Dorothy A. Counts
University of Waterloo
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The first: does modernization affect the health of elderly women in different ways than it does other categories of people? Included in the answer to this question is a discussion of the understanding by both women and men of the causes of sickness and death, the question of whether menopause is seen as a health problem, and a consideration of the predicament of elderly widows who have no children or other close kin resident in the local community.
The second question: has modernization affected the role that older women have traditionally played in the health care system? If so, what is the nature and extent of their changed role, and what are the implications of this change for local health care and for the meaningful and valued participation of elderly women in community life?
I will focus my discussion on the Lusi people of the community of Kandoka located on the north coast of the Kaliai area of West New Britain, Papua New Guinea. Kandoka, with its associated hamlets, is the largest community in the area and the place where I have done most of my research. The residents speak Lusi, an Austronesian language, and practice slash and burn horticulture. They earn almost all of their cash by producing and selling copra in the nearest town, Kimbe, located about 160 kilometers to the east. Kimbe, which was established in 1971, is the provincial capital and the site of a hospital, high school, copra marketing board, shops and trade-store wholesalers as well as provincial and federal government offices. Because there are no roads that link Kaliai villages to one another, to the rest of the province, or to Kimbe, almost all travel is by sea. The significance of this fact for the purposes of this essay is that the only locally available modern health care is found at the Kaliai health center. It is located on the premises of the Kaliai Roman Catholic mission about ten kilometers west of Kandoka. The health center is staffed only by nurses and their assistants and provides basic medical services including first aid, treatment for minor infections and illness, obstetric care, and a well-baby clinic. People with a severe illnesses must go to the hospital in Kimbe. This is often a hazardous and uncomfortable trip that takes about twelve hours of travel by sea on an outrigger canoe fitted with an outboard engine. Seriously ill people are frequently unwilling to make this trip.
Old age is not a problem -- or a luxury -- for most of the people of Papua New Guinea, many of whom die of disease and trauma before they reach middle age. In 1984 the life expectancy at birth in Papua New Guinea was 49 years (Filion 1986:165), while according to the 1971 census only 12.8 percent of the country's population was over 45 years and only 1.5 percent were 65 years of more (Agyei 1979). Demographic data from specific Papua New Guinea societies consistently report that these are young populations with a small number of aged people. For example, among the coastal Asmat 41 percent are under the age of 15 and 53 percent are between the ages of 15 and 50, while only 5.9 percent are over the age of fifth and less than 1 percent are more than 65 years (Van Arsdale 1981:34-35). Among the Tsembaga Maring 13.2 percent are over 45 years (Rappaport 1964:16) while only 12 percent of the Kapaka are in the age bracket of 45 and over (Bowers 1971:15).
The same demographic profile is true for the Lusi people of Kandoka. Although there are no accurate records for people who were born before the 1950s, it is possible to place the population of the village into indigenous categories in the life cycle. The Lusi recognize a number of named stages of development: maseknga 'new born'; kekele 'child'; iriao 'youth' and tamine vilala 'maiden'; tamine/tomone uainga 'married woman/man' tanta pao 'new person' or 'parent of dependent children'; tamparonga/taparonga 'elder' or 'senior female/male'; and tanta taurai 'decrepit/dependent elderly person'. In 1985 there were 405 people living in Kandoka and its associated hamlets. Of these 174 (43 percent) were maseknga or kekele, infants or children still attending the local school, while 80 (20 percent) were youths and maidens -- young people who had finished primary school and who were either living with their parents, residing in their men's house, or students in high school. Because most married people quickly become parents of their own and/or adopted children, and most parents are married, the labels for married people and parents of dependent children are usually interchangeable. The term chosen depends on which role the speaker is emphasizing. There were 102 people (25 percent) in the village in these categories, including divorced or widowed persons.
Forty-two, or 10.3 percent, of the villagers were called male or female elder and were at least 45 years of age; 20 were men, 22 were women. The primary criterion for inclusion in this category is the birth of a grandchild. Four of the elders were great-grandparents who were still actively engaged in gardening and were self-sufficient. The terms tamparonga and taparonga are designations of respect and do not necessarily imply physical decline, lack of fertility, or an 'empty nest', for a number of people who were called elders were still caring for dependent children. Unlike the Asmat who conceptualize old age in women as being partially correlated with menopause (Van Arsdale 1981:35), Lusi do not associate elder status for women with the end of the child-bearing years, for it is possible for a woman to have a child after becoming a tamparonga. There is, in fact, no Lusi term for menopause. Women do not associate the end of menstruation with any set of symptoms except for the inability to bear children, and most express relief that they cannot become pregnant again.
In 1985 Kandoka had seven taurai (1.7 percent), elderly persons who were dependent on younger people to meet at least some of their needs. Most of the taurai (six of seven) were women. Some of these were decrepit and totally dependent while others contributed in a meaningful way to the households where they lived. All of them were widows or widowers, but not all widowers or widows in the community were in this dependent category. For comparison with the rest of Papua New Guinea (recall that only 1.5 percent of the national population is aged 65 or over), the 11 people who were either great-grandparents or dependent elderly and were (probably) over 65-years-old made up 2.7 percent of Kandoka's population.
The presence of Kimbe with its modern hospital has not significantly altered the health of Kaliai's elderly people. This is true partially because the Kaliai medical model is alien to the Western view which is based on the germ theory of disease and focuses on intervention using modern medical technology. There is, for example, no Kaliai tradition that diagnoses an illness and its cause entirely on the basis of physical symptoms, that emphasizes the prevention of illness, or that focuses on the search for cures for a great array of diseases, as there is in North America.
The Kaliai distinguish between minor illnesses and those that are potentially lethal. They consider problems -- such as head colds, stomach aches, joint pains, and minor injuries -- that cause discomfort but are not life-threatening to occur naturally. They treat these either with a mixture of herbal remedies and ritual or by a visit to the health clinic. In contrast, the etiology -- and therefore the cure -- of life-threatening illness lies in the social realm. Kandokans do not think of serious illness -- the sort that commands attention and causes people to commit time and resources to the search for treatment -- as diseases of the body. Instead they envision these illnesses as evidence of a rupture of social relationships. They believe a gravely ill person to be the victim of malevolent magic which has been contracted for by someone whom the patient has offended so seriously that the perpetrator -- usually a relative or close neighbor -- has paid an expert to cause the victim agony and, perhaps, death.
The Kandokan expert in malevolent magic, the tanta musoaia, is always a male. I translate this term as 'sorcerer' because anyone who purchases magical knowledge and has the will and intelligence to learn it can become a practitioner. People credit sorcerers with causing, and curing, a wide range of problems. Everything from death in childbirth, to suicidal depression, to rectal prolapse is attributed to sorcery. These ailments have in common that they cause extreme discomfort, they are considered to be potentially fatal, and they do not respond to Western medical treatment. Kandokans test whether a serious illness is caused by sorcery by exposing the victim to the medical care that is available at the Kaliai health center. If the medication given by the nurse does not give quick relief, the patient and his kin assume that the problem is due to sorcery and that Western medical technology is powerless to heal it. Only a person knowledgeable in the type of magic causing the problem is capable of curing it, and the treatment is likely to be lengthy and costly in both cash and traditional wealth items. The cure also usually involves an inquiry into the patient's behavior and social relationships in an effort to identify the aggrieved individual who hired the sorcerer so that the grievance can be settled and the magic neutralized. In the Kandokan system, the expertise of the sorcerer is complementary to, but not replaced by, modern medical technology.
A person who is suffering a gradually worsening condition may travel to the hospital at Kimbe to seek treatment, but attempts to find a cure there are often unsuccessful. This is usually because the individual waits until the problem is too far advanced or because the treatment is a long-term proposition that requires on-going supervision. Villagers are often reluctant to stay for long period of time in Kimbe. They lack the resources for such a stay, their gardens and pigs will suffer from their absence, and they worry about the violence and sorcery that they associate with collections of strangers in urban areas. Doubts about the efficacy of Western medicine to cure sorcery-induced illnesses and the discomfort involved in the trip generally cause people who are gravely ill or in great pain to refuse to make the long journey down the coast to Kimbe and hospitalization.
Lusi generally think that chronic or degenerative illnesses -- of the sort that characterize advancing age and that cause persistent but tolerable discomfort -- are either an inevitable part of the aging process or sorcery induced. In either case, the only Western medicines that are thought to be effective for these problems are those that provide short-term symptomatic relief. This is the type of treatment that is now provided by the Kaliai clinic and that formerly was obtained from local curers. People usually endure the ailments of old age without seeking relief unless they threaten to limit function seriously or unless the condition worsens and is seen as life-threatening. Kandokans do not consider the death of an old person to be a natural event unless he or she is decrepit, totally dependent, and -- effectively -- socially dead. Although their relatives usually try to determine the source of the illness and find a cure, elderly persons who are critically ill usually refuse to go to the hospital at Kimbe for the reasons given above and also because they do not wish to die in a hospital miles from kin and friends. Old people prefer to die in their home village, surrounded by their relatives, friends and exchange partners in an environment that facilitates leave-taking and the closure of business and personal affairs. I know of no elderly Kandokan who has died in the hospital in Kimbe.
In summary, modern medical technology and the presence of a hospital in Kimbe have had little impact on the health of elderly Kandokans, women or men. Modern medicine has not greatly affected the health of elderly villagers at least in part because of the assumptions that they make about the nature and etiology of illness. These assumptions lead them to consider modern medical treatment to be ineffective in treating critical illness or the degenerative diseases of old age. Modern medicine is also largely beside the point, as far as the elderly are concerned, because the on-going supervision and long-term care that chronic degenerative illnesses require is inappropriate for villagers whose homes and kin are two days travel away.
Although exposure to development has had little direct medical effect on the health of elderly women in Kaliai, the quality of life for the decrepit elderly may be adversely affected by one by-product of modernization: childlessness in old age. A woman may find herself in this condition as a result of one of several factors associated with development. She may choose to have fewer children or to bear them later in life in order to go to school, to work outside her home, or to otherwise enter the money economy. As Rubinstein observes (1987:3):
Lower fertility and delayed age at birth of first child are demographic trends associated with industrialization.... Whatever women gain for themselves by being childless in the childbearing years or limiting number of births may, in effect, be a trade off against a less secure old age.
The elderly may also be isolated from their children when young people emigrate to urban areas in search of employment and other opportunities, leaving their aging parents without a social network of caretakers to meet their needs. Both of these possibilities can be especially significant for the changing role of women in developing countries and a serious problem for elderly women in communities such as Kandoka where the majority of dependent elderly people are women.
The plight of elderly people who are either childless or who have no children leaving nearby on whom they can depend is reported to be grim in almost all societies, even those that are not fully modernized. Nydegger says of old people who have no surviving children and only marginal claims on their more distant kin: "Without personal resources and in the absence of institutionalized aid, their position is generally wretched, even in societies professing reverence for the aged" (1983:28). Although almost nothing has been reported about the treatment and needs of the childless elderly in developing countries, the available evidence suggests that Nydegger's statements hold true in those societies as well as in industrialized ones. For instance, Guemple recounts that elderly Inuit who outlive their children are treated with respect as long as they are productive. However, they are likely to be isolated or reduced to severe poverty if they become dependent (Guemple 1969). Sangree says that the position of the childless elderly in Tiriki, Kenya is "very difficult, indeed untenable, in traditional communities" (Sangree 1987:201).
In her study of the Gende of Papua New Guinea, Zimmer provides a detailed account of the treatment of elderly people who are without co-resident children. Zimmer says (1987:66):
Childless elderly who are only minimally involved in the affairs of their community are particularly vulnerable to the degradations and insults accompanying the status of 'rubbish person.' Judged by others to be selfish and/or worthless persons, childless elderly may suffer isolation and shame, and in some cases outright physical abuse. Objects of suspicion and dislike, they may be shunned by others as being greedy, inhuman monsters and sorcerers who plot their neighbors' destruction.... As the years take their toll or they are struck by illness, few if any persons feel obligated to care for them or to sacrifice pigs in order to restore their strength. When they die, their death is unimportant and unattended.
The plight of childless elderly women is not yet a common problem in Kandoka. Five of the six dependent old women living in the village in 1985 had co-resident children and the other one was being cared for by her younger brother. However, the death in 1975 of one dependent elderly woman (described below) may be directly attributed to the fact that she had no resident children who were responsible for her care.
Mary was a decrepit and blind old woman whose children were all living in distant towns. Consequently, the responsibility for her care rested with two of her foster children, each of whom had a large family. Mary resided with neither of them but lived in a small lean-to near the house of her foster son. There she was easy prey during the day for the thoughtless teasing of the village children who beat with sticks on the walls of her house, shaking them until it seemed to the old woman that the building would fall down. Other times they snatched the burning faggots of her small fire, leaving her without a source of warmth. Because she could not see, Mary was totally dependent on others to bring her firewood, food and water; to lead her to the bush when she needed to relieve herself; and to stir up the embers of her fire when it burned low. Unlike other dependent elderly Kandokans, she had no grandchild living with her to meet these needs, so she could be heard during the day and in the middle of the night keening and begging for a little food, for some water, or for a bit of fire because she felt cold. The children of her foster children were called upon to care for her and, as long as she had resident teenaged foster granddaughters to attend her, her condition was tolerable. But eventually the girls left the village to attend high school and university. Consequently, her care was left to younger girls and boys who were often out of the village while their parents were busy providing for their own large families. One day everyone left the village to garden or on other errands, and Mary was left alone. Apparently she attempted to stir up the coals of her small fire and stumbled, falling across the live embers. By the time the others returned to the village she had lost consciousness. She died shortly thereafter of her burns.
Mary's fate does not represent any current pattern of neglect in the care of dependent elderly women in Kandoka. She is the only old woman who has suffered such a grim fate. However, the case studies collected by Rubinstein (1987), and evidence presented by Nydegger (1983), suggest that as more villagers move permanently to the urban centers leaving their elderly parents alone, other helpless old people will also experience loneliness and neglect.
In general, Kandokans recognize two kinds of traditional health-care practitioners: those who possess a combination of ritual expertise and herbal knowledge that enables them to deal with minor problems that are not considered to be potentially lethal, and those whose knowledge of muso 'malevolent magic' enables them to cause and cure life-threatening illness.
The herbalist-cum-ritual expert is usually an elderly person and may be either male or female. Specialists in reproductive matters (fertility-inducing or contraceptive procedures, abortifacients, midwives, and those with remedies to assist in labor) are elderly women. Sometimes an old woman who is an authority on herbal remedies and healing ritual works cooperatively with a male diagnostician who employs the aid of a spirit familiar. These experts are unlike sorcerers in that the illnesses they heal do not derive from troubled social relationships, and their ability to cure does not imply responsibility for having caused the problem. They are called on for a variety of complaints such as croup or low-grade fevers in young children (thought to be due to the ingestion of mother's milk contaminated by semen(1), stomach upset, abrasions, coughs, sore throats, conjunctivitis, muscle aches and pains, reproductive problems, constipation, diarrhea, wounds and injuries -- the same sorts of problems that the Kaliai clinic is the most adept at treating.
Before the establishment of a medical clinic in Kaliai in the early 1950s, villagers traditionally sought local remedies (usually combinations of herbal infusions and spells) when they suffered from minor wounds or illnesses. These problems were regarded as naturally occurring inconveniences and were not evidence of social relationships gone bad. Today they are more likely to go to the clinic for treatment because the "white man's medicines" that they get there are usually stronger and act more quickly than do traditional remedies. Although they may seek treatment for minor injuries and ailments, villagers do not lay up a supply of medication as a hedge against possible future illnesses. People do not travel to Kimbe to purchase patent medicines or across-the-counter remedies such as aspirin, magnesia tablets, chloroquine phosphate for malaria, antiseptics, analgesics, or bandages. Nobody in the village maintains a medicine chest. Instead sufferers endure minor problems if it is inconvenient to travel to the clinic or if the family does not wish to pay the small fee that the clinic charges for treatment. Charlton (1984) observes that one of the costs of modernization for women in third world countries is that the provision of public services such as medical and health facilities often diminishes the traditional bases of female prestige. This is true in Kandoka. Whereas old women who were accomplished traditional healers were once respected for their knowledge and were given food and shell money in return for their services, the value of the knowledge diminished and demand for their services declined with the introduction of Western medical practice. This decline is exacerbated by health clinic nurses who put great pressure on pregnant women to come to the clinic before their due date or at the first sign of labor so that birth occurs under their supervision. Women who give birth in the village are scolded and required to pay a fine to the clinic that is equivalent to the birth fee. Consequently most women try to deliver their babies at the clinic rather than with the aid of village midwives. Western remedies such as penicillin, pain killers, iodine, and malaria suppressants often act more quickly and effectively than do herbal or ritual cures. In addition they are dispensed by nurses who, because of their Western education and association, often enjoy greater prestige than do traditional healers. Consequently young women are not learning curing or midwifery skills from their mothers and grandmothers. In 1981 only a few elderly village women were proficient in identifying and preparing plants that were traditionally believed to have medicinal properties. By 1988 all but one of these women were dead and their medical knowledge lost.
The modernization that has occurred in West New Britain in the past twenty years has not significantly improved the lives of elderly Kaliai women. While demographic changes may deprive dependent old people of co-resident children and the care they provide, the introduction of modern medical technology has not been of great benefit to the health of the elderly. There are several reasons for this lack of benefit. First, the assumptions that Lusi make about the cause and treatment of illness are inconsistent with the Western medical model emphasizing the germ theory of disease, the effectiveness of intrusive medical intervention, and the extensive use of both prescription and patent medicines to prevent illness and relieve symptoms. Instead people assume that serious illnesses are caused by sorcery and can only be dealt with by a combination of magical treatment and the restoration of harmonious social relationships. The introduction of Western medicine has not altered these beliefs, and seriously ill people seek traditional cures rather than depend on the introduced medical system.
A second reason why the introduction of Western medicine has not had a great impact upon the health of elderly Kaliai women is that the intensive and long-term medical care required for the degenerative diseases of old age is not locally available. People who are critically ill or who suffer from these diseases are frequently unwilling to travel to Kimbe for hospital care. Their reluctance is based on the belief that Western medicine is ineffective in treating illnesses caused by sorcery and by the fear that they might die far from home, kin and friends without settling their affairs.
Modernization has, however, eroded the healing role of elderly women who traditionally assisted young women with contraceptive infusions, abortions, and midwifery services and who also performed healing rituals and gave herbal remedies for illnesses that were not attributed to sorcery. These medical needs and minor complaints are the ones that are the most receptive to the kind of assistance that is provided by the Kaliai clinic. As villagers have become more dependent on the clinic, their reliance on women's healing powers and herbal knowledge have decreased. Consequently the healing role and prestige of elderly female healers has declined, younger women no longer learn from them, and their skills and medical knowledge is being lost.
Research for this paper was conducted in West New Britain, Papua New Guinea in 1966-67 with the support of the U.S. National Science Foundation and Southern Illinois University, in 1971 with the support of the Wenner Gren Foundation and the University of Waterloo, in 1975-76 with the support of the University of Waterloo and the Canada Council, in 1981 and 1985 with the support of the University of Waterloo and the Social Sciences and Humanities Research Council of Canada. I wish to thank David Counts and Jay Sokolovsky for their suggestions on the content of this paper and to Jay Sokolovsky for making it possible for me to attend the 1988 International Congress of Anthropological and Ethnological Sciences in Zagreb, Yugoslavia where an earlier version of this paper was given.
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1. See Counts and Counts 1983; Counts 1984.