The Health Situation of Women and Children in Central African Pygmy Peoples - May 2006

 

We are completely neglected and forgotten. Even our wives do not have access to midwives. They are permanently exposed to death because of lack of care during their pregnancy and deliveries. This came with the so-called modern life into which we were dragged. It did not exist when we were living in our natural environment. We had so many plants for such problems... Twa man from Kalehe district, Kivu, Democratic Republic of Congo (DRC)[2]

 

Pygmy peoples’[3] health situation is changing due to changes in their traditional forest-based hunter-gatherer livelihoods and culture. Logging, farming, infrastructure projects and the creation of protected areas are restricting Pygmy peoples’ access to forest resources; many Pygmy groups are spending more time in road-side settlements, have closer contact with neighbouring ‘Bantu’[4] farming communities and are more involved in farming, wage labour and the cash economy. These changes are most pronounced in the Great Lakes region where most of the Twa communities have had to abandon a forest-based lifestyle, and have become landless and impoverished.[5] Pygmy peoples’ health situation is also affected by the negative stereotyping, exclusion and subjugation they encounter from their neighbours and dominant society.[6] This article looks at the way environmental and social factors impact on Pygmy women and children’s health, and the health of Pygmy communities in general.

Reproduction

Available data indicates that the fertility of Pygmy women is generally high. For example, in the late 80s the number of births per reproductive life span reported by Aka women from different communities in Central African Republic (CAR) was 5.1, 5.6 and 6.2, and for Mbuti women in DRC was 5.0.[7] These rates are similar to those in many traditional societies. The very low fertility (2.6) of Efe women in DRC in the mid 90s was attributed to sterility caused by diseases such as gonorrhoea[8] associated with inter-marriage with neighbouring farming communities.

Infant mortality

Mortality rates of Pygmy children are high. Among the Aka in CAR and the Twa in Uganda, infant mortality rates are reported as 20-22% and 20-21% respectively– the latter being 1.5-4 times higher than neighbouring non-Twa communities.[9] Under-five mortality rates for Mbendjele in northern Congo of 27%, and for Twa in Uganda of 40%, are reported to be 1.5-2.4 times higher than nearby non-Pygmy populations.[10]

One of the main causes of childhood death in Pygmy communities is measles, accounting for 8-20% of deaths of Aka children in CAR. In Congo, mortality from measles was more than five times higher in Mbendjele children than in Bantu children.[11]

Nutrition

Pygmy communities that have access to forest and farm resources have seasonally variable, but usually adequate, nutrition due to a varied diet of game, invertebrates, fruits, mushrooms, forest leaves, oily nuts, wild yams, honey and cultivated starchy foods.[12]Pygmy women participate in hunting, and gather a wide range of forest food products. Among the Baka in southern Cameroon, numerous medicinal uses of wild yams, which contain steroids affecting contraception and pregnancy, and several prohibitions affecting women’s consumption of yams suggest close links between wild yams and fecundity.[13]  

Depletion of forest food resources through logging, commercial poaching or restricted access to protected areas increases the risk of malnutrition and mortality, particularly if Pygmy communities lack alternative lands on which to grow their own food.[14] When Ugandan Twa families were given land, under-five mortality rates dropped from 59% to 18%, demonstrating the crucial importance of land for survival.[15]As traditional egalitarian social systems have become eroded, the responsibility for children’s well being and household food provisioning has fallen increasingly on Twa women, whereas in traditionally-living, forest-based communities these roles are more equitably shared between men and women.Twa women who have to rely on begging or badly-paid wage labour to obtain food have great difficulty meeting their family food needs.>[16] Children and pregnant women are particularly vulnerable[17] exacerbated by the breakdown of traditional food sharing mechanisms.

Loss of access to forest lands and resources also deprives Pygmy communities of their renowned traditional herbal pharmacopoeia. Many of the plants used by Baka women in Cameroon to treat family ailments include active compounds against intestinal helminthiasis, guinea worm, jaundice, malaria, diarrhoea, toothache and cough.[18]

Morbidity

As the forest frontier is pushed back, Pygmy communities spend more time in fixed settlements along the roads, closer to farming populations. Here health problems increase due to increased exposure to infected malarial mosquitoes, and the build up of parasites due to increased population density and lack of adequate sanitation.[19] Heavy infestations of chiggers (burrowing fleas) in fingers and toes cause painful and crippling infections.[20] Spiritual health also suffers as communities have less access to forests for traditional nocturnal singing and dance ceremonies to maintain harmony between the forest and the community. Social tensions, alcohol abuse and domestic violence against women increase.[21]

Compared with nearby non-Pygmy communities, studies of forest-based Mbendjele, Aka, Baka, Mbuti, Efe and Bongo communities have shown lower prevalence of malaria, rheumatism, respiratory infections, goitre, scabies, syphilis, Loa loa filarial infections, hepatitis C (3 to 7 times less), and dental caries. On the other hand, leprosy, conjunctivitis, chiggers, periodontal disease and dental attrition are more common.[22] Intestinal parasite levels in forest-based Pygmy groups are high, but tend to be similar to, or lower than, Bantu communities, whereas in sedenterised, village-based Pygmy groups parasite levels tend to be higher.[23]

Yaws, a painful skin infection that can progress to destruction of bone, cartilage, skin and soft tissue, is more common in forest-based Pygmy communities in CAR, Cameroon and DRC, with up to 90% of individuals infected. Children are particularly affected.[24]

Twa communities in the Great Lakes region report malaria, intestinal worms, diarrhoea and respiratory complaints as their most serious illnesses.[25] Comparative health data is lacking, but the impoverished living conditions of the Twa can be expected to cause significant health inequalities compared with neighbouring communities. Forty-three percent of Twa households in Rwanda and 53% in Burundi have no farm land - 3.5 times more than the respective national populations. The situation of the Ugandan Batwa is similar.[26] The connection between landlessness and increased child mortality was noted above. Twa households are also likely be more at risk of respiratory illness and parasite infections due to inadequate housing, lack of sanitation and lack of safe drinking water, which are respectively six times, seven times and two times higher in Rwandan Twa households than the national population.

HIV-1

Studies in the 1980s and 90s in Cameroon and Republic of Congo showed a generally lower prevalence of HIV-1 in Pygmy people (range 0% - 1.6%) than in neighbouring populations (range 0% to 5.4%).[27] Isolation may have protected Pygmy communities from contact with sexually transmitted viruses such as HIV and hepatitis C. Intermarriage with Bantu people is infrequent, and is almost always by Pygmy women marrying out of their communities – their low bride price and their perceived higher fertility making them a more attractive prospect for Bantu men.[28] However, once the HIV virus has been introduced into a Pygmy group, it could spread rapidly as it is common for Pygmy men and women to have serial marriage partners. The lower rates of polygamy reported in Pygmy communities compared with neighbouring communities[29] may nevertheless confer some protection on Pygmy women.

Indications are that HIV prevalence is increasing in Pygmy populations. Between 1993 and 2003, HIV infection of Baka people around Yokadouma in eastern Cameroon is reported to have increased from 0.7% to 4%.[30] Logging, road building and infrastructure projects, such as the Chad-Cameroon oil pipeline, increase STD transmission by employing transient male labourers who seek sexual services from the local women. Pygmy women are particularly vulnerable to HIV infection due to the widespread belief of other ethnic groups that sexual intercourse with Pygmy women confers protection against back-ache, AIDS and other ailments, due to their special powers as forest dwellers.[31]

Access to health care

Rural communities throughout Central Africa suffer from inadequate health care facilities. For example, in the mid-90s, 80% of the rural population in two northern provinces of Republic of Congo were estimated to lack access to health care.[32] Pygmy people are particularly disadvantaged as they are less able to pay for treatment, often lack ID cards needed to travel or obtain treatment, and are liable to be humiliated by health centre staff because they are Pygmies.[33]

Pygmy communities’ mobility and remoteness makes it harder for public health campaigns to reach them, but discrimination is also an important factor. Reports note that medical resources, including vaccination materials, childhood immunizations, intravenous infusions, anti-malarial drugs, aspirin and oral rehydration mix, were preferentially given to Bantu.[34] In northern Congo, local Bantu intermediaries responsible for delivering medication to Mbendjele leprosy sufferers often made the patient work for them in order to receive their pills; unwilling to endure months of servitude, the Mbendjele preferred to abandon their treatment.[35] However, with good planning and commitment, health campaigns can reach remote Pygmy communities: during the mid-1990s a private campaign treated hundreds of Aka people in northern Congo with the single injection of penicillin needed to cure yaws, and UNICEF has succeeded in reaching Pygmy children in its polio vaccination campaigns.[36]

The attitudes of health staff in some cases are beginning to change[37] and more Pygmy communities are now aware of free government health services. In Rwanda in 2004, 68% of Twa women received antenatal vaccinations and 90% of under-fives received one or more of DTaP, polio, TB and measles immunisations.[38] Rwandan Twa communities benefiting from NGO-run income-generating projects are now enrolling in local health insurance schemes and investing in improved housing and sanitation, which should reduce illness.

Missionaries, NGOs, logging companies and development agency health programmes are often the main source of health care for Pygmy communities. Several such programmes have trained ambulant Pygmy primary care workers and established community-run dispensaries, giving communities a stake in their own health care provision.[39] Indigenous support organisations have also set up health projects, such as the nutrition centre run by the Programme d’Intégration et de Développement du Peuple Pygmée au Kivu during the 1990s, which eventually had to close due to lack of funding and damage during the armed conflicts in eastern DRC. Also in eastern DRC, L’Union pour L’Emancipation des Femmes Autochtones provided a counselling and medical aid service for Twa women victims of sexual violence.

Conclusions and recommendations

According to the UN’s Millennium Development Goals (MDG) 2005 Progress Report, sub-Saharan Africa has shown no progress or a deterioration in reaching the MDG 4,5 and 6 targets i.e. a 2/3rd reduction in child mortality, a ¾ reduction in maternal mortality and a halt and reduction in the incidence of HIV-AIDS, malaria and TB infections. Primary health services are grossly inadequate in most of Central Africa, affecting millions of rural and urban Africans. The relative extent to which the MDGs are being realised for Pygmy peoples is very difficult to assess, as reliable and comprehensive data on Pygmy peoples’ health is scarce, government data rarely disaggregated by ethnic group, and research by anthropologists, missionaries and NGOs often localised and based on small sample sizes. The existing information, however, indicates that particularly among landless or sedenterised groups, Pygmy peoples’ health is frequently worse than that of their non-Pygmy neighbours. The remoteness of forest-based communities has limited their exposure to some diseases but also increased the difficulties of health service delivery. The high mortality of Pygmy children from measles and the higher prevalence of endemic diseases such as yaws and leprosy in Pygmy communities are indicators of lack of access to health services.[40]

To ensure that national health policy efforts towards MDGs 4 (Reduce child mortality), 5 (Improve maternal health) and 6 (Combat HIV/AIDS, malaria and other diseases) also reach Pygmy communities, governments and health service providers need to address the issues of remoteness, poverty and discrimination against Pygmies, as well as landlessness, which is a key factor in child mortality as suggested by data from Uganda. The increasing trend towards ‘cost sharing’ in health service provision must be complemented by dispensation schemes for very poor families, and state services should educate their staff to eradicate discriminatory attitudes that deny fair treatment to Pygmy patients.

Pygmy associations and support organisations can help by supporting income-generating activities and saving schemes that enable Pygmy families to pay for health care, or enrol in health insurance schemes. They can also relay information about HIV and malaria prevention and testing facilities, as well as free health services, monitor Pygmy families’ access to such services and support families to claim these rights from local service providers.

Conservation NGOs and missionaries have implemented a range of different models of health provision for Pygmy communities, adapted to local situations. The experience gained from these initiatives indicates that health services for Pygmy people should incorporate both mobile and sedentary strategies, including methods of community-based health provision involving traditional healers who are accountable to communities and have their trust. Trained community members can help deliver primary health care to remote communities. Regular refresher training and support is important for the sustainability of such schemes, as is their endorsement and support by the state health service.

Land is crucial for survival and access to forests is a vital component of Pygmy peoples’ physical, mental and spiritual health and wellbeing. Meeting the health MDGs for Pygmy peoples will require strategies based on secure rights to lands and forests, developed in consultation with Pygmy communities.

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Notes

[1] This paper contains some material from Nyang’ori O, Willis R, Jackson D, Nettleton C, Good K and Mugarura B Indigenous Peoples’ Health in Africa, Lancet 2006; 367: 1937–46, part of a series on indigenous peoples’ health that is freely available on the Lancet’s website.

[2] Barume 2000

[3] The term ‘Pygmy’ is used here as a term adopted by indigenous activists and support organisations to encompass the different groups of central African forest hunter-gatherers and former hunter-gatherers, and to distinguish them from other ethnic groups who may also live in forests, but who are more reliant on farming, and who are economically and politically dominant. An estimated 300,000-500,000 Pygmy peoples (Jackson 2005) live in Cameroon, Central African Republic, Equatorial Guinea, Gabon, Republic of Congo (Congo), Democratic Republic of Congo (DRC), Uganda, Rwanda and Burundi, and comprise several distinct groups including the Gyéli, Baka, Aka, Bongo, Efe, Mbuti, Sua and Twa.

[4] A term conventionally used for settled farming peoples, although these groups include Oubangian and Sudanic language speakers as well as Bantu language speakers.

[5] Jackson 2003

[6] Jackson 2003; Observatoire Congolais des Droits de l’Homme 2004; Tchoumba 2005; Forest Peoples Programme and UOBDU 2005

[7] Hewlett 1991; Pennington 2001

[8] Pennington 2001

[9] Hewlett 1991; Episcopal Medical Missions Foundation n.d

[10] Lewis 1999; Episcopal Medical Missions Foundation n.d

[11] Lewis 1999

[12] Jenike 2001; Hewlett 1991

[13] Dounias 2001 

[14] Lilly 2005; Kabananukye and Wily 1996  

[15] Balenger et al. 2005 

[16] Jackson 2003

[17] Barume 2000; Froment 2001

[18] Betti 2004

[19] Kretsinger 1993; Froment 2001 

[20] Lilly 2005

[21] Jackson 2003; Froment 2001

[22] Lewis 1999; Hewlett 1991; Noireau et al 1989 ; Walker and Hewlett 1990; Louis et al 1994; Kowo et al 1995; Baquillon et al.1992

[23] Froment 2001 ; Lewis 1999 ; Lilly 2005

[24] Salomone 2000; Froment 2001; Meheus and Antal 1992

[25] Jackson 2003

[26] Jackson 2003; CAURWA and Forest Peoples Project 2005; Forest Peoples Programme and UOBDU 2005

[27] Ndumbe et al 1993; Kowo et al 1995; Salomone 2000; Moulia-Pelat et al 1992

[28] Jackson 2003; Hewlett 1991

[29] Jackson 2003; Hewlett 1991

[30] Tchoumba 2005

[31] Jackson 2003; Observatoire Congolais des Droits de l’Homme 2004 

[32] Lewis 1999

[33] Lewis 1999; Kabananukye and Wily 1996

[34] Lewis 1999; Hewlett nd

[35] Lewis 1999

[36] Salomone 2000

[37] Jackson 2003; Balenger et al 2005

[38] CAURWA and FPP 2005

[39] Jackson 2005; Lewis 1999; Kretsinger 1993; Wilkie and Morelli 2005

[40] Meheus and Antal 1992.