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Drink Boiled Cooled Water: A

Cultural Analysis of a Health


Education Message
Mark Nichter

Lack of sensitivity to the health concerns of lay persons, and the


introduction of educational messages that fail to take their health
culture into consideration result in misinterpretation, the
compartmentalization of information, and desensitization to
priority issues. The international health literature is riddled with
this sermon. Rather than engage in polemic, I will present a brief
case study which illustrates why it is important to monitor how
public health messages delivered by primary health care workers
are interpreted by the populations they serve. The example is
taken from Sri Lanka and concerns what might appear to be the
most basic of health messages, drink boiled cooled drinking
water.
Four decades ago Wellin (1955) presented an insightful
ethnographic account of water boiling education in Peru to
demonstrate how this behavior was influenced by culture:1
A trained health worker can perceive contamination in water
because his perceptions are linked to certain scientific
understandings which permit him to view water in a specially
conditioned way. A Los Molinos resident also views water in a
specially conditioned way. Between him and the water he
observes, his culture filters in cold, hot or other qualities
that are as meaningful to him as they are meaningless to the
outsider. (Wellin 1955:100)
The present case complements that presented by Wellin. In
contrast to Peru, a large majority of the Sri Lankan population is
literate (male 90%, female 82%) and have easy access to health
facilities (the average person is within three miles of a health
center). Over the past two decades, the country has experienced a
notable decrease in infant mortality, which is presently 37 per 1,
000 births. Diarrheal diseases continue to be a leading cause of
morbidity and mortality, accounting for 53% of all infectious

400 ANTHROPOLOGY AND INTERNATIONAL HEALTH

disease deaths in 1979. In the same year, these diseases


constituted the third leading cause of death for the population at
large, yielding 44.9 deaths per 100,000.2 One study (Pollack 1983)
indicated that deaths from water-borne diseases has steadily
increased by 49% in the five years between 197176. Reviewing
existing morbidity/mortality data, Pollack observed:3
The trend of decreasing disease specific mortality in hospitals
without parallel decreases in morbidity, suggests that, for
specific diagnosis (e.g., gastroenteritis, typhoid fever, and
malnutrition), there is an awareness of the availability of
curative intervention, but the preventive intervention
components have not been emphasized or have been
unsuccessful. (Pollack 1983:93)
To learn why preventive intervention has been unsuccessful for
water-related diarrheal diseases, forms of behavior identified as
main elements in the spread of these diseases were studied:
defecation habits, food handling, and water consumption behavior.
This chapter is confined to a cultural consideration of the last
variable. Public health inspectors and family health workers in Sri
Lanka have been encouraging the public to drink boiled cooled
water for well over three decades. Despite their efforts, field
workers readily admit that the message is largely unheeded.4 One
popular public health inspector with whom I spent considerable
time in the field estimated that less than 10% of the rural families
he visited regularly prepared and used boiled cooled drinking
water. Why should the largely literate Sri Lankan public pay little
credence to health messages conveyed by health workers who
enjoy some degree of social status in the community?5 Let us
consider two of the more obvious possibilities: fuel scarcity and a
lack of time to prepare boiled water. In some areas of Sri Lanka
these are undoubtedly important variables affecting water
drinking behavior. This was not the case, however, among those
informants selected for study in the Horana-Ratnapura region of
southwest Sri Lanka. Firewood was available, and if anything, was
unnecessarily expended in poorly constructed hearths typically
composed of three bricks over which a cooking pot would be
placed.
Is the underlying issue one of the local culture not paying much
credence to the qualities of water? This certainly is not the case in
Sri Lanka. Indeed, one of the few material possessions a Sinhalese
Buddhist monk is prescribed to carry is a water filter. Among the
lay population, the taste, smell, and inherent qualities of water are

DRINK BOILED COOLED WATER 401

important health concerns. Villagers are keen to see the source of


their drinking water. This is one reason that closed wells are not
popular. Another reason for their unpopularity is that a limited
amount of sunlight is believed to be necessary for keeping water
fresh. Having to drink water from an unknown source is
considered a hardship. In fact, one way a villager expresses to a
friend the hardship of having to remain in Colombo city for a
period of time is to exclaim ayyo! pipe watura [pipe water]you
have to drink and bathe in it!
While commuting daily to Colombo from a rural village about
one and a half hours away, I observed many passengers on the bus
jostling water bottles as well as lunch packets amidst a terrific
crowd. Bringing lunch packets from home was easily understood
in relation to microeconomics, but water? When questioned, my
commuter friends explained that quite frankly they did not trust
Colombo pipe water. They spoke of pipe water as marana watura
dead wateror kivul waturawater tasting of iron and
associated with urinary problems. They disliked the medicinal
smell of chlorinated water, and felt that boiled cooled water was
tasteless.6 But was it just the tastelessness of boiled water which
they did not like or were there other reasons for preferring to
transport small bottles of their own unboiled well water an hour
and a half by crowded bus? Why should they ignore the advice of
public health workers?
Before considering why people do not do something, it is often
more prudent to consider what it is that they do and why. It is,
however, difficult to respond to why questions out of context. To
ground such questions in context, it is advantageous to engage
informants in discussion about practices they easily recognize. In
the present case, individual interviews and focus group
discussions were initiated around the observation that boiled
cooled water was routinely prepared for the ill, but not generally
consumed by others. These discussions led me to question a
common explanation for lay behavior offered to me by public
health colleagues. They reasoned that because the message drink
boiled cooled water was originally introduced and most
adamantly repeated during epidemics of cholera, typhoid, and
gastroenteritis, people had come to associate the practice of
boiling water with illness.7
Three health-related reasons for heating or boiling were
identified during interviews and group discussions. The first
requires an appreciation of indigenous water management. The
qualities of water from different sources vary and affect the
purposes for which it is used. When water is plentiful, villagers

402 ANTHROPOLOGY AND INTERNATIONAL HEALTH

choose to use different water sources for drinking and bathing in


accord with the waters clarity, depth, and exposure to the sun.
When water is scarce, an available source is used for many
purposes, but efforts are differentially expended to transform the
qualities of water used for drinking purposes. For those who are
strong and healthy, little concern is expressed about water
routinely used except when its color, smell, or taste changes. For
those who are ill or in a transitional body state (such as infants
and pregnant women), more subtle qualities of water are
considered. For example, water from a deep well is believed to
have a cooling quality which is harmful for those suffering from or
vulnerable to illnesses linked with coolness (body stiffness and
pain) or an excess of phlegm (Nichter 1987). On the other hand,
water directly exposed (overexposed) to the sun is deemed to be
sun baked (Karunadasa 1984) and inappropriate for those
suffering from or prone to heating illnesses. When these water
sources are the only ones available, healthy persons will use them
without much restraint. When the same sources are the only ones
available to the ill or vulnerable, however, drinking water will be
boiled in an attempt to mitigate its excessive properties. For
bathing purposes, traditional prescriptions specifying appropriate
times for bathing will be more rigorously followed (Nichter 1987).
A second reason water will be heated is to reduce its shock
effect on those at risk to illness. Shock is an important concept in
South Asian health cultures related to vulnerability to illness as
well as spirit attack. Shock may be a primary cause of illness or it
may compound an existing illness. The body-mind is a continuum
in which extreme emotional distress like fear, and extreme
physical distress like heat or cold may cause or exacerbate illness.
Shock occurs when a person is subjected to an excess of hot or
cold, particularly when in a vulnerable state. Out of concern for
shocking the body, those predisposed to phlegm problems will not
consume cold liquids on hot days. Similarly, the ill will only
consume and wash with water which is tepid. The health message
drink boiled cooled water, is interpreted by some villagers in
relation to the concept of shock as it pertains to vulnerability as
well as illness.8
Because many villagers do not associate boiling water with
killing bacteria, they place more emphasis on administering tepid,
rather than fully boiled water to the ill. It is not uncommon for
villagers to boil water for the ill or vulnerable, and then add cool
unboiled water to it so as to attain a tepid temperature, thereby
recontaminating the water.9 A point not to be lost sight of
however, is that the preparation of tepid water through boiling is

DRINK BOILED COOLED WATER 403

an act of caring accorded positive value. This introduces some


irony into the context of hospital care. Although the instruction to
drink boiled cooled water is propagated by health workers, tepid
water is not available in government hospitals where patients and
their families feel they need it. This fact is cited by lay people as
an example of the poor care they receive at public health
institutions, as distinct from the poor quality of medicines or
doctors.
A third association with boiled water involves the Sinhala
concept of lightness (sehellu). When ill, a central health concern
within Sinhalese popular culture and the learned system of
yurvedic medicine is digestion. Dietary regulations vary in accord
with the ascribed characteristics of different illnesses. Regardless
of the specific characteristics of an illness, however, a general
restriction will prevail against the consumption of heavy (bhara)
foods. Becoming well requires a light diet that will restore normal
digestion as a part of the healing process.10 Indeed, this is
fundamental to balancing bodily humors, and the restrictions
against heavy foods includes a conception of heavy water.
Well water is considered heavy unless it is boiled. Boiling causes
water to lose some quality (guna) or residue, which then renders it
light. The heaviness of unboiled water is considered good for
health when one is in a normal state. Clear, unboiled well water
(hondai watura) is said to satisfy thirst better than light boiled
water. Furthermore, unboiled well water is considered fresh,
full of life, and having strength in contrast to pipe water, which
is dead, and boiled water, which lacks strength. In one
informants words:
The guna of water is like the guna of green leafy vegetables.
When you eat them fresh, they have life. If you pluck them,
transport them and keep them for sale, they lose their life
and wilt. When you cook vegetables, they loose their
freshness rapidly. It is like that with water. When water is
running or in a well exposed to the sunlight, it is fresh. If you
collect it and transport it through pipes it is marana watura,
dead water, and if you boil it, water looses its guna, its
strength.
The drinking of boiled cooled water is associated with illness
except in the eveningwhen it may be associated with health
promotion. Since heavy food and heavy water are relatively
difficult to digest, some people regularly drink light tepid water
in the evening. Their reasoning reflects a general concern that

404 ANTHROPOLOGY AND INTERNATIONAL HEALTH

digestion is weakest during inactivity and sleep. The message


drink boiled cooled water, is interpreted by some villagers in
conjunction with the concept of sehellu and deemed most relevant
for those having weak digestive capacity.11 This interpretation, like
that involving shock, is supported by the advice of yurvedic
practitioners to the ill, pregnant women, and mothers of infants.
CONCLUSION
The development of effective health education messages requires
formative research which incorporates an ethnographic
perspective. In the present case, multiple reasons underlie local
interpretations of the drink boiled cooled water message.
The message is emphasized at times of epidemics and
associated with yurvedic advise to take a light diet and tepid
water when ill, weak, or vulnerable to illness. Underscoring lay
interpretations of these messages are folk health concepts,
specifically, ideas about the qualities of water, shock, and
digestive capacity. In order for a health message as simple as
drink boiled water to be communicated effectively, careful
observation of habitual behavior and an analysis of popular health
concerns is essential. Like water, understanding seeks its own
level.
NOTES
1. Wellins study compared the motives and circumstances of women
who boiled water with those who did not. His research illustrates
that a combination of culture, ecology, economics, and social status
influenced water boiling behavior. Out of a sample of 200
households subjected to a two year period of face-to-face education
on the part of a hygiene worker, the number of acceptors rose from
15 at baseline to 26 at the time of evaluation.
2. Statistics on diarrheal diseases were gleaned from the following
sources: Pollack (1983) and Gaminiratne (1984:59). It should be
noted that district-wise, standardized death rates due to diarrheal
diseases differ significantly. These range from 10.1 in Trincomallee
and 16.5 in Matara to 127.3 in Batticaloa and 90.8 in Amparai.
Percentage deaths due to these diseases range from 1.5% in
Kalutara District and 2.9% in Matara to 15.1% in Amparai and 12.
6% in Batticaloa. To correct any misconception that urban
conditions contrast markedly with rural conditions, it may be noted
that the Colombo infant mortality rate due to diarrheal diseases is
158% the national averagealthough for all age groups it is
considerably lower than the national average. Among children one

DRINK BOILED COOLED WATER 405

3.

4.

5.

6.

7.

8.

9.

to four years old, 16% of deaths are directly related to diarrheal


diseases. During the period 197179, of the 10 leading causes of
infant mortality, only diarrheal diseases showed no downward trend
after 1975.
This study conducted by the Sri Lankan Department of Health
Services was quoted in the Marga Institute report (Sri Lankan
Department of Health Services 1982:93). The report also notes that
in the Mahaveli Development region, diarrheal disease accounts for
some 40% of all persons seeking medical treatment and that these
cases of diarrheal disease are largely related to contaminated water
sources.
For more recent data which documents the lack of water boiling
among the Sinhalese population, see Caldwell et al. (1989:369) who
report that only one-fifth of families in their study sample did so.
Also noted is the association of drinking boiled water with illness.
Public health inspectors and family health workers enjoy social
status in Sri Lanka equivalent to that of a secondary school teacher.
As Wellin reported of Peru, advice by health workers to alter healthrelated behavior carries significantly less weight than the same
advice offered by a doctor. This weight was more evident in respect
to immunization and family planningtechnical fixesthan in
respect to water boiling as a long-term enterprise related to
preventive health. On this point I must note that in India boiled
cooled water is not regularly used even by the educated. In a
personal communication, Charles Leslie noted to me that drinking
boiled cooled water is uncommon among New Delhi academics. He
was told by a Professor of Social Medicine at Benares Hindu
University that the highest rate of typhoid in Varanasi in the early
1970s was among faculty and students living in university housing.
I do not wish to underplay tastelessness as a factor negatively
influencing water boiling behavior anymore than time or the cheap
availability of fuel. My purpose is rather to identify other cultural
factors impacting on water boiling behavior.
Routine water supply testing is not performed by Public Health
Inspectors and attempts at well purification are only done during
epidemics.
A subtle but important distinction needs to be drawn between
primary and secondary illness prevention related to the concept of
vulnerability. Primary prevention denotes the prevention of factors
which may either cause illness or open one up to the effect of such
factors. Secondary prevention entails preventing an illness or state
of vulnerability from becoming exacerbated.
An opposite case scenario was encountered in Honduras during a
cholera epidemic in 1994. A health communication message
instructed the population to drink boiled water. Doctors reported
that some citizens drank boiling water thinking this was essential to
purify the body. While some scalded their mouths, others only
sipped small quantities due to this misperception.

406 ANTHROPOLOGY AND INTERNATIONAL HEALTH

10. Generalizing the sehellu rationale might prove helpful in getting


mothers to administer boiled water to children under three. The
concept might also be useful in marketing a weaning food less likely
to be shared in the family than the present weaning food Triposha to
which people ascribe both a strength giving and neutral quality
suitable for general consumption. For a short discussion of the
CARE weaning food, Triposha, see Nichter 1987. A new
supplementary weaning food might be marketed as sehellujust
what a child needs for its developing or weak digestive system. I am
suggesting this idea as an example of how cultural concepts might
be used as health resources in social marketing. I do not claim that
this particular idea would prove effective, but suggest that it would
be worth looking into.
11. Perceptions of vulnerability offset judgements about risk. Some
informants who described themselves as having a strong
constitution did not deem it necessary to drink boiled water,
although they thought this practice was useful for those more prone
to illness.

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of Morbidity and Mortality Data. USAID, Sri Lanka, June 1983.
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Report on Intersectoral Actions for Health, p. 93. Colombo, Sri Lanka,
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Foundation.