READER pp 415-422. Ethnomedicine and Oral Rehydration Therapy . . .
This article illustrates the practical application of ethnomedical beliefs. No matter how effective a biomedical remedy may be, if local beliefs contraindicate its use-it won't get used! These remarks are intended as a supplement to TEXT.
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I. DIARRHEAL DISEASE
We think of diarrhea as an inconvenience to travelers or something we experience occasionally in our daily lives. Worlds wide, especially in the developing countries without safe drinking water, diarrhea is a serious problem. According to the World Health Organization, diarrheal diseases are a major health threat in the non-industrialized world. They are usually associated with poverty and its correlates: malnutrition, poor sanitation, contaminated drinking water. Five to seven million people die of it each year. Many are children. Long term solutions are economic and political-changes that lies far in the future.
Safe drinking water is taken for granted in this country. I recall vividly treating my own water for dental office use in Viet Nam. I used filter paper borrowed from an Army laboratory to clarify it and swimming pool treatment powder to chlorinate it.
II. AN IMMEDIATE TREATMENT: ORAL REHYDRATION THERAPY (ORT)
In this country, we treat dehydration intravenously with water and electrolyte replacement with administration of an intravenous solution. The results are dramatic and life saving. This option often is not available in the Third World. A low-cost alternative is ORT; it has received support of the World Health Organization. ORT is a salt/sugar solution taken orally, not by intravenous drip.
ORT is a recent innovation. The key to its success is that it is a combination of both salt and sugar. Here is a homemade recipe from Werner:
It is taken in small sips every five minutes day and night until the person begins to urinate normally
Commercial versions of it appear here as Pedialyte, Lytren, and Infalyte. The solution contains potassium, sodium, and glucose in physiologic concentrations. It is taken by mouth.
A dry concentrate prepared in inexpensive packets for mixture with water on site has the potential to save many lives. ORT is a safe and inexpensive way to prevent and treat the life-threatening dehydration associated with diarrhea in infants and children. Yet, in many parts of the world, mothers are reluctant to use ORT even when made available at no cost.
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IV. EXPERIENCE IN PAKISTAN
In rural Pakistan ORT has been promoted by the Ministry of Health since 1983. Packets of ORT were made available free of charge through government health centers. (More than 18 million ORT packets are produced annually by Pakistan's own pharmaceutical industry.) Field researchers found that many of the mothers were ignorant of whom the solution should be used and were often reluctant to use it. They perceived diarrhea in a very different way than that of Western science.
Some mothers said that diarrhea was very common in their area; therefore, it was normal and 'natural.' They said that was a part of teething and growing up, not an illness. Their folk model of perceiving disease was very different from that of Western science. This was only the beginning of the acceptance problem in rural Pakistan.
It was said that it was dangerous to try to stop the diarrhea, or else the 'trapped heat' within the child would spread to the brain and cause a fever. Others saw it as due to certain folk illnesses such as the 'evil eye,' malevolent sprits, or a 'fallen fontanelle' which would cause difficulty in infant sucking. Traditional remedies were preferred.
Mothers did not connect the 'fallen fontanelle' with severe dehydration. (My note: they saw a sunken fontanelle as the disease, not as a symptom of dehydration.) Some tried to 'raise' the fontanelle by applying sticky substances to the top of the infant's head or by pushing up on the hard palate with a finger.
Diarrhea was frequently understood in the 'hot/cold' model. Diarrhea was a 'hot' illness which required a 'cold' treatment--such as a change in maternal diet or giving certain foods and herbs to the infant in order to restore the sick infant to a 'normal temperature.'
Most Western medicines--such as antibiotics and vitamins are believed to be 'hot' and therefore inappropriate for a diarrheal child. A few even rejected the ORT packets (which contain salt) because they thought that salt was 'bad for diarrhea.'
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V. READING THIS ARTICLE
The site of the study is in Honduras. Do read pp 415-418 to see the community and its health care system in perspective.
This study is significant because it sought to understand the local perception of diarrhea before attempting to distribute ORT. Packets of ORT issued in Honduras were called Litrosol ("solutions in a liter").
Read pp 418-419 carefully. Pay attention to the indigenous beliefs about diarrhea cause:
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This is a great article for this course. SHOULD fieldworks tell a falsehood (ORT is a purgative good for treating empacho OR try to reeducate the folks?
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Pay attention to the degree of penetration of ORT in the community. How universal was it? Any suggestions?
..... CJ '99
Resource
Hellman, C. Culture, Health, and Illness 3rd ed. London: Butterworth Heinman, 1994.
Nickter & Nickter Anthropology and International Health. Canada: Gordon Breech, 1996.
Werner, D. Where There Is No Doctor Berkely: The Hesperian Foundation, 1998.
Wills, C. Yellow Fever, Black Goddess Reading: Helix Books, 1996.
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READER pp 389-400
The Biocultural Approach in Nutritional Anthropology: Case Studies of Malnutrition in Mali.
-This article is a bridge between this week and issues of malnutrition that are in the next chapter in TEXT.
-The author Katherine Dettwyler is an excellent writer and has done extensive fieldwork in medical anthropology. A portion of her Dancing Skeletons has been used in Annual Editions Anthropology.
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-We expect children to be valued and for siblings to be treated well and equally.
-Here you will meet children who are malnourished, but the author goes beyond inadequate diet and goes on to examine growth failure due to cultural factors.
-The term socio-cultural malnutrition is used to describe the social deficit. It again illustrates the interrelationship of health, disease, and culture.
-There is an extensive literature on growth and development. The best single resource is the Cambridge Encyclopedia of Growth and Development which was published in 1998. The studies in the West began with the social reform movement in Europe and America in the last century. Social reform and social justice are implicit everywhere in it.
-On page 390, note how in some cultures, mothers "give up" on severely malnourished children and let them die. Among the Masai, infants who cry a lot get more attention than. placid babies.
-The women in the Mali culture described live in a system of patrilocality (live with the husband's family) and patrilineal descent. Resources for the children are not always generously provided by the father of the children.
-This article touches on another major topic that we cover later on, namely the health of women. In many cultures in the world, girls are less well fed than boys, grow up smaller than their biological potential, are sold off as wives early in their teenage years to become pregnant-and often dies when they are unable to successfully deliver children through their small, immature pelvis.
-I urge you to read the case studies to see life in the Third World.
TEXT pp 179-200
-This is the second half of the chapter we began last week, The Ecology and Economics of Nutrition.
-The first section, Subsistence by Hunting and Gathering found the contemporary hunting/gathering diet of the Ju/'hoansi to be varied with choices designed to maximize energy efficiency. These folks seemed to be fit and well nourished. They used the monogongo nut year around which are rich in protein, fats, and is high energy food like peanuts. Lee found that gathering is more efficient from energy input/calories obtained perspective than is hunting. Nowadays, fewer and fewer people live by foraging alone.
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I. SUBSISTENCE BY FARMING p 179
A. Tropical Farmers p 179
-Tropical farmers use domesticated plants, but they don't farm the same plot of land over and over the way we do. We fertilize and have good soils that tolerate 'short fallow' intensive agriculture year after year.
-In tropical areas, the soil is poor and the bulk of the biomass is in the uppermost couple of inches or in the forest litter above ground. Folks here hack down the forest, work the biomass into the thin topsoil, grow their crops for a couple of years, and then move on. The technique is variously called swidden, slash and burn, or 'long fallow.'
-Tropical cultigens tend to be high in starchy bulk but are protein-poor.
-These crops:
-Many tropical farmers grow pigs. They convert scraps into protein and fat.
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-This is a mini-unit on pigs based on the book A Perfect Harmony. There are lots of pigs on earth-500 million today. If you think that is a lot, there are four billion goats! 'A pig factory' is a new form of agribusiness. It is a vigorous debate in state legislatures today. They are excellent domestic meat animals. Even in Israel, pork is sometimes called 'white beef.' Islam also forbids the consumption of pork. Bacon in these cultures is sold as 'zebra.'
-Pigs eat anything, grow fast (2 ½ lbs./day, grow big, and have large litters. For many indigenous cultures they are wealth and food storage on the hoof. They don't provide milk products, however.
-Their conversion of junk food into meat and lard is unsurpassed. Their efficiency is about 35% of intake, far ahead of 13% for sheep and 6% for cattle. Pigs get a bad rap in the Bible and our daily language as people refer to a glutton or policeman. Pigs in mating pairs were often left on islands by explorers to serve later for sport and food. No domestic mammal is routinely treated with as much cruelty as is the pig.
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B. Pastoralists p 182
-Pastoralists keep domesticated animals and use their products such as milk, blood, dung, and meat. All but meat are renewable resources.
-Be sure to read pp 182-183; I am supplementing the reading with additional mini units.
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-This is a mini unit on domestication of dogs (not in text) Early hunters had the dog. Recent reports (1997) suggest that our relationship with them goes back far longer than the 10,000 years cited for other domestications. (See Science '97 and A Perfect Harmony.
-MtDNA studies suggest origins as early as 100,000 years ago and that it happened at least twice. Modern dogs come in a stunning variety of sizes, shapes, and colors. Domestication from wolves seems a certainty.
-Dogs, like many domesticated animals display 'neotony' which is the adult retention of juvenile characteristics. Most dogs are 'grown-up cubs.'
-The MtDNA of dogs shows them to be closest to wolves (all 67 varieties of them can interbreed). They are less related to coyotes and jackals. Dogs worldwide represent a genetic diversity and a well-mixed gene pool. Only one other mammal exhibits worldwide diversity and a well-mixed gene pool-us.
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-What if animals had not been domesticated? See A Perfect Harmony p 25. Latitudes north of 66 would not have been inhabited. Much of the flowering of Neolithic culture would have never been possible. Without camels, oxen, horses, and donkeys-there would not be caravans or the plow used in heavy European soils or in the New World. They have provided are a reliable source of nutrition, transport, clothing, conquest, and companionship.
-In the Old World, large herbivores transformed society and brought disease, too.
-In the New World, there were few animals to domesticate and this placed constraints on cultural development.
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-The Turkana in Kenya get about 62% of their dietary intake from milk. Blood and meat bring it up to 80% from animal products. Energy intake is low, but protein is very adequate. The Turkana herders are tall, have little body fat, and their growth continues into their twenties.
-Larger herbivores can eat plants or wastes that we can't digest or wouldn't eat. Herding permits exploitation of environments too dry for farming. In this country, agricultural abundance permits use of corn to feed cattle-a wasteful practice
-In Africa, Bantu farmers have squeezed the !Kung out of much of Africa and onto the Kalahari desert. -The Bible reflects the ancient conflict between farmers and herders in the story of Cain and Abel. In Kenya, cattle, camels, goats, sheep and donkeys forage for different plants thus exploiting the environment more fully.
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-Lactose intolerance (a.k.a. lactase insufficiency) is an old warhorse in anthropology. These remarks are from Overfield.
-The vast majority of persons (some 80%-90%) of persons in every ethnic population EXCEPT Europeans are lactose intolerant as adults. Figures for lactose intolerance:
Lactose intolerance means gastrointestinal problems that are dose-dependent. The more ingest, the more sever are the problems. Yet, many can drink eight ounces of milk with meals and have no problems. Symptoms of intolerance are bloating, flatulence, and cramps. What happens is that the lactose is not metabolized. -Genetically, lactose intolerance is polygenic, highly penetrant, autosomal dominant.
-In most people, the gene for lactase is 'switched off' at age four years (in mammals generally, lactase production ends at weaning).
-Many years ago, powdered milk was shipped to Africa and Asia as food aid. The folks used it for whitewash!
-People who can consume milk products as adults probably come from folks with a heritage in dairying.
-Indigenous folks who are lactose intolerant get around the problem by using products acted upon by bacteria such as cheese and yogurt. Another oddity of lactose is that it acts like vitamin D and helps calcium absorption. In the Old World, lactose tolerance is greater at the higher latitudes.
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C. Peasant Farmers pp 183 (See Overfield p 146)
-Most of the food energy and protein for the majority of people on Early come from cereal crops such as wheat, rice, and corn.
-We are used to machines run by petroleum and yields enriched by fertilizers; however, much of the world's farmers grow food by hand much as it was done thousands of years ago.
-In Southeast Asia, rice cultivation is very labor intensive with hillsides terraced to increase the acreage of land available for farming.
-Many folks depend on a single crop. Such foods are called superfoods not because they are so great, but because of the overwhelming dependence upon them. -Your mom had it right. Lack of dietary variability can lead to nutritional deficiency diseases. This is especially so in poor countries.
-(from Overfield) The world's cuisines can be distinguished by their dietary staple. As a rule, cuisines in developed nations depend less on dietary staples; however, the poorer a family in a society, the more it is tied to the dietary staple.
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CORN
-When it is a single staple, the resulting nutritional diseases are pellegra or protein deficiency. Pellegra afflicted sharecroppers in the United States. The disease is due to a lack of niacin. The bound niacin in corn is not released unless it has been treated with alkali (derived from ashes). People who used the alkali to soften the husk of the corn also had improved nutrition-an unintended benefit. Pellegra did not occur in Central or South America because soaking the corn in alkali (ashes) also released the niacin and protein.
-Complementing corn with beans also overcomes the niacin deficiency/protein problem. Corn and beans together in the diet complement each other. A supplement of fruits and vegetables further improves nutrition.
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RICE
-Rice-based diets may be low in protein, fats and water soluble vitamins. The addition of soybean products, fish, fish sauce, and vegetables over rice can make up for it.
-Milled (white) rice can cause Beriberi, a thiamine deficiency disease. Fish in the diet helps to avoid it. Beriberi arises primarily in people who subsist on polished rice. Boiling before husking disperses the vitamin through the grain. Beriberi causes fatigue, irritability, poor memory, and sleep disturbances. The making of white rice removes the water soluble vitamins. Par boiling or steaming before milling keeps more vitamins, but most Asians don't like parboiled rice.
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WHEAT
-Wheat-based diets may be low in protein, vitamins, and mineral but are rarely low in carbohydrates. Wheat is not as strongly associated with deficiency disease as the others. Very poor people show mineral deficiency because of the coarse bread which interferes with mineral absorption.
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D. A Hungry World pp 186-188
-The practice of absentee land ownership and crops sold for cash can result in malnutrition to those who do the farming. If the farmers can have private plots, they can supplement their diets with foods from that land.
-Dietary change in the Solomon Islands resulted in women maturing earlier and being heavier as adults. (My note: we will examine the trend in developed countries for persons to mature earlier and grow taller. This is called the secular or generational growth trend).
-Economics can distort food access in strange ways. During the infamous Great Potato Famine in Ireland, the country continued to export food!
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II. FAMINE IN ETHIOPIA Profile pp 188-192
-You can read this on your own
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III. NUTRITION IN INDUSTRIALIZED SOCIETIES p 193.
-In the industrialized countries, there has been an epidemiological transition in the causes of mortality.
-(My note: The following section is not in TEXT.) An article in a Chicago Tribune article (9/16/96) reported that infectious diseases are steadily receding. The coming epidemic is in noncommunicable diseases. By 2002, it is estimated that depression will become the 2nd health threat because of a 'graying' population. Accidents, especially on roads will increase as more young people in developing countries 'hit the road.' In 1995, noninfectious disease caused half of the deaths. By 2020, seven of ten deaths will be due to noninfectious disease. The life expectancy of women in 2020 is estimated to approach 88 years of age.
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-Inactivity and diet seem to be involved. This is especially true as we encounter 'calorie dense' fast foods and the newest sales effort to 'super size it!'
-Protein in the United States tends to come from corn fed beef which is high in animal fat.
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IV. ALL THAT GOES IN THE MOUTH IS NOT FOOD p 198.
-We have covered the issues of pica which is the consumption of inappropriate non foods (such as lead based paint chips) and geophagy, the deliberate eating of dirt.
-Some other unusual ones come to mind. Ancient Nubians consumed naturally occurring tetracycline antibiotics in their beer; the evidence is in their bones where the tetracycline staining shows up under ultraviolet light. In a future TEXT section, we'll meet coca leaf chewing by highland Peruvians. Early in this decade, women who painted luminescent dials on clocks ingested radium when they licked their paint brushes. Their grave remains are still radioactive.
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V. ANTHROPOLOGY OF FOOD HABITS pp 195-198.
-This section you can read; my remaining remarks here focus on a dentist, Weston Price. I've been in dentistry since 1960, but hadn't learned about him until I read this book in 1994. It was a revelation.
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A. Weston Price, an Unrecognized Pioneer
During the 1930s, Weston Price traveled the world to document the nutrition and physical degeneration of people who had adopted a contemporary diet of commercially prepared soft foods. His work is ignored today, dismissed for its association with alternative medicine and the lack of academic rigor now demanded in scientific literature. His evidence is largely observational. Yet, when read carefully, Price reveals himself as perceptive, thoughtful, and penetrating. His 1939 book was reprinted in 1989 by the Pottinger Price Foundation. A group devoted to 'nutrition' issues. His scientific questions were these:
Price attributed both to dietary change and to changes in chewing habits.
He vividly documented dental degradation in societies across the globe, past and present. It is an unparalleled piece of field work. He attributed the increase in dental problems to modern diets.
(My note: malocclusion may be described as 'an unsatisfactory arrangement of the teeth.' The term 'caries' describes tooth decay. In very recent years, the rate of tooth decay in this country has declined markedly.)
Price attributed the tooth decay and malocclusion to a lack of trace elements-a popular idea in his time. This notion is no longer accepted by mainstream science. The increase in caries is attributed to carbohydrates, particularly sticky ones.
Besides trace elements (not accepted now), the cause of malocclusion was also attributed to disuse. This theory says that a lack of function in childhood results in reduced jaw growth. This is called the 'disuse theory' which was popular with many pioneers in orthodontics early in this century.
The 'disuse theory' is good science because it can be tested. Corrucinni at Southern Illinois University has resurrected the disuse theory and has accumulated much corroborating evidence. He is ignored about as much as Price. That is a shame.
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B. The Disuse Theory
Malocclusion arises from the lack of chewing stress in modern processed diets. Is this good science? You bet it is! The theory has been tested in several ingenious ways.
1. An impoverished Kentucky community that subsisted largely on farming and hunting was observed many years ago. The same community was again studied 25 years later after factory jobs with cash wages let to consumption of processed soft food purchased in supermarkets. The rate of malocclusion in children increased.
2. In India, children of higher economic status had more malocclusion than their rural counterparts on an impoverished diet that required heavy chewing. The impoverished group had more ideal occlusions with wider dental arches.
3. In the laboratory, rats were fed either pelleted rat chow as a hard diet, or water-soaked rat chow to provide a soft diet. The animals on the soft diet had smaller mandibles, less bone density radiographically, and smaller muscles of mastication.
4. Rhesus monkeys and baboons fed a soft diet in adolescence developed malocclusion.
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Corrucinni has confirmed and extended the findings of Price with human and animal studies. What do we do with this evidence? Should growing children eat beef jerky instead of Twinkies? My experience with freshman dental students and graduate orthodontic students is that they are indifferent to the disuse theory. It has largely disappeared in recent textbooks on clinical orthodontics. It deserves more attention.
..... CJ'99
Resources (Corrucinni has a long list of publications; only an 'entry' article is listed here.)
Corrucinni, R. "Anthropological Aspects of Orofacial and Occlusal Variation and Anomalies" in Advances in Dental Anthropology New York: Wiley-Liss, Inc., 1991 pp 295-323.
Price, W. Nutrition and Physical Degeneration 50th anniversary edition New Canaan: Keats Publishing Co., 1989.