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Al-Ahram Weekly 7 - 13 October 1999 Issue No. 450 
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Published in Cairo by Al-Ahram established in 1875 |
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Al-Ahram Weekly 7 - 13 October 1999 Issue No. 450
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| Published in Cairo by Al-Ahram established in 1875 |
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Egypt Region International Economy Opinion Culture Interview Features Profile Travel Living Sports People Time Out Chronicles Cartoons Letters Al-Ahram:
A Diwan of contemporary life (306)
Early this century, when infant mortality rates in Egypt were shockingly high, Al-Ahram launched several campaigns on children's health care, the most prominent being Dr Shakhashiri's articles in which his advice to mothers is still taken today. Hygiene, proper nourishment and fresh air were Dr Shakhashiri's ABC's to ensure healthy generations. Shakhashiri focused particular attention on breastfeeding, calling mother's milk the best nourishment for infants and warned against the hazards of dairy milk, "the true calamity." Dr Yunan Labib Rizq * describes the nation's physical well-being at the time and the writings of the good doctor
An ounce of prevention...
High infant mortality rates had long been one of Egypt's recurring nightmares. As such, it was also one of the preoccupations of Al-Ahram in which the issue would sometimes become a full-scale public awareness campaign.
In the summer of 1907, for example, the infant mortality rate climbed alarmingly. Approximately 3,000 children per month had died that summer, a considerable number in a population that, at the time, was less than 12 million. On 15 July of that year, Al-Ahram alerted its readers to the "rising mortality among children", a phenomenon it attributed to the heat, improper child care and poor sanitation. Under the headline, "The nourishment of children", the newspaper cited "ignorance" as one of the leading causes of the high infant mortality rate. Egyptian women were unaware of the proper nourishment for their children. In the countryside, no sooner is a child born than he is fed lahsa, a mixture of ghee, honey and bread. "What could be worse for a child's stomach?" asks the writer, who goes on to add, "Then, at five or six months, children are fed everything their parents eat, from every type of dairy product to cooked meats. This exposes children to disease and places their lives at risk." But ignorance was not the preserve of rural women. In the cities, the newspaper cites poor breastfeeding practices as a major cause of infant mortality. Women of the prosperous classes, in particular, tended to substitute cows milk for breastfeeding and, worse yet, they were "unaware of the essentials of administering milk to children." Using cows milk requires "systematic hygiene. The milk must be sterilised and the utensils used to do this must be sterilised as well." Failing to do so will produce "severe intestinal ailments." By way of corroboration, the article argues that one reason infant mortality rates climbed in the summer months was that the heat caused milk to spoil more quickly. The same applies to fruits and vegetables, it adds. Therefore, if women followed the newspaper's advice, with even greater vigilance in the summer, "the infant mortality rate will decline and our children will become healthier and acquire greater immunity to disease."
illustration: Makram Henein
The following summer the newspaper supported an appeal made by Dr Abdel-Aziz Nazmi, one of the pioneers of community work in Egypt, to found a childcare society. One of the society's primary aims was to reduce infant mortality through the establishment of health clinics which would provide medical treatment to children, dispense medication and offer material and moral assistance to mothers. All these services were to be provided free of charge. The clinics were to operate in the hospitals administered by the Ministry of Awqaf (religious endowments) in the afternoons, at the end of the hospitals' normal working hours.
Toward the end of 1910 Al-Ahram initiated another awareness drive for children's health care. On this occasion it featured "A sound mind in a sound body" by Dr Tawfiq Sousa. The first three installments of what eventually became a 12-part series discussed hygiene and clothing while nine focused on ailments. One interesting piece of advice Sousa gave his readers was to bathe in water ranging between eight and 16 degrees centigrade regardless of the weather. On food, he gave special attention to milk which "for the elderly, as it is for the very young, is the only form of nourishment that can be tolerated by the stomach." He then surprises his readers with the little known fact that, of the four types of milk -- mother's, cows, goats and donkeys -- donkey milk "is the closest in composition to mothers milk while goats milk is the second closest."
It would not be until over a decade later that Al-Ahram would launch another campaign to promote children's health care. In the summer of 1921 the newspaper presented another series of articles, this time by the reputed pediatrician Dr Shakhashiri, who appropriately called his series: "An ounce of prevention is worth a pound of cure."
Before proceeding to Dr Shakhashiri's column, certain general observations about the people involved in the children's health care drive and their work merit our attention. It would appear from Al-Ahram's public awareness campaigns that most of the physicians involved were of Syrian origin, as was the case with doctors Sousa and Shakhashiri. To what extent Al-Ahram's sampling of the medical profession was representative is difficult to determine. Certainly the Syrian origins of the newspaper's founding fathers, as well of its editor-in-chief in the opening decades of this century, would have rendered it more naturally disposed towards other members of the Syrian community in Egypt. Still, it cannot be disputed that Syrian physicians made up a significant proportion of that segment of the medical community which founded and operated community health clinics. Egyptian physicians, for the most part, seemed to have joined this endeavor at a much later date. It is true that one might have expected a greater representation from the many generations of Qasr Al-Aini graduates since the founding of that medical academy in 1828. On the other hand, that very academy had established the equally old expectation that its graduates would dedicate their services to government-run hospitals. Apart from Egyptians, of all the other Mediterranean physicians involved in charitable health services, only the Syrians contributed effectively to the public awareness drive. Whatever the contributions of the French, Greek or Italian medical communities to the advancement of medicine in Egypt, they could not write down their work in Arabic.
In one of his articles in "An ounce of prevention", Dr Shakhashiri wrote that the annual mortality rate in Cairo alone was 49 deaths per 1,000. "This is the highest mortality rate in the world and is the result of an extraordinarily high infant mortality rate," he comments. Given the gravity of the situation, it is difficult to understand Al-Ahram's silence on the issue from the time Dr Sousa's series was published in 1910 and its publication of Dr Shakhashiri's series 11 years later. Perhaps the explanation lied in World War I accompanied by the declaration of the British protectorate over the country. Undoubtedly the events of the war would have drawn the attention of Al-Ahram's editorialship to the battlefront. At the time, financial straits, not to mention paper shortages, placed substantial restrictions on the newspaper's size and diversity in content. Then, following the war, Egypt experienced the tumultuous events of the 1919 Revolution, which would naturally preoccupy public opinion and, consequently, Al-Ahram.
Whatever the reasons, on 23 June 1921, the date on which Dr Shakhashiri's first article appeared in Al-Ahram, Egypt was very different to that of a decade earlier. The recent revolution had charged every aspect of life, something which Dr Shakhashiri was not familiar with. Indeed, we observe the prevailing atmosphere in his opening remarks: "It is incumbent upon us to safeguard this emerging nation by taking all precautions to rescue its young from the diseases to which they are exposed." Later in his introduction he proclaims: "The nation which provides the healthy soil upon which to raise its children shall prevail in the conduct of its most pressing affairs. No navy, however powerful its guns, shall dare approach its shores, nor will the mightiest of armies be able to scale its walls because of the immunity with which it has fortified itself through a sound body." Toward this end the author informs Al-Ahram's readers that he had provided "several episodes to be published on the pages of this venerable newspaper to which we are indebted to for allowing my feeble voice to be conveyed to those upon whom we shall depend upon to realise our aspirations."
Like Dr Sousa over a decade earlier, Dr Shakhashiri emphasised the importance of proper nourishment. Indeed, over half of his articles dealt with the subject. Nor did the two physicians have any significant disagreement regarding the importance of mother's milk. Dr Shakhashiri, too, believed that it was the best nourishment for infants, although he cautioned that breastfeeding could be excessive. Many mothers were given to breastfeeding their newborn simply to stop them from crying, "whereas hunger may be the infant's last reason for crying." He held that it takes at least three hours for a child to feel hungry again after its last feeding and urged mothers to desist from the "deleterious custom" of breastfeeding their children at shorter intervals.
"Thorough hygiene, proper food and fresh air," were Dr Shakhashiri's three building blocks for ensuring a sturdy generation. These essentials were closely related. He observed, for example, that three out of every four children were bottle fed, "which increases the risks of impurities in the food, and therefore, the exposure to microbes." The risk was particularly great in the summer, when infectious diseases were more contagious and when the heat "debilitates all of an infant's bodily tracts and weakens its ability to regulate its body temperature, unlike the mature body, which retains its temperature regulating facility."
The true "calamity" resides in dairy milk, which can easily become contaminated. Dr Shakhashiri warned that "all precautions must be taken to prevent milk from being contaminated and becoming spoilt at every phase of the milking and distribution process." The same care and attention should be given to milk "as we do to all our important national resources," and toward this end he urges the government "to impose severer controls on milk merchants to ensure that they take all the necessary precautions to guard their products from contamination." Indeed, he exhorted the government to emulate the US which "accords generous allocations toward keeping milk free of contaminants" and which "does not leave a stone unturned or a theory unexplored in its quest to rally all possible scientific means toward ensuring the safety of that nation's milk." Even then, Dr Shakhashiri cautions, milk may not be totally free of contamination.
In order to drive home his plea to provide children with better hygiene and food care, the eminent pediatrician drew a picture of the consequences of negligence. "Who in this country has not been moved by that feeble, fleshless child's body with a distended stomach, ashen skin, swollen joints and concave chest and by those eyes sunken behind jutting cheekbones and that frail, aged voice from a mouth so young?" These children, moreover, are too weak to stand or sit without assistance. "Either they have to be carried by their mothers or lay prone on the ground, groaning in pain from the slightest touch."
One of the most prevalent summer illnesses to claim children's lives in the early part of this century was dysentery. It is little wonder, therefore, that Dr Shakhashiri would dwell in length on what he termed "summer diarrhoea", which, he claimed, did not even spare children who were breastfed. This was because "most mothers are accustomed to feeding buffalo milk to their children at the first signs of illness or fever. Most mothers rely on this remedy before they bring their child to a doctor. That curious milk, certain to be ridden with all forms of filth and germs, is the first recourse mothers seek. Children do sometimes recover. But that is a quirk of fate, for generally the milk is a prime cause for the aggravation of the disease."
Curiosity drove the author to explore the origins of the widespread belief that cold buffalo milk drives down fever. He confesses in the end to have failed in this task, although he still cannot bring himself to accept any validity in the belief. "Even granting that boiling the milk will kill germs and perilous contaminants," he argues, "it will not effect the composition of other foul matter. And, in the final analysis, how many people boil the milk before giving it to their children? Very few indeed, because they believe that it has to be administered cold in order to bring down the temperature."
We have seen that Dr Shakhashiri alerted his readers to a misconception that is still prevalent: that boiling milk alone is sufficient to kill off all contaminants. He insists that this is not the case and urges the government to become more actively involved in the supervision of the sterilisation and preservation of milk, "as is the case in the countries of Europe." Moreover, should the government plead non-availability of funds, "it could level a one-piastre tax and accumulate more than enough money for this purpose."
But contaminated milk was not the sole cause of "summer diarrhoea." Shakhashiri devotes two installments of "An ounce of prevention" to an analysis of this acute dehydration which claimed the lives of so many children. Summer diarrhoea, which he defined as "severe intestinal convulsions resulting from the aggravation of the intestinal viscera," came in three forms: "mechanical, bacterial and septic."
"Mechanical diarrhoea" was prevalent among one-year-old children, reached epidemic proportions "in the summer among the uneducated poor," and "generally results in death." It was induced by giving children foods that were difficult to digest, such as cucumbers, watermelon, fuul beans, pickled vegetables, ta'amiya, rabbit, beef and veal. Unpeeled foods and foods containing seeds were to be avoided, "because the skins and seeds irritate the fine intestinal viscera and disrupt the smooth functioning of the digestive tract." In addition to operating a private clinic for children, Dr. Shakhashiri also was a pediatrician for the British Hospital. He thus had ample personal experience on which to base his conclusions. He described, for example, a year-old infant who had been fed an apple "including its skin and seeds." An hour after eating the apple, "the infant began to display symptoms of indigestion and intestinal disorders, including vomiting and diarrhoea, and its feces contained pieces of undigested apple." If these symptoms remain untreated, the doctor warned, within a few days the child would develop "septic poisoning."
Bacterial diarrhoea also tended to affect children in the same age category and was especially virulent in the summer. It was caused by micro-organisms to which the intestinal viscera were vulnerable, such as "dysenteric and gas producing bacteria." It was distinguishable from mechanical diarrhoea by the perilously high fevers it induced, sometimes peaking at over 41 degrees. The symptoms were also longer lasting and tended to reach their most critical stage on the fifth or sixth day, "at which point the child may pass more than 20 diarrhoea excretions within a 24- hour period while his feces will contain a high proportion of blood and pus." In spite of the severity of these symptoms, Shakhashiri assures readers that this dysentery is not difficult to cure. But, he adds, "it is far better for the mother to guard the child's food against contamination and to take all essential hygienic precautions especially before feeding time."
The most dangerous form of summer diarrhoea in the doctor's opinion was what he called "septic diarrhoea," which, out of the three forms, claimed the most lives. It was induced by "the corruption and decomposition" in foods, whereby the "putrefying" ingredient irritates the intestinal viscera. The presence in the body of fermenting sugar was one of the primary sources of putrefaction and Shakhashiri cautions mothers not to feed their children more sugar than their infants' constitution can absorb or to feed them foods which generate large quantities of saccharine. Excess quantities of sugar, he warns, can produce infections in the respiratory tract and intestinal disorders which, in turn, impair the body's ability to breakdown and absorb the sugar, creating undigested residues that are subject to fermentation. He adds, "the summer heat is one of the primary causes of sugar fermentation, for the heat causes all bodily functions to grow sluggish, including the digestive tract, thereby offering an ample breeding ground for microbes."
The pediatrician arrives at the heart of the issue in his sixth episode in which he describes the effects of dehydration. "The child becomes extremely frail. His stomach sags, his skin wrinkles, his cheekbones jut out and his eyes grow sunken and hollow. In a matter of days, the child displays the decrepitude of an aged man suffering the ravages of time." Given the horrifying consequences of dehydration, the doctor was shocked by the widespread practice of withholding water from children until the first bout of illness had passed. "We have found difficulty in our attempts to persuade mothers to relinquish this appalling custom. We have met with some success, but for the most part we failed," he remarks. He takes the opportunity to cite an American study which places dehydration high among the causes of infant mortality and goes on to urge mothers to administer water to their ailing children. "Water is the basis of life," he says. "Heed the advice of doctors who tell you that water is useful, indeed indispensable to small and adult bodies. Have you not observed how birds provide water from their beaks to the beaks of their thirsty chicks before they have taught them to fly?"
In his final episode, Dr Shakhashiri continues to admonish mothers, this time about hygiene in general. He seeks "cleanliness and more cleanliness" in everything that pertains to the child, his body, clothing, bed, food, home and "the entire environment in which he comes into contact, inclusive of other human beings and material objects." In addition, infants should be kept away from all domestic livestock such as rabbits, goats and chickens, "which are frequently the source of certain virulent diseases or the conduit through which the diseases are spread to children." Furthermore, he counsels mothers to avoid fresh milk and to use powdered milk instead, recommending in the process a specific brand. "Galaxo can be found in all the well-known pharmaceutical outlets in Egypt... its only drawback is its price." Another piece of advice concerned infants' clothing which "should consist of a one-piece pajama, a belt, an outer garment and diapers." A final admonishment was directed to breastfeeding mothers. "Do not indulge excessively in coffee or tea," he instructs them, although he reserves special chastisement for smoking women. "If you are addicted to smoking and have transformed your beautiful mouth into a chimney, this is the time to demonstrate your willpower to overcome this odious habit." While the brand names of powdered milk have changed, Dr Shakhashiri's advice to mothers continues to hold true up until today.
* The author is a professor of history
and head of Al-Ahram History Studies Centre.
