Cow dung, rock salt, and medical innovation in the Hindu Kush of Pakistan: The cultural transformation of neonatal tetanus and iodine deficiency

In mountain villages of Chitral District in northwestern Pakistan, dried cow dung is used as Westerners would use talcum powder when babies are swaddled and rock salt is consumed in tea and other foods. Both substances are esteemed as conveying beneficial 'heat' and 'strength'. Unfortunately, however, cow dung sometimes contains a bacterium that causes neonatal tetanus, and the resulting toxin may enter through the baby's unhealed umbilical cord and cause death. Further, rock salt contains no iodine, and Chitral's soil is so iodine-deficient that goiter is very common. Thus local health workers advocate use of talcum powder rather than cow dung, immunization against tetanus, and replacement of rock salt by powdered iodized salt. The present report documents widespread community acceptance of these innovations despite the fact that the biomedical model of tetanus and goiter was not well understood and indigenous concepts of the causes of the diseases remained virtually undisturbed. Most of the villagers were Ismaili Muslim followers of the Aga Khan; their receptivity to such health messages was influenced by the high value that their religion places on advancement through 'education' and was correlated with their proximity to Ismaili health workers whom they trusted. A major implication of this research for primary health care programs is that when one is attempting to change existing health practices, explication of biomedical models should not be the only focus of concern. Attentiveness to the context in which behavior changes are introduced and interpreted is at least equally important. Further, the fact that new knowledge was added to the old without replacing it illustrates the complexity of human cognition and points to limitations in the KAP (knowledge-attitude-practice) model of health belief and behavior. This report adds to a small but important body of literature documenting the dynamic nature of medical pluralism in the developing world.