ‘stomach upset’ with vomiting. Often no cause can be found. There may be mild stomach or gut ache or fever. This kind of simple vomiting usually is not serious and clears up by itself.

Vomiting is one of the signs of many different problems, some minor and some quite serious, so it is important to examine the person carefully.

Vomiting often comes from a problem in the stomach or guts, such as: an infection (see diarrhea, page 153), poisoning from spoiled food (page 135), or ‘acute abdomen’ (for example, appendicitis or something blocking the gut, page 94).

Also, almost any sickness with high fever or severe pain may cause vomiting, especially malaria (page 186), hepatitis (page 172), tonsillitis (page 309), earache (page 309), meningitis (page 185), urinary infection (page 234), gallbladder pain (page 329) or migraine headache (page 162).

Danger signs with vomiting seek medical help quickly!

• dehydration that increases and that you cannot control (page 152)

• severe vomiting that lasts more than 24 hours

• violent vomiting, especially if vomit is dark green, brown, or smells like shit (signs of obstruction, page 94)

• constant pain in the gut, especially if the person cannot defecate (shit) or if you cannot hear gurgles when you put your ear to the belly (see acute abdomen: obstruction, appendicitis, page 94)

• vomiting of blood (ulcer, page 128; cirrhosis, page 328)

To help control simple vomiting:

♦ Eat nothing while vomiting is severe.

♦ Sip a cola drink or ginger ale. Some herbal teas, like camomile, may also help.

♦ For dehydration give small frequent sips of cola, tea, or Rehydration Drink (page 152).

♦ If vomiting does not stop soon, use a vomit control medicine like promethazine (page 385) or diphenhydramine (page 386). But do not give these medicines to children under 2 years old.

Most of these come in pills, syrups, injections, and suppositories (soft pills you push up the anus). Tablets or syrup can also be put up the anus. Grind up the tablet in a little water. Put it in with an enema set or syringe without a needle.

When taken by mouth, the medicine should be swallowed with very little water and nothing else should be swallowed for 5 minutes. Never give more than the recommended dose. Do not give a second dose until dehydration has been corrected and the person has begun to urinate.

If severe vomiting and diarrhea make medication by mouth or anus impossible, give an injection of one of the vomit-control medicines. Promethazine may work best. Take care not to give too much.

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HEADACHES AND MIGRAINES

SIMPLE HEADACHE can be helped by rest and aspirin. It often helps to put a cloth soaked in hot water on the back of the neck and to massage (rub) the neck

For simple or nervous headache, folk cures sometimes work as well as modern medicine.

folk cure aspirin and shoulders gently. Some other home remedies also seem to help.

Headache is common with any sickness that causes fever. If headache is severe, check for signs of meningitis (page 185).

Headaches that keep coming back may be a sign of a chronic illness, poor nutrition, or chemicals at work or in the environment. It is important to eat well and get enough sleep. If you think that chemicals could be causing the headaches or if they do not go away, talk with a health worker.

A MIGRAINE is a severe throbbing headache often on one side of the head only. Migraine attacks may come often, or months or years apart.

A typical migraine begins with blurring of vision, seeing strange spots of light, or numbness of one hand or foot. This is followed by severe headache, which may last hours or days. Often there is vomiting. Migraines are very painful, but not dangerous.

TO STOP A MIGRAINE, DO THE FOLLOWING AT THE FIRST SIGN:

♦ Take 2 aspirins with a cup of strong coffee or strong black tea.

♦ Lie down in a dark, quiet place. Do your best to relax. Try not to think about your problems.

♦ For especially bad migraine headaches, take aspirin, if possible with codeine, or with another sedative. Or obtain pills of ergotamine with caffeine (Cafergot, page 379). Take 2 pills at first and 1 pill every 30 minutes until the pain goes away. Do not take more than 6 pills in 1 day.

WARNING: Do not use Cafergot during pregnancy.

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COLDS AND THE FLU

Colds and the flu are common virus infections that may cause runny nose, cough, sore throat, and sometimes fever or pain in the joints. There may be mild diarrhea, especially in young children.

Colds and the flu almost always go away without medicine. Do not use penicillin, tetracycline, or other antibiotics, as they will not help at all and may cause harm.

♦ Drink plenty of water and get enough rest.

♦ Aspirin (page 378) or acetaminophen (page 379) helps lower temperature and relieve body aches and headaches. More expensive ‘cold tablets’ are no better than aspirin. So why waste your money?

♦ No special diet is needed. However, fruit juices, especially orange juice or lemonade, are helpful. For treating coughs and stuffy noses that come with colds, see the next pages.

WARNING: Do not give any kind of antibiotic or injections to a child with a simple cold. They will not help and may cause harm.

If a cold or the flu lasts more than a week, or if the person has fever, coughs up a lot of phlegm (mucus with pus), has shallow fast breathing or chest pain, he could be developing bronchitis or pneumonia (See page 170 and page 171). An antibiotic may be called for.

The danger of a cold turning into pneumonia is greater in old people, in those who have lung problems like chronic bronchitis, in people who cannot move much, and in people with HIV. People with HIV can take cotrimoxazole daily to prevent pneumonia and other infections (see page 357).

Sore throat is often part of a cold. No special medicine is needed, but it may help to gargle with warm water. However, if the sore throat begins suddenly, with high fever, it could be a strep throat. Special treatment is needed (see page 310).

Prevention of colds:

♦ Getting enough sleep and eating well helps prevent colds. Eating oranges, tomatoes, and other fruit containing vitamin C may help. Washing hands often especially before touching your face, nose, mouth, or anything you put into your mouth is also good prevention.

♦ Contrary to popular belief, colds do not come from getting cold or wet (although getting very cold, wet, or tired can make a cold worse). A cold is ‘caught’ from others who have the infection and sneeze the virus into the air.

♦ To keep from giving his cold to others, the sick person should eat and sleep separately and take special care to keep far away from small babies. He should cover his nose and mouth when he coughs or sneezes, and wash his hands often if possible.

♦ To prevent a cold from leading to earache (page 309), try not to blow your nose just wipe it. Teach children to do the same.

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STUFFY AND RUNNY NOSES

A stuffy or runny nose can result from a cold or allergy (see next page). A lot of mucus in the nose may cause ear infections in children or sinus problems in adults.

To help clear a stuffy nose, do the following:

  1. In little children, carefully suck the mucus out of the nose with a suction bulb or syringe without a needle, like this:

  2. Older children and adults can put a little salt water into their hand and sniff it into the nose. This helps to loosen the mucus.The water should not be too salty. 1/4 teaspoon of salt mixed in a cup of water is enough.

  3. Breathing hot water vapor as described on page page 168 helps clear a stuffy nose.

  4. Wipe a runny or stuffy nose, but try not to blow it. Blowing the nose may lead to earache and sinus infections.

  5. Persons who often get earaches or sinus trouble after a cold can help prevent these problems by using decongestant nose drops with phenylephrine or ephedrine (page 383). After sniffing a little salt water, put the drops in the nose like this: With the head sideways, put 2 or 3 drops in the lower nostril. Wait a couple of minutes and then do the other side.

CAUTION: Use decongestant drops no more than 3 times a day, for no more than 3 days.

A decongestant syrup (with phenylephrine or something similar) may also help.

Prevent ear and sinus infections, try not to blow your nose, just wipe it.

165

SINUS TROUBLE (SINUSITIS)

Sinusitis is an acute or chronic (long-term) inflammation of the sinuses or hollows in the bone that open into the nose. It usually occurs after a person has had an infection of the ears or throat, or after a bad cold.

Signs:

• Pain in the face above and below the eyes, here (It hurts more when you tap lightly just over the bones, or when the person bends over.)

• Thick mucus or pus in the nose, perhaps with a bad smell. The nose is often stuffy.

• Fever (sometimes).

• Certain teeth may hurt.

Treatment:

♦ Drink a lot of water.

♦ Sniff a little salt water into the nose (see page 164), or breathe steam from hot water to clear the nose (see page 168).

♦ Put hot compresses on the face.

♦ Use decongestant nose drops such as phenylephrine (Neo-synephrine, page 383).

♦ Use an antibiotic such as tetracycline (page 355), ampicillin (page 352), or penicillin (page 351).

♦ If the person does not get better, seek medical help.

Prevention:

When you get a cold and a stuffy nose, try to keep your nose clear. Follow the instructions on page 164.

HAY FEVER (ALLERGIC RHINITIS)

Runny nose and itchy eyes can be caused by an allergic reaction to something in the air that a person has breathed in (see the next page). It is often worse at certain times of year.

Treatment:

Use an antihistamine such as chlorpheniramine (page 386). Dimenhydrinate (Dramamine, page 386), usually sold for motion sickness, also works.

Prevention:

Find out what things cause this reaction (for example: dust, chicken feathers, pollen, mold) and try to avoid them.

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ALLERGIC REACTIONS

An allergy is a disturbance or reaction that affects only certain persons when things they are sensitive or allergic to are:

• breathed in

• eaten

• injected

• or touch the skin

Allergic reactions, which can be mild or very serious, include:

• itching rashes, lumpy patches, or hives (page 203)

• runny nose and itching or burning eyes (hay fever, page 165)

• irritation in the throat, difficulty breathing, or asthma (see next page) • allergic shock (page 70)

• diarrhea (in children allergic to milk a rare cause of diarrhea, page 156)

An allergy is not an infection and cannot be passed from one person to another. However, children of allergic parents also tend to have allergies.

Often allergic persons suffer more in certain seasons or whenever they come in touch with the substances that bother them.

Common causes of allergic reactions are:

  • pollen of certain flowers and grasses

  • chicken feathers

  • dust

  • specific food, especially sh, shell sh, beer, etc.

  • chemicals in your home, school, or work

  • hair from cats and other animals

  • certain medicines, especially injections of penicillin or antitoxins made from horse serum (see page 70)

  • kapok or feather pillows

  • moldy blankets or clothes

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ASTHMA

A person with asthma has fits or attacks of difficult breathing. Listen for a hissing or wheezing sound, especially when breathing out.

When he breathes in, the skin behind his collar bones and between his ribs may suck in as he tries to get air.

If the person cannot get enough air, his nails and lips may turn blue, and his neck veins may swell. Usually there is no fever.

Asthma can also be caused by unclean air (air pollution), such as smoke from cigarettes, inside cooking fires, burning fields, or cars and trucks.

Asthma often begins in childhood and may be a problem for life. It is not contagious, but is more common in children with relatives who have asthma. It is generally worse during certain months of the year or at night.

An asthma attack may be caused by eating or breathing things to which the person is allergic (see page 166). In children asthma often starts with a cold. Nervousness or worry may bring on an asthma attack.

Asthma can also be caused by unclean air (air pollution), such as smoke from cigarettes, inside cooking fires, burning fields, or cars and trucks.

Treatment:

♦ If asthma gets worse inside the house, the person should go outside to a place where the air is cleanest. Remain calm and be gentle with the person. Reassure him.

♦ Give a lot of liquids. This loosens mucus and makes breathing easier. Breathing water vapor may also help (see page 168).

♦ Strong coffee or black tea can help relieve an asthma attack if you do not have any medicines.

♦ For attacks, treat with the rescue inhaler salbutamol (albuterol, see page 384) as often as needed. This is a spray medicine that you want to breathe in as deeply as possible. See page 384 to learn how to make a spacer for your inhaler.

♦ For frequent attacks, or asthma that makes you gasp for breath while walking or during mild exercise, also use the controller inhaler (beclomethasone, see page 384). Using a controller medicine can prevent attacks, save you money, and make you feel better than always responding to an asthma emergency. Using a “spacer” with your inhaler allows more medicine to get to the lungs.

♦ For severe asthma where you cannot get enough air and do not improve with salbutamol, use prednisolone by mouth right away, and then continue for 3 to 7 days (see page 385). In emergencies if you have no other medicines you can inject epinephrine (adrenalin, see page 385) under the skin.

♦ In rare cases, worms cause asthma. Try giving mebendazole (page 373) to a child who starts having asthma if you think she has worms.

If the person does not get better, seek medical help.

Prevention:

A person with asthma should avoid eating or breathing things that bring on attacks. The house or work place should be kept clean. Keep chickens and other animals outside. Air bedding in the sunshine.

Sometimes it helps to sleep outside in the open air. Drink at least 8 glasses of water each day to keep the mucus loose. Persons with asthma may improve when they move to where the air is cleaner.

If you have asthma do not smoke, smoking damages your lungs even more.

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COUGH

Coughing is not a sickness in itself, but is a sign of many different sicknesses that affect the throat, lungs, or bronchi (the network of air tubes going into the lungs). Below are some of the problems that cause different kinds of coughs:

DRY COUGH WITH LITTLE OR NO PHLEGM:

COUGH WITH MUCH OR LITTLE PHLEGM:

COUGH WITH A WHEEZE OR WHOOP AND TROUBLE BREATHING:

CHRONIC OR PERSISTENT COUGH:

COUGHING UP BLOOD:

  • tuberculosis (page 179)

  • pneumonia (yellow, green, or blood-streaked phlegm, page 171)

  • severe worm infection (page 140)

  • cancer of the lungs or throat (page 149)

Coughing is the body’s way of cleaning the breathing system and getting rid of phlegm (mucus with pus) and germs in the throat or lungs. So when a cough produces phlegm, do not take medicine to stop the cough, but rather do something to help loosen and bring up the phlegm.

169

Treatment for cough:

  1. To loosen mucus and ease any kind of cough, drink lots of water. This works better than any medicine.

Also breathe hot water vapors. Sit on a chair with a bucket of very hot water at your feet. Place a sheet over the bucket to catch the vapors as they rise. Breathe the vapors deeply for 15 minutes. Repeat several times a day. Some people like to add mint or eucalyptus leaves or Vaporub, but hot water works just as well alone.

CAUTION: Do not use eucalyptus or Vaporub if the person has asthma. They make it worse.

  1. For all kinds of cough, especially a dry cough, the following cough syrup can be given:

Mix: 1 part honey 1 part lemon juice + Take a teaspoonful every 2 or 3 hours.

WARNING: Do not give honey to babies under 1 year. Make the syrup with sugar instead of honey.

  1. For a severe dry cough that does not let you sleep, you can take a syrup with codeine (page 383). Tablets of aspirin with codeine (or even aspirin alone) also help. If there is a lot of phlegm or wheezing, do not use codeine.

  2. For a cough with wheezing (difficult, noisy breathing), see Asthma (page 167), Chronic Bronchitis (page 170), and Heart Trouble (page 325).

  3. Try to find out what sickness is causing the cough and treat that. If the cough lasts a long time, if there is blood, pus, or smelly phlegm in it, or if the person is losing weight or has continual difficulty breathing, see a health worker.

  4. If you have any kind of a cough, do not smoke. Smoking damages the lungs.

HOW TO DRAIN MUCUS FROM THE LUNGS (POSTURAL DRAINAGE)

When a person who has a bad cough is very old or weak and cannot get rid of the sticky mucus or phlegm in his chest, it will help if he drinks a lot of water.

Also do the following:

♦ First, have him breathe hot water vapors to loosen the mucus.

♦ Then pound him lightly on the back with a cupped hand. This will help to bring out the mucus.

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BRONCHITIS

Bronchitis is an infection of the bronchi or tubes that carry air to the lungs.

It causes a noisy cough, often with mucus or phlegm. Bronchitis is usually caused by a virus, so antibiotics do not generally help.

Use antibiotics only if the bronchitis lasts more than a week and is not getting better, if the person shows signs of pneumonia (see the following page), or if he already has a chronic lung problem.

CHRONIC BRONCHITIS

Signs:

• A cough, with mucus that lasts for months or years. Sometimes the cough gets worse, and there may be fever. A person who has this kind of cough, but does not have another long term illness such as tuberculosis or asthma, probably has chronic bronchitis.

• It occurs most frequently in older persons who have been heavy smokers.

• It can lead to emphysema, a very serious and incurable condition in which the tiny air pockets of the lungs break down. A person with emphysema has a hard time breathing, especially with exercise, and his chest becomes big ‘like a barrel’.

Treatment:

♦ Stop smoking.

♦ Take an anti-asthma medicine with salbutamol (page 384).

♦ Persons with chronic bronchitis should use cotrimoxazole or amoxicillin every time they have a cold or ‘flu’ with a fever.

♦ If the person has trouble coughing up sticky phlegm, have him breathe hot water vapors (page 168) and then help him with postural drainage (see page 169).

Emphysema can result from chronic asthma, chronic bronchitis, or smoking.

If you have a chronic cough (or want to prevent one), DO NOT SMOKE!

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PNEUMONIA

Pneumonia is an acute infection of the lungs. It often occurs after another respiratory illness such as measles, whooping cough, flu, bronchitis, asthma or after any very serious illness, especially in babies and old people. Also, persons with HIV may develop pneumonia.

Signs:

• Sudden chills and then high fever.

• Rapid, shallow breathing, with little grunts or sometimes wheezing. The nostrils may spread with each breath.

• Fever (sometimes newborns and old or very weak persons have severe pneumonia with little or no fever).

• Cough (often with yellow, greenish, rust colored, or slightly bloody mucus).

• Chest pain (sometimes).

• The person looks very ill.

• Cold sores often appear on the face or lips (page 232).

A very sick child with fast, shallow breathing probably has pneumonia. For a newborn baby, fast breathing means more than 60 breaths a minute.

For a baby between 2 months and 1 year, fast breathing is more than 50 breaths a minute, and for a child between 1 and 5 years old, 40 breaths a minute. (If breathing is rapid and deep, check for dehydration, page 151, or hyperventilation, page 24.) Do not count the breaths while the child is crying or just after she has stopped.

Treatment:

♦ For pneumonia, treatment with antibiotics can make the difference between life and death. Give benzylpenicillin (page 351), cotrimoxazole (page 357), or erythromycin (page 354). In serious cases, inject procaine penicillin (page 352), adults: 1,000,000 units (1 g) a day, or give amoxicillin by mouth (pages page 352 to page 353), 500 mg, 3 times a day. Give small children 1⁄4 to 1⁄2 the adult dose. For children under 6, amoxicillin is usually best.

♦ Give aspirin (page 378) or acetaminophen (page 379) to lower the temperature and lessen the pain. Acetaminophen is safer for children under 12.

♦ Give plenty of liquids. If the person will not eat, give him liquid foods or Rehydration Drink (see page 152).

♦ Ease the cough and loosen the mucus by giving the person plenty of water and having him breathe hot water vapors (see page 168). Postural drainage may also help (see page 169).

♦ If the person is wheezing, an anti-asthma medicine may help (see page 384).

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HEPATITIS

Hepatitis is an inflammation of the liver usually caused by a virus, but also by bacteria, alcohol, or chemical poisoning. There are 3 major types of hepatitis (A, B, and C) and it can spread from person to person whether or not there are signs of the disease. Even though in some places people call it ‘the fever’ (see page 26), hepatitis often causes little or no rise in temperature.

A person with Hepatitis A or Hepatitis B is often very sick for 2 to 3 weeks, weak for 1 to 4 months after, and then usually gets better. Hepatitis A is usually mild in small children, but more serious in older persons and in pregnant women.

Hepatitis B is more serious and can lead to permanent scarring of the liver (cirrhosis), liver cancer, and even death. Hepatitis C is also very dangerous and can lead to permanent liver infections. It is a major cause of death for people with HIV.

Signs:

• Feels tired. Does not want to eat or smoke. Often goes days without eating anything.

• Sometimes there is a pain on the right side near the liver. Sometimes there is pain in the muscles or joints.

• May have a fever.

• After a few days, the eyes and skin turn yellow.

• Sight or smell of food may cause vomiting.

• The urine may turn dark like Coca Cola, and the stools may become whitish, or the person may have diarrhea.

Treatment:

♦ Antibiotics do not work against hepatitis. In fact some medicines such as acetaminophen will cause added damage to the sick liver. Do not use medicines.

♦ The sick person should rest and drink lots of liquids. If he refuses most food, give him orange juice, papaya, and other fruit plus broth or vegetable soup. It may help to take vitamins. To control vomiting, see page 161.

♦ When the sick person can eat, give a balanced meal. Vegetables and fruit are good, with some protein (pages page 110 to page 111). But do not give a lot of protein (meat, eggs, fish, etc.) because this makes the damaged liver work too hard. Avoid lard and fatty foods. Do not drink any alcohol for at least 6 months.

Prevention:

♦ Small children often have hepatitis without any signs of sickness, but they can spread the disease to others. It is very important that everyone in the house follow all the guidelines of cleanliness with great care (See page 133 to page 139).

♦ The Hepatitis A virus passes from the stool of one person to the mouth of another by way of contaminated water or food. To prevent others from getting sick, bury the sick person’s stools. The sick person, his family and caregivers must try to stay clean and wash their hands often.

♦ The Hepatitis B and Hepatitis C viruses can pass from person to person through sex, injections with unsterile needles, transfusions of infected blood and from mother to baby at birth. Take steps to prevent passing hepatitis to others: use a condom during sex (see page 287), follow the HIV prevention suggestions on page 401, and always boil needles and syringes before each use (see page 74).

♦ Vaccines now exist for Hepatitis A and Hepatitis B but they may be expensive or not be available everywhere. Hepatitis B is dangerous and there is no cure, so if the vaccine is accessible all children should be vaccinated. There is a new medicine for Hepatitis C, but it is very expensive and not widely available.

WARNING: Hepatitis can also be transmitted by giving injections with unsterile needles: Always boil needles and syringes before each use (see page 74).

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ARTHRITIS (PAINFUL, INFLAMED JOINTS)

Most chronic joint pain, or arthritis, in older people cannot be cured completely. However, the following offer some relief:

♦ Rest. If possible, avoid hard work and heavy exercise that bother the painful joints. If the arthritis causes some fever, it helps to take naps during the day.

♦ Place cloths soaked in hot water on the painful joints (see page 195).

♦ Aspirin helps relieve pain; the dose for arthritis is higher than that for calming other pain. Adults should take 3 tablets, 4 times a day. If your ears begin to ring, take less. To avoid stomach problems caused by aspirin, always take it with food, or a large glass of water. If stomach pain continues, take the aspirin not only with food and lots of water, but also with a spoonful of an antacid such as Maalox or Gelusil.

♦ It is important to do simple exercises to help maintain or increase the range of motion in the painful joints.

If only one joint is swollen and feels hot, it may be infected especially if there is fever. Use an antibiotic such as penicillin (see page 350) and if possible see a health worker.

Painful joints in young people and children may be a sign of other serious illness, such as rheumatic fever (page 310) or tuberculosis (page 179). For more information on joint pain, see Disabled Village Children, Chapters 15 and 16.

BACK PAIN

Back pain has many causes. Here are some: Chronic upper back pain with cough and weight loss may be TB of the lungs (page 179).

Mid back pain in a child may be TB of the spine, especially if the backbone has a hump or lump.

Low back pain that is worse the day after heavy lifting or straining may be a sprain.

Severe low back pain that first comes suddenly when lifting or twisting may be a slipped disc, especially if one leg or foot becomes painful or numb and weak. This can result from a pinched nerve.

Standing or sitting with the shoulder drooped is a common cause of backache.

In older people, chronic back pain is often arthritis. Pain in the upper right back may be from a gallbladder problem (page 329).

Acute (or chronic) pain here may be a urinary problem (page 234).

Low backache is normal for some women during menstrual periods or pregnancy (page 248).

Very low back pain sometimes comes from problems in the uterus, ovaries, or rectum.

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Treatment and prevention of back pain:

♦ If back pain has a cause like TB, a urinary infection, or gallbladder disease, treat the cause. Seek medical help if you suspect a serious disease.

♦ Simple backache, including that of pregnancy, can often be prevented or made better by: 1.always standing straight 2.sleeping on a firm surface 3.back-bending exercises (done very slowly)

♦ Aspirin and hot soaks (page 195) help calm most kinds of back pain.

♦ For sudden, severe, low back pain that comes from twisting, lifting, bending, or straining, quick relief can sometimes be brought like this:

Have the person lie with one foot tucked under his knee.

Then, holding this shoulder down, gently but steadily push this knee over so as to twist the back.

Do this first on one side and then the other.

CAUTION: Do not try this if the back pain is from a fall or injury.

♦ If back pain from lifting or twisting is sudden and severe with knife-like pain when you bend over, if the pain goes into the leg(s), or if a foot becomes numb or weak, this is serious. A nerve coming from the back may be ‘pinched’ by a slipped disc (pad between the bones of the back). It is best to rest flat on your back for a few days. It may help to put something firm under the knees and mid back.

♦ Take aspirin and use hot soaks. If pain does not begin to get better in a few days, seek medical advice.

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VARICOSE VEINS

Varicose veins are veins that are swollen, twisted, and often painful. They are often seen on the legs of older people and of women who are pregnant or who have had many children.

Treatment:

There is no medicine for varicose veins. But the following will help:

♦ Do not spend much time standing or sitting with your feet down. If you have no choice but to sit or stand for long periods, try to lie down with your feet up (above the level of the heart) for a few minutes every half hour. When standing, try to walk in place. Or, repeatedly lift your heels off the ground and put them back down. Also, sleep with your feet up (on pillows).

♦ Use elastic stockings (support hose) or elastic bandages to help hold in the veins. Be sure to take them off at night.

♦ Taking care of your veins in this way will help prevent chronic sores or varicose ulcers on the ankles (page 213).

PILES (HEMORRHOIDS)

Piles or hemorrhoids are varicose veins of the anus or rectum, which feel like little lumps or balls. They may be painful, but are not dangerous. They frequently appear during pregnancy and may go away afterwards.

♦ Certain bitter plant juices (witch hazel, cactus, etc.) dabbed on hemorrhoids help shrink them. So do hemorrhoid suppositories (page 391).

♦ Sitting in a bath of warm water can help the hemorrhoid heal.

♦ Piles may be caused in part by constipation. It helps to eat plenty of fruit or food with a lot of fiber, like cassava or bran.

♦ Very large hemorrhoids may require an operation. Get medical advice.

If a hemorrhoid begins to bleed, the bleeding can sometimes be controlled by pressing with a clean cloth directly on the hemorrhoid.

If the bleeding still does not stop, seek medical advice. Or try to control the bleeding by removing the clot that is inside the swollen vein.

First, clean the anus with soap and water. Use a blade that has been sterilized by boiling to cut a small opening in the hemorrhoid. Use sterilized tweezers to pull out the clot. Put pressure on the cut with a clean cloth until bleeding stops.

CAUTION: Do not try to cut the hemorrhoid out. The person can bleed to death.

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SWELLING OF THE FEET AND OTHER PARTS OF THE BODY

Swelling of the feet may be caused by a number of different problems, some minor and others serious. But if the face or other parts of the body are also swollen, this is usually a sign of serious illness.

Women’s feet sometimes swell during the last three months of pregnancy. This is usually not serious. It is caused by the weight of the child that presses on the veins coming from the legs in a way that limits the flow of blood.

However, if the woman also has high blood pressure, swollen face, a lot of protein in her urine, or sudden weight gain, she may be suffering from pre-eclampsia (see page 249). Seek medical help fast.

Old people who spend a lot of time sitting or standing in one place often get swollen feet because of poor circulation. However, swollen feet in older persons may also be due to heart trouble (page 325) or, less commonly, kidney disease (page 234).

Swelling of the feet in small children may result from anemia (page 124) or malnutrition (page 107). In severe cases of malnutrition the face and hands may also become swollen (see Kwashiorkor, page 113).

Treatment:

To reduce swelling, treat the sickness that causes it. Use little or no salt in food. Herbal teas that make people urinate a lot usually help (see corn silk, page 12). Also do the following:

WHEN YOUR FEET ARE SWOLLEN:

Do not spend time sitting with your feet GOOD down. This makes them swell more.

When you sit, put your feet up high. This way the swelling becomes less. Put your feet up several times a day. Your feet should be above the level of your heart.

Also sleep with your feet raised.

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HERNIA (RUPTURE)

A hernia is an opening or tear in the muscles covering the belly. This permits a loop of gut to push through and form a lump under the skin. Hernias usually come from lifting something heavy, or straining (as during childbirth). Some babies are born with a hernia (see page 317). In men, hernias are common in the groin. Swollen lymph nodes (page 88) may also cause lumps in the groin. However . . .

A hernia is usually here, and you can feel it with a finger, like this.

It gets bigger when you cough (or lift).

Lymph nodes are usually here and do not get bigger when you cough.

How to prevent a hernia:

Lift heavy things like this

How to live with a hernia:

♦ Avoid lifting heavy objects.

♦ Make a truss to hold the hernia in.

PLAN FOR A SIMPLE TRUSS:

Put a little cushion here so it presses against the groin.

CAUTION:

If a hernia suddenly becomes large or painful, try to make it go back in by lying with the feet higher than the head and pressing gently on the bulge. If it will not go back, seek medical help.

If the hernia becomes very painful and causes vomiting, and the person cannot have a bowel movement, this can be very dangerous.

Surgery may be necessary. Seek medical help fast. In the meantime, treat as for Appendicitis (page 95).

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SEIZURES (FITS, CONVULSIONS)

We say a person has a seizure when he suddenly loses consciousness and makes strange, jerking movements (convulsions). Seizures come from a problem in the brain. In small children, common causes of seizures are high fever and severe dehydration. In very ill persons, the cause may be meningitis, malaria of the brain (cerebral malaria), or poisoning. In pregnant women, it may be eclampsia (see page 249). A person who often has seizures may have epilepsy.

♦ Try to figure out the cause of a seizure and treat it, if possible.

♦ If the child has a high fever, lower it with cool water (see page 76).

♦ If the child is dehydrated, give an enema of Rehydration Drink slowly. Send for medical help. Give nothing by mouth during a seizure.

♦ If there are signs of meningitis (page 185), begin treatment at once. Seek medical help.

♦ If you suspect cerebral malaria, inject quinine or artesunate (see page 366).

♦ If you suspect eclampsia, give medicine (see page 390).

EPILEPSY

Epilepsy causes seizures (fits) in people who otherwise seem fairly healthy. Seizures may come hours, days, weeks, or months apart. In some persons they cause loss of consciousness and violent movements. The eyes often roll back.

In mild types of epilepsy the person may suddenly ‘blank out’ a moment, make strange movements, or behave oddly. Epilepsy is more common in some families (inherited).

Or it may come from brain damage at birth, high fever in infancy, or tapeworm cysts in the brain (page 143). Epilepsy is not an infection and cannot be ‘caught’. It is often a life-long problem. However, babies sometimes get over it.

Medicines to prevent epileptic seizures:

Note: These do not ‘cure’ epilepsy; they help prevent seizures. Often the medicine must be taken for life.

♦ Phenobarbital often controls epilepsy. It costs little (see page 389).

♦ Phenytoin may work when phenobarbital does not. Use the lowest possible dose that prevents seizures (see page 389).

When a person is having a seizure:

♦ Try to keep the person from hurting himself: move away all hard or sharp objects.

♦ Put nothing in the person’s mouth while he is having a seizure. No food, drink, medicine, nor any object to prevent biting the tongue.

♦ After the seizure the person may be dull and sleepy. Let him sleep.

♦ If a seizure lasts more than 15 minutes, put liquid diazepam in the rectum using a plastic syringe without a needle. For dosage see page 389. Do not inject phenytoin, phenobarbital, or diazepam into the muscles. These medicines can be injected in the vein, but it is very dangerous if you have little experience. Only a person with experience giving injections into a vein should give injections of these medicines.

For more information on seizures, see Disabled Village Children, Chapter 29.

14

serious illnesses that need special medical attention

The diseases covered in this chapter are often difficult or impossible to cure without medical help. Many need special medicines that are difficult to get in rural areas. Home remedies will not cure them. If a person has one of these illnesses,

THE SOONER HE GETS MEDICAL HELP, THE BETTER HIS CHANCE OF GETTING WELL.

CAUTION: Many of the illnesses covered in other chapters may also be serious and require medical assistance. See the Signs of Dangerous Illness, page 42.

TUBERCULOSIS (TB, consumption)

Tuberculosis of the lungs is a chronic (long-lasting), contagious (easily spread) disease that anyone can get. But it often strikes persons between 15 and 35 years of age, especially those who are weak, poorly nourished, have HIV, or live with someone who has TB.

Because so many people with HIV (page 399) get very sick with TB, all people with HIV should get a TB test.

People with HIV can take isoniazid (see page 360) to prevent TB from developing. Encourage people with TB to also be tested for HIV and find help with a treatment program if they are positive.

Tuberculosis is curable. Yet thousands die needlessly from this disease every year. Both for prevention and cure, it is very important to treat tuberculosis early. Be on the lookout for the signs of tuberculosis. A person may have one or many of them.

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Most frequent signs of TB:

  • A cough that lasts longer than 3 weeks, often worse just after waking up.

  • Slight fever in the evening and sweating at night.

  • There may be pain in the chest or upper back.

  • Chronic loss of weight and increasing weakness.

In serious or advanced cases:

  • Coughing up blood (usually a little, but in some cases a lot).

  • Pale, waxy skin. The skin of a dark skinned person tends to get lighter, especially the face.

  • Voice grows hoarse (very serious). In young children: The cough may come late. Instead, look for:

  • Steady weight loss.

  • Frequent fever.

  • Lighter skin color.

  • Swellings in the neck (lymph nodes), or the belly (page 20)

TB is usually only in the lungs. But it can affect any part of the body. In young children it may cause meningitis (see page 185). For skin problems from TB, see page 212.

If you think you might have tuberculosis:

Seek medical help. At the first sign of tuberculosis, go to a health center where the workers can examine you, and test the stuff you cough up (phlegm or sputum) to see if you have TB or not. Many governments give TB medicines free. Ask at the nearest health center. You will probably be given some of the following medicines:

It is very important to take the medicines as directed. Treatments may be different in different countries, but usually the treatment has 2 parts. You will take 4 medicines for 2 months and then test your sputum. If you are getting better, you will take 2 or 3 medicines for another 4 months. Then you will be tested again to make sure you are cured. Do not stop taking the medicines, even if you feel better. This can lead to the illness coming back and infecting you and other people, with a form of TB that is much harder to cure, multi-drug resistant tuberculosis (see page 359). To cure TB completely can take from 6 months to more than a year.

Eat as well as possible: plenty of energy foods and also foods rich in proteins and vitamins (pages page 110 to page 111). Rest is important. If possible, stop working and take it easy until you begin to get better. From then on, try not to work so hard that you become tired or breathe with difficulty. Try to always get enough rest and sleep.

Tuberculosis in any other part of the body is treated the same as TB of the lungs, but the treatment may be longer. This includes TB in the glands of the neck, TB of the abdomen (see picture on page 20), TB of the skin (see page 212), and TB of a joint (like the knee). A child with severe TB of the backbone may also need surgery to prevent paralysis (see Disabled Village Children, Chapter 21).

Tuberculosis is very contagious. It spreads when someone with TB coughs germs into the air. Anyone, especially a child, who lives with someone who has TB runs a great risk of catching the disease.

If someone in the house has TB:

  • If possible, see that the whole family is tested for TB (Tuberculin test).

  • Have the children vaccinated against TB with B.C.G. vaccine.

  • Everyone, especially the children, should eat plenty of nutritious food.

  • The person with TB should eat and sleep separately from the children, if possible in a different room, as long as he has any cough at all.

  • Ask the person with TB to cover his mouth when coughing and not spit on the floor.

  • Watch for weight loss and other signs of TB in members of the family. Weigh each person, especially the children, once a month, until you are sure no one in the household is sick with TB.

TB in family members often starts very slowly and quietly. If anyone in the family shows signs of TB, have tests done and begin treatment at once.

Early and full treatment is a key part of prevention.

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RABIES

Rabies comes from the bite of a rabid or ‘mad’ animal, usually a rabid dog, cat, fox, wolf, skunk, or jackal. Bats and other animals may also spread rabies.

Signs of rabies in the animal:

  • Acts strangely, sometimes sad, restless, or irritable.

  • Foaming at the mouth, cannot eat or drink.

  • Sometimes the animal goes wild (mad) and may bite anyone or anything nearby.

  • The animal dies within 5 to 7 days.

Signs in people:

  • Pain and tingling in the area of the bite.

  • Irregular breathing, as if the person has just been crying.

  • Pain and difficulty swallowing, and fear of liquids. A lot of thick, sticky saliva.

  • The person is alert, but very nervous or excitable. Fits of anger can occur.

  • As death nears, seizures (convulsions) and paralysis.

If you have any reason to believe an animal that has bitten someone has rabies:

  • Tie or cage the animal for a week.

  • Clean the bite well with soap, water, and hydrogen peroxide. Do not close the wound; leave it open.

  • If the animal dies before the week is up (or if it was killed or cannot be caught), take the bitten person at once to a health center where he can be given a series of anti-rabies injections.

The first symptoms of rabies appear from 10 days up to 2 years after the bite (usually within 3 to 7 weeks). Treatment must begin before the first signs of the sickness appear. Once the sickness begins, no treatment known to medical science can save the person’s life.

Prevention:

  • Kill and bury or cage for one week any animal suspected of having rabies.

  • Cooperate with programs to vaccinate dogs.

  • Keep children far away from any animal that seems sick or acts strangely.

Take great care in handling any animal that seems sick or acts strangely. Even if it does not bite anyone, its saliva can cause rabies if it gets into a cut or scratch.

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TETANUS (Lockjaw)

Tetanus results when a germ that lives in the feces of animals or people enters the body through a wound. Deep or dirty wounds are especially dangerous.

wounds very likely to cause tetanus

  • animal bites, especially those of dogs and pigs

  • gunshot and holes made with knife wounds dirty needles

  • injuries caused by barbed wire

  • puncture wounds from thorns, splinters, or nails

causes of tetanus in the newborn child

Tetanus germs enter through the umbilical cord of a newborn baby because of lack of cleanliness or failure to take other simple precautions. The chance of tetanus is greater

  • when the cord has been cut with an instrument that has not been boiled and kept completely clean, or

  • when the cord has not been cut close to the body (see page 262), or

  • when the newly cut cord is tightly covered or is not kept dry.

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Signs of tetanus:

  • An infected wound (sometimes no wound can be found).

  • Discomfort and difficulty in swallowing.

  • The jaw gets stiff (lockjaw), then the muscles of the neck and other parts of the body get stiff. The person has difficulty walking normally.

  • Painful convulsions (sudden tightening) of the jaw and finally of the whole body. Moving or touching the person may trigger sudden spasms like this:

Sudden noise or bright light may also bring on these spasms.

In the newborn, the first signs of tetanus generally appear 3 to 10 days after birth. The child begins to cry continuously and is unable to suck. Often the umbilical area is dirty or infected. After several hours or days, lockjaw and the other signs of tetanus begin.

It is very important to start treating tetanus at the first sign. If you suspect tetanus (or if a newborn child cries continuously or stops nursing), make this test:

test of knee reflexes

With the leg hanging freely, tap the knee with a knuckle just below the kneecap.

If the leg jumps just a little bit, the reaction is normal.

If the leg jumps high, this indicates a serious illness like tetanus (or perhaps meningitis or poisoning with certain medicines or rat poison).

This test is especially useful when you suspect tetanus in a newborn baby.

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What to do when there are signs of tetanus:

Tetanus is a deadly disease. Seek medical help at the first sign. If there is any delay in getting help, do the following things:

  • Examine the whole body for infected wounds or sores. Often the wound will contain pus. Open the wound and wash it with soap and cool, boiled water; completely remove all dirt, pus, thorns, splinters, etc.; flood the wound with hydrogen peroxide if you have any.

  • Inject 1 million units of procaine penicillin at once and repeat every 12 hours for 7 to 10 days (page 352). (For newborn babies crystalline penicillin is better.) After using injected penicillin for 2 days, you can switch to penicillin by mouth (penicillin V, page 351). If there is no penicillin, use another antibiotic, like tetracycline.

  • If you can get it, inject 5000 units of Antitetanus Immunoglobulin (human tetanus immune globulin, HTIG), 1 time only. Be sure to follow all the precautions (See page 70 and page 388).

  • As long as the person can swallow, give nutritious liquids in frequent small sips.

  • To control convulsions, give diazepam (Valium) by mouth or in the rectum (for dosages See page 388 to page 390).

  • Touch and move the person as little as possible. Avoid noise and bright light.

  • If necessary, use a catheter (rubber tube) connected to a syringe to suck the mucus from the nose and throat. This helps clear the airway.

  • For the newborn with tetanus, if possible, have a health worker or doctor put in a nose-to-stomach tube and feed the baby the mother’s breast milk. This provides needed nutrition and fights infection.

How to prevent tetanus:

Even in the best hospitals, half the people with tetanus die. It is much easier to prevent tetanus than to treat it.

  • Vaccination: This is the surest protection against tetanus. Both children and adults should be vaccinated. Vaccinate your whole family at the nearest health center (see page 147). For complete protection, the vaccination should be repeated once every 10 years. Vaccinating women against tetanus each time they are pregnant will prevent tetanus in newborn infants (see page 250).

  • When you have a wound, especially a dirty or deep wound, clean and take care of it in the manner described on page 89.

  • If the wound is very big, deep, or dirty, seek medical help. If you have not been vaccinated against tetanus, get the vaccination and also get an injection of antitetanus immunoglobulin (see page 388).

  • In newborn babies, cleanliness is very important to prevent tetanus. The instrument used to cut the umbilical cord should be sterilized (page 262); the cord should be cut short, and the umbilical area kept clean and dry.

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MENINGITIS

This is a very serious infection of the brain, more common in children. It may begin as a complication of another illness, such as measles, mumps, whooping cough, malaria, or an ear infection. Children of mothers who have tuberculosis sometimes get tubercular meningitis in the first few months of life.

Signs:

  • Fever

  • Severe headache.

  • Stiff neck. The child looks very ill, and lies with his head and neck bent back, like this:

  • The back is too stiff to put the head between the knees.

  • In babies under a year old: the fontanel (soft spot on top of the head) bulges out.

  • Vomiting is common.

  • In babies and young children, early meningitis may be hard to recognize. The child may cry in a strange way (the ‘meningitis cry’), even when the mother puts the child on her breast. Or the child may become very sleepy.

  • Sometimes there are seizures (fits, convulsions) or strange movements.

  • The child often gets worse and worse and only becomes quiet when he loses consciousness completely.

  • Tubercular meningitis develops slowly, over days or weeks. Other forms of meningitis come on more quickly, in hours or days.

Treatment:

Get medical help fast, every minute counts! If possible take the person to a hospital. Meanwhile:

  • Inject ampicillin every 6 hours, 500 mg for children or 1 g for adults (see page 353). Also give ceftriaxone or gentamicin (see page 358).

  • If there is high fever (more than 40°), lower it with wet cloths and acetaminophen or aspirin (See page 378 to page 379).

  • If the mother has tuberculosis or if you have any other reason to suspect that the child has tubercular meningitis, inject him with 20 mg of streptomycin for each kg. he weighs and get medical help at once. Also, use ampicillin in case the meningitis is not from TB.

  • If you know the meningitis came from malaria, give an injection of artesunate or quinine at once (see page 366).

Prevention:

For prevention of tubercular meningitis, newborn babies of mothers with tuberculosis should be vaccinated with B.C.G. at birth. Dose for the newborn is 0.05 ml (half the normal dose of 0.1 ml).

For other suggestions on prevention of TB, see pages page $1 to 180.

186

MALARIA

Malaria is an infection of the blood that causes chills and high fever. Malaria is spread by mosquitos. The mosquito sucks up the malaria parasites in the blood of an infected person and injects them into the next person it bites. People with HIV are twice as likely to catch malaria.

Signs of malaria

The typical attack has 3 stages:

  1. It begins with chills, and often headache. The person shivers or shakes for 15 minutes to an hour.

  2. Chills are followed by fever, often 40° or more. The person is weak, rushed (red skin), and at times delirious (not in his right mind). The fever lasts several hours or days.

  3. Finally the person begins to sweat, and his temperature goes down. After an attack, the person feels weak, but may feel more or less OK.

  • Usually malaria causes fevers every 2 or 3 days (depending on the kind of malaria), but in the beginning it may cause fever daily. Also, the fever pattern may not be regular or typical. For this reason anyone who suffers from unexplained fevers should have his blood tested for malaria.

  • Chronic malaria often causes a large spleen and anemia (see page 124). For people with HIV (page 399) it can cause them to get sick faster.

  • In young children, anemia and paleness can begin within a day or two. In children with malaria affecting the brain (cerebral malaria), seizures (fits) may be followed by periods of unconsciousness.

Also, the palms may show a blue gray color, and breathing may be rapid and deep. (Note: Children who have not been breastfed are more likely to get malaria.)

Analysis and treatment

  • If you suspect malaria or have repeated fevers, if possible go to a health center for a blood test. In areas where an especially dangerous type of malaria called falciparum occurs, seek treatment immediately.

  • In areas where malaria is common and blood tests are not available, treat any unexplained high fever as malaria. Take the malaria medicine known to work best in your area. (See page 363 to page 367for dosages and information on malaria medicines.)

  • If you get better with the medicine, but after several days the fevers start again, you may need another medicine. Get advice from the nearest health center.

  • If a person who possibly has malaria begins to have seizures or other signs of meningitis (page 185) he may have cerebral malaria. If possible, inject quinine or artesunate at once (see page 366).

187

How to avoid MALARIA and DENGUE

Malaria occurs more often during hot, rainy seasons. If everyone cooperates, it can be controlled. All these control measures should be practiced at once.

  1. Avoid mosquitos. Sleep where there are no mosquitos or underneath a bed net treated with insecticide or under a sheet. Cover the baby’s cradle with treated mosquito netting or a thin cloth.

  2. Cooperate with the malaria control workers when they come to your village. Tell them if anyone in the family has had fevers and let them take blood for testing.

  3. If you suspect malaria, get treatment quickly. After you have been treated, mosquitos that bite you will not pass malaria on to others.

  4. Destroy mosquitos and their young. Mosquitos breed in water that is not flowing. Clear ponds, pits, old cans, or broken pots that collect water. Raise mosquito-eating fish in ponds or lakes. Fill the tops of bamboo posts with sand and keep water containers covered.

  5. Malaria can also be prevented, or its effects greatly reduced, by taking anti-malaria medicines on a regular schedule. See page 363 to page 367.

DENGUE (breakbone fever, dandy fever)

This illness is sometimes confused with malaria. It is caused by a virus that is spread by mosquitos. In recent years it has become much more common in many countries.

It often occurs in epidemics (many persons get it at the same time), usually during the hot, rainy season. A person can get dengue more than once. Repeat illnesses are often worse.

To prevent dengue, control mosquitos and protect against their bites, as described above.

Signs:

  • Sudden high fever with chills.

  • Severe body aches, headache, sore throat.

  • Person feels very ill, weak, miserable.

  • After 3 to 4 days person feels better for a few hours to 2 days.

  • Then illness returns for 1 or 2 days, often with a rash that begins on hands and feet.

  • The rash then spreads to arms, legs, and finally the body (usually not the face).

A severe form of dengue may cause bleeding into the skin (small dark spots), or dangerous bleeding inside the body. Go to a hospital immediately.

Treatment:

  • No medicine cures it, but the illness goes away by itself in a few days.

  • Rest, lots of liquids such as rehydration drink, fruit juice, or milk, acetaminophen (but not aspirin or ibuprofen) for fever and pain.

  • In case of severe bleeding, treat for shock, if necessary (see page 77).

188

BRUCELLOSIS, UNDULANT FEVER, MALTA FEVER

This is a disease that comes from drinking fresh milk from infected cows or goats. It may also enter the body through scrapes or wounds in the skin of persons who work with sick cattle, goats, or pigs, or by breathing it into the lungs.

Signs:

• Brucellosis may start with fever and chills, but it often begins very gradually with increasing tiredness, weakness, loss of appetite, headache, stomach ache, and sometimes joint pains.

• The fevers may be mild or severe. Typically, these begin with afternoon chills and end with sweating in the early morning. In chronic brucellosis, the fevers may stop for several days and then return. Without treatment, brucellosis may last for years.

• There may be swollen lymph nodes in the neck, armpits, and groin (page 88).

Treatment:

♦ If you suspect brucellosis, get medical advice, because it is easy to confuse this disease with others, and the treatment is long and expensive.

♦ Treat with tetracycline, adults: two 250 mg. capsules 4 times a day for 3 weeks. For precautions, see page 357. Or use cotrimoxazole. (For dosage and precautions, see page 357.)

Prevention:

♦ Drink only cow’s or goat’s milk that has been boiled or pasteurized. In areas where brucellosis is a problem, it is safer not to eat cheese made from unboiled milk.

♦ Be careful when handling cattle, goats, and pigs, especially if you have any cuts or scrapes.

♦ Cooperate with livestock inspectors who check to be sure your animals are healthy.

PREVENT BRUCELLOSIS: never drink unboiled milk

189

TYPHOID FEVER

Typhoid is an infection of the gut that affects the whole body. It is spread from feces‐to‐mouth in contaminated food and water and often comes in epidemics (many people sick at once). Of the different infections sometimes called ‘the fever’ (see page 26), typhoid is one of the most dangerous.

Signs of typhoid:

First week:

• It begins like a cold or flu.

• Headache, sore throat, and often a dry cough.

• The fever goes up and down, but rises a little more each day until it reaches 40° or more.

• Pulse is often relatively slow for the amount of fever present. Take the pulse and temperature every half hour. If the pulse gets slower when the fever goes up, the person probably has typhoid (see page 26).

• Sometimes there is vomiting, diarrhea, or constipation.

Fever goes like this:

  • 1st day: 37.5°C

  • 2nd day: 38°

  • 3rd day: 38.5°

  • 4th day: 39°

  • 5th day: 39.5°

  • 6th day: 40°

Second week:

• High fever, pulse relatively slow.

• A few pink spots may appear on the body.

• Trembling.

• Delirium (person does not think clearly or make sense).

• Weakness, weight loss, dehydration.

Third week:

• If there are no complications, the fever and other symptoms slowly go away.

Treatment:

♦ Seek medical help.

♦ Give ciprofloxacin (page 356), chloramphenicol (page 356), ampicillin (page 352), or cotrimoxazole (page 357). Ask a health worker which medicine works best where you live.

♦ Lower the fever with cool wet cloths (see page 76).

♦ Give plenty of liquids: soups, juices, and Rehydration Drink to avoid dehydration (see page 152).

♦ Give nutritious foods, in liquid form if necessary.

♦ The person should stay in bed until the fever is completely gone.

♦ If the person shits blood or develops signs of peritonitis (page 94) or pneumonia (page 171), take her to a hospital at once.

Prevention:

♦ To prevent typhoid, care must be taken to avoid contamination of water and food by human feces. Follow the guidelines of personal and public hygiene in Chapter 12. Make and use latrines. Be sure latrines are a safe distance from where people get drinking water.

♦ Cases of typhoid often appear after a flood or other disaster, and special care must be taken with cleanliness at these times. Be sure drinking water is clean. If there are cases of typhoid in your village, all drinking water should be boiled. Look for the cause of contaminated water or food.

♦ To avoid the spread of typhoid, a person who has the disease should stay in a separate room. No one else should eat or drink from the dishes he uses. His stools should be burned or buried in deep holes. Persons who care for him should wash their hands right afterwards.

♦ After recovering from typhoid some persons still carry the disease and can spread it to others. So anyone who has had typhoid should be extra careful with personal cleanliness and should not work in restaurants or where food is handled. Sometimes ampicillin is effective in treating typhoid carriers.

190

TYPHUS

Typhus is an illness similar to but different from typhoid. The infection is transmitted by bites of lice ticks rat fleas

Signs:

• Typhus begins like a bad cold. After a week or more fever begins, with chills, headache, and pain in the muscles and chest.

• After a few days of fever a typical rash appears, first in the armpits and then on the body, then the arms and legs (but not on the face, palms of the hands, or soles of the feet). The rash looks like many tiny bruises.

• The fever lasts 2 weeks or more. Typhus is usually mild in children and very severe in old people. An epidemic form of typhus is especially dangerous.

• In typhus spread by ticks, there is often a large painful sore at the point of the bite, and the lymph nodes near the bite are swollen and painful.

Treatment:

♦ If you think someone may have typhus, get medical advice. Special tests are often needed.

♦ Give tetracycline, adults: 2 capsules of 250 mg. 4 times a day for 7 days (see page 355). Chloramphenicol also works, but is riskier (page 356).

Prevention:

♦ Keep clean. De-louse the whole family regularly.

♦ Remove ticks from your dogs and do not allow dogs in your house.

♦ Kill rats. Use cats or traps (not poison, which can be dangerous to other animals and children).

♦ Kill rat fleas. Do not handle dead rats. The fleas may jump off onto you. Drown and burn the rats and their fleas. Put insecticide into rat holes and nests.

191

LEPROSY (Hansen’s disease)

This mildly infectious disease develops slowly, often over many years. It can only spread from persons who have untreated leprosy, to persons who have low resistance to the disease.

In areas where leprosy is common, children should be checked every 6 to 12 months especially children living with persons who have leprosy.

Signs:

Leprosy can cause a variety of skin problems, loss of feeling, and paralysis of the hands and feet.

The first sign of leprosy is often a slowly growing patch on the skin that does not itch or hurt. At first, feeling inside the patch may be normal. Keep watching it.

If feeling in the patch becomes reduced or absent (see page 38) it is probably leprosy.

Examine the whole body for skin patches, especially the face, arms, back, butt, and legs:

  • Pale patch without clear border.

  • Patches are a different color from surrounding skin, but never completely white or scaly.

  • Ringworm‐like patch with or without raised border.

Later signs differ according to the person’s natural resistance to the disease. Watch out for:

• Tingling, numbness or loss of feeling in hands or feet. Or deformities or loss of feeling in skin patches.

• Slight weakness or toes deformities in the hands and feet. Clawed toes. Drop foot.

• Swollen nerves that form thick cords under the skin. Nerves may or may not be painful when you press them. Check for thick nerves in wrist ankle, elbow, neck, near armpits, behind knees :

Advanced sign may include:

  • burns and scars where feeling has been lost

  • ear lobe thick and lumpy

  • loss of eyebrows

  • blindness

  • nose sometimes deformed

  • painless sores on hands or feet

  • paralysis and deformity of the hands and feet

Treatment of leprosy:

Leprosy is usually curable, but medicine must usually be taken for years. The best medicine is dapsone, combined with 1 or 2 other medicines (See page 362 to page 363).

If a ‘lepra reaction’ (fever, a rash, pain and perhaps swelling of hands and feet, or eye damage) occurs or gets worse while taking the medicine, keep taking it but get medical help.

192

Prevention of damage to hands, feet, and eyes:

The large open sores often seen on the hands and feet of persons with leprosy are not caused by the disease itself and can be prevented. They result because, when feeling has been lost, a person no longer protects himself against injury.

For example, if a person with normal feeling walks a long way and gets a blister, it hurts, so he stops walking or limps.

But when a person with leprosy gets a blister, it does not hurt.

So he keeps walking until the blister bursts and becomes infected. Still without pain, the infection gets deeper and attacks the bone.

In time the bone is destroyed and the foot becomes more and more deformed.

  1. Protect hands and feet from things that can cut, bruise, blister, or burn them:

Do not go barefoot, especially not where there are sharp stones or thorns. Wear shoes or sandals. Put soft padding inside shoes and under straps that may rub.

When working or cooking meals, wear gloves. Never pick up an object that might be hot without first protecting your hand with a thick glove or folded cloth. If possible, avoid work that involves handling sharp or hot objects. Do not smoke.

  1. At the end of each day (or more often if you work hard or walk far) examine your hands and feet very carefully or have someone else examine them. Look for cuts, bruises, or thorns.

Also look for spots or areas on the hands and feet that are red, hot, swollen or show the beginnings of blisters. If you find any of these, rest the hands or feet until the skin is completely normal again. This will help callous and strengthen the skin. Sores can be prevented.

  1. If you have an open sore, keep the part with the sore very clean and at rest until it has completely healed. Take great care not to injure the area again.

  2. Protect your eyes. Much eye damage comes from not blinking enough, because of weakness or loss of feeling. Blink your eyes often to keep them wet and clean.

If you cannot blink well, close your eyes tightly often during the day, especially when dust blows. Wear sun glasses with side shades, and maybe a sun hat. Keep eyes clean and flies away.

If you do these things and begin treatment early, most deformities with leprosy can be prevented.

For more information about Hansen’s disease, see Disabled Village Children, Chapter 26.

15

skin problems

Some skin problems are caused by diseases or irritations that affect the skin only, such as ringworm, diaper rash, or warts.

Other skin problems are signs of diseases that affect the whole body, such as the rash of measles or the sore, dry patches of pellagra (malnutrition).

Certain kinds of sores or skin conditions may be signs of serious diseases, like tuberculosis, syphilis, leprosy, or HIV infection.

This chapter deals only with the more common skin problems in rural areas. However, there are hundreds of diseases of the skin.

Some look so much alike that they are hard to tell apart, yet their causes and the specific treatments they require may be quite different.

If a skin problem is serious or gets worse in spite of treatment, seek medical help

Many skin problems can be helped by keeping the body clean. Try to wash once a day with mild soap and clean water.

If the skin becomes too dry, wash less often and do not use soap every time. Try rubbing petroleum gel (Vaseline), glycerin, or vegetable oils into the skin after bathing. Wear loose cotton clothing.

194

GENERAL RULES FOR TREATING SKIN PROBLEMS

Although many skin problems need specific treatment, there are a few general measures that often help:

RULE 1

If the affected area is hot and painful, or oozes pus, treat it with heat. Put hot, moist cloths on it (hot compresses).

If the skin shows signs of serious infection such as:

  • inflammation (redness or darkening of skin around the affected areas)

  • swelling

  • pain

  • heat (it feels hot)

  • pus

Do the following:

♦ Keep the affected part still and elevate it (put it higher than the rest of the body).

♦ Apply hot, moist cloths.

♦ If the infection is severe or the person has a fever, give antibiotics (penicillin, a sulfonamide, or erythromycin).

Danger signs include: swollen lymph nodes, a red or dark line above the infected area, or a bad smell. If these do not get better with treatment use an antibiotic and seek medical help quickly.

RULE 2

If the affected area itches, stings, or oozes clear fluid, treat it with cold. Put cool, wet cloths on it (cold compresses).

If the affected skin forms blisters or a crust, oozes, itches, stings, or burns, do the following:

♦ Apply cloths soaked in cool water with white vinegar (2 tablespoons of vinegar in 1 quart of pure boiled water).

♦ When the affected area feels better, no longer oozes, and has formed tender new skin, lightly spread on a mixture of talc and water (1 part talc to 1 part water).

♦ When healing has taken place, and the new skin begins to thicken or flake, rub on a little vegetable lard or body oil to soften it.

RULE 3

If the skin areas affected are on parts of the body often exposed to sunlight, protect them from the sun.

RULE 4

If the skin areas most affected are usually covered by clothing, expose them to direct sunlight for 10 to 20 minutes, 2 or 3 times a day.

195

Instructions for Using Hot Compresses (Hot Soaks)

  1. Boil water and allow it to cool until you can just hold your hand in it.

  2. Fold a clean cloth so it is slightly larger than the area you want to treat, wet the cloth in the hot water, and squeeze out the extra water.

  3. Put the cloth over the affected skin.

  4. Cover the cloth with a sheet of thin plastic or cellophane.

  5. Wrap it with a towel to hold in the heat.

  6. Keep the affected part raised.

  7. When the cloth starts to cool, put it back in the hot water and repeat.

196

SKIN PROBLEMS: A Guide to Identification

If the skin has small or pimple-like sores

AND LOOKS LIKE CHECK
Tiny bumps or sores with much itchingfirst between fingers, on the wrists, or the waist scabies
Pimples or sores with pus or inflammation, often from scratching insect bites. May cause swollen lymph nodes. infection from bacteria
Irregular, spreading sores with shiny, yellow crusts. impetigo (bacterial infection)
Pimples on young people’s faces, sometimes chest and back, often with small heads of pus. acne, pimples, blackheads
A sore on the genitals without itching or pain syphilis or maybe venereal lympho granuloma
A sore on the genitals with pain and pus. chancroid

If the skin has a large, open sore or skin ulcer

AND LOOKS LIKE CHECK
A large chronic (unhealing) sore surrounded by purplish skin, on or near the ankles of older people with varicose veins. ulcers from bad circulation (possibly diabetes)
Sores over the bones and joints of very sick persons who cannot get out of bed. bed sores
Sores with loss of feeling on the feet or hands. (They do not hurt even when pricked with a needle.) leprosy
A bump and then a sore that will not heal, anywhere on the body or face. leishmaniasis

If the skin lumps under the skin

AND LOOKS LIKE CHECK
A warm, painful swelling that eventually may break open and drain pus. abscess or boil
A warm, painful lump in the breast of a woman breastfeeding. mastitis (bacterial infection), possibly cancer
A lump that keeps growing. Usually not painful at first. cancer (also see lymph nodes)
One or more round lumps on the head, neck, or upper body (or central body and thighs). river blindness (also see lymph nodes)

197

If the skin has swollen lymph nodes

AND LOOKS LIKE CHECK
Nodes on the side of the neck that continuously break open and scar. scrofula (a type of tuberculosis)
Nodes in the groin that continuously break open and scar. venereal lymphogranuloma chancroid

If the skin has large spots or dark patches

AND LOOKS LIKE CHECK
Dark patches on the forehead and cheeks of pregnant women. mask of pregnancy
Scaly, cracking areas that look like sunburn on the arms, legs, neck, or face. pellagra (a type of malnutrition)
Dark spots on the skin or in the mouth that start small and then grow. They look like swollen bruises. They are painless. Kaposi’s Sarcoma (KS, cancer related to HIV)
Purple spots or peeling sores on children with swollen feet. malnutrition

If the skin has large spots or white patches

AND LOOKS LIKE CHECK
Round or irregular patches on the face or body, especially of children. tinea versicolor (fungus infection)
White patches, especially on hands, feet, or lips that begin with reddish or bluish pimples. pinta (infection)
White patches, especially on hands, feet, or lips that begin without other signs. vitiligo (loss of color, nothing more)

If the skin has large spots or red patches

AND LOOKS LIKE CHECK
Reddish or blistering patches on the cheeks or behind the knees and elbows of young children. eczema
A reddish, hot, painful area that spreads rapidly. erysipelas (cellulitis or very serious bacterial infections)
A reddish area between the baby’s legs. diaper rash from urine or heat
Beef-red patches with white, milky curds in the skin folds. yeast infection (Candida)
Raised reddish or gray patches with silvery scales; especially on elbows and knees; chronic (long-term) psoriasis (or sometimes tuberculosis)

If the skin has raised reddish or gray patches

AND LOOKS LIKE CHECK
Raised reddish or gray patches with silvery scales; especially on elbows and knees; chronic (long-term). psoriasis (or sometimes tuberculosis)

198

If the skin has warts

AND LOOKS LIKE CHECK
Simple warts, not very large. common warts (virus infection)
Wart-like growths on the penis, vagina, or around the anus. genital warts
Bumpy, wart-like growths on other parts of the body. yaws
Large warts (more than 1 cm.), often on arms or feet. a type of tuberculosis of the skin

If the skin has rings

Rings (spots with raised or red edges, often clear in the center)

AND LOOKS LIKE CHECK
Small rings that continue to grow or spread and may itch. Ringworm (fungus infection)
large circles with a thick border that do not itch. advanced stage of syphilis
Large rings that are white or lighter colored and become numb in the center. (A needle prick does not hurt them.) leprosy
Small rings, sometimes with a small pit in the middle, found on the temple, nose, or neck. cancer of the skin

If the skin has welts or hives

Rings (spots with raised or red edges, often clear in the center)

AND LOOKS LIKE CHECK
Very itchy rash, bumps, or patches. (They may appear and disappear rapidly.) allergic reaction

If the skin has blisters

Rings (spots with raised or red edges, often clear in the center)

AND LOOKS LIKE CHECK
Blisters with bumps and much itching and weeping (oozing). contact dermatitis (like poison ivy or sumac)
Small blisters over the whole body, with some fever. chickenpox
A patch of painful blisters that appears only on one part of the body, often in a stripe or cluster. Herpes zoster (shingles)
A gray or black bad smelling area with blisters and air pockets that spread. gas gangrene (very serious bacterial infection)

If the skin has blisters

Rings (spots with raised or red edges, often clear in the center)

AND LOOKS LIKE CHECK
A rash that very sick children get over the whole body. measles
After a few days of fever a few small pinkish spots appear on the body; the person is very sick. typhoid fever

199

SCABIES (SEVEN YEAR ITCH)

Scabies is especially common in children. It causes very itchy little bumps that can appear all over the body, but are most common:

  • between the fingers

  • on the wrists

  • around the waist

  • on the genitals

  • between the toes

  • usually does not appear on head and face, except in babies

  • Small itchy sores on the penis and scrotum of young boys are almost always scabies.

Scabies is caused by little animals, similar to tiny ticks or chiggers, which make tunnels under the skin. It is spread by touching the affected skin or by clothes and bedding. Scratching can cause infection, producing sores with pus, and sometimes swollen lymph nodes or fever. The first time a person gets scabies, it can take 2 to 6 weeks for signs to appear. If the person has had scabies before, signs will appear in 1 to 4 days.

Treatment:

♦ If one person has scabies, everyone in his family should be treated. So should all sexual contacts.

♦ Personal cleanliness is of first importance. Bathe and change clothes daily.

♦ Cut fingernails very short to reduce spreading and infection.

♦ Wash all clothes and bedding or, better still, boil them. Hang them in the sun to dry.

♦ Remove all animals from the house.

♦ Use a cream containing permethrin (Elimite, see page 372). First wash the whole body vigorously with soap and hot water. Then rub the cream into the whole body except the face, unless it is affected. Leave it on for 10 to 14 hours, and then bathe again. Be sure to put on clean clothes and use clean bedding after treatment. Repeat treatment 1 week later.

♦ Do not use creams or ointments that include lindane. Lindane is a poison!

♦ If you cannot get permethrin, try crotamiton (Eurax, Crotan) but avoid using it on children under 3 years old.

♦ Or you can try using sulfur powder mixed with lard, Vaseline or body oil – use 1 part sulfur to 10 parts lard or oil. Do not use on children under 1 year old. Apply to whole body (except face) 3 times a day for 3 days. Stop using immediately if rash worsens or other signs of allergic reaction develop (see page 166).

♦ If none of these treatments work, you can try giving a dose of ivermectin (see page 377), and then repeat the dose after 10 to 14 days. This is the best method for a person with HIV.

The itching and rash may last for up to two weeks after treatment. If they last longer, it is possible that the person has been re-infected or that the treatment did not work. If after 2 weeks the signs have not gone away, repeat the treatment again or try a different treatment. Remember to repeat the prevention actions as well.

200

LICE

There are 3 kinds: head lice, body lice, and pubic lice (or ‘crabs’) that live in the hairy parts of the body. Lice cause itching, and sometimes skin infections and swollen lymph nodes. To avoid lice, take great care with personal cleanliness.

Wash clothing and bedding often and hang them in the sun. Bathe and wash hair often. Check children’s hair. If they have lice, treat them all at once, otherwise they will pass them back and forth to each other. Do not let a child with lice sleep with others.

Treatment:

For head and pubic lice: You can usually get rid of lice without medicines by scrubbing the hair well with regular soap or shampoo for 10 minutes. Rinse well, and comb thoroughly with a fine-tooth comb, being sure to remove all the lice and their eggs. Repeat every day for 2 weeks.

Do not use shampoos that include lindane. Lindane is poison!

If regular shampoos do not work, medicated shampoos that include pyrethrins (RID) or permethrin (Nix) may work, but follow the directions carefully. Keep them out of your eyes, watch for allergic reactions, and avoid them if you are pregnant or the person with lice is younger than 2 years old.

After treating for lice, you must also get rid of nits (lice eggs). If the eggs hatch, the lice will be back. People have tried different treatments, but they all include careful combing. Repeat combing every day for 2 weeks to make sure you remove all the lice and nits.

♦ Rub olive oil into the hair. This will loosen the nits so they are easier to remove with a fine-tooth comb. Some people find that oils such as tea tree, rosemary, or eucalyptus (this can feel hot!) work well, but other people have allergic reactions to them.

♦ Soak hair with warm vinegar water (1 part vinegar to 1 part water) for half an hour, then comb it thoroughly with a fine-tooth comb. For body lice: Soak your whole body in a bath of hot water every day for 10 days. After each bath, wash thoroughly with soap and rinse well. Use a fine-tooth comb on any hairy places. If necessary, treat as for scabies. Keep clothing and bedding clean.

BEDBUGS

These are very small, flat, red-brown crawling insects that hide inside mattresses, bedding, furniture, and walls. They usually bite at night. The bites often appear in groups or lines.

To get rid of bedbugs, wash bedding in boiling water or bake in a hot stove (over 120°F/50°C) for at least 20 minutes. If you can find diatomaceous earth (a natural pesticide), sprinkle it around the bed to prevent bedbugs from crawling up. You can also try spraying mattresses, bed frames, and the area in which you sleep with a mixture of 2 parts water, 2 parts alcohol, and 1 part dish soap. Spray everywhere bedbugs might hide, then let dry. You may have to repeat again a few times during 2 weeks. Pyrethrin or permethrin (see Lice, above) might also work.

To prevent bedbugs, spread bedding, mats, and cots in the sun often.

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TICKS AND CHIGGERS

Some dangerous infections or paralysis are spread by tick bites. But careful removal within a few hours usually prevents these problems. So check the whole body well after walking in areas where ticks are common.

When removing a tick that is firmly attached, take care that its head does not remain in the skin, since this can cause an infection. Never pull on the body of a tick.

To remove a tick with tweezers, grasp the tick as close as possible to its mouth, the part sticking into the skin. (Try not to squeeze its swollen belly.) Pull the tick out gently but firmly. Do not touch the removed tick. To kill the removed tick, burn it, or hold a lit match near it, or put some alcohol on it.

To remove very small ticks or chiggers, use one of the remedies recommended for scabies (see page 199). To relieve itching or pain caused by tick or chigger bites, take aspirin and follow the instructions for treatment of itching on page 203.

To help prevent chiggers and ticks from biting you, dust sulfur powder on your body before going into the fields or forests. Especially dust ankles, wrists, waist, and underarms.

SMALL SORES WITH PUS

Skin infections in the form of small sores with pus often result from scratching insect bites, scabies, or other irritations with dirty fingernails.

Treatment and Prevention:

♦ Wash the sores well with soap and cooled, boiled water, gently soaking off the scabs. Do this daily as long as there is pus.

♦ Leave small sores open to the air. Bandage large sores and change the bandage frequently.

♦ If the skin around a sore is red and hot, or if the person has a fever, red lines coming from the sore, or swollen lymph nodes, use an antibiotic, such as penicillin tablets (page 351) or sulfa tablets (page 356).

♦ Do not scratch. This makes the sores worse and can spread infection to other parts of the body. Cut the fingernails of small children very short. Or put gloves or socks over their hands so they cannot scratch.

♦ Never let a child with sores or any skin infection play or sleep with other children.

These infections are easily spread.

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IMPETIGO

This is a bacterial infection that causes rapidly spreading sores with shiny, yellow crusts. It often occurs on children’s faces especially around the mouth. Impetigo can spread easily to other people from the sores or contaminated fingers.

Treatment:

♦ Wash the affected part with soap and cooled, boiled water 3 to 4 times each day, gently soaking off the crusts.

♦ After each washing, paint the sores with gentian violet (page 370) or spread on an antibiotic cream containing bacitracin such as Polysporin (page 370).

♦ If the infection is spread over a large area or causes fever, give cloxacillin or dicloxacillin (page 350). If the person is allergic to medicines of the penicillin family or if these medicines do not seem to be helping, try doxycycline (page 355) or cotrimoxazole (page 357).

Prevention:

♦ Follow the Guidelines of Personal Cleanliness (page 133). Bathe children daily and protect them from bedbugs and biting flies. If a child gets scabies, treat him as soon as possible.

♦ Do not let a child with impetigo sleep with other children or play with them. Begin treatment at the first sign.

YAWS

Yaws is a bacterial infection that you first notice when a painless, bumpy growth emerges and gets larger and may spread a little. After about 6 months, the growth disappears. Months or years later, it reappears, spreads more, and may ooze. This is when it can spread to other people. These signs will also disappear. But if it is not treated, after 5 or 10 years the yaws infection can spread throughout the body, harming bones, joints, and causing other problems.

Treatment:

♦ Though the yaws bacteria is related to syphilis, it is spread by physical, not sexual, contact. Yaws can be tested for using the same test and treated using the same medicines and doses for syphilis (See page 237 to page 238).

BOILS AND ABSCESSES

A boil, or abscess, is an infection that forms a sac of pus under the skin, This can happen when the root of a hair gets infected. Or it can result from a puncture wound or an injection given with a dirty needle. A boil is painful and the skin around it becomes red and hot. It can cause swollen lymph nodes and fever.

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♦ Put hot compresses over the boil several times a day (see page 195).

♦ Let the boil break open by itself. After it opens, keep using hot compresses. Allow the pus to drain, but never press or squeeze the boil, since this can cause the infection to spread to other parts of the body.

♦ If the abscess is very painful and does not open after 2 or 3 days of hot soaks, it may help to have it cut open so the pus can drain out. This will quickly reduce the pain. If possible, get medical help.

♦ If the boil causes swollen nodes or fever, take penicillin tablets (page 351) or erythromycin (page 354) or dicloxacillin (page 350), take 500 mg by mouth, 4 times a day for 7 days.

ITCHING RASH, WELTS, OR HIVES (ALLERGIC REACTIONS IN THE SKIN)

Touching, eating, injecting, or breathing certain things can cause an itching rash or hives in allergic persons. For more details, see Allergic Reactions, page 166.

Hives are thick, raised spots or patches that look like bee stings and itch like mad. They may come and go rapidly or move from one spot to another.

Be on the watch for any reaction caused by certain medicines, especially injections of penicillin and antivenoms or antitoxins made from horse serum. A rash or hives may appear from a few minutes up to 10 days after the medicine has been injected.

Medicines used by people with HIV may cause a rash, especially cotrimoxazole (page 357) and nevirapine (page 397). Sometimes the rash can be avoided by starting with a small amount of medicine and slowly increasing the amount to the full dose.

Treatment of itching:

♦ Bathe in cool water or use cool compresses, cloths soaked in cold water or ice water.

♦ Compresses of cool oatmeal water also calm itching. Boil the oatmeal in water, strain it, and use the water when cool. (Starch can be used instead of oats.)

♦ If itching is severe, take an antihistamine like chlorpheniramine (page 386).

♦ To protect a baby from scratching himself, cut his fingernails very short, or put gloves or socks over his hands.

Treatment:

If you get an itching rash, hives, or any other allergic reaction after taking or being injected with any medicine, stop using it and never use that medicine again in your life!

This is very important to prevent the danger of ALLERGIC SHOCK (see page 70).

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PLANTS AND OTHER THINGS THAT CAUSE ITCHING OR BURNING OF THE SKIN

Nettles, ‘stinging trees’, sumac, ‘poison ivy’, and many other plants may cause blisters, burns, or hives with itching when they touch the skin. Juices or hairs of certain caterpillars and other insects produce similar reactions.

In allergic persons rashes or ‘weeping’ sore patches may be caused by certain things that touch or are put on the skin, Rubber shoes, watchbands, ear drops and other medicines, face creams, perfumes, or soaps may cause such problems.

Treatment:

All these irritations go away by themselves when the things that cause them no longer touch the skin. A paste of oatmeal and cool water helps calm the itching. Aspirin or antihistamines (page 385) may also help. In severe cases, you can use a cream that contains cortisone or a cortico-steroid (see page 370) To prevent infection, keep the irritated areas clean.

SHINGLES (HERPES ZOSTER)

Signs:

A line or patch of painful blisters that suddenly appears on one side of the body is probably shingles. It is most common on the back, chest, neck, or face. The blisters usually last 2 or 3 weeks, then go away by themselves. Sometimes the pain continues or returns long after the blisters are gone.

Shingles is caused by the virus that causes chickenpox and usually affects persons who have had chickenpox before. It is not dangerous, but it can be painful. It is sometimes the first sign of some other more serious problem, perhaps cancer or HIV infection (see page 399).

Treatment:

♦ Put light bandages over the rash so that clothes do not rub against it.

♦ Take aspirin for the pain. Acyclovir can help keep herpes blisters from spreading (see page 373). Antibiotics do not help.

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FUNGUS INFECTIONS (RINGWORM, TINEA)

Fungus infections may appear on any part of the body, but occur most frequently on:

  • the scalp (tinea)

  • the parts without hair (ringworm)

  • between the toes or fingers (athlete’s foot)

  • between the legs (jock itch)

Most fungus infections grow in the form of a ring. They often itch. Ringworm of the head can produce round patches with scales and loss of hair. Finger and toe nails infected with the fungus become rough and thick.

Treatment:

♦ Soap and water. Washing the infected part every day with soap and water may be all that is needed.

♦ Do your best to keep the affected areas dry and exposed to the air or sunlight. Change underwear or socks often, especially when sweaty.

♦ Use a cream of sulfur and lard (1 part sulfur to 10 parts lard).

♦ Creams and powders with salicylic or undecylenic acid, or tolnaftate (Tinactin, page 371) help cure the fungus between the fingers, toes and groin.

♦ For severe tinea of the scalp, or any fungus infection that is widespread or does not get better with the above treatments, take griseofulvin, 1 gram a day for adults and half a gram a day for children (page 371). It may be necessary to keep taking it for weeks or even months to completely control the infection.

But pregnant women should not take griseofulvin.

♦ Many tineas of the scalp clear up when a child reaches puberty (11 to 14 years old). Severe infections forming large swollen patches with pus should be treated with compresses of warm water (page 195). It is important to pull out all of the hair from the infected part. Use griseofulvin, if possible.

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How to prevent fungal infections:

Ringworm and all other fungus infections are contagious (easily spread). To prevent spreading them from one child to others:

♦ Do not let a child with a fungal infection sleep with the others.

♦ Do not let different children use the same comb, or use each other’s clothing or towel, unless these are washed or well cleaned first.

♦ Treat an infected child at once.

WHITE SPOTS ON THE FACE AND BODY

Tinea versicolor is a mild fungus infection that causes small dark or light spots with a distinct and irregular border that are often seen on the neck, chest, and back. The spots may be slightly scaly but usually do not itch. They are of little medical importance.

Treatment:

♦ Make a cream with sulfur and lard (1 part sulfur to 10 parts lard) and apply it to the whole body every day until they disappear. Or use an anti-fungal cream (page 371).

♦ Sodium thiosulfate works better. This is the ‘hypo’ photographers use when developing film. Dissolve a tablespoon of sodium thiosulfate in a glass of water and apply it to the whole upper body. Then rub the skin with a piece of cotton dipped in vinegar.

♦ To prevent the spots from returning, it is often necessary to repeat this treatment every 2 weeks.

♦ Selenium sulfide (page 371) or Whitfield’s ointment may also help.

There is another kind of small whitish spot that is common on the cheeks of dark-skinned children who spend a lot of time in the sun.

The border is less clear than in tinea versicolor. These spots are not an infection and are of no importance. Usually they go away as the child grows up. Avoid harsh soaps and apply oil. No other treatment is needed.

Contrary to popular opinion, none of these types of white spots is a sign of anemia. They will not go away with tonics or vitamins. The spots that are only on the cheeks do not need any treatment.

CAUTION: Sometimes pale spots are early signs of leprosy (see page 191). Leprosy spots are never completely white and may have reduced feeling when pricked by a pin. If leprosy is common in your area, have the child checked.

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Vitiligo (White Areas of the Skin)

In some persons, certain areas of the skin lose their natural color (pigment). Then white patches appear. These are most common on the hands, feet, face, and upper body. This loss of normal skin color, called vitiligo, is not an illness.

It can be compared to white hair in older people. No treatment helps or is needed, but the white skin should be protected from sunburn, with clothing or an ointment of zinc oxide. Also, special coloring creams can help make the spots less noticeable.

Other Causes of White Skin Patches

Certain diseases may cause white spots that look like vitiligo. In Latin America an infectious disease called pinta starts with bluish or red pimples and later leaves pale or white patches.

Treatment of pinta is 2.4 million units of benzathine penicillin injected into the buttocks (1.2 million units in each buttock). For a person allergic to penicillin give tetracycline or erythromycin, 500 mg 4 times each day for 15 days.

Some fungus infections also cause whitish spots (see tinea versicolor, on the opposite page).

General or patchy, partial loss of skin and hair color in children may be caused by severe malnutrition (kwashiorkor, page 113; or pellagra, page 208).

MASK OF PREGNANCY

During pregnancy many women develop dark, olive-colored areas on the skin of the face, breasts, and down the middle of the belly.

Sometimes these disappear after the birth and sometimes not.

These marks also appear sometimes on women who are taking birth control pills.

They are completely normal and do not indicate weakness or sickness. No treatment is needed.

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PELLAGRA AND OTHER SKIN PROBLEMS DUE TO MALNUTRITION

Pellagra is a form of malnutrition that affects the skin and sometimes the digestive and nervous systems.

It is found in places where people eat a lot of maize (corn) or other starchy foods and not enough beans, meat, fish, eggs, vegetables, and other body-building and protective foods (see page 110).

Skin signs in malnutrition (see the pictures on the following page):

In adults with pellagra the skin is dry and cracked; it peels like sunburn on the parts where the sun hits it, especially:

  • on the arms

  • on the nape of the neck

  • on the backs of the legs

In malnourished children, the skin of the legs (and sometimes arms) may have dark marks, like bruises, or even peeling sores; the ankles and feet may be swollen (see page 113):

  • peeling sores and dark marks

  • swollen ankles and feet

When these conditions exist, often there are also other signs of malnutrition: swollen belly; sores in the corners of the mouth; red, sore tongue; weakness; loss of appetite; failure to gain weight; etc. (see Chapter 11, pages page $1 to page 114).

Treatment:

♦ Eating nutritious foods cures pellagra. Every day a person should try to eat beans, lentils, groundnuts, or some chicken, fish, eggs, meat, or cheese. When you have a choice, it is also better to use wheat (preferably whole wheat) instead of maize (corn).

♦ For severe pellagra and some other forms of malnutrition, it may help to take vitamins, but good food is more important. Be sure the vitamin formula you use is high in the B vitamins, especially niacin. Brewer’s yeast is a good source of B vitamins.

209

Before eating well:

The swelling and dark spots on this boy’s legs and feet are the result of poor nutrition. He was eating mostly maize (corn) without any foods rich in proteins and vitamins.

The ‘burnt’ skin on the legs of this woman is a sign of pellagra, which results from not eating well (see page 208).

After eating well:

One week after he began to eat beans and eggs along with the maize, the swelling was gone and the spots had almost disappeared.

The white spots on the legs of this woman are due to an infectious disease called pinta (see page 207).

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WARTS (VERRUCAE)

Most warts, especially those in children, last 3 to 5 years and go away by themselves. Flat, painful wart-like spots on the sole of the foot are often ‘plantar warts’. (Or they may be corns. See below.)

Treatment:

♦ Magical or household cures often get rid of warts. But it is safer not to use strong acids or poisonous plants, as these may cause burns or sores much worse than the warts.

♦ Painful plantar warts sometimes can be removed by a health worker.

♦ For warts on the penis, vagina, or around the anus, see page 402.

CORNS

A corn is a hard, thick part of the skin. It forms where sandals or shoes push against the skin, or one toe presses against another. Corns can be very painful.

Treatment:

♦ Get sandals or shoes that do not press on the corns.

♦ To make corns hurt less, do this:

  1. Soak the foot in warm water for 15 minutes.

  2. With a file or rasp, trim down the corn until it is thin.

  3. Pad the foot around the corn so that it will not press against the shoe or another toe. Wrap the foot or toe in a soft cloth to make a thick pad and cut a hole around the corn. Use rolls of cotton and cotton or cardboard for the sides.

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PIMPLES AND BLACKHEADS (ACNE)

Young people sometimes get pimples on their face, chest, or back, especially if their skin has too much oil in it. Pimples are little lumps that form tiny white ‘heads’ of pus or blackheads of dirt. Sometimes they can become quite sore and large.

Treatment:

♦ Wash the face twice a day with soap and hot water.

♦ Wash the hair every 2 days, if possible.

♦ Sunshine helps clear pimples. Let the sunlight fall on the affected parts of the body.

♦ Eat as well as possible, drink a lot of water, and get enough sleep.

♦ Do not use skin or hair lotions that are waxy, oily, or greasy.

♦ Before you go to bed, put a mixture of alcohol with a little sulfur on the face (10 parts alcohol to 1 part sulfur).

♦ For serious cases forming lumps and pockets of pus, if these do not get better with the methods already described, tetracycline may help. Take 1 capsule

4 times a day for 3 days and then 2 capsules daily. It may be necessary to take 1 or 2 capsules daily for months.

CANCER OF THE SKIN

Skin cancer is most frequent in light-skinned persons who spend a lot of time in the sun.

It usually appears in places where the sun hits with most force, especially:

  • on the ear

  • on the cheekbone or temple

  • on the nose

  • on the lips

Skin cancer may take many forms. It usually begins as a little ring the color of pearl with a hole in the center. It grows little by little.

Most cancers of the skin are not dangerous if treated in time. Surgery is needed to remove them. If you have a chronic sore that might be skin cancer, see a health worker.

To prevent skin cancer, light-skinned persons should protect themselves from the sun and always wear a hat. Persons who have suffered from cancer of the skin and have to work in the sun can buy special creams that protect them. Zinc oxide ointment is cheap and works well.

212

TUBERCULOSIS OF THE SKIN OR LYMPH NODES

The same microbe that causes tuberculosis of the lungs also sometimes affects the skin, causing painless:

  • tumors that disfigure,

  • chronic patches of sores,

  • skin ulcers or

  • big warts.

As a rule, TB of the skin develops slowly, lasts a long time, and keeps coming back over a period of months or years.

Also, tuberculosis sometimes infects the lymph nodes, most often those of the neck or in the area behind the collar bone, between the neck and the shoulder.

The nodes become large, open, drain pus, seal closed for a time, and then open and drain again. Usually they are not painful.

Treatment:

In the case of any chronic sore, ulcer, or swollen lymph nodes, it is best to seek medical advice.

Tests may be needed to learn the cause. Tuberculosis of the skin is treated the same as tuberculosis of the lungs (see page 180).

To keep the infection from returning, the medicines must be taken for many months after the skin looks well.

ERYSIPELAS AND CELLULITIS

Erysipelas (or St. Anthony’s fire) is a very painful acute (sudden) infection in the skin. It forms a hot, bright red, swollen patch with a sharp border.

The patch spreads rapidly over the skin. It often begins on the face, at the edge of the nose. This usually causes swollen lymph nodes, fever, and chills.

Cellulitis is also a very painful, acute infection of the skin that can appear anywhere on the body. It usually occurs after a break in the skin. The infection is deeper and the borders of the patch are less clear than with erysipelas.

Treatment:

For both erysipelas and cellulitis, begin treatment as soon as possible.

Use an antibiotic: penicillin tablets, 400,000 units, 4 times a day, in serious cases, injectable procaine penicillin, 800,000 units daily (see page 352).

Continue using the antibiotic for 2 days after all signs of infection are gone. Also use hot compresses, and aspirin for pain.

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GANGRENE (GAS GANGRENE)

This is a very dangerous infection of a wound, in which a foul-smelling gray or brown liquid forms. The skin near the wound may have dark blisters and the flesh may have air bubbles in it.

The infection begins between 6 hours and 3 days after the injury. It quickly gets worse and spreads fast. Without treatment it causes death in a few days.

Treatment:

♦ Open up the wound as wide as possible. Wash it out with cool, boiled water and soap. Clean out the dead and damaged flesh. If possible, flood the wound with hydrogen peroxide every 2 hours.

♦ Inject penicillin (crystalline if possible), 1,000,000 (a million) units every 3 hours.

♦ Leave the wound uncovered so that air gets to it. Get medical help.

ULCERS OF THE SKIN CAUSED BY POOR CIRCULATION

Skin ulcers, or large, open sores, have many causes (see page 20). However, chronic ulcers on the ankles of older persons, especially in women with varicose veins, usually come from poor circulation.

The blood is not moved fast enough through the legs. Such ulcers may become very large. The skin around the ulcer is dark blue, shiny, and very thin. Often the foot is swollen.

Treatment:

♦ These ulcers heal very slowly, and only if great care is taken. Most important: Keep the foot up high as often as possible. Sleep with it on pillows. During the day, rest with the foot up high every 15 or 20 minutes. Walking helps the circulation, but standing in one place and sitting with the feet down are harmful.

♦ Put warm compresses of weak salt water on the ulcer, 1 teaspoon salt to a liter of boiled water. Cover the ulcer loosely with sterile gauze or a clean cloth. Keep it clean.

♦ Support the varicose veins with elastic stockings or bandages. Continue to use these and to keep the feet up after the ulcer heals. Take great care not to scratch or injure the delicate scar.

♦ Treating the ulcers with honey or sugar may help (see page 214).

Prevent skin ulcers, care for varicose veins early (see page 175).

214

BED SORES (PRESSURE SORES)

These chronic open sores appear in persons so ill they cannot roll over in bed, especially in sick old persons who are very thin and weak.

The sores form over bony parts of the body where the skin is pressed against the bedding. They are most often seen on the buttocks, back, shoulders, elbows, or feet.

For a more complete discussion of pressure sores, see Disabled Village Children, Chapter 24, or A Health Handbook for Women with Disabilities, pages page 114 to page 117.

How to prevent bed sores:

♦ Turn the sick person over every hour: face up, face down, side to side.

♦ Bathe him every day and rub his skin with baby oil.

♦ Use soft bed sheets and padding. Change them daily and each time the bedding gets dirty with urine, stools, vomit, etc.

♦ Put cushions under the person in such a way that the bony parts rub less.

♦ Feed the sick person as well as possible. If he does not eat well, extra vitamins and iron may help (see page 118).

♦ A child who has a severe chronic illness should be held often on his mother’s lap.

Treatment:

♦ Do all the things mentioned above.

♦ 3 times a day, wash the sores with cool, boiled water mixed with mild soap. Gently remove any dead flesh. Rinse well with cool, boiled water.

♦ To fight infection and speed healing, fill the sore with honey, sugar, or molasses. (A paste made of honey and sugar is easiest to use.) It is important to clean and refill the sore at least 2 times a day. If the honey or sugar becomes too thin with liquid from the sore, it will feed germs rather than kill them.

SKIN PROBLEMS OF BABIES

Diaper Rash

Reddish patches of irritation between a baby’s legs or buttocks may be caused by urine in his diapers (nappy) or bedding.

Treatment:

♦ Bathe the child daily with lukewarm water and mild soap. Dry her carefully.

♦ BARE IS BEST. To prevent or cure the rash, the child should be kept naked, without diapers, and he should be taken out into the sun.

♦ If diapers are used, change them often. After washing the diapers, rinse them in water with a little vinegar.

♦ It is best not to use talc (talcum powder), but if you do, wait until the rash is gone.

215

DANDRUFF (Cradle Cap, Seborrhea)

Dandruff is an oily, yellow to white crust that usually forms in patches on the scalp, but also on the cheeks, forehead, eyebrows, nose and ears.

The skin is often red and irritated. In babies, dandruff usually results from not washing the baby’s head often enough, or from keeping the head covered. It is also a common problem for people with HIV.

Treatment:

♦ Wash the head daily. A medicated soap can help, but usually regular soap and water are enough (see page 370).

♦ Gently clean off all the dandruff and crust. To loosen the scales and crust, first wrap the head with towels soaked in lukewarm water.

DO NOT COVER A BABY’S HEAD WITH A CAP OR CLOTH. KEEP THE HEAD UNCOVERED.

♦ BARE IS BEST! Keep the head uncovered, open to the air and sunlight.

♦ If there are signs of infection, treat as for impetigo (see page 202).

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ECZEMA (RED PATCHES WITH LITTLE BLISTERS)

Signs:

• In small children: a red patch or rash forms on the cheeks or sometimes on the arms and hands. The rash consists of small sores or blisters that ooze or weep (burst and leak fluid).

• In older children and grown ups: eczema is usually drier and is most common behind the knees and on the inside of the elbows.

• It does not start as an infection but is more like an allergic reaction.

Treatment:

♦ Put cold compresses on the rash.

♦ If signs of infection develop (page 88), treat as for impetigo (page 202).

♦ Let the sunlight fall on the patches.

♦ In difficult cases, use a cortisone or cortico-steroid cream (see page 370). Or coal tar may help. Seek medical advice.

PSORIASIS

Signs:

• Thick, rough patches of reddish or blue-gray skin covered with whitish or silver-colored scales. The patches appear most commonly in the parts shown in the drawings.

• The condition usually lasts a long time or keeps coming back. It is not an infection and is not dangerous.

Treatment:

♦ Leaving the affected skin open to the sunlight often helps.

♦ Bathing in the ocean sometimes helps.

♦ Seek medical advice. Treatment must be continued for a long time.

16

the eyes

The Eye is composed of:

  • tear gland pupil

  • iris

  • tear tube from eye to nose

  • The conjunctiva is the thin layer that covers the white of the eye.

  • The cornea is the clear or transparent layer that covers the iris and the pupil.

DANGER SIGNS

The eyes are delicate and need good care. Get medical help fast when any of the following danger signs occurs:

  1. Any injury that cuts or ruptures (goes through) the eyeball.

  2. Painful, grayish spot on the cornea, with redness around the cornea (corneal ulcer).

  3. Great pain inside the eye (possibly iritis or glaucoma).

  4. A big difference in the size of the pupils when there is pain in the eye or the head.

  5. Blood behind the cornea inside the eyeball (see page 225)

  6. If vision begins to fail in one or both eyes.

  7. A white glow or reflection in the pupil. This could be a sign of cancer (retinoblastoma) or a cataract (see page 225).

  8. Any eye infection or inflammation that does not get better after 5 or 6 days of treatment with an antibiotic eye ointment.

A big difference in the size of the pupils may come from brain damage, stroke, injury to the eye, glaucoma, or iritis. (A small difference is normal in some people.)

218

INJURIES TO THE EYE

All injuries to the eyeball must be considered dangerous, for they may cause blindness.

Even small cuts on the cornea (the transparent layer covering the pupil and iris) may get infected and harm the vision if not cared for correctly.

If a wound to the eyeball is so deep that it reaches the black layer beneath the outer white layer, this is especially dangerous.

If a blunt injury (as with a fist) causes the eyeball to fill with blood, the eye is in danger (see page 225). Danger is especially great if pain suddenly gets much worse after a few days, for this is probably acute glaucoma (page 222).

Treatment:

  • If the person still sees well with the injured eye, put an antibiotic eye ointment (page 378) in the eye and cover it with a soft, thick bandage. If the eye is not better in a day or two, get medical help.

  • If the person cannot see well with the injured eye, if the wound is deep, or if there is blood inside the eye behind the cornea (page 225), cover the eye with a clean bandage and go for medical help at once. Do not press on the eye.

  • Do not try to remove thorns or splinters that are tightly stuck in the eyeball. Get medical help.

HOW TO REMOVE A SPECK OF DIRT FROM THE EYE

Have the person close her eyes and look to the left, the right, up and down. Then, while you hold her eye open, have her look up and then down. This will make the eye produce more tears and the dirt often comes out by itself.

Or you can try to remove the bit of dirt or sand by flooding the eye with clean water (page 219) or by using the corner of a clean cloth or some moist cotton. If the particle of dirt is under the upper lid, look for it by turning the lid up over a thin stick. The person should look down while you do this:

The particle is often found in the small groove near the edge of the lid. Remove it with the corner of a clean cloth.

If you cannot get the particle out easily, use an antibiotic eye ointment, cover the eye with a bandage, and go for medical help.

219

CHEMICAL BURNS OF THE EYE

Battery acid, lye, gasoline, or a pesticide that gets into the eye can be dangerous. Hold open the eye. Immediately flood the eye with clean, cool water. Keep flooding for 30 minutes, or until it stops hurting. Do not let the water get into the other eye.

RED, PAINFUL EYES, DIFFERENT CAUSES

Many different problems cause red, painful eyes. Correct treatment often depends on finding the cause, so be sure to check carefully for signs of each possibility.

This chart may help you find the cause:

PROBLEM DETAILS
foreign matter (bit of dirt, etc.) in the eye usually affects one eye only; redness and pain variable
burns or harmful liquids one or both eyes, redness and pain variable
‘pink eye’ (conjunctivitis) hay fever (allergic conjunctivitis trachoma measles usually both eyes (may start or be worse in one), usually reddest at outer edge,‘burning’ pain, usually mild
acute glaucoma, iritis, scratch or ulcer on the cornea usually one eye only; reddest next to the cornea, pain often great

‘PINK EYE’ (CONJUNCTIVITIS)

This infection causes redness, pus, and mild ‘burning’ in one or both eyes. Lids often stick together after sleep. It is especially common in children.

Treatment:

First clean pus from the eyes with a clean cloth moistened with boiled water. Then put in antibiotic eye ointment (page 378). Pull down the lower lid and put a little bit of ointment inside, like this: Putting ointment outside the eye does no good.

Prevention:

CAUTION: Do not touch the tube against the eye.

Most conjunctivitis is very contagious. The infection is easily spread from one person to another. Do not let a child with pink eye play or sleep with others, or use the same towel. Wash hands after touching eyes.

EYE OINTMENT

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TRACHOMA

Trachoma is a chronic infection that slowly gets worse. It may last for months or many years. If not treated early, it sometimes causes blindness. It is spread by touch or by flies, and is most common where people live in poor, crowded conditions.

Signs:

• Trachoma begins with red, watery eyes, like ordinary conjunctivitis.

• After a month or more, small, pinkish gray lumps, called follicles, form inside the upper eyelids. To see these, turn back the lid as shown on page 218.

• The white of the eye is a little red.

• After a few months, if you look very carefully, or with a magnifying glass, you may see that the top edge of the cornea looks grayish, because it has many tiny new blood vessels in it (pannus).

• The combination of both follicles and pannus is almost certainly trachoma.

• After several years, the follicles begin to disappear, leaving whitish scars.

These scars make the eyelids thick and may keep them from opening or closing all the way.

Treatment of trachoma:

Or the scarring may pull the eyelashes down into the eye, scratching the cornea and causing blindness.

Put 1% tetracycline or erythromycin eye ointment (page 378) inside the eye 3 times each day, or 3% tetracycline or erythromycin eye ointment 1 time each day. Do this for 30 days. For a complete cure, also take tetracycline (page 355), erythromycin (page 354) or a sulfonamide (page 356) by mouth for 2 to 3 weeks.

Prevention:

Early and complete treatment of trachoma helps prevent its spread to others. All persons living with someone who has trachoma, especially children, should have their eyes examined often and if signs appear, they should be treated early. Washing the face every day can help prevent trachoma. Also, it is very important to follow the Guidelines of Cleanliness, explained in Chapter 12.

Cleanliness helps prevent trachoma.

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INFECTED EYES IN NEWBORN BABIES (NEONATAL CONJUNCTIVITIS)

If a mother has chlamydia or gonorrhea (see page 236), she may pass these infections to her baby at birth.

The infection can get into the baby’s eyes and cause blindness and other health problems.

If the baby’s eyes get red, swell, and have pus in them within the first month, she may have one or both of these infections. It is important to provide treatment immediately.

Treatment for gonorrhea:

♦ Inject 125 mg ceftriaxone in the thigh muscle, 1 time only (see page 359).

Treatment for chlamydia:

♦ Give 30 mg erythromycin syrup by mouth, 3 times a day for 7 to 10 days (see page 354).

If you cannot test to find out which disease is causing the infection, give medicines for both. The baby’s eyes should also be cleaned and treated with the medicines listed below.

Prevention:

Many women have chlamydia or gonorrhea and do not know they are infected. Unless the mother has a test to show that she does not have these infections, give every baby medicine (see page 378) in the eyes to prevent blindness:

• put a line of erythromycin 0.5% to 1% ointment in each of the baby’s eyes within the first 2 hours after birth, OR

• put a line of tetracycline 1% eye ointment in each of the baby’s eyes within the first 2 hours after birth, OR

• if you do not have erythromycin or tetracycline, put 1 drop of 2.5% solution of povidone-iodine in each of the baby’s eyes within the first 2 hours after birth.

Some people use a 1% solution of silver nitrate (or other silver eye medicines) in the baby’s eyes.

These medicines stop blindness from gonorrhea, but they do not stop blindness from chlamydia. Silver nitrate also irritates the baby’s eyes for several days.

If you can get erythromycin or tetracycline eye medicine, or povidone-iodine, use one of them. But use silver nitrate if that is all you have.

If a baby develops gonorrhea or chlamydia of the eyes, both parents should be treated for these infections (page 237 and 359).

IRITIS (INFLAMMATION OF THE IRIS)

Iritis usually happens in one eye only. Pain may begin suddenly or gradually. The eye waters a lot. It hurts more in bright light. The eyeball hurts when you touch it. There is no pus as with conjunctivitis. Vision is usually blurred.

Signs:

  • pupil small often irregular
  • redness around iris severe pain

This is an emergency. Antibiotic ointments do not help. Get medical help.

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GLAUCOMA

This dangerous disease is the result of too much pressure in the eye. It usually begins after the age of 40 and is a common cause of blindness. To prevent blindness, it is important to recognize the signs of glaucoma and get medical help fast.

There are 2 forms of glaucoma.

ACUTE GLAUCOMA

This starts suddenly with a headache or severe pain in the eye. The eye becomes red, the vision blurred. The eyeball feels hard to the touch, like a marble. There may be vomiting. The pupil of the bad eye is bigger than that of the good eye. normal glaucoma

If not treated very soon, acute glaucoma will cause blindness within a few days. Surgery is often needed. Get medical help fast.

CHRONIC GLAUCOMA

The pressure in the eye rises slowly. Usually there is no pain. Vision is lost slowly, starting from the side, and often the person does not notice the loss. Testing the side vision may help detect the disease.

TEST FOR GLAUCOMA

If discovered early, treatment with special eyedrops (pilocarpine) may prevent blindness. Dosage should be determined by a doctor or health worker who can measure the eye pressure periodically. Drops must be used for the rest of one’s life. When possible, eye surgery is usually the surest form of treatment.

Prevention:

Persons who are over 40 years old or have family members who have had glaucoma should try to have their eye pressure checked once a year.

Have the person cover one eye, and with the other look at an object straight ahead of him. Note when he can first see moving fingers coming from behind on each side of the head.

Normally fingers are first seen here.

In glaucoma, finger movement is first seen more toward the front.

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INFECTION OF THE TEAR SAC (Dacryocystitis)

Signs:

Redness, pain, and swelling beneath the eye, next to the nose. The eye waters a lot. A drop of pus may appear in the corner of the eye when the swelling is gently pressed.

Treatment:

♦ Apply hot compresses.

♦ Put antibiotic eye drops or ointment in the eye.

♦ Take penicillin (page 350).

TROUBLE SEEING CLEARLY

Children who have trouble seeing clearly or who get headaches or eye pain when they read may need glasses. Have their eyes examined.

In older persons, it is normal that, with passing years, it becomes more difficult to see close things clearly. Reading glasses often help. Pick glasses that let you see clearly about 40 cm. (15 inches) away from your eyes.

If glasses do not help, see an eye doctor.

CROSS EYES, ‘LAZY’ EYE (Strabismus)

If the eye sometimes wanders like this, but at other times looks ahead normally, usually you need not worry. The eye will grow straighter in time.

But if the eye is always turned the wrong way, and if the child is not treated at a very early age, she may never see well with that eye. See an eye doctor as soon as possible to find out if patching of the good eye, surgery, or special glasses might help.

Surgery done at a later age can usually straighten the eye and improve the child’s appearance, but it will not help the weak eye see better.

IMPORTANT:

The eyesight of every child should be checked as early as possible (best around 4 years). You can use an ‘E’ chart (see Helping Health Workers Learn, page 24-13).

Test each eye separately to discover any problem that affects only one eye. If sight is poor in one or both eyes, see an eye doctor.

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STY (HORDEOLUM)

A red, swollen lump on the eyelid, usually near its edge. To treat, apply warm, moist compresses with a little salt in the water.

Use of an antibiotic eye ointment 3 times a day will help prevent more sties from occurring (see page 378).

PTERYGIUM

A fleshy thickening on the eye surface that slowly grows out from the edge of the white part of the eye near the nose and onto the cornea; caused in part by sunlight, wind, and dust.

Dark glasses may help calm irritation and slow the growth of a pterygium.

It should be removed by surgery before it reaches the pupil. Unfortunately, after surgery a pterygium often grows back again.

Folk treatments using powdered shells do more harm than good. To help calm itching and burning you can try using cold compresses.

Or use eye drops of camomile (boiled, then strained, cooled, and without sugar).

A SCRAPE, ULCER, OR SCAR ON THE CORNEA

When the very thin, delicate surface of the cornea has been scraped, or damaged by infection, a painful corneal ulcer may result.

If you look hard in a good light, you may see a grayish or less shiny patch on the surface of the cornea.

If not well cared for, a corneal ulcer can cause blindness. Apply antibiotic eye ointment, 4 times a day for 7 days (page 378). If the eye is not better in 2 days, get medical help.

A corneal scar is a painless, white patch on the cornea. It may result from a healed corneal ulcer, burn, or other injury to the eye.

If both eyes are blind but the person still sees light, surgery (corneal transplant) to one eye may return its sight. But this is expensive.

If one eye is scarred, but sight is good in the other, avoid surgery.

Take care to protect the good eye from injury.

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BLEEDING IN THE WHITE OF THE EYE

A painless, blood-red patch in the white part of the eye occasionally appears after lifting something heavy, coughing hard (as with whooping cough), or being hit on the eye.

The condition results from the bursting of a small vessel. It is harmless, like a bruise, and will slowly disappear without treatment in about 2 weeks.

Small red patches are common on the eyes of newborn babies. No treatment is needed.

BLEEDING BEHIND THE CORNEA (HYPHEMA)

Blood behind the cornea is a danger sign. It usually results from an injury to the eye with a blunt object, like a fist. If there is pain and loss of sight, refer the person to an eye specialist immediately.

If the pain is mild and there is not loss of sight, put a patch on both eyes and keep the person at rest in bed for several days. If after a few days the pain becomes much worse, there is probably hardening of the eye (glaucoma, page 222).

Take the person to an eye doctor at once.

PUS BEHIND THE CORNEA (HYPOPYON)

Pus behind the cornea is a sign of severe inflammation. It is sometimes seen with corneal ulcers and is a sign that the eye is in danger.

Apply antibiotic eye ointment (page 378) and get medical help at once. If the ulcer is treated correctly, the hypopyon will often clear up by itself.

CATARACT

The lens of the eye, behind the pupil, becomes cloudy, which you can see when you shine a light into it.

Cataract is common in older persons, but also occurs, rarely, in babies.

If a blind person with cataracts can still tell light from dark and notice movement, surgery may let him see again.

During surgery, an artificial lens is put inside the eye to restore vision, without the need to wear glasses afterwards.

Medicines do not help cataracts.

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NIGHT BLINDNESS AND XEROPHTHALMIA (Vitamin A deficiency)

This eye disease is most common in children between 1 and 5 years of age. It comes from not eating enough foods with vitamin A. If not recognized and treated early, it can make the child blind.

Signs:

• At first, the child may have night blindness. He cannot see as well in the dark as other people can.

• Later, he develops dry eyes (xerophthalmia). The white of the eyes loses its shine and begins to wrinkle.

• Patches of little gray bubbles (Bitot’s spots) may form in the eyes.

• As the disease gets worse, the cornea also becomes dry and dull, and may develop little pits.

• Then the cornea may quickly grow soft, bulge, or even burst. Usually there is no pain. Blindness may result from infection, scarring, or other damage.

• Xerophthalmia often begins, or gets worse, when a child is sick with another illness like diarrhea, whooping cough, tuberculosis, or measles. Examine the eyes of all sick and underweight children. Open the child’s eyes and look for signs of vitamin A deficiency.

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Prevention and treatment:

Xerophthalmia can easily be prevented by eating foods that have vitamin A. Do the following:

♦ Breastfeed the baby, up to 2 years, if possible.

♦ After the first 6 months, begin giving the child foods rich in vitamin A, such as dark green leafy vegetables, and yellow or orange fruits and vegetables such as papaya (paw paw), mango, and squash. Whole milk, eggs, and liver are also rich in vitamin A.

♦ If the child is not likely to get these foods, or if he is developing signs of night blindness or xerophthalmia, give him vitamin A. 200,000 units (60 mg. retinol, in capsule or liquid) once every 6 months (page 391). Babies under 1 year of age should get 100,000 units.

♦ If the condition is already fairly severe, give the child 200,000 units of vitamin A by mouth the first day. 200,000 units the second day, and 200,000 units 14 days later. Babies under 1 year old should get half that amount (100,000 units).

♦ In communities where xerophthalmia is common, give 200,000 units of vitamin A once every 6 months to women who are breastfeeding, and also to pregnant women during the second half of their pregnancy.

WARNING: Too much vitamin A is poisonous. Do not give more than the amounts advised here.

If the condition of the child’s eye is severe, with a dull, pitted, or bulging cornea, get medical help. The child’s eye should be bandaged, and he should receive vitamin A at once, preferably an injection of 100,000 units in the muscle.

SPOTS OR ‘FLOATERS’ BEFORE THE EYES

Sometimes older persons complain of small moving spots when they look at a bright surface (wall, sky). The spots move when the eyes move and may look like bits of string or cobwebs. These spots are usually harmless and need no treatment. But if they appear suddenly in large numbers and vision begins to fail from one side, this could be a medical emergency (detached retina). Seek medical help at once.

DOUBLE VISION

Seeing double can have many causes.

If double vision comes suddenly, is chronic, or gradually gets worse, it is probably a sign of a serious problem. Seek medical help.

If double vision occurs only from time to time, it may be a sign of weakness or exhaustion, perhaps from malnutrition. Read Chapter 11 on good nutrition and try to eat as well as possible. If sight does not improve, get medical help.

Dark green leafy vegetables, and yellow or orange fruits and vegetables, help prevent blindness in children.

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RIVER BLINDNESS (ONCHOCERCIASIS)

This disease is common in many parts of Africa and certain areas of southern Mexico, Central America, and northern South America.

The infection is caused by tiny worms that are carried from person to person by small, hump backed flies or gnats known as BLACK FLY (simulids).

The worms are ‘injected’ into a person when an infected BLACK FLY bites him.

Signs of river blindness:

• Several months after a black fly bites and the worms enter the body, lumps begin to form under the skin. In the Americas the lumps are most common on the head and upper body; in Africa on the chest, the lower body, and thighs. Often there are no more than 3 to 6 lumps. They grow slowly to a size of 2 to 3 cm. across. They are usually painless.

• There may be itching when the baby worms are spreading.

• Pains in the back, shoulder or hip joints, or ‘general pains all over’.

• Enlargement of the lymph nodes in the groin.

• Thickening of the skin on the back or belly, with big pores like the skin of an orange. To see this, look at the skin with light shining across it from one side.

• If the disease is not treated, the skin gradually becomes more wrinkled, like an old man’s. White spots and patches may appear on the front of the lower legs. A dry rash may appear on the lower limbs and trunk.

• Eye problems often lead to blindness. First there may be redness and tears, then signs of iritis (page 221). The cornea becomes dull and pitted as in xerophthalmia (page 226). Finally, sight is lost because of corneal scarring, cataract, glaucoma, or other problems.

Treatment of river blindness:

Early treatment can prevent blindness. In areas where river blindness is known to occur, seek medical testing and treatment when the first signs appear.

♦ Ivermectin (Mectizan) is the best medicine for river blindness, and it may be available at no cost through your local health department.
Diethylcarbamazine and suramin are other medicines used to treat river blindness, but these can sometimes do more harm than good, especially when eye damage has already begun. They should only be given by experienced health workers. For dosage and precautions on all these medicines, see page 377.

♦ Antihistamines help reduce itching (page 385).

♦ Early surgical removal of the lumps lowers the number of worms.

Prevention:

♦ Black flies breed in fast-running water. Clearing brush and vegetation back from the banks of fast-running streams may help reduce the number.

♦ Avoid sleeping out-of-doors, especially in the daytime, which is when the flies usually bite.

♦ Cooperate with programs for the control of black flies.

♦ Early treatment prevents blindness and reduces spread of the disease.

17

teeth, gums, and mouth

CARE OF THE TEETH AND GUMS

Taking good care of teeth and gums is important because:

  • Strong, healthy teeth are needed to chew and digest food well.
  • Painful cavities (holes in the teeth caused by decay) and sore gums can be prevented by good tooth care.
  • Decayed or rotten teeth caused by lack of cleanliness can lead to serious infections that may affect other parts of the body.

“This child has a sweet tooth, but soon he’ll have no more” (no more teeth).

To keep the teeth and gums healthy:

1.Avoid sweets. Eating a lot of sweets (sugar cane, candy, pastry, tea or coffee with sugar, soft or fizzy drinks like colas) rots the teeth quickly.

Do not accustom children to sweets or soft drinks if you want them to have good teeth.

“This child has a sweet tooth, but soon he’ll have no more” (no more teeth).

2.Brush teeth well every day, and always brush immediately after eating anything sweet. Start brushing your children’s teeth as the teeth appear. Later, teach them to brush their teeth themselves, and watch to see that they do it right:

  • Brush the teeth from top to bottom like this,

  • not just from side to side.

  • Brush the front, back, top, and bottom of all teeth.

3.In areas where there is not enough natural fluoride in water and foods, putting fluoride in the drinking water or directly on teeth helps prevent cavities. Some health programs put fluoride on children’s teeth once or twice a year. Also, most foods from the sea contain a large amount of fluoride.

CAUTION: Fluoride is poisonous if more than a small amount is swallowed. Use with care and keep it out of the reach of children. Before adding fluoride to drinking water, try to get the water tested to see how much fluoride is needed.

4.Do not bottle feed older babies. Continual sucking on a bottle bathes the baby’s teeth in sweet liquid and causes early decay. (It is best not to bottle feed at all. See page 271.)

A TOOTHBRUSH IS NOT NECESSARY

  • You can use the twig of a tree, like this: Sharpen this end to clean between the teeth.

  • Chew on this end and use the fibers as a brush.

  • Or tie a piece of rough towel around the end of a stick or wrap it around your finger, and use it as a toothbrush.

TOOTHPASTE IS NOT NECESSARY

Just water is enough, if you rub well. Rubbing the teeth and gums with something soft but a little rough is what cleans them. Some people rub their teeth with powdered charcoal or with salt. Or you can make a tooth powder by mixing salt and bicarbonate of soda (baking soda) in equal amounts. To make it stick, wet the brush before putting it in the powder.

if a tooth already has a cavity (a hole caused by rot)

To keep it from hurting as much or forming an abscess, avoid sweet things and brush well after every meal.

If possible, see a dental worker right away, if you go soon enough, he can often clean and fill the tooth so it will last for many years.

When you have a tooth with a cavity, do not wait until it hurts a lot. Have it filled by a dental worker right away.

TOOTHACHES AND ABSCESSES

To calm the pain:

  • Clean the hole in the tooth wall, removing all food particles. Then rinse the mouth with warm salt water.

  • Take a pain medicine like aspirin.

  • If the tooth infection is severe (swelling, pus, large tender lymph nodes), use an antibiotic: tablets of penicillin (page 351), amoxicillin, or ampicillin (page 352). People allergic to medicines in the penicillin family can take erythromycin (page 354).

If the pain and swelling do not go away or keep coming back, the tooth should probably be pulled.

Treat abscesses right away, before the infection spreads to other parts of the body.

A toothache results when a cavity becomes infected. An abscess results when the infection reaches the tip of a root and forms a pocket of pus.

INFECTION OF THE GUMS (PYORRHEA)

Inflamed (red and swollen), painful gums that bleed easily are caused by:

  1. Not cleaning the teeth and gums well or often enough.

  2. Not eating enough nutritious foods (malnutrition).

Prevention and treatment:

  • Brush teeth well after each meal, removing food that sticks between the teeth. Also, if possible, scrape off the dark yellow crust (tartar) that forms where the teeth meet the gums. It helps to clean under the gums regularly by passing a strong thin thread (or dental floss) between the teeth. At first this will cause a lot of bleeding, but soon the gums will be healthier and bleed less.

  • Eat protective foods rich in vitamins, especially eggs, meat, beans, dark green vegetables, and fruits like oranges, lemons, and tomatoes (see Chapter 11). Avoid sweet, sticky, and stringy foods that get stuck between the teeth.

Note: Sometimes medicines for seizures (epilepsy), such as phenytoin (Dilantin), cause swelling and unhealthy growth of the gums (see page 389). If this happens, consult a health worker and consider using a different medicine.

  1. Do not bottle feed older babies. Continual sucking on a bottle bathes the baby’s teeth in sweet liquid and causes early decay. (It is best not to bottle feed at all. See page 271.)

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A TOOTHBRUSH IS NOT NECESSARY

You can use the twig of a tree, like this:

  • Sharpen this end to clean Chew on this end and use between the teeth. the fibers as a brush.

  • Or tie a piece of rough towel around the end of a stick or wrap it around your finger, and use it as a toothbrush.

TOOTHPASTE IS NOT NECESSARY

Just water is enough, if you rub well. Rubbing the teeth and gums with something soft but a little rough is what cleans them. Some people rub their teeth with powdered charcoal or with salt.

Or you can make a tooth powder by mixing salt and bicarbonate of soda (baking soda) in equal amounts. To make it stick, wet the brush before putting it in the powder.

  • piece of rough towel

  • salt

  • bicarbonate of soda

IF A TOOTH ALREADY HAS A CAVITY (a hole caused by rot)

To keep it from hurting as much or forming an abscess, avoid sweet things and brush well after every meal.

If possible, see a dental worker right away, if you go soon enough, he can often clean and fill the tooth so it will last for many years.

When you have a tooth with a cavity, do not wait until it hurts a lot. Have it filled by a dental worker right away.

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TOOTHACHES AND ABSCESSES

To calm the pain:

♦ Clean the hole in the tooth wall, removing all food particles. Then rinse the mouth with warm salt water.

♦ Take a pain medicine like aspirin.

♦ If the tooth infection is severe (swelling, pus, large tender lymph nodes), use an antibiotic: tablets of penicillin (page 351), amoxicillin, or ampicillin (page 352). People allergic to medicines in the penicillin family can take erythromycin (page 354).

If the pain and swelling do not go away or keep coming back, the tooth should probably be pulled.

Treat abscesses right away, before the infection spreads to other parts of the body.

A toothache results when a cavity becomes infected.

An abscess results when the infection reaches the tip of a root and forms a pocket of pus.

AN INFECTION OF THE GUMS (PYORRHEA)

Inflamed (red and swollen), painful gums that bleed easily are caused by:

  1. Not cleaning the teeth and gums well or often enough.

  2. Not eating enough nutritious foods (malnutrition).

Prevention and treatment:

♦ Brush teeth well after each meal, removing food that sticks between the teeth. Also, if possible, scrape off the dark yellow crust (tartar) that forms where the teeth meet the gums. It helps to clean under the gums regularly by passing a strong thin thread (or dental floss) between the teeth. At first this will cause a lot of bleeding, but soon the gums will be healthier and bleed less.

♦ Eat protective foods rich in vitamins, especially eggs, meat, beans, dark green vegetables, and fruits like oranges, lemons, and tomatoes (see Chapter 11). Avoid sweet, sticky, and stringy foods that get stuck between the teeth.

Note:

Sometimes medicines for seizures (epilepsy), such as phenytoin (Dilantin), cause swelling and unhealthy growth of the gums (see page 389). If this happens, consult a health worker and consider using a different medicine.

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SORES OR CRACKS AT THE CORNERS OF THE MOUTH

Narrow sores at the corners of children’s mouths are often a sign of malnutrition.

Children with these sores should eat foods rich in vitamins and proteins: like milk, meat, fish, nuts, eggs, fruits, and green vegetables.

WHITE PATCHES OR SPOTS IN THE MOUTH

The tongue is coated with white ‘fur’.

Many illnesses cause a white or yellowish coating on the tongue and roof of the mouth. This is common when there is a fever. Although this coating is not serious, it helps to rinse the mouth with a solution of warm water with salt and bicarbonate of soda several times a day.

Tiny white spots, like salt grains, in the mouth of a child with fever may be an early sign of measles (page 311).

Thrush:

Small white patches on the inside of the mouth and tongue that look like milk curds stuck to raw meat. They are caused by a yeast infection (Candida) (see page 242).

Thrush is common in newborn babies, in persons with HIV, and in persons using certain antibiotics, especially tetracycline or ampicillin.

Unless it is very important to keep taking the antibiotic, stop taking it. Use nystatin (page 372) or paint the inside of the mouth with gentian violet. Eating yogurt may also help.

In very severe cases, or if thrush moves into the throat and makes it hard to swallow, consult a health worker. A stronger medicine may be needed.

Canker sores:

Small, white, painful spots inside the lip or mouth. May appear after fever or stress (worry). In 1 to 3 weeks they go away. Rinse mouth with salt water. Antibiotics do not help.

COLD SORES AND FEVER BLISTERS

Small painful blisters on lips (or genitals) that break and form scabs. May appear after fever or stress. Caused by a herpes virus.

They heal after 1 or 2 weeks. Holding ice on the sores for several minutes, several times a day may help them to heal faster.

Putting alum, camphor, or bitter plant juices (such as Cardon cactus, page 13) on them may help.

Taking acyclovir (page 373) can make cold sores less painful. For information about herpes on the genitals, see page 402.

For more information on caring for the teeth and gums, see Where There Is No Dentist, also available from Hesperian.

18

the urinary system and the genitals

The urinary system or tract serves the body by removing waste material from the blood and getting rid of it in the form of urine:

  • The kidneys filter the blood and form the urine.

  • The ureters are tubes that carry urine to the bladder.

  • The bladder is a bag that stores the urine. As it fills, it stretches and gets bigger.

  • The urine tube or urinary canal (urethra) carries urine out through the penis in men or to a small opening between the lips of the vagina in women.

The genitals are the sex organs.

The man:

  • bladder urine canal
  • penis or male sex organ
  • scrotum or sac that holds the testicles
  • sperm tube
  • The prostate gland makes the liquid that carries the sperm.
  • The testicles make the sperm, or microscopic cells with tails that join with the egg of a woman and make her pregnant.

The woman:

  • outer lips of the vagina
  • inner lips
  • anus: end of the intestine
  • clitoris: a very sensitive spot that can give sexual pleasure when touched
  • urinary opening: hole where urine comes out
  • opening to the vagina or birth canal. (For inside view, see page 280.)

PROBLEMS OF THE URINARY TRACT

There are many different problems of the urinary tract. They are not always easy to tell apart. And the same illness can show itself differently in men and women. Some of these problems are not serious, while others can be very dangerous.

A dangerous illness may begin with only mild signs. It is often difficult to identify these problems correctly by simply using a book like this one. Special knowledge and tests may be needed. When possible, seek advice from a health worker.

Common problems with urinating include:

  1. Urinary tract infections. These are most common in women. (Sometimes they start after sexual contact, but may come at other times, especially during pregnancy.)

  2. Kidney stones, or bladder stones.

  3. Prostate trouble (difficulty passing urine caused by an enlarged prostate gland; most common in older men).

  4. Gonorrhea or chlamydia (infectious diseases spread by sexual contact that often cause difficulty or pain in passing urine).

  5. In some parts of the world schistosomiasis (blood flukes) is the most common cause of blood in the urine. This is discussed with other worm infections. See page 146.

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Urinary Tract Infections

Signs:

• Sometimes fever and chills or headache.

• Sometimes pain in the side.

• Painful urination and need to urinate very often.

• Unable to hold in urine (especially true for children).

• Urine may be cloudy or reddish (bloody).

• Sometimes it feels as though the bladder does not empty completely.

• Sometimes there is pain in the lower back (kidneys).

• Sometimes the pain seems to go down the legs.

• In serious cases (kidney disease) the feet and face may swell.

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Many women suffer from urinary infections. In men they are much less common. Sometimes the only symptoms are painful urination and the need to urinate often. Other common signs are blood in the urine and pain in the lower belly. Pain in the mid or lower back, often spreading around the sides below the ribs, with fever, indicates a more serious problem.

Treatment:

♦ Drink a lot of water. Many minor urinary infections can be cured by simply drinking a lot of water, without the need for medicine. Drink at least 1 glass every 30 minutes for 3 to 4 hours, and get into the habit of drinking lots of water. (But if the person cannot urinate or has swelling of the hands and face, she should not drink much water.)

♦ If the person does not get better by drinking a lot of water, or if she has a fever, she should take cotrimoxazole (page 357) or amoxicillin (page 352). Pay careful attention to dosage and precautions. To completely control the infection it may be necessary to take the medicine for 10 days. If the infection moves into the kidneys or if these medicines do not work, try ciprofloxacin (page 358). It is important to drink a lot of water while taking these medicines.

♦ If the person does not get better quickly, seek medical advice.

Kidney or Bladder Stones

Signs:

• The first sign is often sharp or severe pain in the lower back, the side, or the lower belly, or in the base of the penis in men.

• Sometimes the urinary tube is blocked so the person has difficulty passing urine, or cannot pass any. Or drops of blood may come out when the person begins to urinate.

• There may be a urinary infection at the same time.

Treatment:

♦ The same as for the urinary infections described above.

♦ Also give aspirin or another painkiller and an antispasmodic (see page 380).

♦ If you cannot pass urine, try to do it lying down. This sometimes allows a stone in the bladder to roll back and free the opening to the urinary tube.

♦ In severe cases, get medical help. Sometimes surgery is needed.

Enlarged Prostate Gland

This condition is most common in men over 40 years old. It is caused by a swelling of the prostate gland, which is between the bladder and the urinary tube (urethra).

• The person has difficulty in passing urine and sometimes in having a bowel movement. The urine may only dribble or drip or become blocked completely. Sometimes the man is not able to urinate for days.

• If he has a fever, this is a sign that infection is also present.

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Treatment for an enlarged prostate:

♦ If the person cannot urinate, he should try sitting in a tub of hot water, like this: If this does not work, a catheter may be needed (page 239).

♦ If he has a fever, use an antibiotic such as ampicillin (page 352) or tetracycline (page 355).

♦ Get medical help. Serious or chronic cases may require surgery.

Note: Both prostate trouble and gonorrhea (or chlamydia) can also make it hard to pass urine. In older men it is more likely to be an enlarged prostate. However, a younger man, especially one who has recently had sex with a person with gonorrhea or chlamydia, probably has gonorrhea or chlamydia.

INFECTIONS SPREAD BY SEX (SEXUALLY TRANSMITTED INFECTIONS)

On the following pages, we discuss some common infections spread by sexual contact (STIs): gonorrhea, chlamydia, syphilis, and bubos.

For information on HIV and AIDS and some sexually transmitted infections that cause sores on the genitals (genital herpes, genital warts, and chancroid) see Additional Information, page 399 to 403.

Gonorrhea (clap, VD, the drip) and Chlamydia

Both men and women can have gonorrhea or chlamydia without any signs.

Gonorrhea and chlamydia can have the same signs, though gonorrhea usually starts sooner and is more painful. Both men and women can have gonorrhea and chlamydia at the same time so it is best to treat for both. If not treated, either gonorrhea or chlamydia can make a man or a woman sterile (unable to have a baby).

If a pregnant woman with gonorrhea or chlamydia is not treated before giving birth, the infection may get in the baby’s eyes and make him blind (see page 221).

Signs in the man:

• Drops of pus from the penis • Sometimes there is painful swelling of the testicles

Signs in the woman:

• Yellow or green discharge from the vagina or anus • Pain in the lower belly (pelvic inflammatory disease, page 243) • Fever • Pain during sex

Signs in both the man and the woman:

• Pain or burning during urination (peeing) • Rash or sores all over the body • Painful swelling in one or both knees, ankles, or wrists

In a man, the first signs begin 2 to 5 days (or up to 3 weeks or more) after sexual contact with an infected person. In a woman, signs may not show up for weeks or months. But a person who does not show any signs can still give the disease to someone else, starting a few days after becoming infected.

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Treatment:

♦ In the past, gonorrhea was usually treated with penicillin. But now in many areas the disease has become resistant to penicillin, so other antibiotics must be used. It is best to seek local advice about which medicines are effective, available, and affordable in your area. Medicines used to treat gonorrhea and chlamydia are listed on page 359. If the drip and pain have not gone away in 2 or 3 days after trying a treatment, the gonorrhea could be resistant to the medicine, or the person could have chlamydia.

♦ If a woman has gonorrhea or chlamydia and also has fever and pain in the lower belly, she may have pelvic inflammatory disease (see page 243).

♦ Everyone who has had sex with a person known to have gonorrhea or chlamydia should also be treated, especially wives of men who are infected. Even if the wife shows no signs, she is probably infected. If she is not treated at the same time, she will give the disease back to her husband again.

♦ Protect the eyes of all newborn babies from chlamydia and especially gonorrhea, which can cause blindness (see page 221).

CAUTION:

A person with gonorrhea or chlamydia may also have syphilis without knowing it. Sometimes it is best to go ahead and give the full treatment for syphilis, because the gonorrhea or chlamydia treatment may prevent the first syphilis symptoms, but may not cure the disease.

For prevention of these and other sexually transmitted infections, see page 239.

Syphilis

Syphilis is a common and dangerous infection that is spread from person to person through sexual contact.

Signs:

• The first sign is usually a sore, called a chancre. It appears 2 to 5 weeks after sexual contact with a person who has syphilis. The chancre may look like a pimple, a blister, or an open sore. It usually appears in the genital area of the man or woman (or less commonly on the lips, fingers, anus, or mouth). This sore is full of germs, which are easily passed on to another person. The sore is usually painless, and if it is inside the vagina, a woman may not know she has it but it can easily spread to other people. If the sore is painful, it may be chancroid (see page 403).

• The sore lasts only a few days and then goes away by itself without treatment. But the disease continues spreading through the body.

• Weeks or months later, there may be sore throat, mild fever, mouth sores, or swollen joints. Or any of these signs may appear on the skin: a painful rash or ‘pimples’ ring-shaped welts all over the body (like hives) an itchy rash on the hands or feet.

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All of these signs usually go away by themselves, making the person think he is well, but the disease continues. Without adequate treatment, syphilis can invade any part of the body, causing heart disease, paralysis, insanity, and many other problems.

Note: Yaws shares many of the same signs as syphilis (see page 202).

CAUTION: If any strange rash or skin condition shows up days or weeks after a pimple or sore appears on the genitals, it may be syphilis. Get medical advice.

Treatment for syphilis: (For complete cure, the full treatment is essential.)

If signs have been present less than 2 years, inject 2.4 million units of benzathine penicillin all at once, half the dose in each buttock (see page 352). If allergic to penicillin, take tetracycline or erythromycin by mouth, 500 mg, 4 times a day for 15 days.

If signs have been present more than 2 years, inject 2.4 million units of benzathine penicillin, half in each buttock, once a week for 3 weeks, for a total of 7.2 million units. If allergic to penicillin, take either tetracycline or erythromycin, 500 mg, 4 times each day for 30 days.

♦ If there is any chance that someone has syphilis, she should immediately see a health worker. Special blood tests may be needed. If tests cannot be made, the person should be treated for syphilis in any case.

♦ Everyone who has had sexual contact with a person known to have syphilis should also be treated, especially husbands or wives of those known to be infected.

Note: Pregnant or breastfeeding women who are allergic to penicillin can take erythromycin in the same dosage as tetracycline (see page 355).

To prevent syphilis, see the next page.

Bubos: Bursting Lymph Nodes in the Groin (Lymphogranuloma Venereum)

Signs:

In a man: Large, dark lumps in the groin that open to drain pus, scar up, and open again.

In a woman: Lymph nodes similar to those in the man. Or painful, oozing sores in the anus.

Treatment:

♦ See a health worker.

♦ Give adults 500 mg of erythromycin, 4 times a day for 14 to 21 days. Or give doxycycline, 100 mg, 2 times a day for 14 to 21 days.

♦ Avoid sex until the sores are completely healed.

Note: Bubos in the groin can also be a sign of chancroid (see page 403).

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#HOW TO PREVENT SPREADING SEXUALLY TRANSMITTED INFECTIONS

  1. Be careful with whom you have sex: Someone who has sex with many different persons is more likely to catch these infections. That is why prostitutes are more likely to get an infection and then pass it on. To avoid infection, always use a condom or have sex with only one faithful partner.

  2. Get treatment right away: It is very important that all persons infected with a sexually transmitted infection get treatment at once so that they do not infect other people. Having one STI also makes it easier to become infected with HIV or other STIs. Do not have sex with anyone until 3 days after treatment is finished. (Unfortunately there is still no cure for HIV. See page 397.)

  3. Tell other people if they need treatment: When a person finds out that he or she has a sexually transmitted infection, he should tell everyone with whom he has had sex, so that they can get treatment, too. It is especially important that a man tell a woman, because without knowing she has the disease she can pass it on to other people, her babies may become infected or blind, and in time she may become sterile or very ill herself.

  4. Help others: Insist that friends who may have a sexually transmitted infection get treatment at once, and that they avoid all sexual contact until they are cured.

HOW AND WHEN TO USE A CATHETER

(A RUBBER TUBE TO DRAIN URINE FROM THE BLADDER)

When to use and when not to use a catheter:

Never use a catheter unless it is absolutely necessary and it is impossible to get medical help in time. Even careful use of a catheter sometimes causes dangerous infection or damages the urinary canal.

• If any urine is coming out at all, do not use the catheter.

• If the person cannot urinate, first have him try to urinate while sitting in a tub of warm water (page 236). Begin the recommended medicine (for gonorrhea or prostate trouble) at once.

• If the person has a very full, painful bladder and cannot urinate, or if he or she begins to show signs of poisoning from urine, then and only then use a catheter.

Signs of urine poisoning (uremia):

• The breath smells like urine. • The feet and face swell. • Vomiting, distress, confusion.

Note: People who have suffered from difficulty urinating, enlarged prostate, or kidney stones should buy a catheter and keep it handy in case of emergency.

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HOW TO PUT IN A CATHETER

  1. Boil the catheter (and any syringe or instrument you may be using) for 15 minutes.

  2. Wash well under foreskin or between vaginal lips and surrounding areas.

  3. Wash hands, if possible with surgical soap (like Betadine). After washing, touch only things that are sterile or very clean.

  4. Put very clean cloths under and around the area.

  5. Put on sterile gloves or rub hands well with alcohol or surgical soap.

  6. Cover the catheter with a sterile lubricant (slippery cream) like K-Y Jelly that dissolves in water (not oil or Vaseline).

  7. Pull back foreskin or open the vaginal lips. And wipe the urine opening with a sterile cotton wetted with soap.

  8. Holding the foreskin back or the lips open, gently put the catheter into the urine hole. Twist it as necessary but DO NOT FORCE IT. Hold the penis straight up.

  9. Push the catheter in until urine starts coming out. For a man, then push it in 3 cm more.

Note: A woman’s urinary tube is much shorter than a man’s.

IMPORTANT: If the person shows signs of urine poisoning, or if the bladder has been over-full and stretched, do not let the urine come out all at once: instead, let it out very slowly (by pinching or plugging the catheter), little by little over an hour or 2.

Sometimes a woman cannot urinate after giving birth. If more than 6 hours pass and her bladder seems full, she may need a catheter put in. If her bladder does not feel full, do not use a catheter but have her drink lots of water.

For more information on catheter use, see Disabled Village Children, Chapter 25.

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PROBLEMS OF WOMEN

Vaginal Discharge (a mucus or pus-like stuff that comes from the vagina)

All women normally have a small amount of vaginal discharge, which is clear, milky, or slightly yellow. If there is no itching or bad smell, there is probably no problem.

But many women, especially during pregnancy, suffer from a discharge often with itching in the vagina. This discharge may be caused by various infections. Most of them are bothersome, but not dangerous. However, an infection caused by gonorrhea or chlamydia can harm a baby at birth (see page 221).

  1. A thin and foamy, greenish-yellow or whitish, foul-smelling discharge with itching. This is probably an infection of Trichomonas. It may burn to urinate. Sometimes the genitals hurt or are swollen. The discharge may contain blood.

Treatment:

♦ It is very important to keep the genitals clean.

♦ A vaginal wash, or douche, with warm water and distilled vinegar will help. If there is no vinegar, use lemon juice in water. For the douche, use 6 teaspoons of vinegar in 1 liter of boiled, cooled water.

CAUTION: Do not douche in the last 4 weeks of pregnancy, or for 6 weeks after giving birth.

♦ You can also use a clove of garlic as a vaginal insert. (Peel the garlic, taking care not to puncture it. Wrap it in a piece of clean cloth or gauze, and put it into the vagina.)

♦ Use the douche 2 times during the day, and each night insert a new clove of garlic. Do this for 10 to 14 days.

♦ If this does not help, use vaginal inserts that contain metronidazole or other medication recommended for Trichomonas, or take metronidazole by mouth. For precautions and instructions, see page 368.

IMPORTANT: It is likely that the husband of a woman with Trichomonas has the infection, too, even though he does not feel anything. (Some men with Trichomonas have a burning feeling when urinating.) If a woman is treated with metronidazole, her husband should also take it by mouth at the same time.

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IMPORTANT: Let water enter slowly during about 3 minutes. Do not put the tube more than 3 inches into the vagina.

  1. White discharge that looks like cottage cheese or buttermilk, and smells like mold, mildew, or baking bread. This could be a yeast infection (Candida). Itching may be severe. The lips of the vagina often look bright red and hurt. It may burn to urinate. This infection is especially common in pregnant women or in those who are sick, diabetic (page 127), have HIV, or have been taking antibiotics or birth control pills.

Treatment:

Douche with vinegar-water (see page 241) or dilute gentian violet, 2 parts gentian violet to 100 parts water (2 teaspoons to a half liter). Or use nystatin vaginal tablets or other vaginal inserts for Candida, like nystatin or miconazole. For dosage and instructions see page 372. Putting unsweetened yogurt in the vagina is said to be a useful home remedy to help control yeast infections. Never use antibiotics for a yeast infection. They can make it worse.

  1. Thick, milky discharge with a rancid smell. This could be an infection caused by bacteria. Special tests may be needed to tell this from a Trichomonas infection. Douche with vinegar-water (page 241), or with povidone-iodine (Betadine: 6 teaspoons in 1 liter of water). Also, you can try inserting a clove of garlic every night for 2 weeks (see page 241). If none of these treatments works, try metronidazole (see page 368).

  2. Watery, brown, or gray discharge, streaked with blood; bad smell; pain in the lower belly. These are signs of more serious infections, or possibly cancer (page 280). If there is fever, use antibiotics (see page 276). Get medical help right away. IMPORTANT: If any discharge lasts a long time, or does not get better with treatment, see a health worker.

How a Woman Can Avoid Many Infections:

  1. Keep the genital area clean. When you bathe (daily if possible) wash well with mild soap.

  2. Urinate after sexual contact. This helps prevent urinary infections (but will not prevent pregnancy).

  3. Be sure to clean yourself carefully after each bowel movement. Always wipe from front to back!

Wiping forward can spread germs, amebas, or worms into the urinary opening and vagina. Also take care to wipe little girls’ bottoms from front to back and to teach them, as they grow up, to do it the same way.

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Pain or Discomfort in the Lower Central Part of a Woman’s Belly

This can come from many different causes, which are discussed in different parts of this book. The following list, which includes a few key questions, will help you know where to look.

Possible causes of pain in the lower belly are:

  1. Menstrual discomfort (page 246). Is it worse shortly before or during the period?

  2. A bladder infection (page 234). One of the most common low mid-belly pains. Is urination very frequent or painful?

  3. Pelvic inflammatory disease (PID). This infection causes pain in the lower belly and fever. It can happen after birth, abortion, miscarriage, or inserting an IUD. Gonorrhea or chlamydia that have gone untreated can also lead to PID (page 236). Treat for gonorrhea and chlamydia (page 359). If the woman is using an intrauterine device (IUD), it may need to be removed. See a health worker.

  4. Problems that are related to a lump or mass in the lower part of the belly. These are discussed briefly on page 280 and include ovarian cyst and cancer. A special exam is needed, done by a trained health worker.

  5. Ectopic pregnancy (when the baby begins to develop outside the womb (page 280). Usually there is severe pain with irregular bleeding. The woman often has signs of early pregnancy (see page 247), and feels dizzy and weak. Get medical help immediately; her life is in danger.

  6. Complications from an abortion (page 414). There may be fever, bleeding from the vagina with clots, belly pain, difficulty urinating, and shock. Start giving antibiotics as for childbirth fever (page 276), and get the woman to a hospital at once. Her life is in danger.

  7. An infection or other problem of the gut or rectum (page 145). Is the pain related to eating or to bowel movements?

Some of the above problems are not serious. Others are dangerous. They are not always easy to tell apart. Special tests or examinations may be needed. If you are unsure what is causing the pain, or if it does not get better soon, seek medical help. For more information on treating women’s health problems, see Where Women Have No Doctor.

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MEN AND WOMEN WHO ARE NOT ABLE TO HAVE CHILDREN (INFERTILITY)

Sometimes a man and woman try to have children but the woman does not become pregnant. Either the man or woman may be infertile (unable to bring about pregnancy). Often nothing can be done to make a person fertile, but sometimes something can be done, depending on the cause.

COMMON CAUSES OF INFERTILITY:

  1. Sterility. The person’s body is such that he or she can never have children. Some men and women are born sterile.

  2. Weaknesses or a nutritional lack. In some women severe anemia, poor nutrition, or lack of iodine may lower the chance of becoming pregnant. Or it may cause the unformed baby (embryo) to die, perhaps before the mother even knows she is pregnant (see Miscarriage, page 281). A woman who is not able to become pregnant, or has had only miscarriages, should get enough nutritious food, use iodized salt, and if she is severely anemic, take iron pills (page 247). These may increase her chance of becoming pregnant and having a healthy baby.

  3. Chronic infection, especially pelvic inflammatory disease (see page 243) due to gonorrhea or chlamydia, is a common cause of infertility in women. Treatment may help, if the disease has not gone too far. Prevention and early treatment of gonorrhea and chlamydia mean fewer sterile women.

  4. Men are sometimes unable to make women pregnant because they have fewer sperm than is normal. It may help for the man to wait, without having sex, for several days before the woman enters her ‘fertile days’ each month, midway between her last menstrual period and the next (see Counting Days Method and Mucus Method, page 291 and page 292). This way he will give her his full amount of sperm when they have sex on days when she is able to become pregnant.

WARNING:

Hormones and other medicines commonly given to men or women who cannot have babies almost never do any good, especially in men. Home remedies and magic cures are not likely to help either. Be careful not to waste your money on things that will not help.

For a man or a woman who is not able to have a baby, there are still many ways to raise or support children and to lead a happy life:

• Perhaps you can arrange to care for or adopt children who are orphans or need a home. Many couples come to love such children just as if they were their own.

• Perhaps you can become a health worker or help your community in other ways. The love you would give to your children, you can give to others, and all will benefit.

• You may live in a village where people look with shame on a woman who cannot have children. Perhaps you and others can form a group to help care for people with special needs or to make other contributions to the community, and to show that having babies is not the only thing that makes a woman worthwhile.

19

infos for mothers and midwives

MENSTRUAL PERIOD (monthly bleeding in women)

Most girls have their first ‘period’ or monthly bleeding between the ages of 11 and 16. This means that they are now old enough to become pregnant.

The normal period comes once every 28 days or so, and lasts 3 to 6 days However, this varies a lot in different women.

Irregular or painful periods are common in adolescent (teenage) girls. This does not usually mean there is anything wrong.

If your menstrual period is painful:

  • There is no need for you to stay in bed. In fact, lying quietly can make the pain worse.

  • It often helps to walk around and do light work or exercises…

  • or to take hot drinks, or put your feet in hot water.

If it is very painful, it may help to take aspirin (page 378) or ibuprofen (page 379) and to lie down and put warm compresses on the belly.

During the period, as at all times, a woman should take care to keep clean, get enough sleep, and eat a well balanced diet. She can eat everything she normally eats and can continue to do her usual work. It is not harmful to have sex during the menstrual period. (However, if one of the partners has HIV, the risk of infecting the other partner may be higher.)

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Signs of menstrual problems:

• Some irregularity in the length of time between periods is normal for certain women, but for others it may be a sign of chronic illness, anemia, malnutrition, tuberculosis, worsening HIV infection, or possibly an infection or tumor in the womb.

• If a period does not come when it should, this may be a sign of pregnancy. But for many girls who have recently begun to menstruate, and for women over 40, it is often normal to miss or have irregular periods. Worry or emotional upset may also cause a woman to miss her period.

• If the bleeding comes later than expected, is more severe, and lasts longer, it may be a miscarriage (see page 281).

• If the menstrual period lasts more than 6 days, results in unusually heavy bleeding, or comes more than once a month, seek medical advice.

THE MENOPAUSE (when women stop having periods)

The menopause or climacteric is the time in a woman’s life when the menstrual periods stop coming. After menopause, she can no longer bear children. In general, this ‘change of life’ happens between the ages of 40 and 50. The periods often become irregular for several months before they stop completely.

There is no reason to stop having sex during or after the menopause. But a woman can still become pregnant during this time. If she does not want to have more children, she should continue to use birth control for 12 months after her periods stop.

When menopause begins, a woman may think she is pregnant.

And when she bleeds again after 3 or 4 months, she may think she is having a miscarriage. If a woman of 40 or 50 starts bleeding again after some months without, explain to her that it may be menopause.

During menopause, it is normal to feel many discomforts, anxiety, distress, ‘hot flashes’ (suddenly feeling uncomfortably hot), pains that travel all over the body, sadness, etc. After menopause is over, most women feel better again.

Women who have severe bleeding or a lot of pain in the belly during menopause, or who begin to bleed again after the bleeding has stopped for months or years, should seek medical help. An examination is needed to make sure they do not have cancer or another serious problem (see page 280).

After menopause, a woman’s bones may become weaker and break more easily. To prevent this, it helps to eat foods with calcium (see page 116).

Because she will not have any more children, a woman may be more free now to spend time with her grandchildren or to become more active in the community. Some become midwives or health workers at this time in their lives.

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PREGNANCY

Signs of pregnancy:

All these signs are normal:

• The woman misses her period (often the first sign).

• ‘Morning sickness’ (nausea or feeling you are going to vomit, especially in the morning). This is worse during the second and third months of pregnancy.

• She may have to urinate more often.

• The belly gets bigger.

• The breasts get bigger or feel tender.

• ‘Mask of pregnancy’ (dark areas on the face, breasts, and belly).

This is the normal position of the baby in the mother at 9 months.

• Finally, during the fifth month or so, the child begins to move in the womb. For more information on pregnancy and birth, see A Book for Midwives.

How to Stay Healthy during Pregnancy

♦ Most important is to eat enough to gain weight regularly especially if you are thin. It is also important to eat well. The body needs food rich in proteins, vitamins, and minerals, especially iron (see Chapter 11).

♦ Use iodized salt to increase the chances that the child will be born alive and will not have learning difficulties. (But to avoid swelling of the feet and other problems, do not use very much salt.)

♦ Keep clean. Bathe or wash regularly and brush your teeth every day.

♦ In the last month of pregnancy, do not use a vaginal douche.

♦ Avoid taking medicines. Some medicines can harm the developing baby. As a rule, only take medicines recommended by a health worker or doctor. (If a health worker is going to prescribe a medicine, and you think that you might be pregnant, tell her so.) You can take acetaminophen, or antacids once in a while if you need them. Vitamin and iron pills are often helpful and do no harm when taken in the right dosage. Get tested for HIV. Medicines that fight HIV can prevent the spread of HIV to the developing baby (see page 398).

♦ Do not smoke or drink during pregnancy. Smoking and drinking are bad for the mother and harm the developing baby.

♦ Stay far away from children with measles, especially German measles (see Rubella, page 312).

♦ Try to rest more, but also get some exercise.

♦ Avoid poisons and chemicals. They can harm the developing baby. Do not work near pesticides, herbicides, or factory chemicals, and do not store food in their containers. Try not to breathe fumes or powders from chemicals.

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Minor Problems during Pregnancy

  1. Nausea or vomiting: Normally, this is worse in the morning, during the second or third month of pregnancy. It helps to eat something dry, like crackers or dry bread, before you go to bed at night and before you get out of bed in the morning. Do not eat large meals but rather smaller amounts of food several times a day. Avoid greasy foods. Tea made from mint leaves also helps. In severe cases, take an antihistamine (see page 385) when you go to bed and when you get up in the morning.

  2. Burning or pain in the pit of the stomach or chest (acid indigestion and heartburn, see page 128): Eat only small amounts of food at one time and drink water often. Antacids can help, especially those with calcium carbonate (see page 381). It may also help to suck hard candy. Try to sleep with the chest and head lifted up some with pillows or blankets.

  3. Swelling of the feet: Rest at different times during the day with your feet up (see page 176). Eat less salt and avoid salty foods. Tea made from maize silk (corn silk) may help (see page 12). If the feet are very swollen, and the hands and face also swell, seek medical advice. Swelling of the feet usually comes from the pressure of the child in the womb during the last months. It is worse in women who are anemic or malnourished. So eat plenty of nutritious food.

  4. Low back pain: This is common in pregnancy. It can be helped by exercise and taking care to stand and sit with the back straight (page 174).

  5. Anemia and malnutrition: Many women in rural areas are anemic even before they are pregnant, and become more anemic during pregnancy. To make a healthy baby, a woman needs to eat well. If she is very pale and weak or has other signs of anemia and malnutrition (see page 107 and 124), she needs to eat more protein and food with iron. Beans, groundnuts, chicken, milk, cheese, eggs, meat, fish, and dark green leafy vegetables are good choices. She should also take iron pills (page 392), especially if it is hard to get enough nutritious foods. This way she will strengthen her blood to resist dangerous bleeding after childbirth. If possible, iron pills should also contain some folic acid and vitamin C. (Vitamin C helps the body make better use of the iron.)

  6. Swollen veins (varicose veins): These are common in pregnancy, due to the weight of the baby pressing on the veins that come from the legs. Put your feet up often, as high as you can (see page 175). If the veins get very big or hurt, wrap them like this with an elastic bandage, or use elastic stockings. Take off the bandage or stockings at night.

  7. Piles (hemorrhoids): These are varicose veins in the anus. They result from the weight of the baby in the womb. To relieve the pain, kneel with the buttocks in the air like this: Or sit in a warm bath. Also see page 175.

  8. Constipation: Drink plenty of water. Eat fruits and food with a lot of natural fiber, like cassava or bran. Get plenty of exercise. Do not take strong laxatives.

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Danger Signs in Pregnancy

  1. Bleeding: If a woman begins to bleed during pregnancy, even a little, this is a danger sign. She could be having a miscarriage (losing the baby, page 281) or the baby could be developing outside the womb (ectopic pregnancy, see page 280). The woman should lie quietly and send for a health worker.

Bleeding late in pregnancy (after 6 months) may mean the placenta (afterbirth) is blocking the birth opening (placenta previa). Without expert help, the woman could quickly bleed to death. Do not do a vaginal exam or put anything inside her vagina. Try to get her to a hospital at once.

  1. Severe anemia: The woman is weak, tired, and has pale or transparent skin (see The Signs of Anemia, page 124). If not treated, she might die from blood loss at childbirth. If anemia is severe, a good diet is not enough to correct the condition in time. See a health worker and get iron sulfate pills (see page 392). If possible, she should have her baby in a hospital, in case extra blood is needed.

  2. High blood pressure or other signs of pre-eclampsia: Blood pressure of 140/90 or greater can be a sign of a serious problem called pre-eclampsia (toxemia). A lot of protein in the urine, sudden weight gain, and swelling are other important signs. Pre-eclampsia can lead to seizures (convulsions, fits) and even death.

If a woman has high blood pressure, ask her to lie down and rest more often. Help her get plenty of good foods and to eat a lot of protein (page 110). She should avoid salty packaged foods and snacks. Re-check her blood pressure in a few days.

If you cannot check for high blood pressure or protein in the urine, watch for these other signs of pre-eclampsia:

• Swollen face, or swelling all over in the morning upon awakening

• Headaches

• Dizziness

• Blurred vision

• Pain high in the belly

If her blood pressure keeps going up (to 160/110 or higher) or if she shows any of these signs , get medical help fast! If she is already having seizures, see page 178.

HIV and Pregnancy

If the mother has HIV, HIV can spread to her baby while it is still in her womb or during birth. Medicines can help prevent the baby from getting HIV. Talk to a health worker who has experience working with people who have HIV, and see page 398 for more information.

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check-ups during pregnancy (prenatal care)

Many health centers and midwives encourage pregnant women to come for regular prenatal (before birth) check ups and to talk about their health needs. If you are pregnant and have the chance to go for these check–ups, you will learn many things to help you prevent problems and have a healthier baby.

If you are a midwife, you can provide an important service to mothers-to-be (and babies-to-be) by inviting them to come for prenatal check-ups, or by going to see them. It is a good idea to see them once a month for the first 6 months of pregnancy, twice a month during months 7 and 8, and once a week during the last month.

Here are some important things prenatal care should cover:

  1. Sharing information

Ask the mother about her problems and needs. Find out how many pregnancies she has had, when she had her last baby, and any problems she may have had during pregnancy or childbirth. Talk with her about ways she can help herself and her baby be healthy, including:

Eating right. Encourage her to eat enough energy foods, and also foods rich in protein, vitamins, iron, and calcium (see Chapter 11).

Good hygiene (Chapter 12 and page 242).

♦ The importance of taking few or no medicines (page 54)

♦ The importance of not smoking (page 149), not drinking alcoholic drinks (page 148), and not using drugs (pages 416 and 417).

♦ Getting enough exercise and rest.

Tetanus vaccination to prevent tetanus in the newborn. (Give at the 6th, 7th, and 8th month if first time. If she has been vaccinated against tetanus before, give one booster during the 7th month.)

  1. Nutrition

Does the mother look well nourished? Is she anemic? If so, discuss ways of eating better. If possible, see that she gets iron pills preferably with folic acid and vitamin C. Advise her about how to handle morning sickness (page 248) and heartburn (page 128).

Is she gaining weight normally? If possible, weigh her each visit. Normally she should gain 8 to 10 kilograms during the nine months of pregnancy. If she stops gaining weight, this is a bad sign. Sudden weight gain in the last months is a sign of pre-eclampsia. If you do not have scales, try to judge if she is gaining weight by how she looks.

Or make a simple scale: bricks or other objects of known weight

Ask the mother if she has any of the common problems of pregnancy.

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  1. Minor problems that they are not serious, and give what advice you can (see page 248).

  2. Signs of danger and special risk Check for each of the danger signs on page 249. Take the mother’s pulse each visit. This will let you know what is normal for her in case she has problems later (for example, shock from pre-eclampsia or severe bleeding). If you have a blood pressure cuff, take her blood pressure (see page 410). And weigh her.

Watch out especially for the following danger signs of pre-eclampsia: (page 249)

• high blood pressure (140/90 or greater)

• protein in the urine }

• sudden weight gain

• swelling of hands and face

• headaches

• dizziness and blurred vision

• pain high in the belly

Some midwives may have paper ‘dip sticks’ or other methods for measuring the protein and sugar in the urine. High protein may be a sign of pre-eclampsia. High sugar could be a sign of diabetes (page 127).

If any of the danger signs appear, see that the woman gets medical help as soon as possible. Also, check for signs of special risk, page 256. If any are present, it is safer if the mother gives birth in a hospital.

  1. Growth and position of the baby in the womb

Feel the mother’s womb each time she visits; or show her how to do it herself.

Each month write down how many finger widths the womb is above or below the navel. If the womb seems too big or grows too fast, it may mean the woman is having twins. Or the womb may have more water in it than normal. If so, you may find it more difficult to feel the baby inside. Too much water in the womb means greater risk of severe bleeding during childbirth and may mean the baby is deformed.

Try to feel the baby’s position in the womb. If it appears to be lying sideways, the mother should go to a doctor before labor begins, because an operation may be needed. For checking the baby’s position near the time of birth, see page 257. Normally the womb will be 2 fingers higher each month.

At 4 1⁄2 months it is usually at the level of the navel.

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  1. Baby’s heartbeat (fetal heartbeat) and movement

After 5 months, listen for the baby’s heartbeat and check for movement. You can try putting your ear against the belly, but it may be hard to hear. It will be easier if you get a fetoscope.

(Or make one. Fired clay or hard wood works well.)

If the baby’s heartbeat is heard loudest below the navel in the last month, the baby’s head is down and will probably be born head first.

If the heartbeat is heard loudest above the navel, his head is probably up.

It may be a breech birth.

A baby’s heart beats about twice as fast as an adult’s. If you have a watch with a second hand, count the baby’s heartbeats.

From 120 to 160 per minute is normal. If less than 120, something is wrong. (Or perhaps you counted wrong or heard the mother’s heartbeat. Check her pulse. The baby’s heartbeat is often hard to hear. It takes practice.)

  1. Preparing the mother for labor As the birth approaches, see the mother more often. If she has other children, ask her how long labor lasted and if she had any problems. Perhaps suggest that she lie down to rest after eating, twice a day for an hour each time. Talk with her about ways to make the birth easier and less painful (see the next pages). You may want to have her practice deep, slow breathing, so that she can do this during the contractions of labor. Explain to her that relaxing during contractions, and resting between them, will help her save strength, reduce pain, and speed labor.

If there is any reason to suspect the labor may result in problems you cannot handle, send the mother to a health center or hospital to have her baby. Be sure she is near the hospital by the time labor begins.

how a mother can tell the date when she is likely to give birth

Start with the date the last menstrual period began, subtract 3 months, and add 7 days. For example, suppose your last period began May 10.

May 10 minus 3 months is February 10, plus 7 days is February 17.

The baby is likely to be born around February 17.

  1. Keeping records

To compare your findings from month to month and see how the mother is progressing, it helps to keep simple records. On the next page is a sample record sheet. Change it as you see fit. A larger sheet of paper would be better. Each mother can keep her own record sheet and bring it when she comes for her check-up.

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record of prenatal care

Make a table and annotate:

  • NAME

  • AGE

  • NUMBER OF CHILDREN

  • AGES

  • DATE OF LAST CHILDBIRTH

  • DATE OF LAST MENSTRUAL PERIOD

  • PROBABLE DATE FOR BIRTH

  • PROBLEMS WITH OTHER BIRTHS

annotate months in the first colunm

  • 1

  • 2

  • and so on

annotate in the other columns for each month:

  • DATE OF VISIT

  • WHAT AFTEN HAPPENS

  • GENERAL HEALTH AND MINOR PROBLEMS

  • ANEMIA (how severe?)

  • DANGER SIGNS (see page 249)

  • SWELLING (where? how much?)

  • PULSE

  • TEMP.

  • WEIGHT (estimate or measure)

  • BLOOD PRESSURE *

  • PROTEIN IN URINE *

  • SUGAR IN URINE *

  • POSITION OF BABY IN WOMB

  • SIZE OF WOMB (how many fingers above (+) or below (–) the navel?)

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things a mother should have ready before giving birth

Every pregnant woman should have the following things ready by the seventh month of pregnancy:

A lot of very clean cloths or rags.

A new razor blade. (Do not unwrap until you are ready to cut the umbilical cord.)

(If you do not have a new razor blade, have clean, rust-free scissors ready. Boil them just before cutting the cord.)

Two bowls, 1 for washing hands, 1 for catching and examining the afterbirth.

Two ribbons or strips of clean cloth for tying the cord. Both patches and ribbons should be wrapped and sealed in paper packets and then baked in an oven or ironed.

An antiseptic soap (or any soap).

A clean scrub brush for cleaning the hands and fingernails.

Alcohol for rubbing hands after washing them.

Clean cotton.

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Additional Supplies for the Well-Prepared Midwife or Birth Attendant

Flashlight (torch).

Suction bulb for sucking mucus out of the baby’s nose and mouth.

Sterile syringe and needles.

Several injections of oxytocin or ergonovine, or tablets of misoprostol (see pages 390 and 391).

HIV medicines for mother and baby if mother or father has HIV (see page 398).

Fetoscope, or fetal stethoscope, for listening to the baby’s heartbeat through the mother’s belly.

Blunt-tipped scissors for cutting the cord before the baby is all the way born (extreme emergency only).

Two clamps (hemostats) for clamping the umbilical cord or clamping bleeding veins from tears of birth opening. Rubber or plastic gloves (that can be sterilized by boiling, see page 74) to wear while examining the woman, while the baby is coming out, when sewing tears in the birth opening, and for catching and examining afterbirth.

Sterile needle and gut thread for sewing tears in the birth opening.

Tetracycline or erythromycin eye ointment for the baby’s eyes to prevent dangerous infection (see page 221).

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PREPARING FOR BIRTH

Birth is a natural event. When the mother is healthy and everything goes well, the baby can be born without help from anyone. In a normal birth, the less the midwife or birth attendant does, the more likely everything will go well.

Difficulties in childbirth do occur, and sometimes the life of the mother or child may be in danger. If there is any reason to think that a birth may be difficult or dangerous, a skilled midwife or experienced doctor should be present.

CAUTION: If you have a fever, cough, sore throat, or sores or infections on your skin at the time of the birth, it would be better for someone else to deliver the baby.

Signs of Special Risk that Make it Important that a Doctor or Skilled Midwife Attend the Birth, if Possible in a Hospital:

• If regular labor pains begin more than 3 weeks before the baby is expected.

• If the woman begins to bleed before labor.

• If there are signs of pre-eclampsia (see page 249).

• If the woman is suffering from a chronic or acute illness.

• If the woman is very anemic or if her blood does not clot normally (when she cuts herself).

• If she is under 15 or over 40, or if it is her first pregnancy and she is over 35.

• If she has had more than 5 or 6 babies.

• If she is especially short or has narrow hips (page 267).

• If she has had serious trouble or severe bleeding with other births.

• If she has diabetes or heart trouble.

• If she has a hernia.

• If it looks like she will have twins (see page 269).

• If it seems the baby is not in a good position (head down) in the womb.

• If the bag of waters breaks and labor does not begin within a few hours. (The danger is even greater if there is fever.)

• If the baby is still not born 2 weeks after 9 months of pregnancy.

the first birth and the last births after having many children

THE BIRTHS WITH THE GREATEST CHANCE OF PROBLEMS ARE:

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Checking if the Baby Is in a Good Position

To make sure the baby is head down, in the normal position for birth, feel for his head, like this:

  1. Have the mother breathe out all the way. With the thumb and 2 fingers, push in here, just above the pelvic bone.

With the other hand, feel the top of the

The baby’s butt is larger and wider. His head is hard and round. womb.

Butt up feels larger high up.

Butt down feels larger low down.

  1. Push gently from side to side, first with one hand, then the other.

If the baby’s butt is pushed gently sideways, the baby’s whole body will move too.

But if the head is pushed gently sideways, it will bend at the neck and the back will not move.

If the baby still is high in the womb, you can move the head a little. But if it has already engaged (dropped lower) getting ready for birth, you cannot move it.

A woman’s rst baby sometimes engages 2 weeks before labor begins. Later babies may not engage until labor starts.

If the baby’s head is down, his birth is likely to go well.

If the head is up, the birth may be more difficult (a breech birth), and it is safer for the mother give birth in or near a hospital.

If the baby is sideways, the mother should have her baby in a hospital. She and the baby are in danger (see page 267).

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signs that show labor is near

• A few days before labor begins, usually the baby moves lower in the womb. This lets the mother breathe more easily, but she may need to urinate more often because of pressure on the bladder. (In the first birth these signs can appear up to 4 weeks before delivery.)

• A short time before the labor begins, some thick mucus (jelly) may come out. Or some mucus may come out for 2 or 3 days before labor begins. Sometimes it is tinted with blood. This is normal.

• The contractions (sudden tightening of the womb) or labor pains may start up to several days before childbirth at first a long time usually passes between contractions, several minutes or even hours. When the contractions become stronger, regular, and more frequent, labor is beginning.

• Some women have a few practice contractions weeks before labor. This is normal. On rare occasions, a woman may have false labor. This happens when the contractions are coming strong and close together, but then stop for hours or days before childbirth actually begins. Sometimes walking, a warm bath, or resting will help calm the contractions if they are false, or bring on childbirth if they are real. Even if it is false labor, the contractions help to prepare the womb for labor.

• The bag of water that holds the baby in the womb usually breaks with a flood of liquid sometime after labor has begun. If the waters break before the contractions start, this usually means the beginning of labor. After the waters break, the mother should keep very clean. Walking back and forth may help bring on labor more quickly. To prevent infection, avoid sexual intercourse, do not sit in a bath of water, and do not douche or put anything in the vagina. If labor does not start within 12 hours, seek medical help.

Labor pains are caused by contractions or tightening of the womb. Between contractions the womb is relaxed like this:

During contractions, the womb tightens and lifts up like this:

The contractions push the baby down farther. This causes the cervix or ‘door of the womb’ to open, a little more each time.

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the stages of labor

Labor has 3 parts or stages:

• The first stage lasts from the beginning of the strong contractions until the womb opens and the baby starts to move through the birth canal.

• The second stage lasts from when the baby enters the birth canal until it is born.

• The third stage lasts from the birth of the baby until the placenta (afterbirth) comes out.

THE FIRST STAGE OF LABOR usually lasts 10 to 20 hours or more when it is the mother’s first birth, and from 7 to 10 hours in later births. This varies a lot.

During the first stage of labor, the mother should not try to hurry the birth. It is natural for this stage to go slowly. The mother may not feel the progress and begin to worry. Try to reassure her. Tell her that most women have the same concern.

The mother should not try to push or bear down until the child is beginning to move down into the birth canal, and she feels she has to push.

The mother should keep her bowels and bladder empty.

If the bladder and the bowels are full, they get in the way when the baby is being born.

Bladder full of urine

Feces (stools)

During labor, the mother should urinate often. If she has not moved her bowels in several hours, an enema may make labor easier. During labor the mother should drink water or other liquids often. Too little liquid in the body can slow down or stop labor. If labor is long, she should eat lightly, as well. If she is vomiting, she should sip a little Rehydration Drink, herbal tea, or fruit juices between each contraction.

During labor the mother should change positions often or get up and walk about from time to time. She should not lie flat on her back for a long time.

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During the first stage of labor, the midwife or birth attendant should:

♦ Wash the mother’s belly, genitals, buttocks, and legs well with soap and warm water. The bed should be in a clean place with enough light to see clearly.

♦ Spread clean sheets, towels, or newspapers on the bed and change them whenever they get wet or dirty.

♦ Have a new, unopened razor blade ready for cutting the cord, or boil a pair of scissors for 15 minutes. Keep the scissors in the boiled water in a covered pan until they are needed.

The midwife should not massage or push on the belly. She should not ask the mother to push or bear down at this time.

If the mother is frightened or in great pain, have her take deep, slow, regular breaths during each contraction, and breathe normally between them. This will help control the pain and calm her. Reassure the mother that the strong pains are normal and that they help to push her baby out.

THE SECOND STAGE OF LABOR, in which the child is born: Sometimes this begins when the bag of water breaks. It is often easier than the first stage and usually does not take longer than 2 hours. During the contractions the mother bears down (pushes) with all her strength. Between contractions, she may seem very tired and half asleep. This is normal.

To bear down, the mother should take a deep breath and push hard with her stomach muscles, as if she were having a bowel movement. If the child comes slowly after the bag of waters breaks, the mother can double her knees like this, while squatting, sitting propped up, kneeling, or lying down.

When the birth opening of the mother stretches, and the baby’s head begins to show, the midwife or helper should have everything ready for the birth of the baby. At this time the mother should try not to push hard, so that the head comes out more slowly. This helps prevent tearing of the opening (see page 269 for more details).

In a normal birth, the midwife NEVER needs to put her hand or finger inside the mother. This is the most common cause of dangerous infections of the mother after the birth.

When the head comes out, the midwife may support it, but must never pull on it.

If possible, wear gloves to attend the birth, to protect the health of the mother, baby, and midwife.

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Normally the baby is born head first like this:

Now push hard.

Now try not to push hard. Take many short, fast breaths. This helps prevent tearing the opening (see page 269). The head usually comes out face down. If the baby has feces (shit) in her mouth and nose, clean it out immediately (see page 262).

Then the baby’s body turns to one side so the shoulders can come out.

If the shoulders get stuck after the head comes out: The midwife can take the baby’s head in her hands and lower it very carefully, so the shoulder can come out. Then she can raise the head a little so that the other shoulder comes out.

All the force must come from the mother. The midwife should never pull on the head, or twist or bend the baby’s neck, because this can harm the baby.

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THE THIRD STAGE OF LABOR begins when the baby has been born and lasts until the placenta (afterbirth) comes out. Usually, the placenta comes out by itself 5 minutes to an hour after the baby. In the meantime, care for the baby. If there is a lot of bleeding (see page 265) or if the placenta does not come out within 1 hour, seek medical help.

CARE OF THE BABY AT BIRTH

Immediately after the baby comes out:

♦ Put the baby’s head down so that the mucus comes out of his mouth and throat. Keep it this way until he begins to breathe.

♦ Keep the baby below the level of the mother until the cord is tied. (This way, the baby gets more blood and will be stronger.)

♦ Dry the baby and if he does not begin to breathe right away, rub his back with a towel or a cloth.

♦ If he still does not breathe, clean the mucus out of his nose and mouth with a clean cloth wrapped around your finger.

♦ If the baby has not begun to breathe within one minute after birth, start MOUTH-TO-MOUTH BREATHING at once (see page 80).

♦ Wrap the baby in a clean cloth. It is very important not to let him get cold, especially if he is premature (born too early).

How to Cut the Cord

When the child is born, the cord pulses and is fat and blue. WAIT.

After a while, the cord becomes thin and white. It stops pulsing. Now tie it in 2 places with very clean, dry strips of cloth, string, or ribbon. These should have been recently ironed or heated in an oven. Cut between the ties, like this:

IMPORTANT: Cut the cord with a clean, unused razor blade. Before unwrapping it, wash your hands very well. Or wear clean rubber or plastic gloves. If you do not have a new razor blade, use freshly boiled scissors. Always cut the cord close to the body of the newborn baby. Leave only about 2 centimeters attached to the baby. These precautions help prevent tetanus (see page 182).

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Keep the cord stump clean and dry. Always wash your hands before touching the cord stump.

If the stump or belly button becomes dirty or caked with dried blood, clean with soap and cool boiled water and a very clean cloth. Do not put anything else on the cord, dirt and dung are especially dangerous. They can cause tetanus and kill the baby, see pages 182 to 184.

If the baby is wearing diapers, keep the diaper folded below the cord.

If the cord or the area around the cord gets red, drains pus, or smells bad, it is probably infected. Clean it well and give the baby amoxicillin (page 353).

The cord stump usually falls off 5 to 7 days after birth. There may be a few drops of blood or smooth mucus when the cord falls off.

This is normal. But if there is a lot of blood or any pus, get medical help.

Cleaning the Newborn Baby

With a warm, soft, damp cloth, gently clean away any blood or fluid.

It is better not to bathe the baby until after the cord drops off. Then bathe him daily in warm water, using a mild soap.

Put the Newborn Baby to the Breast at Once

Place the baby at its mother’s breast as soon as the baby is born. If the baby breastfeeds, this will help to make the afterbirth come out sooner and to prevent or control heavy bleeding.

Care of the Cut Cord

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the delivery of the placenta (afterbirth)

Normally, the placenta comes out 5 minutes to hour after the baby is born, but sometimes it is delayed (see below).

Checking the afterbirth:

When the afterbirth comes out, pick it up and examine it to see if it is complete. If it is torn and there seem to be pieces missing, get medical help. A piece of placenta left inside the womb can cause continued bleeding or infection.

When the placenta is delayed in coming:

Use gloves or plastic bags on your hands to handle the placenta. Wash your hands well afterwards.

If the mother is not losing much blood, do nothing. Do not pull on the cord. This could cause dangerous hemorrhage (heavy bleeding). Sometimes the placenta will come out if the woman squats and pushes a little.

If the mother is losing blood, feel the womb (uterus) through the belly. If it is soft, do the following: Massage the womb carefully, until it gets hard. This should make it contract and push out the placenta.

If the placenta does not come out soon and bleeding continues, push downward on the top of the womb very carefully, while supporting the bottom of the womb like this.

If the placenta still does not come out, and the bleeding continues, give medicines to control the bleeding (see page 266) and seek medical help fast.

hemorrhaging (heavy bleeding)

When the placenta comes out, there is always a brief flow of blood. It normally lasts only a few minutes and not more than a quarter of a liter (1 cup) of blood is lost. (A little bleeding may continue for several days and is usually not serious.)

WARNING: Sometimes a woman may be bleeding severely inside without much blood coming out. Feel her belly from time to time. If it seems to be getting bigger, it may be filling with blood. Check her pulse often and watch for signs of shock (page 77).

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♦ If you have oxytocin or misoprostol, use it, following the instructions on the next page.

♦ Rub the woman’s womb after the birth of the placenta every 15 minutes or so, and anytime you notice bleeding. Rub hard and deep, until the womb feels like a hard, round ball in the center of the belly, below the belly button. If the womb is off to one side, the bladder is full and the woman should urinate.

♦ To help prevent or control heavy bleeding, let the baby suck the mother’s breast. If the baby will not suck, have someone else suck or gently pull and massage the mother’s nipples. This will cause her to produce a hormone that helps control bleeding.

♦ The mother should drink a lot of liquid (water, fruit juices, tea, soup, or Rehydration Drink, page 152). If she grows faint or has a fast, weak pulse or shows other signs of shock, put her legs up and her head down (see page 77).

If heavy bleeding continues, or if the mother is losing a great deal of blood through a slow trickle, do the following:

♦ Get medical help fast. If the bleeding does not stop quickly, the mother may need to be given serum blood in a vein (a transfusion).

♦ Keep massaging the womb. Rub harder, squeezing the womb between two hands. It will hurt, but should work. Rub the womb until it is hard. Then cup 1 hand on the top of the womb.

Put your other hand, in a st, at the bottom of the womb.

If the bleeding still does not stop, you can put one hand inside the vagina, make a fist, and then use the other hand to press the womb into your fist. Note: Although some doctors use it, vitamin K does not help stop bleeding related to childbirth, miscarriage, or abortion. Vitamin K is only helpful for babies. Do not give to adults.

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medicines to control bleeding after birth or miscarriage

Oxytocin, misoprostol, and ergometrine (ergonovine) are medicines that cause the uterus and its blood vessels to contract. They are important but dangerous drugs. Used the wrong way, or before the baby is born, they can cause the death of the mother or the child in her womb. Used correctly, they can save lives. These are their lifesaving uses:

  1. To control heavy bleeding before the placenta comes out. Inject 10 units of oxytocin in the buttock or thigh muscle one time only (page 390). If there is no oxytocin, you can use misoprostol instead. Give 800 mcg to dissolve under the tongue (page 391).

  2. If the bleeding starts after the placenta comes out. Inject 10 units of oxytocin in the buttock or thigh muscle. You can give this dose again in 20 minutes if bleeding does not stop. Or, give the woman 800 mcg of misoprostol to dissolve under the tongue (page 391). Or, you can give ergometrine (page 390), but do not use ergometrine for a woman who has hypertension or before the placenta is out.

IMPORTANT: Midwives and other health workers who help women deliver should carry enough medicines to stop heavy bleeding if it happens. Too many mothers bleed to death who could be saved.

  1. To help prevent heavy bleeding after birth. Some authorities now recommend giving all women a single dose of oxytocin, misoprostol, or ergometrine to prevent heavy bleeding after birth. This will prevent some dangerous bleeding, but also treats many women with medicine when they do not need it. A midwife who only has a little medicine may choose to save the medicine she has for emergencies.

  2. To control the bleeding of a miscarriage (page 281). If the woman is rapidly losing blood and medical help is far away, use oyxtocin, misoprostol, or ergometrine as suggested above.

WARNING: The use of oxytocin, misoprostol, or ergometrine to hasten childbirth or give strength to the mother’s labor is very dangerous for both her and the child. These medicines are rarely needed before the baby is born, and then only a highly trained birth attendant should use them.

THE USE OF MEDICINES TO ‘GIVE STRENGTH’ TO THE MOTHER DURING CHILDBIRTH… CAN KILL THE MOTHER, THE BABY, OR BOTH.

There is no safe medicine to give strength to the mother or to make the birth quicker or easier.

If you want the woman to have enough strength for childbirth, have her eat plenty of nutritious foods, especially during the 9 months of pregnancy (see page 107).

Also encourage her to space a few years between her pregnancies so her body can regain its full strength (see Family Planning, page 283).

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DIFFICULT BIRTHS

It is important to get medical help as quickly as possible when there is any serious problem during labor. Many problems or complications may come up, some more serious than others. Here are a few of the more common ones:

  1. LABOR STOPS OR SLOWS DOWN, or lasts a very long time after being strong or after the waters break. This has several possible causes:

• The woman may be frightened or upset. This can slow down or even stop contractions. Talk to her. Help her to relax. Try to reassure her. Explain that the birth is slow, but there are no serious problems. Encourage her to change her position often and to drink, eat, and urinate. Stimulation (massage or milking motion) of the nipples can help speed labor.

• The baby may be in an unusual position. Feel the belly between contractions to see if the baby is sideways. Sometimes the midwife can turn the baby through gentle handling of the woman’s belly. Try to work the baby around little by little between contractions, until the head is down. But do not use force as this could tear the womb or placenta, or pinch the cord. If the baby cannot be turned, try to get the mother to the hospital.

• If the baby is facing forward rather than backward, you may feel the lumpy arms and legs rather than the rounded back. This is usually no big problem, but labor may be longer and cause the woman more back pain. She should change positions often, as this may help turn the baby. Have her try on her hands and knees.

• The baby’s head may be too large to fit through the woman’s hip bones (pelvis). This is more likely in a woman with very narrow hips or a young woman or girl whose body is not fully grown. (It is very unlikely in a woman who has given normal birth before.) You may feel that the baby does not move down. If you suspect this problem, try to get the mother to a hospital as she may need an operation (Cesarean). Women who are of short stature (dwarfs), have very narrow hips or are especially young should have at least their first child in or near a hospital.

• If the mother has been vomiting or has not been drinking liquids, she may be dehydrated. This can slow down or stop contractions. Have her sip Rehydration Drink or other liquids after each contraction.

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  1. BREECH DELIVERY (the buttocks come out first). Sometimes the midwife can tell if the baby is in the breech position by feeling the mother’s belly (page 257) and listening to the baby’s heartbeat (page 252).

A breech birth may be easier in this position:

If the baby’s legs come out, but not the arms, wash your hands very well, rub them with alcohol (or wear sterile gloves), and then. . .

slip your fingers inside and push the baby’s shoulders toward the back, like this:

or press his arms against his body, like this:

If the baby gets stuck, have the mother lie face up.

Put your finger in the baby’s mouth and push his head towards his chest. At the same time have someone push the baby’s head down by pressing on the mother’s belly like this:

Have the mother push hard. But never pull on the body of the baby.

  1. PRESENTATION OF AN ARM (hand first). If the baby’s hand comes out first, get medical help right away. An operation may be needed to get the baby out.

  2. Sometimes the CORD IS WRAPPED AROUND THE BABY’S NECK so tightly he cannot come out all the way. Try to slip the loop of cord from around the baby’s neck. If you cannot do this, you may have to clamp or tie and cut the cord. Use boiled blunt tipped scissors.

  3. FECES IN THE BABY’S MOUTH AND NOSE. When the waters break, if you see they contain a dark green (almost black) liquid, this is probably the baby’s first stools (meconium). The baby may be in danger. If he breathes any of the feces into his lungs, he may die. As soon as his head is out, tell the mother not to push, but to take short, rapid breaths. Before the baby starts breathing, take time to suck the feces out of his nose and mouth with a suction bulb. Even if he starts breathing right away, keep sucking until you get all the feces out.

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  1. TWINS. Giving birth to twins is often more difficult and dangerous, both for the mother and babies, than giving birth to a single baby.

Because with twins labor often begins early, the mother should be within easy reach of a hospital after the seventh month of pregnancy.

Signs that a woman is likely to have twins:

• The belly grows faster and the womb is larger than usual, especially in the last months (see page 251)

• If the woman gains weight faster than normal, or the common problems of pregnancy (morning sickness, backache, varicose veins, piles, swelling, and difficult breathing) are worse than usual, be sure to check for twins.

• If you can feel 3 or more large objects (heads and buttocks) in a womb that seems extra large, twins are likely.

• Sometimes you can hear 2 different heartbeats (other than the mother’s), but this is difficult. During the last months, if the woman rests a lot and is careful to avoid hard work, twins are less likely to be born too early.

Twins are often born small and need special care. However, there is no truth in beliefs that twins have strange or magic powers.

tearing of the birth opening

The birth opening must stretch a lot for the baby to come out. Sometimes it tears. Tearing is more likely if it is the mother’s first baby.

To be safe, the mother should give birth to twins in a hospital.

Tearing can usually be prevented if care is taken: The mother should try to stop pushing when the baby’s head is coming out. This gives her birth opening time to stretch. In order not to push, she should pant (take many rapid breaths).

When the birth opening is stretching, the midwife can support it with one hand and with the other hand gently keep the head from coming too fast, like this: It may also help to put warm compresses against the skin below the birth opening. Start when it begins to stretch. You can also massage the stretched skin with oil.

If a tear does happen, someone who knows how should carefully sew it shut after the placenta comes out (see page 86 and 379).

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CARE OF THE NEWBORN BABY

The Cord

To prevent the freshly cut cord from becoming infected, it should be kept clean and dry. The drier it is, the sooner it will fall off and the navel will heal. For thiS reason, it is better not to use a belly band, or if one is used, to keep it very loose (see pages 184 and 263).

The Eyes

To protect a newborn baby’s eyes from dangerous conjunctivitis, put a line of 1% tetracycline or erythromycin 0.5% to 1% ointment in each eye within the first 2 hours (page 221 and 378). This is especially important if either parent has ever had signs of gonorrhea or chlamydia (page 236).

Keeping the Baby Warm, but Not Too Warm

Protect the baby from cold, but also from too much heat. Dress him as warmly as you feel like dressing yourself.

To keep a baby just warm enough, keep him close to his mother’s body. This is especially important for a baby that is born early or very small. See ‘Special Care for Small, Early, and Underweight Babies’, page 405.

Cleanliness

It is important to follow the Guidelines of Cleanliness as discussed in Chapter 12. Take special care with the following:

♦ Change the baby’s diapers (nappy) or bedding each time he wets or dirties them. If the skin gets red, change the diaper more often, or better, leave it off! (See page 215.)

♦ After the cord drops off, bathe the baby daily with mild soap and warm water.

♦ If there are flies or mosquitos, cover the baby’s crib with mosquito netting or a thin cloth.

♦ Persons with open sores, colds, sore throat, tuberculosis, or other infectious illnesses should not touch or go near the newborn baby or the woman while she is giving birth.

♦ Keep the baby in a clean place away from smoke and dust.

IN COLD WEATHER WRAP THE BABY WELL.

BUT IN HOT WEATHER (OR WHEN THE BABY HAS A FEVER) LEAVE HIM NAKED.

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(Also see “The Best Diet for Small Children,” page 120.)

Breast milk is by far the best food for a baby. Babies who nurse on breast milk are healthier, grow stronger, and are less likely to die. This is why:

• Breast milk has a better balance of what the baby needs than does any other milk, whether fresh, canned, or powdered.

• Breast milk is clean. When other foods are given, especially by bottle feeding, it is very hard to keep things clean enough to prevent the baby from getting diarrhea and other sicknesses.

• The temperature of breast milk is always right.

• Breast milk has things in it (antibodies) that help protect the baby against certain illnesses, such as diarrhea, measles, and polio.

The mother should give her breast to the baby as soon as he is born. For the first few days the mother’s breasts usually produce very little milk. This is normal. She should continue to nurse her baby often, at least every two hours. The baby’s sucking will help her produce more milk. If the baby seems healthy, gains weight, and wets her diaper (nappy) regularly, the mother is producing enough milk.

It is best for the baby if the mother gives him only breast milk for the first 6 months. After that, she should continue to breastfeed her baby, but should begin to give him other nourishing foods also (see page 122). Mothers with HIV should stop breastfeeding when the baby is 12 months old if they can give enough other nutritious foods.

how a mother can produce more breast milk:

She should…

♦ drink plenty of liquids,

♦ eat as well as possible, especially food with a lot of calcium (like milk products) and body building foods (see page 110),

♦ get plenty of sleep and avoid getting very tired or upset,

♦ nurse her baby more often, at least every 2 hours. Feeding

BOTTLE-FED BABIES ARE MORE LIKELY TO GET SICK AND DIE.

BREAST-FED BABIES ARE HEALTHIER.

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Care in Giving Medicines to the Newborn

Many medicines are dangerous for the newborn. Use only medicines you are sure are recommended for the newborn and use them only when they are absolutely necessary. Be sure you know the right dose and do not give too much.

Chloramphenicol, for example, is dangerous to newborns, especially if the baby is premature or underweight (less than 2 kilograms).

Sometimes it is important to give medicines to a newborn. For example, giving cotrimoxazole to a baby whose mother has HIV can protect the baby’s health. See page 357.

illnesses of the newborn

It is very important to notice any problem or illness a baby may have and to act quickly.

Problems the Baby Is Born With (Also see page 316)

These may result from something that went wrong with the development of the baby in the womb or from damage to the baby while he was being born. Examine the baby carefully immediately after birth. If he shows any of the following signs, something is probably seriously wrong with him:

• If he does not breathe as soon as he is born.

• If his pulse cannot be felt or heard, or is less than 100 beats per minute.

• If his face and body are white, blue, or yellow after he has begun breathing.

• If his arms and legs are floppy, he does not move them by himself or when you pinch them.

• If he grunts or has difficulty breathing after the first 15 minutes.

Some of these problems may be caused by brain damage at birth. They are almost never caused by infection (unless the water broke more than 12 hours before birth). Common medicines probably will not help. Keep the baby warm, but not too warm (see page 270). Try to get medical help. If the newborn baby vomits or shits blood, or develops many bruises, she may need vitamin K (see page 392). If the baby does not urinate or have a bowel movement in the first 2 days, also seek medical help. Problems that Result After the Baby Is Born (in the first days or weeks)

  1. Pus or a bad smell from the navel or cord is a dangerous sign. Watch for early signs of tetanus (page 182) or bacterial infection of the blood (page 275). Clean the cord carefully with soap and cool boiled water, and leave it open to the air. If the skin around the cord becomes hot and red, give the child amoxicillin (page 352).

Diseases that take days or weeks to kill adults can kill a baby in a matter of hours.

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  1. Either low temperature (below 35° C) or high fever can be a sign of infection. High fever (above 39° C) is dangerous for the newborn. Take off all clothing and sponge the baby with cool (not cold) water as shown on page 76. Also look for signs of dehydration (see page 151). If you find these signs, give the baby breast milk and also Rehydration Drink (page 152).

  2. Seizures (fits, convulsions, see page 178). If the baby also has fever, treat it as just described. Be sure to check for dehydration. Seizures that begin the day of birth could be caused by brain damage at birth. If seizures begin several days later, look carefully for signs of tetanus (page 182) or meningitis (page 185).

  3. The baby does not gain weight. During the first days of life, most babies lose a little weight. This is normal. After the first week, a healthy baby should gain about 200 g., a week. By two weeks the healthy baby should weigh as much as he did at birth. If he does not gain weight, or loses weight, something is wrong. Did the baby seem healthy at birth? Does he feed well? Examine the baby carefully for signs of infection or other problems. If you cannot find out the cause of the problem and correct it, get medical help.

  4. Vomiting. When healthy babies burp (or bring up air they have swallowed while feeding), sometimes a little milk comes up too. This is normal. Help the baby bring up air after feeding by holding him against your shoulder and patting his back gently, like this.

If a baby vomits when you lay him down after nursing, try sitting him upright for a while after each feeding. A baby who vomits violently, or so much and so often that he begins to lose weight or become dehydrated, is ill. If the baby also has diarrhea, he probably has a gut infection (page 157). Bacterial infection of the blood (see the next pages), meningitis (page 185), and other infections may also cause vomiting.

If the vomit is yellow or green, there may be a gut obstruction (page 94), especially if the belly is very swollen or the baby has not been having bowel movements. Take the baby to a health center at once.

  1. The baby stops sucking well. If more than 4 hours pass and the baby still will not nurse, this is a danger sign, especially if the baby seems very sleepy or ill, or if he cries or moves differently from normal. Many illnesses can cause these signs, but the most common and dangerous causes in the first 2 weeks of life are a bacterial infection of the blood (see next 2 pages) and tetanus (page 182).

burp your baby after feeding.

A baby who stops nursing during the second to fifth day of life may have a bacterial infection of the blood. A baby who stops nursing during the fifth to fifteenth day may have tetanus.

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If a Baby Stops Sucking Well or Seems Ill

Examine him carefully and completely as described in Chapter 3. Be sure to check the following:

• Notice if the baby has difficulty breathing. If the nose is stuffed up, suck out the mucus as shown on page 164. Fast breathing (60 or more breaths a minute), blue color, grunting, and sucking in of the skin between the ribs with each breath are signs of pneumonia (page 171). Small babies with pneumonia often do not cough; sometimes none of the common signs are present. If you suspect pneumonia, treat as for a bacterial infection of the blood (see the next page).

• Look at the baby’s skin color.

If the lips and face are blue, consider pneumonia (or a heart defect or other problem the baby was born with).

If the face and whites of the eyes begin to get yellow (jaundiced) in the first day of life or after the fifth day, this is serious. Get medical help. Some yellow color between the second and fifth day of life is usually not serious. Give plenty of breast milk by spoon if necessary. Take off all the baby’s clothes and put him in bright light near a window (but not direct sunlight).

• Feel the soft spot on top of the head (fontanel). See page 9.

IMPORTANT:

If a baby has meningitis and dehydration at the same time, the soft spot may feel normal. Be sure to check for other signs of both dehydration (see page 151) and meningitis (see page 185).

• Watch the baby’s movements and expression on his face. Stiffness of the body or strange movements may be signs of tetanus, meningitis, or brain damage from birth. If, when the baby is touched or moved, the muscles of his face and body suddenly tighten, this could be tetanus. See if his jaw will open and check his knee reflexes (page 183).

If the soft spot is SUNKEN, the baby may be DEHYDRATED.

If the soft spot is SWOLLEN, the baby may have MENINGITIS.

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If the baby’s eyes roll back or flutter when he makes sudden or violent movements, he probably does not have tetanus. Such seizures may be caused by meningitis, but dehydration and high fever are more common causes. Can you put the baby’s head between his knees? If the baby is too stiff for this or cries out in pain, it is probably meningitis (see page 185).

• Look for signs of a bacterial infection in the blood.

Bacterial Infection in the Blood (Septicemia)

Newborn babies cannot fight infections well. Therefore, bacteria that enter the baby’s skin or cord at the time of birth often get into the blood and spread through his whole body. Since this takes a day or two, septicemia is most common after the second day of life.

Signs:

Signs of infection in newborn babies are different from those in older children. In the baby, almost any sign could be caused by a serious infection in the blood.

Possible signs are:

• does not suck well

• seems very sleepy

• very pale (anemic)

• vomiting or diarrhea

• fever or low temperature (below 35° C)

• swollen belly

• yellow skin (jaundice)

• seizures (convulsions)

• times when the baby turns blue

Each of these signs may be caused by something other than septicemia, but if the baby has several of these signs at once, septicemia is likely.

Newborn babies do not always have a fever when they have a serious infection. The temperature may be high, low, or normal.

Treatment when you suspect septicemia in the newborn:

♦ Inject 50 mg. of ampicillin (page 352) for each kilogram the baby weighs, 2 times a day for a baby less than 1 week old or 3 times a day if the baby is older than 1 week. If you cannot calculate the dosage, inject the average dose of 150 mg. of ampicillin.

♦ Also inject 5 mg. of gentamicin for each kilogram the baby weighs. Only give gentamicin once a day. If you cannot calculate the dosage, inject the average dose of 15 mg. of gentamicin for a baby less than 1 week old, or 20 mg. if the baby is older than 1 week.

♦ Be sure the baby has enough liquids. Spoon feed breast milk and Rehydration Drink, if necessary (see page 152).

♦ Try to get medical help. Infections in newborn babies are sometimes hard to recognize. Often there is no fever. If possible, get medical help. If not, treat with ampicillin and gentamicin as described above. Ampicillin is one of the safest and most useful antibiotics for babies.

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THE MOTHER’S HEALTH AFTER CHILDBIRTH

Diet and Cleanliness

As was explained in Chapter 11, after she gives birth to a baby, the mother can and should eat every kind of nutritious food she can get. She does not need to avoid any kind of food. Foods that are especially good for her are milk, cheese, chicken, eggs, meat, fish, fruits, vegetables, grains, beans, groundnuts, etc. If all she has is corn and beans, she should eat them both together at each meal. A good diet helps the mother make plenty of milk for her baby.

The mother can and should bathe in the first few days after giving birth. In the first week, it is better if she bathes with a wet towel and does not go into the water. Bathing is not harmful following childbirth. In fact, women who let many days go by without bathing may get infections that will make their skin unhealthy and their babies sick.

During the days and weeks following childbirth, the mother should:

eat nutritious foods and bathe regularly.

Childbirth Fever (Infection after Giving Birth, Womb Infection)

Sometimes a mother develops fever and infection after childbirth, often because someone attending the birth did not keep everything very clean or because he or she put a hand inside the mother.

The signs of childbirth fever are: Chills or fever, headache or low back pain, sometimes pain in the belly, and a foul-smelling or bloody discharge from the vagina.

Treatment:

Give 3 medicines: inject 2 grams of ampicillin for the first dose, and then 1 gram 4 times a day. Also inject 80 mg of gentamicin 3 times a day. Also give 500 mg of metronidazole by mouth 3 times a day. Continue giving these medicines until after the fever has been gone for 2 days.

Childbirth fever can be very dangerous. If the mother does not start to feel better the next day, get medical help.

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breastfeeding, and care of the breasts

Taking good care of the breasts is important for the health of both the mother and her baby. The baby should begin to breastfeed soon after it is born. A baby may want to breastfeed right away or just lick the breast and be held. Encourage the baby to suck because it will help the milk to start flowing. This will also help the mother’s womb to contract and the afterbirth to come out sooner. The mother’s first milk is a thick yellow liquid (called colostrum). The first milk has everything a new baby needs to prevent infection and is rich in protein.

The first milk is very good for the baby, so…

Normally, the breasts make as much milk as the baby needs. If the baby empties them, they begin to make more. If the baby does not empty them, soon they make less. When a baby gets sick and stops sucking, after a few days the mother’s breasts stop making milk. So when the baby can suck again, and needs a full amount of milk, there may not be enough. For this reason,

to milk the breasts by hand

Take hold of the breasts then move your hands To squeeze the milk out, way back, like this, forward, squeezing. press behind the nipple.

begin breastfeeding early

Put the baby to the mother’s breast as soon as possible.

When a baby is sick and unable to take much milk, it is important that the mother keep producing lots of milk by milking her breasts with her hands.

Another reason it is important to milk the breasts if the baby stops sucking is that this keeps the breasts from getting too full. When they are too full, they are painful. A breast that is painfully full is more likely to develop an abscess. Also, the baby may have trouble sucking when the breast is very full.

If your baby is too weak to suck, squeeze milk out of your breast by hand and give it to the baby by spoon or dropper.

Regular bathing will help to keep your breasts clean. It is not necessary to clean your breasts and nipples each time you breastfeed your baby. Do not use soap to clean your breasts, as this may cause cracking of the skin, sore nipples, and infection.

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Sore or Cracked Nipples

Sore or cracked nipples develop when the baby sucks only the nipple instead of taking the nipple and part of the breast when she is breastfeeding.

Treatment:

It is important to keep breastfeeding the baby even if it hurts. To avoid sore nipples, breastfeed often, for as long as the baby wants to suck, and be sure the baby is taking as much of the breast into her mouth as she can. It also helps to change the baby’s position each time she nurses.

If only one nipple is sore, let the baby suck on the other side first, then let the baby suck from the sore nipple. After the baby is finished, squeeze out a little milk and rub the milk over the sore nipple. Let the milk dry before covering the nipple. The milk will help the nipple heal. If the nipple oozes a lot of blood or pus, milk the breast by hand until the nipple is healed.

Painful Breasts

Pain in the breast can be caused by a sore nipple or breasts that get very full and hard. The pain will often go away in a day or two if the baby breastfeeds frequently and the mother rests in bed and drinks lots of liquids. Usually, antibiotics are not needed, but see the next section.

Breast Infection (Mastitis) and Abscess

Painful breasts and sore or cracked nipples can lead to an infection or abscess (pocket of pus).

Signs:

• Part of the breast becomes hot, red, swollen, and very painful.

• Fever or chills.

• Lymph nodes in the armpit are often sore and swollen.

• A severe abscess sometimes bursts and drains pus.

Treatment:

♦ Keep breastfeeding frequently, giving the baby the infected breast first, or milk the breast by hand, whichever is less painful.

♦ Rest and drink lots of liquids.

♦ Use hot compresses on the sore breast for 15 minutes before each feeding. Use cold compresses on the sore breast between feedings to reduce pain.

♦ Gently massage the sore breast while the baby is nursing.

♦ Take acetaminophen (page 379) for pain.

♦ Use an antibiotic. Dicloxacillin is the best antibiotic to use (page 350). Take 500 mg. by mouth, 4 times each day, for a full 7 days. Erythromycin (page 354) or cotrimoxazole (page 357) can also be used.

Prevention:

♦ Keep the nipples from cracking (see above) and don’t let the breasts get overfull.

A painful, hot lump in the breast of a nursing mother is probably a breast abscess (infection).

A painless breast lump may be cancer, or a cyst.

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Breast Cancer

Most women have some small lumps in their breasts. These lumps can change in size and shape, and become tender during her monthly cycle. Sometimes, a breast lump that does not go away can be a sign of breast cancer.

Successful treatment depends on spotting the first sign of possible cancer and getting medical care soon. Surgery is usually necessary.

Signs of breast cancer:

• The woman may notice a slow-growing lump during self-examination of the breasts (see below).

• Or the breast may have an abnormal dent or dimple, or many tiny pits like the skin of an orange.

• Often there are swollen lymph nodes in the armpit, which may or may not be painful.

• There may be redness or a sore on the breast that does not heal.

• She may have abnormal discharge from a nipple.

• At first it usually does not hurt or get hot. Later it may hurt.

self-examination of the breasts

Every woman should learn how to examine her own breasts for possible signs of cancer. She should do it once a month, preferably on the 10th day after her menstrual period started.

♦ Use a mirror to look at your breasts carefully for any new difference between the two in size or shape. Try to notice any of the above signs.

♦ While lying with a pillow or folded blanket under your back, feel your breasts with the flat of your fingers. Press your breast and roll it beneath your finger tips. Start near the nipple and go around the breast and up into the armpit.

♦ Squeeze your nipples. If blood or a discharge comes out, get medical help.

If you find a lump that is smooth or rubbery, and moves under the skin when you push it, don’t worry about it. But if it is hard, has an uneven shape, is painless, or does not move when you push it, get medical advice. Many lumps are not cancer, but it is important to find out early.

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LUMPS OR GROWTHS IN THE LOWER PART OF THE BELLY

The most common lump is, of course, caused by the normal development of a baby. Abnormal lumps or masses may be caused by:

• a cyst or watery swelling, often in the ovaries

• a baby that has accidentally begun to develop outside of the womb (ectopic pregnancy), or

• cancer

All 3 of these conditions are usually painless or mildly uncomfortable at first, and become very painful later. All require medical attention and usually surgery. If you find any unusual, gradually growing lump, seek medical advice.

Cancer of the womb

Cancer of the uterus (womb), cervix (neck of the womb), or ovaries is most common in women over 40. The first sign may be anemia or unexplained bleeding. Later, an uncomfortable or painful lump in the belly may be noticed.

There is a special test called a Pap smear

(Papanicolaou) to find cancer of the cervix when it is just beginning. Where it is available, all women over 20 should try to get a Pap smear once a year. Another method is called ‘visual inspection’ and uses a vinegar solution painted on the cervix. If this makes tissue turn white, then further testing or treatment is needed.

At the first suspicion of cancer, seek medical help.

ECTOPIC (TUBAL) PREGNANCY

  • womb or uterus, where a baby is normally made

  • tube to ovary

  • ovary, where the eggs are made

  • vagina

  • vulva, or lips of vagina

Sometimes a baby begins to form outside the womb, in one of the tubes that comes from the ovaries.

There may be abnormal menstrual bleeding together with signs of pregnancy, also severe cramps low in the belly and a painful lump outside the womb.

A baby that begins to form in the tube cannot live. Ectopic pregnancy requires surgery in a hospital. If you suspect this problem, get medical help soon, as dangerous bleeding could start any time.

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MISCARRIAGE (SPONTANEOUS ABORTION)

A miscarriage is the loss of the unborn baby.

Miscarriages are most frequent in the first 3 months of pregnancy. Usually the baby is imperfectly formed, and this is nature’s way of taking care of the problem.

Most women have one or more miscarriages in their lifetime. Many times they do not realize that they are having a miscarriage. They may think their period was missed or delayed, and then came back in a strange way, with big blood clots. A woman should learn to know when she is having a miscarriage, because it could be dangerous.

A woman who has heavy bleeding after she has missed one or more periods probably is having a miscarriage.

A miscarriage is like a birth in that the embryo (the beginning of the baby) and the placenta (afterbirth) must both come out. Heavy bleeding with big blood clots and painful cramps often continues until both are completely out.

Treatment:

The woman should rest and take ibuprofen (page 379) or codeine (page 383) for pain. If heavy bleeding continues for many days:

♦ Get medical help. A simple operation may be needed to clean out the womb (dilatation and curettage, or D and C, or suction).

♦ Stay in bed until the heavy bleeding stops.

♦ If the bleeding is extreme, follow the instructions on page 266.

♦ If fever or other signs of infection develop, treat as for Childbirth Fever (see page 276)

♦ A woman may continue to bleed a little for several days after the miscarriage. It will be similar to her menstrual flow (period).

♦ She should not douche or have sex for at least 2 weeks after the miscarriage, or until the bleeding stops.

♦ If she is using an IUD and has a miscarriage, serious infection may occur. Seek medical help fast, have the IUD removed, and give antibiotics.

The embryo of a miscarriage may be no longer than 1 or 2 centimeters.

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HIGH RISK MOTHERS AND BABIES

A note to midwives or health workers or anyone who cares:

Some women are more likely to have difficult births and problems following birth, and their babies are more likely to be underweight and sick. Often these are mothers who are single, homeless, poorly nourished, very young, mentally slow, or who already have malnourished or sickly children.

Often if a midwife, health worker, or someone else takes special interest in these mothers, and helps them find ways to get the food, care, and companionship they need, it can make a great difference in the well-being of both the mothers and their babies.

Do not wait for those in need to come to you. Go to them.

20

family planning: having the number of children you want

BOTH THESE FAMILIES LIVE IN POOR COMMUNITIES:

Some mothers and fathers want a lot of children, especially in countries where poor people are denied a fair share of land, resources, and social benefits.

This is because children help with work and provide care for their parents in old age. In such areas, having just a few children may be a privilege only wealthier people can afford.

The situation is different in countries where resources and benefits are fairly distributed. Where employment, housing, and health care are guaranteed and where women have equal opportunities for education and jobs, people usually choose to have smaller families. This is in part because they do not need to depend on their children for economic security.

In any society, parents have a right to make their own decisions about how many children to have, and when to have them.

Different parents have different reasons for wanting to limit the size of their families. Some young parents may decide to delay having any children until they have worked and saved enough so that they can afford to care for them well.

Some parents may decide that a small number of children is enough, and they never want more. Others may want to space their children several years apart, so that both the children and their mother will be healthier. Some parents feel they are too old to have more children.

In some places, men and women know that if they have a lot of children, when the children grow up there may not be enough land for all of them to grow the food their families need.

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FAMILY PLANNING

Having the number of children you want, when you want them, is called family planning. If you decide to wait to have children, you can choose one of several methods to prevent pregnancy. These methods are called family planning methods, child spacing methods, or contraception.

Every year, half a million women die of problems from pregnancy, childbirth, and unsafe abortion. Most of these deaths could be prevented by family planning. For example, family planning can prevent dangers from pregnancies that are:

  • in young women. Women under the age of 18 are more likely to die in childbirth because their bodies are not fully grown. Their babies have a greater chance of dying in the first year.
  • in older women. Older women face more danger in child bearing, especially if they have other health problems or have had many children.
  • too close. A woman’s body needs time to recover between pregnancies.
  • too many. A woman with more than 4 children has a greater risk of death after childbirth from bleeding and other causes.

Millions of women safely use the family planning methods described in this chapter and on pages page 393 to page 396.

Choosing a Family Planning Method

On the following pages, several methods of family planning are described. Each one works better for some people than others. Study these pages and talk with your midwife, health worker, or doctor about what methods are available and are likely to work best for you. As you read about each method, here are some questions you may want to consider:

  • How well does it prevent pregnancy? How effective is it?
  • How well does it protect against HIV and other sexually transmitted infections, if at all?
  • How safe is it? If a woman has any of the health problems mentioned in this chapter, she may need to avoid some types of family planning methods.
  • How easy is it to use?
  • How much does it cost?
  • Is it easy to get? Will you need to visit the health center often?
  • Will the side effects (the problems the method may cause) create difficulties for you?

Family planning methods work best when both the man and the woman take responsibility for preventing pregnancy and protecting each other from sexually transmitted infections (STIs).

The chart on the next page shows how well each family planning method works to prevent pregnancy and to protect against STIs. When a man and a woman use a method correctly every time they have sex, the method will work better.

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Type of Family Planning

Condoms

Preventing Pregnancy: Good

Protection from STIs and HIV: Best

How often: Every time

Other important information: Most effective when used with a spermicide and a water-based lubricant. A condom needs to be used every time you have sex.

Birth control pill: Combination pill

Preventing Pregnancy: Very good

Protection from STIs and HIV: None

How often: Every day

Other important information: Works best if taken at the same time every day. Women who have the health problems listed on page page 289should not use this method.

Birth control pill: Minipill

Preventing Pregnancy: Very good

Protection from STIs and HIV: None

How often: Every day

Other important information: Will only work if it is taken at the same time every day. Can be used while breastfeeding (start after the baby is 6 weeks old).

Implants

Preventing Pregnancy: Best

Protection from STIs and HIV: None

How often: 3 or 5 years

Other important information: Must be inserted and removed by a specially trained health worker and replaced every 3 or 5 years depending on the type.

Injections

Preventing Pregnancy: Very good

Protection from STIs and HIV: None

How often: 1, 2, or 3 months

Other important information: Need to be repeated every 1, 2, or 3 months (depending on the type).

IUD

Preventing Pregnancy: Best

Protection from STIs and HIV: None

How often: 5 or 12 years Effective for 5 or 12 years (depending on the type). Must be inserted and removed by a specially trained health worker.

Pulling out (withdrawal)

Preventing Pregnancy: Least

Protection from STIs and HIV: None

How often: Every time

Other important information: The man needs to withdraw every time you have sex. Even if he pulls out, some liquid from the penis may enter the vagina during sex, which can cause pregnancy or pass STIs.

Breastfeeding (during the first 6 months only)

Preventing Pregnancy: Very good

Protection from STIs and HIV: None

How often: Several

Other important information: times a day and at night This method is only effective if the woman is feeding her baby only breastmilk and if her menstruation has not returned.

Fertility awareness

Preventing Pregnancy: Good

Protection from STIs and HIV: None

How often: Every time

Other important information: This method does not work well for women with irregular menstrual cycles.

Sex without intercourse (penis not inside vagina)

Preventing Pregnancy: Best

Protection from STIs and HIV: Depends

How often: Every time

Other important information: If the penis doesn’t touch the vagina, the woman cannot get pregnant. Anal sex can easily pass STIs, oral sex is less likely to pass STIs, and sexual touch rarely passes any.

Sterilization

Preventing Pregnancy: Best

Protection from STIs and HIV: None

How often: Once

Other important information: Once a man or woman is sterilized, they will never become pregnant or get someone pregnant.

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HOW WOMEN BECOME PREGNANT

When the man ejaculates (comes, climaxes) in or near the vagina, his sperm leave his penis and can get into the womb and tubes.

During the woman’s fertile time, the sperm can join with the woman’s egg. If the sperm fertilizes the egg, it then plants itself in the lining of the woman’s womb. This is pregnancy.

Family planning methods prevent pregnancy by keeping sperm out of the vagina, or by stopping a woman’s body from releasing eggs, or by stopping sperm from joining with an egg.

Men

  • Semen: a fluid that contains millions of sperm, travels through this tube and out the penis

  • Penis

  • Testicles: men make sperm inside their testicles

Woman

  • Clitoris: a sensitive part that can give pleasure when touched

  • Ovaries: about once a month, one of the woman’s ovaries releases a tiny egg into the tube

  • Urethra: where urine (pee) comes out

  • Opening of the vagina

  • Vulva

  • Anus

  • Cervix Vagina

  • Tube: the egg moves down the tube and into the womb

  • Womb: where a baby grows if the woman becomes pregnant

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FAMILY PLANNING METHODS

Condoms

A condom is a thin latex cover the man wears on his penis during sex. The man’s semen stays inside the condom, so sperm cannot get into the womb and cause pregnancy. Condoms are safe and have no side effects.

Condoms are also the most effective way to prevent sexually transmitted infections (STIs), including HIV. Even if you are using another method of birth control, you can also use a condom to protect you and your partner from STIs.

Condoms are the only family planning method that is effective at both preventing pregnancy and sexually transmitted infections. But the man must be willing to use one every time he has sex.

Squeeze the tip of the condom and unroll it all the way over the hard penis. The loose condom tip will hold the man’s sperm. (If you do not leave space for the sperm, the condom might break.)

To help keep condoms from breaking, use a water-based lubricant, such as spit (saliva) or K-Y Jelly. Do not use cooking oil, baby oil, mineral oil, petroleum jelly (Vaseline), skin lotion, or butter with condoms because these oil-based products weaken rubber and can make the condom break. Lubricants can make sex feel more pleasurable for both women and men.

After the man ejaculates (comes), while the penis is still hard, he must hold the rim of the condom to keep it on the penis while he pulls out of the woman’s vagina.

Then take the condom off the penis. (Put the condom in the trash – do not just throw it where others will come across it!) Use a new condom each time you have sex.

Female Condom

Inner ring goes inside the vagina. Outer ring stays outside the vagina. A female condom fits into the vagina and covers the outer lips of the woman’s vulva.

It is bigger than a male condom and less likely to break. It can be put in up to 6 hours before sex and should be removed immediately after sex.

The female condom prevents the man’s sperm from getting into the womb and causing pregnancy, and it also helps protect against HIV and other STIs. Do not use a male and female condom together.

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Birth Control Pills (Oral Contraceptives)

Birth control pills contain hormones that are similar to the natural hormones in women’s bodies. They prevent pregnancy by stopping the woman’s ovaries from releasing an egg.

There are 2 main types of birth control pills: combination pills which contain 2 hormones, estrogen and progestin, and minipills which contain only progestin.

Both types of pill are very effective if taken every day at the same time. They are safe for most women, but women with certain health problems should not take them (see page 289).

Birth control pills do not protect against HIV or other sexually transmitted infections (STIs). To protect yourself, also use a condom.

COMBINATION PILLS

Different brands of combination birth control pills have different doses of 2 hormones, estrogen and progestin. (For descriptions of the most common brands and how to take them, see page 393 and page 394).

THE MINIPILL (progestin-only pills)

This birth control pill does not contain estrogen, only progestin. It is safe for most women who cannot use combined pills for health reasons (see page 289) or who have side effects from combination pills.

The minipill is also very effective for breastfeeding mothers who have not had monthly bleeding since giving birth. For descriptions of the most common brands and how to take them, see page 394.

QUESTIONS AND ANSWERS ABOUT BIRTH CONTROL PILLS

Some people claim birth control pills cause cancer. Is this true?

No! However, if cancer of the breast or womb already exists, taking the pill may make the tumor grow faster.

Can a woman have children again if she stops taking the pill?

Yes. (Sometimes there is a delay of 1 or 2 months before she can become pregnant.)

Is the chance of having twins or defective children greater if a woman has used oral contraceptives?

No. The chances are the same as for women who have not taken the pill.

emergency contraception

If you had sex without birth control or your condom broke, you can still prevent pregnancy with birth control pills. This is called emergency contraception and it works during the first 5 days after you had sex, the sooner you take it, the better it will work. See page 394 and page 395.

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who should not take birth control pills?

A woman who has any of the following signs should not take any type of oral contraceptive and should not use injections or implants:

• Missed period. A woman who thinks she might be pregnant or whose monthly bleeding is late.

• Breast cancer or a hard lump in the breast (see page 279). Birth control pills do not cause cancer, but if a woman already has breast cancer, the pill can make it worse.

• Abnormal bleeding from the vagina during the 3 months before starting to take birth control pills. See a health worker first to find out if there is a serious problem (see page 280).

If you suffer from tuberculosis, diabetes, kidney disease, or epilepsy, get medical advice about taking birth control pills.

who should not take the combination pill?

The combination pill can make some health problems very dangerous. Do not take combination pills if you have:

• High blood pressure, 160/110 or higher (page 125)

• Diabetes for more than 20 years

• Age 35 or older and smoke tobacco

• Migraines (page 162)

• Gallbladder disease (page 329)

• History of stroke (page 327).

• A blood clot in a vein (this usually causes heat and pain in one leg)

• Liver disease or hepatitis (page 172 and page 328)

Most women with any of these health problems can safely use the progestin-only minipill (page 394) or birth control implants or injections (page 396). Women with varicose veins that are not inflamed can usually take birth control pills without problems. But they should stop taking them if the veins become inflamed.

warning signs for problems with combined pills

STOP taking the pill and see a health worker if you:

• have severe headaches with blurred vision (migraines) that begin after you start taking the pill.

• feel weakness or numbness in your arms or legs.

• feel severe pain in your chest and shortness of breath.

• have severe pain in one leg.

• have severe pain in the abdomen.

If you have any of these problems, pregnancy can also be dangerous, so use another type of family planning such as condoms until you can see a health worker trained in hormonal family planning methods.

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OTHER METHODS OF FAMILY PLANNING

Implants

Just like the minipill, implants contain only progestin and can be used by women who cannot use estrogen, or by breastfeeding mothers who have not had monthly bleeding since giving birth.

Women who should not use any type of birth control pill should not use implants either (see page 289). Implants do not protect against HIV and other STIs.

Implants are small plastic tubes placed under the skin on the inside of a woman’s arm.

They prevent pregnancy for 3 to 5 years, depending on the type of implant. Implants must be inserted and removed by a trained health worker. See page 396.

Birth Control Injections

Like the pill, some injections are progestin-only and some are a combination of estrogen and progestin. Women who should not take any type of pill should not use injections either (see page 289).

Both types of injection are usually given by a health worker. These injections do not protect against HIV and other STIs.

Combined injections, such as Cyclofem and Mesigyna, are given once a month. Women who should not use estrogen should avoid these (see page 289).

Progestin-only injections, such as Depo Provera and Noristerat are given every 2 or 3 months. See page 396.

The IUD

An IUD (Intra-Uterine Device) is a small plastic, or plastic and copper, object put into the womb by a trained health worker. Some brands of IUD also contain progestin. The IUD prevents pregnancy in different ways by affecting the egg, sperm, or lining of the womb. See page 395 and page 396.

WHO SHOULD NOT USE AN IUD:

• Women with cancer of the cervix or uterus. Women with breast cancer should not use an IUD with progestin, but they can use a copper-T or similar IUD.

• Women with gonorrhea or chlamydia. See page 236.

• Women with pelvic infection (PID). See page 243.

Spermicide

Spermicides are foam, tablets, cream, jelly, or flat strips that dissolve in the vagina and kill sperm so they cannot fertilize an egg. Spermicide is put into the vagina just before having sex.

It does not work well by itself, but gives extra protection against pregnancy when used with a condom or a diaphragm. Spermicide does not protect against STIs or HIV. See page 395. If used frequently it can irritate the vagina, making it easier for the woman to get an infection, including HIV.

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Diaphragm

The diaphragm is a shallow cup made of soft rubber or thin silicone that a woman wears in her vagina during sex.

The diaphragm covers the cervix (the opening to the womb, deep inside the vagina), so the man’s sperm cannot get into the womb and cause pregnancy. It can be put in just before having sex or up to 6 hours before, and should be left in for at least 6 hours after having sex.

Diaphragms come in different sizes. A trained health worker can recommend the right size for each woman. After each use, the woman should wash the diaphragm with soap and water, dry it, and keep it in a clean, dry place. A diaphragm usually lasts about 2 years.

Check it regularly for holes by holding it up to the light. If there is even a tiny hole, get a new one.

NATURAL METHODS OF FAMILY PLANNING

Breastfeeding

When a woman breastfeeds, her body produces hormones that prevent pregnancy for a few months. Breastfeeding is dependable for preventing pregnancy when:

• The baby is less than 6 months old. AND

• You are giving your baby only your breast milk, no other food or drink, and you feed your baby often, day and night. AND

• Your have not had monthly bleeding since giving birth.

Once you start giving your baby food or you get your period, breastfeeding will no longer prevent pregnancy.

Fertility Awareness

A woman can only get pregnant during her fertile time, when an egg comes from her ovary into her tubes and womb. This time lasts for several days and happens about once a month.

By avoiding sex during the fertile time, you can prevent pregnancy. (Or, if a couple is trying to get pregnant, they can plan to have sex during this time to increase chances of pregnancy.)

For this method to work, the woman must have regular menstrual cycles and must keep good track of each stage of her cycle. The man must be willing to help make this method work too, because during fertile times, they must avoid sexual intercourse (sex with the penis inside the vagina).

They can have other types of sex, like oral sex or sexual touching. Or they can use condoms during the fertile time. Fertility awareness does not give any protection against STIs including HIV, which can be passed at any time of the woman’s cycle.

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HOW TO USE FERTILITY AWARENESS

Count the number of days of your menstrual cycle for a few months. Start counting on the first day of your menstrual period. The last day of the cycle is the last day before you bleed again. If you have about the same number of days in each cycle, and your cycles last between 26 and 32 days, this method can work. Avoid sexual intercourse or use condoms from the 8th day to the 19th day of every cycle.

For example: Suppose your period begins on the 5th day of May. Count that as day number 1.

Mark it like on a calendar:

Then count 8 days. Starting with the 8th day, put a line under the next 11 days like this:

During these 11 ‘fertile days’, do not have sexual relations.

Now suppose your next period begins on the first of June.

Mark it the same way, on the calendar.

Once again count off 8 days and underline the following 11 days in which you will not have sexual contact.

Changes in cervical mucus (the wetness that comes from a woman’s vagina) can also help a woman know when she is in her fertile time.

  • clear, wet, slippery mucus = fertile

  • white, dry, sticky mucus = not fertile

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Withdrawal or Pulling Out (coitus interruptus).

The man pulls his penis out of the woman and away from her genitals before he ejaculates (comes). This method is better than no method, but it does not always work. Even if the man pulls out in time, some liquid that contains sperm can leak out of his penis before ejaculation and cause pregnancy. Pulling out does not protect against HIV or other STIs.

Sex without Intercourse

There are many ways to be close to someone, to have sexual pleasure, and to show love besides sexual intercourse. Many couples practice oral sex: using your mouth to bring pleasure on the penis or the vulva. You cannot get pregnant this way. Sex in the anus (anal sex) also cannot cause pregnancy. But you can pass STIs, including HIV, during anal and oral sex. Using your hands to make someone feel good sexually is very safe. It cannot cause pregnancy and it cannot pass any STIs.

Lemon or Lime Juice

This traditional method seems to make pregnancy less likely but does not always work. Also, it can irritate the inside of the vagina, making sex uncomfortable, and making it easier for women to get sexually transmitted infections including HIV. If you use lemon juice, use a different method at least some days so the vagina is not being irritated so often.

Boil a small sponge or piece of soft fabric to kill any germs in it. Then soak it in 1⁄2 lemon juice, 1⁄2 water. Or use lime juice or vinegar instead of lemon. Put the sponge deep into your vagina before you have sex. Leave it in for 6 hours after you have sex, then take it out and boil it again. As long as you boil it every time, you can use the same sponge over and over.

THESE METHODS DO NOT PREVENT PREGNANCY

Urinating (peeing) after sex is not harmful, but it won’t prevent pregnancy. Urine does not wash semen out of the vagina, because it comes out of a different hole (see page 286).

Washing out the vagina (douching) after having sex doesn’t work either. Sperm move very fast and some will reach the inside of the womb before they can be washed out. Douching can even push sperm up into the womb.

Putting herbs, plants, or harsh chemicals in the vagina to make it dry only causes irritation of the skin inside the vagina, making it easier for women to get infections.

Amulets and prayers do not prevent pregnancy. Women who rely on these methods get pregnant.

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METHODS FOR THOSE WHO NEVER WANT TO HAVE MORE CHILDREN

Sterilization is a safe, simple operation for both men and women. In many countries these operations are free. Ask at the health center. Sterilization does not protect against HIV or other STIs.

For women, the operation is called a tubal ligation, which means to tie the tubes. One method is to make a small cut in the lower belly so that the tubes coming from the ovaries (where eggs are stored) can be cut and tied closed. It usually can be done in a doctor’s office or health center without putting the woman to sleep. This operation has no effect on the woman’s menstrual periods or sexual ability, and may make having sex more pleasant because she does not have to worry about pregnancy.

For men, the operation is called a vasectomy. It can be done simply and quickly in a doctor’s office or a health center without putting the man to sleep. This operation is even safer and faster than the surgery for a woman. The testicles are not removed and the operation has no effect on the man’s sexual ability or pleasure. His fluid (semen) comes just the same, but has no sperm in it. Small cuts are made here so that the tubes from the man’s testicles can be cut and tied.

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health and sicknesses of children

WHAT TO DO TO PROTECT CHILDREN’S HEALTH

NUTRITIOUS FOOD, CLEANLINESS, AND VACCINATION
ARE THE THREE IMPORTANT ‘BODY GUARDS’ THAT KEEP CHILDREN HEALTHY AND PROTECT THEM AGAINST MANY SICKNESSES.

Chapters 11 and 12 tell more about the importance of nutritious food, cleanliness, and vaccination. Parents should read these chapters carefully and use them to help care for, and teach, their children. The main points are briefly repeated here.

Nutritious Food

It is important that children eat the most nutritious foods they can get, so that they grow well and do not get sick.

The best foods for children at different ages are:

  • in the first 6 months: breast milk and nothing more.
  • from 6 months to 1 year: breast milk and also other nutritious foods, such as boiled cereals, mashed-up beans, eggs, meat, cooked fruits and vegetables.
  • from 1 year on: the child should eat the same foods as adults, but more often. To the main food (rice, maize, wheat, potatoes, or cassava) add ‘helper foods’ as discussed in Chapter 11.
  • Above all, children should get enough to eat, several times a day.
  • All parents should watch for signs of malnutrition in their children and should give them the best food they can.

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Cleanliness

Children are more likely to be healthy if their village, their homes, and they themselves are kept clean. Follow the Guidelines of Cleanliness explained in Chapter 12. Teach children to follow them, and to understand their importance. Here the most important guidelines are repeated:

  • Bathe children and change their clothes often.

  • Teach children always to wash their hands when they get up in the morning, after they have a bowel movement, and before they eat or handle food.

  • Make latrines or ‘outhouses’, and teach children to use them.

  • Where hookworm exists, do not let children go barefoot; use sandals or shoes.

  • Teach children to brush their teeth; and do not give them a lot of candies, sweets, or carbonated drinks.

  • Cut fingernails very short.

  • Do not let children who are sick or have sores, scabies, lice, or ringworm sleep with other children or use the same clothing or towels.

  • Treat children quickly for scabies, ringworm, intestinal worms, and other infections that spread easily from child to child.

  • Do not let children put dirty things in their mouths or let dogs or cats lick their faces.

  • Keep pigs, dogs, and chickens out of the house.

  • Use only pure, boiled, or filtered water for drinking. This is especially important for babies.

  • Do not feed babies from ‘baby bottles’, because these are hard to keep clean and can cause illness. Feed babies with a cup and spoon.

Vaccinations

Vaccinations protect children against many of the most dangerous diseases of childhood, whooping cough, diphtheria, tetanus, polio, measles, tuberculosis, hepatitis, and rotavirus.

Children should be given the different vaccinations at different ages, as shown on page 147. Polio vaccines should be first given if possible at birth, but no later than 2 months of age, because the risk of developing infantile paralysis (polio) is highest in babies under 1 year old.

Tetanus of the newborn can be prevented by vaccinating mothers against tetanus during pregnancy (see page 250).

Be sure your children get all the vaccinations they need.

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CHILDREN’S GROWTH, AND THE ‘ROAD TO HEALTH’

A healthy child grows steadily. If he eats enough nutritious food, and has no serious illness, a child gains weight each month.

A child who gains weight more slowly than other children, stops gaining weight, or is losing weight is not healthy. He may not be eating enough or he may have a serious illness, or both.

A good way to check whether a child is healthy and is getting enough nutritious food is to weigh him each month and see if he gains weight normally. If a monthly record of the child’s weight is kept on a Child Health Chart, it is easy to see at a glance whether the child is gaining weight normally.

When used well, the charts tell mothers and health workers when a child is not growing normally, so they can take early action. They can make sure the child gets more to eat, and can check for and treat any illness the child may have.

On the next page is a typical Child Health Chart showing the ‘road to health’. This chart can be cut out and copied. Or larger, ready-made cards can be obtained (in English, Spanish, Portuguese, or Zulu) from Teaching Aids at Low Cost - TALC for address). Similar charts are produced in local languages by the Health Departments in many countries.

It is a good idea for every mother to keep a Child Health Chart for each of her children under 5 years of age. If there is a health center or ‘under-fives clinic’ nearby, she should take her children, with their charts, to be weighed and to have a ‘check-up’ each month. The health worker can help explain the Chart and its use. To protect the Chart, keep it in a plastic envelope.

A child who grows well is healthy.

HOMEMADE BEAM SCALE

You can make a beam scale of dry wood or bamboo. Place all hooks as shown and hang the scale. To make kg. marks on the beam, fill 2 plastic one-liter bottles with water. Place the first bottle where baby would hang. Hang the second bottle, and where beam balances, make the 1 kg. mark, and so on. With a ruler, measure the distance between the marks, and make marks for 200, 400, 600, and 800 grams.

  • two hooks about 5 cm. apart

  • scale hangs from this hook

  • beam (1 meter long)

  • child holder

  • movable weight (about 1 kilogram)

  • Weight is correct when beam stays horizontal.

DIRECT RECORDING SCALE

Available from TALC (see page 431)

The growth chart slips in behind the scales so you can mark the child’s weight directly onto the chart.

It is best to hang this and other scales close to the ground. A baby may be scared of hanging up high.

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CHILD HEALTH CHART

Helps track health progress through time. From birth to 2/3 years old, usually.

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You can get a CHILD HEALTH CHART from talcuk.org

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How to Use the Child Health Chart

FIRST

Write the months of the year in the little squares at the bottom of the chart.

Write the month the baby was born in the first square for each year.

This chart shows the baby was born in March.

SECOND

Weight the child.

Let us suppose that a child was born in April. It is now August, and the child weighs 6 kilograms.

THIRD

Look at the card.

Kilograms are written on the side of the card. Look for the number of kilograms the child weighs (in this case, 6).

Then look for the present month at the bottom of the cart (in this case, August of the baby’s first year).

GOOD - Child growing well

DANGER - Not gaining weight find out why

VERY DANGEROUS - Losing weight. Maybe ill, needs extra care.

WRITE ON THE CHART:

  • Any illness e.g. diarrhea measles

  • Admission to hospital

  • Solids introduced

  • Breastfeeding stopped

  • Birth of next child

WATCH THE DIRECTION OF THE LINE SHOWING THE CHILD’S GROWTH

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FOURTH

Follow the line that goes out from the 6 and the lines that go up from August.

It is easy to know where to put the dot if you hold a square piece of paper against the chart.

  1. Line up one edge of the paper with the child’s weight.

  2. Lineup the other edge of the paper.

  3. Put the dot next to the corner of the paper.

Each month weigh the child and put another dot on the chart.

If the child is healthy, each month the new dot will be higher on the chart than the last.

To see how well the child is growing, join the dots with lines.

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How to Read the Child Health Chart

The 2 long curved lines on the chart mark the ‘Road to Health’ that a child’s weight should follow.

The line of dots marks the child’s weight from month to month, and from year to year. In most normal, healthy children, the line of dots falls between the 2 long curved lines. That is why the space between these lines is called the Road to Health.

If the line of dots rises steadily, month after month, in the same direction as the long curved lines, this is also a sign that the child is healthy.

A healthy child who gets enough nourishing food usually begins to sit, walk, and speak at about the times shown here.

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A malnourished, sickly child may have a chart like the one below. Notice that the line of dots (his weight) is below the Road to Health. The line of dots is also irregular and does not rise much. This shows the child is in danger.

Typical chart of

THE UNDERWEIGHT OR MALNOURISHED CHILD

Dots show that the child has not been gaining weight well, and during the last months has lost weight.

A child with a chart like the one above is seriously underweight. Perhaps he is not getting enough food. Or perhaps he has a disease like tuberculosis or malaria. Or both. He should be given more energy-rich foods more often. He should also be checked or tested for possible illnesses, and visit a health worker frequently until his chart shows he is gaining weight well.

IMPORTANT: Watch the direction of the line of dots.

The direction of the line of dots tells more about the child’s health than whether the dots are inside or below the two curved lines. For example:

DANGER! This child is not gaining weight.

Although the dots for this child are within the curved lines. the child has not been gaining weight well for several months.

GOOD! This child is gaining weight well.

Although the dots for this child are below the 2 curved lines, their upward direction shows the child is growing well. Some children are naturally smaller than others. Perhaps this child’s parents are also smaller than average.

WATCH THE DIRECTION OF THE LINE SHOWING THE CHILD’S GROWTH

  • GOOD Child growing well

  • DANGER Not gaining weight find out why

  • VERY DANGEROUS Losing weight. May be ill; needs extra care

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A TYPICAL CHILD HEALTH CHART SHOWING A CHILD’S PROGRESS:

This baby was healthy and gained weight well for the first 6 months of life, because his mother breastfed him.

At 6 months, the mother became pregnant again and stopped breastfeeding him. The baby was fed little more than corn and rice. He stopped gaining weight.

At 10 months he developed chronic diarrhea and began losing weight. He became very thin and sick.

When the child was 13 months old, his mother learned about ways to give the child enough good food, even without a lot of money or land. He began gaining weight fast. By age 2 he was back on the Road to Health.

breast fed good weight gain

poorly fed poor weight gain

diarrhea weight loss

well fed good weight gain

Example of information to annotate:

  • off breast at 6 months

  • diarrhea begins at 10 months

  • nutritious feeding begins at 13 months

Child Health Charts are important. When used correctly, they help mothers know when their children need more nutritious food and special attention. They help health workers better understand the needs of the child and his family. They also let the mother know when she is doing a good job.

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REVIEW OF CHILDREN’S HEALTH PROBLEMS discussed in other chapters

Many of the sicknesses discussed in other chapters of this book are found in children. Here some of the more frequent problems are reviewed in brief. For more information on each problem, see the pages indicated.

For special care and problems of newborn babies, see from page 270 to 275, and page 405.

Remember: In children, sicknesses often become serious very quickly. An illness that takes days or weeks to severely harm or kill an adult may kill a small child in hours. So, it is important to notice early signs of sickness and attend to them right away.

Malnourished Children

Many children are malnourished because they do not get enough to eat. Or if they eat mainly foods with a lot of water and fiber in them, like cassava, taro root, or maize gruel, their bellies may get full before they get enough energy food for their bodies’ needs.

Also, some children may lack certain things in their food, like Vitamin A (see page 226) or iodine (see page 130). For a fuller discussion of the foods children need, read Chapter 11, especially pages 120 to 122.

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Malnutrition may cause many different problems in children, including:

In mild cases:

• slower growth

• swollen belly

• thin body

• loss of appetite

• loss of energy

• paleness (anemia)

• desire to eat dirt (anemia)

• sores in corners of mouth

• frequent colds and other infections

• night blindness

In more serious cases:

• little or no weight gain

• swelling of feet (sometimes face also)

• dark spots, ‘bruises’, or open peeling sores

• thinness or loss of hair

• lack of desire to laugh or play

• sores inside mouth

• failure to develop normal intelligence

• ‘dry eyes’ (xerophthalmia)

• blindness (page 226)

Severe forms of general malnutrition are ‘dry malnutrition’ or marasmus, and ‘wet malnutrition’ or kwashiorkor. Their causes and prevention are discussed on page 112 and 113.

Signs of malnutrition are often first seen after an acute illness like diarrhea or measles. A child who is sick, or who is getting well after a sickness, has an even greater need for enough good food than a child who is well.

Prevent and treat malnutrition by giving your children ENOUGH TO EAT and by feeding them MORE OFTEN. Add some high energy food, such as oil or fat, to the main food the child eats. Also try to add some body-building and protective foods like beans, lentils, fruits, vegetables, and if possible, milk, eggs, fish or meat.

Diarrhea and Dysentery

(For more complete information see page 153 to 160.)

The greatest danger to children with diarrhea is dehydration, or losing too much liquid from the body. The danger is even greater if the child is also vomiting. Give Rehydration Drink. If the child is breastfeeding, continue giving breast milk, but give Rehydration Drink also.

The second big danger to children with diarrhea is malnutrition. Give the child nutritious food as soon as he will eat.

Fever (see page 75)

In small children, high fever (over 39°) can easily cause seizures. To lower fever, take the clothes off the child. If she is crying and seems unhappy, give her acetaminophen (paracetamol) or ibuprofen in the right dosage (see page 379), and give her lots of liquids. If she is very hot and shaky, wet her with cool (not cold) water and fan her. Also try to find the cause of the fever and treat it.

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Seizures (Fits, Convulsions) (see page 178)

Common causes of seizures or convulsions in children are high fever, dehydration, epilepsy, malaria, and meningitis. If fever is high, lower it rapidly (see page 76). Check for signs of dehydration (page 151), malaria (page 186), and meningitis (page 185).

Seizures that come suddenly without fever or other signs are probably epilepsy (page 178), especially if the child seems well between them. Seizures or spasms in which first the jaw and then the whole body become stiff may be tetanus (page 182).

Meningitis (see page 185)

This dangerous disease may come as a complication of measles, mumps, or another serious illness. Children of mothers who have tuberculosis may get tubercular meningitis. A very sick child who lies with his head tilted way back, whose neck is too stiff to bend forward, and whose body makes strange movements (seizures) may have meningitis.

Anemia (see page 124)

Common signs in children:

• pale, especially inside eyelids, gums, and fingernails

• weak, tires easily

• likes to eat dirt

Common causes:

• diet poor in iron (page 124)

• chronic gut infections (page 145)

• hookworm (page 142)

• malaria (page 186)

Prevention and Treatment:

♦ Eat iron-rich foods like meat and eggs. Beans, lentils, groundnuts (peanuts), and dark green vegetables also have some iron.

♦ Treat the cause of anemia, and do not go barefoot if hookworm is common.

♦ If you suspect hookworm, a health worker may be able to look at the child’s stools under a microscope. If hookworm eggs are found, treat for hookworm (from page 373 to page 375).

♦ If necessary, give iron salts by mouth (ferrous sulfate, page 392).

CAUTION: Do not give iron tablets to a baby or small child. They could poison her. Instead, give iron as a liquid.
Or crush a tablet into powder and mix it with food.

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Worms and Other Parasites of the Gut

If one child in the family has worms, all the family should be treated (see page 140). To prevent worm infections, children should:

♦ Observe the Guidelines of Cleanliness (page 133).

♦ Use latrines.

♦ Never go barefoot.

♦ Never eat raw or partly raw meat or fish.

♦ Drink only boiled or pure water.

Skin Problems

(see Chapter 15)

Those most common in children include:

• scabies (page 199)

• infected sores and impetigo (pages page 201 and page 202)

• ringworm and other fungus infections (page 205)

To prevent skin problems, observe the Guidelines of Cleanliness (page 133).

♦ Bathe and delouse children often.

♦ Control bedbugs, lice, and scabies.

♦ Do not let children with scabies, lice, ringworm, or infected sores play or sleep together with other children. Treat them early.

Pink Eye (Conjunctivitis) (see page 219)

Wipe the eyelids clean with a clean wet cloth several times a day. Put an antibiotic eye ointment (page 378) inside the eyelids 3 or 4 times a day. Do not let a child with pink eye play or sleep with others. If he does not get well in a few days, see a health worker.

Colds and the ‘Flu’ (see page 163)

The common cold, with runny nose, mild fever, cough, often sore throat, and sometimes diarrhea is a frequent but not a serious problem in children.

Treat with lots of liquids. Give acetaminophen (see page 379). Let children who want to stay in bed do so. Good food and lots of fruit help children avoid colds and get well quickly.

Penicillin, tetracycline, and other antibiotics do no good for the common cold or ‘flu’. Injections are not needed for colds.

If a child with a cold becomes very ill, with high fever and shallow, rapid breathing, he may be getting pneumonia (see page 171), and antibiotics should be given. Also watch for an ear infection (next page) or ‘strep throat’ (page 310).

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HEALTH PROBLEMS OF CHILDREN NOT DISCUSSED IN OTHER CHAPTERS

Earache and Ear Infections

Ear infections are common in small children. The infection often begins after a few days with a cold or a stuffy nose. The fever may rise, and the child often cries or rubs the side of his head. Sometimes pus can be seen in the ear. In small children an ear infection sometimes causes vomiting or diarrhea. So when a child has diarrhea and fever, be sure to check his ears.

Treatment:

♦ An ear infection may be very painful. But if the child is generally healthy, the infection usually goes away on its own. Give acetaminophen (page 379) for pain.

♦ If the child is already in poor health, or if the ear infection does not go away after a few days, or if there is pus or blood, give amoxicillin (page 352) or erythromycin (page 354). Always give antibiotics to a baby 6 months or younger with an ear infection.

♦ Carefully clean pus out of the ear with cotton, but do not plug the ear with cotton, a stick, leaves, or anything else. Children with pus coming from an ear should bathe regularly but should not swim for at least 2 weeks after they are well.

Prevention:

♦ Teach children to wipe but not to blow their noses when they have a cold.

♦ Do not bottle feed babies, or if you do, do not let baby feed lying on his back, as the milk can go up his nose and lead to an ear infection.

♦ When children’s noses are plugged up, use salt drops and suck the mucus out of the nose as described on page 164.

Infection in the ear canal:

To find out whether the canal or tube going into the ear is infected, gently pull the ear. If this causes pain, the canal is infected. Put drops of water with vinegar in the ear 3 or 4 times a day. (Mix 1 spoon of vinegar with 1 spoon of boiled water.) If there is fever or pus, also use an antibiotic.

Sore Throat and Inflamed Tonsils

These problems often begin with the common cold. The throat may be red and hurt when the child swallows.

The tonsils (two lymph nodes seen as lumps on each side at the back of the throat) may become large, painful or drain pus. Fever may reach 40°.

Treatment:

♦ Gargle with warm salt water (1 teaspoon of salt in a glass of water).

♦ Take acetaminophen for pain.

♦ Be sure the child drinks enough, even if it hurts to swallow. Try giving tea or watered down fruit juice. If pain and fever come on suddenly or continue for more than 3 days, see the following page.

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Sore throat and the danger of rheumatic fever:

For the sore throat that often comes with the common cold or flu, antibiotics should usually not be used and will do no good. Treat with gargles and acetaminophen.

However, one kind of sore throat, called strep throat, should be treated with penicillin. It is most common in children and young adults. It usually begins suddenly with severe sore throat and high fever, often without signs of a cold or cough. The back of the mouth and tonsils become very red, and the lymph nodes under the jaw or in the neck may become swollen and tender.

Give penicillin (page 350) for 10 days. If penicillin is given early and continued for 10 days, there is less danger of getting rheumatic fever. A child with strep throat should eat and sleep far apart from others, to prevent their getting it also.

Rheumatic Fever

This is a disease of children and young adults. It usually begins 1 to 3 weeks after the person has had a strep throat (see above).

Principal signs (usually only some of these signs are present):

• fever

• joint pain, especially in the wrists and ankles, later the knees and elbows. Joints become swollen, and often hot and red.

• curved red lines or lumps under the skin

• uncontrolled movements

• in more serious cases, weakness, shortness of breath, and perhaps chest pain

Treatment:

♦ If you suspect rheumatic fever, see a health worker. There is a risk that the heart may become damaged.

♦ Give penicillin (see page 350).

♦ Take aspirin in large doses (page 378). A 12-year-old can take up to 2 tablets of 300 mg. 4 times a day. Take them together with milk or food to avoid stomach pain. If the ears begin to ring, take less.

Prevention:

♦ To prevent rheumatic fever, treat ‘strep throat’ early with penicillin, for 10 days.

♦ To prevent return of rheumatic fever, and added heart damage, a child who has once had rheumatic fever should take penicillin for 10 days at the first sign of a sore throat. If he already shows signs of heart damage, he should take penicillin on a regular basis or have monthly injections of benzathine penicillin (page 351) perhaps for the rest of his life. Follow the advice of an experienced health worker or doctor.

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INFECTIOUS DISEASES OF CHILDHOOD

Chickenpox

This mild virus infection begins 2 to 3 weeks after a child is exposed to another child who has the disease.

Signs: spots. blisters, and scabs

First many small, red, itchy spots appear. These turn into little pimples or blisters that pop and finally form scabs. Usually they begin on the body, and later on the face, arms, and legs. There may be spots, blisters, and scabs, all at the same time. Fever is usually mild.

Treatment:

The infection usually goes away in a week. Bathe the child daily with soap and warm water. To calm itching, apply cool cloths soaked in water from boiled and strained oatmeal. Cut fingernails very short. If the scabs get infected, keep them clean. Apply hot, wet compresses, and put an antibiotic ointment on them. Try to keep the child from scratching.

Measles

This severe virus infection is especially dangerous in children who are poorly nourished or have tuberculosis. Ten days after being near a person with measles, it begins with signs of a cold, fever, runny nose, red sore eyes, and cough.

The child becomes increasingly ill. The mouth may become very sore and he may develop diarrhea.

After 2 or 3 days a few tiny white spots like salt grains appear in the mouth. A day or 2 later the rash appears, first behind the ears and on the neck, then on the face and body, and last on the arms and legs.

After the rash appears, the child usually begins to get better. The rash lasts about 5 days. Sometimes there are scattered black spots caused by bleeding into the skin (‘black measles’). This means the attack is very severe. Get medical help.

Treatment:

♦ The child should stay in bed, drink lots of liquids, and be given nutritious food. If she cannot swallow solid food, give her liquids like soup. If a baby cannot breastfeed, give breast milk in a spoon (see page 120).

♦ If possible, give vitamin A to prevent eye damage (page 391).

♦ For fever and discomfort, give acetaminophen (or ibuprofen).

♦ If earache develops, give an antibiotic (page 350).

♦ If signs of pneumonia, meningitis, or severe pain in the ear or stomach develop, get medical help.

♦ If the child has diarrhea, give Rehydration Drink (page 152).

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Prevention of measles:

Children with measles should keep far away from other children, even from brothers and sisters. Especially try to protect children who are poorly nourished or who have tuberculosis or other chronic illnesses. Children from other families should not go into a house where there is measles. If children in a family where there is measles have not yet had measles themselves, they should not go to school or into stores or other public places for 10 days.

To prevent measles from killing children, make sure all children are well-nourished. And have your children vaccinated against measles.

German Measles

German measles are not as severe as regular measles. They last 3 or 4 days. The rash is mild. Often the lymph nodes on the back of the head and neck become swollen and tender. There is often a low fever.

The child should stay in bed and take acetaminophen or ibuprofen if necessary.

Women who get German measles in the first 3 months of pregnancy may give birth to a child with a disability. For this reason, pregnant women who have not yet had German measles, or are not sure should keep far away from children who have this kind of measles. Girls or women who are not pregnant can try to catch German measles before they get pregnant. A vaccine exists for German measles, but is not often available.

Mumps

The first symptoms begin 2 or 3 weeks after being exposed to someone with mumps.

Mumps begin with fever and pain on opening the mouth or eating. In 2 days, a soft swelling appears below the ears at the angle of the jaw. Often it comes first on one side, and later on the other side.

Treatment:

The swelling goes away by itself in about 10 days, without need for medicine. Acetaminophen or ibuprofen can be taken for pain and fever. Feed the child soft, nourishing foods and keep his mouth clean.

Complications:

In adults and children over 11 years of age, after the first week there may be pain in the belly or a painful swelling of the testicles in men. Persons with such swelling should stay quiet and put ice packs or cold wet cloths on the swollen parts to help reduce the pain and swelling.

If signs of meningitis or hearing problems appear, get medical help (page 185).

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Whooping Cough

Whooping cough begins a week or two after being exposed to a child who has it. It starts like a cold with fever, a runny nose, and cough.

Two weeks later, the whoop begins. The child coughs rapidly many times without taking a breath, until she coughs up a plug of sticky mucus, and the air rushes back into her lungs with a loud whoop. While she is coughing, her lips and nails may turn blue for lack of air. After the whoop, she may vomit. Between coughing spells the child seems fairly healthy.

Whooping cough often lasts 3 months or more.

Whooping cough is especially dangerous in babies under 1 year of age, so vaccinate children early. Small babies do not develop the typical whoop so it is hard to be sure if they have whooping cough or not. If a baby gets fits of coughing and swollen or puffy eyes when there are cases of whooping cough in your area, treat her for whooping cough at once.

Treatment:

♦ Antibiotics are helpful only in the early stage of whooping cough, before the whoop begins. It is especially important to treat babies under 6 months at the first sign. Use erythromycin (page 354). If you do not have erythromycin, try cotrimoxazole (page 357), but only use cotrimoxazole for children over 8 weeks old.

♦ If the cough causes convulsions, phenobarbital (page 389) may help.

♦ If the baby stops breathing after a cough, turn her over and pull the sticky mucus from her mouth with your finger. Then slap her on the back with the flat of your hand.

♦ To avoid weight loss and malnutrition, be sure the child gets enough nutritious food. Have her eat and drink shortly after she vomits.

Complications:

A bright red hemorrhage (bleeding) inside the white of the eyes may be caused by the coughing. No treatment is necessary (see page 225). If seizures or signs of pneumonia develop (page 171), get medical help.

Protect all children against whooping cough. See that they are vaccinated at 2, 4, 6, and 18 months of age.

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Diphtheria

This begins like a cold with fever, sore throat, and hoarse voice. A yellow-gray coating or membrane may form in the back of the throat, and sometimes in the nose and on the lips. The child’s neck may become swollen. His breath smells very bad.

If you suspect that a child has diphtheria:

♦ Put him to bed in a room separate from other persons.

♦ Get medical help quickly. There is special antitoxin for diphtheria.

♦ Give procaine penicillin by injection (page 352) or give erythromycin (page 354).

♦ Have him gargle warm water with a little salt.

♦ Have him breathe hot water vapors often or continually (page 168).

♦ Have him sip liquids often, even if it hurts to swallow.

♦ If the child begins to choke and turn blue, try to remove the membrane from his throat using a cloth wrapped around your finger.

Diphtheria is a dangerous disease that can easily be prevented with the DPT vaccine. Be sure your children are vaccinated.

Infantile Paralysis (Polio, Poliomyelitis)

Polio is most common in children under 2. It is caused by a virus infection similar to a cold, often with fever, vomiting, diarrhea, and sore muscles. Usually the child gets completely well in a few days. But sometimes a part of the body becomes weak or paralyzed. Most often this happens to one or both legs. In time, the weak limb becomes thin and does not grow as fast as the other one.

Treatment:

Once the disease has begun, no medicine will correct the paralysis. (However, sometimes part or all of the lost strength slowly returns.) Antibiotics do not help. For early treatment, calm the pain with acetaminophen or ibuprofen and put hot soaks on painful muscles. Position the child to be comfortable and avoid contractures. Gently straighten his arms and legs so that the child lies as straight as possible. Put cushions under his knees, if necessary to reduce pain, but try to keep his knees straight.

Prevention:

♦ Vaccination against polio is the best protection (see page 147).

♦ Do not give injections of any medicine to a child if you think his signs of a cold or fever might be caused by the polio virus. Although it happens only rarely, the irritation caused by an injection could turn a mild case of polio without paralysis into a severe case, with paralysis. Never inject children with any medicine unless it is absolutely necessary.

♦ Breastfeed your baby as long as possible. Breast milk protects your baby against infections, including polio.

Vaccinate all children against polio.

A child who has been paralyzed by polio should eat nutritious food and do exercises to strengthen remaining muscles.

Help the child learn to walk as best he can. Fix 2 poles for support, like these, and later make him some crutches. Leg braces (calipers), crutches, and other aids may help the child to move better and may prevent deformities.

For more information on polio and other childhood disabilities, see Disabled Village Children, also published by Hesperian.

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HOW TO MAKE SIMPLE CRUTCHES

Get a Y shaped tree branch, clean leaves. Get a small piece of wood to act as a stopper, then pull the two top end together and fix them on top with a piece of wood which you have prepared with two holes to fit the size of the top of the Y.

Wrap top with something soft, as cotton balls and secure them with tape.

316

PROBLEMS CHILDREN ARE BORN WITH

Dislocated Hip

Some children are born with a dislocated hip, the leg has slipped out of its joint in the hip bone. Early care can prevent lasting harm and a limp. So babies should be checked for possible hip dislocation at about 10 days after birth.

  1. Compare the 2 legs. If one hip is dislocated, that side may show:
  • The upper leg partly covers this part of the body on the dislocated side.

  • There are fewer folds here.

  • The leg seems shorter or turns out at a strange angle.

  1. Hold both legs with the knees doubled, like this, and open them wide like this.

If one leg stops early or makes a jump or click when you open it wide, the hip is dislocated.

Treatment:

Carry the baby with her knees high and wide apart, like this:

Check the baby again in 2 weeks. If you still feel or hear a jump or click, see a health worker. A harness that holds the baby’s legs open for 2 weeks can prevent lasting harm.

317

Umbilical Hernia (Belly Button that Sticks Out)

A belly button that sticks out like this is no problem. No medicine or treatment is needed. Tying a tight cloth or ‘belly band’ around the belly will not help.

Even a big umbilical hernia like this one is not dangerous and will often go away by itself. If it is still there after age 5, an operation may be needed. Get medical advice.

A ‘Swollen Testicle’ (Hydrocele or Hernia)

If a baby’s scrotum, or bag that holds his testicles, is swollen on one side, this is usually because it is filled with liquid (a hydrocele) or because a loop of gut has slipped into it (a hernia).

To find out which is the cause, shine a light through the swelling.

If light shines through easily, it is probably a hydrocele.

A hydrocele usually goes away in time, without treatment. If it lasts more than a year, get medical advice.

If light does not shine through, and if the swelling gets bigger when the baby coughs or cries, it is a hernia.

A hernia needs surgery (see page 177).

Sometimes the hernia causes a swelling here in either a boy or a girl.

You can tell this from a swollen lymph node (page 88) because the hernia swells when the baby cries or is held upright and disappears when he lies quietly.

318

MENTALLY SLOW, DEAF, OR DEFORMED CHILDREN

Sometimes parents will have a child who is born deaf, mentally slow (retarded), or with birth defects (something wrong with part of his body). Often no reason can be found. No one should be blamed. Often it just seems to happen by chance.

However, certain things greatly increase the chance of birth defects. A baby is less likely to have something wrong if parents take certain precautions.

  1. Lack of nutritious food during pregnancy can cause mental slowness or birth defects in babies. To have healthy babies, pregnant women must eat enough nutritious food (see page 110).

  2. Lack of iodine in a pregnant woman’s diet can cause hypothyroidism in her baby. The baby’s face is puffy, and he looks dull. His skin and eyes may remain yellow (jaundiced) for a long time after he is born. His tongue hangs out, and his forehead may be hairy. He is weak, feeds poorly, cries little, and sleeps a lot. He is mentally slow, may be deaf, and usually has an umbilical hernia. He will begin to walk and talk later than normal babies.

To help prevent hypothyroidism, pregnant women should use iodized salt instead of ordinary salt (see page 130).

If you suspect your baby may have hypothyroidism, take him to a health worker or doctor at once. The sooner he gets special medicine (thyroid) the more normal he will be.

  1. Smoking or drinking of alcoholic drinks during pregnancy causes babies to be born small or to have other problems (see page 149). Do not drink or smoke, especially during pregnancy.

  2. After age 35, there is more chance that a mother will have a child with defects. Down syndrome, which looks somewhat like hypothyroidism, is more likely to occur in babies of older mothers..

It is wise to plan your family so as to have no more children after age 35 (see Chapter 20).

  1. Many medicines can harm the baby developing inside a pregnant mother. Use as little medicine as possible during pregnancy, and only those known to be safe.

  2. Living near factories or industrial farms can expose you to toxic chemicals that can cause birth defects. See A Community Guide to Environmental Health.

  3. When parents are blood relatives (cousins, for instance), there is a higher chance that their children will have birth defects or mental slowness. Cross-eyes, extra fingers or toes, club feet, hare lip, and cleft palate are common defects.

To lower the chance of these and other problems, do not marry a close relative. And if you have more than one child with a birth defect, consider not having more children (see Family Planning, Chapter 20).

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If your child is born with a birth defect, take him to a health center. Often something can be done.

♦ For cross-eyes, see page 223.

♦ If an extra finger or toe is very small with no bone in it, tie a string around it very tightly. It will dry up and fall off. If it is larger or has bone in it, either leave it or have it taken off by surgery.

♦ If a newborn baby’s feet are turned inward or have the wrong shape (clubbed), try to bend them to normal shape. If you can do this easily, repeat this several times each day. The feet (or foot) should slowly grow to be normal.

If you cannot bend the baby’s feet to normal, take him at once to a health center where his feet can be strapped in a correct position or put in casts. For the best results, it is important to do this within 2 days after birth.

♦ If a baby’s lip or the top of his mouth (palate) is divided (cleft), he may have trouble breastfeeding and need to be fed with a spoon or dropper. With surgery, his lip and palate can be made to look almost normal. The best age for surgery is usually at 4 to 6 months for the lip, and at 18 months for the palate.

  1. Difficulties before and during birth sometimes result in brain damage that causes a child to be spastic or have seizures (fits). The chance of damage is greater if at birth the baby is slow to breathe, or if the midwife injected the mother with medicine to speed up the birth or to ‘give force’ to the mother (page 266) before the baby was born.

Be careful in your choice of a midwife, and do not let your midwife use medicines to speed up the birth.

For more information on children with birth defects, see Disabled Village Children, Chapter 12.

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The Spastic Child (Cerebral Palsy)

A child who is spastic has tight, stiff muscles that he controls poorly. His face, neck, or body may twist, and his movements may be jerky. Often the tight muscles on the inside of his legs cause them to cross like scissors.

At birth the child may seem normal or perhaps floppy. The stiffness comes as he gets older. He may or may not be mentally slow.

The brain damage that causes cerebral palsy often results from brain damage at birth (when the baby does not breathe soon enough) or from meningitis in early childhood.

There are no medicines that cure the brain damage that makes a child spastic. But the child needs special care. To help prevent tightening of muscles in the legs or in a foot, straighten and bend them very slowly several times a day.

Help the child learn to roll over, sit, stand, and if possible to walk (as on page 314). Encourage him to use both his mind and body as much as he can (see page 322). Even if he has trouble with speaking he may have a good mind and be able to learn many skills if given a chance. Help him to help himself.

For more information on cerebral palsy, see Disabled Village Children, Chapter 9.

TO HELP PREVENT MENTAL RETARDATION OR BIRTH DEFECTS IN HER CHILD, A WOMAN SHOULD DO THESE THINGS:

  1. Do not have children with a cousin or other close relative.

  2. Eat as well as possible during pregnancy: as much beans, fruit, vegetables, meat, eggs, and milk products as you can.

  3. Use iodized salt instead of regular salt, especially during pregnancy.

  4. Do not smoke or drink during pregnancy (see page 149).

  5. While pregnant, avoid medicines whenever possible, use only those known to be safe.

  6. Do not work in factories which use a lot of chemicals and do not use strong chemical cleaners at home.

  7. While pregnant, keep away from persons with German measles.

  8. Be careful in the selection of a midwife, and do not let the midwife use medicines to speed up the birth or ‘give strength’ to the mother (see page 266).

  9. Do not have more children if you have more than one child with the same birth defect (see Family Planning, page 283).

  10. Consider not having more children after age 35.

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Slow Development in the First Months of Life

Some children who are born healthy do not grow well. Their minds and bodies are slow to develop because they do not eat enough nutritious food. During the first few months of life the brain develops more rapidly than at any other time. For this reason the nutrition of the newborn is of great importance.

Breast milk is the best food for a baby (see The Best Diet for Babies, page 120).

Sickle Cell Disease (Sickle Cell Anemia)

Some children of African origin (or less often from India) are born with a ‘weakness of the blood’, called sickle cell disease. This disease is passed on from the parents, who often do not know they carry the ‘sickle cell’ trait. The baby may appear normal for 6 months, then signs may begin to appear.

Signs:

• fever and crying

• occasional swelling of the feet and fingers which lasts for 1 or 2 weeks

• big belly that feels hard at the top

• anemia, and sometimes yellow color in the eyes (jaundice)

• child frequently sick (cough, malaria, diarrhea)

• child grows slowly

• by age 2, bony bumps may appear on the head (‘bossing’)

Malaria or other infections can bring on a ‘sickle cell crisis’ with high fever and severe pain in the arms, legs, or belly. Anemia becomes much worse. Swellings on the bones may discharge pus. The child may die.

Treatment:

There is no way to change the weakness in the blood. Protect the child from malaria and other diseases and infections that can bring on a ‘crisis’. Take the child for regular monthly visits to a health worker for an examination and medicines.

Malaria. In areas where malaria is common, the child should have regular malaria medicines to help prevent the disease (see page 363). Add to this a daily dose of folic acid (page 392) to help build up the blood. Iron medicine (ferrous sulfate) is not usually necessary.

Infections. The child should be vaccinated against measles, whooping cough, and tuberculosis at the earliest recommended time. If the child shows signs of fever, cough, diarrhea, passing urine too often, or pains in the belly, legs or arms, take him to a health worker as soon as possible. Antibiotics may be necessary. Give plenty of water to drink, and acetaminophen (page 379) for pain in the bones.

Avoid exposure to cold. Keep warm with a blanket at night when necessary. Use a foam mattress if possible.

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HELPING CHILDREN LEARN

As a child grows, she learns partly from what she is taught. Knowledge and skills she learns in school may help her to understand and do more later. School can be important.

But a child does much of her learning at home or in the forest or fields. She learns by watching, listening, and trying for herself what she sees others do. She learns not so much from what people tell her, as from how she sees them act.

Some of the most important things a child can learn, such as kindness, responsibility, and sharing, can be taught only by setting a good example.

A child learns through adventure. She needs to learn how to do things for herself, even though she makes mistakes. When she is very young, protect a child from danger. But as she grows, help her learn to care for herself. Give her some responsibility. Respect her judgment, even if it differs from your own.

When a child is young, she thinks mostly of filling only her own needs. Later, she discovers the deeper pleasure of helping and doing things for others. Welcome the help of children and let them know how much it means.

Children who are not afraid ask many questions. If parents, teachers, and others take the time to answer their questions clearly and honestly, and to say they do not know when they do not, a child will keep asking questions, and as she grows may look for ways to make her surroundings or her village a better place to live.

Some of the best ideas for helping children learn and become involved in community health care have been developed through the Child to Child program. This is described in Helping Health Workers Learn, Chapter 24.

Or write to:

Child to Child Institute of Education
20 Bedford Way London WC1H 0AL
United Kingdom

Tel: +44 207-612-6649

e-mail: ccenquiries@ioe.ac.uk www.childtochild.org

22

health and sicknesses of older people

This chapter is about the prevention and treatment of problems seen mostly in older persons.

SUMMARY OF HEALTH PROBLEMS DISCUSSED IN OTHER CHAPTERS

Difficulties with Vision

After the age of 40, many people have problems seeing close objects clearly. They are becoming farsighted. Often glasses help. (see page 217)

Everyone over age 40 should watch for signs of glaucoma, which can cause blindness if left untreated. Any person with signs of glaucoma (see page 222) should seek medical help.

Cataracts (see page 225) and ‘floaters’ before the eyes (tiny moving spots, page 227) are also common problems of old age.

Weakness, Tiredness, and Eating Habits

Old people understandably have less energy and strength than when they were younger, but they will become even weaker if they do not eat well. Although older people often do not eat very much, they should eat some body building and protective foods every day (See page 110 to page 111).

Swelling of the Feet

(see page 176)

This can be caused by many diseases, but in older people it is often caused by poor circulation or heart trouble (see page 325). Whatever the cause, keeping the feet up is the best treatment. Walking helps too, but do not spend much time standing or sitting with the feet down. Keep the feet up whenever possible.

324

Chronic Sores of the Legs or Feet

(see page 213)
These may result from poor circulation, often because of varicose veins (page 175). Sometimes diabetes is part of the cause (page 127).

For other possibilities, see page 20.

Sores that result from poor circulation heal very slowly.

Keep the sore as clean as possible. Wash it with boiled water and mild soap and change the bandage often. If signs of infection develop, treat as directed on page 88.

When sitting or sleeping, keep the foot up.

Difficulty Urinating

Difficulty Urinating see page 235

Chronic Cough

Older people who cough a lot should not smoke and should seek medical advice. (See page 168)

If they had symptoms of tuberculosis when they were younger, or have ever coughed up blood, they may have tuberculosis.

If an older person develops a cough with wheezing or trouble breathing (asthma) or if his feet also swell, he may have heart trouble (see the next page).

Rheumatoid Arthritis (painful joints)

Many older people have arthritis.(see page 173)

To help arthritis:

♦ Rest the joints that hurt.

♦ Apply hot compresses (see page 195).

♦ Take a medicine for pain; aspirin is best. For severe arthritis, take 2 to 3 aspirin tablets up to 6 times a day with bicarbonate of soda, an antacid (see page 380), milk, or a lot of water. (If the ears begin to ring, take less.)

♦ It is important to do exercises that help maintain as much movement as possible in the painful joints.

325

OTHER IMPORTANT ILLNESSES OF OLD AGE

Heart Trouble

Heart disease is more frequent in older people, especially in those who are fat, who smoke, or who have high blood pressure. Men and women share many of the same signs below, but women more often have unexplained tiredness, sleeping problems, and shortness of breath. Women also feel an ache or tightness in the chest more than the sharper pains felt by men.

Signs of heart problems:

  • Anxiety and dif culty in breathing after exercise; asthma-like attacks that get worse when the person lies down (cardiac asthma).

  • A rapid, weak, or irregular pulse.

  • Swelling of the feet, worse in the afternoons.

  • Shortness of breath without exercise, unexplained tiredness, weakness, dizziness.

  • Sudden, painful attacks in the chest, left shoulder, or arm that occur when exercising and go away after resting for a few minutes (angina pectoris).

  • A sharp pain like a great weight crushing the chest; does not go away with rest (heart attack).

  • In women, a feeling like indigestion, nausea, clamminess, spasms, jaw pain (heart attack).

Treatment:

♦ Different heart diseases may require different specific medicines, which must be used with great care. If you think a person has heart trouble, seek medical help. It is important that he have the right medicine when he needs it.

♦ People with heart trouble should not work so hard they get chest pain or have trouble breathing. However, regular exercise helps prevent heart attacks.

♦ Persons with heart problems should not eat greasy food and should lose weight if they are overweight. Also, they should not smoke or drink alcohol.

♦ If an older person begins having attacks of difficult breathing or swelling of the feet, he should eat food that contains little or no salt for the rest of his life.

♦ Also, taking 1/2 aspirin tablet a day may help prevent a heart attack or a stroke.

♦ If a person has angina pectoris or heart attack, she should rest very quietly in a cool place until the pain goes away.

If the chest pain is very strong and does not go away with rest, or if the person shows signs of shock (see page 77), the heart has probably been severely damaged.

The person should stay in bed for at least a week or as long as she is in pain or shock.

Then she can begin to sit up or move slowly, but should stay very quiet for a month or more. Consider getting medical help.

326

Words to Younger Persons Who Want to Stay Healthy When They Are Older

Many of the health problems of middle and old age, including high blood pressure, hardening of the arteries, heart disease, and stroke, result from the way a person has lived and what he ate, drank, and smoked when younger. Your chances for living and staying healthy longer are greater if you:

  1. Eat well enough nutritious foods, but not too much rich, greasy, or salty food. Avoid getting overweight. Use vegetable oil rather than animal fat for cooking.

  2. Do not drink a lot of alcoholic drinks.

  3. Do not smoke.

  4. Keep physically and mentally active.

  5. Get enough rest and sleep.

  6. Learn how to relax and deal positively with things that worry or upset you.

High blood pressure (page 125) and hardening of the arteries (arteriosclerosis), which are the main causes of heart disease and stroke, can usually be prevented, or reduced, by doing the things recommended above.

The lowering of high blood pressure is important in the prevention of heart disease and stroke. Persons who have high blood pressure should have it checked from time to time and take measures to lower it.

For those who are not successful in lowering their blood pressure by eating less (if they are overweight), giving up smoking, getting more exercise, and learning to relax, taking medicines to lower blood pressure (antihypertensives) may help.

Which of these two men is likely to live longer and be healthy in his old age? Which is more likely to die of a heart attack or a stroke? Why? How many reasons can you count?

327

Stroke (Apoplexy, Cerebro-Vascular Accident, CVA)

In older people stroke or cerebro-vascular accident (CVA) commonly results from a blood clot or from bleeding inside the brain. The word stroke is used because this condition often strikes without warning. The person may suddenly fall down, unconscious. Her face is often reddish, her breathing hoarse and noisy, her pulse strong and slow. She may remain in a coma (unconscious) for hours or days.

If she lives, she may have trouble speaking, seeing, or thinking, or one side of her face and body may be paralyzed. In minor strokes, some of these same problems may result without loss of consciousness. The difficulties caused by stroke sometimes get better with time.

Treatment:

Put the person in bed with her head a little higher than her feet. If she is unconscious, roll her head back and to one side so her saliva (or vomit) runs out of her mouth, rather than into her lungs. While she is unconscious, give no food, drink, or medicines by mouth (see the Unconscious Person, page 78). If possible, seek medical help.

After the stroke, if the person remains partly paralyzed, help her to walk with a cane and to use her good hand to care for herself. She should avoid heavy exercise and anger.

Prevention: See the page before this one.

Note:

If a younger or middle aged person suddenly develops paralysis on one side of his face, with no other signs of stroke, this is probably a temporary paralysis of the face nerve (Bell’s Palsy). It will usually go away by itself in a few weeks or months. The cause is usually not known. No treatment is needed but hot soaks may help. If one eye does not close all the way, bandage it shut at night to prevent damage from dryness.

Deafness

Deafness that comes on gradually without pain or other symptoms occurs most often in men over 40. It is usually incurable, though a hearing aid may help. Sometimes deafness results from ear infections (see page 309), a head injury, or a plug of dry wax. For information on how to remove ear wax, see page 405.

DEAFNESS WITH RINGING OF THE EARS AND DIZZINESS

If an older person loses hearing in one or both ears, occasionally with severe dizziness, and hears a loud ‘ringing’ or buzzing, he probably has Ménière’s disease. He may also feel nauseous, or vomit, and may sweat a lot.

He should take an antihistamine, such as dimenhydrinate (Dramamine, page 386) and go to bed until the signs go away. He should have no salt in his food. If he does not get better soon, or if the problem returns, he should seek medical advice.

328

Loss of Sleep (Insomnia)

It is normal for older people to need less sleep than younger people. And they wake up more often at night. During long winter nights, older people may spend hours without being able to sleep.

Certain medicines may help bring sleep, but it is better not to use them if they are not absolutely necessary.

Here are some suggestions for sleeping:

♦ Get plenty of exercise during the day.

♦ Do not drink coffee or black tea, especially in the afternoon or evening.

♦ Drink a glass of warm milk or milk with honey before going to bed.

♦ Take a warm bath before going to bed.

♦ In bed, try to relax each part of your body, then your whole body and mind. Remember good times.

♦ If you still cannot sleep, try taking an antihistamine like promethazine (Phenergan, page 385) or dimenhydrinate (Dramamine, page 386) half an hour before going to bed. These are less habit-forming than stronger drugs.

DISEASES FOUND MORE OFTEN IN PEOPLE OVER 40 YEARS OLD

## Cirrhosis of the Liver

Cirrhosis usually occurs in men over 40 who for years have been drinking a lot of liquor (alcohol) and eating poorly.

Signs:

• Cirrhosis starts like hepatitis, with weakness, loss of appetite, upset stomach, and pain on the person’s right side below the ribs.

• As the illness gets worse, the person gets thinner and thinner. He may vomit blood. In serious cases the feet swell, and the belly swells with liquid until it looks like a drum. The eyes and skin may turn yellowish (jaundice).

Treatment:

When cirrhosis is severe, it is hard to cure. There are no medicines that help much. Most people with severe cirrhosis die from it. If you want to stay alive, at the first sign of cirrhosis do the following:

♦ Never drink alcohol again! Alcohol poisons the liver.

♦ Eat as well as possible: vegetables, fruit, and some protein (page 110 and page 111). But do not eat a lot of protein (meat, eggs, fish, etc.) because this makes the damaged liver work too hard.

♦ If a person with cirrhosis has swelling, he should not use any salt in his food.

Prevention of this disease is easy: DO NOT DRINK SO MUCH ALCOHOL.

329

## Gallbladder Problems

The gallbladder is a small sac attached to the liver. It collects a bitter, green juice called bile, which helps digest fatty foods. Gallbladder disease occurs most commonly in women over 40, people who are overweight, and people with diabetes.

Signs:

• Sharp pain in the stomach at the edge of the right rib cage: This pain sometimes reaches up to the right side of the upper back.

• The pain may come an hour or more after eating rich or fatty foods. Severe pain may cause vomiting.

• Belching or burping with a bad taste.

• In severe cases, there may be fever.

• Occasionally the eyes may become yellow (jaundice).

Treatment:

♦ Do not eat greasy food. Overweight (fat) people should eat small meals and lose weight.

♦ Take ibuprofen to calm the pain (see page 379). Stronger painkillers are often needed. (Aspirin will probably not help.)

♦ If the person has a fever, she should take ampicillin (page 352).

♦ In severe or chronic cases, seek medical help. Sometimes surgery is needed.

Prevention:

Women (and men) who are overweight should try to lose weight (see page 126). Avoid rich, sweet, and greasy food, do not eat too much, and get some exercise.

## BILIOUSNESS

In many countries and in different languages, bad-tempered persons are said to be ‘bilious’. Some people believe that fits of anger come when a person has too much bile.

In truth, most-bad tempered persons have nothing wrong with their gallbladders or bile.

However, persons who do suffer from gallbladder disease often live in fear of a return of this severe pain and perhaps for this reason are sometimes short-tempered or continually worried about their health.

(In fact, the term ‘hypochondria’, which means to worry continually about one’s own health, comes from ‘hypo’, meaning under, and ‘chondrium’, meaning rib, referring to the position of the gallbladder!)

330

ACCEPTING DEATH

Old people are often more ready to accept their own approaching death than are those who love them. Persons who have lived fully are not usually afraid to die. Death is, after all, the natural end of life. We often make the mistake of trying to keep a dying person alive as long as possible, no matter what the cost.

Sometimes this adds to the suffering and strain for both the person and his family. There are many occasions when the kindest thing to do is not to hunt for ‘better medicine’ or a ‘better doctor’ but to be close to and supporting of the person who is dying. Let him know that you are glad for all the time, the joy and the sorrow you have shared, and that you, too, are able to accept his death. In the last hours, love and acceptance will do far more good than medicines.

Old or chronically ill persons would often prefer to be at home, in familiar surroundings with those they love, than to be in a hospital. At times this may mean that the person will die earlier. But this is not necessarily bad. We must be sensitive to the person’s feelings and needs, and to our own. Sometimes a person who is dying suffers more knowing that the cost of keeping him barely alive causes his family to go into debt or children to go hungry. He may ask simply to be allowed to die, and there are times when this may be the wise decision.

Yet some people fear death. Even if they are suffering, the known world may be hard to leave behind. Every culture has a system of beliefs about death and ideas about life after death. These ideas, beliefs, and traditions may offer some comfort in facing death.

Death may come upon a person suddenly and unexpectedly or may be long-awaited. How to help someone we love accept and prepare for his approaching death is not an easy matter. Often the most we can do is offer support, kindness, and understanding.

The death of a younger person or child is never easy. Both kindness and honesty are important. A child, or anyone, who is dying often knows it, partly by what her own body tells her and partly by the fear or despair she sees in those who love her. Whether young or old, if a person who is dying asks for the truth, tell her, but tell her gently, and leave some room for hope. Weep if you must, but let her know that even as you love her, and because you love her, you have the strength to let her leave you. This will give her the strength and courage to accept leaving you. To let her know these things you need not say them. You need to feel and show them.

We must all die. Perhaps the most important job of the healer is to help people accept death when it can or should no longer be avoided, and to help ease the suffering of those who still live.

23

the medicine kit

Every family and every village should have certain medical supplies ready in case of emergency:

  • The family should have a HOME MEDICINE KIT (see page 334) with the necessary medicines for first aid, simple infections, and the most common health problems.

  • The village should have a more complete medical kit (see VILLAGE MEDICINE KIT, page 336) with supplies necessary to care for day-to-day problems as well as to meet a serious illness or an emergency. A responsible person should be in charge of it, a health worker, teacher, parent, storekeeper, or anyone who can be trusted by the community. If possible, all members of the village should take part in setting up and paying for the medical kit. Those who can afford more should contribute more. But everyone should understand that the medicine kit is for the benefit of all, those who can pay and those who cannot.

On the following pages you will find suggestions for what the medicine kits might contain. You will want to change these lists to best meet the needs and resources in your area. Although the list includes mostly modern medicines, important home remedies known to be safe and to work well can also be included.

How much of each medicine should you have?

The amounts of medicines recommended for the medicine kits are the smallest amounts that should be kept on hand. In some cases there will be just enough to begin treatment. It may be necessary to take the sick person to a hospital or go for more medicine at once.

The amount of medicine you keep in your kit will depend on how many people it is intended to serve and how far you have to go to get more when some are used up. It will also depend on cost and how much the family or village can afford. Some of the medicines for your kit will be expensive, but it is wise to have enough of the important medicines on hand to meet emergencies.

Note: Supplies for birth kits, the things midwives and pregnant mothers need to have ready for a birth, are listed on pages page 254 to page 255.

332

HOW TO CARE FOR YOUR MEDICINE KIT

  1. CAUTION: Keep all medicines out of the reach of children. Any medicine taken in large doses can be poisonous.

  2. Be sure that all medicine is well labeled and that directions for use are kept with each medicine. Keep a copy of this book with the medicine kit.

  3. Keep all medicines and medical supplies together in a clean, dry, cool place free from cockroaches and rats. Protect instruments, gauze, and cotton by wrapping them in sealed plastic bags.

  4. Keep an emergency supply of important medicines on hand at all times. Each time one is used, replace it as soon as possible.

  5. Notice the DATE OF EXPIRATION on each medicine. If the date has passed or the medicine looks spoiled, destroy it and get new medicine.

Note: Some medicines, especially tetracyclines, may be very dangerous if they have passed their expiration date. However, penicillins in dry form (tablets or powder for syrup or injection) can be used for as long as a year after the expiration date if they have been stored in a clean, dry, and fairly cool place.

Old penicillin may lose some of its strength so you may want to increase the dose. (CAUTION: While this is safe with penicillin, with other medicines it is often too dangerous to give more than the recommended dose.)

Keep medicines out of reach of children.

333

BUYING SUPPLIES FOR THE MEDICINE KIT

Most of the medicines recommended in this book can be bought in the pharmacies of larger towns. If several families or the village got together to buy what they need at once, often the pharmacist may sell them supplies at lower cost. Or if medicines and supplies can be bought from a wholesaler, prices will be cheaper still.

If the pharmacy does not supply a brand of medicine you want, buy another brand, but be sure that it is the same medicine and check the dosage.

When buying medicines, compare prices. Some brands are much more expensive than others even though the medicine is the same. More expensive medicines are usually no better. When possible, buy generic medicines rather than brand-name products, as the generic ones are often much cheaper. Sometimes you can save money by buying larger quantities. For example, a 600,000-Unit vial of penicillin often costs only a little more than a 300,000-Unit vial, so buy the large vial and use it for two doses.

334

THE HOME MEDICINE KIT

Each family should have the following things in their medicine kit. These supplies should be enough to treat many common problems in rural areas.

Also include useful home remedies in your medicine kit.

for wounds and skin problems:

Supply Amount Page
plastic or rubber gloves or plastic bags for your hands 1 small pack 75
sterile gauze pads in individual sealed envelopes 20 97 218
clean cotton 1 small pack 14 72 83 254
adhesive tape (adhesive plaster) 1-inch wide roll 2 rolls 85
soap, if possible a disinfectant soap like Betadine 1 bar or small bottle 370
70% alcohol 1⁄4 liter 72 201 211 254
hydrogen peroxide, in a dark bottle 1 small bottle 183
petroleum jelly (Vaseline) in a jar or tube 1 91 97 141 100
white vinegar 1⁄2 liter 241 294 309
sulfur 100 g 205 206 211
scissors (clean, not rusty) 1 pair 85 254 262
tweezers with pointed ends 1 pair 84 175
measuring temperature    
thermometers for mouth 1 each 30 41
thermometers for rectum 1 each 30 41
keeping supplies clean    
plastic bags several 195 332

335

medicines

Supply Amount Page
BACTERIAL INFECTIONS    
Penicillin, 250 mg tablets 40 350
Cotrimoxazole (sulfamethoxazole, 400 mg, with trimethoprim, 80 mg) 100 357
Ampicillin, 250 mg capsules 24 352
WORMS    
Mebendazole tablets 40 tablets of 100 mg. or 2 bottles 372
FEVER, PAIN    
Aspirin, 300 mg (5 grain) tablets 50 378
Acetaminophen, 500 mg tablets 50 379
ANEMIA    
Iron (ferrous sulfate), 200 mg, pills (best if pills also contain vitamin C and folic acid) 100 392
SCABIES, LICE    
Permethrin 1 bottle of shampoo 1 tube of cream 372
ITCHING AND VOMITING    
Promethazine, 25 mg tablets 12 385
EYE INFECTIONS    
Antibiotic eye ointment 1 tube 378

336

THE VILLAGE MEDICINE KIT

This should have all the medicines and supplies mentioned in the Home Medicine Kit, but in larger amounts, depending on the size of your village and distance from a supply center. The Village Kit should also include the things listed here; many of them are for treatment of more dangerous illnesses. You will have to change or add to the list depending on the diseases in your area.

additional supplies

Supply Amount Page
INJECTING    
syringes, 5 ml 2 65
needles # 22, 3 cm long 3 - 6 65
needles # 25, 1 1/2 cm long 2 - 4 65
TROUBLE URINATING    
catheter (rubber or plastic #16 French) 2 239
SPRAINS AND SWOLLEN VEINS    
elastic bandages, 2 and 3 inches wide 2 - 6 102 175 213
LOOKING IN EARS, ETC    
penlight (small flashlight) 1 34 255

additional medicines

Supply Amount Page
SEVERE INFECTIONS    
Penicillin, injectable;    
if only one, procaine penicillin 600,000 U per ml 20 - 40 351
Ampicillin, injectable 500 mg vials 20 - 40 352
Gentamicin 2 ml vials 20 - 40 358
Ceftriaxone 1 g vials 20 - 40 358
Tetracycline, capsules or tablets 250 mg 40 - 80 355
AMEBA AND GIARDIA INFECTIONS    
Metronidazole, 250 mg tablets 40 - 80 368
SEIZURES    
Phenobarbital, 15 mg tablets 40 - 80 389
SEVERE ALLERGIC REACTIONS AND SEVERE ASTHMA    
Epinephrine (Adrenalin) injections, ampules with 1 mg 5 - 10 385
ASTHMA    
Salbutamol, rescue inhaler 1 384
SEVERE BLEEDING AFTER CHILDBIRTH    
Oxytocin for injection, 10 Units/ml 6 - 12 390
or Misoprostol tablets of 200 mcg 18 - 36 391

other medicines needed in many but not all areas

Supply Amount Page
WHERE DRY EYES (XEROPHTHALMIA) IS A PROBLEM    
Vitamin A, 200,000 U capsules 10 - 100 391
WHERE TETANUS IS A PROBLEM    
Antitetanus immunoglobulin, 250 units 2 - 4 vials 388
WHERE SNAKEBITE OR SCORPION STING IS A PROBLEM    
Specific antivenom 2 - 6 387
WHERE MALARIA IS A PROBLEM    
Artemisin-based combination therapy, or whatever medicine are recommended in your area. 50 - 200 vials 363 367
TO PREVENT OR TREAT BLEEDING IN UNDERWEIGHT NEWBORNS    
Vitamin K, injections of 1 mg 3 - 6 392

337

MEDICINES FOR CHRONIC DISEASES

It may or may not be wise to have medicines for chronic diseases such as tuberculosis, leprosy, and schistosomiasis in the Village Medicine Kit.

To be sure a person has one of these diseases, often special tests must be made in a health center, where the necessary medicine can usually be obtained.

Whether these and other medicines are included in the village medical supplies will depend on the local situation and the medical ability of those responsible.

VACCINES

Vaccines have not been included in the Village Medicine Kit because they are usually provided by the Health Department. However, a great effort should be made to see that all children are vaccinated as soon as they are old enough for the different vaccines (see page 147).

Therefore, if refrigeration is available, vaccines should be part of the village medical supplies, especially the DPT, polio, tuberculosis, and measles vaccines.

338

WORDS TO THE VILLAGE STOREKEEPER OR PHARMACIST

If you sell medicines in your store, people probably ask you about which medicines to buy and when or how to use them. You are in a position to have an important effect on people’s knowledge and health. This book can help you to give correct advice and to see that your customers buy only those medicines they really need.

As you know, people too often spend the little money they have for medicines that do not help them. But you can help them understand their health needs more clearly and spend their money more wisely.

For example:

• If people come asking for cough syrups, for a diarrhea thickener like Kaopectate, for vitamin B12 or liver extract to treat simple anemia, for penicillin to treat a sprain or ache, or for tetracycline when they have a cold, explain to them that these medicines are not needed and may do more harm than good. Discuss with them what to do instead.

• If someone wants to buy a vitamin tonic, encourage him to buy eggs, fruit, or vegetables instead. Help him understand that these have more vitamins and nutritional value for the money.

• If people ask for an injection when medicine by mouth would work as well and be safer, which is usually the case, tell them so.

• If someone wants to buy ‘cold tablets’ or some other expensive combination of medicines for a cold, encourage him to save money by buying plain aspirin, acetaminophen, or ibuprofen tablets and taking them with lots of liquids.

You may find it easier to tell people these things if you look up the information in this book, and read it together with them. Above all, sell only useful medicines. Stock your store with the medicines and supplies listed for the Home and Village Medicine Kits, as well as other medicines and supplies that are important for common illnesses in your area. Try to stock low cost generic products or the least expensive brands. And never sell medicines that are expired, damaged, or useless.

Your store can become a place where people learn about caring for their own health. If you can help people use medicines intelligently, making sure that anyone who purchases a medicine is well informed as to its correct use and dosage, as well as the risks and precautions, you will provide an outstanding service to your community. Good luck!

words to the village health worker

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 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 (see page 338);

  • Midwives can counsel parents about the importance of eating well during pregnancy, breastfeeding, 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 WITH HIS PEOPLE. HIS FIRST JOB IS TO SHARE HIS KNOWLEDGE.

w2

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.

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.

LOOK FOR WAYS TO SHARE YOUR KNOWLEDGE.

w3

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. . .

If you can use what is best in modern medicine, together with what is best in traditional healing, the combination may be better than either one alone

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.

w4

4. know your own 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.

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 (see page 265) or inject a medicine to control bleeding (see page 266) 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.

  1. 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.

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  1. 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?)

Good leaders do not tell people what to do. They set the example

  1. 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.)

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  1. 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 (page 133).

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 or money they have?

• Is it because parents have more children than they 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?

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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.

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?

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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 (see page 149). Another is the support and encouragement of his family, his friends, and you.

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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.

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Sample Lists of Questions

To Help Determine Community Health Needs and at the Same Time Get People Thinking

felt needs

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?

housing and sanitation

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?

population

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, page 283.)

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nutrition

How many mothers breast feed their babies? For how long? Are these babies healthier than those who are not breastfed? 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 (page 109) or show signs of poor nutrition? How much do parents and school children 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? (See page 148 to 150.)

land and food

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

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

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?

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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 breastfeed 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.

In your health work always remember: Encourage people to make the most of local resources.

Use local resources whenever possible.

The most valuable resource for the health of the people is the people themselves. BREAST MILK, A TOP QUALITY LOCAL RESOURCE, BETTER THAN ANYTHING MONEY CAN BUY!

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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

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MORE WAYS TO WORK TOWARD BETTER NUTRITION

  • IRRIGATION OF LAND

  • FISH BREEDING

  • BEEKEEPING

  • NATURAL FERTILIZERS

  • BETTER FOOD STORAGE

  • Compost pile

  • SMALLER FAMILIES THROUGH FAMILY PLANNING (page 283)

  • Metal sleeves to keep out rats

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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.

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.

Start small

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:

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!

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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.

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BALANCE BETWEEN TREATMENT AND PREVENTION

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.

Early treatment is a form of preventive medicine.

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.

Work toward prevention , do not force it.

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.

Use treatment as a chance to teach prevention.

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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 (see page 163).

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 (see page 168).

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 (see page 155 to 156). 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.

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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 (see page 58).

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.

To educate people about sensible and limited use of medicines is one of the important jobs of the health worker.

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

For more information about the use and misuse of medicines, see Chapter 6, page 49. For the use and misuse of injections, see Chapter 9, page 65. For sensible use of home remedies, see Chapter 1.

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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 (see page 297), 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 breastfeed 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.

Setting goals often helps people work harder and get more done.

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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

Only when the people themselves become actively responsible for their own and their community’s health, can important changes take place.

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Tools for Teaching

Flannelboards 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.

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.

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