The most common form of hepatitis in Ethiopia is hepatitis A. The antibody to hepatitis A was found in 84% of people studied in Ethiopia. In Israel, where there is a large Ethiopian refugee community, immunity to hepatitis A was nearly 100%.
In the United States, hepatitis B is the disease of concern to medical providers. A serologic survey (1988) revealed a hepatitis B surface antigen carrier rate of 6.2% and a prevalence of overall hepatitis B virusmarkers of 76% in those over 14 years of age. The rate of chronic carriers in the general population may be as high as 11-12%, and even 32% in pregnant women. In Israel, a study showed that the 98% of refugees from Ethiopia had serologic evidence of hepatitis B.
Hepatitis C prevalence is 1.5% in the general population in Ethiopia.
Hepatitis is often associated with a fulminant course and high maternal and fetal mortality, particularly in the third trimester, among pregnant women in Ethiopia.
Tigreans primarily understand hepatitis through its symptoms. The symptoms of yellow or green skin, along with yellow eyes and dark urine is associated with the disease. There is understanding that nausea and vomiting may also be present. The liver is not recognized as the affected organ. For most cases of hepatitis, in two to three weeks, people improve with treatment. But hepatitis can be such that some individuals may become extremely ill and not improve, and some may even die as a result of the disease.
For Tigreans, it is very difficult to understand hepatitis within the frame of asymptomatic disease or a carrier state. Another area of difficulty is the association of hepatitis B and liver cancer.
Translation or Language Equivalents
The traditional word for hepatitis iff shwa literally means bird disease in Tigrinya.
The disease name is related to the traditionalbelief in etiology of the disease as caused by a night bird, or more specifically, a bat. Some people believe, particularly in the more rural areas, that the illness can be transmitted either by the bat’s urine falling on a person outside at night, or early in the morning. Some believe that it can happen if a bat circles above the person three times. There are also many other diseases associated with having contact with bat urine. In Israel, where 32 people were carefully interviewed on cultural beliefs of diseases, many related the cause to a bat, but one person said the cause was heat, another that it was due to malnutrition, while a third person attributed the cause to be seasonal changes.
At Harborview Medical Center, the Interpreter Case Managers use an entirely different word when talking about hepatitis with patients. To alleviate the confusion related to bird disease and all the traditional beliefs, the term kabidy in Tigrinya, which literally means “liver disease”, is used.
Cultural Knowledge and Traditional Treatment
Hepatitis is recognized by its symptoms of jaundice, icteric sclera and changes in urine color. Many people do not believe it is communicable. Since they believe the disease is related to bats, there is no known prevention. However, they have many different medications used by various traditional healers that are believed to cure the disease. One frustration with western medicine is that the people are told there is no treatment, and no effort is made to treat this disease.
The exact medicines used to treat the disease are unknown except to the healers, who probably pass the medicine through generations in the family There are some that believe that the medicine contains bat meat. In one study, some people reported having seen the disease expel itself in the form of bat-shaped feces, and one saw a patient take a steam bath with rat feces. In another study, informants thought that jaundice could be eliminated by verbal means. This source stated that a person is tricked into eating bat flesh. When told what he has eaten he is expected to spontaneously shout the word for jaundice and by doing this, the illness is expelled from the body.
One known treatment is drinking a fermented alcoholic drink. Other treatments include not eating fat, and instead drinking honey, or fermented juice from honey. Rest is also thought to help. It is thought that most people improve with treatment.
In Ethiopia, even when western medicine is available, many Tigreans prefer to go to their traditional healers since western medicine does not treat hepatitis. In the United States, traditional medicine is unavailable due to the lack of the specific roots and herbs that are in the medicines and the lack of traditional healers. If the people do get hepatitis, they will seek medical attention at the local hospital.
In the Refugee Clinic (now called the International Medicine Clinic) at Harborview Medical Center, a brochure is used to aid in explaining the disease. The concept of being a carrier, and the preventive measures to be taken, are difficult and confusing. Transmission of the disease needs to be carefully explained.
References and Further Reading
- Hodes, Richard and Befedaku Teferedegne, Traditional Beliefs and Disease Practices of Ethiopia Jews, Israel Journal of Medical Science, 1996;32:561-567.
- Hodes, Richard M. Cross-cultural Medicine and Diverse Health Beliefs- Ethiopians Abroad, Western Journal of Medicine, 1997; 166:29-36.