The importance of extremes: The social implications of intra-household variation in child mortality

Sm. Sci. Med. Vol. 35, No. 6, pp. 799-810, 1992 Printed in Great Britain. All rights reserved

0277-9536/92 $5.00 + 0.00 Copyright 0 1992 Pergamon Press Ltd

THE IMPORTANCE OF EXTREMES: THE SOCIAL IMPLICATIONS OF INTRA-HOUSEHOLD VARIATION

IN CHILD MORTALITY

MURRAY LAST

Department of Anthropology, University College London, London WCIE 6BT, U.K.

Abstract-The extreme variation in child-rearing among women of the same polygynous household raises questions about the factors involved in child mortality and the social processes that magnify that variation. The extremes may not seem significant statistically and indeed are not widely reported, yet it is precisely the extremes of experience that generate the theories that alter action most. The spectacle of one wife having 90% of her children alive while her co-wife has 90% dead exerts enormous influence not only on people’s beliefs but also on their practical responses in the face of the spectre of serial child death. A high divorce rate, wide inequalities among women and marriage strategies that favour large, rich households are some of the consequences; beliefs in repeatedly returning children and changelings focus blame on the children, while a premium is put on very early diagnosis and often drastic remedial action. Extreme suffering, though seldom spoken aloud, generates its own logic, its own corpus of relevant data.

Key words--child mortality, spirit-children, women’s inequality, West Africa

1. INTRODUCTION

Several surveys of child mortality have examined the variation between households and have shown, for example, an association with levels of maternal education, as well as a clustering of morbidity in particular households [l-3]. There is little infor-

mation, however, on the variation that may occur

within households, yet the existence of wide differences between wives within the same polygynous household raises important further questions as to what factors and processes may be involved in child mortality. For in these circumstances neither edu- cational level nor any of the other obvious variables like nutrition or wealth or water supply and drainage, would seem to account for the anomalous, extreme disparity between individual mothers in their success or failure to rear their children to adulthood. But it is not merely variation that is the problem here; it is the extremes experienced by some women, and the frequency of those extremes, that are remarkable. The purpose of this article is not to explain the intra-household variation (that requires much more data and larger numbers) but rather to examine a few of the social processes involved. Explanations of phenomena, however, are sometimes less important than an understanding of the fears and expectations the phenomena arouse-fears that may dispropor- tionately skew people’s actions and ideas; in this instance the fears are largely unspoken. To know the force of these fears we need to recognise the experience that gives them their reality. In short, extremes of experience may prove more significant, for understanding a community’s response to misfortune, than an average or a norm. Where this is so, interpretations based upon general surveys that seek to estab-

lish average experience are liable to miss what is really significant for people; thus health campaigns based on such interpretations are likely to be seriously flawed.

2. THE DATA ON EXTREME DISPARITIES

The problem I want to raise can be illustrated most simply by data from a single farmstead which I have been living in or visiting regularly over the last 20 years. The data show that extreme disparities are not exceptional; nor, I will argue, are the circumstances in which these disparities occur exceptional. Instead people have to live with these disparities and the everyday consequences that flow from them; their experience of them helps shape the way people of the farmstead plan their lives and seek a tolerable balance between hurts and happiness.

The farmstead (situated in a deep-rural part of Hausa land in northern Nigeria) had a population of around 120 in 1970, the ratio of men: women: children being then 20: 40 : 60 or 1: 2: 3; the population is now 130, considerably less than what Nigeria’s supposed growth rate of 3.1% per annum would lead one to expect. Among the reasons for this stability between 1970 and 1990 are: out-migration has removed two lads from the farmstead, education has delayed marriage for two other boys, conversion to Islam has put a limit on the potential number of wives, and in-migration has dropped off. Of the 20 adult men I knew in 1970, only 10 remained in 1990, and one of these is now senile, another is childless, while a third was forced to live away from the farmstead for the last 19 years but has now returned. (Of the 10 no longer in the farmstead, 6 died and 4

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went away.) The demographic history of the farmstead is not considered unusual for a large house of this kind, with its ability to tolerate in-comers and eccentrics. More generally, a similar pattern of demographic stability Seems to be true of the other farmsteads in the neighbourhood; over the 20 years, no new farmsteads have been established, and none of the old ones have disbanded or expanded.

I will not be discussing here the families of the older generation in the farmstead as their families were complete before I started living there. I will also omit the men with no surviving children and those whose families were broken up by their early deaths or departure. Their omission here is not significant for the point I wish to make. I focus instead on the 7 men whose families were very young or just starting when I first arrived in 1969 to live for 2 years in the farmstead. They constitute the core of the farmstead. Over the last 20 years, these 7 men have been married to a total of 30 women: of these, 6 have left the farmstead and 3 are dead-and 2 are new ‘brides’, previously married elsewhere. Seventeen wives have never been married elsewhere and are unlikely now after all these years to want to leave-for northern Nigeria a very low divorce rate. (Only 5 of the 30 women who as maidens or as divorcees came as brides have failed to conceive in the farmstead; all were already divorcees). Three of the divorced wives between them left behind 2 dead children and 2 children alive. If we omit the two new ‘brides’ (both divorcees) and include the 3 wives who died, then the farmstead’s core of 22 wives have had 131 children, 65 of whom are alive and 66 dead-that is, an average per wife of 3 surviving children and 3 deceased. But, as is often the case with averages, these figures obscure the range in people’s experience and consequently misrepresent the basis on which women assess and plan their reproductive careers.

The key facts at issue here can be summarized quite simply as follows. Wives who have shared the same husband, lived alongside each other for up to 20 years or more and whose children have always played together etc. have reproductive histories like this:

1. Husband A. has 2 wives: the senior, Y. has 2 out of her 7 children alive now (and one of these 2 is deaf); the junior wife, D., has 5 out of her 6 alive. A third wife, divorced before I arrived, had 1 child that died, and another who is still alive.

2. Husband Bj. has had 4 wives: the senior, G., now dead, had 1 out of 5 alive; the second, H. has 6

out of 8 alive; the third, M., now dead, had neither of her 2 children survive; the fourth, D., has 2 out of 6 children alive now.

3. Husband Bw. has had 5 wives: the first, Ad., has 4 out of 6 alive; Md. has 7 out of 8 alive; the third, AZ., now dead, had 1 out of 7 alive; the last, H., has only one birth, and that child is still alive. A further wife, a divorcee new to the house, is childless.

4. Husband Bz. has 5 wives (he is not a Muslim): the first, T., has 5 out of her 8 children now alive; the second, Bj., has only 1 out of 11 children alive; the third, Yr., has 6 out of 10 children alive; the fourth, D., has only 1 out of her 4 children alive now. The fifth, a new divorcee, is childless. Of the 3 other wives he has been married to, only 1 gave birth, and the child did not survive.

5. Husband Dt. has 4 wives: the first, Kk. has 3 out of 5 children alive; the second, Kw. has 2 out of 5 children alive; the third has only 1 alive (and 1 she is fostering); the fourth, Ml. has 5 out of 5 alive. A further wife, now divorced, was childless.

6. Husband Mk. has only had 2 wives: the senior, Z., has 2 out of 9 children alive; the junior, T., 4 out of 8 children alive.

7. Husband S. has 2 wives: the senior, C., has 3 out of 6 children alive; the junior T., has 3 out of 5 alive. A further wife, divorced before I arrived, had 1 child that died.

In short, in 6 out of the 7 domestic units there is extreme disparity between wives (and only one unit, with 2 wives, is close to the ‘average’). Overall there are 4 highly successful mothers with over 70% of their children surviving; 5 are ‘failures’ with less than 30% alive; a further 2 have only ever had one child. Eleven of these 22 have between 30% and 70% of their children alive-i.e. just half of the women have experienced anything remotely like the average of 3 dead, 3 alive.

If we focus however only on the mothers with the ‘best’ and ‘worst’ records in each family unit, the contrasting experience of wives-married to the same husband and bringing up their children at the same time and in the same place-becomes very clear in Table 1.

3. THE ENVIRONMENTAL CONTEXT

The culture of the farmstead is such that the children of co-wives play together, often eat and sleep together, wash and drink from the same water

Table 1. Intra-household variation in child mortality: the extremes

Husband Wife: Her children: Wife: Her children No. of wives

1 .A: Y.- 2b/l alive; D.- 516 alive 3 2.Bj.: GW!- l/5 alive; H.- 6/8 alive 4 3.Bw: ALi-- l/7 alive; Md.- 7/8 alive 5 4.Bz.: Bj.- l/l I alive; T.- 5/S alive 8 5.Dt: KW.- 2/S alive; Ml.- 5/S alive 5 6.Mk.: z.- 219 alive; Tk.- 4/8 alive 2

‘Herself now dead. bOne now deaf.

Social implications of intra-household variation in child mortality 801

supplies, share the same places to defaecate-particularly from the age of 2 years onwards, when they are weaned. Before weaning, mothers breastfeed their own babies, but other children commonly carry the baby around, play with them and feed them bits of food. Furthermore, the children of the various domestic units within the farmstead also play together, and have particular friendships outside their immedi- ate circle. In short, most of the infections current at any one time in the farmstead are likely to be passed round quite rapidly; isolation is rare. Among the mothers worst affected by child deaths, the vast majority of their children died either at between 10 and 15 months old-i.e. before weaning-or soon after weaning at ca 2 + years old (children are sent briefly away to some maternal kinswoman to be weaned, but rarely died away from home). The proportion of these children dying before or after weaning is approximately 2: 1 (but individual mothers differ); and boys and girls died in equal numbers. Weaning at 2 years meant that the ‘successful’ wives tended to have a reproductive cycle of 3 + years, whereas those with the most deaths had a 2-year cycle: the more children that died, the more pregnancies. Thus over the last 20 years, the least successful had some 9 pregnancies, the most successful only 5.

3.1. Accommodation

Mothers have their own rooms, built but not furnished by their husbands, and these rooms, along with their husband’s, form a small courtyard in which the work of preparing food is done; here too babies and children spend much of their time together. Mothers vary little in the standard of furnishings; although women by farming for themselves on land provided by their husbands have different levels of income, the differences are not reflected in their housing. Cement for the floor and for the verandah in front of each room is commonplace, and is kept swept.

3.2. Wealth

Of the 7 men whose domestic units are under discussion here, the first one has become exceedingly rich through very hard farm work and through getting into trade at the right time. He has been to Mecca, as have his mother and his senior wife (the one with only 2/5 children alive). Husbands 3, 4 and 5 are also rich by local standards (3 and 5 have recently been to Mecca), while husband 6 is a younger man with plenty of land since his father’s early death in a road accident. Husband 2 has no inherited rights to land and has had to struggle for his successes; 2 of his wives died relatively young. The seventh man, the eldest and my host, was less interested in success.

Only in the last 5 years (since, that is, it became wealthy) has the farmstead converted to Islam and ceased being ‘pagan’ (Maguzawa) and brewers

of beer. But over the last 20 years there have been other considerable changes, for example in the con- sumption of medicines, with tetracyclines available alongside boiled sweets and Omo on every hawker’s tray. The traders’ capital that used to be tied up in cigarettes has been put into modern medicines (no one smokes now); and transport has made access to the local hospital unproblematic, while self-medi- cation, learnt from years of exposure to doctors and dispensers, is commonplace. Indeed one of the husbands runs his own modern medicine shop in the local market. The house is now relatively ‘modern’, with its own pick-up truck and 8 motorbikes, its own corn-milling machine and some rooms with tin roofs; two lads have even been through secondary school, a third is a junior civil servant. But it is those who missed school that have the new wealth, and the wives.

In short, in terms of wealth and access to modern medicines and hospital treatment all these 7 domestic units could be considered above averageabove that of the normal Muslim Hausa villager.

3.3. Education

Educationally, the level is uniformly low: none of the wives can understand English, nor can any of them read or write in Hausa (their mother- tongue; it has an extensive literature in print, includ- ing newspapers, and is also the common medium of broadcasting and government). None of the wives have had any forma1 schooling whatsoever. Radios are not yet commonly used by women, though their older sons, and sometimes their husbands, may have one. I have never seen health education teams visiting the house. When a measles vaccination team is in the neighbourhood, women go with their children of their own accord, but appear not to be offered any health education while they wait (and indeed they may not even get the vaccine they queued for).

3.4. Health facilities

A university-run hospital is some 25 miles away by road and is of easy access for women, now by bus, before by bicycle. There have been other dispensaries in the neighbourhood with a range of services+ne is closer than the hospital and better run now; and pharmacies prescribe and sell a variety of drugs usually available at the hospital. Getting access to medicines, however, can conflict with the demands on everyone’s time during the rainy season, when agricultural work is at its most intense and when children’s illness is most frequent. And the rains do not make travel then any easier. But the actual peaks in mortality (September, with malaria-linked diseases; April/May, with epidemics of measles, meningitis, cholera) occur when the work load is somewhat lighter. For the mothers with the most dead children, the rains and harvest season were overwhelmingly the time for dying. For them, their

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babies’ first wet season with a reduced maternally- derived immunity was their last.

There has never been, among either men or women of the farmstead, any reluctance in principle to use hospital medicine, though their experience of hospital medicine in practice is marked by the difficulties of actually getting it-hence the many alternative out- lets for what the hospital is meant to provide freely. Ante-natal clinics were recognised as useful, but for serious operations upon their wives (e.g. for the repair of vesico-vaginal fistulae), men of the farmstead have sought out hospitals (and specific sur- geons) of repute up to 500 miles away, and consider them worth paying for.

3.5. Nutrition

Visitors to the farmstead with considerable experience elsewhere (such as Professor H.A.P.C. Oomen, then editor of Tropical and Geographical Medicine, on the basis of his Indonesian work) have commented to me on how they were struck by the good nutritional status of people in the farmstead. An annual ‘hungry season’ is not experienced here. Water supply is from the farmstead’s own deep, concrete-lined and -topped well; other water sources are not necessary, though pools are used, mainly by men, for washing in during the farming season (with, in the past, all the attendant problems of guinea-worm infection; guinea-worm is now very rare).

3.6. Sanitation

Latrines are uncommon; defaecation occurs on the fields around the farmstead; children’s faeces within the house are immediately carried outside, and the place swept clean. Sheep and goat droppings are swept up daily. Urination and washing take place in the open air on ground in the backyard behind one’s room. Flies are a problem countered by keeping lids on food. Mosquitoes are particularly troublesome in September/October, when malarial fevers are com- monest. But the farmstead is sited on high ground, over a mile from the nearest river. Mosquito nets are not used, nor are they necessary for the long dry season of the year.

4. INTERPRETING THE DISPARITIES IN CHILD DEATHS

As mentioned earlier, it is not my intention to attempt an explanation of these disparities in child deaths: the data are limited and the numbers far too small. Instead, as a contribution to finding a solution to the problem, I offer here, on the basis of long, close familiarity with the people concerned, interpretations of social processes that are usually missed by other methodologies that survey much larger populations over a much shorter time. Social processes not only of course require time to become visible, but they are not even easily caught by retrospective interviews: the nuancing and complexities of the moment are quickly

lost. The problem of child deaths is acutely important to the farmstead, and over the 20 years there have been many discussions, as well as many attempts at limiting the loss of children.

Is there, then, anything mother -specific that might bring about such disparities-keeping in mind that the contextual factors are the same for all within the farmstead and that the environment to grow up in seems not only to be remarkably uniform but also to be one shared for all practical purposes by all the children no matter who their mother is? Here, the first issue should be, perhaps paradoxically, not just the important one-why do some mothers’ children nearly all die?-but a more difficult one: why do nearly all the children of some mothers survive? For it is clear that, once a mother has successfully reared 2 or 3 babies, she is quite likely to go on being successful. And the converse is true: once she has lost 2 or 3 babies, she will probably go on losing them-unless she moves house. Hence the second question is not the one made famous by Evans- Pritchard in his analysis of Zande medical logic (“why me?“), but rather, “why is it always me?” [4]. A single, individual death can be interpreted, if necessary, as bad luck; even epidemics can have their explanations. But a “serial epidemic”, cumulative mortality when, in one room over the years, child after child dies, requires a different order of understanding. And survival rather than death is significant here because it shows what can happen when all goes well, and confirms people’s view that there is no necessary reason for so many children to die. In other words, we need to know first what it is that so increases or so reduces the ‘normal’ risk that these disparities come about; and second what might be the feed-back mechanism, if any, that are specific to these mothers. For what most distinguishes one mother from another, it seems, is simply the proportion of their children alive or dead.

In an area where malaria is hyperendemic and where there is a known incidence of the haemoglobin abnormality Hb SS, sickle cell anaemia is usually considered a possible additional factor causing some children to die very young. But the presence of abnormal haemoglobins is, it seems, not sufficient in itself to explain the extremes of mortality experienced by some women. In the Hausa population as a whole, the percentage of neonates who could be expected to be Hb SS is in the order of 2%, with the proportion of adults with Hb AS being in the order of 25-30%; adults, however, who are Hb SS seem to be extremely rare in rural Hausaland (by contrast, in towns with a large middle-class and good medical facilities, some Hb SS children do survive into adulthood) [S, 61.

Evidence for people’s experience of sickle cell anaemia in the farmstead was rare. There was not, for example, a clearly recognised syndrome equivalent to the sickling crisis of sickle cell anaemia. Discussions with the women of the farmstead did not reveal


that any of them had experienced as children the extremely painful, regular deep-bone pain associated with sickle cell anaemia, nor had they recognised it as a distinct phenomenon among infants. Though Hausa medical vocabulary includes the term amosani

for joint pains, and though sanyin kashe (‘cold in the bones’) is a recognised symptom, neither of these terms are associated by people of the farmstead with one specific illness. The terms are used for a range of aches and pains that accompany fevers, cold weather and the fatigue of wet-season work-they would be appropriate for describing the symptoms that occur in a sickling crisis, but not for distinguishing that crisis as a distinct entity which could then be linked to ideas about inheritance. Urban women, however, with experience of sickling children and access to hospitals, were by contrast quite specific about the symptoms, and used terms like sanyin kashe and ciwon kashe (‘bone sickness’) to label them.

There is however some reason to think that a large farmstead of the kind under discussion might not be typical of the population as a whole; it is considered a ‘successful’ house and over generations Hausa marriage strategies have tried to select for such ‘successful’ houses, and against those with demographic ‘blight’ of some kind. But even were we to assume that Hausa ‘indigenous genetics’ had indeed been effective in this instance and that the husbands of these women were Hb AS, while the ‘successful’ mothers were Hb AA and the ‘unsuccessful’ were Hb AS, it would still mean that for each pregnancy there would be only a 25% chance that the child of the AS mother would be Hb SS while, for both the Hb AS mother and the Hb AA mother, the chances of each child being Hb AS are the same-50%. Furthermore while against malaria Hb AS affords a child a certain degree of immunity which the HB AA child does not have (and this advantage has kept the level of Hb S as high as it is in the population), the advantage is not sufficiently great on its own to account for the extreme disparity observed. As Edelstein has pointed out in his analysis of sickle cell in eastern Nigeria, the incidence of Hb SS on its own is too small to have either the scale or the kind of consequences attributed to it [7]. (In Ghana, where people with Hb SS survive in relatively large numbers, Konotey-Ahulu impli- cates alpha thalassaemia as a factor in their survival [8].) So are there other, potentially aother-specific factors?

other times, and likely to be even less resistant to any of the other infections going round the children of the farmstead at the time. In short, children conceived in April, May or June, and therefore born in ca February, March or April are particularly at risk come August, September, October. Any woman, then, who regularly conceived in the dry season or early rains would be more at risk of losing children. Thus, with the season for first-time marriages reach- ing its climax in March when the bride moves into her husband’s house, there is a distinct possibility for everyone that the first-born child will be among those most at risk-and indeed it is commonly assumed that a woman’s first child may well not survive its first full rainy season. Furthermore, though women on their second marriages can move into their new husband’s house at any time, the dry season remains the most convenient period. Thus even births following these marriages then are potentially at risk; subsequent marriages, however, are less seasonal. Nonetheless I have never heard a connection made by women between the date of marriage and subsequent child deaths a year-and-a-half later; nor, when I have suggested it, has a link been seen as probable- the reason being that whereas generally deaths of children (and adults) cluster in the late rainy season, the age at which children die (and consequently their birth dates) varies considerably.

What may be significant in this context, though, is the way conception following the death of a child is likely to occur within the higher-risk period. The peak period of mortality follows a month or two behind the malarial peak, as infants gradually weaken and die. Hence October, November and even Decem- ber are the worst months. As a consequence, when a mother loses her child at this time and then has a 40-day mourning period following the child’s death, her next pregnancy is liable to start in the dry season, and once more result in an infant that will have only transitional immunity during the rainy season. Though women tease those who have frequent pregnancies (kwunika, in Hausa, is a term usually reserved for disparaging animals like goats), I have heard one woman, after 10 pregnancies in 20 years and losing almost all her children to rainy season illnesses, in retrospect refer self-mockingly to herself in this way. Despite such social pressure, she still kept on trying. The very wish, then, to replace the dead child quickly may only serve to perpetuate the cycle.

One such factor centres round the seasonal nature Another, related factor is the concern a mother has of malarial infection. The density of mosquitoes to try and ensure her baby’s survival. When she or reaches a peak in the late rainy season months of other women are convinced it is her ‘bad breast’ that August, September, October and falls to almost nil in is at fault and they turn in desperation to prescribing the dry season months of March and April when even supplements of various kinds whether traditional the ponds from which building earth is dug have or modern, there is the likelihood that infection is shrunk or dried up completely. Theoretically an introduced simply from the water in which these infant in whom the transition from its foetal to its tonics and herbs are given. In my experience of own humoral immunity is occurring just at the time watching medicines actually being given to sickly mosquitoes are at their most numerous is, even infants, the pharmacological properties of the ingre- when breastfed, at greater risk from malaria than at dients (in any case, usually given in very small

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quantities) are probably less significant than the cleanliness (or otherwise) of the spoon or finger, the calabash or cup, the water or other medium in which the infant takes the medicine. Furthermore, the mother in her frantic search for a remedy may travel widely and expose her baby to a different range of infections; it is notable how many previously well infants seem to fall seriously ill once they leave home with their mother. In addition, a mother’s anxiety about her ‘bad breast’ can inhibit her breastfeeding, either by limiting feeding to one side or by a general reluctance to offer her baby the breast. In consequence, the very fact of having already lost several babies brings about actions that may only perpetuate the sequence of deaths. Conversely, the mother who has not experienced a sequence of child deaths does not behave in this way; she does not need to seek out tonics or hasten to get pregnant yet again.

Disaster, then, feeds back on itself to create the conditions for yet another disaster. The only practical way out of this cycle of disaster is seen, by women and men alike, to be to leave both husband and house. Divorce is regretted and it can prove costly; the woman’s kin will try and persuade her to return if the husband strongly seeks her back. But where there are no children, or death seems a recurrent event, there may even be encouragement from her kin and friends to try somewhere else.

Some women, however, do not want to move; they love their husband, they like their house-and they resist the pressure to leave and become one of the group of junior wives elsewhere. For in this rural Hausa culture, the first marriage, for both husband and wife (as teenagers), is often with the sweetheart of their own choice, the culmination of years of courtship. It is precisely these women, the women still in love (as people say), who stoically put up with the continued death of their children, and so end up with the worst statistics. Others have broken the cycle by moving away, to give birth once or twice elsewhere or perhaps to become infertile through infection picked up from a temporary partner. Those who stay put, however, repeatedly get pregnant; they are noted among the other women (and teased) for the way they love their husband, and their husbands love them- and in the shared suffering, their common search for a cure, the bond grows stronger, and separation harder. In this lies the core of the tragedy and its cruelty: greater love led to greater loss and hurt.

I suggest, then, that the most ‘unsuccessful’ wives are those who try the hardest, who love their spouses and stay put despite the mounting number of deaths. Eventually a time comes when there seems no point leaving; when there is nothing more to do but try again and hope the next child-or the next one after that-will survive. Indeed most such women do finally have one or two surviving children out of the many, and that has to be enough. It is these women, then, who have the worst statistics-statistics which are in part an artefact of women’s greater autonomy

and opportunity in a Maguzawa farmstead. Other women, faced with apparently the same dire prospect, have sought better luck with other husbands and thus made their experience less strikingly visible.

5. THE IMPORTANCE OF LOCAL EXPLANATIONS

Although I have just suggested that those women in the farmstead with extremely high mortality among their children are unusual in that they should normally have left the house, as divorcees, years ago and sought better luck elsewhere, the reader should not then think that their experience is dismissed by others as anomalous and of no significance. On the contrary, the ideas used to explain these child deaths are central to the way women plan their lives, and people’s reactions to them have been crucial in shap- ing the basic roles that are available to women in this society. The explanations that account for the variation in child deaths are broadly of two kinds: one focuses attention on the mother and her family tree; the other puts the blame squarely on the nature of the dead children themselves.

(a) Mother-focused explanations

Amongst the mother-specific explanations used within the farmstead, the standard one that people offer as to why children of a particular mother tend to die before weaning is ‘her bad breast’, with its ‘bitter’ milk. Hence mothers present themselves at clinics seeking treatment for it and, getting no satis- faction, try to supplement the breast milk with powdered substitutes; but these are now too expensive to use (and are discouraged: well-meant campaigns against powdered milk are regarded as yet another example of European bad faith-Europeans keep it, like other really necessary things, to themselves). ‘Bad breast’, they say, is usually inherited through the mother’s line; in this it is like the powers of witchcraft which are transmitted, supposedly, through breast milk. But it is not, at least not explicitly, witchcraft that is poisoning a mother’s breast and killing her children off.

In addition, there are other explanations that are used concurrently with ‘bad breast’; one is the diagnosis that some ‘super-social’ interference is to blame (I use the term ‘super-social’ here since the interference is by dead kin on living kin; ‘supernatural’ I reserve for human/non-human interactions). In this instance, one of the mother’s kin, usually her aunt or grandmother, is identified as responsible for mali- ciously blighting her descendant’s life. Another diagnosis is to identify, say, sorcery by the husband or the malice of some witch as killing one child, but it is not a plausible diagnosis for explaining the deaths of all the children of one wife while the children of other wives are spared-no person capable of such evil is so stupid as to draw attention to his deeds in such a way. (Witches are considered to be very wily-which greatly increases people’s fear and dislike of them.


They use epidemics, for example, as cover for their murders, and are dissembling and devious in other ways; they are the loudest mourners at a funeral, for instance.) But if sorcery is indeed diagnosed, then the mother, once the child is dead, simply moves house, and, leaving her husband, ‘drinks other water’, as the euphemism for re-marriage has it; and that is the end of the matter.

(b) Child-focused explanations: changelings

It is of course neither necessary nor necessarily ‘fair’ to focus on the mother. Indeed such blaming could prove counter-productive, as I have suggested. The central issue is not the mother’s failure to nurture, but the child’s failure to thrive. Hausa, therefore, like many West Africans, commonly deflect potential blame away from the mother and her lineage, and focus attention instead upon the child as an independent (and often wayward) being. The Igbo with their ogbanje children (‘returnees’) or the Yoruba with dbikli are well-known for identifying a special category of quick-to-die children whose presence rouses ambivalent attitudes throughout West Africa-the nit-ku-bon of Wolof in Senegal is another notable example of the particularly ‘difficult’ and sensitive child [7,9, lo]. Commonly there are also anxieties that focus on twins as being particularly dangerous and liable to bring death; similarly a dead sibling may ‘call’ a younger living one to join him.

The general concept is that there exists a certain category of children who unlike other children are born specifically with the destiny of dying very young only to re-enter the same mother’s womb, and of repeating the cycle over and over again. Thus the many dead children prove to have been in fact one single child repeatedly born. The mother is merely the victim of this ‘child’. Similarly with changelings that take over a woman’s womb; though these can be identified by some abnormality, it is their short life span that reflects their spirit origin-their early death is inevitable, and the sooner the inevitable occurs, I have heard other women say, the better. Alterna- tively, it is her children’s very attractiveness to some ancestor that is the problem (which accounts for why it is sometimes the strongest child who dies suddenly). As has often been pointed out, a factor common to all the West African cultures that emphasise such ideas is the presence of sickle-cell anaemia [7].

Very little has ever been written about such ideas in Hausa culture, where the phenomenon of repeated deaths is known as wabi; a mother ‘has’ wabi (she is a mai wabi) or she ‘does’ wabi (ta yi wabi)--etymo- logically, the term may derive from the arabic ‘wabi’, ‘infected’ (cf. al-waba’, from which the Hausa alloba, ‘plague’; the tones are different, though). A child thought liable to die because he or she was born following the deaths of previous siblings is known as a dun wabi (child of wabi); the child is usually given a nickname that implies the parents’ contempt or disregard for it, in the hope of disguising their

concern and love which might attract once more the envy of whatever is causing their children to die so young. Another technique to distance the child is to give the child the facial identity-marks (small, neat ‘scars’) of some other group, thus ‘hiding’ it by changing its identity.

All parents, but young mothers especially, are expected not to show overt affection for their first child (through kunya, self-control), though their real anxiety, however well-concealed, is obvious to any close observer-and other women may tease a mother for not concealing her concern well enough. The distancing from a dun wabi, then, is an extension of this customary self-control (but without attracting the teasing). Indeed, though nicknames are a clear indication of people’s anxiety, no one specifically likes to refer to wabi, let alone label a child a dan wabi-a reticence strong enough to cause outside analysts of Hausa medical practice not to have explored this particular aspect of child mortality in Hausa land. Nonetheless it is a term widely under- stood, by men and women of different social class and region, even if actual experience of wabi and what to do about it is more restricted.

If wabi is now the generic (and more Muslim) term for a mother’s repeated loss of children in infancy (so much so that, as Bargery’s Hausa dictionary makes clear, it is used metaphorically for trees that shed fruit prematurely and for any other fruitless effort), a more specific term for a child at risk from an early death is dun ruwa, ‘water child’ [l 11. Water has many dangerous connotations in Hausa as in other cultures and these include, for example, madness and tran- sience. Here the explanation is apparently more simple: pregnant women who visit the river risk having the foetus within them replaced by a water spirit. It is not until they deliver, or even later as the baby develops, that they discover they have given birth to a dun ruwa. The most obvious sign is a characteristic bossing of the head (associated clini- cally with sickle-cell anaemia). To counteract this, one half of the child’s head is kept clean-shaven, making the deformity obvious to everyone; and a specific nickname (such as ‘Barmo’) is given the child. There is a certain ambivalence over what to do: if it is a water spirit, then it will soon go (that is, the child dies) and no one wants it back. To ensure the water spirit will not want to return, the child may be beaten-or so people say. But the dun ruwa I knew well (and still know, 20 years on) was not ill-treated, though it was the father who alone had a very close bond with him. Nonetheless by identifying a category of children in this way, it might seem to legitimate, even to encourage, neglect and to distance the mother from her new-born; and this in turn might hasten the child’s death.

However, both a dun wabi and a dun ruwa are in principle considered treatable, and are not thought to be necessarily bound to die quickly. Indeed, there are plenty of adults alive who are

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called Bawa, Bayi (‘slave’) and other such names indicating how anxious their parents once were for them. Mothers can go to healers-Muslim or non- Muslim-in search of an end to their wabi; for a dun ruwa a specialist in medicine against spirits is preferred. But water spirits may simply go away of their own accord.

Furthermore, mothers have means of avoiding wabi. A mother afflicted by wabi sometimes ‘changes’ her own identity after her last child’s death by getting rid of all her wrappers and begging a new wrapper off women she knows (cf. the widespread Muslim practice of discarding rags and bits of old clothes on thorn trees in waste land). Some also say that if a husbands sleeps again with his wife before the end of her 40 days’ mourning for the dead child, then that child returns-hence women afraid of a wabi may sleep in another’s room for the period.

(c) The children that survive

By contrast, children who live long are thought to be those who have proved, in a hard world, their own inherent strength independently of their parents. Childhood illnesses are thus in some senses ‘good’, being necessary experiences that confirm a child’s toughness. Like all children they have as a matter of course a set of amulets as protection against unspe- cified, unseen forces, but it is not the efficacy of these that has ensured their survival; nor is their survival considered to have been at the expense of others. Instead, a mother’s unusual success in raising children to adulthood is attributed simply to God’s or Allah’s ‘blessings’ (in Hausa, arziki). It is a gift.

This explanation accounts for worldly wealth, too. For both the materially rich and the rich-in-children there is the strong social imperative to be as generous to others as Allah has been generous to themselves: such wealth is assumed to have been an unsolicited gift from Him, whereas the wealth accumulated by the stingy-rich can only have been obtained through evil means. (Indeed the stingy-rich are thought to have fewer children around them because they have had to give some over as payment to the dodo for their riches; evil spirits cannot provide ‘real children’, only changelings.) These notions about the origins of unusual wealth of course conveniently legitimate inequality as much as they enforce the re-distribution of wealth. But it also makes it possible to consider someone’s success in child-rearing as ‘normal’, and not as the result of extra special (or extra-legal) efforts done deliberately at the expense of others. The successful, for example, are not notably ‘religious’ or pious (indeed, in my experience, more often the opposite).

Appropriate generosity can be shown by a successful mother by allowing, if necessary, one of her children to be reared-certainly after it has been weaned aged 2, but often later-by a less fortunate kinswoman in another farmstead (the child eventu-

ally returns to his or her father’s house, and hence to the real mother, when due to marry). Such fostering, incidentally, proves to people (if proof were needed) that it is not any lack of skill on the unfortunate mother’s part that causes children to die after weaning, nor indeed is it anything to do with her environment: children fostered can safely thrive.

(d) Child mortality and marriage strategies

The cluster of concepts discussed above do not have much public prominence or even appear commonly in the academic literature; rather, they seem to gain added force from being rarely spoken about openly. Certainly their practical consequences are considerable. Not just decisions to divorce are based on them. Hausa marriage strategies, for example, are concerned with whether or not there is a wabi recorded in a family. When planning a marriage, both parents and prospective spouses take note of how many brothers and sisters the potential partner has, and whether the partner’s mother and father were themselves an only child. Discussion may not be open, but I know of cases where the family have been opposed to a marriage on these grounds; and certainly the demographic ‘success’ of a house is an important factor in attracting brides as well as divorcees. Success, then, can be sought; while it certainly should not be ‘bought’ through resorting to a pact with evil, it need not be left to Allah alone. Success comes through seeking out the right spouse in the right house, even if that means several divorces (and possibly even leaving one child behind; non-Muslim divorcees however usually take their children, if young, along with them).

The concept of wabi, then, is an integral part of Hausa practical genetics. This suggests at the very least that people are willing to conceive of success or failure in child rearing as potentially a matter of heredity (gudo). As a result, the young men and women of a large farmstead tend to seek their partners from similarly large and successful farmsteads. Furthermore, divorcees choose to marry if they can into a large farmstead, both for its proven fertility and for the greater economic and social opportunities a big household offers. The losers are the small farmsteads, which are apt anyway to be labour-short and more vulnerable to the effects of illness and other stresses [12]. Thus the demographic ‘blight’ caused by wabi can have serious consequences for the whole farmstead’s long-term prosperity: only the largest, most successful of houses (where conven- tionally the widest range of odd characters is congre- gated) are immune. In this way, concepts deriving from the need to understand the extreme variation in child mortality within a household permeate people’s thinking, and influence even the way prosperity and poverty come to be distributed around the farmsteads of the community. It is important to recognise (as men of the farmstead do) the processes by which


men’s lives are affected by inequality among women, though the reverse, the effects of men’s inequalities upon women, is more evident.

6. INEQUALITY AMONG WOMEN

Extremes of success and failure in rearing children raises another issue-that of inequality among women, its origins and consequences. The literature on poverty and wealth has focused mainly on men- for example, Polly Hill’s study on the origins of individual poverty in rural Hausa land (and her subsequent comparison with rural Kamataka in India) [13, 141. Here I will briefly outline both the way extremes of success or failure in child-rearing accentuated inequality and-just as significant perhaps-the apparent efforts that went into controlling the consequences of inequality within the house. While social conventions limited the effects of differences among individual women, at the wider level of the community these differences nonetheless served to generate significant disparities between farmsteads-disparities which also had consequences for women.

(a) Wealth in children

The advantages for a mother of having many children, both boys and girls, are comparatively obvious and well known. Children are seen as essen- tial to a woman’s personal prosperity, enabling her with the extra labour to do things that are otherwise impracticable. In the farmstead, for example, children look after their mothers’ goats and sheep: they guard them when out grazing, they bring them fodder when tethered. Livestock-rearing offers a woman access to a type of capital asset that multiplies more readily than any other: but without children, livestock are a problem. Children also give their mother time for more lucrative work by minding their younger siblings; they collect firewood for her. They also retail round the house or the neighbourhood the cooked foods their mother has made for sale. As they grow older, children can fetch water for her and help her hoe her own fields as well as doing some gardening on their own account (most children have not only patches of land lent to them but also have livestock handed over to rear as their own). In short, a woman with many children can run a thriving enterprise of her own, and through her profits and generosity build a wide social network. In practice, such mothers do not so much amass wealth of their own as create a prosperous environment in which their children in turn prosper, having nice things and marrying with a good dowry.

The contribution the mother’s considerable ‘firm’ makes to her husband’s prosperity is clearly significant in several ways. They are after all also his sons, his daughters, and through them are created the farmstead’s marriage alliances; her sons are the heirs and the working mainstay of the farmstead.

A mother, then, has a position of strength vis a vis her husband; together, she and her children can exert formidable pressure-were she to divorce him, her children might well accompany her to her new house. In consequence, the power of a successful mother is perhaps of greater significance in the farmstead community than is her actual wealth; and it is in the disparities of power that inequality among women is most marked. For generosity only partially mitigates disparities in wealth. Indeed when the indebtedness of others that derives from such generosity is added to the leverage a successful mother can exert on her husband, the woman with few or no children can in the long term be little more than marginal in the councils of the farmstead.

(b) The costs of few children

A woman with few or no children, if she is not exactly a servant to the household, nonetheless is de facto a client of the better-off, rarely able to raise her own capital. Hence, her search for a craft of her own that takes her outside the house. Even when a child is entrusted to her and helps her with work in the house or on the farm, it is scarcely adequate: the labour shortfall still has to be made good by hiring neighbours’ children, and their wages have somehow to be paid for from earlier profits-one’s own children work on credit! The few women who have become very wealthy in their own right, owning cattle which others herd for them, buying land or building up considerable stock in trade, are precisely those who took up some craft of their own in lieu of children. One such craft is that of diviner and specialist in spirit possession, diagnosing and treating the causes of childlessness in others. More mundane trades, such as brewing beer for sale, usually require children to help with the considerable extra work involved.

There is one other disadvantage to childlessness apart from a lack of the labour power necessary to run a successful family ‘firm-and that is the effort that goes into trying to find a cure for apparent failure, with all the expenditure of money and time that is entailed. The pre-occupation with searching out a reason for the lack of success can become an end in itself, with divination repeatedly sought and remedies tried; it can involve changing husband or religion or locality, trying treatment after treatment, or joining one cult or another- especially bori [15]. Yet any really serious search for occult medicines might lead to co-wives becoming suspicious, especially if their children started dying untowardly.

The loss of children, apart from anything else, not only can cripple a woman materially but can leave her without the authority to express her pain and mourn her loss with the intensity she might otherwise feel. There is a clear consensus that expressions of grief need to be limited and overt anxiety controlled; women explicitly condemn persistent indulgence in

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histrionics-and given the power structures among women in the house, condemnation is a powerful sanction. Endurance or uncomplaining patience (hakuri in Hausa) is considered perhaps the prime virtue: it is meant to show your mastery not so much over self as over whatever others-human or non- human, living or dead-can throw at you, thus demonstrating your own autonomy of response no matter what the provocation. In practice, some women found it very hard to hold back their pain: one broke down and ran screaming from her room as yet another of her children died; another seemed quite openly crushed by despair while a third could not conceal her constant anxieties for her baby. Two young mothers from the house became temporarily deranged after their children died. But these were brief moments of open grief or rage.

Conventions within the farmstead restricted not just the behaviour but also the range of diagnoses permitted to those in distress. Although culturally there might seem to be a range of ways to express anger and of targets to attack, in practice the costs of doing so were too great. For example, in the past 20 years serious accusations of witchcraft have only once been made within the farmstead (against the head-of- house’s eldest son). The consequences of this crisis were traumatic for everyone and proved very hard to control: it involved driving the accused out of the farmstead with threats of real violence, and the consequent risk of breaking up the farmstead as a community. Furthermore, the reputation of the farmstead as a desirable place for young brides to marry into was put in jeopardy, while those already married thought they might have to leave. Hence the efforts of the seniors in the farmstead to cool the hysteria of the time; and having once experienced that traumatic episode, no one has made any such accusations subsquently, at least not overtly. Elders-women as well as men-simply give no credence to such suggestions. Therefore, if a woman wants to stay in the house despite the deaths of her children, she conforms.

Women in this position have said openly to me how they wished simply to give up trying to have children: they had birthed so many, so many had died that they had had enough. It was no doubt true, but it was also a legitimate way of asserting to the powers-that-be that birth and death were now of such little importance that those powers should cease blighting her life. Yet women of all sorts openly longed for a respite from the cycle of pregnancy, birth and death: “we breed like hares”, said one with a laugh.

A harder cost for the outsider to assess is the despair, the depression even, that despite the careful masking seemed to me to lie within many of the women. Occasionally I’d be given a glimpse of a kind of persistent, underlying pain, an aching tiredness- the idiom of social life, though, required a certain gaiety and good humour however forced.

(c) Alternative careers

In this context it is significant that the farmstead offered alternative careers for women who had few or no children, providing them with a role in which great value could be put on their particular contribution, as workers, as co-wives, as (often) the life-and-soul of the household for everyone’s children, with their stories, their songs, their humour.

In a traditional farmstead, a man’s third, fourth, fifth wife would be drawn from the pool of divorcees who had just left a husband because their children had died or they seem unable to conceive a child together. Marriage might be initially a rite de passage into adulthood, but in the longer term it is an experiment to see if the relationship will be ‘blessed’ with children that live. There is no real stigma (only considerable private sorrow) if the experiment fails, or indeed has already failed a number of times: a woman might have 5 or more marriages in a lifetime, often ending in old age with one to her childhood sweetheart (sure baya, an ‘after-marriage’, as it is called). When I first lived in the farmstead, childless women therefore sought marriage there as their work and the verve they brought to the house were valued as much as their fertility (especially since the senior wifeand sometimes the second wife too- were expected to be less extrovert in manner).

This much-valued role is currently in danger of disappearing. Now that women no longer work any of the week on their husband’s land, childless women are less sought after, and divorcees stay longer between marriages awaiting suitors at their kinsmen’s home-or else have to turn (as Muslim women have long had to do) to courtesanship in town. Men who before were limited only by their ability to build enough rooms and offer enough gardens to potential wives now find it better to limit their wives to four (or less); in doing so, they also take the opportunity of becoming Muslim. Needless to say it was not the women with few children who demanded change and won the right not to work on the fields of their husbands; it was those with children who were better off as a consequence, and had the power to alter the status quo.

In short, the range of satisfying strategies has in recent years been markedly reduced for the young woman who fears that she is destined to be childless. The penalty for failure has gone up, the potential for inequality has grown greater. It is this that makes just the spectre of extreme failure a matter of so much importance. The possibility of such a personal disaster as losing all one’s children sustains a sense of anxiety, a paranoia almost, that makes divorce seem a ready solution, and keeps alive the beliefs that seek to make sense of such a fate.

7. IN CONCLUSION

I have sought to show here not merely that extremely disparities in child-rearing are part of


people’s everyday experience, but how these disparities generate for women important long-term economic and social inequalities which give rise to distinct careers having sharply different cultural meanings. These inequalities affect men too, not only as spouses, fathers or brothers, but also more abstractly in the way inequalities among wives tend to feed back onto and accentuate the differences between large, prosperous farmsteads and the smaller, poorer ones.

Extremes of this sort have a further, less obvious consequence: they give rise to a particular kind of explanation and response. By definition extremes of experience, such as the serial deaths of the children of one mother, only turn out to be extreme in hindsight, when it is already too late. There is a premium, then, on any explanation that will offer a chance not only of early detection but also of remedial action in order to abort a series-in-the-making. A young wife, after the death, say, of her second child, needs at least to consider what the future holds for her and what to do about it; and if she does not think about it, then her family and friends will. A single death, even two deaths, can have many explanations, some of them ad hoc-but a possible sequence of deaths is in a different category, and a matter of some urgency and anxiety.

Certain theories about the causes of death can therefore have an undue salience because they prompt pre-emptive and sometimes drastic action. What is classed by the outside observer as merely anomalous or extreme, to an insider is simply what can happen, quite normally, whenever appropriate preventative measures have not been taken. And cases are sufficiently commonplace that this belief is confirmed in everyday experience. In short anomalies of this kind are not just the tail of a normal statistical distribution, a tail that can be ignored, but rather a dire warning of what might happen if society’s efforts to forestall such anomalies were to be relaxed.

These theories, then, explain what conventional hospital-based medicine does not explain-why, when rearing children in an apparently similar environment, some women are very successful and some are not. Small wonder, then, that health promotion campaigns carry little conviction: the logic that underlies them fails to tackle the full range of experience, and fails precisely over those segments of the range that people most fear (“my children always die”) and most desire (“her children always thrive”). By contrast, local theories are designed like dams or ridgesdesigned to bear not just the normal load-

‘s of everyday life, but to withstand the extreme -es imposed by sustained, cumulative disaster:

nstitute a different kind of cognitive engin- 7rn the usual explanatory models. Local

uire a sense of time and of linking that episodic view of illness; they have to be

against disproof. Should the time + children survive, these theories

will not have been proved wrong; it will merely be that the causes of deaths have finally been overcome (‘the spirits have gone’). Beliefs fade not because they are erroneous but because they have become irrelevant.

Intra-household variation in child mortality is thus significant at several levels. It raises strictly medical questions as to what factors are at work; it also offers insight into the forces that structure people’s lives, and particularly the patterning of divorce, its consequences and attendant stresses. Finally, it draws attention to the different logic, and above all to the different data required for pre-emptive medicine. We must know about people’s experience of extremes and their explanations of those extremes if we are to understand their reactions whether it be to outside interventions or to their own experience. Knowing just what is normal is not enough.

REFERENCES

1. Caldwell J. C. Education as a factor in mortality decline: an examination of Nigerian data. Pop. Stud. 33, 395413, 1979.

2. Mosley W. H. and Chen L. C. An analytical framework for the study of child survival in developing countries. In Child Survival: Strategiesfor Research, Supplement to Pop. Dev. Rev. 10, 2545, 1984.

3. Das Gupta M. Death clustering, mothers’ education and the determinants of child mortality in rural Punjab, India. Poe. Stud. 44. 4899505. 1990.

4. Evans-Pritchard E. E. Witchcraft, Oracles and Magic among the Azande, Chap. 4. Clarendon Press, Oxford, 1937.

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5. Molineaux L. and Gramiccia G. The Garki Project: Research on the Epidemiology and Control of Malaria in the Sudan Savanna of West Africa, Chap. 7. World Health Organisation, Geneva, 1980. In this study, 2.1% of 574 neonates were Hb SS. while no adult Hb SS were found among 2742 people tested. The sickling trait (Hb AS) has been found, by this and other contemporary surveys in the region, to occur in 25.9-28.9% of the population. Fleming A. F. et al. Anaemia in young primigravidae in the guinea savanna of Nigeria: sickle cell trait gives partial protection against malaria. Annls trap. Med. Parasitol. 78,395404, 1984. No Hb SS presented in this study. Edelstein S. J. The Sickled Cell: from Myths to Molecules, Chaps 3 and 4. Harvard University Press, Cambridge, MA, 1986. Konotey-Ahulu F. I. D. The Sickle Cell Patient: Natural History from a Clinico-epidemiological Study of the First 1550 Patients of the Korle Bu Hospital Sickle Cell Clinic. Macmillan, London, 1991. Verger P. La Socibte e&P drun des abikti, les enfants qui nai&nt pour mourirmaintes fois. Bull. 1’I.F.A.N. %, ser. B, 1448-1487, 1968. Zempleni A. et Rabain J. L’Enfant Nit-Ku-Bon. Un tableau psycho-pathologique traditionnel chez les Wolof et Lebou du Senegal. Psychopathol. Afr. 1.3, 329441, 1965. Bargery G. P. A Hausa-English Dictionary and an English-Hausa Vocabulary. Oxford University Press, London, 1934. Last M. The presentation of sickness in a community of non-Muslim Hausa. In Social Anthropology and Medicine (Edited by Loudon J. B), pp. 136139. Academic Press, London, 1976.

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13. Hill P. Population, Prosperity and Poverty: Rural 15. Last M. Spirit possession as therapy: bori among non- Kane 1900 and 1970. Cambridge University Press, Muslims in Nigeria. In Women’s Medicine: the Zar-Bori Cambridge, 1977. Cult in Africa and Beyond (Edited by Lewis I. M.,

14. Hill P. Dry Grain Farming Families: Hausaland (Nigeria) Al-Safi A. and Hurreiz S.), pp. 49-63. Edinburgh and Karnataka @din) Compared. Cambridge University University Press for the International African Institute, Press, Cambridge, 1982. Edinburgh, 199 1.

The importance of extremes: The social implications of intra-household variation in child mortality

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