I read a bunch of articles for my public health coursework, but one that has stuck in my mind and thus been on my things-t0-blog-about list for some time is "Mystification of a simple solution: Oral rehydration therapy in Northeast Brazil" by Marilyn Nations and L.A. Rebhun. Unfortunately I can't find an ungated PDF for it anywhere (aside: how absurd is it that it costs $36 USD to access one article that was published in 1988??) so you can only access it here for free if you have access through a university, etc. The article describes the relatively simple diarrhea treatment, ORT (oral rehydration therapy), as well as how physicians in a rural community in Brazil managed to reclaim this simply procedure and turn it into a highly specialized medical procedure that only they could deliver. One thing I like is that the article has (for an academic piece) a great narrative: you learn how great ORT is ... then about the ridiculous ritualization / mystification of a simple process that keeps it out of reach of those who need it most ... then about the authors' proposed solution ... and finally a twist where you realize the solution has some (though not certainly not all) of the same problems. Here's one of their case studies of how doctors mystified ORT:
Benedita, a 7-month-old girl with explosive, watery diarrhea of 5 days duration, weakness, and marked dehydration, was brought by her mother to a government hospital emergency room. White-garbed nurses and physicians examined the baby and began ORT. They meticulously labeled a sterilized baby bottle with millimeter measurements, weighed the child every lSmin, mixed the chemical packet with clean water, gave the predetermined amount of ORT, and recorded all results on a chart, checking exact times with a wristwatch. The routine continued for over 3 hr, during which little was said to the mother, who waited passively on a wooden bench. Later interviews with the mother revealed that she believed the child’s diarrhea was due to evil eye, and had previously consulted 3 [traditional healers]. Despite her more than 5 hr at the clinic, the mother did not know how to mix the ORT packet herself. When asked if she thought she or a [traditional healer] could mix ORT at home, she replied, “Oh no, we could never do that. It’s so complicated! I don’t even know how to read or write and. I don’t even own a wristwatch!”
They then discuss how they trained a broader group of providers (including the traditional healers) to administer the ORT themselves. But the traditional healers end up ritualizing the treatment as much or more than the physicians did:
... Dona Geralda cradled the leaves carefully so as not to spill their evil content as she carried them to an open window and flung them out. The evil forces causing diarrhea are believed to disappear with the leaves, leaving the child’s body ‘clean’ and disease-free...Turning to the small altar in a comer of the healing room, Dona Geralda offered the ORS 'holy water' to the images of St Francisco and the folk hero Padre Cicero there.
There's more to both sides of the ritualization in the body of the article, and the similarities are striking. I'm not sure the authors intended to make it this way (and this likely speaks more to my own priors or prejudices), but the traditional healers' ritualization sounds quite suspicious to me, full of superstition and empty of understanding of how ORT works, while at the same time the physicians' ritualization, as unnecessary as it is, is comfortingly scientific. The crucial difference though is that the physicians' ritualization seriously impedes access to care, while the healers' process does not -- in fact, it even makes care more accessible:
Clearly, our program did not de-ritualize ORTdelivery; the TH’s administration methods are highly ritualized. The ceremony with the leaves, the prayer,the offering of the ORS-tea to the saints, are all medically unnecessary to ensure the efficacy of ORT.They neither add to nor detract from its technologial effectiveness. But in this case, the ritualization, insteadof discouraging the mother from using ORT and mystifying her about its ease of preparation andadministration, encourages her to participate actively in her child’s cure.
Neat.