29/06/2014

CAM 305 7/7/14

Custom, culture, human

behaviour and Tropical Medicine
The aim of this lecture is to discuss the effects
of human cultures, customs and behaviour on
the health of communities, especially in
developing and tropical regions.
It emphasizes the need for health
professionals in the tropics to be aware of
these factors and their effects on the health
picture on the community they serve.

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Introduction 1

When one visits or

does an elective in a
developing or tropical
country, one may initially
find the conditions and
culture encountered
strange or even disturbing
known as culture
shock

Introduction 2
Scientific knowledge is not everything in
the practice of medicine!
Human customs, culture and behaviour can all affect the
presence, absence or prevalence of an infection in a
community and all can impact on the practice of medicine
diagnosis, specimen collection, treatment, management
as well as epidemiology and planned control measures.

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Behaviour and disease

transmission
The behaviour of Homo sapiens, the
forgotten factor in the transmission of
tropical disease
Gillett, J.D. (1985) Trans. R.Soc.Trop.Med.Hyg. 79, 12-20

Disease transmission
Factors which can affect the transmission of
infection within communities include:
Human behaviour
Community living
Religious beliefs
Traditional medicine and healers
Sexual customs and practices
Relationship with animals
Food and food preparation
Sanitation and hygiene
Travel
Stupidity!!

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Community living
With small population
numbers and a
nomadic way of life,
crowding and
pollution are kept to a
minimum which in
turn keep the
transmission of many
diseases at a low level

When population
numbers increase,
disease transmission is
facilitated through
close contact,
crowding and
environmental
pollution.

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Religion
Religion can influence behaviour and this in turn
can impact on health - a good example comes from
the Jews

Trichinella spiralis is a
nematode in pigs and is
transmitted to humans
when pork is ingested the ancient Jews were
aware of the dangers of
eating pork:
(Photo: Peters and Gilles:
Colour Atlas of Tropical Medicine and
Parasitology. Wolf.)

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Like the Jews, Moslems do not

eat pork and would thus also be
protected from pig-borne
infections such as pork
tapeworm and trichinosis; while
Hindus, who do not eat beef,
would be protected from such
diseases as beef tapeworm and
bovine spongiform
encephalopathy (mad cow
disease).

The promotion of condom

use (often utilising a
distinct local icon) to
ensure safe sex is vital to
help prevent STDs
(STIs) and the
prohibition of condom use
on religious or local
cultural grounds can
severely hamper control
programmes developed
for STIs and HIV-AIDS.

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An important point which arises as regards religious/cultural antagonism

to birth control/contraceptive techniques --- as we reduce the childhood
mortality rates from infection etc in developing countries, we must also
control the birthrate or we will be merely substituting one problem for
another!

However, this may not be straightforward due to cultural and

religious views on birth control/contraception:
Some considerations to think about:
Cultural: Africans Traditionally favour large family to support aged
parents; accept boys (continue family name) and girls as
bring
Lobola, or bride price, to father)
Chinese Traditionally favour large family for old age support.
With 1 child policy, prefer boys.
Indian (Hindu) prefer boys as girls require father to pay
dowry to prospective husband
Religious:

Catholicism against birth control and contraceptives

Judaism orthodox Jews tend to disapprove of birth
control
Islam mostly accept contraception if both parties
agree some conservatives forbid.
Hinduism no problems
Buddhism no problems

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Traditional Medicine

Other medaeval traditional superstitions impacting on health/

well being:
Judaism
Baal Shem Jewish Cabalistic mystics
Healing and magic powers, including curses

Islam
Jinns mischievous/evil spirits; demons

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So, what about the role of traditional herbal

(plant) therapy and such alternate medical
practices as homoeopathy in the world of today?

What about the claims made in modern traditional/alternate medical practices?

1.Traditional European medicinal plants

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2. Traditional African medicinal plants*

*Muller and Ritz-Muller, 1999

Many herbs used in

traditional treatments have
contributed to modern
scientific medicine (eg.
digitalis, emetine, quinine,
artemisinin) and we
should never dismiss out
of hand a traditional
medication for its
potential beneficial
properties..

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but it must be scientifically evaluated!

Graham Pinn*, in a paper published in

the Annals of the ACTM, noted that
for the majority of the world, for cultural

or financial reasons, plant therapy remains the

mainstay of treatment and that In the last
30 years or so the western world has rediscovered natural remedies and also that
This change in attitude, (is) typically found
in middle-aged, middle-class females. He
further warns that There is a misguided
belief that natural substances are safe and
synthetic substances are harmful and quotes
a paper by Way et al (1996) reporting
that 48% of patients in a Sydney
Emergency Department were taking
some sort of alternative medicine.

This would certainly seem to suggest that

to ask the question of intending
travellers: Are you taking any herbal
medications? might well be worthwhile.
* Pinn, G. (2006). Traditional medical treatments VII.
What modern medicine can learn from traditional
medicine. Ann of the ACTM; 7: 23-24.

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However, as Pinn* has recently rightly

cautioned us:
There is an antagonism
between alternative
practitioners, who regard
orthodox medicines as
chemical poisons, and the
medical profession who
regard natural therapists as
snake-oil salesmen. We have
forgotten the origin of many
our medicines and this
antagonism should not
prevent proven natural
therapies being adopted as
orthodox treatment.

* Pinn, G (2012 in press) Tropical phytotherapy the good, the bad

and the ugly. In Topics in Tropical Medicine. ACTM. Townsville

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Most cultures have

traditional healers/witch
doctors/shamans whose
advice often relies on a
belief in the supernatural.
These may have a place in
a health care situation
although their role must be
carefully evaluated and
defined.

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Traditional healers around the world

PNG; India; N. America

In some cases the image of the traditional healer has

changed and the profession has modernized
South AfricaBrazil S E Asia

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What is a witchdoctor?

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In Zimbabwe

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Interestingly, in Zimbabwe an
attempt has been made to set up
a register of recognised
Ngangas.
As their techniques are secret and
cannot be disclosed, their
registration and acceptance as a
recognised Nganga relies, not
on an examination, but on the
supporting evidence of the local
villagers confirming his/her
success as a practitioner of the
art!

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Traditional African treatments

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..and is actually increasing in some parts of the world

In PNG, (as well as Vanuatu

and the Solomons),
unexplained deaths, illness or
misfortune often blamed on
witchcraft (sanguma).
The accused witch is often
tortured and burned to death.
In PNG, sorcery-related
attacks have been increasing
since the 1980s , with 150
cases of violence and killings
each year in Simbu province
alone according to a 2013
report in The Global Mail.
Picture: www.theglobalmail.org

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but also in developed countries!!!

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The claims of traditional healers can be excessive - and

dangerous!

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One problem that

arises when people
initially consult
traditional healers is
that of delayed
diagnosis and
treatment when they
do eventually come to
the clinic/hospital.

Examples of dangerous and/or undesirable forms of traditional

medicine include:
- witchcraft (including use of human tissues as medicine); giving of
dangerous medications; blaming a witch for a disease.
- killing endangered animal species for medicine (eg rhino horn in
Chinese medicine)

Some cases possibly involving witchdoctors/ traditional

healers/misguided superstition follow:

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A case of lumpy skin disease

A case of pentastomiasis

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A case of a worm in the brain

A case involving wee worms

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A case of a snake in the head

A sad case from Samoa

Case by Hannah Chapman

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Professor Edzard Ernst (2012)* in his

assessment of homoeopathy
concluded:

Finally the assumption that

homeopathy cannot harm patients is
demonstrably wrong. The inescapable
conclusion from all this is that
homeopathy is a fascinating chapter
from the history of medicine but not
an evidence-based, ethical therapeutic
approach
*Ernst, E. (2012) Testing the water.
The Biologist. 59; 1: 18 -21.

What about herbalism and the use of traditional medicines?

It is still widespread in Africa.
Photo: Muller and Ritz Muller (2000)

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.in Asia and many other part of the world.

In Australia too, natural therapy is gaining ground

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but there are dangers in the use of natural or herbal

therapies

Sex
Sexual activities are a very
efficient mode for
transmission of infection.
Transmission of STDs
(STIs) is facilitated by
the type of sex, having
unprotected sex and
having sexual intercourse
with multiple partners

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The potential for STD spread!

Ross (1977) quotes a study in which

80 American sailors, on one voyage, had
sex with 615 women at 112 ports in 45
countries!

STD (STI)
lumps and ulcers
vaginal/urethral discharges; disseminated/wasting

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Of course, Australians have some weird behavioural ideas too..

and promises made by politicians dont help!

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In cultures where
pubic hair is routinely
shaved, the
prevalence of pubic
louse infestation is
declining! In Western
societies too, pubic
hair waxing in the
bikini sect is
threatening the
survival of the pubic
louse

Remember - STIs are

often multiple and
especially where
multiple partners are
involved!

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Living with animals

Where humans live in close association with domestic and companion
animals they become exposed to a different range of diseases.
(Photo: THEC)

.. and this is
exacerbated when
humans mix with
various animal species
and live in close and
overcrowded
conditions..

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. or where bad animal

husbandry techniques
are used

.or sometimes even after quite minor and transient

contact with animals!

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* not in Australia

Cats

Dogs
Rabies*
Salmonellosis
Ringworm
Cryptosporidiosis
Giardiasis
Dipylidium caninum
Hydatid
Toxocariasis
Cutaneous larva migrans
Eosinophilic enteritis
Dirofilaria immitis
Ectoparasitic arthropods

Rabies*
Cat scratch fever
Pasteurella multocida
Capillaria aerophila
Salmonellosis
Ringworm
Cryptosporidiosis
Giardiasis
Toxoplasmosis
Dipylidium caninum
Toxocariasis
Ectoparasitic arthropods

* not in Australia

Cattle:

Ringworm; campylobacteriosis; cryptosporidiosis

beef tapeworm; mad cow disease*, EHEC
(incl. STEC).

Sheep:

Cryptosporidiosis; toxoplasmosis; sarcocystosis;

enzootic abortion (Chlamydophilia abortus)_

Pigs:

Jap B encephalitis, balantidiasis; Pork tapeworm*;

toxoplasmosis; trichinosis

Marsupials: RRV, ringworm; salmonellosis; toxoplasmosis;

giardiasis; trichinosis; ?haycocknematosis;

animal scabies

Flying foxes/bats: Rabies*; Lyssavirus, Ebola*; Hendra virus

Histoplasmosis

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These diseases of animals (zoonoses) can

be transmitted to humans in a number of
ways:
1.
2.
3.
4.

Directly to the humans

Environmental contamination (soil/water)
Animal eaten as food
Arthropod vectors

Some zoonotic
infections are
accidently acquired
such as this
acanthocephalan,
Moniliformis
moniliformis, passed
in Tasmania by a child
from Darwin

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Toxoplasmosis 1

Some zoonoses (eg Toxoplasma gondii) may

have a very complex epidemiology

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Particularly high
levels of human
toxoplasmosis often
relate to food habits of
particular communities
eg Parisians and
Bedouin Arabs

Toxoplasmosis is a
particularly interesting
disease in that
infection can change
the behaviour of
intermediate hosts to
make them more
susceptible to being
caught by cats!

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It is claimed that
chronic toxoplasmosis
can cause similar
changes in human
behaviour resulting in
humans developing
more risky
behaviour patterns

The hydatid story

In the 1960s,
Tasmania had an
unacceptably high
prevalence of hydatid.
(Photo: THEC)

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The reason for this was failure to regularly treat dogs; feeding of sheep
offal to dogs; lack of education about the disease

To combat this infection THEC was formed

Tasmanian Hydatid Eradication Council

Dept Agriculture
Veterinary Assoc
Farmers and Graziers
Young Farmers
Dept of Health
Parents and Teachers
Medical Practitioners
Univ. of Tas Medical School

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THEC introduced:
Checking of all rural dogs
Checking sheep at slaughter
Feeding of sheep offal to
dogs illegal
Notification of all human
cases
Quarantine of infected farms
Education
(Photo: THEC)

The effects were spectacular

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Continuing decline in human cases

Eradication of endemic hydatids in

Tasmania was finally achieved in 1995.
The campaign was a spectacular success largely due to involvement of the entire
community!

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However the danger

of re-introduction
remains particularly due to
hunters bringing
infected dogs from
the mainland

Hydatids and the Turkana

Highest prevalence in the world

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The reason hydatid is so common amongst the Turkana is

that there is a dog-human/cattle-dog cycle and dogs trained
to act as nursemaids to children and human bodies are
commonly devoured by dogs

Food and food preparation

To a large extent, the
infections we acquire from
food depend on what we
eat and how we prepare it.
We like to think that the
food we eat is safe and
that its preparation is
beyond reproach

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.. but appearances can be deceptive..

while cultural or
personal eating habits
can be relevant..
. and some foods can
only be described as
disgusting - this man
is eating a special
delicacy - a tapeworm!
(Photo from Throwim way leg by Tim
Flannery)

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Even within a
population/tribal group,
food differences between
the tribes or even the
sexes can determine the
presence/prevalence of an
infection eg:
Lung fluke in the Bakosi of
W. Africa and
Kuru in the Fore of PNG

So, what we eat and

how we prepare it has
a great influence on
what infections we can
and do acquire (eg
pork or beef
tapeworm)

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The Trichinella story

Infection with the
nematode Trichinella
spiralis is contracted
by ingestion of pork or
other meat containing
the larvae.

Distribution of species infecting humans

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In the 1980s there

occurred an
inexplicable
number of deaths
amongst the
Tasmanian Devil
population in the
Cradle Mountain
area. These deaths
were investigated
by Dave Obendorf
(Photo: Gregg Brill)

Imagine the
concern when it
was found that the
devils had died
from trichinosis..

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These infections
were further
investigated by
Obendorf et al.,
(1990), who
showed trichinosis
to be widespread
across Tasmania in
the devils, the
quolls and possibly
in possums as well..

Trichinosis was
also detected in
the quolls..
(Photo: Gregg Brill).

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.and the finding

of trichinosis in
possums further
fuelled concerns
(Photo: DIPWE)

..not only for

the export market
which was selling
possum meat for
eating, but to
possum skinners!

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What relief then,

when the worm was
found to be
Trichinella
pseudospiralis
(which had never
been recorded as
affecting humans),
not T. spiralis (an
important zoonotic
species) and thus no
threat to the pig
industry (and
humans).

However, shortly afterwards in New Zealand

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The identification was proved beyond doubt

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Then a short time later, another case - was it also

T. pseudospiralis?

A squash preparation
of the freshly biopsied
muscle from this
patient, revealed a
writhing mass of
microscopic worms

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On histology, the
muscle biopsy
showed that this
parasitic worm was
different from, and
was certainly not,
Trichinella
pseudospiralis!!
What was it?

A worm new to science!

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In an interesting sequel to the story, a re-evaluation of the

New Zealand case revealed it was a dual infection with both T.
pseudospiralis and H. perplexum - does this suggest that
infection with the latter occurs by meat ingestion as it does
with the former?

Since the description of the original case of Haycocknema

perplexum in Tasmania, four other cases have been diagnosed:
The NZ diagnosed case of T. pseudospiralis was found on reexamination, to be also infected with H. perplexum.
A case was diagnosed in Townsville in a patient who had
visited Tasmania many years previously (Norton, pers. comm.)
A fourth case was diagnosed in Innisfail in an Aboriginal
woman who has never visited Tasmania (Marshall, pers.
comm).
A fifth case has been diagnosed in Townsville with travel only
to Victoria.

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So, what do we know about Haycocknema perplexum?

We can diagnose it from muscle biopsies
We can treat it successfully with albendazole
What do we not know about Haycocknema perplexum?
What is its normal host?
How is it transmitted - meat ingestion?

- insect?
How common is the infection in animals and humans?
How widespread is it through Australia is it an infection from
tropical regions of Australia (tropical myositis)?
Is infection confined to Australia? The report of H. perplexum
from a horse in Switzerland is doubtful and was probably
Halicephalobus gingivalis.

Human infection with Trichinella and

maybe Haycocknema are thus dependant
upon what meat is eaten and how it is
prepared (ie cooking)

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Sanitation and hygiene

Pollution has always

helped the spread of
infection.

.. as did some
traditional farming
systems where human
faecal waste was used
as fertiliser

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.. farming systems
which often persist
even today!

Where human faeces

is used as fertiliser,
parasitic disease
spreads and not
only in the
developing
countries of the
world!

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Stoll (1946) pointed

out that 6/7 of human
helminth infections
would be prevented if
humans could be
isolated from their
own faecal waste

However, he had been pipped at the post by a couple of

thousand years!

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Even today, most of

the worlds population
has no toilet
facilities.

and where no
toilet facilities exist,
people will use any
convenient spot!

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Amoebiasis and giardiasis are transmitted through

contaminated water and can thus be controlled by sanitation
and hygiene (Photo: Peters and Gilles. Wolf Colour Atlas))

Geohelminth infections can also be controlled

through sanitation and hygiene

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Toilets come in many shapes and sizes.

(Baglin & Mullins: Dinkum Dunnies).

..but sophistication of
design does not
guarantee functional
efficiency
(Photo: Dr. Vic Clark)

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.and sometimes
simplicity in design is
the answer!
(Photo: Dr Vic Clark)

We were asked to
investigate a mission
station in Zimbabwe
which had a long history
of amoebiasis - despite
getting its water from a
borehole and despite
chlorination of the water.

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The answer here

proved to be poor
planning - the
borehole was
surrounded by 5 septic
tanks which were
leaking into the
borehole water due to
underground land
faults.

Some words of caution!

Cairncross: There is more to hygiene and sanitation
than merely owning or having access to a latrine it must be used!
Mwosu: The role of sanitation in reducing infections
is well knownbut the possibility of altering
human behaviour to minimise contact with
infecting agents and thereby reduce infection has
been received with some cynicism
Nelson: In the past, with a few notable exceptions,
there has been no planned scientific studies on
human defaecatory habits or on the behavioural
aspects of sanitation.

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Viruses transmitted
through faecally
contaminated water:
Hepatitis A
Hepatitis E
Poliovirus
Rotavirus
Norovirus

Bacterial infections
transmitted through
faecally contaminated
water:
Cholera
Typhoid
Non-typhoidal salmonellosis
Campylobacteriosis
ETEC

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Protozoan infections
associated with faecally
contaminated water:
Amoebiasis
Giardiasis
Cryptosporidiosis
All these are resistant to chlorination

In Zimbabwe,
schistosomiasis due to
water contact, is a
major problem which
can be solved by
sanitation and the
provision of a safe
water supply

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One can put up signs

warning of the danger

Despite this, people often

ignore the warning

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However, how do
people manage if this
is the only water
available.

and how do you

stop little boys playing
and urinating in snailcontaining and
bilharzia-infected
water?
(Photo: Dr Vic Clark)

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Water points were

established in Zimbabwe
to provide clean,
uncontaminated and safe
water - they were a great
success!!
(Dr Vic Clark)

Where ablution blocks

are established, they
must be properly sited
with easy access and
they must be easy to
maintain

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What is the diarrhoeal situation world-wide?

100,000,000 cases of
diarrhoea occur each year
and 6,000,000 children die
of diarrhoea as compared
to 5,000,000 children
dying each year from
diphtheria, pertussis,
polio, tetanus and TB
combined.

What is the gastroenteritis situation in Australia?

Mostly viral aetiology

17 million cases/year
200 000 GP visits/year
20 000 hospitalisations/yr
(Kirkwood, 2006)

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Is immunization the answer to the control of infectious diseases?

Immunization is the best answer

where an effective and safe vaccine
is available.

Important new vaccines are being developed

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However, here too,

community support is
necessary for success and
there is a vocal antiimmunization lobby. It
must be acknowledged
that side effects can occur,
but the benefits far
outweigh the dangers.

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Argument in support of immunization:

1. Immunizations mostly highly
effective
2. Side effects do occur, but
usually mild and the dangers
of the disease far outweigh the
dangers of the vaccine.
3. If children who are medically fit
are not immunized, they
constitute a reservoir and
source of infection which will
hinder control/eradication and
put at serious risk, those
children who, for medical
reasons, cant be immunized.

One must not forget

another human urge the urge to travel. It
exposes people to new
diseases and can be
important in the
transmission, spread
and control of
infection

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Stupidity!!
The chicken concept..

..eating slugs for a dare!

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A good infection control/eradication programme

may involve some or all of the following:
- A sound scientific knowledge of the epidemiology of the
infection(s)
- Treatment of infected people/reservoirs
- Immunization of humans/reservoirs
- Vector control
- Provision of acceptable toilet facilities
- Provision of clean water
- Education of the population
- Ensuring that the community is involved
Measures introduced must be safe, effective and financially
achievable
BUT..

..will we ever succeed in eradicating infectious

diseases?

Victory over infectious diseases is

imminent.it is time to close the book
on infectious disease.
William H. Stewart
U.S.Surgeon-General, 1967.

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Disease eradication programmes

Success rate to date

Hookworm - failed
Malaria - failed
Smallpox - Success
Dracontiasis promising in about 10 15 years
Poliomyelitis - promising
Leprosy promising but zoonotic leprosy a local
problem in Latin America
Lymphatic filariasis in progress (2020)

Cynical but true?

It has been claimed that
smallpox was eradicated,
not due to humane
attitudes within the
developed countries of the
world, but because it was
cheaper for them to
allocate funds to eradicate
it from the developing and
tropical countries than to
continuing spending
money vaccinating their
own populations!

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How important was infection at the turn

of the Century?
Armelagos (1995) 29 new diseases in the last 25
years.
WHO (1996) 8500 new cases of HIV each day.
WHO (1998) TB will kill more people this year
than at any time in history
WHO (1998) Infection remains the biggest threat to
humans
Headlice - $7 mill/year in Australia.

To what extent has it progressed at the start of this

Century?

1. WHO (2011) Childhood mortality has

dropped (12 million to 7.6 million), but is
still unacceptably high
2. New infections are still emerging/being
recognised (eg STEC; Lujo virus)
3. WHO (2011) TB deaths have declined for
the first time in 10 years, dropping from 9
million to 8.8 million

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Other important human activities that can affect the health of the
community and the efficient practice of medicine:

1.
2.
3.
4.

Political instability
Official corruption/
incompetence
Wars tribal, civil, religious,
racial, international
Global financial issues

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To control, or better still, eradicate any disease,

three factors must be considered:
The health profession must have the will to control/eradicate the
disease
The wealthy countries must be willing to provide funds to make
it possible
and
The programme MUST also take into account the culture,
customs and behaviour and aspirations of the community
involved and get their backing through a good education
programme.

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