Bad Blood, Spoiled Milk:Bodily Fluids as Moral Barometers in Rural

Haiti

An Article by Paul Farmer

Presented by Rockie Reiss

Overview

•Analysis of cultural illnesses Move san and Lèt gate•Discussion of Farmer’s research and methods•two case histories•move san as an “interpreted disorder”•many different personal interpretations of the illness•discussion of different causes of the illness•a conclusion drawing all of the information together

Move San

Literal English Translation – “Bad Blood” Some believe only women are afflicted Not been systematically studied Believed to be caused by malignant (very

dangerous or harmful) emotions Symptoms: first an eruption of itchy bumps all

over body, then headache, fever, dry-mouth, very jumpy, feel weak or stiff. “Blood turns to water”

Treatment: Herbal medicines. Left untreated, or treated unsuccessfully,

outcome is said to be dismal, some individuals studied said they have had friends or relatives die from the illness

Main, if not only, cause of Lèt gate

Lèt gate

Literal English Translation – “Spoiled milk” Seen in pregnant of lactating women Milk described as thin or watery Can pass itchy bumps and diarrhea to

children through milk Frequently cited motive for early weaning

which leads to malnutrition and very poor health

Thought to be detrimental more to the mother than the infant

If “spoiled milk” infiltrates brain you will go crazy

According to some, if it gets to the uterus you will die.

The Republic of Haiti

1982 population is around 5.1 million

345 per square kilometer

74% of the country’s inhabitants are rural

Life expectancy of 48 years

Do Kay

Place studied in depth by Farmer 134 households Total population of 772 Average number of individuals per

household – 5.76 Most homes are two bedroom huts No running water No electricity Prior to hydraulic pump being installed

it was an hike 800 vertical feet below the village to get water, now there are three public fountains along the road

Paul Farmer’s methods and survey results

36 of mothers (77%) who were interviewed experienced one episode of move san

Majority of cases were treated professionally, but only after home medicine, and herbal remedies were also used after the professional care

In all cases that also involved Lèt gate it was shown to be caused by move san

During the preliminary interviews there was no specific set of symptoms of move san that emerged

Ti Malou Joseph, the most upon elaborated case study Case followed over a “long period of time” –

20 months She has had recurrent episodes of move san She believes it is due to a tumultuous

relationship with the father of her children Believed to be the poorest family in the

village While pregnant, she was hit by the father of

her children Ti Malou says “If you’re having troubles (nan

kont) with someone, and they yell at you or strike you, you can become ill…He struck me in the face. That’s what makes the blood rise up to my head and spoil the milk.”

Case study Continued

Complained of severe lower-back pains, muscle cramps, headaches, dizziness, light-headedness, diarrhea, crampy stomach pain and was eventually unable to get out of bed

Delayed herbal remedies therapy because she was pregnant and the “medicine is too strong for the baby”

Many complications during the birth of her child that occurred during the move san episode

Lèt gate occurred in the infant and he broke out into the itchy bumps

Took a long time for Ti Malou to gain the funds for the herbal remedies and treatments, and others thought that it was “scandalous” that she had not attended to “their” illness properly

Eventually both were cured

Farmer’s Methods of Explanations

Adopts a “meaning-centered approach” Uses Explanatory models (EMs) of

individuals involved in Ti Malou’s case This model “attaches narrators to

narratives” Allowing study to happen with periodic

interviews over 20 months it allows one fundamental flaw in using EMs to study move san in the idea that EMs change over time

Ti Malou’s Explanatory Model

Believes beyond a doubt that there are social and psychological causes to her physical distress and illness

When discussing treatment the separation of blood from mild was seen as a necessity by Ti Malou

Says that her Lèt gate was characterized by “weak watery” milk and that she had been “invaded by bad blood”

According to Farmer, in reaction to this interview, “Move san and Lèt gate, it is clear, are embedded in social interactions

Ti Malou’s Mother’s Explanatory Model

There were many different incidences in this woman’s life that led her to the conclusion that “Ti Malou’s illness arose against a backdrop of unremitting struggle”

Prior to her third trimester her mother said “I think it is a difficult pregnancy, not move san”

Shortly before the birth her mother then was confident that move san was the cause of her daughter’s symptoms

The change in opinion of the condition of her daughter could have been brought on by a family friend and confidante

Mme. Joseph (Ti Malou’s mother) went from believing it was a difficult pregnancy exacerbated by a fall to believing it was move san, “and finally as the full diapason of move san/lèt gate triggered by a malevolent lover.

Madame Anita Kado, a confidant’s EM

 • According to Farmer, Kado was the first to

suggests that Ti Malou’s difficulties were due to move san

• She also says that “it’s necessary to wean the baby temporarily. If nothing is done about it, even the next child will be affected” by lèt gate

• As an older member of the society Kado has much authority and knowledge of the illnesses

• She says that babies never die from lèt gate, but the mothers are in danger.

Madame Anita Kado, a confidant’s EM (Continued)

• When asked “how can one be sure that a baby’s [itchy rash] and diarrhea are due to move san?”– “Well, we knew the milk was no good: it was as

clear as water. But to make sure, express some of the milk into a large spoon; if it’s thick and white, it’s probably not spoiled. Take the spoon and hold it over a flame. As it begins to boil, put a small twig in it. If the cream climbs up the stick, the milk is good. If it doesn’t make cream, it’s no good. But it’s usually not necessary to do this.”

• Kado believed that the emotion exclusively could have caused the problem failed pregnancy, and “when the illness is so bad that the baby dies, you begin to think that the bad person did more than yell at the woman.”

Ti Malou’s Healer’s Explanatory Model

• Madame Victor’s idea of the causes of move san is somewhat different than the previous individuals interviewed

• She believes it is not exclusively a woman’s disorder• She gave the detailed description of symptoms shown at the

beginning of the presentation• Mme. Victor linked the theme of weak or watery blood to poverty• This healer also gives a very elaborate explanation of what the

remedy entails and there are variations on the main theme, but that the “principal ingredients” always remain the same.

• She doesn’t believe that any modern medicine can cure the ails of move san

• She also said nothing in the interviews with Farmer about the possibility of the spoiled milk infiltrating the uterus and causing death

A Short Summary of a Doctor’s EM

• Although doctors have heard about these problems, he was really not willing to address them.

• When asked about move san the doctor laughed

• Farmer: “Worth noting throughout these exchanges are, first the degree to which the EMs of the patient, the mother, the confidante and the local healer converge, and then how little these have in common with the EM held by the doctor.”

Farmer’s Ideas, Post Interviews

• “The ‘illness’ might in fact be ‘illness behavior,’ a form of chronic somatization that is related to strong social pressures”

• According to Miriam-Webster’s dictionary somatic is “of, relating to, or affecting the body especially as distinguished from the germplasm or the psyche.” In other words, a condition caused by neither psychological nor biological origins.

• Farmer also points out that in the different case studies he took and in the explanatory models he found that the subjects always attributed social problems and their psychological state as the cause of their problems, but afterward only focused on the somatic symptoms.

Farmer’s Ideas, Post Interviews (Continued)

• Farmer then claims that move san is the physical signs of a distressing home life and that using this illness to show the world what is happening in the home is in sense a “moral barometer”. Using the fear of peer judgment as an incentive not to harm the important females in your life so they will not experience these very public symptoms of this emotionally caused illness.

• Off of this idea, Farmer also makes the claim that lèt gate runs with move san, but the “added factor of milk complicates the course of the malady. It indicates, I suspect, the gravity of the initial offense, the malignancy of the emotion. It recalibrates the barometer.”

• These ideas still allow room for the idea that these illnesses could have a biological or organic basis, but Farmer concludes this section of his essay with the idea that even if an organic basis is not found there is much cultural meaning that this disease is based on, and that therefore allows a broader based approach.

Economic Forces as Causation

• In the argument for what this disease is actually caused by there are many unclear definitions and far too many possible causes to name them all, but one major idea is that the poor economy of rural Haiti could be an influence.

• Do Kay individuals attribute what they are calling an epidemic of these illnesses to “the gradually deteriorating economy of the village in which they work.”

• Poverty could be seen as a contributing factor. Poverty leads to disputes in the home which could lead to abuse (verbal or physical) due to frustration and an inability to care for one’s family. This abuse is believed to be the main cause of the move san/lèt gate syndrome.

Economic Forces as Causation (Continued)

• The workforce of Haiti has an exceptionally large number of women. This is because the wages women make are necessary for family survival.

• Women in the workforce, and traveling to Port-au-Prince for much of the year to work could also be an attributing factor, according to Farmer.

• Farmer also believes that the course of the illness, rather than its incidence, could be attributed to the mother’s occupation although there was no discernable evidence for the individuals in Do Kay that he studied.

• After looking at all of these possible economic causes for move san/lèt gate Farmer comes to the conclusion: “I do not believe that move san/lèt gate is a direct product of economic forces. But I do believe that the weight of material deprivation may change the incidence and course of the illness, and even serve as a causal factor in some instances.”

Using the DSM-III to Diagnose Move San/Lèt Gate

• The first disorder Farmer attempts to have move san fit into is Major Depressive Disorder. (For specifics on Major Depression go to: http://www.psychnet-uk.com/dsm_iv/major_depression.htm)

• This idea was thrown out because there seemed to be much more anxiety involved than depression. After some more consideration Farmer comes up with a “modified ‘somatized’ MDD category” that would include some of the physical symptoms, but this really isn’t on par with the APA guidelines.

• Another suggested diagnosis would be Generalized Anxiety Disorder, but the diagnosis requires persistent anxiety for at least one months’ duration which may not describe some women’s intermittent phases of move san.

• Though GAD could explain more of the somatic symptoms, it really doesn’t paint the entire picture of these women’s suffering and illness.

Using the DSM-III to Diagnose Move San/Lèt Gate(Continued)

• The most useful diagnosis when viewing move san from the DSM perspective would be Somatization Disorder which isn’t discussed directly by Farmer (it may have been added in more recent DSM editions). His idea is that move san is “not only physical symptoms that occur in the absence of organic findings, but also the amplification of complaints caused by established pathology, such as a chronic illness.”

• The conclusion of this discussion is also somewhat vague in that Farmer believes that “The disorder, and their [the psychologists] view of it, calls into question the tenaciously dissecting gaze not only of psychiatry, but of much medical anthropology as well.”

• My personal opinion on the matter has me leaning toward a Somatization Disorder (for more information visit: http://www.psychnet-uk.com/dsm_iv/somatization_disorder.htm) and there likely being very few physical symptoms behind the illness, but that leaves me questioning how move san and lèt gate could be related.

Farmer’s Conclusions• Very simply Farmer states, in the first paragraph of his conclusion, that the

illness is culturally constructed.• He also makes a clear and intriguing point in the overall meaning of the

disorders: “Viewed as a cultural artifact, the most striking thing about move san is the lurid extremity of its symbolism: two of the body’s most vital constituents, blood and milk, are turned to poisons.”

• He also brings back the idea that “As somatic indices, ‘bad blood’ and ‘spoiled milk’ submit private problems to public scrutiny…and lethal body fluids serve as a moral barometer”

• Farmer closes the article with a perplexing inquiry of his audience. When discussing the herbal remedy with the healer a moral dilemma was subtly posed of Farmer. The healer said “Surely you are collecting these leaves in order to better understand their power and improve their efficacy?” “Had she added, ‘If you think we’ll be satisfied with a symbolic analysis of move san/ lèt gate you’re quite mistaken,’ I would not have been more surprised.”

• There the article ends with the audience left to wonder if this in depth analysis of this illness really helps anyone more than the curious anthropologist.

THE END!